This section of our NREMT Study Guide is for the medical portion of the exam, which, combined with obstetrics & gynecology, accounts for 27%–31% of the total content. These topics carry the highest percentage of questions on the exam, so it’s important to have a good understanding of the material. In this section you will learn how to identify the nature of illness in a patient having a medical emergency, the different steps involved when performing a patient assessment, how to manage patients experiencing a medical emergency, and deciding on a transport destination.
After you have completed your review, you will find five practice questions to test your understanding and retention of the material you have read.
Nature of Illness (NOI)
As an EMT, the calls you run will be medical, trauma, or both. For example, you could have a patient with low blood sugar become unconscious behind the wheel and crash their car, causing traumatic injuries, but there is still an underlying medical emergency that must be addressed.
When assessing a patient experiencing a medical emergency, you will take a somewhat different approach than with a trauma patient. The assessment order will remain the same, but you will focus on the general type of illness the patient is experiencing, also known as the nature of illness (NOI), rather than the mechanism of injury (MOI), which is used when assessing trauma patients.
The NOI is the general type of illness the patient is having, which is best described by the patient’s chief complaint. If the patient is unable to communicate, the nature of illness can be determined by talking with the patient’s family or bystanders, who can explain why 911 was called. For example, you may ask the patient what is bothering them or why EMS was called. If they respond that they are having trouble catching their breath, their nature of illness would be difficulty breathing. The importance of determining the NOI is to help direct your assessment and treatment of the patient.
Patient Assessment
Assessing your patients is one of the most important skills you can develop as an EMT. This essential skill is used in every patient interaction and is the basis for the treatment you will provide. The patient assessment process is divided into five main parts:
- Scene size-up
- Primary assessment
- History taking
- Secondary assessment
- Reassessment
While these steps represent a logical approach to your patient assessment, the order in which you perform them may change depending on the patient’s condition and the environment in which you find your patient.
Scene Size-Up
The most important lesson EMTs and other first responders are taught is to keep yourself safe. Your safety and the safety of your partner and crew are of the utmost importance when working in EMS. If you become injured or killed while helping a patient, you become another victim and put more strain on the system.
The scene size-up starts with the call from dispatch, taking mental notes about what you may find when you arrive on scene. As you approach the scene, look for the number of vehicles in the drive, unrestrained dogs, crowds of people, downed power lines, uneven sidewalks or other surfaces, people with obvious weapons, or anything else that looks unusual.
Listen for sounds like yelling, gunshots, dogs barking, or other loud and unusual noises. If the scene is not safe or you feel uncomfortable for any reason, ask dispatch for law enforcement to respond and retreat to a safe location.
Once you have determined the scene appears safe to enter, you will go to your patient’s location. If they are indoors, look for obvious weapons, illegal drugs, prescriptions, or drug paraphernalia. Take notice of their living conditions, which can offer clues about what may be causing their medical emergency.
Before any patient interaction, remember to take standard precautions to further protect yourself and your patient. When at the patient’s side, determine the NOI. If there are multiple patients or you need additional resources for your patient, notify dispatch at this time. After you have performed your scene size-up, you can move on to the primary assessment.
Primary Assessment
The goal of the primary assessment is to quickly identify and treat immediate life threats. When greeting the patient, you want to form a general impression of them and assess their airway, breathing, and circulation (ABCs), as well as their level of consciousness (LOC). The patient will either be unconscious, conscious with an altered LOC, or conscious without an altered LOC. To determine their orientation, which tests the patient’s mental status, you will ask them four questions to determine their ability to remember these four things:
- Person: Does the patient remember their name?
- Place: Can the patient remember where they are?
- Time: Does the patient know the year, month, and approximate date?
- Event: Can the patient tell you what led up to EMS being called?
If the patient can answer all four questions accurately, they are described as alert and oriented times 4, or A&O x 4.
You will not take a full set of vital signs until the secondary assessment, but you will look at their respiratory rate and feel a pulse, which is part of the ABCs. If you identify an imminent or immediate life threat, work to correct the issue before moving on.
When approaching a conscious patient, be sure to introduce yourself and approach where they can see you so you do not startle them. Identify yourself as an EMT and that you are there to assist them. Ask if they would like your help, which gives you expressed consent.
As you form your general impression, you will note the patient’s approximate age, sex, level of distress, race, and overall appearance. Sex and race are important because women and men have different signs and symptoms for certain medical conditions, and different races are predisposed to specific conditions. These are used as clues to help you identify what medical condition might be troubling the patient.
History Taking
While history taking is listed after the primary assessment, it can be started while the primary assessment is being performed. Your partner or another first responder might start by gathering information from bystanders or family members. Ask what provoked the call to 911, the patient’s medical history, what medications they are prescribed, and if they have any allergies. History taking provides important details about the chief complaint and past medical history, and it can help determine how to best treat the patient.
The mnemonic SAMPLE is used by EMTs to help remember the questions to ask when obtaining the patient’s history. SAMPLE stands for:
S: Signs and symptoms
A: Allergies
M: Medications
P: Pertinent past medical history
L: Last oral intake
E: Events leading up to the illness
When taking the patient’s history, you want to document your findings for your patient care report (PCR). You will ask their name, age, and date of birth and record what medications the patient takes and any known allergies. You will also document the patient’s vital signs when taken during the secondary assessment, the time the vitals were taken, and what treatment you provided.
Secondary Assessment
The secondary assessment can be performed on scene if the patient is stable or en route to the hospital if the patient is unstable. The purpose of the secondary assessment is to focus on the patient’s chief complaint, also called a focused assessment. The patient’s chief complaint will dictate what aspects of the physical exam will be performed. The following guidelines help you determine how and what to assess during your exam.
- Inspection: Inspect your patient for abnormalities, such as an increased respiratory rate or pale skin.
- Palpation: Touch the patient to determine abnormalities, such as palpating the patient’s abdomen when they complain of abdominal pain.
- Auscultation: Listen (auscultate) to sounds the body makes using a stethoscope. Auscultation refers to listening to breath or heart sounds or measuring a patient’s blood pressure.
The goal of your focused assessment is to concentrate on the body system(s) associated with the patient’s chief complaint. For example, if the patient has chest pain and shortness of breath, you will focus on the patient’s cardiovascular and respiratory systems.
During the secondary assessment, you will obtain a complete set of vital signs (vitals) if your partner has not already done so while you were obtaining the patient’s history. You will take their pulse, blood pressure, and respiratory rate. You will also place the patient on oxygen, attach a heart monitor, and assess their blood sugar and pulse oximetry based on their chief complaint.
Reassessment
The reassessment is performed en route to the hospital and is performed every 5 minutes for unstable patients and every 15 minutes for stable patients. You will reassess and document the patient’s vital signs, reassess their chief complaint (is it better or worse), and note the effects of the treatment provided. If the patient is getting better, continue with your treatment. If the patient’s condition is deteriorating, adjust your treatment plan and notify the receiving hospital of the patient’s condition.
Patient Management and Transport Destination
As an EMT, you are limited in how you can manage a medical patient in the field. Most medical patients will need an accurate diagnosis and a higher level of definitive care in a hospital setting. After you perform your primary assessment, you will determine if your patient is a low, medium, or high-priority patient, which will determine your on-scene time, the type of transportation the patient needs, and where they will be taken to receive the care they need.
Scene Time
The time you spend on scene with a patient depends on their priority level. If the patient is stable, you may spend more time on scene taking the patient’s history and performing your secondary assessment. If the patient has any of the following medical conditions, they will be considered a high-priority (critical) patient and must be transported immediately:
- Unconscious/unresponsive
- Difficulty breathing
- Complicated childbirth
- Severe chest pain
- Poor skin signs or other signs of poor perfusion
- Altered level of consciousness
- Severe pain
- Uncontrolled bleeding
- Poor general impression
Critical patients always require rapid transport, and your on-scene time should be 10 minutes or less. When you have a trauma patient, you are taught about the “Golden Hour” or “Golden Period.” These terms refer to the time of injury or onset of illness to definitive care, where the patient has a stronger chance of survival. These terms also apply to medical patients. If a patient has a heart attack, stroke, diabetic emergency, or another critical condition, you should aim to have them at the hospital within one hour of the onset of symptoms.
Selecting the Destination
Most jurisdictions will advise you to transport the patient to the closest emergency department (ED). However, sometimes the closest ED is not the most appropriate destination for the patient. You may have a patient with stroke-like symptoms who needs a hospital that is capable of performing catheterization, but the closest ED does not have that available at their facility. Or, you could have a pediatric patient having a medical emergency who needs a children’s hospital.
For these reasons, you must learn what each hospital in your jurisdiction is capable of. You should know which hospitals can handle pediatric emergencies, strokes, heart attacks, and complicated childbirth. If you have questions regarding if the closest hospital can receive the patient, call medical control for advice. It is best to travel to a further and more appropriate destination rather than waste time taking the patient to the closest ED that does not have the resources to treat the patient.