2 Patient Assessment and Clinical Judgment

Assessment as a continuous process

Patient assessment is continuous: gather information, identify immediate threats, act within EMT scope and local protocols, and check for changes in the patient’s condition. Assessment includes gathering information, providing care, and repeatedly evaluating whether the patient is stable, improving, or deteriorating.

Pediatric care is integrated throughout assessment. The National Registry EMT examination includes five domains. Scene size-up and safety account for $15\text{–}19\%$ of the examination, primary assessment for $39\text{–}43\%$, and secondary assessment for $5\text{–}9\%$.

Scene safety and size-up

Assessment begins before patient contact. Use dispatch information to anticipate hazards and needed resources, then reassess conditions on arrival. Do not enter an unsafe scene: stage or withdraw, communicate the hazard, and request appropriate support.

Hazards, patients, and resources

Use personal protective equipment (PPE) appropriate to the hazards and follow standard precautions. Check for traffic, fire, electricity, violence, hazardous materials, unstable structures, animals, and environmental conditions.

Consider the mechanism of injury (MOI) or nature of illness (NOI): what happened, and what injuries or illness might it have caused? Identify the number of patients. If there are multiple patients, begin or support triage when needed and request additional EMS, fire, law enforcement, or specialized resources.

Plan safe access to patients and a safe way to remove them. Scene size-up is ongoing: a newly identified hazard, additional patient, or change in conditions can require a new plan. Protecting responders and the public, identifying patients, triage, and requesting resources are included in EMT scene-size-up competencies.

Initial impression and primary assessment

The initial impression is a rapid overall view formed at first contact. Consider approximate age, apparent severity, position, behavior, work of breathing, skin appearance, and whether the patient appears critically ill or injured. It guides urgency; it is not a diagnosis.

Establish rapport, identify the chief complaint when possible, and assess responsiveness. Use a consistent scale, such as AVPU, according to training and protocol. Then rapidly assess airway, breathing, and circulation:

• Airway: Determine whether it is open and maintainable. Look and listen for obstruction, abnormal sounds, or inability to protect the airway.

• Breathing: Assess rate, effort, depth, chest movement, and adequacy. Treat inadequate breathing promptly within EMT scope and protocol.

• Circulation: Assess pulse, skin signs, and major bleeding. Control life-threatening external bleeding promptly using approved methods.

Determine whether the patient needs urgent treatment, rapid transport, or additional resources. Treat critical threats as they are found; do not delay essential care to complete a detailed history or examination. Repeat the primary assessment after interventions and whenever the patient worsens. Responsiveness, airway, breathing, circulation, chief complaint, life threats, baseline vital signs, and the need for rapid treatment or transport are included in the National Registry’s EMT test plan.

History and examination

After immediate threats are addressed, investigate the complaint and look for relevant findings. The depth and order of history-taking and examination depend on patient stability, complaint, MOI or NOI, age, and protocol.

History

Ask clear, direct questions. Obtain information from the patient, witnesses, caregivers, or available records as appropriate. Use OPQRST to characterize a symptom: onset, provocation or palliation, quality, region or radiation, severity, and time or course. Use SAMPLE to ask about signs and symptoms, allergies, medications, pertinent medical history, last oral intake, and events leading to the illness or injury.

Ask about pertinent negatives—important symptoms the patient denies—as well as positive findings. For a trauma patient, clarify the mechanism, timing, protective equipment, and any loss of consciousness when relevant. Adapt questions to the patient’s age, communication needs, and condition. EMT history-taking competencies include the chief complaint, MOI or NOI, associated symptoms, past history, and pertinent negatives.

Examination and baseline findings

Choose a focused examination when the complaint or injury is localized and the patient’s condition allows. Examine the relevant body system or region and compare sides when useful. For significant trauma, an unclear history, or possible multiple injuries, perform a systematic head-to-toe examination as appropriate to the patient’s stability and protocol.

Obtain and document baseline findings, including vital signs and pain assessment. Findings may include pulse, respiratory rate and quality, blood pressure, skin signs, level of responsiveness, and oxygen saturation when available and appropriate. A measurement does not replace clinical assessment: interpret it alongside the patient’s appearance and symptoms. Record significant findings, including pertinent negatives, and report changes.

Reassessment and monitoring

Reassessment checks whether the patient is stable, improving, or deteriorating, and whether care is working. Repeat it after important interventions, during transport, and whenever the patient’s condition changes. Reassess airway, breathing, circulation, responsiveness, chief complaint, relevant examination findings, and vital signs. Compare results with baseline findings and prior observations.

Recheck equipment and interventions, address new threats, and update the receiving team. Follow local protocol for reassessment intervals. Unstable patients and patients receiving active treatment require especially frequent monitoring. Knowing how and when to reassess is an EMT education competency.

Transport and handoff

Base transport decisions on the primary assessment, patient stability, time-sensitive threats, response to care, available resources, and local protocols. A patient with compromised airway or breathing, shock, altered responsiveness, severe bleeding, or another serious time-sensitive condition generally needs prompt transport while necessary care continues. Do not prolong scene time for a complete secondary assessment when immediate transport is indicated.

For a stable patient, complete an appropriate focused history and examination, continue monitoring, and select a destination and transport mode consistent with patient needs and local policy. Request additional resources or a higher level of care when indicated. Communicate the patient’s condition, key findings, treatments, and changes to the receiving facility. Follow applicable procedures for informed refusal if a patient declines care or transport.

For example, a patient with chest discomfort who is alert, breathing adequately, and not showing signs of instability may allow a focused history, examination, and baseline vital signs before departure. If the patient develops worsening breathing, altered responsiveness, or signs of shock, reassess immediately, prioritize time-sensitive care and transport, and communicate the deterioration.