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The speaker discusses upcoming events and an assignment for a healthcare class. The assignment is a 1,500-word paper on any healthcare topic, with a focus on tying it to EMS. The speaker emphasizes the importance of readability and proper spelling, especially for medical terms. The paper is due next Thursday. The speaker also mentions the importance of patient assessment in EMS and outlines the steps involved. They stress the need for consistency and constant reassessment of patients. The speaker emphasizes the importance of scene size-up and situational awareness in EMS, as well as the need for safety precautions. They mention various environmental conditions and the importance of protecting bystanders. You'll enjoy it, and then now we have patient assessment on, I mean, pediatrics on Thursday. And then, exam form, right? That's it? Exam form. I think so. That's Tuesday. Yes, Tuesday. Tuesday, exam form. And what did you do, exam form? Paper. Paper. Paper. You should have already started. I recommend that you do it at the end. Anybody have any questions on the paper? Yeah, what do we have to do again? Do the whole entire thing. Wow. I work too much. I'm sorry. It's okay. All right, so listen up. What is it? You need to write a 1,500-word paper. It doesn't have to be in any specific format on anything related to healthcare. I do not want you to give me the engine specs on the average ambulance today. That's not what I mean. It's something related to healthcare. If you do something that is not EMS-related, tie it in. So, let's say you do it on muscular dystrophy. So, the last paragraph, tell me what kind of emergencies would we see with patients with muscular dystrophy and what you might do. That's all. So, if you do something like trauma, then that's emergency. The whole paper is trauma. If you do something on a condition, tell me in the last paragraph what we might see or encounter in EMS. About 1,500 words, it's about three pages. I want a bibliography, but nothing dramatic. Just tell me where you got your information from. Did you get it all from the book? Did you get it all from the book? Did you get it all from the website? Did you get it from the website? I don't care. Just tell me where you got it from. This is an English paper. Make it readable. And I'm not really super worried about spelling other than medical terms. Spelling for medical terms is important. I'm going to read each one of those papers. Hopefully I get through them. I'm usually pretty good. I might not with 19, but I'm usually pretty good about getting them read and getting your grades back. When we come in the following Thursday, we'll review the exam. I'll give you your grades. Whoever tells them to get their grades that night. It is worth a test grade, so just make sure you give me a good ephronage. It can go over 1,500. I don't want it below 1,500. Don't come in with one page and go, it's all I got. You're not going to like your grade. Any questions? Is it due next Thursday? Yes. Tuesday. It's the fourth exam. The one with the fourth exam. And, like, I can do it, like, so medical conditions or, like, dysentery, dissecting, aortic aneurysm? Aortic aneurysm, absolutely. Okay. It's a good topic to do. Scratch your back with a knife. You didn't notice that? I do it so often I remember now. You guys have seen me pull it out. I can't reach my back. What's that? Can you carry that in your head? And what happens if you don't use it for self-defense? Is there a problem then? It wouldn't be a problem for me. I know how to do it, but I wouldn't recommend it for anybody who doesn't. If you don't know how to use a knife, you're going to get taken by the police. Yeah, that's supposed to ring, but I'm just saying. Good luck taking it from me. But, anyway, I digress. All right. All right. Patient assessment. Okay. So, I talk about patient assessment. I use the analogy of golf. I can hit a golf ball 300 yards. If I could do that every single time, I love you guys, but I'd be in the PTA. It's about consistency. So I'm doing the same thing all the time. Same thing with patient assessment. They say in order to get good at patient assessment, you have to do a real patient assessment 100 times. All right? Any skill. You want to master it, you've got to do it 100 times. So it's just about concentrating and doing the same thing all the time. That's what it's all about, so you don't miss anything. Now, patient assessment can encompass minimal dialysis or the multi-system trauma. You're going to do all the same steps, but many of them are going to be kind of doubled up or just kind of glanced over. You know Nana Noodles has got a good pain and airway because you're talking to her. You know she's up, she's ambulating. That's going to be a whole different set of assessments to the patient at the moment. But assessment steps are the same, and we're going to go over that. So the AMT, the patient assessment is very important. And again, you're going to use the same assessment guidelines and principles for every patient. You must master that. And patient assessment is used to some degree in every patient, like I said. So there are actually more than this. So first of all, you're going to do your scene size up, scene safety. Make sure the scene is safe. That's an overview of the scene. You're actually getting that when you get your dispatch information, when you're driving to the scene, when you arrive at the scene, when you get out of the ambulance. If you're looking it over. Then you're going to do your general impressions. Your general impression is the overview of the patient. How are they presenting? Are they conscious and alert? Are they talking with their eyes? Do they have tonsil and lung dysfunction? Do I see bleeding? Do I see shortness of breath, vomiting? What position are they in? That kind of thing. Then you're going to do your primary assessment. Primary assessment is LOC and ABC. Then you're going to make your transport decision. Then you're going to take your history sample, OPQRSP, right? And then you're going to do your secondary survey, which is your head-to-toe assessment for those patients that are altered or historians or unresponsive or a focused assessment for patients who can give you a history. And then you're going to do your reassessment. And remember, you're constantly reassessing your patients. Unstable patients, vitals every five minutes. Stable patients every 15. You're constantly talking to your patients. Chat it up. Find out what their hobbies are. Find out what they like to do. Whatever. Keep them talking. Rarely does one sign of symptom show you the patient's status or underlying problem, especially nausea and vomiting. Nausea and vomiting is a sign of symptom that's pretty much with everything. So you can't look at somebody and say, oh, nausea and vomiting? I know what you have. There's no way. Same with a headache. So a symptom is a subjective condition that the patient feels and tells you about. Nausea. I can't see nausea. It's subjective. A sign is objective, like a street sign. I can see it. Vomiting on my shoes. So your evaluation of the conditions in which you will be operating in is to see size up. Maintain that situational awareness. In the military, we call it battlefield awareness. In the civilian, we call it situational awareness. It's about having your head on a swivel. Paying attention to little hairs on the back of your neck that are standing up, right? Looking around, making sure the scene is safe. It is not a static thing. I don't walk up to the scene, oh, it's safe, and then put blinders on and walk right to the patient. I am constantly aware and alert and am viewing my scene. Both myself and my partner, police, fire, who's ever on the scene, we all have our eyes open. Don't just focus on the patient. Keep your eyes on the scene, right? It combines an understanding of the situation and conditions prior to responding. What happened? Why were we called? Dispatch of basic information. And remember the saying, shit in, shit out. The dispatch information is only as good as what they get. And observations of the scene. What you see. What you see when you pull up. Issues can range from minor difficulties to major dangers. Life threatening. Violence. Hazardous materials. Fire. Do not enter a scene unless it's safe for you and your team. If you walk up to a scene and realize it's unsafe, even if you've made patient contact, get out of the scene. If you can bring the patient, great. If you can't, leave the scene until it's safe. That is not patient abandonment. Typically the way you enter is the way you will leave. That's called ingress and egress. Ingress is the way I go in. Egress is the way I come out. Many times, though, the way you ingress is not the way you egress. Especially with like obese patients. You get up to the third floor and some of these triple neckers, you ain't bringing them down the way you went in. You're going to have to find a different way. We're high visibility safety vests on the roadways. We have reflective jackets. Yellow, bright yellow reflective jackets. If not, if you have safety vests, wear them. Trust me, you do not want to be brushed by a mirror on a pickup truck at 70 miles an hour on a mass flight. I can tell you from personal experience, it's not fun. So, consider the difficult terrain. Right? I mean, imagine if you're picking a patient. It's one thing to bring a patient from the house to the ambulance where it's a straight shot, there's no stairs. What happens if you have multiple stairs? If you're bringing somebody up from the basement? What if they're three miles into the woods? Traffic. Consider traffic safety issues. We don't have traffic control on our vests. We don't have tactical or police. We don't have fire suppression or hazmat. That's not what we do. Our job is patient care. We can lend a hand, but that's not our responsibility. And consider environmental conditions. And again, we can have every environmental condition known to mankind in this area. Snow, rain, sleet, hail, fire, tornadoes, hurricanes, earthquakes. We can have it all. Blizzards. If appropriate, help protect bystanders from becoming patients. I tell the bystanders, get away. And if they continue to stay, they get hurt. Nothing I can do about it. I'm concentrating on my patient. I'm going to alert everybody to stay away, but I can't keep my eye on them, right? That's what the police are for. Get the bystanders away. If you find a problem, if you're on scene, bystanders keep coming around. Have the fire department or the police department, especially the police, move them away. Hazardous rain from extreme weather conditions due to threats of physical violence. An emergency scene is dynamic and changing. It is never static. Even when, you know, man's noodles for dialysis. I've been taking her four years, three times a day, three times a week for four years. I know her house. I know where everything is. It doesn't mean that I walk into that house with blinders. I still use scene safety, picking scene size up, because each scene is different. Each scene is different. I've never done the same call twice. Even if I've gone to the same location a hundred times, it's never the same call twice. Cause of assistance can be categorized medical or trauma or both. I have a heart attack and fall down the stairs. I have a stroke and fall, you know, and I fall, you know, off a ladder, right? Something like that. The mechanisms of injury, we have to assess the type of model force, how long it was applied, and where it was applied to the body part. If it breaks the tensile strength of the tissues, it will cause an injury. Blood trauma, the force occurs over a wide area. Usually, the skin is not broken, although blood force can break the skin. Tissue and organs below the area may be damaged. And remember, you may have far more damage below than what seems to be above, especially in children. Children's bones are very flyable. I hit a kid with a baseball bat in the chest, the bones give and bounce back. And palpate has no broken ribs. That doesn't mean the underlying organs couldn't be severely damaged. Penetrating trauma, the force of the injury occurs over a small point, and you get that penetration through the skin. It could be a penetration, which goes in, or a perforation, which comes out the other side. Open wounds with high potential for infection. And again, we don't necessarily, we're not going to see the effects of infection, but we know what they are, and our job is to ensure the wound is clean and protected so further infection doesn't develop. So, for medical patients, determine the nature of illness, the MOI. Similarities between the mechanism of injury and nature of illness. Assessment is assessment is assessment. We are looking at different things between nature of illness and mechanism of injury, but a patient assessment is a patient assessment. It's all the same. Talk with a patient, family, a bystander, sometimes family or friends can be a great resource of information. Use all your senses. Check for clues. Accept the sense of taste. Unless man and noodles have some good cooking, then you can have taste. Otherwise, don't use it. Be aware of scenes with more than one patient with similar signs and symptoms. So, I walk in, you're altered, you have cherry red flushed skin, you have an unexplained cough, headache, dizziness, shortness of breath. You don't. Maybe you brought it, maybe you look affected by carbon monoxide somewhere else, but carbon monoxide didn't get you in this room because it didn't affect you. Unless you just walked in. But if you all have it, then there's something in the room that affected you all. That goes with food poisoning too. You have a patient that's really, really sick. You have a household of people, and they're really, really sick. You know, the three of you live together. You share food, right? So, you get the flu. You're sick for a couple days before you get it, and then you get it. You see how it goes through the house, but it's got it at a different time? Sometimes they overlap. If it's food poisoning, you're all going to get it at the same time. And that's when we question. We say, wait a minute, when did you get your symptoms? Are you going to live an hour or two with each other? Oh, that's not a flu, generally speaking. So, things like carbon monoxide poisoning, which I just gave you the signs and symptoms for carbon monoxide, could indicate an unsafe scene for the MC as well. If you recognize an unsafe scene, get the patient out of it immediately. Fresh air is the way to be. So, considering the mechanism of injury and injury-related illness early can be a value in preparing the patient. It can give you an idea as to the condition of the patient, what you need to do to treat or stabilize the patient, and where the patient needs to go. You may be tempted to categorize the patient immediately as either trauma or medical. Don't do that. Don't get that tunnel vision. It could be both. You don't know. Speaking of which hospital to go to, Massachusetts just put out the SAME protocol. We talked about that sexual assault nurse examiner. Leinster Hospital and Hayward Hospital now have a permanent SAME nurse. So, you can go to those hospitals now, which is great. They've got 13 more hospitals in Massachusetts. So, I think 51 out of 67 large medical facilities in Massachusetts have a SAME nurse. So, that's excellent. That's great. So, you guys have seen this slide before. I can remember when I first saw this slide before. It's an old slide, but before COVID, looking at the thing, oh, what the hell is going on with all that stuff? What kind of society are we talking about? Well, we've learned now that one good thing we got out of COVID is this is the proper way to approach the patient. They have no idea what this patient has. Standard precautions have been recommended for use in dealing with objects, blood, bodily fluids, or other potentially exposure risks from chemical diseases. Standard precautions states basically, if it's warm, wet, and sticky, and it's not mine, I don't want to touch it without gloves and protection, right? It's the idea that any bodily fluid is potentially infectious. Just because you're responding to Elon Musk's house, and he's, you know, Elon Musk is the person who's been to reach 300 billion in that work. So, $300 million. He could buy Tanzania. I'm just going to buy a country today. But anyway, don't just assume that because you go up to somebody who's very wealthy, oh, they must be clean, because they can have all the same diseases as everybody else. When you step out of EMS vehicles, standard precautions must have already been taken. We actually kind of do that on the way. You'd think that's supposed to, but I put on gloves and a mask while I'm driving. But you get all grounded. You don't want to pull up on scene, oh, wait a minute, let me put my gloves on, put my mask on, all right. You want to be prepared when you go. So, that's what you and your partner do. Get ready before you go. Consider glasses and a mask or protective, you know, eye pro, we call it eye pro. During team size-up, actually identify the total number of patients. It is more like, it is, you are less likely to call for assistance after you make patient care, because you're so in tune with the patient. So, we always call for medical, we always call for additional resources before we even get out of the ambulance, or once we get out of the ambulance, and we assess the scene. Remember the five-to-one ratio. For every five patients in a scene, you're going to need an additional ambulance, because it's estimated that out of every five people, at least one is going to go to the hospital. Now, if you arrive on scene to a mass casualty, your ambulance is the command ambulance until it's taken, until somebody else takes it over. So, you, if you've got ten patients, you're going to need two more ambulances, because you're recharged. Use the, when there are multiple patients, use the incident command system, identify the total number of patients in triage. We're actually going to do the ICF, the incident command system, that's one of our lectures that's coming up in the oral check section. Triage is a French word meaning to sort. It's about treating, it's about sorting the patient by the severity of the condition. And it goes red, yellow, green, gray, and black. Red is immediate. These are patients that are unstable, and they need immediate treatment and transport to the hospital. But, they've got a pulse, and they're breathing. The next one is yellow. These are delayed. These are patients that can do 30 minutes or an hour, 30 minutes to an hour, right? And we're going to talk about each one. Green is the walking movement. Those are the patients that are minimal injuries that, you know, if you can hear my voice, get up and walk to my voice, and they walk over to you. Many of these patients don't even get seen, like they don't even get transported by the ambulance. A family member comes and picks them up. Gray. Gray are patients who we would normally treat, but because of it's a not casualty situation, we don't. Patients that are cardiac or pulmonary arrest, but no obvious mortal wounds, like no definitive signs of death. Like if the head's over the air and the body's over the air, we don't do CPR on that, right? But if I don't show obvious signs of mortal injury, and I don't have a pulse or breathing, I'm workable. Asystole is a treatable rhythm, right? So, those are gray. The black are the patients who are, they're dead dead, right? The head's over the air, the body's over the air. Transsection, you know, massive open chest trauma, pulso-synaptic. Massive open head trauma with, you know, brain matter exposed, pulso-synaptic. Patients who have rigor mortis. Those patients, we know we're not doing anything with those. So, what you do is you treat them. You treat the reds first, get them out. And then you go to the yellow. Then you go to the green. And then if, once all the patients are triaged, and you get them to where they need to go, then you can go to the gray patients and see if you can work them. Some patients require more ambulances, like I said, in the hazmat, or specialized resources. You can see there's hazmat right there. This is a level A encapsulated suit, completely enclosed suit. Maybe you need ALS, advanced life support. Remember, you're supposed to call for ALS the moment you recognize a patient with benefits from ALS level care. You may not get one, but you're supposed to ask for it. Air medical support, if your transport's over 25 minutes, or if you need a higher level of care, or if you just need another ambulance, and they're the only ones that are available. Fire departments, you may handle high angle rescue, hazardous materials, water rescue. Of course, fires, vehicle crashes, whatever. And, of course, law enforcement for tactical situations, for traffic control. To determine if you require additional resources, ask yourself, does the scene pose a threat to me, my patient, or others? If you feel unsafe, don't just say, ah, it's just not being a baby. No. If you feel there's a problem, ask, how many patients are there to do with the resources to respond to their conditions? So, your primary assessment, after I've done my scene safety BSI, I've done my general impression. I'm going to do my primary assessment, which is LOCs and ABCs. LOC, level of consciousness, that's affluent A and O, then airway, breathing, circulation. And you're going to actually say DE, disability, and exposed. Not X, A, B, C? Well, X, A, B, C, yeah, we put the X in the front of it. Yes, because he's right. Bleeding, life-threatening bleeding needs to be treated immediately. So, your general impression is formed to determine the priority of care. Maybe not when you guys first start out, but after a year or so, or two years in the field, when you've done a few 911 calls, you can look at somebody and go, oh, yeah, that's a high priority. I can walk up to a patient and know, high priority, or we have time to stay in play. So, it's the first part of the primary assessment. It's actually before the primary assessment. They include it in the primary assessment here, but I like to include it as a separate entity. Scene safety BSI, general impression, then your primary assessment. Your general impression is before you make contact with the patient, 30 seconds or less as you approach. The primary assessment is when you actually make contact with the patient. So, we're going to be looking at age, sex, and race, level of distraction, overall appearance. It doesn't take a trauma surgeon to look at somebody and say, you just look like shit. You need to go to the hospital. Know the patient's position. Don't stand over him. What's up, kid? Right? Get down at their level. Address the patient by name. Now, obviously, at this point, you're doing your primary assessment because you're speaking with the patient. Introduce yourself. I always shake every patient's hand. Hello, ma'am or sir, how are you? If they're unconscious, pick up their, no, I'm kidding. If they're unconscious, obviously not. But any patient, it's my way of getting, remember we talked about proxemics? I approach at about six feet. When I go to shake their hand and say, hello, now we've become a little familiar, right? We're acquaintances. So, I get a little closer. Ask about the chief complaint. What is the chief complaint? Why are you here? Why is the ambulance here? What the chief complaint is, in their own words, and the easiest way to assess that is to say, why is the ambulance here? Address life threats immediately, like X, A, B, C, like we do. Determine the patient's condition. Is it stable? Stable but potentially unstable or unstable? A stable patient would be a psych, a drunk, minor bone fracture, lacerations with controlled breathing, shortness of breath corrected with oxygen. Stable but potentially unstable. Your heart attacks, your chest pains, your altered mental status and questioning strokes, your, you know, your, you know, injuries where a tourniquet is applied but bleeding is controlled, that kind of thing. Unstable is unresponsive, doing CPR, uncontrolled bleeding, uncontrolled airway. Uncontrolled external breathing takes priority over other assessments. Put a glove hand on it, put a tourniquet on it, you don't even have to do it. Hey, firefighter, put a glove hand on that. Partner, go put a tourniquet on that, I'm going to open up this airway. You're never doing this alone. For the national exam, remember how we did patient assessment for you guys? You're going to do the station yourself because they want to see how you do it. But in real life, we could have multiple people doing multiple things at once. The level of consciousness should tell you a great deal about the patient's neurological and physiological status. Their astral and then ANO status, first in place, time and event, date of birth. Assessment of unconscious patient focuses on airway, breathing and circulation. Sustained unconsciousness should warn you of a critical respiratory, circulatory, central nervous system problem. Somebody's unresponsive. You come upon scene, you start assessing them. You start jarring them up, right? Put them on oxygen, checking for pain and all that. Patients should come around, right? Especially when you put them on oxygen, they should respond. If they maintain their unconsciousness, even as you're treating them, there's a problem. A sustained neurological problem. Consciousness with altered levels of consciousness may lead to inadequate perfusion. Maybe it's poor oxygenation. Maybe it's shock. Maybe it's some form of drug or alcohol poisoning. To assess for responsiveness, use the mnemonic, absolutely know this. It is a sternal pinch, a cheek pinch, a clavicular pinch. I like the ear pinch. Sometimes they pinch over the eyebrows. You can use a, take a pen and you drive it into the thumb as hard as you can. As hard as you can? Not ever until I count. The sternal rubs are great. I'm not a big fan of sternal rubs in the presence of trauma. So I try to avoid those because if there's damage to the chest, it could make it worse. But you know what sternal rubs work great? In the prisons. When you get the guys who've got carceritis who just want to take a trip to the hospital. And they're really not sleeping. The other thing you can do is if I'm lying flat, you pick up my hand and let it drop. If it does this, they're conscious. Because if I drop my hand, if I pick up your hand and drop it over your face, it should fall right in your face. Another little trick we learned. Orientation tests mental status. We look for person, place, time and event, date of birth. And again, orient it to a patient. If I'm an 80-year-old retiree, I might not know what day and time it is. If I'm a 5-year-old kid, I might not know time or event. So you've got to ask questions that are apropos to the patient. Favorite color, favorite cartoon, favorite dessert, what's mom and daddy's name, what's your phone number. So what we're doing is we're evaluating short-term, intermediate-term and long-term memory with those questions. Alternative mental status is any deviation from person, place, time and event. It might be ANO times 3, ANO times 2. Maybe you just alert yourself. Maybe nothing. But again, it all depends on the patient's baseline, right? If we don't know the baseline, we assume they have normal orientation and this is an acute medical problem until somebody comes up and says, yeah, that's Papa Joe, he's a little And okay, we accept that then. We can take that as their vital signs. Because it's baseline vital. Conditions that can cause sudden death, the bad stuff. Airway obstruction. Well, airway obstruction doesn't cause sudden death, but it will cause death very quickly. Respiratory failure, which leads to respiratory arrest, which leads to cardiac arrest, especially in children. Shock, severe bleeding and primary cardiac arrest, which can be caused by pulmonary embolisms, you know, commotional cortis, which is traumatic arrest. And believe it or not, it's a lot harder than you think to stop the heart. It's not something, I mean, it happens every day in the world, but we've got 8 billion people. As a general rule, people don't just drop from a stopped heart. In most cases, begin with airway, followed by breathing and circulation in some cases. We're going to go C first, circulation because of bleeding. XABCs or CAB. Maybe we're going to CAB because we checked there's no pulse, no breathing, patient needs CTL. Moving through the primary assessments, stay alert for signs of airway obstruction. Nothing's going to kill the patient faster than a lost airway, such as pulmonary embolism. Response to patients. Patients who are talking or crying have an open airway. I love a crying baby or small child. Not at home at 2 o'clock in the morning when I'm trying to sleep, but in the back of my ambulance, I got this kid, they got a good, tight airway, they're pissed off, they don't like where they are. Right? Perfect. The worst thing is a child that's not responsive and just kind of lying there looking up at you. Without, you know, a child that's really sick, that makes me nervous. Watch and listen how the patient speaks. If you identify an airway problem, fix it immediately. Maybe you've got to put an OPA, NPA, maybe an IGEL. In our response to patients, immediately assess the airway, use the jaw thrust technique. When you don't, unknown ideation, unknown in, unknown, unknown, unknown reason or known trauma. We use modified jaw thrust. If we know it's a medical patient, we've got the history, no signs of trauma, we can use a modified jaw thrust. Oh, excuse me, the head tilt can lift. Relaxation of the tongue muscles cause the airway obstruction. The tongue literally falls in the back of the throat. Signs of obstruction in unconscious patients. Obvious blood and obstruction. Right? So, we know the patient took trauma to the neck or the face. We've got bubbling or gurgling in the airway. Right? That fluid in the lungs. Noisy breathing, snoring, crowing would be more like airway obstruction like dentures or most commonly the tongue. Number one airway obstruction in unconscious patients is the tongue. It should be shallow or absent breathing. Make sure the patient has a good open airway. You've got to give them an open airway. If they're not breathing, make them breathe. Many times, you come upon a scene where the patient was snoring, respirations or gurgling or crowing, you open the airway and immediately their respirations correct themselves. Ask yourself, is the patient breathing? Is it adequate? And is the patient hypoxic? So, is the patient cool, pale, clammy skin, cyanosis, lips and fingernails or maybe simple cyanosis? Right.