7.2 Core Workflows and Decision Points

Patient Assessment Is the Backbone

Every clinical-judgment item rests on the patient-assessment workflow. The paramedic moves through predictable stages, and the exam hides the decisive cue inside one of them:

The scene size-up is not a formality - it sets the entire frame. Mechanism of injury (a 25-foot fall, a starred windshield) or nature of illness, the number of patients, and the need for additional resources all shape the priority list before you touch the patient. An exam stem that mentions 'a single car into a tree at highway speed' is signaling high-energy trauma and a low threshold for spinal motion restriction and rapid transport.

The Primary Survey and the X-A-B-C Order

The primary survey identifies and corrects life threats in the order they will kill the patient, treating each as it is found rather than completing a full exam first. The paramedic forms a general impression in the first seconds - the single most important early judgment is sick vs not-sick.

For most medical patients the order is A-B-C (Airway, Breathing, Circulation). For trauma, current evidence places massive hemorrhage control first, giving the sequence X-A-B-C:

• X (eXsanguinating hemorrhage): apply a tourniquet high and tight or direct pressure/hemostatic gauze before anything else - a patient can bleed out faster than an airway can be lost.
• A (Airway): open and protect; reposition, suction, adjuncts, or advanced airway as needed.
• B (Breathing): assess rate, depth, work, breath sounds, oxygen saturation; treat tension pneumothorax with needle decompression, ventilate inadequate breathing.
• C (Circulation): control remaining bleeding, assess perfusion (skin, pulses, capillary refill), establish IV/IO access.

The rule the exam tests relentlessly: do not move past an unmanaged life threat. If the airway is occluded, you do not auscultate lungs first; if a femoral arterial bleed is spurting, you do not start an IV first. The 'what do you do NEXT' answer is almost always the most immediately lethal unaddressed item.

Sick vs Not-Sick and the General Impression

Forming a sick vs not-sick impression in the first 10-15 seconds is a hallmark of paramedic clinical judgment. It is built from across-the-room cues:

• Sick cues: altered mental status, tripoding or accessory-muscle use, pallor/cyanosis/diaphoresis, retractions, an abnormal cry or silence in a child, a narrow pulse pressure, poor capillary refill.
• Not-sick cues: alert and conversant, normal work of breathing, warm/dry/pink skin, age-appropriate behavior.

This impression sets transport urgency and whether you 'stay and play' or 'load and go.' A clearly sick patient with a time-critical condition (major trauma, STEMI, stroke, refractory shock) drives early transport to the appropriate specialty center with treatment en route.

History, Secondary Exam, and Reassessment

After life threats are addressed, the focused history (OPQRST for pain, SAMPLE for background) and secondary exam refine the differential. The decisive cue for choosing between two plausible answers is usually here - a key medication, a missed allergy, a subtle finding.

The loop closes with reassessment: recheck mental status, the ABCs, vital signs, and the effect of every intervention. Reassess unstable patients every ~5 minutes and stable patients every ~15 minutes. Trending is the judgment skill that catches deterioration early and tells you whether the plan is working - the topic of section 7.5.

Treat-vs-Transport and the 'What Do You Do NEXT' Logic

A second decision point runs in parallel with assessment: how much do I treat on scene versus how fast do I move? The judgment is driven by whether the patient has a time-critical, definitive-care-elsewhere problem:

For time-critical patients, on-scene time is itself a treatment - prolonging it to perform a non-essential procedure is the wrong judgment. Conversely, leaving an unsecured airway or an uncontrolled bleed to 'get moving' is equally wrong. The reconciling principle is: perform the interventions that change survival now, defer the rest, and transport to the facility that provides definitive care.

This is the engine behind the exam's signature 'what do you do NEXT' items. The correct answer is the action that addresses the highest current threat to life given everything in the stem - not the most advanced procedure, not the most thorough exam, and not the textbook treatment if a detail makes it unsafe. Reading these items well means re-scanning the stem for the single most lethal unaddressed problem before committing to an option, because the adaptive engine specifically probes whether your prioritization holds as cases get harder.