In today’s micro lecture, Australian Paramedical College Hon. Snr. Lecturer Sam Willis discusses prioritising patient care; using your clinical judgement, your decision making, your trained skills and knowledge in paramedical practice, to prioritise the care that you give to a patient.
In this session, we’re going to talk about prioritising patient care. When you arrive on scene as a paramedic, it’s important that you’re able to use your clinical judgment, your decision making, all that skills and knowledge that you learned from the textbooks and the workshops as well as any other life experiences you have to be able to prioritise the care that you give to a patient.
In this session, we’re going to talk about recognising the need to prioritise care and how important that actually is in paramedic practice. We’re also going to introduce you to the primary and secondary survey approach that allows you to prioritise care. In other words, it’s not just … and a mnemonic and an assessment tool that helps you with your prep classes, but it also helps you to work out what you should be treating first. We’re also going to identify specific situations that require managing first.
For example, there are certain patient presentations whereby you should be treating something first and leaving other things until later on, because those things that require urgent treatment are more likely to kill your patient if you don’t address them right away.
As the paramedic, wherever you’re working, whether you’re working for a state service, whether you’re working on a mine site, or whether you’re working for an event company or anywhere else where the pre-hospital response system is required, you must be able to look at the entire situation you’ve just walked into and be able to establish treatment priorities.
A larger proportion of paramedic care is not urgent life-threatening, and that’s why it’s important to be able to work out, “Okay, this can wait until a little bit later on. I need to establish some facts and some history before I go rushing in.” However, there are those patients who do present with time critical illness that requires your assessment and management straight away.
This can be achieved by following the universal assessment approach using the primary and secondary survey. This is something that you will have already read about in your units of competency, and you may have even practiced at a workshop, if not even implemented with a real patient in a practical setting. The good news is the primary and secondary survey really does help you to prioritise and treat patients in a systematic manner.
There’s no hidden secret that the more you do of this, the better you are going to become and the easier it does get, but in the earlier stages of your career, the more you’re able to apply the systematic approach to your patient, the easier it will be for you to make decisions.
And of course, as it says here, you’re going to have to develop a sound underpinning knowledge of everything related to paramedic practice, and that’s everything including your typical subjects of anatomy and physiology, clinical skills, through to those subjects that you may not find interesting, like ethics and the law, health promotion, those subjects that, whether or not you understand right now, they do actually have a massive impact on how and when and where you treat the patients.
A sound underpinning knowledge will absolutely make you better at triaging patients. And of course, something we haven’t mentioned yet is the ability of you guys to be successful in a clinical placement setting, working with a clinical mentor who can help you and guide you and support you with real patients. That’s really really important.
Here we have the primary survey. You’ve already seen this in your readings. Danger, response, airway, breathing, circulation, disability, and expose is something that is used all around the world, and it’s something that you will be drawing upon heavily when you get into your face-to-face workshops. This is something that you will need to demonstrate to your tutors that you can actually do this before they tick the boxes to say that you’ve been signed off as safe in your practice.
The other thing that you can see here in this mnemonic in bold red at the top is “address the need as it occurs.” What this means is working through this, so danger, is there a danger to yourself or your crewmate or your patient? If there is and you can’t resolve it safely, leave the scene, get in the ambulance, move around the corner, wait for the police or the firies or whoever to arrive.
Response, is there a response to you? Using your AVPU and your GCS, establish if there’s a response and then act accordingly based upon that response. Airway, if there’s a blocked airway or a trauma to the airway, deal with it straight away. Don’t move on to breathing or circulation. Just manage the airway as you find it.
Breathing, if there’s a problem with their breathing, and we’re going to talk about all of these in some detail in a moment. If there’s a breathing problem, resolve it straight away. Don’t go on and do a blood pressure or a vital sign survey if there’s a breathing problem, because it’s going to kill your patient. Deal with it there and then, quickly.
Circulation, make sure that there’s no circulatory compromise. For this, you may need to do another assessment. For example, if your patient is on the floor in a semi-conscious or unconscious state, you may need to pop an OP airway in the patient’s mouth as part of airway. You may need to do a blood sugar test if you’re suspecting that it’s a hypoglycemic event.
But if they’re looking like their circulation is compromised, one of you is going to be getting out the oxygen. The other person’s going to be doing the test, the blood sugar test, but both of you will be communicating with each other, talking, deciding, being flexible, making these decisions together. That is crucial and underpins safe paramedic care.
Disability and exposure, these are two things that we’ll talk about later on. As I’ve already mentioned, talking and communicating with each other is crucial. If you are the primary physician, in other words, if you are the one who’s tasked with treating the patient, the primary responder, work with your secondary. For example, talk to him and say, “Look, can you do this for me? Can you do that for me?”
And if you’re the secondary, and if you think something needs to be done first, say to the primary, “Look, would you like me to help you with doing this?” And just work together. That is what underpins safe care. It’s something that we’ll talk about time and time again. There’s a theoretical concept called non-technical skills, and that’s where that falls into.
Let’s talk about a few situations that require priority treatment using this ABCD approach. Blocked airway then, there are going to be many situations when your patients have blocked airways. Take for example a Friday night where people have been out clubbing and they’ve been out partying. They’ve had too much to drink. They’re in an unconscious or semi-conscious state on the floor. Their airway may be blocked by their tongue or vomit. Maybe there’s been some fighting and that’s blocked by loose teeth. Maybe there’s bits being blocked by other types of trauma.
The first thing for you to do is manage that airway. In the cases where no trauma is present, that could be something as simple as a head tilt chin lift. If there is trauma, using your jaw thrust and your triple maneuver techniques that you’ll be shown in your clinical workshops. The tongue, remember the tongue is this big muscle that can block the airway so easily, and something as simple as a head tilt chin lift can lift the tongue away from the airway and prevent it from being blocked.
Vomit can be resolved by tipping the patient on their side if they haven’t had any trauma, or if they have had trauma, using a two person control technique where one person monitors the head, takes hold of the head, and sometimes you will be able to use suction, but the best technique in my experience has been to roll the patient on their side and allow it to naturally drain out of the patient’s mouth.
Teeth is something we’ve already mentioned, and remembering guys that when you’re suctioning, using the suction device, again something you’ll be taught in your workshop, only suction what you can see. If you see the patient’s got loose teeth really deep down in the airway, you may not be able to get at it, so you might need something like a Magill’s forceps. Again, you’ll be shown that in workshop too.
Excessive salivation doesn’t always happen in a typical environment. Usually you have to have something like drug overdoses or organophosphate poisoning for this to happen, remembering that excessive salivation is caused by a sympathetic nervous system overstimulation. However, if there’s excess amounts of mucus and fluid, you’re going to need to clear that airway using suctioning.
We briefly mentioned trauma, so think about your typical types of trauma that will cause an airway blockage. Somebody may be hit by a fast-moving vehicle. Somebody may have been assaulted. Somebody may have been hit by a projectile, something that’s been thrown at speed. Again, you’ve got to assess this carefully, because if something going to block the airway, you need to be able to remove it, and it’s not always easy with regards to what we call maxillofacial trauma.
Choking is something that’s resolved using the Australian Resuscitation Council guidelines, whereby we use five back slaps and five chest thrusts. However, if the patient goes unconscious, you need to start CPR right away. And again, if you’re trained in the use of skill laryngoscopy, so larynx, being in the larynx here, the part of the upper airway, -oscopy meaning looking into. If you’re trained in laryngoscopy, certainly you can use that skill to unblock the upper airway.
Burns to the airway is really difficult to manage. There’s not a massive amount you can do about that. However, if you’re suspecting burns to the upper airway, you also have to suspect burns to the lungs. Have a listen to the patient’s chest when you’re assessing the lungs. Certainly have a look in the patient’s mouth. Ask the patient to open their mouth and have a look in, particularly if they’ve been dragged out of a fire by the fire brigade.
Again, even though you can’t do a massive amount for upper airway burns, you may be able to call an intensive care crew who can sedate the patient and intubate them if necessary, but it also helps you to work out how fast you have to treat the patient. And of course, in addition to listening to the chest and treating any added sounds that you might find, added sounds just meaning anything that’s not air, you may be able to treat with albuterol or any other type of drug that you have in your scope of practice at the time.
Loose false teeth is something that you do need to worry about if they are loose and only if they are loose. If false teeth are not loose, I suggest you leave them in place, because if you have to resuscitate the patient, you put the mask over the face from the BVM, the bag valve mask, and you’re not going to be able to get a proper seal if there’s no teeth in place, so make sure that you do not remove false teeth if they are not loose.
Situations requiring priority treatment using the DRABCDE approach, breathing. Breathing, here we have a number of terms: Tachypnea, so tachypnea, meaning fast breathing. Bradypnea means slow breathing. Added sounds are any sound that is not air. The only thing going in and out of your lungs should be air. Silent chest can be caused by asthma. Major burns to the chest and trauma to the chest.
Let’s talk through these in a little bit of detail here. The normal respiratory rate is between 12 and 20 breaths per minute, and of course, there’s an inspiratory phase and an expiratory phase. Both of these phases are important. When somebody has a rate below 12 or above 20, you need to consider if the patient is being ventilated enough. If they’re not ventilating effectively, they might be showing signs of hypoxia, pale, sweaty, clammy skin.
Maybe their oxygen saturations have dropped below 92%. This patient is either indicated for oxygen or, if they’re not able to ventilate, in other words take the oxygen in, use it in their lungs to make oxygen to their tissues, and breathe out CO2, then you’re going to need to ventilate for the patient. But the rate is only one thing that we use. The other thing that we use is the actual work of breathing, so it’s not just rate, but it’s also work of breathing.
Tachypnea would be anything over a rate of 20 breaths per minute. Remember guys, if the patient is just on the borderline, you might want to try and slow the breathing down. It could be the case that the patient’s having an anxiety attack, and if this is the case, simply do a breathing exercise, such as telling your patient to breathe in through their nose, hold it for three seconds, 1-2-3, out through the mouth. Get them to do that three times or more.
Some techs say do it at least 10 times, and of course, it will depend on the patient and the situation, but just sit there and do it with them. Of course, that’s dependent on if it’s an actual anxiety attack, because it could be a range of other things including asthma, trauma to the chest, and of course that won’t always work for that.
Bradypnea is a rate below 12, and of course again, if a patient’s tolerating a rate of 12, then that’s it, but if they’re not, you need to think about whether you’re going to just give oxygen or whether you’re going to ventilate. If the patient has a rate of 12 or below, and it looks like they are breathing adequately, but they are a bit pale, try them on oxygen first.
Then if their GCS starts to drop, then you can consider using bag valve mask ventilation if they’re bradypneaic. Typical causes of tachypnea include stress, trauma, respiratory problems, and drugs, stimulant drugs such as cocaine and ecstasy. Typical causes of bradypnea again include late stages of shock, heroin, and other types of drugs.
We said that added sounds are anything that’s not air, and that includes expiratory wheeze caused by asthma, and upper wheeze, which is a sign of a blockage called stridor. It could also be fluids caused by heart failure or cigarette smoking. These are all things that you’re going to need to do a little bit of reading around to be able to work out how to assess for them and how to treat them. Here, we’re just introducing these terms just in case you’re unfamiliar with them.
Silent chest is typical of a life-threatening asthma attack. These patients will not be shifting air in or out, and it’s up to you as a paramedic to recognize this and treat them with intramuscular adrenaline as soon as possible. With the patient who has life-threatening asthma, you would not make any other treatment decision apart from intramuscular adrenaline, and you do that very quickly. If you don’t treat it very quickly, your patient will go into cardiac arrest and may not recover from it, so you’re treatment priority should be staying calm, establishing that it’s life-threatening asthma, getting the adrenaline ready, and treating straight away.
Major burns to the chest is pretty difficult to manage pre-hospital unless you’re an intensive care paramedic. Again, the principles for managing burns are in another session, but it includes managing the pain, cooling the pain, cooling the burn, establishing how deep the burn is and how large the burn is using the rule of nines, treating any types of infection that may be there using cling wrap, and getting the patient to the major trauma center quickly.
For those patients who can’t breathe because they’ve been burnt so badly, there is a procedure known as an escharotomy, but this is only performed by intensive care paramedics, and some services don’t allow their intensive care paramedics to do that procedure anyway.
Other types of breathing problems can be caused by types of trauma to the chest. One type of example of something that will affect a ventilation is a flail segment. This can be caused by direct blunt trauma to the chest, such as being hit by a motor vehicle or falling from a height.
A flail segment is something whereby two or more ribs have been damaged and broken, and they’ve detached from the sternum, so when you breathe in, instead of the ribcage, instead of that flail segment coming upwards and outwards with the normal chest, they go inwards. When you breathe out, instead of it relaxing, they come outwards. It affects ventilation in that manner. To treat that, you simply apply a dressing over the wound, just to try and stabilize the chest walls.
There’s something else called paradoxical movement of the chest, which is a little bit like flail segment, but twice as bad, whereby one side of the chest will move independently of the other. And of course again, the similar principles apply. You’re trying to stabilize the chest wall by using some kind of a dressing.
Okay, circulation. This first slide here just reminds us that we don’t do danger, response, airway, and breathing, and then manage any kind of catastrophic hemorrhage, because the patient will likely be dead by then. What we do need to do is treat any catastrophic hemorrhage first. And guys, listen, we’re talking about catastrophic hemorrhage here. We’re not talking about minor cuts and bleeding.
We’re talking about major hemorrhage that is all over the pavement and all over the road, wherever they are, and if you don’t find that source of bleeding and plug the holes, your patient’s going to die quickly. Ambulance services are now also starting to use blood replacement, because let’s face it, fluids, sodium chloride, these are known as crystalloid solutions. They’re not that great for replacing blood, because they don’t carry oxygen. All they do is replace volume. That’s all they do.
But the key take home message here is manage catastrophic hemorrhage first. Other things that will cause you a problem that require urgent treatment include tachycardia, so a heart rate over 100. If your patient has a heart rate between 80-100 and they’re at rest, you do need to be asking yourself, “What’s happening here?” Because an adult heart rate at rest should be 60-80 beats per minute.
We do not ignore a heart rate between 80-100 if they’re at rest, but chances are they’re just suffering from something like rest, anxiety, some kind of worry that you’re there in their front room. However, we need to make sure they’re not going into a state of shock.
Bradycardia, I’m going to talk about these two together, because the opposite of tachycardia is bradycardia. A bradycardia means a slow heart rate, and that’s anything below 60. If you’ve got a patient with a heart rate of 59, you don’t need to start worrying straight away and start panicking.
But what you do need to do is start asking, “Why has this patient got a heart rate below 60? Is this normal for them? What medications are they on? Are they really looking unwell and they’re starting to become in the later stages of decompensated shock?” There are occasions when patients can tolerate bradycardia, and that’s fine, but you just need to work out that that’s okay for them and normal for them, and you can do this by simply asking the patient, “Is this normal for you?”
Irregular heartbeats aren’t something that we necessarily have to worry about straight away. However, we need to work out what’s causing this irregular heartbeat, because the patient may or may not know what’s causing it. They may even be on medications for this, such as digoxin. However, they may have had this irregular heartbeat for a long time and not known they’ve had the irregular heartbeat, and then you guys have been called, and it’s up to you guys to then work out what you’re going to do about it.
Remembering that sometimes, if your patient’s got an irregular heartbeat, not only is this a risk factor for strokes and heart attacks, but your patient may be asking, “Why do I feel unwell? Why can I feel my heart fluttering? Why do I feel sick?” It could be down to that irregular heartbeat, so don’t ignore it.
And then of course, the last two that we’re going to talk about here are cardiac output. Cardiac output simply refers to the amount of blood the heart ejects when it contracts. If there is no cardiac output on the radial pulse, try another pulse site. You might be able to feel for the carotid site, for example.
But if there’s definitely no cardiac output anywhere and they’re unconscious, you need to be doing CPR. The difficulty is that the Australian Resuscitation Council guidelines do not expect you to check for a pulse when trying to determine cardiac arrest. This is something you’ll discuss in some detail at the workshops.
However, the Australian Resuscitation Council guidelines do say that, if as a healthcare professional, you want to check for a pulse, you can, but no longer than 10 seconds, because you should really be doing CPR. And again, this is something you’ll need to negotiate with your trainers at the clinical workshops.
Now, let’s say a patient’s saying that they feel lightheaded and dizzy, and you feel a radial pulse and it’s very weak. Again, you need to think about this. Is it in your scope of practice to give oxygen at this point? Maybe you need to give some fluids. Maybe you don’t need to give any fluids, because that’s what your guidelines say. This is where you need to know what your internal guidelines say.
In the presence of trauma, if a person has a weak pulse, that’s fine. You don’t give fluids. In a medical situation, you may need to be giving fluids if they’ve got a very low blood pressure and a very weak or no radial pulse, so you need to take this into consideration.
We mentioned trauma a few times. We’ve also mentioned here that you need to manage catastrophic hemorrhage first, and number two, if trauma is suspected, you need to manage the C-spine at the same time as managing the airway. This is achieved as simply as saying to your patient, “My colleague is going to come and hold your head. Stay nice and still for us, just in case you do have any injuries to the C-spine.” And then of course at this point, this is where you would try and establish C-spine injury using the five points of the NEXUS criteria.
Once you’ve done this primary survey, you can follow the secondary survey, which will help you to prioritize treatments even further. You’ll need to undertake a vital signs survey, including blood pressure, ECG, possibly ECG, respiratory characteristics, cardiac characteristics, blood pressure, blood group commentary, temperature, SpO2, and whatever else your ambulance service guidelines tell you comes within vital signs survey.
And of course, this is where you can start piecing the pieces of the jigsaw puzzle together, with your crewmate and by talking to the patient, trying to work out exactly why you’re there today. And of course, 80% of what we do as paramedics is history taking. Be sure to ask lots and lots of questions of your patient in a really relaxed and informal way, because let’s face it, we don’t like to be bombarded with questions. The more informally you do it, the better it is for your patient. And for those patients who have reported trauma, make sure you do conduct a head-to-toe survey, but only if they have reported trauma. Otherwise, it’s an unnecessary task.
Our final slide is about pain. It’s so important that you do manage pain, but do not be distracted by a patient’s pain. If you approach a patient, and they’re screaming and shouting in pain, and say, “Ow, my leg, my leg, my leg,” you still need to deal with your primary survey first, airway, breathing, circulation, because this is what we call a distracting injury.
Being distracted away from the airway, away from the C-spine, both things that come before a fractured leg. They may have signs of shock, and you need to treat that more rapidly. Do not be distracted by a distracting injury. However, do be mindful that it is unethical to leave a person in pain. Never just say, “Oh, well the hospital’s 10 minutes away. We’re going to leave you in pain, because they can give you something.”
And don’t ever believe that the pain should be left as it is, because then you giving a strong pain relief will mask the assessment when you get to hospital. The idea is that you do a visual analog scale by asking a patient on a scale of nought to 10, “What is your pain score?” Then the pain is whatever the patient says it is. They say it’s a seven, then it’s a seven. Then you treat the pain and you monitor the pain. You monitor the treatment you’ve given and you continue to monitor and evaluate that pain. Follow the Primary Survey approach before treating the pain, and treat the patient’s pain as quickly as possible, and do not leave the patient in suffering unnecessarily.
In this session, we discussed the need to prioritize patient care, the use of the primary/secondary survey model. We’ve talked a little bit about trauma, and we’ve identified specific situations that require managing first, and those that can be left until later.