Wednesday, January 25, 2012

Wilderness First Aid Patient Assessment System

Dijukno before you can properly care for any patient, you have to assess what is wrong with the them?  An assessment is a step by step process.  Although some of the steps may change in order, depending on the immediate status of the patient.  No step should be left out.

Stop! Size Up The Scene!

Take a few moments to stand apart and survey the scene, checking for specific information, before you step into the scene, these may prove to be the most valuable moments in your response to a patient.
  1. Survey the scene for hazards.  Is there immediate danger to you, other rescuers, bystanders, and, or the patient or patients?  Make sure the scene is safe.  You must do all you can to ensure you never create a second patient.  Humans are resources who can think, help tend to the patient, and participate in carrying them out.  A second patient not only doubles the trouble but also reduces the resources.  The problem becomes more than twice as serious.
  2. Determine, if possible, the mechanism of injury (MOI).  Are there clues suggesting what happened to the patient, or the forces involved?  How far, for instance, did a patient fall, and what made up the "landing zone"?
  3. Establish body substance isolation (BSI).  Take proper Precautions.  Put on rubber gloves, and perhaps glasses, to protect you and the patient from germ transmission.
  4. Determine the number of patients.  A patient in obvious (and noisy) distress may temporarily hide the fact that you have another patient lying silently a few yards away.
  5. Form a general impression of the patient. Are they very hurt or very sick?  Not seriously hurt, or only a little sick?


PERFORM AN INITIAL ASSESSMENT: ABCDE

Once safely at your patient's side, perform an initial assessment.  The goal is to identify and treat any immediate threats to life.   If you discover a threat, stop and fix it.  Immediate loss of life will be from ABCDE:  A) loss of an airway; B) inadequate or nonexistent breathing; C) loss of adequate circulation because the heart has stopped or too much of the patient’s blood is leaving the circulatory system (e.g., onto the ground or spilling inside a body cavity); D) extensive disability from damage to the spinal cord; or E) extremes of the environment.  At your patient's side, check ABCDE.
 
  1.  Identify yourself and your level of training, and ask for consent to provide care: "Hi, my name is __ and I've been trained in first aid.  Can I help you?” If the patient says something like "Yes" or nods in acceptance, or even says nothing to indicate lack of consent, you have consent to treat. (For a patient with a mental status too low to allow a response, resort to Airway, Obstructions, and CPR.
  2. Establish the patient's level of consciousness (see "Vital Signs" below), and place a hand on the patient's head to initiate spine control: "Please do not move until I know more about you. Can you tell me who you are and what happened?" The patient may identify a chief complaint: "I twisted my left knee, and it really hurts!" If the patient does not identify a chief complaint, feel free to ask what hurts.
  3. Assess for A, an airway: "Can you open your mouth?" Take a look in the mouth to check for possible obstructions to the airway and, of course, remove anything blocking the airway.
  4. Assess for B, breathing: "Take a deep breath, please. Good.  Does that feel okay?" If breathing is difficult, you need to figure out why and fix the problem (see Airway, Obstructions, and CPR, Chest Injuries, and Medical Emergencies).
  5. Assess for C, circulation: Assess for an adequate pulse (see Vital Signs, below). There may be something you can do for a heart beating too fast or too slow (see Shock and Medical Emergencies). Then perform a quick scan for major bleeding. lf you find major bleeding, stop the blood loss. Immediately expose the wound and use direct pressure on the wound and, if possible, elevate the wound to control the bleeding (see Wound and Wound Infection Management).
  6. Assess for D, disability: Your hand is still on the patient's head. Investigate the mechanism of injury more thoroughly to decide if you need to maintain spine control (see Spinal Injuries).
  7. Assess E, the threat of the environment: Prolonged exposure to environmental extremes can cause changes in body core temperature that threaten the patient's life. The most common threat is cold. For that reason a patient should be protected from the environment. e.g., gently placed on a sleeping pad and covered as protection from cold as soon as safely possible. This can be done now (see Spinal Injuries) or, more often, after the patient exam (see below). The E for environment can also be an E for exposure, a reminder that you must sometimes expose parts of the patient's body to assess the extent of damage and provide immediate care, if necessary.


PERFORM A FOCUSED EXAM AND HISTORY

When the patient is free from all immediate threats to life, you need to start gathering clues. The focused exam and history continues the step-by-step examination of the patient. The goal is to find everything that is not in perfect working order.  Since these problems are not immediate threats to life, treatment can usually wait. This examination includes three phases:

Patient Exam

Check the patient from head to toe to locate any damaged parts.  Look for wounds, swelling, or other deformities.  Ask where it hurts and if it hurts when touched.  Feel gently but firmly, using a massage like action with your hands spread wide to elicit a pain response but without causing further damage. Be aware of unusual smells (e.g., alcohol) or sounds (e.g., labored breathing).  If you suspect an injury may be hidden beneath clothing, you must take a look at skin level.  "Go to skin to assess" is the mantra of the rescuer.

Check:
  1. Head, looking for depressions in the skull, damage to the eyes, and fluid in the ears, nose' or mouth'
  2. Neck, for Pain or deformity.
  3. Shoulders, for pain and symmetry of the shoulders.
  4. Chest, for pain, ability to take a deep breath, uneven breathing movements of the chest wall, and abnormal breathing sounds.
  5. Abdomen, gently pressing on all four quadrants (with the belly button as the central point) for pain.
  6. Pelvis, for pain by pushing on the two pelvic crests.
  7. Genitals, if and only if it seems relevant.
  8. Legs, for pain and including symmetry and the ability to move the feet.
  9. Arms, for pain and including symmetry and the ability to move the hands.
  10. After this head to toe check, roll the patient found flat on their back to assess the back.  If the patient has an injury that could have damaged the spine, the roll must be performed carefully (see Spinal Injuries).  Press on every bone of the spine.  Note: This is a fine time to place the patient on a pad as protection from the cold ground.


Vital Signs

Vital signs are measurements of the physiological processes necessary for normal functioning.  They do not often tell you what is wrong, but they do tell you how the patient is doing.  Changes in vital signs over time are indicators of changes in the condition of your patient.  Check early, and keep checking.  To better monitor a patient, record the time at which you take each set of vitals.

Vital signs include:

  1. Level of consciousness (LOC): To check how well the brain is communicating with the outside world, use the AVPU scale:  (A) Is the patient alert, able to answer questions?  A+Ox4: Patient knows who, where, when, and what happened. Note: lf the patient knows what happened, they usually knows the rest of the story as well.  A+Ox3: Patient cannot remember what happened but does remember who, where, and when.  A+Ox2: Patient can only relate who and where.  A+Ox1: Patient only remembers who they are. (V) Does the patient respond only to verbal stimuli?  Grimacing or rolling away, for instance, from your voice when you speak or shout?  In what way does the patient respond?  (P) Does the patient respond only to painful stimuli, such as an aggressive knuckle rubbing into the sternum or a pinch? In what way does the patient respond?  (U) Is the patient unresponsive?
  2. Heart rate (HR):  Count the number of heartbeats/minute by pressing two or three fingers just above the wrist on the thumb side where you find the radial pulse.  For speed, count for fifteen seconds and multiply by four.  Note the rhythm and quality of the pulse.  Is it regular or irregular?  Weak or strong?  Normal heart rates are strong and regular; usually somewhere between fifty and one hundred beats per minute.
  3. Respiratory rate (RR):  Count the number of breaths/minute without telling the patient what you are doing.  A patient who knows you are checking often alters the breathing rate in an attempt to be accommodating.  Note also the rhythm and quality of respirations. Normal lungs work about twelve to twenty times per minute at a regular and unlabored pace.  Note:  Without a watch, you should still get a rough estimate of heart and respiratory rates.  Rough guesses are better than no idea.
  4. Skin color, temperature, and moisture (SCTM):  Normal skin is pink in non-pigmented areas such as the inner surface of the lips and eyelids, warm, and apparently dry to your touch.


SAMPLE History

More information is usually gathered by subjective questioning than by objective checking.  This information is known as a patient's history. Hopefully the patient will provide the answers.  Sometimes witnesses are sources of important information.  Speak calmly, and do not use leading questions.  In other words, say "Describe your pain” instead of “Is it a sharp pain?"  Be aware of your tone of voice, body language, and eye contact.  Patients usually feel better and respond better if they think you are nice, but do not make promises you can’t keep.  If you gain trust, you must maintain trust.

The SAMPLE questions:

S for symptoms: Pain, nausea, lightheadedness, other things you cannot see.
A for allergies:  Any known allergic reactions?  What happens?
M for medications:  Anything legal or illegal?  Why?  How much?
P for pertinent medical history:  Anything like this happen before? Currently under a physician's care for anything?
L for last intake and output:  When was food or drink last taken?  How much?  When were the most recent urination and defecation?  Were they normal?
E for events:  What led up to the accident or illness?  Why did it happen?


SOAP:  THE WRITTEN REPORT

In an emergency your brain tends to become a sieve instead of a bowl. The acronym SOAP reminds you to write everything down (to collect documentation) as soon as possible.  As long as taking notes does not interfere with patient care.  Retention of information for medical and legal reasons is important.

S for subjective/summary:  A summary of who the patient is (including age and sex), what the patient complains of, and what happened to the patient.

O for objective/observations:  Observations and results of patient exam, vital signs, and SAMPLE history.

A for assessment:  What you think is wrong?

P for plan: What you are going to do immediately for the patient and the answer to the evacuation question. Stay or go; fast or slow? A part of every plan is to monitor the patient for changes and developing needs.  You might also add A for anticipated problems:  What changes you might see in the patient.


SOAP:  THE VERBAL REPORT

If you can make radio or phone contact and ask for support, you will need to give the SOAP note in verbal form.  The person hearing your verbal SOAP should hear something like this:

(S) I have a 34 year old male patient whose chief complaint is left knee pain.  The patient states, "I was running, and I tripped over a stump, and twisted my left knee."

(O) The patient was found lying on his back about 3 miles from Auburn on the Western States Trail.  Patient exam revealed swelling of the left knee.  The left knee is about twice the size of the right knee and red in color.  Patient denies loss of consciousness.  Patient denies pain or tenderness along the spine.  There is normal circulation below the left knee.  Nothing else was found.  

At 3:00 p.m. the vital signs were LOC=A+Ox4; HR=78 regular and strong; RR=1 8 regular and unlabored; SCTIVI=pink, warm, and sweaty.

The patient reported the following history:  No symptoms other than pain in the left knee.  Patient is allergic to aspirin, but denies taking aspirin.  Patient denies taking any medications.  Patient denies pertinent medical history.  Patient describes his fluid intake as "about two liters of water today" and his food intake as "a grilled cheese sandwich" for lunch.  He reports a clear urination "about an hour ago."  Patient states he was not watching the trail closely and failed to see the stump sticking up.

(A) Based on the MOI, this is not a possible spinal injury.  His problem is a left knee injury that makes walking impossible.

(P) I will improvise a splint for the left knee.  I am alone, and I will need assistance to carry the patient to the trailhead.

(A) I will monitor the patient for loss of circulation below the swollen knee and for loss of body heat.



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