5 steps to an accurate detailed physical exam
You are on scene with a patient who has multi-system trauma; what tips can improve your physical exam of this patient?
After arriving on scene and performing an initial assessment of your patient, you should have a general sense for which physical exam needs to be performed in order to complete your assessment.
The focused physical exam is generally reserved for medical patients or those trauma patients who have a limited number of body systems involved in their trauma. In the case of our auto vs. pedestrian patient, he has suffered multi-system trauma from a significant mechanism and may have any number of injuries. As a result, you should plan to perform a detailed physical exam when cataloging his injuries.
Here are five assessment tips when performing a detailed physical exam.
1. Be timely
After determining the need for a detailed physical exam, you next need to decide when and where to perform the exam. A multisystem trauma patient may have suffered life-threatening injuries. In these cases, delaying treatment, transport and ultimately definitive surgical care to perform an exam on scene may not be appropriate.
In the cases of these life threats, consider extricating the patient to the ambulance as soon as practical and perform your detailed exam during transport. If your patient does not appear to be suffering from life-threatening injuries, you may be able to remain on scene while performing your assessment.
Be sure to account for other factors on scene, however, when making the determination of when and where to assess your patient. For instance, if you anticipate a delay in transport due to a prolonged extrication from a remote location, it may not be advisable to delay assessment until the patient is in the ambulance.
2. Be methodical
It is natural for the EMS provider to prioritize the severity of a patient’s injuries during the detailed physical exam. We all want to focus our attention on the injuries which are most likely to cause lasting harm to our patients. However, jumping around during the detailed physical exam makes it far more likely that another injury is missed. Remember that the most serious physical injuries may not be the most obvious.
When performing the detailed physical exam (also referred to as the head-to-toe exam) the easiest way to avoid missing something is to proceed in a methodical way, starting at the patient’s head and working your way down to his toes.
3. Be consistent
Most EMS students learned to perform a detailed physical exam one way during their training. While many aspects of EMS cannot be approached in a one-size-fits-all fashion, the detailed physical exam is an important outlier. By consistently performing the exam the same way on each patient, you can reduce the chance that an injury is missed.
Remember that you identified obvious life threats during the primary assessment and corrected them during that process. The goal of the detailed physical exam is to understand the extent of the patient’s injuries.
Just like skilled EMS providers write a patient care record using the same format every time, these same providers assess patients in a consistent fashion making sure that no region of the body is missed.
4. Be communicative
A detailed physical exam can be an uncomfortable experience for your patient. In addition to attempting to preserve modesty whenever possible, let the patient know what steps are involved in the exam before you perform them. Don’t use clinical terminology, but simply state what you are going to do and what that assessment is checking for. If appropriate, tell the patient whether or not you found something of interest.
Obviously, in the case of our auto vs. pedestrian patient, the fact that he is unresponsive makes it difficult to communicate with him. Be communicative, however, whenever possible.
5. Be clear
After performing a detailed physical exam, record those findings in similar detail on your patient care report. Simply writing “WNL” (which stands for “within normal limits” or, sometimes, more accurately, “we never looked”) doesn’t do justice to the importance of the examination you performed and does little to pass that information along to the care team at the hospital.
Documenting detailed findings can help the hospital staff understand the mechanism of injury and may guide their further assessment and treatment of the patient. For instance, if you find that the patient has a laceration, record the location and approximate size as well as whether it is actively bleeding or not.
After securing the patient’s airway and placing him on oxygen, you elect to perform a detailed physical exam in the ambulance on the way to the hospital. After cutting off his clothes, you begin methodically assessing, beginning with his head. You find blood matted in his hair as well as instability and crepitus in his chest wall and pelvis. When assessing his extremities, it is apparent that he suffered bilateral fractures of his lower legs.
You splint his injuries and continue to treat and monitor him on the way to the hospital. When you arrive, you provide a brief report to the trauma surgeon and then a more detailed report of your findings to the scribe.
Radiographic studies of the patient reveal a closed head injury, fractured ribs, a pelvic fracture and bilateral tib/fib fractures. The patient undergoes several surgeries and is ultimately admitted under the neurology service.
He is able to be extubated several days later and is discharged for rehabilitation after a two week hospital stay.