EMT Medical Assessment Guide
EMT Medical Assessment Guide
EMTs and Paramedics have unique assessments that target whether life threats are present and identifying whether the patient is “sick or not sick” from the minute they see the patient. You will often hear this term in EMS and being competent in it will lead you to being a great medic, nurse, PA, doctor, or whatever discipline you choose to further after EMT. Let’s break that phrase down to what it means, is the patient stable or unstable and do they appear to have a chief complaint?
Now we need to start thinking of assessments in the sense of “blocks”. We have referenced this term and realized it can be region specific and not all schools teach this mentality but each “block” refers to your place in the assessment . You need to make sure to stay in your blocks to keep your flow. If you deviate from this then it is very hard to get back to where you were, especially as a new student or EMT, so the goal is not to jump around. However, thankfully, once you get your blocks down you can jump right back into from where you left off. Scroll to the bottom for a full layout of assessment blocks.
As you have read in the How to Master Your Psychomotor Exam Guide, we always start with our scene size up. This will never get old. Even if you are assisting a family or friend in a medical emergency off-duty, it should be a habit to always be on alert with situational awareness. This could be as simple as making sure someone who has been stung by bees isn’t sitting next to a beehive where you could potentially be stung multiple times. It could also mean surveying the area for violence from other individuals or checking for sharps in the setting of a chronically ill individual.
Taking a look at the NREMT skill sheet (https://content.nremt.org/static/documents/skills/E202_NREMT.pdf), we immediately establish BSI/Scene Safety and ensure the scene is safe. Again, during proctoring skills, we are verbalizing this out loud. While in the field, you are scanning with your eyes and all your senses for danger. Next we lead into our PENMAN acronym for our scene size-up. If you have not read our How to Master Your Psychomotor Exam Guide, I suggest you take a look at that prior to continuing. That guide goes over the most common mistakes made during the psychomotor exam. For real-life scenarios, we need to determine if we will be ordering more resources and the other factors that are going to come into play like c-spine.
The first block in the medical patient assessment is Scene Safety. For testing purposes, our PENMAN would be verbalized as:
P-BSI, Scene Safety, Standard Precautions
E-Environment: No hazards noted
N-Appears I have 1 patient
M-Appears to be nature of illness not mechanism of injury but will keep both in mind
A-No need for additional resources at this time
N- No need for c-spine at this time
In real life scenarios, all of these things will be noted in your head. Things to mention out loud would be the need for c-spine to your crew or calling for ALS or an airship.
Just as you would in testing, in real life, we move onto our second block which is our primary survey. Each approach may be slightly different depending on the nature and the location of call but is important to get a flow of your skill sheet as it will lead you down a smooth flow of an assessment. We always start off our primary survey with our general impression of the patient. This doesn’t necessarily mean that you are repeating out loud “I see a 65 year old male sitting upright in the recliner with what appears to be levine’s sign”. This is you identifying from across the room whether your patient is sick or not sick. THIS WILL TAKE TIME. As a brand new EMT, you will usually not be able to identify this right off the bat, unless maybe they’re unconscious. For beginners, identifying sick vs. not sick should come after assessing ABCs. At this point, in the real life scenario, we are noting if they are alert and tracking, how they are sitting or laying, how do their ABCs look from across the room? You will be able to see things like levine’s sign, tripod position, accessory muscle use, choking, etc.
Once you have established a general impression, you can establish their LOC/mental status. This appears as AVPU on your skills sheet. This is where your basic orientation questions come into play. Alert & Oriented x3 is ideal for a medical patient, unless maybe they had a syncople episode in which you need to rule out any trauma. Once you’ve gained an orientation, you can assess for any life threats. In real life, this can include things like obvious bleeds you didn’t initially see from afar.
Next, you want to go through your ABCs. Remember, just like in our skill sheet, we are still in our primary survey or primary assessment. ABCs come before anything else which is why they are primary. In a testing scenario, a prompt may look like:
A-Patient’s airway is open and patent, no need for suctioning at this time.
B-The patient is breathing at a rate of ___ x minute, full/shallow/labored, effective/ineffective, with adequate/inadequate tidal volume. Patient is speaking in ___-___ word sentences/full sentences.
*(Lung sounds are clear in all fields ← done right away in real life for SOB patients, done later in vital signs block for exam purposes)
*You can place an pulse oximeter device on the patient now and determine if oxygen therapy is necessary
C-No signs of bleeding, pulse is strong/weak, rapid/slow, @ radial site, skins are pink/warm/dry.
If you note an immediate need to address the ABCs, always do so. This applies in real life, psychomotor exam testing, and computer NREMT testing. At this point, in real life and in testing, you can determine whether you should be transporting this patient as well. For beginners still working on the sick vs. not sick idea, you should be able to determine this after assessing ABCs.
The third block in the patient assessment is history taking or chief complaint assessment. This is where you put on your investigator hat and get to the bottom of the patient’s chief complaint. We will examine 2 different ways of investigating a chief complaint.
[Be advised, make sure to ask questions during your program about assessing ALOC/AMS patients. In our county we have a unique acronym that is not used in a lot of places. It will be in our NREMT-EMT Guide which will be out later sometime soon!]
Our first example is something you always see. It is a NREMT favorite, the good ole’ OPQRST. This is mostly for pain. This acronym can be used for different chief complaints but works best for pain related complaints. Now some people really struggle with obtaining information in this format but think about as if you are just talking to someone. It’s that simple. You are talking to someone to figure out what their problem is. A good way to script this is:
O- Did this come on all the sudden or gradually?
P- What were you doing when this started?
Q- What does it feel like?
*We NEVER want to lead a patient with words on how they may feel but if a patient is continuously unable to give you descriptive words, you can give them choices. Remember, we want to identify if they are having burning epigastric pain or pressure like substernal chest pain.
R(region)- Where is the pain/discomfort?
R(radiation)-Does it move anywhere else?
R(recurrence)-Does it come and go or is it constant?
R(relief)-Does anything make it better or worse?
S-On a scale of 1-10, with 1 being very little pain to 10 being extreme pain, what would you rate your pain/discomfort?
T-About what time did this start?
Since OPQRST works best for pain assessments, here is a common acronym known as PASTE used in different places for SOB/respiratory complaints which seems more appropriate and is as follows:
Provoked-What were you doing when this started? Did it come on sudden or gradually?
Associated chest pain-Do you have any pain with this SOB? If so, which came first? Does it feel harder to get air in, get air out, or both?
Sputum-Have you been experiencing any coughing? Have you been coughing anything up?
T- When did this start? Have you had a temperature? Chills?
E-Is it worse when you get up and move around, lay down, or no difference? Are you normally on oxygen?
Next, still within your history, you can ask your SAMPLE questions:
Signs are things YOU observe as the provider.
Symptoms are what the patient experiences.
S- Are you having any other symptoms, for example nausea, dizziness, etc? [Please note how the patient responds. Some patients are yes men and will say yes to everything so be careful how you ask.]
A- Do you have any allergies?
M- Are you currently taking any medications?
P- What kind of medical history do you have like diabetes,asthma, copd, chf, hypertension, stroke, etc?
L- Did you eat today? What did you have? Did you take your medications appropriately?
*Please do not repeat to a patient “what was your last oral intake”, speak to them like you would speak to another person normally
E- i’m going to repeat everything you told me to make sure I don’t miss anything…
*Even if you are nervous, you should be able to repeat everything they told you
This can be followed by any special questions. We will have a special questions guide put up soon so make sure to check that to help guide you!
The fourth block is vital signs. Get used to delegating priority vital signs. If it is just you and a partner, you are the lead patient assessment person, or you are assisting, you should start to prioritize your vital signs. For example, in a patient complaining of palpitations, the priority vital sign would be heart rate followed by oxygen saturation and blood pressure. There are different acronyms that you can use for obtaining vitals: PRBELLS, PROBEESLOST, BRIMBEST. For the sake of consistency across the states, we will focus on PRBELLS. Stay tuned to learn the others. Prior to our vitals, we want to do a quick physical examination (known as the secondary exam on the NREMT skill sheet). We can summarize this as:
Inspect-Check for stingers, hives, rashes, pacemakers/implanted devices, CABG scars, etc.
Palpate- Palpate the chest to see if pain is reproducible, palpate abdomen for distention or rebound tenderness during abdominal pain
Auscultate-can be done our vitals for lung sounds
*During IPA, we are looking for abnormalities or any clues to the patients complaint
P-Pulse: rate/rhythm/quality
R-Respirations: rate/rhythm/quality/spo2
B-Blood pressure: auscultated/palpated
E-Eyes: perl/unreactive/@___mm
L-Lung Sounds:___ in all fields/bases
L-LOC: A&oX___
S-Skins/Sugar: pink/warm/dry
The fifth and final block is treatment and reassessment. If you look at the NREMT skill sheet (https://content.nremt.org/static/documents/skills/E202_NREMT.pdf), treatment and reassessment are in two different blocks but it is much easier to remember to treat then reassess and as long as you do it in that order, you will not only pass the psychomotor exam, but you will also feel comfortable treating your patient within in the blocks.
So you have done all this investigative work to now treat your patient but please make sure to treat appropriately! Ask your chest pain patients if they have taken viagra, cialis, levitra, velitri, flolan, or revatio, prior to assisting in administration of nitroglycerin.
We also reassess every 5 minutes for unstable patients and every 15 minutes for stable patients UNLESS you see a significant change in patient status or orientation in which you should intervene sooner.
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Not let’s put it all together:
Block 1: Scene Safety
P-BSI, Scene Safety, Standard Precautions
E-Environment: No hazards noted
N-Appears I have 1 patient
M-Appears to be nature of illness not mechanism of injury but will keep both in mind
A-No need for additional resources at this time
N- No need for c-spine at this time
Block 2: Primary Survey
GI-General Impression (Age, Sex)
AVPU-A&O x ___ (Name, location, date/time)
C/C-Why call 911 today? What seems to be the problem/Determine Chief complaint)
Testing→ Any life threats
A-Patient’s airway is open and patent, no need for suctioning.
B-The patient is breathing at a rate of ___ x minute, full/shallow/labored, effective/ineffective, with adequate/inadequate tidal volume. Patient is speaking in ___-___ word sentences/full sentences Pulse oximeter device now and determine if oxygen therapy is necessary
C-No signs of bleeding, pulse is strong/weak, rapid/slow, @ radial site, skins are pink/warm/dry.
Block 3: History/CC Assessment
O- Did this come on all the sudden or gradually?
P- What were you doing when this started?
Q- What does it feel like?
*We NEVER want to lead a patient with words on how they may feel but if patient’s are continuously unable to give you descriptive words, you can give them choices. Remember, we want to identify if they are having burning epigastric pain or pressure like substernal chest pain.
R(region)- Where is the pain/discomfort?
R(radiation)-Does it move anywhere else?
R(recurrence)-Does it come and go or is it constant?
R(relief)-Does anything make it better or worse?
S-On a scale of 1-10, with 1 being very little pain to 10 being extreme pain, what would you rate your pain/discomfort?
T-About what time did this start?
-or-
Provoked-What were you doing when this started? Did it come on sudden or gradually?
Associated chest pain-Do you have any pain with this SOB? If so, which came first? Does it feel harder to get air in, get air out, or both?
Sputum-Have you been experiencing any coughing? Have you been coughing anything up?
T- When did this start? Have you had a temperature? Chills?
E-Is it worse when you get up and move around, lay down, or no difference? Are you normally on oxygen?
(secondary assessment on skills sheet)
S- Are you having any other symptoms, for example nausea, dizziness, etc? [Please note how the patient responds. Some patients are yes men and will say yes to everything so be careful how you ask.]
A- Do you have any allergies?
M- Are you currently taking any medications?
P- What kind of medical history do you have like diabetes,asthma, copd, chf, hypertension, stroke, etc?
L- Did you eat today? What did you have? Did you take your medications appropriately?
*Please do not repeat to a patient “what was your last oral intake”, speak to them like you would speak to another person normally
E- i’m going to repeat everything you told me to make sure I don’t miss anything…
*Even if you are nervous, you should be able to repeat everything they told you
Block 4: Vital Signs
I-Visual Inspection
P-Physical touch inspection
A-Auditory Inspection
P-Pulse: rate/rhythm/quality
R-Respirations: rate/rhythm/quality/spo2
B-Blood pressure: auscultated/palpated
E-Eyes: perl/unreactive/@___mm
L-Lung Sounds:___ in all fields/bases
L-LOC: A&oX___
S-Skins/Sugar: pink/warm/dry
Block 5: Treatment & Reassessment
Rx- 5 Rights (Right Patient, Right Medication, Right Dosage, Right Route, Right Time/Not expired), no contraindications
Reassess-Every 5 minutes vs. Every 15 minutes (ABCs, LOC, CC-Worse or Better, Vitals)
