We’ve got most of the sections of the assessment described by now meaning that only the history taking and reassessment sections are left. If you need a refresher on scene size up and the primary assessment go check out Basic Necessities Part 1 or if you’re looking to review the parts of a secondary assessment you’re looking for the content in Basic Necessities Part 2.

With the very final pieces of an emergency assessment left, it’ll be comforting to know that a portion of the history taking section has already been mentioned. Regardless of the type of assessment you are doing the SAMPLE (Signs/Symptoms, Allergies, Medications, Past Pertinent History, Last Oral Intake, Events Leading Up to Emergency) questions play a big role in this section. Which makes sense when you think about it; history taking…taking down the patients recent and past history. The other portion of this section that most people don’t consider, especially since the NREMT skill sheets for the psychomotor exam don’t require you to ask, is in regards to the patients general background history. Knowing if a person has had a similar emergency in the past is important, but you also may want to be aware of other conditions the patient has that may be a contributing factor to the current emergency.

Most patient care reports that ambulance services use include a section to mark off if a patient has diabetes, hypertension, heart problems, seizure, cancer, or a stroke history. This section is in there to be a helpful reminder to the provider that the emergency the patient is currently experiencing may be linked to one of these other conditions. Asking additional questions about what the patient’s “normal” is can be very helpful when it comes to evaluating their mental status as well as their vitals. Just because the vitals you obtain are in what I called the “textbook normal range” it does not mean they are acceptable for the patient. For example if you get a blood pressure of 124/76 which is relatively close to “textbook normal”, but the patient is typically hypo- or hypertensive, they are exhibiting an abnormal vital that you need to take into consideration when determining the overall health of your patient.

Speaking of vitals, the history taking section is the portion of the assessment they fall under. When taking vitals the three basics values you’ll need to gather are Pulse, Blood Pressure, and Respirations. With the ease of technology today most hospitals will expect you to record the peripheral capillary oxygen saturation (also known as SpO2), blood glucose level, temperature, and the measurement of the eyes when applicable to the emergency, but we’ll get into those measurements another time. When obtaining the basic vitals one of the most important pieces of equipment to the provider that is often overlooked is an analog watch. It is rare now a days for anyone to where a watch due to the accessibility of cellular telephones, but it’s even more rare to find someone wearing an analog watch due to the release of Apple Smart Watches and Fitbits. In order to get an accurate vitals measurement you will need to be able to monitor the number of seconds that have passed, so if you don’t have one already, your first purchase as an EMS provider should be an analog watch with a second hand.

The other pieces of equipment that will be necessary for obtaining accurate vital signs are a stethoscope and a blood pressure cuff. Now in order for an ambulance to pass the requirements to be operational on the road, these two pieces of equipment are mandated to be on the truck, but the version one ambulance company uses may be completely different than another. That being said the type of blood pressure cuff available in my experience does not make too big of a difference. The two stations I work for both have manual cuffs onboard and one of the stations has an automatic cuff available for use. The manual cuffs are nice because they are not attached to a heavy piece of equipment and I have the ability to control the pressure I am exerting on the patient when I am taking my measurement. However, every time I need a blood pressure I have to attach the cuff and auscultate for the pressure with a stethoscope, which can be difficult in the back of a moving ambulance or where there is a lot of noise. The automatic cuff that I have access to is attached to a Lifepak cardiac monitor which as I have stated before is not a light piece of equipment, however the cuff will exert the pressure automatically and obtain a blood pressure without me needing to auscultate for it. I can also set the automatic cuff to take a pressure after a certain amount of time lapses rather than needing to remember on my own.

Now when it comes to stethoscopes, I can honestly say the type of stethoscope you are using makes a huge difference. I was given a stethoscope my first day of my EMT program from Harrisburg Area Community College and I had never used a stethoscope for any reason before, so when I was practicing taking vitals either in class or on my own I just assumed it was difficult to hear. My instructor recommended that once the class passed the mid-term and if we wanted to practice in the medical field, we go and buy a quality stethoscope. Following his advice I purchased a customized Littmann Classic III Monitoring stethoscope and it made a world of difference. There’s also stethoscopes you can purchase that are electronic and actually amplify the sounds you are auscultating. I’ve used one and I swear I can hear a patient’s heartbeat through the side of their chest as clearly as if I had the scope directly over the center of the chest. So if you are hard of hearing, and not just selectively, there are scopes you can buy to make auscultating sounds much easier you just have to be willing to pay for them. It’s not a bad investment and on some calls your are going to want anything that will make your job easier; I’m currently saving a small portion of my paycheck to buy an electronic scope myself.

Another tricky aspect regarding vitals is that depending on the age of the patient there is a different “textbook normal range”. You need to be aware of the differences so you can effectively communicate to the next provider your overall impression of your patient and whether or not this is a “load and go” situation or if you can “stay and play”. It will also help the next provider decide what intervention if any they need to start. In the following table you’ll see what the accepted norms are for a couple different age groups and you can also see why communicating with abbreviations in medicine is sometimes ineffective. Under the Pulse column bpm means beats per minute, while under the Respirations column bpm means breaths per minute.

	Pulse	Systolic Blood Pressure	Respirations
Newborn	100-180 bpm	70-90 mmHg	30-60 bpm
Infant	100-160 bpm	70-90 mmHg	25-40 bpm
Toddler	80-130 bpm	72-100 mmHg	24-30 bpm
Preschooler	80-120 bpm	78-104 mmHg	22-34 bpm
School Age	70-110 bpm	80-115 mmHg	18-30 bpm
Adolescent	60-105 bpm	88-120 mmHg	12-20 bpm
Adult	60-100 bpm	80-120 mmHg	12-20 bpm

The other section of an assessment I wanted to address was the reassessment portion. This is in my opinion the easiest of the sections because all it requires you to do is to monitor the patient and recheck vitals and interventions you may have started. An easy way to remember everything you need to accomplish in this portion of the assessment is to use the acronym ALIVE:

A: Airway, Breathing, Circulation. In patients who are unstable, you as the provider are going to want to double check the patient’s lifelines to living as I call them. Make sure their airway is still patent (open), make sure they are breathing an adequate number of times and at an appropriate depth, make sure they have a pulse, and that they have no apparent life threats that need to be addressed.

L: Level of Consciousness. You will want to check that the patient’s consciousness level has not changed on the AVPU scale (Alert, Verbal, Pain, Unconscious). If it has you may want to think about an intervention to return them to the condition you found them in, if not a better one.

I: Interventions. Did you give the patient oxygen? Should you increase or decrease the titration? When did you give a medication last? Should you give another dose? Reevaluating interventions can help you determine if you need to start a more aggressive treatment or if there is another treatment you should try instead.

V: Vitals. Monitoring vitals is the only quantitative way to measure your patient’s condition and it can also help you identify positive and negative trends. It will help you determine if the patient’s condition is improving or deteriorating.

E: Every X Minutes. When you are responding to a call as the provider you tend to get a sense of the patient’s stability and whether you should consider them a priority/critical patient or not. In doing so you can determine how often you should reassess your patient. The general rule of thumb is for an unstable/priority/critical patient you should reassess them every 5 minutes that they are in your care where as with stable patients you should reassess them every 15 minutes they are in your care.

“Sometimes we can’t see why normal isn’t normal.” -Dr. House (House)

And that concludes the run down of an emergency assessment. Of course there are a lot sections to remember and hearing it all for the first time can be overwhelming. However with how often you do assessments in this field, you’ll soon be completing each section without consciously knowing you are doing so. If there is any section you would like further clarification on, please let me know. Each of these posts were a brief run down of the sections and if you’d like something more in-depth I am more than willing to help.