*Scene Size-Up and Initial Assessment*
When first coming onto a scene where someone is sick or injured, there are certain steps to be taken to evaluate the situation. All aspects of the scene must be taken into consideration to fully understand what is going on, and to determine what happened. In a way, itís like be an investigator and a medic. Be aware of everything around you, the bystanders on the scene, the objects or people that caused the injury, the injured party, the mechanisms of the injury, any hostile parties involved and their location, weapons, hazardous materials, and a host of other things. Remember, "everyone sees, but few observe." Donít just "see" your surroundings, OBSERVE them. Make mental notes of everything, whether it seems pertinent or not. Talk to bystanders who witnessed the injury or onset of the illness. In this article we will discuss all of these things, in what order to do them as well as patient assessment.
No matter how "the call comes in", whether it be for ambulance crews receiving it from their dispatch center, a neighbor running to your house screaming for help, or actually witnessing an event, the first thing that should enter your mind is, "Is the scene safe?" Observe the scene for any dangers. Are there hostile people on scene? Are there live electrical wires down? Are there any hazardous chemicals or unknown substances spilled anywhere? Any animals, domestic or wild roaming about? Before entering a scene, make every effort to secure the safety of that scene. During current times, call the necessary resources using 911 or other emergency numbers. If you arenít sure how to secure the scene, donít attempt it. Making yourself a casualty will compound and complicate the situation further. In a PSHTF scenario, use your teammates to assist in this task.
After securing the safety of the scene, the next thing to observe is the mechanism of injury. In other words, what happened? What caused the patient to be injured? A fight? Gun shot? Stab wound? Vehicle crash? A fall? Burns? Some type of machinery malfunction? With each of these mechanisms there are yet other questions to be asked. If the patient was beat up, did the assailant use just his fists and/or feet to inflict the injuries, or did he/she use any other objects to inflict injury? If it was a stabbing or cutting, what type of knife was used-how long was the blade? Was it serrated, double edged? Is it still impaled? If not, WHERE is it? The same types of questions apply for a gunshot wound (GSW). What type of gun was used, what caliber, from what distance, how many shots, and WHERE is the weapon now? In current times, if you should walk into a crime scene, DO NOT TOUCH ANYTHING!!!!! Preserving evidence in of utmost priority. Patient care can be accomplished without contaminating a crime scene. In a PSHTF scenario, your groupís rules may determine what to do. Most likely, the weapon will be secured by someone of authority to prevent anyone else from becoming injured. For patients in a motor vehicle crash (MVC), what type of collision was it-head on, rear end, T-bone, rollover, etc? Are the patients still in the auto? Were seatbelts utilized? Did any airbags deploy? What is the condition of the passenger compartment? Is the windshield broken? HOW is it broken-spider webbed, a hole in it where someoneís head or body may have penetrated it? Is the steering wheel bent or broken? Is the steering column intact? Are the passenger seats intact? If it was a floor shift vehicle is the gearshift intact---make sure it isnít impaled in someoneís body. Are any utility poles involved, and if so, are their wires down? For falls, how far did the patient fall? On which part of the body did they land? What was the surface they landed on? Did they land on anything that could have impaled them? For burns, what caused the burn? How long was the person exposed to the agent? Is the agent a chemical, and if so what type? If it was fire, is the fire out? These are the questions to help determine the extent of injuries the patient may have endured.
Now for patient assessment. For the purposes of this article, letís say the patient is lying on his/her back. The first step in assessing a patient is called the primary survey, or the ABCís, which stands for Airway, Breathing and Circulation. You can establish this simply by asking the patient, "Hey bud, are you ok?" or something similar. If they respond, you have just determined, yes this patient has an open airway, yes they are breathing, and yes they have blood circulation. But what if they donít respond? If they appear unconscious or lethargic, first establish a patent, meaning open, airway. Do this using the head tilt-chin lift maneuver (refer to your CPR training, which ALL of you should have!!). Once you have opened the airway, assess the respirations, again using what you learned in CPR training. Then assess the pulse. If the patient is breathing they will have a pulse, BUT they can have a pulse and not be breathing (granted the pulse wonít last long). Now, once youíve established these three things, you will either be doing artificial respiration, full CPR, or be able to move on to the next step.
Talking to your patient is of utmost importance. Let them know what you are doing and that you care about them. Many medics get burned out and take the "I hate everyone and everything attitude" and it shows in their poor bedside manner and sloppy skills. Now we have to ask the patient what happened and get some vital information that can help us make a decision on whatís wrong. This is called getting a SAMPLE history. SAMPLE stands for: Signs/Symptoms, Allergies, Medications, Physician, Last oral intake, and Events leading to the Illness/Injury. You will also need to ask the patient about their medical history; such as do they have diabetes, seizures, high blood pressure, cardiac problems, respiratory problems, cancer, communicable diseases, etc. Look at the personís medications first hand, if theyíre available. Sometimes they wonít tell you all of the medical conditions they have, or theyíll forget some of them (especially elderly). By looking at the medications and having a little background in pharmacology, you can figure out most of the history yourself and prompt the patient if theyíve left something out. The difference in signs and symptoms is, a sign is something you, the rescuer sees, touches, or hears. A symptom is what the patient feels. Chest pain is a symptom. Deformity of the arm is a sign. Remember when questioning the patient about their symptoms, keep it related to the mechanism of injury or the chief complaint.
If the patient is complaining of a tummy ache, pain from a blister on their left foot isnít pertinent. When asking about allergies, you want not only to know about medication allergies, but also food or other allergies. In current times, the patientís physician is important, but ATSHTF, that honor will go to your team medic, who should have a complete medical file on everyone in the group.
Last oral intake isnít always important, but can be extremely important for certain cases like abdominal pain, allergic reactions, chest pain, vomiting or diarrhea, etc. Event is basically the patient telling what happened to cause the illness or injury. IF the patient is unconscious, you will have to use your noggin to figure out from the mechanism of injury or from bystanders accounts, what happened....
Which brings me to this pointÖtalk to the bystanders! Who witnessed the event? What did they see? Do they personally know the patient? If they patient is unable to talk, can they give you any of the information you need? History is very valuable when determining what is going on with a patient, especially with an illness situation.
While asking all of these questions, you can be doing other thingsÖlike taking vital signs. Take the patientís blood pressure (BP), pulse, and count the rate and quality of the respirations. If a thermometer is available, temperature may be taken. In adults it may only be necessary if fever is present or if infection is a possibility. In children a temperature is a MUST, regardless of the problem.
Now we come to the Secondary Survey. This will be a detailed examination of the entire body, looking for trauma, or abnormalities. You can also start the secondary survey, after finishing the vitals and while still asking questions in the SAMPLE history. When doing the secondary survey, key in on parts of the body that were possibly affected by the mechanism of injury or the chief complaint. The chief complaint is what the patientís primary complaint of illness or injury is, i.e. My stomach hurts, I canít catch my breath, I fell off my bike and my shoulder hurts, etc.
The whole body should be examined, but pay closer attention to the affected areas. The best way to do the secondary survey is to do it "head to toe", which is why it is also called in some places the," head to toe" survey! First start at the head and palpate, which means feel, the head and scalp. All while palpating the body ask the patient if it hurts anywhere you touch. Are there any abnormalitiesÖlumps, bumps (hematomas), lacerations, depressions, etc.
Next, the face, is there any soft tissue trauma to the face, is the face symmetrical, do the eyes appear focused. Using a penlight or low power flashlight, check the pupilary response. Are both pupils equal in size, round in shape, and do they react to the light. To properly assess reaction to light it must be fairly dim in the room and the patient should focus on a stationary object (I usually have them look me in the eye or look at my nose). The pupils should be checked one at a time and they should constrict quickly when the light is shined in the eye. If they donít react, are unequal in size, shape or response t light, make note of this. A common way to notate pupillary response is to use the acronym PERRL (pronounced pearl) It stands for Pupils Equal, Round Reactive to Light. Next feel around the orbits and cheekbones, any crepitus (crunching sounds or feeling) found, can the patient track an object with his/her eyes and do the eyes move together. Any deformity to the nose? Any blood or fluid leaking from the nose? Look at and in the ears, any blood or fluid leaking from them? Now the mouth, are the teeth intact, denture plates in? Any trauma to the tongue? Foreign objects should have been removed from the mouth during the primary survey.
Once you have completed the head and face, move to the neck. Is there any deformity, soft tissue trauma or swelling to the neck? Is the patient using the accessory muscles (the muscles on the sides of the neck) to breathe, are there neck veins standing out (called Jugular Vein Distention, JVD for short), is the trachea midline?
After assessing the neck move to the shoulders and chest. In some cases exposing the chest may not be necessary, however, if there is ANY trauma to the chest, remove the patients clothing to have full view of the chest and abdomen. Do this as discreetly as possible to help decrease the patientís level of embarrassment. Have sheet or towel available to cover the exposed areas after the exam. Look at the shoulders and collarbones (clavicles)-are they symmetrical? When palpating them does the patient experience any pain or tenderness? Is there any crepitus or subcutaneous emphysema (a bubbly, crackling kind of feeling like the bubbles on packing material)? Any swelling, soft tissue trauma, deformity noted?
From the shoulders go to the arms. Does there appear to be any deformity? Are there good radial pulses? Have the patient squeeze you hands at the same time. Is the grip strong and equal? If not which side is weaker?
Now go to the chest. Is it symmetrical, on inspiration and exhalation, does it expand and contract symmetrically? On palpation do you notice any crepitus or sub Q emphysema? Any soft tissue trauma, especially penetrating trauma? Any discoloration? Listen to the breath sounds with a stethoscope. Listening to breath sounds isnít difficult, it just takes practice to understand what youíre hearing. There are technically five areas, called lobes. Two lobes, upper and lower in the right lung, and three lobes, upper, middle and lower, in the left lung. The reason there are only two lobes on the right is so there is room for the heart. To listen, place the large bell of the stethoscope on the patients skin, on the chest, just below the right collarbone. This is called the mid-clavicular line. Then have the patient breathe deeply, in and out. Listen carefully at the air exchange. To listen on the left, place the bell on the chest just below the left clavicle, on the left side mid-clavicular line. This is the area to listen to the two upper lobes. To listen to the lower lobes, place the bell on the patients side, under their arm, at nipple level, which should place it on the side, next to the breast. This is called the mid-axillary line. Again have the patient breathe deeply in and out. Do this on the other side too. The fifth lobe is very small and doesnít have to be auscultated (listened to) necessarily, but if you want to hear it, place the bell on the left side of the patientís back just below the shoulder blade (scapula), and listen to the breath. Now, what do the sounds youíre hearing mean? Things you want to note: are the sounds equal bilaterally (on each side), are they clear? Clear breath sounds through a stethoscope will kind of sound like Darth Vader breathing. Other sounds you may hear are wheezes, which are a high pitched squeaky sigh sound. Wheezes are common with asthmatics, allergic reactions, and elderly people with Chronic Obstructive Pulmonary Disease (COPD), which includes emphysema and chronic bronchitis. Wheezing can be faked in the upper airway, but to call the fakers bluff listen to the lungs, because they canít fake their lung sounds! Rhonchi (pronounced Ronk-eye) is a crackly sound. Hold a tress of hair next to your ear and rub it between your fingers, the crackling sound you hear is similar to rhonchi. This is another sound heard with COPD patients or people with breathing disorders. Some people refer to rhonchi as "crackles". Rales (two pronunciations a: Rails, with a long Ďaí sound b: rales, with a short Ďaí sound as in Ralph) is a wet bubbly sound. This usually indicates there is fluid in the lungs caused by pneumonia, congestive heart failure (CHF), pulmonary edema (PE), as well as others. Patients in true respiratory distress will want to still bolt up right, or slightly leaning forward with their hands resting on their knees. This position is called the "tri-pod" position. They will also be pursing their lips when they breathe or using the accessory muscles in their neck. These are generally not things the patient does spontaneously, itís a reaction of their body trying to breathe better.
After evaluating the lungs and chest, move to the abdomen. Looking at the belly, does it look bloated, distended, swollen, discolored? Before touching the stomach, use your stethoscope to listen to the bowel sounds. The abdomen is divided into four quadrants, called the Left Upper Quadrant (LUQ), the Left Lower Quadrant (LLQ), the Right Upper Quadrant (RUQ) and the Right Lower Quadrant (RLQ). Looking at your stomach, draw an imaginary vertical line from the middle of your sternum at the xiphoid process (something you should have learned in CPR class) through the navel and down to the pubic bone. Now draw an imaginary horizontal line across the belly button. Now the abdomen has been divided into four areas, which are the quadrants. When referring to the RUQ, it is the patientís right upper side, not your right (if youíre facing him). Ok, now place the bell of your stethoscope in the center of each quadrant and listen for a few seconds. You should hear a gurgling sound, similar to when you hear your stomach growl from hunger. If you donít hear bowel sounds, it could be from constipation, trauma to the abdomen, or other gastrointestinal (GI) problems.
After assessing the abdomen, move to the hips and pelvis. Once again, it may not be necessary to expose the pelvis and genitalia, unless there is suspected trauma to that area. Maintain discretion when exposing the body. Place one hand on each of the patientís hip bones the ones that stick up when lying down. These bones are called the iliac crests. Place your palms on these bones and gently apply pressure to the bones. Do they hold firm or do they give? Any crunching or cracking? Now rock the bones back and forth, do they rock or move independently of each other? Now place your palms on the outside of the patientís hips where the thigh and hip meet. Gently apply pressure toward the center of the body, called medial pressure. Is there any crunching or crackling? Do the bones seem to "give"?
After the hips and pelvis, and if the mechanism or injury or chief complaint calls for it, visually examine the genitalia. Does anything look abnormal? Most genitourinary problems can be figured out by talking to the patient. The procedure is different for childbirth situations, but that is a different article.
Next go to the legs and feet. Look at both legs, any signs of trauma? Palpate the legs, feeling for trauma or to see if there is a response of pain. Do the legs look the same? Is there any swelling, deformity, or soft tissue trauma? Are the legs equal length? Now go to the feet. Is there a pedal pulse? Hold the palms of your hand against the sole of the patientís feet and ask him/her to push against your hands, like theyíre trying to step on your fingers. Then place you fingers on the top of the patientís foot and pull down on the toes like youíre trying to point the patientís toes, at the same time tell the patient to resist you, pulling their toes up toward their head. When doing the foot push/pull, were both sides strong and equal? If shock is suspected, check the capillary refill in the toenails and fingernails. To check capillary refill, press on the nailbed and release it. Normally the nailbed is pink, when you depress it, it will turn white for a split second then turn pink again. What weíre looking for is how long it takes for the nail bed to turn pink again. If it takes longer than 2 seconds, there may be circulatory compromise. One thing to remember is cold extremities will delay the cap refill too.
Now, if no spinal injury is suspected, roll the patient onto his/her side and examine the back. Touch and feel the ribs and run your fingers down the spine. Ask the patient if there is any pain. Look for impaled objects or other soft tissue trauma. If none is found, roll the patient back into the supine (lying on his/her back) position.
We have now completed the scene size-up and the primary and secondary survey, the SAMPLE history and vital signs. You should have a good idea of the extent of the patientís injuries or complaints, and should be able to relay all of this information to your team medic. You can practice these procedures on your family members to become good at it and to help you remember all of it. The WHOLE process of everything listed above should take no longer than 3 MINUTES to complete!!!!!!!!!!!!! The way to do it that quickly, is to practice, practice, practice!! I hope most of you find this information useful!
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