Let’s talk patient assessment. If we look back at the progress of aerial rescue (AR), we can see the industry trending toward an emphasis on the patient and their condition rather than getting up the rope and back down with the patient as quickly as possible. My point is, the emphasis on speed alone can do a disservice to the victim as much as doing nothing and waiting for help to arrive. The actions we take can improve the situation or may make it drastically worse.
The progression of the AR has now incorporated the patient’s injuries and condition into the scenario. What does that mean for us? During the AR climbing competitions, we verbalize assessing the patient. Hopefully we’re observing the things we are saying, such as, “The patient is breathing and has a pulse.” Did we actually observe these findings, or are we conditioned to vocalize out loud what we need to have checked off on the score sheet? Do we know what we are looking at? Are we handling the patient gently so as not to make potential injuries worse? Are we in go-mode and muscling them into position as fast as possible to score the extra points for speed? Did what we do potentially make the situation worse?
I have observed the very best of AR’s turn into an absolute disaster for the victim due to patient handling. Train how you work! Competition AR is a training event, regardless of your view on playing “the game” of competitive tree climbing. If you practice questionable methods, when the actual emergency occurs, you’re likely to revert back to what you know. If you are yanking the dummy around like a rag doll, oblivious to what you would be doing to a real patient with real injuries, this will be what you do under the stress of a job-site accident. Trust me. After 25 years as a career firefighter and almost 30 years as a paramedic, I’ve observed this to be a consistent outcome. Shortcuts in training lead to the same shortcuts under the real-life stressors of an incident.
Patient assessment can appear a daunting task. The amount of training and information input can be intimidating. All the steps you must remember to check and understanding what they mean can put even the most savvy practitioner in a tailspin. At our level as arborists and tree workers, we can evaluate input based on common sense and life experiences. Just the fact that you’ve looked at other humans all your life qualifies you to perform an assessment. Do we necessarily need to have in-depth knowledge of all the processes and bodily functions that result in the findings we are seeing? At our level, the answer is no. The key to what we are looking for is to identify anything abnormal or the lack of abnormal findings when our gut tells us we should see injuries. An example can be explained in a simple scenario.
Consider a 30-foot fall from a tree. In your mind, what are you assuming? I’m assuming at least one injury, if not multiple. If they are uninjured, are you surprised? Does your gut tell you they should be injured? I’ll assume, based on my gut, that perhaps the patient has an injury that hasn’t manifested yet. Maybe it’s internal. Maybe they are in denial about the injury due to any combination of human factors. Should this patient be evaluated by competent medical personnel, or do we just get back in the tree?
Switching the scenario findings, we notice bleeding and a deformity of their leg. When we look at the injury, do we cringe and think, “Wow, that looks bad”? Would it not be prudent, based on our initial reaction, to assume it is bad? Even with no medical training, thinking it’s bad, treating it like it’s bad, is still better than assuming it’s not and finding out later that it was. In the medical community, this is called a high index of suspicion. Assume the worst. Expect injuries based on what happened. Treat for both. In this situation, you won’t kill anybody by overtreating.
Patient assessment is an organized, systematic evaluation of the patient, done with priority placed on functions essential to life. We use all our senses when assessing. Use your knowledge of the functions of maintaining life, evaluation of the events that occurred, high index of suspicion and keen observation skills to unravel this mystery. Sound complicated? With a little common sense and an organized approach, it isn’t.
The common-sense approach
The absolute foundation of a patient assessment is common sense. Think about one situation when you’ve looked at another person and intuitively known something wasn’t physically OK about them. They looked sick, pale, out of breath, hurt, intoxicated or disoriented. The first time you did this, probably at age 5, you performed your first patient assessment. Parents are astute at performing assessments on their children. You are always evaluating if they are “OK.” It really is common sense. If you see something that tells your gut that something is wrong, it probably is. If you see bleeding and think there’s a lot of blood outside the body, there probably is. If you think they are breathing too quickly, too slowly, too noisily, erratically or with increased effort, they probably are. Trust your gut!
Assessment is completed in a systematic way. Being organized and having a memorable flow keeps us on track to first work through the most important aspects necessary for survival. If we stick to this, we’ll avoid the moth-to-the-flame tendency that will throw us off our priorities and cause us to overlook life threats. You can’t go straight for the blood and ignore breathing. If you do, you will successfully control the bleeding on a person who died because they weren’t breathing or had an airway obstruction.
Initial assessment: When it all starts
When does the assessment start and how? We begin our assessment when we’re alerted to the need for help. Naturally, we ask what happened if we didn’t see it occur. This matters, because all the events leading up to this point play into the assessment. Two factors are called the Mechanism of Injury (MOI) and Nature of Illness (NOI).
These two very important pieces of information carry from the initial assessment to the highest level of medical care in the hospital. MOI can predict severity and patterns of predictable injuries. MOI indicates what we should be looking for with our high index of suspicion. NOI can provide specific medical information or a series of events that help narrow down what is actually going on.
An example of this is an allergic reaction. The patient ate something homemade by a customer and developed an allergic reaction, such as difficulty breathing, and became unconscious. The key information to relay would be, “I know my co-worker has food allergies. Soon after they ate the food, symptoms started.” This is absolutely critical information for the medical professionals. It’s not easy walking into a situation with a patient who can’t tell you anything. Imagine having to figure out why they’re sick and how to treat them with little to no information. Every little bit of information provided helps the clinician.
Scene size-up, initial assessment and the DABCs
The assessment is broken up into segments. The first one we just covered, scene size-up, meaning “what happened?” The next section is the initial assessment. This is where we evaluate the life threats, the airway, breathing and circulation, or ABCs. In all practicality, it is the DABCs, with “D” being disability or level of consciousness (LOC). When do you just walk up to someone and start touching them? We learn in CPR to shake their shoulder, shout and call for help. This prevents chest compressions on someone who’s asleep and who will probably resist you physically. From a legal standpoint, we’re preventing
assault-and-battery charges. From a medical standpoint, we are evaluating the central nervous system.
Do you think being unresponsive in a situation when a person would normally be responsive is a bad thing? Common sense tells us yes. The manifestation of LOC is important and can indicate many things. Being awake is good. In order of severity, we are looking for the LOC response: Awake and alert, awake and disoriented, not awake but arousable to voice, not awake and arousable to painful stimuli like a pinch or a sternal rub, unarousable or unconscious.
What’s causing this, for us, is not as important as us noticing abnormalities and relaying these to EMS. Details such as “was awake and then became unconscious” or “in and out of being awake” are very important observations to share. They can indicate patterns of brain injury. These findings take seconds and can happen as you’re approaching the patient.
Next we move on to Airway (A). Is it open or closed? With an open airway, there should be air moving quietly in and out of the mouth and nose. We look, listen and feel for air. Some of this is also evaluation of breathing, so we do these two steps concurrently. Breathing should not be noisy. Snoring and gurgling can indicate a partial airway obstruction that needs to be corrected immediately. The treatment for these isn’t within the scope of this article and should be gained through a formal training program. If you don’t treat airway, the patient will die.
Breathing (B) is a continuation of A. We are looking for air movement, evaluating rate, rhythm and quality. We look at chest rise and fall. If it looks shallow, it probably is. If you feel like they are breathing really quickly or slowly, they probably are. Those findings, using common sense, indicate an abnormality. Is it really necessary to know a number of breaths per minute at our level? It would be nice, but the mere fact you think it’s abnormal is a sign that it probably is. For adults, the normal breathing rate is 12 to 24 breaths a minute.
Think about how you breathe. It’s a laminar flow, in and out, in a steady rhythm. If it’s not like that, breathing is abnormal. So if it looks like the rate is not normal, the effort is not normal and quality – quality being deep breaths, shallow or hardly breathing – is not normal, those findings need to be identified and shared with medical personnel. The crux is, if you think something looks abnormal, it probably is. If you think they are trying really hard to breath or are hardly breathing, they probably are. Maybe they’re not breathing at all.
ABC-assessment findings are stop-and-fix items. You cannot sustain life without fixing these findings. So much goes into the breathing aspect to stop and fix, we are very limited with what we can do. If you lack advanced training and the patient is breathing, move on to Circulation. If the patient is not breathing and you are trained to do so, start rescue breathing.
Circulation (C) is probably the most visible and thus the easiest to get pulled into treating immediately. You must resist the urge to go directly to bleeding. If the bleeding is severe and you think you can manage the bleeding while performing A and B, then do so. It is difficult for most technicians to multitask with such critical items. Assign another person to bleeding control while you move through D, A and B.
Circulation assessment is multifaceted. The primary objective is to determine if the patient has a pulse. We are evaluating the presence of a pulse as well as rate, rhythm and quality.
A pulse is found where a superficial artery crosses over a bony prominence close to the skin. Primarily, we would be focusing on the radial and the carotid pulse. (See Graphic 1)
There are other pulses available to check, though they can be a challenge to find without practice. (See Graphic 2)
Any presence of a radial pulse in the wrist indicates a systolic blood pressure of at least 90 mmhg (millimeters of mercury, still used as the standard unit of measure). The presence of a pulse in the carotid artery indicates a systolic blood pressure of at least 60 mmhg. The loss of a radial pulse is a critical finding.
Blood pressure is the measurement of pressure in the circulatory system during contraction of the heart (systole) and the relaxation of the heart (diastole). This loosely equates to pump pressure and residual pressure. Blood pressure (BP) as a stand-alone finding is not significantly important. Vital signs such as heart rate, respiratory rate and BP are generally used for trending the body’s response to injury, illness or treatment. While heart rate and respiratory rates are important as a stand-alone finding, one single reading of a BP is of little significance.
If BP is the only indicator that the patient is in bad shape, you’ve missed the point of the assessment. There are many other indications of the patient’s status that should be evaluated before BP. Those findings would have informed you that the patient is in bad shape, and the taking of a BP would only solidify what you already discovered through the assessment.
When evaluating pulse, if you think it’s fast, it probably is. If you think it’s slow, it probably is. If you are unsure whether you feel a radial pulse, then move on to the carotid. If you’re not sure if you feel a pulse, err on the side of assuming one is not there and begin CPR, if trained. Normal adult pulse rate is 60 to 100 beats per minute.
Skin color, temp, blood sweep
Continuing with C is the assessment of skin color/temperature. Being hot when you should be cold and vice versa is an abnormal finding. Being dry when everyone else is sweaty is abnormal, as well as sweating when not appropriate. People should not appear pale, blue or gray. Those skin tones are an indication of abnormality.
During circulation, we use our hands to sweep for bleeding. If bleeding is found under clothing, the area of bleeding should be gently exposed to find the injury. Keep in mind, chain-saw pants will hold a substantial amount of bleeding before you see any evidence outside of the clothing. Be careful not to manipulate the injured area while trying to expose it. Use trauma shears or a sharp cutting instrument to expose the injury. Don’t worry about cutting clothing and gear.
Evaluate the bleeding. We’re looking for rate of bleeding and color. Dark-red blood comes from veins. It has less pressure pushing out of the body and flows or dribbles. Bright red is arterial. Arterial bleeding is a critical stop-and-treat item using direct pressure and absorbent bandages.
Arterial often spurts out of the wound every time the heart contracts. If you think there is a lot of bleeding, then roll with that impression. It’s better to assume it’s worse and be wrong. Place pressure with your hand and a thick dressing to try to absorb and slow bleeding. If the dressing becomes saturated, don’t remove and replace it. Place a fresh dressing on top of the saturated one and repeat if needed. If you are holding direct pressure, you’re stuck doing that until someone else takes over or the patient goes into cardiac arrest and you need to start CPR.
I caution the use of clotting powder and anything you put into the wound. Unless you have advanced training, you run the risk of introducing a substance and/or an unsterile item into the body. One of the main causes of death after an injury is infection. If you don’t have advanced training on a specific product, opt for direct pressure. It works.
Likewise, I caution the use of a tourniquet. If you do not have training on the use of a tourniquet, when it’s indicated and when it’s not, get the training. There are situations when the application of a tourniquet can complicate the situation and hamper full recovery. This is a deep and involved discussion and beyond the scope of this article. Advanced training is to everyone’s advantage.
The last item is the capillary refill. Capillaries are the smallest blood vessels in the body. Cap refill is an indication of circulatory status. When you squeeze the top of your index finger with one squeezing finger on the nail and the other on the fingerprint side, the nail bed should be pale when you release pressure. (Photo 1)
The nail bed should return pink within two seconds under normal circumstances. Taking longer than two seconds is indicative of circulatory problems. When weather is cold and the patient’s hands are cold, you’ll see a greater-than-two-second refill. Note the abnormality and move on.
DCAP-BTLS, focused history and physical exam
We’ve briefly covered the ABCs or DABCs. If you have time before EMS arrives, move on to a focused history and physical exam. This exam encompasses the DABCs. Those should constantly be evaluated for any changes, better or worse. Assessment is a continuous process. Once you finish one step, it doesn’t mean that step is done. DABC should be revisited frequently.
The focused exam is information gathering. For a trauma patient, we are doing a head-to-toe survey looking for additional injuries. This has the acronym DCAP-BTLS (deformities, contusions, abrasions, penetrations or perforations-burns, tenderness, lacerations and swelling). You may stop and treat any items in the assessment if you are trained and equipped to do so. The acronym is an easily memorable way of identifying all the things you need to evaluate during the head-to-toe assessment. (Graphic 3)
Patient history is also important. Inquire about medical history, medications, allergies, drug allergies, last food/drink, recent illnesses, drug or alcohol use or anything else you can think to ask. It’s important to get as much information from the patient as possible while we can. They may be unable to answer those questions once help arrives. If you’ve already gotten this for EMS, you’re greatly helping the patient in their treatment.
If possible, write everything down so you don’t forget anything. Repeat all the steps frequently and look for changes. In my opinion, one person should take lead on assessment. Others can help with treatment and documentation. Multiple people asking the patient questions simultaneously can be difficult for the patient and the assessors. That doesn’t mean you can’t provide suggestions, just don’t assess by committee. It doesn’t work efficiently. There needs to be a lead person for a fluid and organized process and to prevent chaos.
This article does not take the place of formal training but gives a solid foundation to build from. Take first aid and CPR. I suggest wilderness first aid, as it’s designed for remote medical emergencies. We may not be remote by distance, but considering the time it takes for a rescue, we should be considered remote by time and resources.
The next step would be EMT class. There’s also Wilderness EMT. Start somewhere and make a greater difference in the positive outcome of a workplace incident. If you carry advanced medical gear, know how to use it proficiently. Know when to use it and when not to.
Remember, the AR is only about the patient. Speed is only a factor. The treatment of life threats is more important than the speed to the ground. Stabilizing a patient aloft will have a greater impact than getting somebody to the ground super fast while they bleed out and die during the process. We are past time for all aspects of the AR, in competition or training, to look at it this way!
There are even occasions when it may not be in the patient’s best interest to move them to the ground. Sometimes we stabilize and wait for the trained responders. Our goal is to make things better for the patient, not worse. This subject could fill several more articles of its own accord.
Do your best. Use common sense and observation of the obvious. Identify abnormalities and describe them to EMS. Keep assessing. You really can do this! Your assessment will make a difference in patient outcome. Lastly, get some training, then train some more.
Stephen Connally is a Virginia Certified Arborist, a Certified Treecare Safety Professional (CTSP), Electrical Hazard Awareness Program (EHAP) certified, an NCCCO Articulating Boom Crane Operator, an instructor for Ascension Group Northwest and Crane Safety Climber School, a Research Climber – The
Center for Conservation Biology and The College of William and Mary, a captain with Norfolk Fire Rescue (ret.) and a Commonwealth of Virginia Paramedic (ret.)