Assessment-Based Management

EFFECTIVE ASSESSMENT
• Is taking the information you obtain from your patient
assessment and using it to treat the patient. You should
not use a "cookbook" approach for every patient.
• Assessment-based management requires you to use
the information you have learned about illnesses and
injuries and correlate it with the assessment
information you gather from a specific patient.

• You then evaluate that data and pull it all together to

create a treatment plan and provide the appropriate
emergency care.
 Accurate Information
• To make decisions you must have accurate information.
Often 80% of a medical diagnosis is based on the patient's
history. Your knowledge of disease processes and injury
patterns and maintaining an index of suspicion affect the
quality of the history you acquire from the patient.
• The history you obtain from the patient should focus on his
or her chief complaint and the associated problems. The
patient's ability to describe his or her symptoms and your
ability to listen have a great effect on the assessment.
• You can miss important clues if you do not listen carefully.
When performing the physical examination, focus on the
body systems associated with the patient's complaint.
 Accurate Information
• Do not overlook the importance of the
physical examination. In addition, do not
perform the examination in a cursory manner.
However, the thoroughness with which you
arc able to perform a physical examination can
be affected by field situations, such as an
unsafe scene.
 Pattern Recognition
• As a paramedic, you gather patient
information, relate it to your knowledge of
pathophysiology and the signs and symptoms
of illnesses and injuries, and determine
whether the patient's presentation fits a
particular pattern or not.
 Pattern Recognition
• With pattern recognition you consider the patient's
chief complaint as well as all the patient's assessments
and symptoms. For example, you have been called to a
patient who is reporting difficulty breathing.
• Difficulty breathing can result from a variety of
illnesses or injuries. Medical conditions associated with
difficulty breathing include allergies, congestive heart
failure, chronic obstructive pulmonary disease, asthma,
pneumonia, pulmonary edema, pulmonary embolism,
anxiety, and many others.
 Pattern Recognition
• A chief complaint of difficulty breathing in a
trauma patient may be the result of a chest
injury, choking, neck injury, shock, head injury,
or airway burn, among other causes. The
greater your knowledge base, the more likely
you will make an accurate assessment and
accurate patient care decisions.
 Pattern Recognition
• Convergent thinking, or the "inverted pyramid"
approach, is an effective method of approaching
patients when using pattern recognition. This
style of thought considers all of the patient's
complaints and presentations in an effort to
determine the most likely cause of the
complaints.
• This avoids the situation where a cause is
erroneously determined based on one complaint.
 Field Impression
• Paramedics receive training in the general approach, assessment, differential
diagnosis, and management priorities for the following patients and conditions:
• Chest pain
• Medical and traumatic cardiac arrest
• Acute abdominal pain
• Gastrointestinal bleeding
• Altered mental status Dyspnea
• Syncope
• Seizures
• Environmental or thermal problem
• Hazardous material or toxic exposure
• Trauma or multitrauma patients
• Allergic reactions
• Behavioral problems
• Obstetric or gynecologic problems
• Pediatric patients
 Field Impression
• Your ability to recognize patterns of illness or injury in
these situations enables you to form a field impression
and then formulate a treatment plan.
• Sometimes pattern recognition is a gut instinct based
on experience. For example, you arc dispatched to a
residence for an older adult who is reporting
abdominal pain. You notice a distinct odor as you enter
the residence, and you immediately know that the
patient has gastrointestinal bleeding. This odor is
difficult to describe; but once you have experienced it,
it is unforgettable.
 Field Impression
• When contacting medical direction, you must
paint an accurate verbal picture of the patient so
that the physician can clearly sec the patient and
the situation as you see it.
• Your ability to accurately paint that verbal picture
helps the physician develop trust in your
judgment. If the physician cannot trust your
judgment, he or she is unlikely to allow you to
make patient care decisions based on your own
assessment.
 Factors Affecting Assessment and
Decision Making
• A Paramedic's Attitude.
• A paramedic's attitude can affect patient
assessment and decision making. Your attitude
must be nonjudgmental. Otherwise you may
short circuit the information gathering process.
This can lead to GIGO, or "garbage in, garbage
out." And, as previously emphasized, without
adequate information you may be unable to
recognize illness or injury patterns.
 Factors Affecting Assessment and
Decision Making
• Uncooperative Patients
• Uncooperative patients can be a challenge to
assess and treat. Keep in mind that
uncooperative behavior may be a result of an
illness or injury. In all uncooperative, restless,
belligerent patients, consider the following as
possible causes:
• Hypoxia • Hypovolemia • Hypoglycemia • Head injury
or concussion • Drug or alcohol use, toxins, poisons
• Fever or hyperthermia • Electrolyte imbalances
 Factors Affecting Assessment and
Decision Making
• Labeling and Tunnel Vision
• Labeling is using a derogatory term when referring to a
patient based on an event, habit, or personality trait
that may not be accurate. Labeling a patient sets an
inappropriate tone, may be distracting, and may result
in a biased assessment .
• Examples of labels include "just another drunk,"
"druggie," and "frequent flyer." Labeling is
unprofessional and simply bad practice. Having tunnel
vision means focusing or considering only one aspect
of a situation without first taking into account all
possibilities.
 Factors Affecting Assessment and
Decision Making
• Environment
• Environmental factors can also affect your assessment and decision
making. Scene chaos, violent or dangerous situations, crowds of
bystanders, crowds of responders, excessive noise, and inclement
weather can all be distractions. In addition, sometimes obvious
injuries (e.g., amputation, severe burn) may distract you and take
your attention away from more serious problems.
• You must learn to recognize the seriousness of the injury, move past
it, and get yourself in gear to provide the appropriate patient care.
This includes performing a primary survey to f1nd all life-
threatening conditions. The obvious injuries that are not life
threatening can be treated after the patient's life-threatening
conditions have been treated. Remember: having tunnel vision may
cause you to make an early judgment without all the information
you need to provide the appropriate emergency care.
 Factors Affecting Assessment and
Decision Making
• Patient Compliance
• The patient's willingness to cooperate can affect your
assessment. For example, the physical examination of a
cooperative patient is more likely to reveal important
information that you can use to form your field impression
than an assessment of a patient from a distance. The latter
assessment may be all that you can accomplish with a
patient who is combative or refusing care. The decisions
you make about the patient's treatment plan also may be
affected by the patient's compliance.
• A patient is more likely to be cooperative if he or she has
confidence in those providing care. Cultural and ethnic
barriers also may affect the patient's compliance.
 Factors Affecting Assessment and
Decision Making
• Manpower Considerations
• Manpower can affect the paramedic's assessment of the
patient and decision making. If you are the lone paramedic
on the scene, you will need to develop a system with your
EMT partner for gathering information so that treatment
can begin as quickly as possible. If two paramedics are on
scene, information gathering and treatment can be done at
the same time. If multiple responders are present, the
scene can quickly become confusing and chaotic.
• This confusion and chaos typically occurs because too many
people are asking the same questions of the patient. This
results in disorganized information gathering. Therefore
you must preplan and designate roles before arrival on the
scene.
 Assessment and Management
Choreography
• During a multiple-tier response, many challenges can
occur when gathering the information you need for
patient care. Too many people may ask for a patient
history, and the noise level may become excessive.
• This situation can quickly worsen if responders are of
the same certification level and have no clear plan. This
is often referred to as "assessment by committee" and
is not an effective practice because it fragments the
clinical picture necessary for pattern recognition and
assessment-based management.
 Assessment and Management
Choreography
• When a scene is well choreographed, each person is
assigned a role and a chaotic scene becomes quiet and well
managed.
• This gives the patient and family a sense of confidence in
their rescuers. Before responding to a call, members of the
team must have a preplan. A universally understood plan
allows others to participate effectively.
• A basic game plan helps prevent chaos. However, a preplan
should not be cast in stone because field situations are
dynamic and can change at any moment. Do not forget to
give the first responders who initiated care before your
arrival time to let you know what they have found, rather
than brushing by them to get to the patient
 Assessment and Management
Choreography
• The preplan must include designated roles assigned to
team members. Paramedics working alone must
assume all ALS roles on scene. Two paramedics or
crews of multiple paramedics must have a preplan.
• In other words, you must find a way to designate who
is going to do what. This can be simple. The person
sitting in the passenger seat can attend the patient and
lead the call. After every call, switch roles. Alternately,
if you have the same partner all the time, you can
trade tasks each shift. Regular partners may develop
their own plan and flow.
 Assessment and Management
Choreography
• The team leader is usually the one who stays with the patient
through to definitive care. The team leader establishes contact and
a dialogue with the patient. He or she obtains the history, performs
the physical examination, gives a verbal report over the radio and at
the receiving facility, and completes the prehospital care report.
The team leader attempts to maintain an overall patient
perspective, provide leadership to the team by designating tasks,
and coordinate transportation.
• During the resuscitative phase of patient assessment, the team
leader actively participates in critical interventions. In multiple-
casualty situations, the team leader may act as EMS command.
When on the scene of a cardiac emergency, the team leader
interprets the patient's ECG, talks on the radio, gives (or relays) drug
orders, controls the drug box, and documents the medications
given and their effects.
 Assessment and Management
Choreography
• The patient care person performs the following important tasks:

1. Provides scene cover (watches the team leader's back)

2. Gathers scene information, talks to relatives and bystanders
3. Attaches monitoring leads
4. Administers oxygen
5. Establishes vascular access
6. Administers medications
7. Obtains transportation equipment
8.Acts as a triage group leader during multiple casualty situations
9 Administers medications, monitors endotracheal tube placement,
and monitors BLS interventions during cardiac emergencies