Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
SCENARIO 1 - RAPID TRAUMA ASSESSMENT (MARK QUESTION N/A)
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Dispatch Info – You are dispatched to Gunpowder Falls State Park for a trauma injury. On arrival you are directed to a nearby trail and find an 18 y/o white male lying supine next to a large rock with a bicycle lying next to him. He is not wearing a helmet and appears to be unconscious. <br><br>Scene Safety – No obvious hazards present<br><br>BSI – (Student should be wearing gloves and verbalize any other BSI considered)<br><br># Pt’s – 1<br><br>MOI/NOI – Bicycle Accident with potential spinal injury<br><br>Additional Resources – (Student should request an Engine & ALS)<br><br>General Impression – 18y/o white male, 135 lbs, poor condition<br><br>AVPU – Unconscious (Student should attempt to determine patient status)<br><br>Airway – Gurgling is heard on inspiration (Student should open airway using modified jaw thrust & verbalize suctioning patient). Suctioning does resolve blood in airway. There was also broken teeth removed during suctioning.<br><br>Breathing:<br>Rate – 30<br>Rhythm – Regular<br>Quality – Shallow, rapid<br><br>Circulation:<br>Rate – 122 (Student should check carotid and radial pulses simultaneously)<br>Rhythm – regular<br>Quality – Thready<br><br>Dense Bleeding – None noted<br><br>Patient Priority – (Student should verbalize patient as a PRIORITY 1)<br><br>Rapid Trauma Assessment (Student should verbalize DCAP-BTLS)<br>HEENT – (Fluid, Pupils, Crepitis) Pupils are PERRL, no fluid, no other findings.<br>NECK – (Crepitis, JVD, TD, Stoma, Medic Alert); No findings; (Student should size and place cervical collar)<br>CHEST – (Lung Sounds, Paradoxal Movement, Crepitis). (=) L/S, (=) Chest Rise, no other findings.<br>ABD – (Rigidity, Distension, Guarding). (+) Rigidity ULQ, ½ dollar sized contusion RLQ.<br>PELVIS – (Crepitis, Pelvic Stability) Pelvis is stable; (Student should complete 3-point stability check on pelvis).<br>GROIN – (Blood, Urine, Feces, Fluid, Foreign Obj) No findings.<br>LOWER EXTREM – (Crepitis, PMS); (-) Pulse (L) leg, Obvious deform of (L) Tib/Fib. (Student should note injuries and move on)<br>UPPER EXTREM – (Crepitis, PMS); (+) Pulses both extrem, deformed (R) Radius/Ulna.<br>BACK – (Crepitis); No findings.<br><br>Vital Signs<br>Pulse – 122 Thready<br>Respirations – (12 IF BVM ventilations started by student during airway assessment) or (30 and very labored if no BVM)<br>B/P – 92/64<br>Skin – Pale, cool, diaphoretic<br>PSO2 - 99% if BVM / 86% if no BVM<br>B/S – 122 dL<br><br>Detailed Physical Exam – (Student should verbalize completing an in-depth full assessment)<br><br>Ongoing Assessment:<br>Reassess ABC’s – Airway is intact, breathing controlled through BVM ventilations, pulse is regular and decreased to 92. <br>Check Interventions – BVM ventilations continue without issue.<br>Reassess Vital Signs – P-92, R-12 (BVM), B/P-102/68, Skin- Pale, cool, diaphoretic, B/S-118 dL<br>Consult with Hospital – (Student should verbalize intention to consult)
INITIAL ASSESSMENT
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Determines SCENE SAFETY.
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Demonstrates proper BSI
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Determines the NUMBER OF PATIENTS.
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Determines the MOI / NOI.
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Initiates (considers) SPINAL STABILIZATION.
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Requests (considers) appropriate ADDITIONAL RESOURCES.
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Determines the patient's level of responsiveness. AVPU
PRIMARY ASSESSMENT
Circulation
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Determines the RATE, RHYTHM, & QUALITY of circulation.
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Assesses SKIN (Color, Temperature, Condition)
Airway
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Determines if the AIRWAY IS OPEN and patent.
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Inserts an AIRWAY ADJUNCT if appropriate.
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SUCTIONS patient's airway if appropriate
Breathing
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Determines the RATE, RHYTHM, & QUALITY of breathing.
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Applies OXYGEN using the appropriate device and at the correct flow rate.
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Demonstrates / Ensures proper VENTILATION of patient.
Dense Bleeding
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Assesses / Controls DENSE BLEEDING.
Patient Priority
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Identifies patient PRIORITY/ Makes transport decision
FOCUSED ASSESSMENT & PHYSICAL EXAM
Rapid Trauma Assessment
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HEENT -Iinspects and palates the scalp and ears.
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HEENT - Assess the eyes and PUPILS.
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HEENT - Assess the face including oral and nasal areas
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NECK - Inspects and palates the neck.
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NECK - Assess for JVD.
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NECK - Assess for TD.
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NECK - Assess for STOMA.
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NECK - Assess for MEDIC ALERT necklace.
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NECK - Sizes and applies appropriate CERVICAL COLLAR.
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CHEST - Inspect and palate chest
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CHEST - Auscultate LUNG SOUNDS.
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CHEST - Assess for PARADOXICAL MOVEMENT.
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ABD - Inspect and palate abdominal region.
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ABD - Assess for RIGIDITY.
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ABD - Assess for DISTENTION.
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ABD - Assess for GUARDING.
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PELVIS - Assess PELVIC STABILITY (Three point assessment)
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GROIN - Inspect groin for BLOOD
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GROIN - Inspect groin for URINE.
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GROIN - Inspect groin for FECES.
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GROIN - Inspect groin for FLUID.
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GROIN - Inspect groin for FOREIGN OBJECTS.
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EXTREM - Inspects / Palpates all four extremities.
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EXTREM - Assess PMS (all extremities).
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BACK - Inspects / Palpates posterior surface.
Vital Signs
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Assess PULSE
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Assess RESPIRATIONS.
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Assess BLOOD PRESSURE (BP)
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Assess SKIN (Color, Temperature, Condition)
SAMPLE / OPQRST
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Obtains SAMPLE History
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Obtains OPQRST
DETAILED PHYSICAL EXAM
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Verbalized completion of detailed physical exam.
ONGOING ASSESSMENT
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Repeats INITIAL & PRIMARY ASSESSMENTS.
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Repeats FOCUSED ASSESSMENT based on patient complaints.
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Checks INTERVENTIONS.
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Re-assesses VITAL SIGNS (5 min for unstable / 15 min for stable patients)
EVALUATOR FEEDBACK
Critical Fail Points (If answered YES Evaluator must explain in detail)
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Failed to take BSI precautions.
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Failed to determine SCENE SAFETY.
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Failed to consider C-SPINE STABILIZATION (If applicable)
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Completion of rapid trauma assessment or detailed assessment before initial or primary assessment.
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Failed to ensure adequate ventilation.
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Failed to initiate / delayed initiation of OXYGEN delivery.
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Failed to initiate rapid transport on critical patient.
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Failed to find or address LIFE THREATS or CHIEF COMPLAINT.
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Failed to assess / control MAJOR BLEEDING.
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VITAL SIGNS are outside of allowable 10 point range
SCENARIO 2 - FOCUSED ASSESSMENT (MARK QUESTION N/A)
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Dispatch Info – You are dispatched to 1325 Church Road for a chest pain patient. On arrival you find a 84 y/o Hispanic female sitting in her garden in front of a large single family home with a well kept yard. <br><br>Scene Safety – No obvious hazards present<br><br>BSI – (Student should be wearing gloves and verbalize any other BSI considered)<br><br># Pt’s – 1<br><br>MOI/NOI – CHest Pain<br><br>Additional Resources – (Student should request ALS)<br><br>General Impression – 84 y/o Hispanic female, 155 lbs, good condition<br><br>AVPU – Alert (Student should attempt to determine patient status)<br><br>Airway – Open and patent<br><br>Breathing:<br>Rate – 18<br>Rhythm – Regular<br>Quality – Mild dyspnea<br><br>Circulation:<br>Rate – 68 (Student should check carotid and radial pulses simultaneously)<br>Rhythm – regular<br>Quality – bounding<br><br>Dense Bleeding – None noted<br><br>Patient Priority – (Student should verbalize patient as a PRIORITY 1)<br><br>Vital Signs<br>Pulse – 68 regular<br>Respirations – 18<br>B/P – 108/64<br>Skin – Pale, cool, diaphoretic<br>PSO2 - 99% on NRB / 90% if no NRB<br><br>SAMPLE:<br>S- CP in mid-sternum radiating to left arm<br>A - Sulfa drugs, bee stings<br>M - Nitroglycerin, Lipitor, Norvasc, Prozac<br>P - Angina, hypertension, high cholesterol, anxiety disorder<br>L - Lunch (PB&J sandwich) at 1:30 pm<br>E - Gardening in the front yard<br><br>OPQRST:<br>O - 20 mins ago<br>P - nothing can change the pain<br>Q - sharp and squeezing<br>R - Left shoulder and arm<br>S - 8/10<br>T - 20 mins / Took 2 nitro PTA of EMS and it has not helped!<br><br><br>Detailed Physical Exam – (Student should verbalize completing an in-depth full assessment)<br><br>Ongoing Assessment:<br>Reassess ABC’s – Airway is intact, breathing controlled, pulse is regular and has maintained at 68. <br>Check Interventions – High flow O2 via NRB has helped the dyspnea. Increased PSO2 to 99%<br>Reassess Vital Signs – P-70, R- 16 (NRB), B/P-102/68, Skin- Pale, cool, diaphoretic<br>Consult with Hospital – (Student should verbalize intention to consult)
INITIAL ASSESSMENT
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Determines SCENE SAFETY.
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Demonstrates proper BSI
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Determines the NUMBER OF PATIENTS.
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Determines the MOI / NOI.
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Initiates (considers) SPINAL STABILIZATION.
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Requests (considers) appropriate ADDITIONAL RESOURCES.
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Determines the patient's level of responsiveness. AVPU
PRIMARY ASSESSMENT
Airway
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Determines the RATE, RHYTHM, & QUALITY of breathing.
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Inserts an AIRWAY ADJUNCT if appropriate.
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SUCTIONS patient's airway if appropriate
Breathing
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Determines the RATE, RHYTHM, & QUALITY of breathing.
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Applies OXYGEN using the appropriate device and at the correct flow rate.
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Demonstrates / Ensures proper VENTILATION of patient.
Circulation
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Determines the RATE, RHYTHM, & QUALITY of circulation.
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Assesses SKIN (Color, Temperature, Condition)
Dense Bleeding
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Assesses / Controls DENSE BLEEDING.
Patient Priority
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Identifies patient PRIORITY/ Makes transport decision
FOCUSED ASSESSMENT & PHYSICAL EXAM
Vital Signs (ALL must be within 10 of actual - Evaluator to document ACTUAL & STUDENT ASSESSED vital signs)
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Assess PULSE
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Assess RESPIRATIONS.
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Assess BLOOD PRESSURE (BP)
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Assess SKIN (Color, Temperature, Condition)
SAMPLE
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Signs & Symptoms
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Allergies
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Medications
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Past Medical History
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Last Oral Intake
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Events leading to illness / injury
OPQRST
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Onset
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Provocation
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Quality
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Radiation
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Severity
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Time / Trending
DETAILED PHYSICAL EXAM
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Verbalized completion of detailed physical exam.
ONGOING ASSESSMENT
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Repeats INITIAL & PRIMARY ASSESSMENTS.
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Repeats FOCUSED ASSESSMENT based on patient complaints.
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Checks INTERVENTIONS.
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Re-assesses VITAL SIGNS (5 min for unstable / 15 min for stable patients)
EVALUATOR FEEDBACK
Critical Fail Points (If answered YES Evaluator must explain in detail)
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Failed to take BSI precautions.
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Failed to determine SCENE SAFETY.
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Failed to consider C-SPINE STABILIZATION (If applicable)
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Completion of focused assessment or detailed assessment before initial or primary assessment.
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Failed to ensure adequate ventilation.
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Failed to initiate / delayed initiation of OXYGEN delivery.
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Failed to initiate rapid transport on critical patient.
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Failed to find or address LIFE THREATS or CHIEF COMPLAINT.
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Failed to assess / control MAJOR BLEEDING.
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VITAL SIGNS are outside of allowable 10 point range
General Comments
Suggested Student Outcome
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Student A
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Student B
Evaluator Signature
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Evaluator
