1. ADVANCED ASSESSMENT Approach To The Patient
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ADVANCED ASSESSMENT Approach To The Patient
Instructor Notes by
Lori Smith AEMCA, ACP
Rob Theriault EMCA, RCT(Adv.), CCP(F)
Revised – November 2006
Donna L. Smith AEMCA, ACP
2007 Ontario Base Hospital Group

2. ADVANCED ASSESSMENT Approach to the Patient
AUTHORS
Mike Muir AEMCA, ACP, BHSc
Paramedic Program Manager
Grey-Bruce-Huron Paramedic Base Hospital
Grey Bruce Health Services, Owen Sound
Kevin McNab AEMCA, ACP
Quality Assurance Manager
Huron County EMS
References – Emergency Medicine
REVIEWERS/CONTRIBUTORS
Lori Smith AEMCA, ACP
Kitchener-Waterloo-Wellington Base Hospital
Rob Theriault EMCA, RCT(Adv.), CCP(F)
Peel Region Base Hospital
Donna L. Smith AEMCA, ACP
Hamilton Base Hospital
2007 Ontario Base Hospital Group

3. SCENE ASSESSMENT - INITIAL APPROACH The first step in patient assessment is to STOP and evaluate the scene for the following:
Environmental Hazards (Is it safe for you, your partner and patient?)
Mechanism of Injury (Note the series of events that caused the injury, if applicable)
Casualties (How many patients are you working with?)
Additional Resources required (ambulance or other emergency services.)
Personal protection (gloves, eye protection)
Introduce yourself and your partner.
Advise patient to limit movement to reduce further harm when appropriate.
Instructor Notes:
EMCA PIA occurs from the moment we receive the call..from leaving the station to approaching the scene, the patient
While not often verbalized is subconsciously done
If not all steps are taken, potential exists for mistakes (missing a patient, missing a c-spine injury)

4. PARAMEDIC ROLES ON SCENE DEFINED
Instructor Notes:

5. ATTENDING PARAMEDIC TECHNICAL PARAMEDIC
HISTORY OF CURRENT CONDITION
PHYSICAL EXAM
(PERTINENT TO PATIENT PRESENTATION)
ATTENDING PARAMEDIC
LEVEL OF DISTRESS
ASSESS LOA (AVPU)
C-SPINE CONTROL IF INDICATED
ASSESS
AIRWAY
BREATHING
CIRCULATION
INTERVENE
IF REQUIRED
(OXYGENATION/VENTILATION)
GATHER CHIEF COMPLAINT
CHEST AUSCULTATION
PAST MEDICAL CONDITION
MEDICATIONS
ALLERGIES
TECHNICAL PARAMEDIC
REMOVE EQUIPMENT OFF AND PREPARE STRETCHER
ATTACH CARDIAC MONITOR
ATTACH SP02 MONITOR
OBTAIN VITAL SIGNS
OBTAIN BLOOD GLUCOSE
REPORT ALL FINDINGS TO PARTNER AS FOUND
ASSIST PARTNER IN ANY TREATMENTS
Instructor Notes:
The EMS Paramedic is the medical authority on a scene where there are First Responders
TREATMENT DECISION
APPROXIMATELY 5 MINUTES

6. ASSESSING THE PATIENT SICK – NOT SICK Instructor Notes:
“first impressions” are critical
SICK – NOT SICK

7. Does the patient pass the “look” test?
first impressions are critical
observations and instincts are key elements for a savvy clinician
first impressions may lead to “load & go”
Instructor Notes:
“first impressions” will include, but is not exclusive to: e.g.
scene safety, scene appearance
patient position
facial expression (pain, fear, etc)
level of awareness
respiratory effort
accessory muscle use for breathing
smells
visible blood, vomit, feces, etc

8. DETERMINING LEVEL OF AWARENES
Utilize the AVPU scale
A - Alert- does the patient look at you when you walk in the room
V- Does the patient respond to your verbal commands
P- Does the patient only respond to painful stimulus
U- Unresponsive (patient does not respond to painful stimuli)
ASK – closed questions at first to determine LOA
What is your name?
Where are you?
What month is it?
Instructor Notes:

9. ASSESS C-SPINE Does the mechanism of injury suggest trauma?
Do you have any discomfort in your head or neck region?
Instructor Notes:

10. DETERMINING LEVEL OF DISTRESS
(mild, moderate, severe)
Evaluate 4 Areas
1) What is patients level of awareness
2) Workload of breathing
3) Position
4) Skin (color, condition, temperature)
Instructor Notes:
As we approach the patient, we are noting immediately their level of awareness.
Does this patient pass the “first look” test

11. ASSESS AIRWAY Patent or not Manageable Correct if needed
Instructor Notes:
Is the airway clear of any obstructions, fluid etc. Does the patient speak…is there evidence of respiratory insufficiency, stertorous breathing, stridor or gurgling?
A compromised airway obviously needs immediate attention prior to proceeding with exam

12. ASSESS BREATHING Rate Volume Workload
Correct if needed (Oxygenation / Ventilation)
Instructor Notes:
Symmetrical chest rise
Expose, auscultate and palpate

13. CIRCULATION Pulses-rate, where found (radial, brachial, carotid)
Does the pulse match monitor (pulse deficit)
Capillary refill
Instructor Notes:
Capillary refill provides information regarding the patient’s cardiovascular status - Greater than 2 seconds indicates inadequate circulation and impaired cardiovascular functions. Beware of age gender and environment

14. CHIEF COMPLAINT
The complaint that troubles the patient the most (Reason
for calling the Ambulance) Is the patient complaining of
any SOB (always ask)
Instructor Notes:
What made you decide to call the ambulance at this time?
What is worse today than the normal?
MVC/trauma patients…where does it hurt the most?

15. CHEST AUSCULTATION
Assess all lung fields (optimum is auscultation on the back)
Assess for breath sounds apices to bases
Equality
Adventitious Sounds
Instructor Notes:
While auscultating - great time to assess for accessory muscle use/indrawing check for scars

16. GATHER HISTORY OF CURRENT CONDITION
(EXPAND UPON CHIEF COMPLAINT AND LOOK
FOR ASSOCIATED SYMPTOMS)
Concentrate on this area
ONSET (when did C/C start)
ACTIVITY (what were you doing when C/C started)
DURATION (length of time of c/c, is it constant, increasing in severity)
DESCRIBE CHIEF COMPLAINT (type of discomfort, location, radiation, scale,
similar discomforts, aggravating relieving factors)
ASSOCIATED COMPLAINTS (always assess chest, head, abdo for pain
or discomfort)
ANY WEAKNESS OR DIZZINESS
ANY NAUSEA OR VOMITING
ANY HISTORY OF COUGH COLD OR FEVER, FLU Symptoms
ANY RECENT ILLNESSES
HOW HAVE YOU BEEN EATING AND DRINKING
BOWEL AND URINE OUTPUT
Instructor Notes:
Standard format is OPQRST Onset
Provokes/palliates
Quality
Region/radiation/Relieved
Severity
Timing (constant, intermittent?)
Standardized questions great to use for any pain evaluation..especially chest pain
Events preceding – eg. Slept in chair all night do to increased SOB when laying down

17. PAST MEDICAL HISTORY (examples)
MI, angina, hypertension, diabetic, respiratory
disorders, CVA/TIA
Instructor Notes:
Look for Medic Alert

18. MEDICATION What medications? Are you taking them regularly?
As prescribed? Any new medications?
Any over the counter medications?
LOOK AT MEDICATIONS – WRITE DOWN NAMES &
DOSAGES, OR OPTIMALLY, TAKE THEM WITH YOU
TO THE HOSPITAL!
Instructor Notes:
If unsure of the action of a medication, ask the patient why they are on it or utilize a handbook (if available)
Check to see if there are any naturopathic medications used
Was the patient given any medications by bystanders or family that is not their own?
Knowing the functional classification of commonly prescribed drugs is important so that in the absence of a reliable history, the patient’s meds can be used to help determine the medical history

19. ALLERGIES
Do any pills make you sick? Are you allergic to any medications?
What happens to you when you come into contact with the medicine or products that you are allergic to?
Instructor Notes:
Epi pen
look for Medic Alert
inquire about reaction(s) - is this a true allergy or an adverse effect?

20. SECONDARY SURVEY
Keep assessment pertinent to call - focused on specific organ systems on medical calls compared with trauma calls where a broader assessment is performed
Keep it organized as you work your way down from head to toe
Instructor Notes:

21. GENERAL APPEARANCE
Distress level, LOA, skin color condition, facial expression
Neural exam, person, place, time
Take an overall view, communicate
Visual assessment look first then palpate
Instructor Notes:

22. HEAD
Skin condition, mucous membranes, facial droop, pupil size, equality reaction,unilateral stare( staring to one side only)
Take a better look at the airway (possible/potential) problems e.g. dentures, partial plates
Discharge from ears or nose (can palpate fontanels lightly)
Instructor Notes:

23. NECK
JVD while patient 45 degrees > 3 cm above clavicle= abnormal
can block jug to see if distal pressure disappears, lowest pressure in the body, if jug vein needed lift legs
tracheal deviation, palpate suprasternal notch, approx 1 finger either side
subcutaneous emphysema
palpate C-spine for tenderness, step deformity
carotid artery palpate both to see if difference in pressure
auscultate for Carotid Bruits (swishy sound on auscultation caused by atherosclerosis
carotid endarterectomy = removal of plaque, look for scar (contraindication of CSM)
Instructor Notes:
JVD may indicate that the right ventricle is unable to adequately pump the blood it receives (preload) either as a result of left ventricular failure and congestion, a pulmonary embolus or hypokinesis of the right ventricle as a result of acute right ventricular infract (or old infarct) or right ventricular ischemia.
Tracheal deviation may be difficult to palpate in the setting of a pneumothorax. This does not rule out a tracheal shift. The Paramedic should rely on other clinical signs such as absent or markedly diminished A/E, severe respiratory distress, SC emphysema, hypotension (in combination with the previous S&S), etc
SC emphysema in the neck can be a sign of a pneumothorax or a tracheal fracture, both of which may be life-threatening
Carotid bruit indicates a high risk of stroke. Note: never palpate both carotids simultaneously

24. CHEST Look first CLAPS, Paradoxical movements
Auscultate (reassess for changes)
Palpate for TICS (tenderness, instability, crepitus,subcutaneous emphysema)
Instructor Notes:
C-Constusions
L- Lacerations
A-Abrasions
P-Penetrating Trauma
S-subcutaneous emphysema, swelling OR
T-tenderness
I-instability
C-crepitus
S-subcutaneous emphysema

25. ABDOMEN (proper assessment patient must be supine)
Look before touching, masses, bruising, symmetry, discoloration, scarring
Size: obvious distention (normal or not) Gas? Bleeding?
Do not palpate masses or pulsations
Peritonitis: guarding, rigidity
Pain near diaphragm: think abdomen as well as chest (heart problem)
Child baring years think ectopic pregnancy
Look for previous surgeries (scars)
Instructor Notes:
Any masses should be documented as well as borders marked on the skin so changes in size can be noted on later assessment.
Use a felt tipped marker to mark borders of mass, then the ER will have a reference point for later assessments.

26. PELVIS No need to assess if medical
Trauma is critical (large amount of blood loss) needs rapid transport
Palpate at least 2 planes for stability, crepitus
Instructor Notes:
Note if incontinence
Sickle cell anemia, leukemia can present with persistent painful priaprism
If there is pain in ONE region upon palpation, STOP
Consider the potential for open book pelvic fracture in the trauma patient

27. EXTREMITIES If medical go distal
Edema: pitting or not, how far up legs, duration, changes
Cap refill, sensation, movement equal or not
Arms (assess bilateral B/P if chest pain)
Dialysis Patient: shunt (never start an I.V in same arm)
PICC line?
Instructor Notes:
Don’t take a blood pressure in a arm with a shunt unless completely necessary

28. PATCHING FORMAT
Instructor Notes:

29. PATCH FORMAT Introduction of yourself, name, medic # , run #
How you are patching (cell phone, radio, landline)
Make sure they can hear you (confirm reception)
Where you are (location, e.g. 25th floor)
Age, weight, sex, LOA, level of distress
Chief complaint
Incident history
Vitals, ECG, SpO2
Exam findings
Past medical history, Medications, Allergies
Treatment & Response
Instructor Notes:

30. PATCH FORMAT (DETAIL)
Pulse, respirations, blood pressure, skin, pupils
Rhythm on the monitor
Physical assessment
Head, neck, patency of airway, cyanosis, JVD
Chest- Breath sounds, trauma
Abdomen (assessed not assessed) report findings if any
Extremities- pulses present, Edema pitting or not location
Treatment done so far & response, any change
What receiving hospital, amount of time to have patient receive transfer of care
Modify patch format to give report at emergency room
Follow same structure
Instructor Notes:

31. Question # 1 What is the purpose of obtaining a patient history?
to detect signs of injury B
to establish priorities of patient care C
to make the patient feel comfortable D
to see if you can “no service” the patient

32. Question # 1 What is the purpose of obtaining a patient history?
to detect signs of injury B
to establish priorities of patient care C
to make the patient feel comfortable D
to see if you can “no service” the patient

33. Question # 2
When gathering information from the elderly, it is important to: A
speak loudly since most are deaf B
refer to the patient as “dear” C
anticipate numerous medications D
not expect any variation in the exam

34. Question # 2
When gathering information from the elderly, it is important to: A
speak loudly since most are deaf B
refer to the patient as “dear” C
anticipate numerous medications D
not expect any variation in the exam

35. Question # 3
From the following list, in which situation is important to determine the last oral intake? A
patient with a welding flash burn to the eye B
patient with a nail through his foot C
dizzy patient D
adult with dental pain

36. Question # 3
From the following list, in which situation is important to determine the last oral intake? A
patient with a welding flash burn to the eye B
patient with a nail through his foot C
dizzy patient D
adult with dental pain

37. Question # 4 The approach to the paediatric patient should include:
Establishing a rapport with the parents B
Calm and confident approach C
Observing the patient prior to physical examination D
All of the above

38. Question # 4 The approach to the paediatric patient should include:
Establishing a rapport with the parents B
Calm and confident approach C
Observing the patient prior to physical examination D
All of the above

39. Question # 5
In which of the following cases is the paramedic most likely to perform a detailed physical examination? A
34 year old patient in status seizure B
40 year old shot in the chest C
80 year old in cardiac arrest D
59 year old weak and diaphoretic

40. Question # 5
In which of the following cases is the paramedic most likely to perform a detailed physical examination? A
34 year old patient in status seizure B
40 year old shot in the chest C
80 year old in cardiac arrest D
59 year old weak and diaphoretic

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