Sunday, February 17, 2013

Lesson Sixteen: Primary Survey

Lesson Sixteen: Assessment In A Hurry – The Primary Survey

 Springing from a private question, one of the topics I'd planned to hit eventually was this exact subject.

When it was taught to me my instructors always put us on I-395, on the backside of Yosemite, somewhere between Barstow and Bishop. Because other than Death Valley, it's the closest thing you'll get to the middle of nowhere.

So there you are, and unfortunately, Harry Superdoctor doesn’t pull up and offer to help. It's just you, the kit you brung, and the two twisted heaps of Detroit and Japanese steel tangled in the middle of the road ahead, complete with an abundance of patients.

Take a deep breath. Look at your two hands. With these hands you're going to do the exact same thing as Dr. Harry would have done (perhaps a bit slower, but darn near as well) and possibly save a life or two.

You remember your ABCs. In fact, you've been reading all the prior lessons, and you remember your SR?ABCs.

Safety: You determine that the scene is safe. Nothing's on fire nor about to be, and there's no traffic. In fact, that's rather a bummer, because another helper would be nice about now. As Superchicken always told Fred, "You knew the job was dangerous when you took it." And you first put on your set of trusty barrier gloves (latex or other-than. In fact, even leather work gloves are better than bare hands.)

Rescue?: No one needs to be pulled out imminently.

While you're pondering these first two, you're doing a quick scene survey, and getting a mental head count of victims.

You see there are four (which is at least three more than you'd prefer. Two people in one car have extricated themselves, and they're walking around, looking at each other and their new car. They can wait.

Car Number Two has two people as well. The passenger has a bloody nose and some cuts from broken glass, but she's walking and talking, so you point her to the side of the road, and ask her to have a seat.

As you get to the driver's side, you see the driver, not moving much. Time to get to work.

You're first going to do 8 things in the next 20 seconds.

{___} Observe respirations. Normal, fast, or slow.

Normal is 12-20 per minute. Normal looks normal. Practice counting on regular people, using your watch. Count for 20-30 seconds and triple/double it for your per minute count. On seriously injured people, count for a whole minute -- but not yet.

{___} Introduce yourself: "Hi. I'm Joe, and I know first aid/am an EMT/RN/MD/stayed at Holdiay Inn Express/watched an episode of ER once. I'm going to help you."

{___} Obtain permission to treat. If they say no, stop. But by not directly asking for their permission, (“I’m going to help you”, not “Can I treat you?”) you've cleverly put them in an implied consent position if they don't stop you. Their response will either be immediate, or not. In noting it, you're actually CHECKING FOR CONSCIOUSNESS.

They'll be at one of four levels:

Alert Noting what's going on around them. Most of us live here.

Verbal They respond when spoken too, but aren't alert. Think of your teenaged children when their favorite show is on, or a guy who's "not quite there". Injured/ill people can be at this level frequently.

Pain They only respond to physical/painful stimuli, as when you tap them on the shoulder; or perhaps need to either moderately rub their sternum (breastbone) with your knuckles, or squeeze a couple of their fingers, which are both mildly painful -- without being torture. Popping an ammonia ampule under someone's nose is torture. Don't do it.

Unconscious They don't respond to anything.

Remember AVPU (av-poo) when assessing Level Of Consciousness. Which you’ve just done.

Now, let's talk about consent for a minute.


If you tell them your level of training, and ask if it's okay to examine/treat them, and they say yes, you have informed consent. This only applies with legal-aged, unimpaired adults, and certain minors. Check your local laws.

If you tell them your level of training, and they don't refuse, you have implied consent.

If they're unconscious, you get to assume that they would agree to being helped if they could, because an ordinary, prudent person would, so that's also implied consent.

All of the above will work, from a Good Samaritan/legal standpoint.

With minors, you generally can't do anything except things which are necessary to save life or limb without the parent/guardian's informed consent. (e.g. you can do CPR, but not put on a band-aid. Go figure.)

If you attempt to touch someone after they say "Don't touch me," it's simple assault (in my state). If you actually make physical contact at all, it escalates to battery. Leaving a patient after starting care, without turning them over to higher care (fire department paramedics or ambulance, etc. can be considered patient abandonment.

These would be bad forms of first aid.

There are exceptions, which we'll get to in a minute.

Good Samaritan laws generally hold you to the level of action/care that a similar reasonable and prudent person, with similar training and equipment, would have done in this same situation.

I'm not a lawyer, just a practitioner. I've treated thousands of patients as both a volunteer and a paid professional, and never been sued. (SO far, in 20 years, thank you Jesus!) But I'm still young, and it could happen someday. So I strongly urge you to learn and know the standards of care and Good Samaritan coverage/principles in your own state.

Exceptions: A person not alert and oriented because they're injured/drugged/intoxicated can't give consent nor competently refuse treatment. And if someone becomes combative, you're allowed to abandon care rather than risk injury. Just back off, and wait for them to pass out from whatever cause (brain injury, blood loss, etc.). Then you have implied consent again, and can get back to work.

Nota bene that you cannot club them into unconsciousness to achieve the same state of affairs, no matter how much better for them this might be, how much they might deserve it, nor how much personal satisfaction it might give you.

After introducing yourself and obtaining consent for further treatment, ask them their NAME and their AGE.

A) Because calling everyone "buddy" gets old. Learning their name helps show professionalism, concern, and build some rapport.

B) Because it makes a difference in care if they're 35 or 75.

{___} Ascertain their CHIEF MEDICAL COMPLAINT. "Hit head", "hurt left arm", etc. Not "that idiot swerved in front of me and wrecked my car".

FYI:  AGE, SEX, and CHIEF COMPLAINT is 3/4ths of any fire/paramedic dispatch on any call. You're already there, assuming you can tell a male from a female. The other 1/4th is LOCATION. We'll get to that in a bit.

{___} Do a quick check under their body from head to toe for gross bleeding. Using those gloved hands, feel gently under them, and see if you come back with bloody gloves. That's it.

{___} Do a quick (gentle, but firm) check on top and sides of body for wounds/deformities. Holes, tenderness, bones poking out their body.

This should all take about 20 seconds. (And note that in 20 seconds, clever fellow you, you've covered Airway, Breathing, and Circulation.

I made this easy. You only have one victim to concentrate on. (Really, you have four, but I made them simple.) Suppose you had four, all equally injured?

You'd stop, and repeat this process for each one. And write down Name, age, sex, chief complaint, level of consciousness, and ABCs for each one. Then you'd focus on your more, or most, serious patient.

In this way, you'd see the entire situation, and not get sucked into helping someone who might be a relatively stable minor injury like a head laceration, and miss the guy not breathing.

Once you've seen all your patients, you are prepared to make a report, if possible.

Have someone call 9-1-1, and report a sex, age, and chief complaint on all patients, generally including their level of consciousness. This way, they know whether they need to send the whole world to you, or just one ambulance.

But, you're on lonely 395, so it's going to be awhile before anyone comes to help.

The good news is you've only got one patient (I'm not an ogre; but Life isn't always this fair. Be prepared.)

Now, using your Calibrated, Highly Developed Brain, with Loads of Common Sense, and an Incredible Sense of Calm Professionalism (even if this is your first accident), you're going to prioritize your patients (in this case, one), and starting with the most serious one, work your way through the rest of your primary survey. In less than 5 minutes.

Warning: This will require "STUFF."

Required items:

STUFF You’re Going To Need In Your Kit list

In most cases, TWO FUNCTIONING HANDS (gloved!!), and CLEAR VISION.* (See flashlight, below.)

A WRISTWATCH, visible, with either a sweeping second hand, or seconds which tick that you can count along with. (roll the glove cuff back on this gloved hand)

A STETHOSCOPE that you know how to use.

A BLOOD PRESSURE CUFF that you know how to use.

A SMALL FLASHLIGHT. Either a little penlight, or ideally, a small hands-free headlamp. NOT a Surefire X-200 Weaponlight or the like. We want to see them, and their pupils, not melt their corneas.

PAPER and PEN/PENCIL to write information down.

This tallies up to almost $25 worth of equipment, all reuseable except for the gloves, and all highly stable and weather resistant if kept in a small case the size of a shaving kit, with which you can assess 99% of patients with equal or better accuracy than *I* can in my gazillion-dollar, 21st Century Emergency Room. Cross my heart, I promise.

{___}Level of Consciousness

We already covered AVPU. Now, for those who were A or V or P, we want to know how ORIENTED they are. So we ask them their

_____Full Name _____ Where (they are) _____ When (today's time, day of week, of month, the month, the year) _____ What (happened)

A person who knows their name, where they are, what happened, and what date/time it is is "ALERT and ORIENTED TIMES FOUR" (AOX4) in Medicalese. Or 3, or 2 or 1. If a person can't name the day, try the date. Then try the month. Then ask the year. See how fuzzy they really are. The last thing most people lose, mentally, is their own name. A patient who is alert, but completely confused may be drunk, impaired, or seriously injured or ill. The brain is the most sensitive organ, so pay attention to LEVEL OF CONSCIOUSNESS and ORIENTATION, and re-assess it for CHANGE over time which could indicate improvement, or worsening of condition.

{___}Skins Signs 

We're looking at color, temperature, and moisture. ideally, we're hoping for pink, warm, and dry, rather than cool, pale, and clammy. Persons with darker skin can be assessed on (unpainted) nailbeds on the hands or toes, and palms, for color.

{___}Respiration  _____ Rate _____Depth _____ Rhythm _____ Adequate tidal volume

Rate: How many times per minute. Normal rate is 12-20 for adults. Less than 8/min or more than 30/min are bad. Note that children breathe faster.

Depth: Shallow, Normal, or Deep.

Rhythm: Regular, or Irregular. Not Disco or Jazz. Regular is good. Irregular probably isn't good.

Adequate Tidal Volume: Are they getting enough air, or getting worse, turning blue, etc. Oh, and is it equal on both sides of their chest?

{___}Pulse _____ Rate _____ Strength _____ Rhythm

Rate: Rates are variable across the lifespan. Average adults are 60-100. Kids you'll need to research -- it'd take me too long to cover here. 100-200 is a useful range from newborn to adolescents. Some adult athletes are in the high 40s to 50s, because their hearts are in superb shape. Less than 40, or more than 140, for a resting adult, is generally a bad thing.

Strength: Thready, Shallow, Weak, Normal, Bounding. As usual, we want Normal.

{___}Blood Pressure Expressed as "XXX over XXX" the Systolic pressure (while the heart's pumping) over Diastolic (while the heart is at rest). Check the arm for injuries before measuring it. Learn how to do blood pressures, select and place cuffs, and auscultate (listen) or palpate (feel) for readings by taking a course that teaches the skill. It's waaaaaay easier than you think, and you can practice on friends and family to keep the skill sharp. Learn how to do this NOW.


_____Size (in mm) _____ Equal (to each other) _____ Reactive to light -- or not (using that SMALL penlight, shined into and out of the iris). Note that BOTH should shrink when the light is shined into EITHER eye. It takes four checks to confirm this for both eyes. And while you're there, do they have contact lenses, or any blood, injuries or foreign bodies in the eye?

{___}Medical History

We want any four of these answered, at minimum:

_____ Allergies (to medicine or food) I'm not going to give them any cats or flowers, so that's far less important.

_____ Medications they take all the time, or today/recently. Including anything they bought for "recreational" use, as well as RX or OTC meds.

_____ Chronic conditions  Like diabetes, seizures, high blood pressure, heart attacks, strokes, etc.

_____ Major or recent surgeries

_____ Doctor If they regularly see one, or any specialists, like heart, lung, kidney, or cancer docs, among others.

_____ OB/GYN  For females of child-bearing years (10-60 in my book): Are they, or might they possibly be, pregnant? If so, how many times, how far along are they, etc.?

_____ Trauma  Prior, or the one you're dealing with now

_____ Other Medical history/information

Important note: You are RECORDING all this information as you get it in your NOTES. That’s the whole point of asking for it.

That's it. 

It takes less than 5 minutes (with a minimum of practice) to do all these steps on any given patient, assuming they cooperate.

You will have, at that point, completed a History and Physical Assessment equal to anything you'll get in a hospital on each patient you do this for.

And the more times you practice or do it, the sharper, quicker, and better you'll get at it. Doctors are thrown into this for their last 2 years of medical school, and their intern year. So with a few thousand tries, they've obviously got a leg up on you. But this baseline Primary Survey done competently and adequately, is all anyone could expect from you, and goes a tremendous way towards assessing and focusing your (and higher) treatment, and deciding treatment priorities for multiple patients in any emergency.

Back in my fabulous volunteer wilderness first aid course, we were required to be able to demonstrate doing a full patient assessment, Primary and Secondary, covering 143+ separate points of information, in under 15 minutes.

Missing anything on the Primary, or more than 19 items on the Secondary, was an automatic No Go. And we had to do it twice.

I saw persons like myself, with ZERO prior medical background, practice and pass this standard time after time after time. After failing their first attempts, time after time. Failure in practice is good. The embarrassment helped me to remember the things I'd forgotten, so I didn't forget them again. That's why observed practice works. Do it!

I've just told you what the Primary Survey entailed. It may look like a lot, but it really isn't much at all.

In another Lesson, I'll cover the Secondary Survey.

It's up to you to practice.
It's the only way you're going to learn this.

No comments: