第 6 章
The Assessment Puzzle: Gathering Critical Patient Information
Effective patient assessment forms the cornerstone of emergency medical care, requiring both systematic methodology and adaptable thinking. The EMT approach consists of five essential components that flow in a logical sequence while allowing for simultaneous actions when necessary: scene size-up, primary assessment, patient history, secondary assessment, and reassessment.
Scene size-up begins the moment a call is received and continues as a dynamic process until patient care is transferred. EMTs must evaluate multiple factors: scene safety (with EMT safety always taking precedence), environmental hazards such as weather or hostile individuals, implementation of appropriate personal protective equipment (PPE), determining the number of patients and additional resources needed, and careful assessment of mechanism of injury (MOI) for trauma patients or nature of illness (NOI) for medical patients. For instance, in a motor vehicle collision, EMTs evaluate vehicle damage patterns, displacement distance, and intrusion into passenger spaces to anticipate potential injuries.
The primary assessment identifies and treats immediately life-threatening conditions through a structured approach. It begins with forming a general impression - those crucial first seconds where EMTs observe the patient's age, sex, position, obvious distress signals, and overall appearance. Level of consciousness assessment employs the AVPU scale: Alert (fully aware), responsive to Voice (responds to verbal stimuli), responsive to Pain (responds only to painful stimuli), or Unresponsive. For unresponsive patients, the CAB approach prioritizes Circulation (checking pulses, initiating CPR if needed), Airway (assessing patency, managing obstruction), and Breathing (evaluating rate and quality, providing ventilation support when necessary).
Patient history gathering requires both art and science, beginning with identifying the chief complaint - the patient's most significant concern in their own words. The SAMPLE history framework provides crucial background: Signs/symptoms (what the patient is experiencing), Allergies (medications, environmental, food), Medications (prescribed, over-the-counter, supplements), Past medical history (chronic conditions, surgeries, hospitalizations), Last oral intake (timing and nature of food/drink), and Events leading to injury/illness (complete sequence of relevant events). EMTs must master different questioning techniques: open-ended questions ("Can you describe your chest pain?") encourage detailed responses but require more time, while closed-ended questions ("Did the pain start suddenly?") provide quick, specific information crucial in time-sensitive situations.
The secondary assessment systematically identifies remaining signs, conditions, or injuries without delaying critical transport. This may involve either a comprehensive head-to-toe examination or a focused assessment targeting specific body areas based on the chief complaint. Assessment techniques include careful inspection (looking for visible abnormalities), palpation (feeling for tenderness, deformities, or abnormal movement), and auscultation (listening to breath sounds, heart tones). Baseline vital signs establish initial patient status, with subsequent measurements every 15 minutes for stable patients or every 5 minutes for unstable patients.
Vital signs provide both quantitative measurements and qualitative observations essential for patient assessment. Standard vital signs include detailed evaluation of respirations (rate, depth, effort, sounds), pulse (rate, rhythm, strength, equality), blood pressure (systolic/diastolic readings, trends), pupils (size, equality, reactivity to light), skin signs (color, temperature, moisture, turgor), and pulse oximetry readings. Each vital sign offers specific diagnostic clues - for example, skin signs can indicate shock, carbon monoxide poisoning, or cyanosis.
Reassessment represents ongoing vigilance, occurring at regular intervals (every 5 minutes for unstable patients, every 15 minutes for stable patients) and after any significant interventions or changes in patient condition. This systematic reevaluation includes reassessing level of consciousness, airway status, breathing effectiveness, circulatory status, response to interventions, and trending vital signs. Documentation of these reassessments provides crucial information about patient response to treatment and condition changes during transport.
