Chapter 38 Assessment-Based Management Chapter Goal Integrate principles of assessment-based management to perform appropriate assessment & implement management plan for patients with common complaints Explain how effective assessment is critical to clinical decision making Explain how EMT-Is attitudes affect assessment & decision making Explain how uncooperative patients affect assessment & decision making Explain strategies to prevent labeling & tunnel vision 1
Develop strategies to decrease environmental distractions Describe how manpower considerations & staffing configurations affect assessment & decision making Synthesize concept of scene management & choreography to simulate emergency calls Explain roles of team leader & patient care provider List & explain rationale for carrying essential patient care items Explain general approach to emergency patient Describe how to effectively communicate patient information via person to person, telephone, radio communications, & writing Explain general approach, patient assessment, & management priorities for patients who complain of: Chest pain Altered mental status Medical & traumatic cardiac arrest Shortness of breath Acute abdominal pain 2
Explain general approach, patient assessment, & management priorities for patients who complain of: Trauma GI bleeding Allergic reaction Pediatric emergencies Introduction Most important skill any medical practitioner can possess ability to effectively assess patients Development of working diagnosis As information gathered cognitively compared As you learn more knowledge base Development of field impression initial impression based on: Current presentation Past education Experiences 3
Working diagnosis initial determination based on: Information available Subject to modification Assessment & decision making Factors Attitude Patient s demeanor Horrific or distracting injuries Environmental factors Personnel resources Proper attitude developed with knowledge base Understanding traumatic injuries & medical emergencies Training Proper use of life-saving equipment Understanding responsibilities to patient Patient demeanor Majority of patients are genuinely thankful Attitude/behavior creates barriers Possible root cause for behavior Hypoxia Hypovolemia/shock Hypoglycemia Head injury Stroke Alcohol intoxication Drug intoxication Psychiatric conditions 4
Environmental factors Lighting Noise Winds/temperatures Mass casualty incidents Personnel resources Composition EMS unit directly affects manner in which: History obtained Patient assessed Therapy initiated Evaluation & Treatment Team Preplan Team members Roles assigned Job responsibilities clear Avoid performing same duties Evaluation & Treatment Team Patient care providers Success depends on: Strengths of team leader Attributes of care providers Job duties include: Gathering information Obtaining vital signs Overall scene safety Performing interventions 5
Evaluation & Treatment Team Tools of trade Neglecting to bring key equipment seriously compromises patient care Items of critical need: Airway devices Oral/nasal airway adjuncts Suction devices Laryngoscope & blades Selection of ET tube sizes, stylets, securing devices Bag-mask device or pocket mask O 2 tank & regulator Cardiac monitors/defibrillators Basic assessment tools Infection control supplies Evaluation & Treatment Team Optional items depend on: Reported patient problems Local medical protocols Personnel available Accessibility to patient Venous access Most patients IV access warranted Venous access supplies General Approach to Patient Care Scene size-up Temperature & weather conditions Hazards in environment MOI information Number of patients Areas patients may have self-evacuated Total number of victims in mass casualty incidents 6
General Approach to Patient Care Initial assessment Sets tone Different types of approaches: Evacuation Resuscitative Uncomplicated General Approach to Patient Care Identifying problems Hallmark of EMS system systematic approach to patient assessment: Identify life-threatening conditions Assess ABCs on each patient encountered Includes: Rapidly identify chief complaint Assess degree of distress Perform initial assessment Take complete set of vital signs Focused interview of relevant history Focused physical examination General Approach to Patient Care Multitasking Process multiple pieces of information Determine actions to be taken Perform actions while continuing to assess patient Patient reliability significant importance Describe events Pain Critical EMT-I s ability to: Properly listen Pick up on clues 7
Communications Failure to effectively communicate one of weakest links Universal aspect communications with other health care providers Face to face at hospital Important writing patient care record Communications Highlights of effective communications Concise reports (<1 minute) Follow standard reporting formats Pertinent pieces Pertinent negative findings 1 st part of medical report working diagnosis Remainder of report Basic history Vital signs Specific information Preparing for Common Complaints Impossible to prepare for every type Practice scenario-based simulations Practice laboratory-based simulations 8
Summary Preparation & development allow you to recognize disease/injury patterns Have clear understanding of each team member Formulation of correct working diagnosis is important Have proper equipment on hand Summary Effective communications conducted when turning over care at ED Skills described can be strengthened through experience & by simulating patient encounters & discussing assessment & intervention skills Develop & practice habit of systematic approach to patient history, physical examination, interventions, & communications Questions? 9