Grid Down Hospital: Part VI – Patient Assessment Overview

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The latest from the team:

Patient Assessment Overview

Entire medical text volumes have been written about a full patient assessment, and what it should encompass. This will not be one of them, but it will serve as a reasonable overview for your efforts.

The type of assessment you perform is entirely based on time and resources devoted, which dictates the scope.

The first, and largely ignored, is the Eyeball Assessment. What you see in the first few to twenty seconds of contact with your patient.

Are they conscious? Alert? Oriented to person, place, time, and events?

Breathing? Normally?

Bleeding?

Do they have any Stevie Wonder fractures, i.e. obvious deformities?

What color is their skin, as in normal nail-bed pink, or pale, jaundiced, etc.?

In short, can they walk, talk, and basically function normally?

This is a Go/No Go evaluation, and determines the likely severity of their situation, and the scope of your further efforts.

The second, usually deployed in the Mass Casualty Event (a Mass Casualty is ANY event when demands exceeds immediate resources, and could be as little as one patient), is known in the biz as the START assessment, for Simple Triage And Rapid Treatment.

A picture being worth 1000 words, here it is:

startadulttriagealgorithm

The algorithm above embiggens. Learn it, love it, live it.

Use of this algorithm enables one person, with a handful of triage tags with four color choices (which determine rather exactly your medical future) to triage multiple patients in a few seconds apiece, and then get back to focusing on the worst first without wasting resources on those who died or soon will.

There are multiple videos on YouTube covering START Triage which explain this process. A quick survey showed that they’re all bad (in being poor quality, lousy presenters, boring as f***, but..), but pick one and follow along, because they cover the information, while unfortunately being largely unwatchable.

The next level of patient assessment is used for most contacts – the Primary Assessment.

The list is a little more involved, and from this point onwards, all assessments need to be seen as only one data point. This means while true, they don’t tell you much by themselves; the key is to do multiple assessments, and note the trend, over time. That’s where they gain their true value.

This requires adequate documentation each and every time, and completeness, each and every time, at least of the pertinent items.

You want the following:

Baseline mental ability: awake, alert, oriented times four items?
Body Temperature?
(Note that even lacking a thermometer – which you shouldn’t but…- hot/warm/cold to touch is still clinically useful.)
And skin color and moisture: pink/dry is normal. Pale/diaphoretic(sweaty) is not.
(Note also that if lacking medical terminology, plain English will suffice.)
Pulse: regularity (or not), rate (beats per minute), and quality (weak/strong/bounding).
Respirations: regularity (or not), rate, including chest symmetry, and any further medical description of the respirations (which requires more than laymen-level instruction), if appropriate.
Blood pressure: With a cuff, and where (on the patient’s body) taken.
Pulse oxygenation, if you have the capability.

The above is standard from field and ER triage desks to surgical anesthesiology, and will stand you in good stead if you equip for it, learn it, and do it. Practice now, and on patients from infants to the elderly, any time the opportunity presents itself.

Ancillary equipment in any of those environments can get you more information, but you can’t suffice with less, in most instances, nor should you try.

I repeat: Documentation, Accuracy, and Trend Over Time.

Lastly is the Secondary Assessment. It is a complete review of the body from head to toe.

I can do a pretty thorough one in two to five minutes on a prone patient, even if they’re unconscious. The checklist runs to two or three pages. (Flighterdoc, I , or some other author may devote a separate essay to same in the future.) As this is where patient assessment and other medical texts come in handy, the short summary is that you look at and palpate (touch and feel) everything from the top of the scalp to the soles of the feet, which you have to be able to get to and see – which is why the doctor always wants you in that annoying loose gown first, and why paramedics cut your clothes to ribbons nine times out of ten at an accident scene. Jeans and boots are replaceable, death is not.

You are looking for obvious deformities, bleeding and/or other fluid leaks, bruising, other wounds, skin color, movement, nerve sensation, circulation, intactness of bones, normality of reflexes, or any and all deficits in the above. Head, neck, torso, abdomen, groin, arms to the fingertips, and legs to the toes, including rolling on the side to inspect everything, particularly the spinal column, from head to tailpipe, inclusive.

If the patient is awake and responsive, it also includes hearing, eye movements, and verbal expression checks, because these give you cranial nerve function times twelve (you should look these up) without a CT scan, in about a minute.

After that, you progress to things like laboratory blood, urine and fluid tests, and diagnostic imagery (Xrays, Ultrasounds, CTs, MRIs) which probably are – but need not necessarily be – beyond your scope. For one example, you can get a bedside ultrasound machine for about the price of a thermal weapon scope. One can pick out a target at 1500 yards, and the other can diagnose internal bleeding or appendicitis. You decide whether either of those things are important, and devote your resources appropriately.

You can also, even in degraded conditions, do blood laboratory work and cultures of specimens to detect infection, if you have the equipment, training, and resources. SF 18Ds are expected to meet that standard, and did so in sandbag hooches in SEAsia amidst a war. You get what you pay and train for, and your people will bless or curse you, depending on your abilities and their outcomes.

8 responses to “Grid Down Hospital: Part VI – Patient Assessment Overview

  1. With respect to triage.

    I was told that, in battle, medics may upend the rules.

    That is, a man with light injury might be treated in preference to one who is more seriously hurt … for the simple reason that he can quickly returned to battle.

    The downside is that the more seriously injured guy might die, owing to the delay in receiving treatment.

    Not quite sure how that squares with the Hippocratic Oath.

  2. outlawpatriot

    Far too much info. Most of which cannot be acted upon.

    But everybody gotta have a gig, right?🙂

    • At least you’re consistent about pissing in the punchbowl every time.
      If that <5 minute overview was too much or too hard for you to follow or do, don't bother with even a TQ or an IFAK. They're far too complicated to act upon.
      Just pack more beer and porn, and perhaps some lighter fluid for someone to light you in a viking funeral pyre come the day.

    • Well, you can treat patients your way (once, at least). Or we can save their lives.

  3. Since no one actually takes the Hippocratic Oath anymore, least of all military medics, it’s a moot point, officially. The Oath is, like the Pirate’s Code, really only useful as a more or less a guideline.

    In reality, if you need the lightly wounded back in the battle that fast, you’re pretty far up the creek without a paddle.
    A minor wound is care-delayed, and immediate treatment means immediate treatment. The only exceptions are when you’re in the Care Under Fire phase of TCCC, which is an entirely different animal.

    At that point, your priority is achieving fire superiority so that you can even attempt to reach and treat the wounded, and your primary tool is your handy bullet launcher.

    Once you get to the luxury of triaging two different patients, ignoring the “Immediate” treatment casualty in order to return the “Delayed” treatment patient to the fight generally means you’ve just sacrificed one, when you could have saved both. Anyone wounded so slightly that you could get them back into the fight should probably have been taken care of with self- or buddy-aid, and not crossed your path in the first place nine times out of ten, but I’m open to alternative views and examples from people who’ve been there doing it with rounds snapping overhead.

  4. Thanks to Aesop for writing this.

    And once again, we are writing on grid-down hospital procedures, not tactical medicine. Sick people outnumber trauma wounds something like 1000-1 in the US military in COMBAT, and illness kills a million people for every death caused by fighting in the rest of the world.

  5. Bogbeagle…..the oath taken by medical students (not doctors, and usually at their graduation) is some locally developed variant of the Lasagna Oath (seriously – check on wiki). The original oath, as attributed to Hippocrates, is flawed in many ways….talking about polytheism (“…by all the gods and goddesses….”, rape (sex with slaves), slavery, nepotism, to name only a few.

    The phrase “first do no harm” is not in either version, it’s attributed to a 19th century physician.

    And triage (sorting) is a necessary part of medicine, when there are simply not enough resources to go around.