THE BLIND DATE PATIENT ASSESSMENT RAMEDIC A P

THE BLIND DATE: PATIENT ASSESSMENT RAMEDIC A -P R N. , . S M I LD IA C N O C T MAT CUE S E R FI T S E R C IL -G LE IL V PLATTE EMS DIVISION CHIEF

DISCLOSURE STATEMENT üI HAVE NO ACTUAL OR POTENTIAL CONFLICT OF INTEREST IN RELATION TO THIS PRESENTATION üWE ARE DEEP INTO PUMPKIN PIE SEASON AND IT IS DELICIOUS üICE CREAM IS STILL AMAZING üMEMORY FOAM MATTRESS ARE LIKE SLEEPING ON CLOUDS üTHE NEW ENGLAND PATRIOTS SHOULD BE KICKED OUT OF THE NFL-BANNED TO THE CFL üAUDIENCE PARTICIPATION ENCOURAGED

OVERVIEW v COMPONENTS OF A PATIENT ASSESSMENT v PEARLS OF PATIENT ASSESSMENT v PERFORMING THE ASSESSMENT v MEDICAL VS. TRAUMA v ON GOING ASSESSMENT v PUTTING IT TO PRACTICE

COMPONENTS MEDICAL q SCENE SIZE UP q PRIMARY ASSESSMENT q VITAL SIGNS q SAMPLE q SECONDARY ASSESSMENT/PHYSICAL q ONGOING REASSESSMENT

COMPONENTS TRAUMA q SCENE SIZE UP q PRIMARY ASSESSMENT q SECONDARY ASSESSMENT/PHYSICAL q VITAL SIGNS q SAMPLE q ONGOING REASSESSMENT

PEARLS OF PATIENT ASSESSMENT q SYSTEMATIC APPROACH q WHAT TO WEAR-BSI q ENGAGE THE PATIENT q ASK OPEN ENDED QUESTIONS q ACTIVE LISTENING q ONE ON ONE INTERVIEW

SYSTEMATIC APPROACH q q CONSISTENT ADULTS o HEAD TO TOE q PEDIATRICS o TOE TO HEAD o DEMONSTRATE ON PARENT FIRST

SYSTEMATIC APPROACH Ø WHEN DOES PATIENT ASSESSMENT BEGIN Ø DISPATCH/MDT NOTES Ø WINDOW SURVEY Ø WALK INTO THE ROOM-FIRST EYES ON PATIENT

WHAT TO WEAR- ON THE DATE… BSI q GLOVES q EYE PROTECTION

WHAT TO WEAR BSI q MORE EXTREME ü MASK- SURGICAL OR N 95 § WHEN? ü GOWN § WHEN?

PEARLS OF PATIENT ASSESSMENT ENGAGE THE PATIENT v ESTABLISH A MEANINGFUL CONTACT OR CONNECTION WITH v TO ENTER INTO A CONFLICT

PEARLS OF PATIENT ASSESSMENT WHAT IT LOOKS LIKE

PEARLS OF PATIENT ASSESSMENT ENGAGE THE PATIENT q DEVELOP RAPPORT EARLY ü INTRODUCE YOURSELF ü GET THEIR NAME ü GET AT EYE LEVEL ü POSITION YOURSELF APPROPRIATELY o TO SIT ON COUCH OR NOT TO SIT ON COUCH… v APPROACH PATIENT IS SITUATIONALLY DEPENDED

PEARLS OF PATIENT ASSESSMENT ENGAGE THE PATIENT q GET HANDS ON… ü FEEL A PULSE ü FEEL SKIN SIGNS

PEARLS OF PATIENT ASSESSMENT ASK OPEN ENDED QUESTIONS q WHAT IS YOUR NAME? q WHAT CITY ARE YOU IN/WHERE ARE YOU? q WHAT YEAR IS IT? q HOW ARE YOU FEELING… q TELL ME ABOUT THE PAIN YOU ARE FEELING…

PEARLS OF PATIENT ASSESSMENT ACTIVE LISTENING Ø Ø PROCESS BY WHICH AN INDIVIDUAL SECURES INFORMATION FROM ANOTHER INDIVIDUAL OR GROUP THE “ACTIVE” ELEMENT INVOLVES TAKING STEPS TO DRAW OUT INFORMATION THAT MIGHT NOT OTHERWISE BE SHARED

PEARLS OF PATIENT ASSESSMENT ACTIVE LISTENING ü BUILDING TRUST AND ESTABLISHING RAPPORT ü DEMONSTRATING CONCERN ü PARAPHRASING TO SHOW UNDERSTANDING ü NON-VERBAL CUES WHICH SHOW UNDERSTANDING q q q NODDING EYE CONTACT LEANING FORWARD

PEARLS OF PATIENT ASSESSMENT ACTIVE LISTENING ü BRIEF VERBAL AFFIRMATIONS LIKE “I SEE, ” OR “I UNDERSTAND” ü ASKING OPEN-ENDED QUESTIONS ü ASKING SPECIFIC QUESTIONS TO SEEK CLARIFICATION- “HELP ME UNDERSTAND THIS BETTER” ü WAITING TO DISCLOSE YOUR OPINION ü DISCLOSING SIMILAR EXPERIENCES TO SHOW UNDERSTANDING ü LANGUAGE § AVOID TERMS OF ENDEARMENT

THE DATE…AKA ASSESSMENT THE INTERVIEW q CLOSED ENDED QUESTIONS ü FOR DIFFICULTY BREATHING PATIENTS TALKING IN 4 -5 WORD DYSPNEA OR LESS ü DIFFICULT PATIENTS WHO ARE HAVING TROUBLE ANSWERING OPEN ENDED QUESTIONS § USE CAUTION NOT TO LEAD THEM DOWN A PATH o USE…DO YOU HAVE ANY OTHER SYMPTOMS OR PAIN? • INSTEAD OF… “DO YOU HAVE CHEST PAIN? ”

THE DATE…AKA ASSESSMENT THE INTERVIEW q INTERVIEW FAMILY AND/OR BYSTANDERS ü COMPARE STORIES WITH WHOMEVER IS DOING THE PATIENT ASSESSMENT ü CLARIFY DISCREPANCIES q IF TIME PERFORM DETAILED HISTORY ü TO INCLUDE FAMILY HISTORY (IF RELEVANT AND TIME)

THE DATE…AKA ASSESSMENT PRIMARY IMPRESSION-ABCS (+DE) q RESPONSIVENESS/LEVEL OF CONSCIOUSNESS (AVPU) q ASSESS AIRWAY PATENCY q ASSESS BREATHING ü APPROX. RATE ü QUALITY (ACCESSORY MUSCLE USE, WORK OF BREATHING) ü DEPTH

THE DATE…AKA ASSESSMENT PRIMARY IMPRESSION-ABCS (+DE) q ASSESS CIRCULATION ü APPROXIMATE RATE ü REGULARITY ü STRENGTH q DISABILITY (ALTERED MENTATION) q EXPOSE

THE DATE…AKA ASSESSMENT ORIENTATION/MENTAL STATUS q PERSON / PLACE / TIME / SITUATION (EVENT) ü WHAT IS YOUR NAME… ü WHAT CITY ARE YOU IN… ü WHAT YEAR IS IT OR WHAT MONTH IT IS ü WHAT PROMPTED THE CALL TO 911 OR… ü TELL ME WHAT HAPPENED

PEARLS OF PATIENT ASSESSMENT AVOID ASKING q WHO IS THE PRESIDENT q WHAT IS TODAY’S DATE, OR WHAT DAY IS IT TODAY q COMPLEX MATH PROBLEMS

THE DATE…AKA ASSESSMENT DECISION MAKING CAPACITY ü Understands nature of illness/injury ü Understands consequences of refusal ü Not intoxicated ü No criteria for mental health hold v Competency caveat

THE DATE…AKA ASSESSMENT CHIEF COMPLAINT ü HOW ARE YOU FEELING RIGHT NOW ü WHAT IS BOTHERING YOU TODAY ü HOW CAN WE HELP YOU ü WHAT IS THE REASON WE WERE CALLED OUT TODAY

THE DATE…AKA ASSESSMENT SAMPLE q SIGNS AND SYMPTOMS v WHAT DO YOU SEE (SIGNS) ü SKIN SIGNS ü INJURIES (LIFE THREATENING VERSUS NON-LIFE THREATENING) ü BODY POSITION v WHAT ARE THEY COMPLAINING OF (SYMPTOMS) ü LIFE THREATENING VERSUS NON-LIFE THREATENING

THE DATE…AKA ASSESSMENT SAMPLE q SYMPTOMS ü O- ONSET ü P- PROVOKE ü Q- QUALITY ü R- REGION/RADIATES ü S- SEVERITY SCALE ü T- TIME ü I- INTERVENTIONS

THE DATE…AKA ASSESSMENT SAMPLE (CONTINUED) q ALLERGIES q MEDICATIONS q PAST HISTORY q LAST ORAL INTAKE OR LAST MENSTRUAL CYCLE q EVENTS (SITUATION) LEADING UP TO IT (WHAT WERE THEY DOING)

THE DATE…AKA ASSESSMENT VITALS SIGNS q PULSE q BLOOD PRESSURE q RESPIRATIONS ü *1 -2 SETS ON REFUSAL ü *3 -4+ SETS ON TRANSPORT

THE DATE…AKA ASSESSMENT VITALS SIGNS (OPTIONAL AT TIMES) q SPO 2 ü RESPIRATORY OR CHEST PAIN PATIENT ü ALTERED ü POSSIBLE INFECTION (SEPSIS) ü LETHARGY OR GENERAL WEAKNESS ü ANXIOUS PATIENT ü SYNCOPAL EPISODE

THE DATE…AKA ASSESSMENT VITALS SIGNS (OPTIONAL AT TIMES) q CAPNOGRAPHY ü RESPIRATORY/CARDIAC ü ALTERED ü POSSIBLE INFECTION (SEPSIS) ü LETHARGY OR GENERAL WEAKNESS ü ANXIOUS PATIENT

THE DATE…AKA ASSESSMENT VITALS SIGNS OPTIONAL (AT TIMES) q BGL ü DIABETICS ü ALTERED MENTATION ü LETHARGY OR GENERAL WEAKNESS ü SYNCOPAL EPISODE ü SICK PEDIATRICS

THE DATE…AKA ASSESSMENT TRANSPORT DECISION q THINK EARLY TO PLAN PROPER TREATMENTS ü C-SPINE? ü NEED FOR IV ü NEED FOR MEDICATION v ASPIRIN, ANTI-NAUSEA, PAIN MEDS, ETC. q ASK… “DO YOU WANT TO GO TO THE HOSPITAL OR WHAT HOSPITAL WOULD YOU PREFER? ”

THE DATE…AKA ASSESSMENT PHYSICAL ASSESSMENT q HEAD TO TOE ü ALTERED PATIENTS ü TRAUMA PATIENTS ü PROVIDER JUDGEMENT GET HANDS ON!!!!!!! ü PUSH FIRMLY

THE DATE…AKA ASSESSMENT PHYSICAL ASSESSMENT q FOCUSED PHYSICAL EXAM ü BROKEN OR DEFORMED EXTREMITIES ü PINPOINT PAIN § ABDOMINAL § CHEST § EXTREMITY

THE DATE…AKA ASSESSMENT WHEN TO DO EKGS q SYNCOPAL EPISODES q CHEST PAIN q RESPIRATORY* (A & B BEFORE C) q FLU LIKE SYMPTOMS IN PT’S OVER 55 q POOR SKIN SIGNS q GENERAL WEAKNESS q STROKES q SEPSIS q CRUSH INJURIES

THE DATE…AKA ASSESSMENT MEDICAL VS. TRAUMA q MEDICAL ü FOCUS IS ON THE MEDICAL COMPLAINT- LIMITED PHYSICAL EXAM ü RECOGNIZED AND DETERMINE ü TREAT ACCORDINGLY

THE DATE…AKA ASSESSMENT MEDICAL VS. TRAUMA q TRAUMA ü FOCUS IS ON THE MECHANISM OF INJURY ü MORE DETAILED PHYSICAL EXAM TO FIND PRIMARY & SECONDARY INJURIES ü TREAT LIFE THREATS IMMEDIATELY

THE DATE…AKA ASSESSMENT TRAUMA q X-A-B-C-D o CONTROL MAJOR BLEEDING o AIRWAY o BREATHING o CIRCULATION o DISABILITY/MENTAL STATUS q BATH o BLEEDING o AIRWAY o TENSION PNEUMOTHORAX o HYPOTHERMIA q MARCH o MASSIVE HEMORRHAGE o AIRWAY o RESPIRATION o CIRCULATION o HYPOTHERMIA

BATH- 30 SEC ASSESSMENT q DIAMOND HAND APPROACH VS. OPPOSING PRESSURE v SWEEP/RAKE q q PRIORITY 1, 2 THEN 3 ü LEGS, ARMS ü PELVIC AREA, SHOULDERS, NECK ü BACK, CHEST, ABDOMEN, HEAD PLUS 1 q PENETRATING INJURY q ELECTROCUTION

TRAUMA DCAP/BTLS - LEGEND OR MYTH? Ø DEFORMITIES Ø CONTUSIONS/CREPITUS Ø ABRASIONS Ø PENETRATIONS Ø BLEEDING/BURNS Ø TENDERNESS Ø LACERATIONS Ø SWELLING

TRAUMA Ø LOOK FOR SIGNS OF INJURIES ü HEAD ü NECK ü SHOULDERS ü CHEST ü ABDOMEN ü PELVIS ü EXTREMITIES ü BACK

ON-GOING ASSESSMENT REASSESSMENT ü VITAL SIGNS v STABLE- EVERY 15 MIN v UNSTABLE- EVERY 5 MIN ü PT ASSESSMENT v DETAILED PHYSICAL EXAM v REASSESS 12 LEAD v REASSESS BGL v REASSESS CMS v DIG DEEPER INTO PATIENTS COMPLAINT Ø CIRCUMSTANCES SURROUNDING IT

PUTTING IT INTO PRACTICE v STATES, “I CAN’T BREATH”

PUTTING IT INTO PRACTICE q INITIAL IMPRESSION q PRIORITIES o POSITION o LUNG SOUNDS o SPO 2 o CAPNOGRAPHY o TREATMENT o EKG o TRANSPORT o REASSESS

PUTTING IT INTO PRACTICE q SUICIDAL IDEATION q HEARING VOICES IN HEAD

PUTTING IT INTO PRACTICE q INITIAL IMPRESSION q PRIORITIES q SAFETY q DID THEY ATTEMPT TO HARM SELF q DO THEY HAVE A PLAN q PRIOR HISTORY/VIOLENCE q TREATMENT/TRANSPORT

PUTTING IT INTO PRACTICE q POSSIBLE INGESTION/POISONING q TEEN SEEN ACTING WEIRD

PUTTING IT INTO PRACTICE q INITIAL IMPRESSION q PRIORITIES o SAFETY o FACT FINDING • MEDICAL COMPLAINT • CALL INTO POISON CONTROL o NEED FOR TREATMENT o TRANSPORT o REASSESSMENT

PUTTING IT INTO PRACTICE q CALLED TO A GSW q UNRESPONSIVE q WEAK PULSE q SLOW SHALLOW REPS

PUTTING IT INTO PRACTICE q INITIAL IMPRESSION q PRIORITIES o STOP THE BLEEDING • LOOK FOR CRITICAL WOUNDS TO STABILIZE o AIRWAY o VENTILATIONS/HIGH FLOW O 2 o NEEDLE DECOMPRESSION* o TRANSPORT o KEEP WARM o VITALS o TRAUMA NAKED o REASSESS

PUTTING IT INTO PRACTICE q PATIENT STATES CHEST FEELS TIGHT

PUTTING IT INTO PRACTICE q INITIAL IMPRESSION q PRIORITIES o SKIN SIGNS o EKG o VITAL SIGNS o LUNG SOUNDS o SPO 2 o CAPNOGRAPHY o TREATMENT o TRANSPORT o REASSESS

QUESTIONS? ? ?