PENMAN - Using the PENMAN mnemonic helps the first responder approach every incident in a safe, methodical and organized way. The goals are to ensure the responder and response team(s) are safe, and that they remember to request appropriate additional resources to stabilize and mitigate the incident in a timely manner. Reviewing the elements of PENMAN is done continually from the start of the dispatch throughout the incident until the patient(s) is/are transported to the hospital.
Training in Scene Assessment is included in this California-based EMT program as it is required for passing several of the higher level skills tested for California certification.[1]
The letters in PENMAN stand for:
Personal Protective Equipment, (PPE), for self and crew that is appropriate for the type of incident.
Environmental hazards at the scene including people, hazardous fluids/chemicals, biological contamination.
Number of victims.
Mechanism of Injury, (MOI) or Nature of Illness, (NOI).
Additional resources that might be required such as fire, police, or utility company.
Need for C-spine immobilization.
PERSONAL AND PERSONNEL SAFETY
Safety is a primary concern that should be addressed long before the first responders arrive at an incident site. There is a golden rule among first responders no matter which role they provide on-scene: Everyone goes home. To have the greatest chance of providing the highest level of care to patients while protecting the health and wellbeing of the first responders requires preparation and planning.
The first step is ensuring that the responders are mentally and physically ready, and properly equipped to address the type of emergency incident. Questions that the first responders must ask themselves upon dispatch are:
Where is the emergency incident?
Is it a residence or office?
Is the incident at an intersection, or an industrial area?
These are important to determine if any particular call is likely to involve unusual hazards. Once the type of incident is understood, the next important questions are:
Do we have the personal protective equipment (PPE) needed to be physically safe for this type of incident?
Will we need any specialized protective equipment such as body substance isolation equipment (BSI), or respiratory protection for this incident?
And then finally:
Are these items immediately available?
Appropriate PPE should be donned prior to arriving at the scene or set out to be immediately available to the responder.
ENVIRONMENTAL HAZARDS
Environmental hazards that can hurt you should be anticipated, but also actively assessed upon arrival at the scene and planned for accordingly (therefore, "E" also addresses elements of safety). Some common hazards that can, and do, kill emergency responders include:
Vehicular traffic, leaking fuel or downed power lines at a traffic collision
An armed and dangerous individual on-scene at a reported shooting or domestic violence call
Weather hazards such as lightning
Airborne contaminants at an industrial accident
Some hazards can be mitigated to render the scene safe (such as setting up flares and parking an ambulance to divert traffic around an accident), other hazards require specialized mitigation and the first responders should remain staged at a safe distance from the incident until other qualified responders such as police, fire or a Hazardous Material (HAZMAT) Team, can render the scene safe so EMS personnel may perform their duties.
NUMBER OF VICTIMS
The Number of victims in any incident are those people on-scene affected by the event or illness in one way or another. First responders arriving on-scene need to rapidly assess how many victims may require medical treatment/transportation to aid them in requesting and appropriate amount of additional resources. The people on-scene cease being victims and become patients as soon as the responder begins assessing and treating them, but starting in on patient care before calling for a sufficient numbers of responders to address the number of victims can result in deadly delays in care.
MECHANISM OF INJURY OR NATURE OF ILLNESS
Beyond the raw number of victims, it is critical to understand how was the incident caused - the Mechanism of injury. Investigating how the victim(s) were injured or the circumstances leading to their illness will provide clues to the extent of the victims' injuries or illness. This will guide your most urgent initial actions. For example:
If the incident was a traffic collision, or other blunt force trauma incident, the first responders should survey the scene, observing the position of the victims with respect to what they were hit with, noting any debris or vehicle deformation to help determine how much force may have been transferred to the victims. Was this a fall from a ladder, and if so how high and onto what kind of surface? Was this a small car into a minivan, and if so what was the likely speed of the vehicle(s)? Did airbags deploy? All of these hold clues to the likely severity of the blunt force trauma and/or deceleration injuries you may be dealing with.
Does it appear that the incident includes a hazardous material release? This should be suspected if there are multiple casualties without an observable mechanism of injury such as in the case of a possible carbon monoxide exposure where the residents of a particular house present with headaches and/or general malaise.
Does this appear to be a medical emergency involving one person only? These patients are often much sicker than they first appear and may have multiple, overlapping complaints.
Careful observation is key here. Determining "M" may take seconds as the responder pulls up to the scene, or may take longer if the responder needs to look deeper into the scene's history. Don't get focused too quickly on the first mechanism observed - a fall victim may have had a medical incident that caused the fall, and focusing too intently on the trauma can cause you to miss the underlying serious medical issue.
ADDITIONAL RESOURCES
All of the previous (P, E, N and M) assessments now prepare you to answer "A": What Additional resources do I need to adequately and safely respond to this incident? Needs can be IMMEDIATE, or DELAYED
For incidents that involve more patients than your crew can handle, triage should be performed (based on the Simple triage and rapid treatment) and "additional resources" requested which may include:
Additional ambulances in the EMS network, an Advanced Life Support team, or a supervisor. A good rule of thumb is an ambulance for every two victims, and an engine company for every four.[citation needed]
Fire agencies which in addition to providing active fire suppression can usually provide additional fire responders via engines, trucks, and squads, supervisors, HAZMAT, and investigative personnel as well as USAR (Urban Search and Rescue)
Police, tactual units for incidents involving crime or actively aggressive/dangerous individuals
Utility services to control water, electricity, gas disruptions
Air Transport for serious conditions in remote areas
Coroner (Medical Examiner) for deceased victims
A Chaplain or mental health counselors for bystanders who have witnessed an upsetting incident
These resources should be requested as quickly as possible. It is better to overestimate the number of patients, it is always better to over order than under order. Additional resources can be released or cancelled when it is determined they are not needed. These resources should provide the equipment and personnel necessary to complete the tactics and tasks necessary to mitigate the event. In some cases the responder must make an estimate of the number of victims simply because there are too many to immediately count or all the victims cannot be seen, and update dispatch as the incident unfolds.
Mass Casualty. If there is an ongoing danger or dynamic that is generating additional patients, the incident needs to be considered a "mass casualty incident" and specialized help and procedures should be called in. It is important to understand within your agency and nearby what resources are available, and to specify to the dispatcher a need for a multi-casualty unit to use on-scene. In natural disasters, larger scale emergency response may involve calling in the American Red Cross.
Prior to any emergency incident it's a good idea to be familiar with the capabilities within your agency and to understand your local collaborative inter-agency policy addressing what resources may be dispatched for both common incidents and multi-agency mass casualty incidents.
NEED FOR C-SPINE PRECAUTIONS
Cervical spine injuries can result in paralysis and death in patients if protection of the spinal cord is not properly managed in the field. The question that the first responder should ask themselves in any initial scene survey include:
Does the MOI (Mechanism Of Injury) have the potential for injuring my patient's spine?
If it does (such as car accidents, falls, and penetrating trauma), the first responder should immediately start following EMS system protocols for inline stabilization of the C-Spine in parallel with performing the Primary Assessment. NOTE that this is held at the same level of importance as assessment of immediate threat to life (the ABCs) which is why the assessment of a Need for C-Spine sits in the scene size-up, prior to the primary assessment. If, at any point, during later history or secondary assessment, new information becomes available that indicates the patient does, or could, have a spinal injury, C-Spine Precautions should be immediately instituted if they were not previously.
Documentation
Environmental hazards of the scene size up do not need to be included if the scene is, in fact, safe for entry without any identifiable possible hazards (although it never hurts to include such information in a PCR). Any deviation from a "normal and safe" scene may be placed in the narrative as justification or clarification for why EMS/patient access was delayed. An example would be "M26 staged on McLoughlin and Story for incident involving "gunfire" per EMS dispatch. Arrived on scene after PD report scene secure to find patient... etc". In this incident, the scene was unsafe for the crew to enter, resulting in a delayed time to patient contact.
For MCI (Multiple Casualty Incidents), patients may be given a number. This should be documented to aid in patient tracking post EMS transport or evaluations. This is the same as if multiple patients are transported in the same ambulance.[2]
C-Spine procedures should always be documented in the PCR in addition to CSM (Circulation, Sensation, Motor response) before and after immobilization. Take care to describe WHY the patient was placed in spinal precautions.
Environmental hazards also include: rough terrain, cluttered rooms with trip/slip hazards, ice/puddles, environments with poor visibility or lighting, etc.
Pay attention to your surroundings at all times, not just when initially sizing up a scene. Scenes are dynamic and may change quickly and with little warning. A previously complacent patient or bystander may suddenly become aggressive and you should have easy egress from the situation, if possible. This means taking measures to be certain that the gurney or other equipment does not block methods of exit.
Safety of the crew supersedes all patient problems, bar nothing. If a rescuer is injured attempting to help a patient, the scene has gained a patient and lost a rescuer and additional resources will need to be called, potentially impacting patient treatment depending on the severity of the rescuer's injury. The general rule of thumb is Personal safety, then Partner safety, then Patient safety. You cannot help the patient if you yourself are injured and in need of assistance.
In cul-de-sacs, position the ambulance ahead of time, if possible. It is safer to back with a backer, and if the patient needs emergent transport it is preferable to be facing out of the cul-de-sac ready to exit than it is to nosing in and having to back out into traffic or into a 3-5-7 point turn without a backer.
