Secondary Survey (HB)

Once we make it to the secondary survey, we have time. While we don’t want to hang out in the backcountry with a patient any longer than we have to, we do want to take the time to do a thorough and complete assessment. Our job here is to be as comprehensive as possible and treat all of the things we find. This is also our opportunity to collect objective data about our patient.

The following sections do not have to be performed in order, so long as you complete all of them as necessary.

Physical Exam

Not all patients will require a detailed physical exam. This is where your judgment as a provider comes in. If you saw the patient stumble and roll their ankle, and that is their only complaint, you probably do not have to perform a full spine exam.

We refer to the Physical Exam as a “Head to Toe.” The reason is to give us an organized plan for inspecting the entire patient. We start from the head and work down to the toes.

We complete this exam to find less critical problems, as a backup in case we did miss something in the primary assessment, and to prove or disprove assumptions we have about the patient.

You are looking for abnormal things, so it is important to know how “normal” looks. We all are built and function the same way. Two elbows in one arm are not normal. Typically we are looking for NEW deformities, bruises, abrasions, penetrations, swelling, crepitus (broken bones grinding together), or fluids that should not be present.

If you find an unresponsive patient and don’t know the history (or can’t ask a bystander), you need to be very focused and thorough in your exam. On the flip side, if your patient is awake and reliable and gives you good information, you can focus on that part of the patient. The less you know, the more you need to do.

Remember that things change over time. Problems can get better or worse, so periodic reassessment is important.

Vital Signs

Vital Signs indicate how well different systems perform overall, but it is important to know what normal is. Below is a list of the clinically normal vital signs. It is important to remember these represent the normal values for most people. Some patients may have different normals, so you should ask the patient if you are able:

For “Mental Status,” we expect patients to be awake, acting normal, able to answer questions, and aware of their surroundings. Any changes to these can indicate an altered mental status.

Their skin should be pink (or brown), warm, and dry. Patients that are bluish or gray, are cool to the touch, and damp or moist could be having a problem. The areas around the mouth, nostrils, palms of the hands, soles of the feet, and nail beds might be the first parts to show change.

The normal pulse rate (or heart rate) is between sixty and one hundred beats per minute while at rest. Some highly trained athletes and people in peak physical condition could have heart rates in the low forties. Ideally, you take a radial pulse and measure for at least 15 seconds (though preferably 30 or 60 seconds).

Finding a radial pulse:

A healthy adult should have a respiratory rate of twelve to twenty breaths per minute while at rest. The rhythm of those respirations should be regular and non-labored. When you assess the respiratory rate, don’t tell the patient that is what you are doing. Breathing is one of the vitals that can be manually controlled, and you do not want the patient to try and control their breathing in an attempt to seem healthier.

The core temperature of most people is between 96 and 100 degrees Fahrenheit. The core temperature is taken INTERNALLY and is not something you will typically do in the field. Skin temperature is not a good measure since the environment can significantly affect this.

The first set of Vital Signs that we take is our baseline. It establishes a starting point to help decide your patient’s overall condition and gives an objective set of data to compare against potential changes. As we take the vital signs over a period of time, we can see trends. Those trends let us know if our patient is getting better, staying the same, or getting worse.

You should write these vital signs down along with the time. How often you repeat them is based on the severity of the problems with your patient. With unstable patients, you may want to take vitals every 5-10 minutes until they stabilize. Otherwise, you can repeat the vitals every 20-30 minutes.

SAMPLE History

SAMPLE is an acronym that we use to remind us of the questions we need to ask our patients about their medical history and gather information on the history of the present incident. If the patient is complaining of pain, we have some additional questions we can ask.

Some of the information we try to gather may seem unimportant or irrelevant, and in some cases, it is. In other cases, that seemingly irrelevant information can be the thing that helps you decide between a serious emergency and a problem you can fix in the field.

It is especially useful for medical and environmental problems in identifying things you may not know and confirming things you think might be going on. For traumatic injuries, some questions are not as helpful: e.g., asking a patient that fell off a cliff, “when did the pain start?”

You should get in the habit of asking all the questions that you need to be relevant to the situation. In other words, “use your head.”

Signs/Symptoms:

Signs and symptoms are a subjective question. Take a look at your patient and note down things that are out of place. Maybe their nose is running, or they are sweating profusely. Perhaps you can hear significant wheezing, or the patient is hunched over in the “tripod” position. This question can also include things that your patient tells you: “I have a headache,” “I feel dizzy,” etc.

Signs and symptoms are things you observe about the patient that cannot be measured. It also includes what the patient is complaining about or what they tell you is wrong. Certain questions are helpful to ask as it pertains to their complaint(s):

• “When did it start?”
• “How long ago?”
• “Was it a sudden onset, or was it gradual?”
• “Has it changed over time?”
• “Is it getting better, staying the same, getting worse?”

Allergies:

When we ask a patient about allergies, we want to know two things: what is the allergy to and what kind of reaction they get? We will talk more about allergies in a later lesson. For now, it is important to develop a list of allergies and their severity.

We also want to know if it Is a localized response (“my mouth itches when I eat strawberries”) or a systemic response (“I get hives and have trouble breathing and swallowing when I eat strawberries”).

Medications:

We need to know about any medications/drugs the patient is taking. These could be in the form of Prescription, Over The Counter(OTC), Natural/Herbal, or Recreational.
You should ask them what they take the medication for, how often they take it, and if they have been taking it following the prescription. We would also like to know if the prescription is temporary or if the patient needs it regularly.

Some medications should not be combined with others due to potential side effects. As a provider, we are not here to judge, and the only interest is to make sure that we are not going to cause further harm to the patient.

Past Pertinent History:

To help diagnose the problem with the patient, it is helpful to know about any past history that could be related to this current event. The history could include chronic or acute medical conditions, recent surgeries, or recent trauma. If you ask this after asking about medications, you may have already learned about some medical conditions, and you can ask clarifying questions here if you need to.

We are only concerned with things that are relevant to the current situation. So a report of an ankle injury 15 years ago is less important than the patient reporting rolling their ankle three times in the past week.

We are trying to figure out what medical problems the patient may have and do those problems play a part in the present situation. Does the patient see a doctor or medical practitioner for anything other than an annual physical?

With biologically female patients, we will also ask about menstruation and the possibility of pregnancy, especially if the patient is complaining of abdominal pain.

Last Ins/Outs:

As we move away from trauma and into medical conditions, one of the important factors is how the digestive tract is working and whether or not the patient is adequately intaking nutrition and hydration and eliminating wastes. Asking questions about intakes and outputs gives us a good idea of the patient’s overall hydration and nutrition levels and the function of their genito-urinary and gastrointestinal systems.

We want to know the last time the patient ate, what they ate, how much, and if the meal was typical for them. We also want to know when they last drank, what they drank, how much, and if that is a normal amount of fluid in that period.

Regarding eliminations, we want to know the last time they urinated, how much, and if the color was anything other than a light straw color. We also want to know if there were any strong odors or burning sensations. Again, for bowel movements, we want to know when the last time, what the quality was (was it firm, loose, diarrhea, etc.), and if the timing was normal for them.

Events (leading up to the need for medical care):

We want to develop a reverse timeline of everything that led up to the patient getting sick or injured. How far back we need to go depends on when we have found enough information to make an informed decision about the cause.

Ask the patient what was going on right when the problem started and just prior to the start. Then work your way back from there, letting the patient’s answers inform new questions. We want to know if there was anything unusual or out of the ordinary they did or experienced.
If you’re not sure, ASK. If you think you’re sure, ASK. If you know you’re sure, ASK.

Pain:

If the patient is experiencing pain, ask them to describe in their own words the pain: sharp, dull, crushing, tearing, etc. Do not lead the questions by asking those specific descriptions.
Remember, if someone is experiencing an Acute Stress Reaction (ASR), they might be focused on one injury and unaware of others. (We will cover ASR in the lesson on Circulatory System)
If the patient is experiencing pain, we can use another acronym: OPQRST.

• Onset: We want to know when the pain started and how rapidly the pain came on. Common questions are: “Did your pain start suddenly or gradually get worse and worse?” and “What were you doing when the pain started?”
• Provokes: We want to know what is causing the pain, so a question could be, “What makes the pain better or worse?”
• Quality: We want the patient to describe the pain in their own words, so avoid using leading questions (like sharp or dull). Instead, try: “Can you describe the pain for me?”
• Radiates: Knowing if the pain is radiating is important (it is a classic sign of a heart attack). Ask, “Can you show me where the pain hurts the most? Does the pain move? Where does it go?”
• Severity: This is a subjective measure. We want to know if this is mild or the worst pain they have ever felt. We usually use a scale so we can compare over time. “On a scale of 1 to 10 (with ten being the worst pain you have ever felt), what is your current pain?”
• Time: We want to know when the pain started. “How long ago did the pain start?”

Additionally, we can use the five “S” ‘s of pain to decide if the pain is more serious. If the patient reports the pain as Sudden, Sharp, Steady, Severe, or Specific, we should be a little more concerned. These are all indications of an acute problem that could be serious.

Example: Your patient is complaining of being light-headed with a headache and is acting a little cranky. They report an allergy to peanuts and are taking insulin for their diabetes. They took their insulin, as usual, this morning right before breakfast, which was normal for them. They drank a cup of coffee and a glass of water just like normal, which was the last time they took in fluids. The patient reported having a bowel movement as normal this morning. It was a nice day, so they decided to go for a hike, and after about 2.5 hours on the trail started feeling bad. They report the headache came on over the past hour or so, and nothing seems to make it better or worse, but it is only a “3”. It is not radiating and just feels like a dull throbbing behind their eyes.

What do you think is wrong with this patient? What information do you want to know? Would you ask any further questions?