The initial assessment (known to old-timers as the “primary survey,” but it’s all the same idea) is the first phase of patient contact. It’s the initial period where you aim your eyeballs at the human being you’re going to be caring for and uncover the most basic facts about them.
Nowadays it’s taught as a discrete series of steps, usually something like this:
- General impression
- Assess responsiveness: AVPU
- Assess life threats: ABCs
- Assess and manage airway
- Assess and support breathing
- Assess and support circulation
- Determine patient priority
All good stuff, and there’s a reason it’s taught this way. All of these steps are important, and in order to teach (and test) them, they have to be broken down and explicitly described.
But this can be a shame, because in reality, the initial assessment isn’t like a recipe for a cake — mix this, then add that, then stir, then bake. It’s a brief burst of information, compacted into a dense flash of simultaneous sight, sound, and touch, and it can always be completed within a few seconds. In many cases it will be near instantaneous. In some it might take up to ten seconds. But it should never take as long as you’d need to actually verbalize all the steps.
The initial assessment should be a tight, elegant performance, and it’s one of the EMT’s most important skills. In the field, patients don’t come with charts or reports; all we know is what we’re dispatched with, which is usually wrong. But 90% of what you need to know about the patient can be learned promptly in the initial assessment. This is how you orient yourself to the situation and discover immediate life threats; more information and a more detailed assessment will follow, and it may reveal important findings, but our most critical job is to discover and treat what’s killing them, and that happens in the initial assessment. If you never got past this step you’d still be doing all of the most important things for the sickest people.
Here’s the process I recommend. It condenses everything you need to know into three simple steps.
Step 1: Look
You walk up and encounter your patient. What do you see?
Is he standing? Then he’s certainly conscious and alert. Is he moving purposefully or talking? Same business. Is he lying on the ground unconscious? We’ll learn more in a moment.
If he’s talking, his airway is intact and likely secure. You can roughly assess his breathing in about two seconds. Is he gasping for breath? Is he apneic? Is he speaking in full sentences?
Look at his skin. Is it pink? Is it pale and sweaty? Is it cyanotic? Is there obvious major trauma, such as significant bleeding anywhere or a puncture wound to the chest?
Step 2: Talk
Greet the patient and introduce yourself. “Hi, I’m Brandon.”
On a 911 response, you then ask for the patient’s name. How does he respond? Does he fail to recognize your presence at all? Does he look at you, but say nothing? Does he respond with a moan? Does he respond with, “George,” but his wife shakes her head and tells you otherwise? Does he promptly tell you his name?
To hear your words and verbalize an appropriate response requires alertness, engagement, memory, eye movement, vocal activity, and more. It requires the use of his airway and respiratory system, and thus reveals much about their status. Is he gurgling as he breathes? Gasping? You’ve learned a great deal already.
If you’re transferring a patient from a facility, you will already know the patient’s name, and pretending otherwise may make them wonder if you’ve got the wrong room. Better to skip their name and ask instead how they’re feeling. This leads you right into their chief complaint and subjective wellness, which is another huge slice of information. Are they in pain? Nauseous? Dizzy?
Step 3: Touch
As you talk, grasp the patient’s arm. You might politely interject, “May I grab you?” as appropriate.
Feel his skin. Is it dry, moist, or wet? Is it warm, hot, cool, or cold?
Feel his radial pulse. Is it present or absent? Is it weak, strong, or bounding? Is it slow or rapid, regular or irregular? There’s no need to count; that can wait for a full, proper set of vitals, which will come after our initial assessment. We’re just looking for a quick snapshot here.
This single touch tells you all sorts of things about his circulatory status. A patient with warm skin and a strong, regular radial pulse almost certainly has adequate volume and no immediate systemic crises. And anyway, taking someone by the hand is comforting in a primal way.
Let’s watch a few examples of this process at work.
Upon your arrival, you see a sedan in the middle of the road, with minor damage to the front bumper and right quarter panel. Beside it, you see an adult male walking around, slightly obese but appearing generally well.
He is ambulating easily and has no obvious bleeding or deformities. He therefore has a patent airway, largely adequate breathing and circulation, and his general impression is good. You could stop here, but we won’t.
You approach him, saying with a smile, “Hi, I’m Brandon. What’s your name?” He replies, “Greg Rogers — some idiot tried to pull out in front of me.” His breathing appears unlabored. As you talk, you take him by the wrist, feeling warm, dry skin and a strong, regular, slightly rapid radial pulse.
He appears neurologically intact, with good memory and appropriate responses. His breathing is normal and his circulation appears fine, although he is obviously a little excited.
[Initial asessment complete. Total time: 1 second to learn everything important; 5 seconds from soup to nuts. He has no life threats and is a low transport priority.]
Dispatched: Welfare check
You walk in the room to find an elderly woman supine on the bed, curled in an awkward position and motionless.
You are already highly suspicious of a depressed level of consciousness. It is possible she is merely sleeping, but most people would not sleep in such a position.
Approaching, you lean over and call, “Ma’am! Can you hear me?!” You gently shake her shoulder while you do. There is no response.
She is not alert. This is the “are you napping?” test; if she were easily roused in the same way you’d wake up your roommate, we would call her alert, not “responsive to voice”. You don’t lose points just for being asleep.
You lean into her ear and call again, this time in a loud shout. There is no response.
She is unresponsive to verbal stimuli. A loud, intrusive sound elicited no reaction.
Rolling her over, you note the sound of snoring respirations. Her chest is rising and falling with good depth, but not very quickly. Her skin is slightly ashen. You give her brachial plexus a tight pinch, to which she flinches and withdraws slightly.
She is responsive to painful stimuli, but does not open her eyes. (If you later wanted to calculate her GCS, she would earn a 5.) Her airway needs managing, and an OPA would probably be appropriate. She should receive supplemental oxygen as well, and may require assistance with the BVM. Since she’s breathing, she presumably has a pulse.
With one hand, you palpate her carotid pulse, while you palpate her radial pulse with the other. Her pulses are regular and slightly slow. Her radial is strong, and her skin is warm and dry both at the neck and at the wrist.
She has adequate circulation, perhaps with a slight bradycardia due to hypoxia. Her volume is adequate.
[Initial assessment complete. Total time: 6 seconds. She will need airway and breathing support, then a rapid assessment and transport due to her diminished level of consciousness.
Dispatched: Discharge to skilled nursing
You walk into the hospital room to find your patient in bed, semi-Fowler’s. Her eyes are open and staring at the ceiling, but she makes no acknowledgement of your presence. She is breathing adequately and without labor. Her skin appears dry and slightly pale.
She appears conscious, has an airway, and is breathing. She presumably has a pulse. She appears unremarkable for an ill but stable elderly patient, perhaps with a baseline dementia.
You approach her, saying, “Ms. Smith!” She turns her head and makes eye contact. “I’m Brandon. How are you feeling?” She replies, “Hi…” After another couple attempts, the best response she gives is to call you “Aaron” and ask about the elephants.
She is alert and engaged with her surroundings, but poorly oriented and disconnected with reality.
While you talk, you ask if you can see her arm; she pulls it slightly out from the sheets. You take her wrist with one hand. Her skin is pale, dry, and slightly cool peripherally, with poor turgor. Her radial pulse is very weak and irregularly irregular.
She is able to follow commands, but physically weak. Her peripheral circulation is poor, likely secondary to both poor cardiac output (her irregular pulse is consistent with atrial fibrillation) and peripheral vascular disease.
[Initial assessment complete. Total time: 8 seconds. Her presentation is consistent with her documented history and she is likely ready for transport.]
You may notice in all this that we haven’t performed any interventions — not even a lowly nasal cannula. The initial assessment is usually taught in a “treat as you assess” fashion; if you check the airway and find it compromised, you should address it before moving on. But look how fast we moved through all this! Wouldn’t you rather bang out your initial assessment in a few seconds, then move on to your treatments having a full knowledge of the situation? If we check the airway, and go to the trouble of sizing and inserting an OPA, by the time we’re done we still have no idea about breathing or circulatory status — something that would have taken another second or two to assess at most.
Initial assessments are like a flash of lightning: you start with nothing, and with a sudden burst of light, you end up with a great deal. That flash won’t tell you the whole story, and you’ll always need to keep looking and keep digging. But with a smart and efficient initial assessment, you’ll set the stage and choose the course for everything else to come. All in under ten seconds.