EMR - Assessments

Patient Assessment Model

  1. Rescue Scene Evaluation (Never put yourself in harms way)

  2. Primary survey

  3. Secondary survey

  4. Ongoing assessments

Rapid Scene Assessment (RSE)

H - hazards (sharps, toxic materials, needles, animals, weather)

E - environement (places, location, weather… inside, outsite etc…)

M - mechanism of injury (how did they get hurt? fall? chest pain? SOB? MVI? Reason for call?)

P - # of Pts (more than 1 means you need more help)

P - PPE (what ppe is needed, N95, mask, gloves, gown, face shield, etc…)

B - Backup (another car? ALS? Fire? Hydro? highway?)

C - condition of pt(s) (what condition is the patient in? what info can we get from dispatch)

Primary Survey

D/D - Delicate spine or deadly bleed

LOC - Level of Conciousness

ABC - Airway, Breathing, Circulation (CAB if unresponsive)

RBS - Rapid Body Scan (get eyes/hands on head, neck, chest, abd, back, legs, and arms to ensure no bleeding or issues that need to be dealt with ASAP, FAST)

S - skin (colour, warmth, moisture (PCC = pale cool clamy)

O - oxygen (pale or cyanotic (peripheral central), clammy, sweaty, diapheretic, decreased LOC, SPO2 readings, restlessness, increased HR and RR)

A - airway (reassess pts airway, consider OPA/NPA) auscultation (listening for the sounds of the body using the stethoscope)

P/P/P - Position (Supine - back, Laterial = side, ¾ Prone = recovery position, Fowler - straight up 60-90 degrees, Semi-Fowler = sitting at an angle 10-40 deegrees. pt should be in either position of comfort or the best position for their condition ex COPD should be in half fowler) Packaging (how are you going to trasnport them? gerney? Clamshell? Spine board?) Protocols (what protocols are in effect or need to be in effect?)

I - Interventions (what have you done for the pt, oxygen? CPR? medications?)

T - Transport decision (ALS? RT? NRT?)

Airway Management

    Recovery position, jaw thrust or chin thrust