Trauma Assessment,Documentation and Communication

MOD-3 is the first assessment module. Traditionally it has been difficult to learn since it takes a lot of memorization. Students often feel overwhelmed. Breaking the assessment up into smaller sections is useful. My recommendation is to have the student take the test skill sheet and commit it to memory. There are various ways of doing this but my favorite is to copy it by hand many times till you can write it down from memory.

There are 10 lessons in this module which should cover approximately 21 hours. Our traditional course is taught in 3 hour sessions so this makes for 7 classes.

Lesson 3-1 Scene Size-Up

Enhance the EMT Basic's ability to evaluate a scene for potential hazards, determine by the number of patients if additional help is necessary, and evaluate mechanism of injury or nature of illness. This lesson draws on the knowledge of Lesson 1-2.

Lesson 3-2 Initial Assessment

Provides the knowledge and skills to properly perform the initial assessment. In this session, the student will learn about forming a general impression, determining responsiveness, assessment of the airway, breathing and circulation. Students will also discuss how to determine priorities of patient care.

Lesson 3-3 Focused History and Physical Exam - Trauma Patients

Describes and demonstrates the method of assessing patients' traumatic injuries. A rapid approach to the trauma patient will be the focus of this lesson.

Lesson 3-4 Focused History and Physical Exam - Medical Patients

Describes and demonstrates the method of assessing patients with medical complaints or signs and symptoms. This lesson will also serve as an introduction to the care of the medical patient.

Lesson 3-5 Detailed Physical Exam

Teaches the knowledge and skills required to continue the assessment and treatment of the patient.

Lesson 3-6 On-Going Assessment

Stresses the importance of trending, recording changes in the patient's condition, and reassessment of interventions to assure appropriate care.

Lesson 3-7 Communications

Discusses the components of a communication system, radio communications, communication with medical direction, verbal communication, interpersonal communication, and quality improvement.

Lesson 3-8 Documentation

Assists the EMT Basic in understanding the components of the written report, special considerations regarding patient refusal, the legal implications of the report, and special reporting situations. Reports are an important aspect of prehospital care. This skill will be integrated into all student practices.

Lesson 3-9 Practical Skills Lab: Patient Assessment

Integrates the knowledge and skills learned thus far to assure that the student has the knowledge and skills of assessment necessary to continue with the management of patients with medical complaints and traumatic injuries.

Lesson 3-10 Evaluation: Patient Assessment Module

Conduct written and skills evaluation to determine the student's level of achievement of the cognitive, psychomotor and affective objectives from this module of instruction.

MOD-3 usually has only a single practical test along with a written test. Occasionally our program ran short of time in MOD-1 for vitals practice so we will test vitals in this module although this is not what is called for in the national curriculum program.

The MOD-3 practical test involves a single student performing a patient assessment on a live patient. We supply oxygen equipment as well as a blood pressure cuff and a stethoscope. In actuality if we have a large number of students to evaluate we may verbalize vitals and oxygen use but we supply the equipment to help remind the student they can use the equipment if necessary.

I usually give some initial instruction to the student prior to the actual assessment. It is something of the form:

You are going to be evaluated in the MOD-3 patient assessment module. You have ten minutes to complete this evaluation. You may use any equipment set before you or request any additional equipment not present. Any information that you would normally see upon arrival will be given to you. I will answer any questions as though I was the patient. You may assume that you have an equally trained partner with you. Please remember that I can not read your mind. You may decide not to perform a procedure or assessment - and that may be the correct action depending on the scenario - but I do not know if you made a decision or forgot something. In either case if you say nothing you will fail the point. Please if you make a decision please let me know. Are you ready?

This rather stern message is to let the student know that they need to say things pertinent to the assessment. For example, if the scenario does not involve a significant mechanism of injury and the patient has good skin color, condition and temperature the student may decide not to use oxygen. This may be correct but if they don't mention that fact then I assume they forgot and they fail a critical portion of the assessment.

I will then provide a scenario. I have used this scenario for many years:

You and your partner have arrived on scene of a motor vehicle crash with roll-over and patient ejection. You find a patient laying motionless and supine on the sidewalk. The time is 13:00 and the police have cordoned off the scene. Please begin your assessment.

There are several objectives to this assessment. First if the patient is lying supine then it is easier for the student to make the assessment. Next, the time is during the day so it is daylight and the patient has been involved in a roll-over with ejection so there is a significant mechanism of injury. This should prompt a rapid assessment. Finally since the patient is on the sidewalk, out of traffic the scene is safe.

When testing MOD-3 I look to see if the student mentions or uses BSI. I also want them to consider and then take up cervical spinal immobilization. I want to see that the scene size up is completed before the initial assessment. During the initial assessment I want to see the student open the airway, look, listen and feel (the patient is always breathing in my MOD-3 assessments) and have them insert an oropharyngeal airway. I then hope to see them add 100 % oxygen via a non-rebreather (my patients always breath with a normal rate during assessment evaluations). Finally I want to see some evaluation of breath sounds or chest rise. The student should finish off the initial assessment with a radial pulse, blood sweep and skin assessment. They need to mention that this is a high priority patient.

The student next gets to pick an assessment. The choices are focused trauma, rapid assessment, detailed assessment or ongoing assessment. Of course the correct choice is a rapid assessment. If they pick this assessment I make them perform the assessment. When completed they need to take vitals. If I am pushed for time I will let them verbalize vitals. I then want to see an attempt at SAMPLE history.

Finally I want to see what they would do after the rapid assessment. Whether they would perform a focused assessment or the ongoing assessment. I usually do not let them perform a detailed assessment since the rapid assessment is so similar.

The MOD-3 skill sheet shows the student what to study. The written test covers assessment and documentation and communication.

Click here to download a Free sample MOD-3 quiz and skill sheets
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