Mastering The Head-To-Toe Assessment

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. 

Read More Goodness:

Test For Unconsciousness: The Hand-Drop

Five Big Trauma Scene Mistakes You Can Avoid

5 Assessment Findings That Should Concern You

The EMT Code of Ethics

Beyond The 1-10 Pain Scale

Comments

  1. For your first point, I’m not exactly sure why you would do a head to toe on some of those patients. The infant I can understand, because it is smaller and weaker. But if the person tripped and fell at the mall, or the person getting punched doesn’t seem like it would necessitate one. My instructor told me that head to toe assessments are used when their is a major mechanism of injury. If there is a major MOI, then its likely that there are other injuries that could be overlooked by not assessing the whole body. Are you taking a better safe than sorry approach, or is there another reason?

  2. Sean Fontaine says:

    Steve,
    I’ve had preceptors and partners reinforce over the years the wealth of information and numerous benefits of a quick head to toe exam. I say quick because I’ve learned to go head to toe in less than sixty seconds, allowing me to assess pulse (rate and quality), cranium, CTLS spine/back, axillary regions (for stab/gunshot wounds), chest, respiratory effort/retractions, abdomen, pelvis, and extremities. This is a cursory head to toe though, often performed with the patient standing or seated in a chair, if nothing is found I still follow up w/a more thorough exam enroute once they are on the pram. Just as any set of vitals should have breath sounds, I agree that you will always find out more about your patient’s condition from a head to toe assessment, whether or not they have a substantial MOI.
    The point of interacting w/your patients is great, many providers don’t fully engage their patients and as such don’t develop that quick, essential rapport to have people trust that you are treating them w/their best medical interests in mind.

  3. Medtech21 says:

    Why would the other two examples NOT be a good reason to do a head to toe. Especially on the guy in the bar fight. Just because you can see the obvious punch to the face, alcohol tends to cause people to mask their symptoms and sometimes unconciously. Whats to say he wasnt kicked in the ribs and stomach 5 times after the punch knocked him out briefly. But because he is drunk doesnt remember or feel it till you palpate it. A lot of people get the idea that a trauma patient needs to have obvious signs of trauma or MOI, but all in all, injury is trauma. In my opinion, a focused assessment is really only for true medical patients.

  4. Sean Fontaine says:

    Medtech21 I agree w/your thoughts on this, the presumed mechanical slip/fall @ the mall could be as a result of a CVA, arrythmia, or just simply be a geriatric pt who sustained a humoral/femoral head or hip fracture from their seemingly innocuous fall and don’t show pain due to neuropathys. The drunk has decreased pain sensation and may not tell the whole story for any number of reasons, drunks and assaults always need a head to toe, especially when it was the drunk who was assaulted and has every reason to hope we don’t assess them.
    Good post Steve, this is a skill that is somewhat glossed over in EMT-B class, where it should be reinforced.

  5. Steve Whitehead says:

    Jeremy, I appreciate your comment and I’m glad that it was first in the string because what you were taught is a perfect example of the problem I’m describing. If you wait for your major mechanism injuries and those are the only patients who get the head-to-toe, your head-to-toes are going to suck. It’s never going to be natural.

    I thought the kid was the least likely to need the head-to-toe in my three examples. babies may be smaller but I’d disagree with your weaker statement. Kids are amazingly resilient in trauma. A kid in a car seat in a low mech injury is still going to get the head-to-toe in my book. But the drunk assault and the fall down the stairs? They’re getting the full-court-press. For all the reasons that Sean and MedTech already said.

  6. In my EMT class, we were taught that if you really want to learn something and learn it to the point that you have unconscious confidence, you need to practice it until you are sick of it and then do it 20 more times. Rapid physicals are “key”, because you always want to err on the side of benefiting your patient.. There could always be something that you missed, and it doesn’t help anyone when you miss something.

  7. It all comes down to communicating with your pt. If you are not prepared to do so, then maybe EMS isn’t for you. Obviously you can’t communicate with an unconscious pt. However, if you have been conversing with as many pts as possible while doing your quick head-to-toe exams, when you come to a pt who can’t talk and tell you what hurts, you’ll know what to do, what to look and feel for, how to feel for it, and you’ll know when you see or feel something not right. If you don’t communicate and take the opportunity to do H-T-T’s, when you come to that unconscious trauma pt, you may miss something that could cost that pt their life.

  8. Steve Whitehead says:

    @Kevin I agree. When researches examined the difference between musical virtuosos and average musicians they found that the one key difference was their shear tolerance for repetition and practice.

    @Amy Agreed.

  9. For the record, I did work somewhere where this wasn’t the case–but that was because most patients didn’t get any sort of hands-on assessment. If it wasn’t an unconscious trauma patient, nobody really laid hands on.

    Need a pulse? That’s what the pulse-ox is for.

    Here was my head-to-toe: “Where do you hurt, sir.”

    Amazing I didn’t bring in more dead bodies… or maybe I did.

  10. Midnight Cassiopeia says:

    Thanks Steve!! I’m in an OEC class, and my Dad pointed out your site to me. It’s really helpfull, but this on? It’s even more so!! Thanks sooooooo much!!!