Every clinician in and out of the hospital should have a very regimented way of going in and looking at patients in distress.
First, remember to bring help (a wingman or wingperson) with you. I can tell you from personal experience that it is difficult being in a room with a patient in severe distress and having to leave to get help. If you think you may be stepping into a serious situation, bring someone with you.
In the hospital, it goes without saying, you need to go and see the patient; don’t try to diagnose anything much more serious than a request for Tylenol over the phone. If you get called and it sounds like the patient is coding, you need to tell the nurse, look if you feel you need to call a code you need to go ahead and call it while you’re on your way. Never tell them to wait until you get there (see previous posts on inertia and arrogance).
When you go see the patient you obviously do the ABC’s. The key issue in airway and breathing is to see whether the patient needs to be intubated or not. That’s your decision; you have to think of what you’re looking at, not with respect to the findings but what findings will indicate that you need to move to the next step. These are some of the things we use to determine if emergent intubation is required: can the patient say more than 4 or 5 words in a row? is the patient unresponsive? does the patient have vomit or a jeopardized airway? These are all indications that the patient needs to be intubated. In the case of not being able to talk, you may have time to get an ABG, CXR, and pulse oximetry first, but you should also prepare for intubation. Remember that we’d rather have you intubate somebody than to let somebody get sicker.
To evaluate breathing, you need to rule out the acute causes of breathing problems. Obviously any unequal breath sounds, if you get truly unequal breath sounds, should prompt an immediate examination of the position of the trachea to diagnose tension pneumothorax. If there’s no tracheal deviation, which there usually will not be, you need to get a chest x-ray because it’s very hard to interpret any of those physical findings without one (despite what people might say about fremitus and whispered pectoriloquy, go to Wiki if you don’t know what those things are).
Circulation: check your vital signs, feel the distal pulses, and get a gestalt of the patient’s overall perfusion. Check carotid pulses then move farther and farther from the heart until you are assessing perfusion in the distal extremities. If they have good perfusion in their nailbeds, they are probably OK, for the moment..
Next, make sure everybody has IV access, and make sure everybody has supplemental oxygen. Even if it’s not an indication, in my humble opinion, it’s always right to put them on supplemental oxygen. You should also consider ordering a group of labs and x-rays that you need to get a handle on what is going on. One suggestion is CBC, lytes, Troponin, EKG, ABG and chest x-ray. And often the reason you need to put that into the initial algorithm is that it takes a while to get those things (see post on inertia). A chest x-ray does not magically appear after you call for it, it takes time. So as soon as you see that it’s a sick patient, not something that you can correct pretty quickly, you need to get those things rolling. And the bottom line is that the physical exam is not great for many serious conditions (MI, pneumonia, if somebody’s got something subtle going on in their abdomen, if somebody’s having significant electrolyte abnormalities, and anemia doesn’t show up until it is severe). So worry about saving money tomorrow, if you have a seriously ill patient in front of you, do what you need to do to get control of the situation.