Hazards of the patient assessment


CarolinaFireJournal - Jason Boan
Jason Boan
10/14/2010 -

The patient assessment algorithm is drilled into our heads from day one in EMS. It does not matter what class you take: EMT-B, EMT-I, EMT-P, ITLS, PEDS, PALS, GEMS, NRP, AMLS, ASLS, or any other combination of letters someone can come up with. They all revolve around some form of the patient assessment chart. Some of the classes use the same one, a few adjust them to fit the specific topic of the class, but they all use some form of it. Everything we do in EMS is based on what we find during the patient assessment.

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Whatever version you use, they all have one thing in common: the patient. Our job is to find and assess a patient, then treat what we find during that assessment. Every service has different standing orders and protocols, but they are based on being able to give the patient the best treatment possible. In all of these classes, we are taught to put the patient’s needs first and do everything with the patient’s best interest in mind.

In caring for the patient, however, we are exposing ourselves to lots of hazards. From the scene size-up, to the treatment of the patient, we are on dangerous scenes, driving code, and using needles in the back of a moving vehicle. This is the first in a series of articles looking at the hazards associated with the different steps of the patient assessment. 

Personal and crew safety during the scene size-up

The most important part of the patient assessment is the scene size up. Body Substance Isolation (BSI), scene safety, moi/noi, number of patients, and the need for additional resources are the five things we do and/or think about on the way to a call, and as we arrive on scene. We can recite it in our sleep. You say it before you do anything in any class, you think about it before you answer any question on a test, and it is a real step you do before every call. But have you thought about the reason we do it and what it protects us from? This step is more of a benefit to our safety than to patient care. 

BSI: Gloves — check; Safety-toed boots — maybe; Safety glasses — they are on my head; Gowns and masks — I think they were in the cabinet this morning. Not all of these need to be worn on every call. You need to quickly assess the scene and determine the appropriate level of BSI. As uncomfortable and unstylish as these things are, they protect us from lots of possible exposures and injuries. Most services provide these things for us, and in some places they are required to be worn. Gloves, safety glasses, and safety- toed boots should be a minimum on every call. The boots don’t just protect your toes on the car you are cutting up. Every patient you come into contact with will be carried at some point, whether it is with a stair chair or on a spine board. Accidents can happen anywhere, anytime. A lot of services have gone to power lift stretchers, however, you don’t want one of the wheels of a patient loaded stretcher to come down on your toes.

Putting on gloves and safety glasses is probably the most important thing you can do for personal safety. There are the obvious reasons, the patient is bleeding or you are doing an invasive procedure — iv’s, intubation. But even when you have a patient that does not have any exposed body fluids or a need for an invasive procedure, you never know what can happen enroute to the hospital. An intoxicated or mental health patient may suddenly become agitated and spit. When they do, it is often aimed for the face, so safety glasses will keep it out of your eyes.

Gloves protect us from so much more than just blood. Until you actually assess the patient, you do not know what they may have been exposed to. For example, they could be soaked in gasoline, have some type of pesticide or chemical on them, mace from the police, or an unpleasant level of personal hygiene. With all the illnesses and diseases today, an N-95 should be worn on any type of cold and flu or respiratory call. You should also wear one when intubating, starting an IV, or giving an aerosolized medication. Once enroute to the hospital you and the patient are in a confined area. If they have some type of upper respiratory infection, it does not take much for them to cough and you breathe it in.

The plastic gowns most people just use for deliveries can keep so much more off of you than just amniotic fluid and blood from delivering a baby. They may be extremely uncomfortable, but they keep anything on the patient off you. Trauma and intoxicated patients may move, squirm and fight. If they have blood, fluids, are wet, or have glass and debris on them, you don’t want it transferred to you. You can change at the hospital, but it may be a long time to sit in it until you get there. A lot of medical patients get carried. Cardiac patients are usually diaphoretic. Seizure and intoxicated patients urinate on themselves. Then there are the ones with poor or no personal hygiene. With such close contact may come an unpleasant aroma that lasts throughout your shift. Therefore, the plastic gown keeps everything off you. Two words sum up why you should wear all of the above — projectile vomiting.

Is the scene safe?

It is not always possible, but this should be determined prior to entering any scene. If the police or fire department are on scene, why are they there? Are there any obvious dangers such as fire, a collapsed structure, gas cloud, active fight, smoking vehicles or uncontrolled traffic? In addition to obvious scene hazards, you also need to prepare for unseen hazards. You need an exit strategy prior to parking the unit. If you have to leave in a hurry, how can you plan ahead to make this possible?

The unit needs to be parked with the final step of treatment in mind and crew safety if on a roadway. Instead of using the ambulance to block traffic, let law enforcement, the fire department, or first responders take on this responsibility. Parking the unit close to the house or patient may not always be the best option. It takes a little more work, but you may need to walk farther to and from the patient location.

If law enforcement is on the scene, check with them before proceeding in. If you feel you or your crew are in a dangerous situation, fall back to the unit and request assistance. Calm and non-threatening scenes can quickly turn dangerous with little or no warning. Unfortunately, more often than it should, you are dispatched for one signal and when you get on scene it may be something totally different. You need to prepare for this before arriving. 

The other three questions all tie in together. The mechanism of injury, nature of illness, and number of patients all affect your consideration of additional resources. Sometimes you can decide when arriving on scene if you are going to need more help. The earlier you can decide who, what, or if you need, the better for the patient and your crew. If there are multiple vehicles involved, you may need an extra set of spinal equipment. You might not have extrication tools on your unit. It may be something as simple as a couple of extra set of hands to help lift a large patient or carry someone over adverse terrain. Do not hesitate to call for lifting assistance; your crew’s safety and well being are worth asking for help. You may not think the patient is going to be a problem to move, but consider how well prepared the members of your crew may be. Take into consideration their size and physical abilities when making a decision. The ditch the patient is in may not be deep, but is it wet, do you have to carry them in a way that one of you has to walk backwards? Four people carrying a patient are safer for everyone than two people trying to rush or not wanting to wait for help. Most back injuries can be avoided by just doing a good assessment of the scene and asking for assistance.

When you have multiple patients, you may be hanging one or two, depending on your units capability. Most ambulances are able to carry a patient suspended above the bench, but none that I have seen are designed in a way that makes it easy. To do it safely, you need at least three people, one on each end to hold the patient up, and one to secure the spine board. Unfortunately, most people foolishly choose to do it with just the two crew members. 

We are doing the patient assessment for the patient, but the first five steps are there for the responders. They are there for the safety of everyone involved with the call. In order to properly care for and treat the patient, you need to be prepared for any number of scenarios.

If you do not consider your personal and crew safety first, you will not be able to care for the patient. Slow down and carefully think through these five things when approaching any scene. In addition to these things, consider your crews’ abilities and what resources you have available to you if you need them. Do not hesitate to ask for help. 

Jason Boan has 13 plus years in emergency medicine, starting as a volunteer EMT/firefighter in high school in Texas onto six years as a combat medic in the U.S. Army. Boan has been in involved in EMS in South Carolina for the last six years. He currently works as a paramedic for Aiken County EMS and part time at Ft. Jackson EMS.

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