Bad Assessments Kill Good Medicine

Assessments: The Foundation We Build Everything On

In EMS, we love interventions. Tubes, drugs, monitors, gadgets, lights and sirens. They’re flashy. They feel productive. But none of that matters, none of it, without a solid patient assessment. You cannot out-treat a bad assessment.

Assessment is not the thing we do before the real work. Assessment is the work.

Every treatment plan, every differential diagnosis, and every transport decision you make comes directly from how well you assess your patient. If your assessment is sloppy, rushed, or inconsistent, your entire plan is built on sand.

Why Standardized Assessments Matter

Having a standardized, repeatable, and detailed methodology to assessing patients is how we stay consistent under pressure.

When chaos is high and time is short, your assessment process should be automatic. You shouldn’t be “thinking about what to do next”—your hands and brain should already know the flow.

A standardized approach:

• Prevents missed injuries and subtle findings

• Creates cleaner handoffs and documentation

• Allows trends to be recognized over time

• Builds defensible medical decision-making

• Separates guessing from clinical reasoning

  
  

Good assessments turn information into insight.

Hickam’s Dictum: The Reality Check

“A patient can have as many diseases as he damn well pleases.”

This is where a lot of providers get burned.

We love clean answers. One cause. One problem. One fix. Reality doesn’t work that way.

The shortness of breath patient might have:

• CHF and pneumonia

• COPD and sepsis

• Anxiety and hypoxia

• Trauma and intoxication

  
  

If you stop assessing once you find something, you risk missing the other thing that actually kills them.

Good assessments acknowledge that patients are messy, complicated, and rarely fit into neat boxes. You're not treating patients. You're treating your assessment.

Types of Assessments (And When to Use Them)

Focused Assessment

A focused assessment is exactly what it sounds like—centered on the chief complaint.

This is typically your primary and early secondary assessment, especially when time matters.

Key principles:

• Start with orientation and mental status

• Gather a SAMPLE history

• Assess systems related to the complaint

• Divide tasks when possible—one provider on vitals, one on assessment

  
  

Focused doesn’t mean rushed. It means intentional.

Comprehensive (Head-to-Toe) Assessment

A comprehensive assessment is your safety net.

This is usually done:

• After a focused assessment

• In stable patients

• In multi-system trauma

• When the story doesn’t match the presentation

  
  

A true head-to-toe means every system, typically starting neurologic and working downward. The goal isn’t speed, it’s nothing missed.

What “Good” Assessment Actually Looks Like

You don’t need a 20-minute exam. You need a deliberate one.

Here are examples of strong assessment habits without drowning in minutiae:

Neurologic

• Alertness and orientation

• Speech quality

• Facial symmetry

• Pupils and eye tracking

• Strength and sensation in all extremities

  
  

If stroke or intracranial pathology is suspected, escalate quickly and communicate clearly.

Airway & Breathing

• Work of breathing

• Chest rise and symmetry

• Lung sounds (not just “clear/diminished”)

• Ability to speak in full sentences

Listen. Look. Reassess.

Cardiac & Circulatory

• Pulse quality, not just rate

• Skin signs

• Heart tones when appropriate

• Blood pressure trends, not single numbers

Abdominal

• Distension or rigidity

• Tenderness and guarding

• Referred pain patterns

• Bowel sounds when relevant

Abdominal complaints hide killers. Respect them.

Musculoskeletal

• Strength and symmetry

• Range of motion

• Sensation and perfusion

• Subtle deformities

Back & Posterior

• Wounds and bruising

• Lung sounds posteriorly

• Spine tenderness when indicated

If you don’t look, you won’t find.

Assessment Is a Team Sport

One of the most valuable things you can do as a provider is watch how others assess patients.

Physicians

Nurses

APP's

Paramedics

EMT's

Everyone does something a little differently, and there’s gold in that.

Borrow techniques. Steal flow patterns. Ask questions. The best providers are students forever.

From Assessment → Differential → Plan → Transport

This is the chain. Break any link and the system fails.

1. Assessment gives you data

2. Data forms your differential diagnoses

3. Differentials guide treatment choices

4. Treatment response influences transport decisions

   
   

ALS vs BLS

Emergent vs non-emergent

Closest vs specialty center

None of those decisions should come from vibes.

Final Thoughts

Assessments aren’t glamorous. They aren’t Instagram-worthy. They don’t beep or flash.

But they are the foundation of our profession.

If you want to be faster, assess better. If you want to be safer, assess better. If you want to be taken seriously as a clinician, assess better.

Everything else follows.

Training is Continuous