The Five Minute Assessment
The Volunteer Fire Department that I am a member of does not provide transport services. Those services are provided by our neighboring city as well as county Fire Departments. We are the first line of care for the patients in our district. Usually there is only four to five minutes before the transporting agency arrives. In order to give an appropriate patient report so we can properly transfer care to the transporting agency, a thorough patient assessment must be performed as quickly as possible.
The Five Minute Assessment allows us to quickly ascertain the patient’s current condition and establish baseline values for the patient’s respiratory, circulatory, and neurologic systems. The overall goal is to minimize assessment time and to provide appropriate interventions in a timely manner.
So where do we start?
Dispatch provides the location of the call as well as initial information regarding the call, this information may include:
- The Mechanism of Injury (MOI) or Nature of Illness (NOI)
- The number of patients
- The age and sex of patient
The main thing to keep in mind is that the information that you get from dispatch is only as good as the information provided to dispatch.
Do not get tunnel vision – Erroneous information may have been given to dispatch!
So let’s say you get this call:
Medic 29 delta chest pain at 2959 E. Grove cross of River Road. Time: 2343
What would the NOI be?
Number of Patients?
In many jurisdictions you would not get the age and sex of the patient until you go en route. For this exercise let’s say it is a 52 year old male.
En Route to the Call
So you have your dispatch information. You are going to use this information to start forming a game plan that you are going to use for this call. Realize that you must constantly adapt and change the plan based on the reality of the call itself. Your starting game plan should include:
- Assigning tasks to personnel
- Deciding on additional equipment and resources
- Reviewing differential diagnoses
A differential diagnosis is the process of weighing the probability of one disease versus that of other diseases. For example, the differential diagnosis of rhinitis (a runny nose) includes hay fever, the abuse of nasal decongestants, and the common cold. By thinking about a differential diagnosis you are exploring the alternatives that will keep you from getting lost in tunnel vision. After all, not all chest pain is cardiac, and not all cardiac issues result in chest pain.
So according to our previous dispatch information we are responding to a single patient with chest pain. Given the age of the patient what differential diagnosis might we ponder?
Here is a quick list I came up with:
Myocardial Infarction
Angina
CHF
Pneumonia
Anxiety Attack
Acute Bronchitis
Acid Reflux (GERD)
Pulmonary Embolism (PE)
Even though not all chest pain is cardiac related – You must consider it to be cardiac until it is ruled out.
So what if our patient was a 22 year old male? Would that change our differential diagnosis at this point? It would probably make you think of some other causes other than cardiac such as musculoskeletal causes or give more consideration to PE or anxiety. However, you would still need to rule out cardiac involvement.
Scene Size-Up
Scene Size-Up is the assessment of the scene and surroundings to assure the safety yourself and your crew and to provide potentially useful information about the patient.
Components of the Scene Size-Up:
- Scene safety
- Standard-precautions (BSI) determination
- Mechanism of Injury (MOI)/Nature of Illness (NOI)
- Number of patients
- Resource determination (MCI, heavy rescue, hazmat, etc.)
- C-Spine consideration based on MOI
The safety of you and your crew is the number one priority. Safety IS everyone’s responsibility!
As you approach the scene you should be surveying the area for potential hazards. Be on the lookout for these hazards:
| Signs of Violence |
Look for knocked over furniture, holes in walls, listen for loud voices and yelling. |
| Fires and structural collapse |
Smoke and fire emanating from the building or automobile, smell of smoke or burning materials |
| Electrical |
Fallen power lines, arcing sounds, smell of electrical components burning |
| Hazardous materials |
Chemical spills, gasoline, household cleaners, drain unclogging chemicals, chlorine, etc. |
| Crime scenes |
Fighting or loud voices; Weapons visible; Signs of alcohol/drug use; unusual silence; Knowledge of prior violence. One danger that is present at many scenes is the family dog. Even ones that look harmless could attack if they feel threatened. |
| Environmental |
Ice and snow are examples of environmental hazards |
| Animals |
Many animals can pose a threat to you and your crew especially that sweet innocent looking family dog. |
| Suspicious Individuals |
People acting strangely, people who look out of place, people coming and going |
Scene Size-Up does not stop once you get on scene. It is a continual process throughout a call.
Also keep an eye out for…
- General Living Conditions
- Sounds of distress
- Unusual odors
- Oxygen tubing running through the house
- Open/Empty alcoholic beverage bottles
- Drug paraphernalia (especially sharps!)
- Medication containers
These all provide clues to help you better assess your patient. To properly evaluate your patient you must use all of your senses. Think about this, if you can hear your patient wheezing from the doorway and you see oxygen tubing running through the house what might you expect as the patients underlying condition?
As you arrive on scene you should be getting your BSI ready.
Always Remember and Never Forget …
- Scenes are dynamic places and can change very quickly.
- Do not get tunnel vision – Maintain Situational Awareness
- Maintain an escape route (multiple routes are even better!)
- If a scene turns hazardous – leave.
Situational Awareness is the ability to identify, process, and comprehend the critical elements of information about what is happening to the crew with regards to the scene. More simply, you must always know what is going on around you.
The Initial Assessment or Making Contact
Purpose: To quickly identify any immediate life threats and attempt to manage those threats.
Components of the Initial Assessment:
- General Impression
- Determine Level of Consciousness (LOC)
- Determine Chief Complaint/Apparent Life Threats
- Status of the Airway
- Efficiency of Breathing
- Circulation/Perfusion Status
- Priority
Most of the information you need is gathered simultaneously utilizing all your senses during the examination.
When assessing your patient you must act like a detective looking for clues. Be on the lookout for things that just do not add up. As you gain experience you will learn to process or filter this information into what is pertinent regarding the current status of your patient. Information is gathered either by observation or by interaction. In case you have not heard EMS is a hands-on occupation.
Information gathered by patient observation:
- Patient’s physical appearance
- Dress, hygiene, expression, size, posture, odors, overall state of health
- Critical or Non-Critical (Sick or Not Sick) – The “Look Test”
- Sleepy, head bobbing, Altered Mental Status
- Positioning indicating difficulty breathing or chest pain (Position of Comfort)
- Signs of significant distress
- Poor skin color and diaphoresis
Information gathered by patient interaction:
- Airway Status
- If they are talking they have a patent airway
- Work of Breathing
- Look for gasping breaths – how many words are they able to speak before taking a breath?
- Circulatory Status
- If they are talking, they should have a pulse
- Level of Consciousness
- Is the patient oriented to Person, Place, Time, and Events?
- Cognitively if the patient is oriented to Event then all other metrics are intact and therefore the patient is AOx4.
So this brings us to the point where the clock starts ticking and the actual five minutes begins. While the goal is to perform the patient assessment quickly it does not mean we skip key steps or compromise patient care. In the next post I will cover this five minute period of the patient assessment. Until next time, get addicted and become an EMS Junkie!
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