During scene size up, calls are typically classified as which of the following?

KEY CONCEPTS:

Upon completion of this topic, it is expected that the reader will understand these following concepts:

• Thorough scene size-up

• An algorithmic approach to carry out the primary assessment

• Determining level of consciousness, airway, breathing, and circulation status plus treatment of life-threatening conditions

• The value of vital signs

Case study:

Two Paramedic crews were called to the scene of a motor vehicle versus bicycle collision. When the first crew arrived, they notified dispatch that there was a teenager, down on the ground, apparently unresponsive; the driver of the pickup truck was complaining of shortness of breath; and an elderly gentleman was leaning against a tree complaining of chest pain.

A witness stated that the bicycle darted out from between two parked cars. She did not see an airbag deploy in the truck and didn’t believe that the truck was moving very fast as it had been stopped for a traffic signal just before the incident. As soon as the bike was struck, she said the elderly gentleman yelled that he was his grandson and immediately slumped down against a tree.

OVERVIEW

An experienced care provider at any level may take only minutes to complete a primary assessment. However, in those moments he or she may acquire pertinent information that will dictate further care. This topic outlines the methods used to carry out this valuable assessment. Paramedic safety and patient safety are paramount when arriving on-scene and treating the patient. Knowing how to size-up a scene reduces the risk for injury or exposure and offers an organized way to assess environmental conditions, type and number of patients, and need for additional resources. Each component is vital in determining any life-threatening conditions that require immediate interventions.

Patient Assessment

Patient assessment is required as part of every patient contact. During a medical emergency, time is of the essence— environmental conditions may be less than ideal, sometimes even dangerous, and the sights and sounds stressful. In these situations the Paramedic must quickly and thoroughly form an impression of the patient’s medical condition and assess the need for any additional resources, all while continuously assessing the safety of the scene. This requires both the science of medicine and the art of crisis and resource management. Regardless of skill level, an algorithmic approach to these situations will assist the Paramedic to provide assessment in the safest, most efficient, most effective, and most consistent manner.

Initially, the Paramedic must assess the scene to evaluate its safety and determine the need for other resources. Next, she must determine the general problem, and then perform a primary assessment of the patient (Figure 13-1).

The goal of the primary assessment is to find and manage any life-threatening injuries or conditions the patient might have by assessing for, and correcting, if possible, any threats to airway, breathing, and circulation. Once life threats have been assessed for and managed within the skills of the Paramedic, he/she identifies patients in need of immediate transport.1-3

High priority patients are generally transported immediately, with further assessment being performed en route. The assessment of low priority patients is typically conducted in a more focused manner while remaining on the scene. If time and personnel allows for it, a full set of vital signs can be obtained at any point during the primary assessment. This process should, however, never interfere with the performance of the primary assessment.

Scene Size-Up

Every scene that the Paramedic responds to requires an assessment of safety, environmental conditions, type and number of patients, and need for specialized resources to assist in scene management. Some of this information may be obtained, and some at least anticipated, before the Paramedic arrives at the scene. What was the dispatch information? Did the dispatch give any hints of possible scene hazards, such as fire or hazardous materials? What is the area like that the Paramedic is responding to? Is it possible that there may be multiple patients or the need for specialized rescue services? All of these issues should be considered while on the way to the scene.

Scene Safety

The first step in any patient assessment is to assure that the scene is safe to enter. Scene safety assures the Paramedic’s well-being. An injured Paramedic is not helpful to anyone. Likewise, unsafe scenes must never be entered. The Paramedic must continually ask if the conditions remain safe enough for continued work on the scene. It must be remembered that even dangerous scenes may initially appear safe and that conditions may deteriorate quickly.

When assessing scene safety, the first priority should always be that of personal protection.4-7 Many of the scenes where EMS is called have the potential for danger. Vehicular crashes, industrial accidents, and rescue scenes all expose the Paramedic to potential injury from moving vehicles, sharp surfaces, pinching or crushing hazards, and electric shock or exposure to fire.

Certain situations involve hazardous materials, toxic gasses, or an environment without adequate oxygen. These can lead to injury or death. Crime scenes and calls for assistance to emotionally disturbed persons always carry the risk for violence.

Often Paramedics are injured at scenes by far less obvious hazards. Falls from slips on unstable surfaces, ice, puddles, and unseen trip hazards are quite common. Domestic animals, often agitated by the unusual and chaotic activities at emergency scenes, have also been known to injure emergency personnel.

Figure 13-1 Algorithm of scene size-up and primary assessment.

Body Substance Isolation

Along with the visible safety hazards at an emergency scene, one should always remember the unseen potential for exposure to blood- and airborne pathogens. The Paramedic should apply body substance isolation (BSI) precautions to all patient encounters regardless of the suspected diagnosis. BSI creates a barrier between the Paramedic and possibly infectious materials through the use of gloves, masks, gowns, and eye protection (Figure 13-2).8-11 Gloves should always be worn when the Paramedic is interacting with body fluids, non-intact skin, and moist body surfaces.1214

The use of a mask and eye protection or a face shield to protect the eyes, nose, and mouth is imperative whenever performing procedures or patient care activities that might generate splashes or sprays of blood or body secretions. A gown should also be worn to protect skin and prevent soiling of clothing whenever the possibility of splashes of blood or body secretions exists.

Proper hand washing is one of the most important things that the Paramedic can do to prevent the spread of infection.

STREET SMART

For hands that are not visibly soiled, waterless hand cleaner is a good option. The Paramedic should wash with soap and water as soon as time and location permit.

Mechanism of Injury or Nature of Illness

After assuring the safety of the scene, the next step is to assess the patient’s mechanism of injury (MOI) or the patient’s nature of illness. For patients who have experienced traumatic events, the Paramedic must determine the MOI by obtaining information from the patient, family, or bystanders, as well as from an inspection of the scene. The MOI is the instrument or event which resulted in harm to the patient. Often, the MOI is obvious, such as a motor vehicle collision (MVC) or a fall. Sometimes, however, it is not so clear.

Figure 13-2 Personal protective equipment for body substance isolation includes gloves, gown, goggles, and a mask.

When in doubt, it is safest to assume that the condition is related to trauma and take appropriate precautions to avoid worsening possible injuries which might not be immediately obvious (Figure 13-3).

When assessing the MOI, remember to note the environmental surroundings so as to make a report of these findings to hospital staff who are unable to determine these conditions for themselves. The nature of illness is essentially the history of present illness.

Number of Patients

Every scene must be investigated to determine the actual number ofpatients.17 Although this probably seems intuitive, it is not unusual to have "tunnel vision" and focus efforts immediately on caring for the first patient found rather than determining if there are more patients. It is essential to make a determination of how many patients will need care on the scene.

If there are more patients than the responding units can effectively care for, then a mass casualty plan should be initiated. Any additional resources required should be called for. In these situations, it is important for the first responding unit to establish command and begin triage. A Paramedic is less likely to organize an adequate response of additional resources if directly involved in patient care activities.

The Primary Assessment

After assuring the scene is safe to enter and making a scene size-up, the Paramedic can begin the primary assessment. The primary assessment—the first evaluation performed on every patient—is the beginning of "hands on" patient assessment and is performed to address life-threatening problems.

The primary assessment involves forming a general impression of the patient, assessing the patient’s mental status, airway, breathing, and circulation and determining which patients require immediate transport. Any immediate life threats found in the primary assessment must be addressed as they are discovered and then reassessed on a regular basis.

General Impression

The first step of the primary assessment is to integrate the observations obtained in the scene survey into a general impression of the patient’s condition. The Paramedic should concentrate on the patient and ask himself if this patient appears very ill or severely injured. Experienced providers often can identify critically ill patients within a few seconds of entering the room (Figure 13-4). This initial impression has been called "the look test" or "gut impression" by some experienced clinicians attesting to the speed at which these providers can determine through observation if a patient is critically ill or not. Some demographic information can also be obtained by observation, and the Paramedic should note the patient’s approximate age, sex, and race.

Figure 13-3 Questionable mechanism of injury: The Paramedic must assume a traumatic cause until proven otherwise.

Figure 13-4 Forming a general impression.

What happens during a scene size

What are the 5 components of scene size

Which of the following is an element of the scene size

What three things should you consider when sizing up the scene?