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The main ideas from this information are: - When providing positive pressure ventilations, consider the patient's respiratory rate rather than just the numbers. - The goal for oxygenation is 94-99%, unless the patient has a baseline oxygen level lower than that. - Assessing the patient's effort and signs of distress, such as retractions or nasal flaring, can indicate respiratory issues. - It is important to evaluate the patient's pulse, skin color, temperature, and capillary refill to assess circulation. - Controlled external bleeding should be addressed before airway or breathing issues. - Stabilize injuries before transporting the patient. - The primary assessment helps determine transport priority, with high-priority patients including those with unresponsiveness, difficulty breathing, uncontrolled bleeding, severe pain, or signs of shock. - The "golden period" refers to the time from injury to definitive care, which may be more or less than an hour. - Immediate transport is crucial Consider providing positive pressure ventilations with the area at whenever a patient's respiratory rate is greater than 28 or less than 8. And I say treat the patient, not the numbers, because, you know, patients could have, I know patients sitting down watching TV, you know, marathon runners who breathe 8 times a minute. I'm going to jump on top of them and start bagging me, they're going to punch me in the face. So treat the patient, not the numbers, but nobody should be less than 8, no matter what. The only people who should be greater than 28 are infants, okay? The goal is for oxygenation in most patients is 94 to 99, greater than 94% is what we shoot for. Or, they're baseline. So you've got a patient with COPD or interstitial lung disease, they're on 2 liters of oxygen, you have, what's your normal, what do you normally set at, what's your normal blood oxygen level? Oh, I live at 91. Okay, 91 is what I want. I don't want to get them to 96, because we could have that oxygen toxicity, unless she's short of breath. If she feels more short of breath than normal, I will kick up the oxygen. And how to observe, observe how much effort is required for the patient to breathe. Retraction. You get this clavicular retraction, these costal retractions, right? You can tell if it's, you look at a patient and it looks like it just ran a marathon and they've been sitting around eating chips. That's not the way it's supposed to be. You should assess your numbers. Nasal flaring. Nasal flaring and grunting is common in kids. Mm, mm, mm. That's very common in kids. Two and three, four, this man. That's actually a medical term. Okay, you have to take a breath between every two to three words, because you can't spit it out. I love going to the calls where the patient says to you, oh my God, I haven't been able to breathe since last Friday. I'm having this trouble breathing. I'm trying to call the doctor. The doctor won't even, and they go on and on for 20 minutes. I'm like, okay. You're really not short of breath, because you haven't taken a breath between the last seven sentences. What? Tri-flat position, we talked about that. Sniffing position is levered. Respiratory distress, you'll have an increased work of breathing and increased rate and effort. You might also see more shallow breathing, right? More rapid and shallow breathing. The faster I breathe, the less deeply I breathe when it comes to respiratory issues. Respiratory death occurs when the blood is inadvertently oxygenated and the body is unable to meet those demands. Respiratory, it goes respiratory distress or dyspnea, respiratory failure, and then respiratory arrest. And again, respiratory arrest leads to cardiac arrest in children. Assessmental status, pulse and skin, right? You're going to do your CSM, you're going to do your AFU and ANO status, you're going to do your CSMs, check your skin. The pulse of the pressure wave that occurs at each heartbeat causes a surge in the blood circulating through the arteries. It's a palpable pulse. We talked about where to check a pulse, how to check a pulse. If you've got palpated pulse and unresponsive patients in the CBR, it is estimated about 60% of healthcare providers misdiagnose cardiac arrest. They're not sure. So the idea is if you put your finger there and in five to ten seconds you're not sure, start CPR. Period. Can you do CPR on a patient with a pulse? Absolutely. So don't worry about, oh my God, I'm going to pop the heart. No, you're not going to pop the heart. Do CPR if you're not sure. Evaluate the patient's skin, color, temperature, moisture, and capillary flow. A normal functioning circulatory system produces a skin without oxygenating blood. If you see a patient who's unresponsive and you're not sure if they have a pulse but they are actively bleeding, they have a pulse. If the heart's not beating, they won't bleed. If I see blood going, I can count the pulse by the number of spurts. Don't do that, I'm just saying. Skin. Determined by the blood circulating through the vessels and the amount of pigment in the skin. The more pink the skin is, the better it is. But it can be too pink. Poor circulation will cause the skin to be pale, ashen, white, ashen, or gray. So somebody who's black, their skin will look like gray. You'll be able to look at it and go, oh my God, I can tell. Pale for them is gray. Now your book, although this isn't bad here, but your book has a much better picture of it. If the lips and fingers are blue, that's called acrocyanosis. But look at this little form right here. This is all blue. That's central cyanosis. That's bad. That is impending cardiac arrest in infants. This you don't want to see. If I see this, I'm already bagging this kid. Skin temperature. Normal skin will be warm. Your skin should be warm, pink, and dry. And normal skin temperatures are hot, cool, cold, or clammy. When your body closes off those capillary sphincters, shut off, and shunt blood to the core, you continue to sweat, but you don't evaporate that sweat. So your skin gets cold and wet. That's called diaphoresis. That's a sign of shock. Again, skin is warm, pink, and dry. Capillary refill. I take your finger, and I push it, and I let go. And I say, capillary refill on my head. If it takes that much time for the blood to fill in, that's okay. But if I go, capillary refill. Plus one, plus two, plus three. Okay, it's pink now. That's poor circulation. Very bad. If I take a less than three years old, all I have to do is squeeze, and let go, and watch it pink up. That's actually more accurate than a blood pressure in somebody who's less than three years old. If I say capillary refill, if I say good capillary refill to a doctor for somebody under three, doctor's like, solid. He knows what that means. That's capillary refill right there. And it's pinking up. Assessing controlled external bleeding with trauma patients should occur before addressing airway or breathing. We should be assessing for that bleeding right away. Bleeding from large veins is characterized by that steady flow. It can be very significant, especially if you have one of those varicose veins ruptured. But arterial bleeding is obviously that spurt. You'll know the difference. Controlled external bleeding can be simple. Apply direct pressure if necessary. Apply a tourniquet. Put on a tourniquet. Direct pressure is not quickly and successfully. Well, I'd put a pressure on it, and then a pressure dressing. If that doesn't stop it, then I can do it. Any arterial bleed, don't even bother. You put direct pressure on it until you get the tourniquet on. Any arterial bleed gets a tourniquet automatically. Any arterial bleed from a hole in the center of the body where you can't put a tourniquet on, you take the hemostatic gauze and you pack it in there. You just shove it in until you can't fit anymore. Identify injuries that must be managed or protected before the patient is transported. We always want to stabilize the patient before we move them, right? Especially with fractures and unstable pelvis, we always want to stabilize them before we move them onto the backboard and onto the stretcher and into the endos. We've got to move them. We've got a long road to put them on the backboard, check the back, and treat what we need to. This rapid exam takes 60 to 90 seconds. It is not a systematic or focused physical exam. It's just going to assess really quickly the life-threatening needs of the patient. Primary assessment assists in determining transport priority. We do a high-priority transport. We do our primary assessment and then we make our transport decision. Again, after you've been doing this a few years like me, I can look at a patient and say, yes, that's a rapid transport. We want to get moving. High-priority patients include those with unresponsiveness, difficulty breathing, or uncontrolled bleeding. And technically, if I put a tourniquet on a patient and it stops the bleeding, is that technically a high-priority patient? I would go high-priority, but it's really not. I stop the bleeding. You'll be fine. You can stay there all afternoon, right? I stop the bleeding. It's going to be uncomfortable. So high-priority patients are also mental status, severe chest pain, pale skin or the signs of pulperfusion because that's signs of shock, complicated childbirth, which we're going to talk about, and severe pain in any body area. Pain outside, which you expect to see. Remember that compartmental syndrome? Ah! Passive stretching pain. Ah! Right? You should expect to see that. The golden hour or golden period is the time from injury to definitive care. We don't really go with the golden hour. We don't go with the golden hour anymore. We say the golden period because it could be more or less than an hour. I mean, I've done calls where we had an hour before the patient was extricated to where I could treat them, and I've done calls where literally we arrive on scene, the patient's lying on the ground. We scoop him up, get him in the ambulance, and we're at the hospital in less than 10 minutes. Complete scene guy, 10 minutes. Or complete call guy, 10 minutes. So it all depends. Treatment of shock and traumatic injuries must occur, and again, treat on scene. OEMS wants you to do some treatments now. They don't want scoop and screw anymore. I mean, I know of medics in WEMS that haven't given a med in years because they have such a quick transport time. They scoop him up, they're at the hospital, oh, here you go. That's not what OEMS wants to see, especially if you're working in an outlying area where you have a little bit of a transport time. You want to do some stuff. Immediate transport is one of the keys to survival of patients who need immediate care that the EMT cannot provide. Again, we don't really, there's not much we can do on scene that we can cure, bye-bye, have a good day, see you later. Most, vast majority of things that we deal with need definitive care. So the golden hour, you've got discovery of the incidence, activation of EMS, around 20 minutes, they say. Then there's the platinum 10 minutes. This is the time you want to stay on scene. Now, that's all right. This may be 20 minutes, it may be 10 minutes, it may be 30 minutes. We don't know how long it takes. The 10 minutes is the time we're going to spend on scene. You know, I don't want you, yeah, the shorter the better, but I don't want you looking at your watch going, oh my God, it's 9 minutes 30 seconds and we still haven't gotten the patient packaged. And you start whipping the patient on the board and going, that's not what I mean. Move with a purpose. Do what you're going to do, just do it in a good clip. That's all I'm saying. Don't worry about time, do what you need to do. And then transport and stabilization, and that's where we get that power. We go more like calling a gold screen. Transport decisions should be made at this point based upon the patient's condition, availability of enhanced care, distance of transport, and local protocols. And again, nobody's ever going to fault you if you're questioning your patient's stability, you're questioning what the condition is, nobody's going to fault you for going high priority. Just don't do it because it's the end of shift and you want to go home. History taken provides detail about the patient's key complaint and the signs and symptoms. I will tell you that a history is 80% of patient care. 80% of what you do is based upon your history. You get a good history from the patient and you can tailor your treatment modalities to what you found. It's basically what we do. We want to get the date of the incident, age, gender, race, past medical history, part of your sample, and your current health status. Again, that's the sample history right there. So age, gender, race, and the sample history. So make introductions, make the patient feel comfortable and obtain permission to treat. And if I'm talking to the patient and the patient says, no, don't touch me, that's permission to treat. Ask a few simple and direct questions, see how the patient's mentally settling, see how they're going to, what's that? He said, no, don't touch me, and he said that's permission to treat. As long as they don't say, no, don't touch me. If they say, don't touch me, we don't. But if they don't say, don't touch me, we treat. Refer to them always as Mr. and Mrs. in their last name. Yes, sir, my name is Greg, I'm Nancy. What is your name? Oh, my name's Bob. Do you mind if I call you Bob? Okay, Bob. And ask open-ended questions. An open-ended question is something that's designed to get the patient to talk to you. I don't want to know, are you having pain? And they say, yes. Because that tells me, okay, somewhere in the body there is some form of pain, something, right? It's going to take a long time to get information if I'm asking closed-ended questions. Open-ended questions get the patient to talk. Closed-ended questions confirm it and give that reflective listening. Ma'am, can you tell me where is your pain and what is it like? Oh, my pain is in my chest, it's a crushing chest pain. I'm having trouble breathing. So what you're telling me is you're having crushing chest pain and you're having trouble breathing. Yes. Open-ended questions get the information. Closed-ended questions, yes or no, to confirm. And it also gives that reflective listening. Let the patient know that we're listening to you. If the patient is unresponsive, patient information patient information includes what the incident must be of pain from maybe family members, maybe bystanders, friends, who knows? Medical alert jewelry, always look for medical alert tags. They've got bracelets, necklaces, anklets. Other patient medical history documentation. Maybe they've got a discharged summer in their back pocket. You'd be surprised. Maybe they've got one of those little chips in their wallet that has all their health information on it. Use your OPTRS phenotype to assess symptoms, onset, provocation, palliation, quality, radiation, reason, severity, and time. I talk about this as being the assessment for discomfort. Sample is your history. This is for discomfort, whether it be shortness of breath or pain. And identify pertinent negatives. A pertinent positive leads you toward a differential diagnosis. A pertinent negative detracts you from it. Sample is the history of the patient. Signs and symptoms, allergies, medications, past pertinent history, last early intake, and events. So what do we do for critical thinking in your assessment? You have to do critical thinking. It's not cookbook medicine. It used to be many, many years ago, even before I started AMS, it was really cookbook medicine. It's not, you see this, you do this, you see this, you do this. It's not like that anymore. They want you to think. They want you to use that, you know, that space between your ears, right? So gather your information. Evaluate what you see, what the information means. Put it together and formulate a patient's treatment and transport plan. That's what we do all the time. Alcohol and drugs. Sign may be confusing, hidden, or disguised. Alcohol and drugs makes it very difficult to assess what's wrong with patients. The more intoxicated they are, the more difficult it is to get information. Patient may deny having problems. History gathering may be unreliable. You can have patients with, matter of fact, an altered mental status patient, trauma patient, automatically gets a caller. Probably put them on a board if it was a significant mechanism of injury automatically. Because the alcohol or the drugs may mask the pain. They could have a severe back or neck injury. We don't know it because they're not going to be accurate with their claim of pain. Do not judge the patient. Everybody likes to party. That's why I used to love doing the college calls on Friday and Saturday nights. It was a lot of fun. The kids were all upset. I'm going to get kicked out of school. My parents are going to hate me. I'm like, you don't worry about it. Be professional in your approach. Physical abuse and violence. Report all physical abuse and domestic violence to the appropriate authorities. You are a mandatory reporter, 51A, if abuse and neglect in a child under the age of 18 or a patient in need of services. Same with elder abuse, 19A, which is those over 65 or older. But anybody that you feel is unsafe, domestic abuse, whatever, abuse of a disabled person, report it. Tell it to the nurses or the doctors. Maybe call and have the police meet you at the loading dock. Whatever you need to do. You're a patient advocate. So if your patient is in need of services, your job is to advocate for them. You want to go to every patient as if nobody else cares about that patient but you. That's the attitude you need to take every single time. Do not accuse. Instead, involve law enforcement. In sexual history, consider all female patients of childbearing age who report lower abdominal pain to be pregnant. Why? They might know it, but what would be the problem? Lower abdominal pain, with or without spotting, could be the indication of what? Exopic pregnancy. The number one cause of maternal demise in the first trimester of pregnancy. Exopic pregnancy. So we always consider that a woman could be pregnant. When you're dealing with sexual history, whether it be man or woman, you're going to have to ask questions that might be uncomfortable. Are you sexually active? Do you use birth control? Could you be pregnant? When was your last menstrual cycle? Are you having a discharge or a foul odor? Those kinds of questions are difficult to ask. If you ask them, like you ask it, you ask it as if it's the same question you ask every single day. You ask it professionally, and the patient will respond in time. I've seen it a thousand times, right? Don't be nervous or squeamish or uncomfortable about asking it. Just do it. Do it. Just do it. Ask about the patient's last menstrual cycle. Ask about urinary symptoms in the male. Ask about STDs. Do you have anything that I don't want to get? Especially when I'm going to do an IV, I'll always ask that. Do you have anything that I need to know about? Do you have any illnesses I need to know about? And they usually, most, even homelessly, the IV drug users, most of them are pretty good. Yeah, I got AIDS, I got hepatitis, whatever. Silence. Patience is extremely important. Is silence because the patient doesn't want to talk to you, the patient doesn't know the answer, or the patient can't formulate the answer because of a mental deficit? We have to figure that out. That can be big. Those can be big differences. When you have a patient that doesn't want to answer you, use closed-ended questions. Maybe they'll go yes or no. Maybe they'll just nod, right? Maybe they can't answer you. Overly talkative. The reason why a patient may be overly talkative. Excessive caffeine use. Excessive stimulant use. Nervousness. Maybe they've done something they don't want you to know about. Ingestion of cocaine, crack, methamphetamines, or underlying psychological issue. Could be like manic depressive and they're on a manic phase. Could be like schizophrenia, a schizoaffective disorder. Multiple symptoms. Prioritize the patient's complaints. You wouldn't triage. What's wrong today? Oh, my back hurts. I've got constipation. I'm tired. I've got a headache. I'm not sleeping right. It goes all the way down. Well, why was the ambulance here today? Oh, my chest hurts. All right. That is the main. That's the top one. Then we go down from there. And all of those may or may not be associated symptoms. But the reason the ambulance was called might not be from the patient. It might be from a family member or a bystander. But that's what you want to get. Start with the most serious and end with the least serious. Anxiety. Some patients show signs of psychological shock. They're going to show. Some patients can have an anxiety disorder, a panic disorder. They can have an anxiety or panic attack. And it will present like a heart attack. They think they're having a heart attack. Pallor, which is pale skin. Diaphoresis, that cold, wet sweat. Shortness of breath. Numbness in the hands and feet. Usually that's caused from rapid breathing. They're literally hyperventilating. Dizziness or lightheadedness. Again, usually due to the hyperventilation. And then it can cause a loss of consciousness. The beauty of that is, they pass out. Usually they come out of it. And they wake up calm. And that's when we slip the IV in. Anger and hostility. Not you. I'm just saying you need a lot of sleep. Anger and hostility. Family, friends, and bystanders may direct anger and rage towards you. I always say keep your feelings at home. Put them in a box. They don't do anything. They don't do you any good. What happens at work stays at work. What happens at home stays at home. But with that said, don't become a verbal or physical punching bag. There is a limit to what I'll take. But I understand people are raging. They're upset. And they're going to take it out on me because I'm there to help. We go after or we attack the ones that we love or are trying to care for us the most. It is what it is. It's part of human nature. Remain calm, reassuring, and gentle if the scene is not safe or secure. Get it secure. That may mean leaving it. Do not put an intoxicated patient in a position where he or she feels threatened. Never argue with a drunk or a drug addict or a schizophrenic. Potential for violence and physical confrontation is high. They will lash out at you. Alcohol dulls the patient's sense of senses as well as it releases their inhibitions. They do things they wouldn't normally do. Crying. A patient who cries may be sad, in pain, or emotionally overwhelmed. Again, remain calm. Be patient, reassuring, and confident. Talk to them in a soft voice. Let them know it's okay. It's all right to cry. Tell me what is bothering you, what's upsetting you. You might get a whole host of things you never expected. Depression among the leading cause of worldwide disability should include suicide. Symptoms include sadness, hopelessness, stress, and spirit ability, sleeping and eating disorders, and increased level of energy. Be a good listener. You can tell. If you start talking to a patient, you can tell that sadness, that air of hopelessness. You've got to ask them, do you feel you want to hurt yourself? I don't want to live. That's bad. Or, yeah, I'm going to jump in front of a truck. That's really bad. That's suicidal ideations with a plan. You can be depressed and not have suicidal ideations, but that is one of the leading causes of suicide. Confusing behavior history. Conditions such as hypoxia, stroke, diabetes, trauma, medications, or other drugs could cause an alteration in the patient's explanation of events. Sometimes they just don't want to know what they were doing. They don't want you to know what they were doing, so they come up with some completely other story. Then when you get to the hospital, the truth comes out. Older patients could have dementia, delirium, or Alzheimer's disease. Dementia, and dementia, a form of, the most common form of dementia is Alzheimer's disease, but there are other forms. Delirium is acute. It's a medical emergency. It's treatable. Dementia and Alzheimer's disease is not. So, patients with limited cognitive abilities. Maybe they have, you know, maybe they're altered. Maybe they have dementia. Maybe they are, you know, mentally disabled. Keep your questions simple and limit the use of medical terms. Talk to them as you would talk to anybody else, but just make it simple. Simple, short questions. Don't make them long, these long explanations. Be alert for partial answers and keep asking questions. Rely on family members, caregivers, or friends. What's the best way, you know, can you add to that answer, or is there something else I'm looking for? What's the best way to talk to this patient? Cultural challenges. Do not use medical language. It's not going to do any good. Patients may prefer to speak with a healthcare provider of the same gender. Always try that if you can, right? Especially if the patient seems apprehensive or fearful of you. You know, and that goes for ladies with men or men with women. Gain assistance with a patient or family members. Enlist the help of healthcare providers of the same cultural background. That's the beauty of being in EMS. I work with everybody from every race, creed, color, you know, sexual orientation, socioeconomic background. So that's the beauty of it is we get to learn about each other. We get to learn what our patients are like because the crew members we work with are as diverse as patients. Language barriers. Find an interpreter if possible. Remember, it is not a HIPAA violation to enlist a stranger to be an interpreter. The patient talks to the interpreter and the interpreter talks to me. That's okay. You can do that. If not, determine if the patient understands you. Sometimes patients know enough to get by. You might know enough. They might know enough to get by. Keep the questions straightforward and brief. Use hand gestures. Not this one. And be aware of the language diversity in your community. There are a lot of languages. Like in Worcester, there's probably 60 languages in Worcester. So you're not going to know them all. You're not going to be able to pick little words out of each language. So your Google Translate is great or other translation software is great. Just remember when you use it, don't use it in the eye of the public. Hearing problems. Ask slowly and clearly. Ask questions. Speak to the patient. Look at them. Let them look at your face. Maybe you can turn the stethoscope around. Reverse stethoscope and talk into the bell. Simple sign language, if you know it. Pencil and paper is great. Your best piece of equipment that you have is a small notepad and a pen. It has shaved my ass more times than I care to remember. Visual impairments. Identify yourself verbally when you enter the scene. Don't sneak up on them. Return any items that have been moved to the previous position. If you're moving things around, make sure you put them back because they kind of house the setup because they know where things are. Explain to the patient what's happening in each step, especially with vital signs. Constantly stay in communication with your patient or constant contact, whether it be physical or verbal communication. Let the patient feel comfortable. Explain everything that's happening as it's happening. Your secondary assessment, it could be performed on scene, especially with a delayed extrication, in the back of the ambulance or if you're doing pump and blow the whole ride, not at all. If you're just doing CPR, you're not doing any patient assessment. I like to do my patient assessment in the back of the ambulance. Like I'll do a quick 60 to 90 second assessment, put the patient on the board or the scoop stretcher or directly on the stretcher, get him in the ambulance and then I'll do my head to toe. That's my office. That's where I feel comfortable. I have everything I need in there. If the patient crumps, we're ready to screw. But if you're on scene, if you're on scene, you could have a problem if the patient crumps. Now the patient crumps, you're on scene, now you've got to move a crumped patient, it may be more difficult. But you can do an assessment on scene as well. The purpose is to perform a systematic physical examination of the patient. It may be a head to toe. If my patient is altered or unresponsive or post-historian or they have a significant mechanism of injury, I'm going to do a head to toe assessment. All kids get a head to toe assessment. It only takes two minutes. For a patient that has a focused, like an isolated injury and there ain't no time score that can tell me exactly what happened, I'll do a focused assessment and I can focus on the chief complaint. How to assess.