How To Do a Complete and Detailed Patient Assessment
Once a patient has been accessed, rescuers should begin each rescue by surveying the scene. The scene survey consists of several parts, but the most important is safety for you, other rescuers and the patient(s). Placing a rescuer at undue risk can complicate the situation, if not create additional patients. Surveying the scene requires you to identify the number of patients, understand each patient’s condition and note the presence of bystanders, equipment, and other clues that may be useful in determining the cause of the injury or illness.
1. SCENE SURVEY
Is the scene safe for me to enter? If hazards are identified, take steps to mitigate them or wait until it becomes safe. Consider external hazards such as the following:
• Physical dangers (rockfall, snow/ice/avalanche, trees, fires, wildlife, etc.)
• Weather/environment (hot/cold temperatures, lightning, high altitude, etc.)
• Other people (bikers on a single track, climbers above you, hunters, etc.)
Will the scene remain safe? If not, what is my plan?
• Safe zones
• Moving patients to a safe area
Is it safe for me to physically care for the patient(s)? Gloves and barrier devices, such as a face mask, should be considered with every patient to prevent disease transmission through bleeding, vomiting, etc.
How many patients are there? Which one(s) need help first?
• The patient’s equipment may provide information about the mechanism of injury (MOI).
• Bystanders may have witnessed the patient’s injury or may be able to assist with patient care.
• Are there resources near the scene that may be useful in treating or evacuating the patient?
Approaching, Identifying, and Getting Permission to Treat the Patient(s)
• When approaching the patient, use caution so that you do not expose them to additional hazards such as rocks or icefall. Consider marking the route to the scene if additional rescuers are to follow.
• Immediately identify yourself and request the patient’s permission to treat. If the patient is unconscious or confused, then their consent to treatment is implied. Otherwise, the patient has the right to decline treatment.
• Ask the patient’s name and say, “can you tell me what happened?” If the patient cannot answer these questions, they are either unconscious or have an altered level of responsiveness; start with the primary survey.
• This is an opportunity to determine the Level of Consciousness (LOC) of your patient. For this, we use the AVPU (Alert, Verbal, Painful, Unresponsive) scale. Is the patient Alert and oriented, responsive only to Verbal stimulation (talking to them), responsive only to Painful stimulation, or Unresponsive to any stimulation? If the patient shows any signs of life such as movement, moaning, or talking, then you move on to the primary survey (below). For those patients who are completely unresponsive, the rescuer must quickly move forward with Basic Life Support (BLS) / CPR. This is extremely important if the situation involves a lightning strike, drowning or avalanche. These are wilderness situations where immediate CPR, which includes breathing for the patient may save a patient’s life.
2. PRIMARY SURVEY: MARCH
The goal of the Primary Survey is to identify and treat conditions that pose an immediate threat to life. Approaching the patient using the acronym M A R C H allows the rescuer to address the life-threatening issues in order of importance. Anytime there is major bleeding you should always stop the bleeding. Preventing major haemorrhages is so important that it supersedes the airway in the MARCH acronym for the primary assessment. We are not able to replace massive blood loss in the wilderness, so we must do our best to preserve blood volume and our patients. The airway does come early in the MARCH acronym, but massive haemorrhage is first. Therefore, we would stop the massive bleeding before moving on to the airway. Evaluating the patient’s pulse falls under the C for circulation in the MARCH acronym and would therefore not be the next best step.
Asking the patient if he takes any blood thinners will be part of your focused history, which comes after your primary assessment. You may be able to obtain this information during the primary assessment, but this should not distract from your assessment.
Because this portion of the assessment is searching for critical conditions, it is most applicable to patients who have an altered level of consciousness or have a significant injury. However, this survey should be utilized in every patient whom one treats in the wilderness. In those patients who are alert and appear well, this assessment may be brief. Problems found that are life-threatening should be addressed immediately before continuing the survey.
M - Massive Hemorrhage Management
• Massive haemorrhage must be rapidly managed because a patient can lose most of their blood volume in a matter of minutes with major arterial or venous bleeding.
• In the wilderness, you cannot replace this blood, and the patient may be required to be much more active than the typical hospitalized patient.
• This step is applicable only for major bleeding and does not include injuries with only minor oozing that will be addressed later in the secondary survey. Generally, these types of injuries are rare in the wilderness but can have fatal consequences if not treated rapidly.
• Treatment usually consists of the placement of a tourniquet if it is an extremity injury. If one does not have a tourniquet or if the injury is not amenable to the use of a tourniquet (e.g. facial or torso wound), then a pressure dressing directly on the area of bleeding is the best option.
• The placement of the tourniquet does not mandate that the tourniquet stays in place until the patient reaches definitive medical care. The expectation is that that the rescuer will reassess the wound and the bleeding after the patient has been stabilized in the secondary survey and ongoing assessment stage. The use of tourniquets and their management are covered in depth in the wound management chapter.
A - Airway with Cervical Spine Stabilization
The “airway” is the continuous path from the patient’s lips all the way down to the vocal cords at the base of the throat. Any blockage of this pathway can limit the flow of air into the lungs.
There are two issues in the assessment of the victim’s airway:
1. Is the airway currently open and is air flowing easily in and out?
2. Is the patient able to keep their airway open with good airflow without your help? This is termed “maintaining their airway”.
First, Is the airway open?
• If the awake patient is moving air but has noisy breathing, they will often put themselves in the best position that allows them to keep their airway open. Do not force them into a position that they do not want to go into. Generally, we like to place patients on their back, but you should not force a patient into this position if they cannot tolerate it.
• If the patient has a decreased level of consciousness, then roll them onto their back as a single unit, being careful not to twist or jerk the spine or neck. Once the patient is on their back, then attempt to open the airway using the head tilt-chin lift manoeuvre unless you think the patient was injured or involved in an accident.
• If you suspect that the patient has head or spinal injuries, use the jaw-thrust technique to minimize neck movement by placing one hand on each side of the patient’s head and grasping the angles of the patient’s lower jaw and lifting up and forward with both hands.
• If the patient has a decreased level of consciousness and is not moving air well with initial positioning, then inspect for and remove any foreign objects from their mouth. In patients of avalanches, snow burial, or major trauma, it is not unusual to see snow, teeth, dirt and leaves in their mouths.
Second, Is the patient able to maintain their airway?
• There are potential airway issues, especially in trauma and allergic reactions, where the patient may develop worsening obstruction or blockage to their airway and have difficulty breathing. This is important when you consider how to evacuate the patient(s) and which patient should be evacuated first.
R - Respiration
• Respiration involves the evaluation of how well the patient is breathing and whether there is any potential for respiratory compromise in the future.
• If the patient does not start breathing after the airway has been opened, begin rescue breathing as described for basic CPR using current guidelines.
- Each breath should be delivered over one second with enough air to see the chest rise.
- If the breath does not go in, reposition the airway and try again
• If the patient is breathing, briefly assess the quality of the respirations. Does the patient appear to be working hard to breathe, are they breathing rapidly/slowly, is their breathing appropriate, etc? Be mindful of the potential for flail chest and/or tension pneumothorax in trauma patients and consider needle thoracostomy if appropriate and able.
C – Circulation
• Any patient who is awake or showing any sign of life will have a heartbeat. This step is to assess the patient’s cardiovascular status with a focus on the heart rate, pulse strength and to treat non-massive haemorrhage.
• You can assess the pulse at the pedal/tibial, radial, brachial, femoral or carotid arteries.
• Assess the quality of the pulse. Is it weak/thready, bounding, rapid, or irregular?
• Check for bleeding by performing a blood sweep. This is a rapid (5 - 10 seconds) full, head-to-toe check for blood, wet clothing, swelling or other signs of significant bleeding. Don’t forget to look under bulky clothing, coats, and other layers. A blood sweep also affords the rescuer the opportunity to simultaneously note major deformities.
H - Hyperthermia and Hike vs Helicopter
• At this point in the primary survey, the rescuer has treated any immediate threats to the patient’s life and has taken steps to mitigate those threats. Wilderness medicine presents an additional issue that one must consider: the environment and its potential to worsen the patient’s medical course.
• Recognize that whatever the environment, the patient has likely been exposed to it for a longer period and has not been compensating as well as the rescuers.
• A patient in a cold/hot environment will likely be colder/hotter than the rescuer.
• Steps should be taken to limit the patient’s exposure to the environment.
• Hypothermia in trauma can lead to the cascade of acidosis and coagulopathy with increased mortality.
• Think about the evacuation plan (hike vs. helicopter).
1. The life-threatening injuries have been identified at this point.
2. What types of resources will you need and how can you get them to you to help your patients?
3. This is also a point to consider sending someone to go get help depending on the situation. This can be helpful because that individual can relay more valuable information beyond the initial “someone’s unconscious.”
4. If you are going to send somebody ahead to get help, you should send two people to help ensure that help is reached and that something does not occur to that single person sent out.
• As a general rule, and especially when dealing with possible injuries to the spinal column, perform first aid on the patient where he or she lies. However, there are special circumstances under which there is a potential for more severe injury or death if the patient is not moved.
• At the end of your primary survey, it is also the time to decide if this patient needs an immediate evacuation (“load and go”) or if it’s suitable to “stay and play” and manage their issues at the current location.
Primary Survey in Conscious Patients
When the patient is conscious, the rescuer may be able to substitute portions of the complete primary survey with questions.
For example:
- A talking patient has, for the time being, intact airway, breathing and circulation. The rescuer should still assess the quality of the breathing and pulse.
- Asking a patient about what happened and if they are bleeding may eliminate the need for blood spinal immobilization.
3. SECONDARY SURVEY
The goal of the secondary survey is to identify and treat any remaining injuries and illnesses. These conditions may become a problem if left unnoticed or if they require advanced medical attention.
This portion of the patient assessment is comprised of two key elements:
• An abbreviated medical history
• A physical exam including vital signs
The order in which these components are performed depends on the issue. For example, a fallen rock climber should have the physical exam portion of the secondary survey performed first to identify any other traumatic injuries, whereas an abbreviated history from a camper who has developed abdominal pain may be more useful.
Abbreviated Medical History
• Most of the patient’s history is obtained immediately by asking “what happened?” However, a few other key questions must be answered to ensure the patient’s problems are treated properly.
• The mnemonic SAMPLE will help you to remember the essential points of patient history.
• For critical patients, you may be the only person who can get to talk to the patient while they are still conscious. Therefore, if an initially unconscious patient regains consciousness, immediately obtain a history.
• In patients with an altered level of consciousness, other clues may be needed to obtain the history.
• The mnemonic AEIOUTIPS can be helpful in unresponsive patients. A few examples of clues:
- Medical alert tags can be found in the form of necklaces, bracelets, anklets, tattoos, etc.
- List of medications or medical problems may be found in a wallet.
- Medications or devices such as a glucometer (blood sugar meter) or epinephrine auto-injector may be found in a patient’s bag/tent/pocket/etc.
- Bystanders or family members may be familiar with a patient’s past or present medical history.
• Cell phones may be employed to contact family members.
• To assist you in characterizing a patient’s pain, use the acronym COLDERR. Notice that this is most helpful in patients with pain from medical problems rather than traumatic injuries.
Potential Sources of Major Bleeding
• These are potential areas of internal bleeding that are not obvious when just looking at the patient.
• These are all areas to consider when evaluating a trauma patient and are picked up mostly on the physical examination portion of the secondary survey.
• We use the CARTS mnemonic to help remember these potential areas for significant bleeding.
CHEST
The chest is a common source of bleeding, particularly in high-energy trauma. Look for shortness of breath, pain with breathing, and coughing up blood. Examine for chest tenderness, crepitance over the ribs and sternum, flail chest and crackling noises of the chest consistent with air under the skin.
ABDOMEN/PELVIS
Assume abdominal and/or pelvis bleeding in every trauma patient until proven otherwise. Look for bruising over the abdomen and pelvis. Palpate for abdominal and pelvic tenderness on compression.
RENAL
Usually, the bleeding is from the kidneys. Look for blood in the urine if you have a prolonged time with the patient. Examine for tenderness of the spine and chest and the lowest level of the ribs.
THIGH
This may occur if there is a femur fracture. Look for deformity, swelling and bruising of the thigh. Palpate for tenderness and crepitance of the thigh.
SKIN/STREET
This is the most obvious place for a rescuer to detect blood. A common error in the wilderness setting is the failure to remove clothing or to roll the patient to look for bleeding. Also, ensure that you survey the area immediately surrounding the patient for a large amount of blood on the ground that may have come from the patient. Specifically, an arterial injury that bleeds significantly may be in spasm at the time you are evaluating the patient and not be an obvious source of bleeding.
4. ONGOING SURVEY
• A unique aspect of wilderness life support is that the rescuer may care for a patient for several hours to days. For this reason, it is important to continue the patient assessment over a longer period. The ongoing survey very much depends on the patient’s condition, and as such, changes often.
• Initial vitals obtained during the secondary survey should be compared to vitals taken throughout the evacuation or management period. Changes in vitals help alert the rescuer to an improving or deteriorating patient.
• As changes occur, such as the patient’s condition, level of responsiveness or the environment, go back to the beginning of the patient assessment.
• Use your knowledge of the mechanism of injury/illness to try and anticipate problems rather than merely being reactive to acute changes. This can be particularly challenging in a wilderness or other austere setting but trying to think ahead can greatly assist evacuation and other planning.
• If the rescuer has the time and appropriate materials, he or she should try to document the important details. When this is handed off to medical professionals later, they will have a better understanding of the patient’s history.
