Assessment

After getting all the basic facts about the patient and their observations, it’s time to head over and assess them fully. This is a must and there really is no substitute. We suggest 3 major steps to this process and explain the A-E approach.

1.Eyeball the patient.

If the patient is completely unknown to you (a highly likely scenario if you’re covering all medical wards), it might be sensible to “eyeball” the patient first and determine if you have time to glance over their notes. If the patient is clearly in distress, deteriorating or needs urgent assessment/ treatment, then obviously reading the notes is not the priority; crack on with the A-E assessment. 

2.Read patient notes briefly.

However, if they seem fairly stable and their observations are reasonable, it might be wise to read their notes briefly to determine the facts first-hand and see what the “day-team” (who look after the patient during the day) have said about their condition and plan. This may be an invaluable step that saves you a lot of time and ensures you provide the planned care. Whilst the patient is the expert of themselves, often they may not be the best historian and may forget to mention important medical information. So, it’s always wise to cover all bases by ensuring you read the notes at some point at least. This ensures you don’t miss vital information and can speed up your assessment of the patient, whilst giving you a preliminary idea of what to look out for.    

3.A-E assessment & Correct as you go 

This is the cornerstone of emergency medicine and should always feature in both your OSCE answers and clinical practice. A-E assessment involves assessing and correcting any problems with the patients’: Airway, Breathing, Circulation, Disability and Everything Else. There are several sources of guidance on this topic, the Oxford Handbook has a good summary and I have summarised the format I personally use in my OSCE answers below. 

Airway

Assess if the patient is safe to maintain their own airway. This assessment involves simple steps like determining if the patient is talking. If they are, then the airway is patent (open) and the patient is able to maintain it. If the patient is non-responsive, it is possible that they cannot maintain their airway. At this stage, we have to start with simple measures like a head-tilt-chin-lift (check if there is a risk of C-Spine trauma before this) and then escalate by calling the “crash team” with the view to intubate (putting a tube down their airway to connect to an external ventilator). Once you’ve dealt with this step or satisfied that their airway is patent, move on to the next step.

Breathing 

Assess the patient’s breathing by measuring respiratory rate, oxygen saturation levels and listening to their chest (for breath sounds). If you find that their oxygen saturation levels are low, then start them on 15L high-flow oxygen using a bag-valve mask (also known as non-rebreathe mask). Check if the patient is at risk of CO2 retention and what their personalised targets are. 

Circulation 

Measure the patient’s heart rate, blood pressure, listen to the chest (for heart sounds) and get an ECG trace. If there is tachycardia and/or a low blood pressure, then put in a cannula and start fluids (typically 500ml 0.9% sodium chloride over 15 mins IV bolus). Then re-assess heart rate and blood pressure and consider another bolus if things are not improving.   

Disability 

This involves assessing the degree of patient consciousness objectively. For speed, things like AVPU is used (A= alert, V=voice, P=pain & U=unconscious). A GCS (Glasgow Coma Scale) can also be used in more intensive or experienced settings. This helps you to determine if things require escalation and can they maintain their away.

Everything Else

This refers to carrying out an “emergency systems review”. This involves checking glucose levels, sources of infection and exposing the patient adequately to check if there’s anything else going on that may not be obvious.