As you arrive on scene you re led to a 58-year-old male who is complaining of shortness of breath. His wife tells you he has a history of emphysema and pneumonia, and he developed heart failure after his last heart attack. You immediately place the patient on high-flow oxygen and begin your assessment. Why is the patient short of breath today?
Patient assessment is arguably one of the most important tasks preformed by the EMT. It can be said that poor assessment can lead to poor treatment. Therefore the EMT must be complete, thorough and objective. A focused physical exam should include visualization, palpation and auscultation of the area if appropriate and questioning about the event.
Assessment begins with an evaluation of the scene. The EMT must look for clues to medical history, such as wheel chairs, oxygen and pill bottles. Notice how the patient is positioned. Are they lying supine, sitting upright in a tri-pod position gasping for breath or, perhaps pacing in pain? All these positions play a part in helping the EMT solve the assessment puzzle.
In EMT class we learned the mnemonic OPQRST for the history of the current event and SAMPLE to help determine more about past medical history. These pneumonics function as good memory aids to help remember steps of assessment, but in application they re more than just single-word reminders. This article will focus on assessment of the current event.
“O” stands for onset, which means more than just “when did this start?” The EMT wants to know everything about the onset of the symptoms. Information to be discovered by the EMT includes the following. What was the patient doing when the symptoms began? Pain with an onset during exertion commonly has different origins than pain beginning at rest. The EMT should ask of the patient if other signs or symptoms presented at the onset that have now subsided. For example, when a patient has a pulmonary embolism it commonly will cause chest pain and shortness of breath. By the time the EMT arrives on scene the chest pain may have subsided, leaving the patient with the sole complaint of shortness of breath. Other signs or symptoms that commonly present with onset and then dissipate are diaphoresis, syncope, nausea and vomiting.
“P” stands for provocation. It also stands for palliation. What the assessment should reveal is what makes the patient s condition better and what makes the condition worse. For example, if a patient has dizziness caused by hypoperfusion, standing will exacerbate the dizziness. If a neurological condition, such as a tumor, causes the dizziness, the position of the patient may not change the nature of their dizziness. The EMT should expose the area of complaint and visualize for abnormalities. They should then palpate and, in the case of the lungs and heart, auscultate. They should take note during the assessment of anything that changed the nature of the patient s complaint.
“Q” stands for quality. How the patient describes the discomfort — such as crushing, stabbing, aching or throbbing — can help the EMT determine a possible cause. Patients with thoracic dissections will commonly use such words as ripping or tearing. Patients experiencing a heart attack may use such descriptors as pressure or crushing. In the absence of a pain, this may be a difficult assessment question to apply.
“R” is for radiation and referred. Here, the patient can describe the movement of the discomfort. Radiating pain moves from one point to another and may follow a system. For example, kidney stones or renal calculus will cause pain radiating from the flank to the groin. It follows the path of the ureter from the kidney to the bladder. Referred pain is when an area is damaged and a different area of the body hurts. This is due to the body s inability to localize the pain. For example, inflammation of organs in the upper abdomen commonly cause right shoulder pain. This is known as Kehrs sign.
“S” stands for severity. This is a subjective evaluation by the patient about the intensity of their condition. Commonly a scale of 0 to 10 is used to label the pain. It should be noted that severity of pain does not by itself identify the severity of the condition. It should be used as a bench mark for treatment and should be re-evaluated frequently.
“T” is for time. Determining the exact time of symptom onset may play a crucial role in the long-term care of patients. Patients experiencing a myocardial infarction have the greatest chance of survival if they can receive reperfusion therapy within six hours of onset of symptoms. The time frame for patients experiencing a cerebral vascular accident (CVA) or stroke is three hours of symptom onset. “T” also stands for treatment. Many patients will do at least one thing before calling 9-1-1. The EMT needs to know what was done prior to on-scene arrival. For example, if a patient with chest pain took four nitro tablets prior to the arrival of EMS, then the on-scene care by the EMT may be altered.
Performing a good assessment can help the EMT establish a treatment plan and can help prepare the hospital for patients prior to their arrival. The patient at the beginning of this article was determined to have shortness of breath that has been increasing for several days. Pain associated with deep breaths on the right side exists, and breath sounds reveal crackles over that area. The shortness of breath is rated a 3 by the patient, and nothing seems to make it better. The patient was determined to have pneumonia.
