Patient F – Initial Assessment and Management

ATLS Instructor Evaluation Form

Patient F – Initial Assessment and Management

Faculty *

Performer *

Critiquer *

Critical Treatment Decisions (check yes or no): The students must: *

	YES	NO
Perform the assessment and management phases properly and in the correct sequence, recognizing that priorities are the same as for the nonpregnant patient.	YESPerform the assessment and management phases properly and in the correct sequence, recognizing that priorities are the same as for the nonpregnant patient. YES	NOPerform the assessment and management phases properly and in the correct sequence, recognizing that priorities are the same as for the nonpregnant patient. NO
Assess and secure a patent airway and relate the potential for a cervical spine injury.	YESAssess and secure a patent airway and relate the potential for a cervical spine injury. YES	NOAssess and secure a patent airway and relate the potential for a cervical spine injury. NO
Recognize and treat the patient's initial shock, initiating treatment specific to the pregnant trauma patient.	YESRecognize and treat the patient's initial shock, initiating treatment specific to the pregnant trauma patient. YES	NORecognize and treat the patient's initial shock, initiating treatment specific to the pregnant trauma patient. NO
Relate appreciation for and the significance of the patient's recurrent hypotension, identifying a differential diagnosis for the pregnant trauma patient.	YESRelate appreciation for and the significance of the patient's recurrent hypotension, identifying a differential diagnosis for the pregnant trauma patient. YES	NORelate appreciation for and the significance of the patient's recurrent hypotension, identifying a differential diagnosis for the pregnant trauma patient. NO
Relate the need for early consultation with a general surgeon and an obstetrician.	YESRelate the need for early consultation with a general surgeon and an obstetrician. YES	NORelate the need for early consultation with a general surgeon and an obstetrician. NO
Relate that the best treatment for the fetus is the optimal treatment of the mother.	YESRelate that the best treatment for the fetus is the optimal treatment of the mother. YES	NORelate that the best treatment for the fetus is the optimal treatment of the mother. NO
Recognize the need for identifying the Rh status and the possible need for Rh immunization.	YESRecognize the need for identifying the Rh status and the possible need for Rh immunization. YES	NORecognize the need for identifying the Rh status and the possible need for Rh immunization. NO
Identify and manage the conditions requiring critical treatment decisions in the order listed.	YESIdentify and manage the conditions requiring critical treatment decisions in the order listed. YES	NOIdentify and manage the conditions requiring critical treatment decisions in the order listed. NO

Potentials for Adverse Outcome: If the student’s performance is borderline and the student fails to recognize or perform one or more of the items below, the instructor may determine that the student’s overall performance is unsuccessful.

Observed List of Maneuvers (Decisions) *

Comments

Instructor Potential *

Rating – Completed only during the initial examination *

Successful
Incomplete/remedial
Incomplete/repeat course

Remedial Rating-Completed only during the review *

Successful
Incomplete/repeat course

	YES	NO
Did not delay in recognizing pregnancy.	YESDid not delay in recognizing pregnancy. YES	NODid not delay in recognizing pregnancy. NO
Requested early surgical/obstetrical consultation.	YESRequested early surgical/obstetrical consultation. YES	NORequested early surgical/obstetrical consultation. NO
Performed vaginal examination in a timely fashion.	YESPerformed vaginal examination in a timely fashion. YES	NOPerformed vaginal examination in a timely fashion. NO
Recognized possible uterine hemorrhage in a timely fashion.	YESRecognized possible uterine hemorrhage in a timely fashion. YES	NORecognized possible uterine hemorrhage in a timely fashion. NO
Avoided excessive manipulation of the pelvis.	YESAvoided excessive manipulation of the pelvis. YES	NOAvoided excessive manipulation of the pelvis. NO
Monitored the fetus.	YESMonitored the fetus. YES	NOMonitored the fetus. NO
Recognized the potential for fetal distress.	YESRecognized the potential for fetal distress. YES	NORecognized the potential for fetal distress. NO
Ordered Rh immunoglobulin.	YESOrdered Rh immunoglobulin. YES	NOOrdered Rh immunoglobulin. NO
Immobilized the right femur fracture.	YESImmobilized the right femur fracture. YES	NOImmobilized the right femur fracture. NO
Performed a neurovascular examination before and after the immobilization.	YESPerformed a neurovascular examination before and after the immobilization. YES	NOPerformed a neurovascular examination before and after the immobilization. NO
Protected the patient from hypothermia.	YESProtected the patient from hypothermia. YES	NOProtected the patient from hypothermia. NO
Considered the need for tetanus prophylaxis.	YESConsidered the need for tetanus prophylaxis. YES	NOConsidered the need for tetanus prophylaxis. NO
Did not delay in recognizing the need for transfer.	YESDid not delay in recognizing the need for transfer. YES	NODid not delay in recognizing the need for transfer. NO
Did not delay transfer to perform diagnostic tests.	YESDid not delay transfer to perform diagnostic tests. YES	NODid not delay transfer to perform diagnostic tests. NO
Adequately prepared for contingencies during the transfer process, such as hemodynamic deterioration, fetal distress, and the onset of labor.	YESAdequately prepared for contingencies during the transfer process, such as hemodynamic deterioration, fetal distress, and the onset of labor. YES	NOAdequately prepared for contingencies during the transfer process, such as hemodynamic deterioration, fetal distress, and the onset of labor. NO