Once any and all life threatening injuries it is time to complete a full focused Examination of the patient and to gather a patient history and vital signs to discover any ailments that might affect the patient and to record a start point for the vital signs. This process is often referred to as the Secondary Survey.
In an urban environment it is normal if the patient has any life threatening injuries, or if the Mechanism of injury (MoI) suggests serious underlying problems or if your intuition tells you that there is more going on than you are prepared to handle the patient would be on the way to hospital. The Secondary Survey would then be completed during transport or on arrival at the receiving hospital. Rapid evacuation is rarely possible in a remote environment even by helicopter, which means 2 things: firstly critically injured patients have a higher mortality rate in the wilderness and secondly you will have time to carry out a Secondary Survey on patients who you are not treating for a life-threatening injury.
During the secondary survey it is likely that the patient will have to be partially undressed to expose and investigate injuries etc, in urban protocols this is often expressed as E – for Expose but in the wilderness we must think of E – as Environment and before we start further investigations protect our patient from that Environment.
The Secondary Survey comprises of 3 elements:
Vital Signs Recording
The order that these are completed is not didactic. With an ill patient it may make sense to get a History and Vital Signs before a physical Examination whereas with a confused trauma patient it would make sense to discover the sum of the injuries first.
Before starting a physical examination it is good practise to ask the patient what the main problem is. Knowing the chief complaint will give you a primary clue to your final decision making.
The Physical Examination is a head to toe survey of the body where you:
Look for bruises or discolourations, bleeding, swelling and other deformities, or anything else that is out of the ordinary. Look for any pain responses from a patient with any altered level of consciousness.
Ask about pain, tenderness and sensations.
Feel for unusual hardness, softness, rigidity, discontinuity, angulation of limbs, heat and cold.
Listen for unusual breathing sounds, and grunts or groans when feeling for injury.
Smell for unusual body odours, breath, and clothing and any odours in the environment.
Remember to look and feel inside clothing, most medical care needs to be done at skin level; Outdoor clothing is often bulky which can mask injuries and/or waterproof so that bleeding is hidden inside it.
A full Primary and Secondary survey is required for all critically illness and injury treatments however the majority of non-trauma patients do not need the same level of rapid interventions and head to to examination. A quick review of ABCD’s, protection from the Environment are needed but the examination can be guided by the history and be more focussed.
The art of questioning and obtaining a good history is one of the keys to patient assessment. An experienced Wilderness practitioner will often quickly come to a working diagnosis from questioning.
Always ask open questions and seek clarification from the patient, it is also important to seek answers to the questions from the patient themselves, not from a parent or partner.
For example if you ask “Is it a crushing pain” the patient will often assume that you know best and agree with you; where as asking “Describe your pain” which may result in a more verbose answer, will give you a clearer indication of what the patient is experiencing.
A commonly used and understood mnemonic for gathering a patient history is SAMPLE
S – Symptoms are what the patient complains about – the sensations they feel – Pain, numbness, heat, cold. (not to be confused with Signs, which is what you can see)
A – Allergies – Is the patient allergic to anything and are any of those allergies severe enough to provoke anaphylaxis.
M – Medications, prescription or over the counter is the casualty taking. Have they taken alcohol or recreational drugs, have they missed a medication dose or taken too much.
P – Past medical history – Is there anything that is possibly relevant, has something like this happened before, are they seeing a Doctor for anything,
L – Last Intake of food and last toilet functions. What and when was the last meal and fluid intake. When did they last urinate and what was the colour, when did they last defacate and was it normal.
E – Events – What caused or led up to the injury or illness, has this been a slow or rapid onset?
SAMPLE is used for all patients to gather a history for patients complaining of an illness or non-traumatic pain further history taking by using OPQRST is helpful.
O – Onset: What initiated the chief complaint – Slow or Sudden onset
P – Provokes: What changes the complaint, for example does changing position or taking a deep breath improve or make the condition worse.
Q – Quality “Describe the pain” sharp or dull, constant or intermitent
R – Radiate: Does the pain radiate, if so from where to where or is it targeted in a specific position. Ask the patient to point.
S – Severity: How bad is the pain on a scale of 1-10 with 10 being the worst imaginable.
T – Time: How long has the problem been an issue, when did it start.
Vital Signs Recording
Vital Signs do not tell you what is wrong with your patient! they may give you some additional clues as to what s wrong with your patient but their most useful function when recorded with a time is to give you a reference point. From an initial set of Vital Signs we can refer any subsequent measurements back to ascertain if our patients general condition is stable, improving or getting worse. Circumstances will dictate how often Vital Signs are measured as a rule of thumb they should be monitored every 5-10 minutes initially and continue at they frequency for all patients who have abnormal Vital Signs that are not improving. Vital Signs are viewed as a complete set and individual measurements cannot be viewed in isolation.
The Vital Signs that are measured are:
LOR – Level of Response using AVPU (A– Alert, V – Responds to voice, P – Responds to painful stimulus, U – Unresponsive) Alert can be subdivided 4-1, (how many questions can the patient answer about person, place, time/date, event)
HR – Heart Rate (Pulse) Measure rate, rhythm and quality noting the position the pulse was measured (preferably a distal site)
RR – Respiratory Rate Measure Rate, Rhythm and Quality
SCTM – Skin, Colour, Temperature & Moisture
BP – Blood Pressure (If Sphygmomanometer available)
SpO2 – Oxygen Saturation (If monitor available – SpO2 monitors are unreliable in the cold)
P – Pupils: Are both Pupils Equal Round and Reacting to Light (PERRL)
T – Temperature of Patients Core (if equipment available).
You now, finally, should have enough information to make a plan for how you are going to manage this patient. And if you have got this far you have ruled out or stabilised any Life Threatening Injuries.
The plan will include considerations of treatment, evacuation, care and monitoring.
Whilst in an urban environment it is normal to dial 999/112 as early as possible and have the patient transported to a medical facility as fast as possible. This quick transportation option may not be available to us in the wilderness. Therefore it is important that we have as much available information before making our Plan. Unless you discover a life threatening injury that is not immediately resolved it is best to gather all the facts and consider your options before calling 999/112/911.
The final stage of the Patient Assessment Process is to make a decision based on what you know about the patient, the environment, distance from help.
Treatment & Rapid Evacuation
Treatment, Monitoring & Slow or Delayed Evacuation
Treatment, Monitoring and Continue Activities
The Patient Assessment Process is sequential, depending on the scene and the patients condition, some of the elements may only take a second to confirm in your mind whilst in other situations the process could take longer. It is important that all the steps are considered and for your safety and that of the casualty they are considered in order.
We are hopeful that the past 3 posts following a Patient Assessment Process will help you should you need to treat anybody for an injury or illness in the field. These posts cannot replace proper training but our hope is that they will provoke thought to support any previous training you may have.
If you are interested in taking part in a First Aid Course based on Remote Environments or the Wilderness please complete the following form to register or contact us directly by e-mail. If you want to know what course will be best for you our next posts will look at the Scope of Practice for Wilderness First Air Providers.
All images in this post are courtesy of NOLS Wilderness First Aid Guide.