You probably practiced your head-to-toe assessment a bunch in your EMT class. Maybe more than any other skill in the EMT curriculum. If your class was or is anything like mine (as a student or a teacher) you performed the head-to-toe assessment again and again.
As much as we practice this skill in EMT class, I often wonder why so many EMT’s have such bad head-to-toe skills out on the street. It seems that, once we get out on the street, the systematic, thorough head-to-toe assessment falls out of favor and quickly gets replaced with the faster, more direct focused assessment.
That works just fine most of the time. If it didn’t, I figure it probably wouldn’t be such a universal phenomenon. (For the record, have you ever worked somewhere where this wasn’t the case? Neither have I.) The downside is that when the patient arrives who really needs a, honest-to-goodness, rapid, complete head-to-toe, we’re not up to the task.
I happen to believe that patient assessment skills are one of the defining qualities of a talented EMT. Here are seven tips to keep your head-to-toe in top form.
1. Do head-to-toe assessments frequently.
I mean more frequently than you’re doing it right now. You have a lot more opportunities to do a a good head-to-toe than you’re currently taking advantage of right now. Drop the surprised expression. This is just you and me talking here right?
That infant in the car seat involved in the fender-bender could have used one. That trip and fall at the mall would have been prefect too and so would that dude punched in the bar fight. You let them all go without a top-to-bottom physical exam. The more you do head-to-toe exams, the more comfortable and efficient you’ll become.
2. Be systematic.
It’s called a head-to-toe for a reason. No, that doesn’t mean that you need to start at the head every time. (In fact, with kids, I recommend starting at the feet.) But you do need to have a system and stick to it. If you make up your physical exam each time you do it you’re never going to be smooth. When an emergency is in full-swing, the assessment won’t come naturally.
People tried to teach me this lesson for a long time and I don’t know why I was so slow to learn it. I guess it just seemed silly to force myself to do the assessment the exact same way every time. I’m glad I finally relented. Now I understand. If you want to be efficient when it counts, you have to be systematic.
3. Pay attention to the patient’s facial expressions during your assessment.
Sure we ask the patient if it hurts, but you’ll pick up on a lot more if you pay attention to the patients face. Are they distressed or relaxed? Are they paying attention or distracted? Do they wince or grimace during palpation? There are many reasons why a patient might try to conceal their discomfort and if you are in the habit of only looking at the body part you’re checking, you’re going to miss some stuff.
4. Interact with the patient.
I don’t just mean, breathe deep, does this hurt, yada, yada. That’s the patient interview. But it isn’t real interaction. Talk to people while you’re assessing them. Family doctors have mastered this skill, and for good reason. There’s a wealth of patient assessment information to be gained by just talking with folks about what happened, where they were going and whatever else is on their minds.
You don’t need a fancy mental status exam to figure out if people are oriented and responding in context. Just talk to them. If their brain isn’t working right you’ll figure it out.
5. Visualize the structures beneath the skin.
This requires you to know your anatomy. If you’re palpating parts of the body and you can’t visualize the structures beneath the skin, go back to your anatomy text book or try to find a cadaver lab to attend.
It’s a worthwhile skill to be able to visualize what lies beneath the patients skin and it’s essential when we are calculating the possibility or probability of injury and developing a differential diagnosis.
6. Feeling, really feeling, is harder than you might think.
Of course, we feel the patients body. Palpation is feeling. What else would we be doing? Actually most of what’s going on is looking and asking. Things that we see like bruises and abrasions are rarely missed in a proper physical assessment. Pain and tenderness is also pretty easy to pick up on. Push, “ouch”, got it.
But things that we need to feel. Things like crepitus or masses, or fever or coolness or rigidity. Those things tend to get missed. we miss them because it’s easy to go through the motions of palpation, but it requires some mental energy and practice to really feel for abnormalities.
It’s also something we never really get to practice until were doing real-deal patient assessments. In class we get in the habit of looking and pushing but you can’t really feel abnormality on a mannequin. They feel hard and plastic every time. When you’re palpating a human, focus on what you’re feeling.
7. Be confident.
Have you ever watched an ER physician do a physical exam? Pay attention the next time you get an opportunity. Watch not only the types of assessments they do but the manner in which they move from one assessment to the next, interacting with the patient, describing the needed behaviors or responses.
ER physicians do thousands of patient assessments and it shows. They don’t need to think about the next step in the process. They just do it. It’s the same way a short order cook doesn’t need to think about the ingredients in your Denver omelet. It’s the same way a professional baseball pitcher doesn’t need to think through the steps to throw a slider. They have reached a level of unconscious competence.
When you’re working on your head-to-toe technique, strive for that level of unconscious competence. Where you are confident in your ability because you know what comes next without ever needing to think about it. At that level of ability you can really focus on what you’re seeing, feeling and hearing.
I said it at the beginning but it bears repeating. Your physical assessment skills are one of the defining qualities of your patient care ability. When I’m evaluating a new EMT or paramedic, one of the first things I want to see them do is perform a complete head-to-toe assessment.
Performing that skill well, with calm confidence, is one of the hallmarks of a good EMS provider. It is an essential, foundational skill that speaks volumes about your ability. Could yours use a tune-up?
Now it’s your turn: Have you ever known a really good EMT who couldn’t do a near-perfect head-to-toe assessment? Have you ever known a really bad one who could? What are your tips for mastering this skill? Other readers would like to know. Leave a comment and help make this post even better.
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