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PRACTICAL: Scene survey?
- BSI PPE
- I am surveying the scene, do I see, hear or smell anything dangerous to myself, my partner or my patient? Do the bystanders or patient appear dangerous?
- I am surveying for MOI / NOI and asking bystanders what happened.
- How many patients are there? I am looking for evidence of others & asking bystanders.
- How many assistants do I have? (Police, Fire, First Aid etc)
- Do we need more help or specialized equipment? Decision is based on the number of patients & circumstances.
- I am requesting back up now
PRACTICAL: PATIENT OVERVIEW?
- As I approach the patient are their eyes open and tracking?
- What is their skin colour?
- Do they appear to be in any respiratory distress?
- Do I see any deadly bleeding or obvious fractures or dislocations?
PRACTICAL: PRIMARY SURVEY?
- C-Spine Control (if indicated)
- I am delegating C-Spine control to my partner, fire, or law enforcement.
- Critical interventions
- Rapid physical assessment
- Transport decision
- My name is __________; I am with EMS.
- Please do not move until we have checked you for injuries.
- We are here to help:
- can you tell me your name?
- can you tell me where you are right now?
- can you tell me today’s date?
- can you tell me what happened?
- can you take a deep breath?
- do you hurt anywhere?
- did you hit your head or lose consciousness at any time?
- If the patient does not respond I am assessing their response to voice and pain.
- The patient's LOC is AO X___.
- Alert: The patient is talking so I assuming the airway is clear.
- Not Alert: I am performing a head-tilt/chin-lift OR a modified jaw-thrust if required.
- *I am looking to see if the airway is clear. I am listening and looking for fluids or gurgling.
- *I am suctioning the airway if required.
- *If the patient is not alert I am checking for an eyelash flicker (gag-reflex) and sizing and inserting an OPA / NPA
- *I am assessing respirations for 10 seconds.
- *I am checking the rate, rhythym and depth of respirations.
- *If the patient is not breathing I am ordering 2 ventilations immediately.
- *If the patient's respiration rate is over 30 or under 10 I am ordering assisted ventilations.
- *I am ordering my partner to apply O2 to the patient. I am stating the O2 flow rate & delivery device used.
- *I am assessing circulation at the radial and carotid pulses. I am checking the rate, rhythm & quality of the pulse.
- *If the patient is pulseless I am initiating AED protocols and/or CPR.
- *I am checking skin colour, condition and temperature with the back of my ungloved hand.
- *I am performing a rapid wet-check, for any significant bleeding or loss of body fluids.
- Critical Interventions
- *I am checking all critical interventions I have completed.
PRACTICAL: Rapid physical assessment?
- *I am visualizing the head, do I see any DCAPP-BTLS?
- *I am palpating the head, do I feel any TIC?
- *I am exposing and visualizing the neck, do I see any DCAPP-BTLS?
- *I am looking for any medic-alert tags.
- *Are the neck veins flat or distended? Is the trachea mid-line?
- *I am palpating the neck, do I feel any TIC?
- *I am sizing and applying a cervical collar now (if required)
- *I am exposing and visualizing the chest do I see any DCAPP-BTLS?
- *I am looking for any retractions or accessory muscle usage, any
- barrel-chestedness or paradoxical chest movement.
- *I am auscultating for breath sounds bilaterally; are they present and equal at the apices & bases?
- *I am palpating the chest, do I feel any TIC?
- *I am exposing and visualizing the abdomen do I see any DCAPP-BTLS?
- *I am palpating the four quadrants of the abdomen, do I feel any distention, rigidity or tenderness?
- *I am exposing and visualizing the chest, do I see any DCAPP-BTLS?
- *I am looking for any retractions or accessory muscle usage, any barrel-chestedness or paradoxical motion.
- *I am looking for any surgical scars, medication patches or any subcutaneous emphysema.
- *I am auscultating for breath sounds; are they present and equal at the apices & bases bilaterally? I am palpating the chest, do I feel any TIC?
- *I am exposing and visualizing the abdomen, do I see any DCAPP-BTLS?
- *I am looking for any pulsating masses, eviscerations, needle marks or surgical scars.
- *I am palpating the four quadrants of the abdomen, do I feel any DRT?
- *I am exposing and visualizing the pelvis, do I see any DCAPP-BTLS?
- *Do I find any incontinence, priapism or vaginal bleeding.
- *I am palpating the iliac crests, do I feel any TIC?
- Lower Extremities
- *I am exposing and visualizing each lower extremity, do I see any DCAPP-BTLS?
- *I am looking for medic-alert tags.
- *I am palpating the lower extremities, do I feel any TIC?
- *I am assessing CMS bilaterally by asking the patient to push and pull with their foot against my hand and asking if they can feel where I am touching.
- Upper Extremities
- *I am exposing and visualizing each upper extremity, do I see any DCAPP-BTLS?
- *I am looking for any medic-alert tags.
- *I am palpating the upper extremities, do I feel any TIC?
- *I am assessing CMS bilaterally by asking the patient to push and pull with their hand against my hand and asking if they can feel where I am touching.
- Posterior (may be checked before rolling onto a backboard)
- *I am exposing and visualizing the posterior, do I see any DCAPP-BTLS?
- *I am palpating the posterior, do I feel any TIC?
PRACTICAL: TRANSPORT DECISION BLURB
- immobilize all injuries before rolling/moving
- *The patient's chief complaint is XXX
- *This patient is a "Load and Go" or a "Stay and Stabilize".
- *Spinal Motion Restriction Procedure (if indicated)
- *If "Load & Go" we are loading the patient into the ambulance, switching to the main oxygen and leaving the scene. We are bringing a pertinent bystander, the pts. personal effects & medications. I am having a fire fighter drive. I am reassessing ABC’s and LOC.
PRACTICAL: SAMPLE OPQRSTA
- A: Do you have any allergies?
- M: Are you on any prescription, OTC, recreational, herbal or other medications?
- P: Do you have any previous medical conditions? Heart, respiratory, diabetic, other?
- L: When was the last time you had anything to eat and drink?
- E: What were you doing before this started? How did you feel B4 the event occured?
- Onset: Did the pain come on suddenly or gradually?
- Provoke: What provokes it or makes it worse?
- Quality: Describe how does the pain feels?
- Radiation: Does the pain radiate or move anywhere?
- Severity: On a scale of zero to ten, ten being the worst, how does this pain rate right now?
- Time: How long has this been going on? Is it constant or intermittant?
- Aleve: Does anything make this better?
- Alcohol, Apnea, Anaphylaxis
- Epilepsy, Environmental
- Infection, Ischemia
- Psychiatric, Poisoning
- Stroke, Shock
PRACTICAL: CRITICAL INTERVENTIONS?
- *Is the OPA/NPA still inserted and being tolerated
- *Is the O2 still flowing, no kinks in the hose and bag still 2/3 full
- *C-Spine Control still being held/Check straps and rolls for Spinal Motion Restriction
- *Bandages still in place/functioning/sealed, have bandages bled through, impaled objects still stablized.
- *Fractures/Dislocations still stabilized.
- *Bee stinger removed
SPECIALIZED ASSESSMENTS: Medical?
- Confirm indications & no contraindications
- amount of medication already taken by pt.
- Medication Verified (6 rights) medication, dose, route, time, patient, documentation
- Confirm 3 C’s and E : Color, Clarity, Concentration, Expiry Date
- Vitals taken before administration
- Inform patient of side-effects
- Confirm online direction or protocols
- Administer or assist with medication (follow local protocols)
- Right documentation: time, dose, route, effect
- Reassess vital signs within five minutes of administration
SPECIALIZED ASSESSMENTS: Neurological?
- *Assess Level of Consciousness (AVPU)
- *Assess CMS x4
- *Assess pupils for EARRL and size (mm)
- *Consider AEIOU-TIPS
SPECIALIZED ASSESSMENTS: Gastrointestinal / Genitourinary?
- *"When was your last bladder and bowel movement?"
- *"Was there any bleeding or anything unusual about your last bladder or bowel movement?"
- *"Have you been coughing up blood?" (coffee-ground like appearance)
- *"Is there any chance you could be pregnant?"
SPECIALIZED ASSESSMENTS: Poisoning / Overdose?
- *"What have you taken? How much did you take?"
- *"When did you take it?"
- *"What else have you taken?"
- *"How much do you weigh?"
SPECIALIZED ASSESSMENTS: Obstetrical?
- *"How long have you been pregnant? When are you due?"
- *"How many children do you have? How many times have you been pregnant?"
- *"Are you having contractions? How far apart are they? How long do they last?"
- *"Do you feel as though you have to push or move your bowels?"
- *"Have you had any spotting or bleeding? Any gushing of fluid from the vagina?"
- *"Have you had a complicated pregnancy in the past?"
- *"Is there any possibility of a multiple birth?"
- *"Does your doctor expect any complications?"
PATCH TO HOSPITAL / ALS UNIT?
PRACTICAL: BASELINE VITAL SIGNS?
- *I am ordering my partner to take and document my patient's vital signs.
- Skin: What is the color, condition, and temperature of the skin?
- LOC: What is the LOC of the Patient?
- Eyes: Are the pupils EARRL (Equal & Round, Regular in size, react normally to Light) & what's their size in mm?
- Resp: What is the rate, rhythm and depth of their respirations?
- Pulse: What is the rate, rhythm and quality of their pulse?
- Temp: What is their temperature, measured via tympanic thermometer?
- BP: What are the systolic and diastolic pressures?
- BGL: What is the blood glucose level (in mmol/l)
- Pulse Oximetry: What is their SpO2 reading?
PRACTICAL: Mega-Outline of practical?
- Scene Survey
- Pt Overview
- Primary Survey (C-spine, LOC, ABCs, Crit Inter, Rapid physical assessment, Trans decision)
- Enroute 1st set of Vitals
- Sample History
- Specializes Survey(s)
- Crit Inter
- Secondary Survey (detailed physical exam)
- 2nd set of vitals
- Pain reassessment (OPQRSTA)
- Specializes Survey(s) if necessary
- Crit Inter
- Hospital Patch