IX. Patient Assessment System – Checklist

Part 9 of 9: PATIENT ASSESSMENT CHECK LIST:

SCENE SURVEY:
Is the SCENE SAFE?
Is the PATIENT SAFE?

PRIMARY SURVEY: 
Are they CONSCIOUS?
Do they have an OPEN AIRWAY?
How is their BREATHING?
Do they have a PULSE? 
Are they BLEEDING?
Are there any serious injuries on the CHUNK CHECK?
Is their neck and spine STABLE?
Do they need to be MOVED?
Do we need to protect them from the ENVIRONMENT?
How is everyone else DOING?

SECONDARY SURVEY – VITAL SIGNS:
What is their RESPIRATORY RATE & EFFORT?
What is their HEART RATE & EFFORT?
What is their LEVEL OF CONSCIOUSNESS?
What is their SKIN COLOR, TEMPERATURE, & COLOR?

SECONDARY SURVEY – PATIENT EXAM:
HEAD  – scalp, face, eyes, nose, mouth.
NECK  – spine, trachea.
CHEST – clavicles, shoulders, ribs.
ABDOMEN – compress the abdomen.
PELVIS – compress the pelvis anterior/posterior and lateral.
LEGS  – circulation, sensation, and motion.
ARMS  – circulation, sensation, and motion.
BACK  – log roll and palpate the length of the spine.

SECONDARY SURVEY – AMPLE HISTORY:
ALLERGY – allergy to drugs, foods, insects, etc. 
MEDS  – prescription and non-prescription drugs.
PREVIOUS – significant past medical history, surgeries, etc.
LAST   – last intake & last output.
” EVENT – events leading up to this crisis.

SOAPnote:
Putting it all together and creating a treatment plan.

RESCUE PLAN:
” Looking at all factors and creating a rescue or evacuation plan.

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VIII. Patient Assessment System – Rescue Plan

Part 8 of 9: PAS – STOP – RESCUE SURVEY: Do we need help?

Are we staying or going?
What is our plan to get help?
Who is going to go to get help?
What do we do to protect the patient while waiting for help to arrive?
What do we do to protect ourselves while waiting for help to arrive?
Is the scene safe?

RESCUE PLAN: Do we need help?

Group’s condition:
How well is each individual in the group doing?
How well prepared is the group to stay put and bivouac?

Decisions:
Do we need to evacuate the patient or can we all go on?
If evacuation is needed, send for help.
While waiting for rescue – build a bivouac.

Sending for help:
Send two to get help if possible.
Send out a SOAPnote on the patient.
Send out a list of the rest in the group and how well prepared you are to bivouac.
Send out a map with your exact location and time marked on it.

While waiting for help to arrive:
Know where everyone is; pair people up to massage each other’s feet, etc.
Keep everyone busy.
Create shelter for everyone.
Get water or melt snow and make something warm to drink.
If food available, make a meal & eat.
Keep spirits up, be positive, reassure, make sure everyone has something to do.
Create light and warmth; build a fire.
Make yourselves big, easy to find.
Continuously monitor your patient.
Continuously monitor everyone else in the group.

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VII. PAS – Secondary Survey – SOAPnote:

Part 7 of 9: PAS – SOAP note: What is our patient care plan? 

The SOAP note is organized into the Subjective date, Objective date, the Assessment, and the Plan.

Subjective:
The subjective date is their age, sex, the mechanism of injury (MOI), and the chief complaint (C/C), i.e., what they are complaining of.

Objective: 
The objective date consist of their vital signs, the patient exam, and the AMPLE history.

Vital signs: 
Time the vitals signs are taken:   
RR & Effort    
HR & Effort(BP)    
LOC    
Skin: C/T/M    

Patient exam:  Describe locations of pain, tenderness & injuries.
                                                                                                                                               
AMPLE history:
Allergies:           
Medications:             
Past pertinent medical history:         
Last intake & output:           
Events leading up to accident:         

A – Assessment:  (problem list)
1.                                                                                                                                                  
2.                                                                                                                                                   

P – Plan:  (plan for each problem on the problem list)
1.                                                                                                                                                   
2.                                                                                                                                                  
3.  MONITOR – reSOAP your patient every 5 – 15 minutes.

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VI. PAS – Secondary Survey – AMPLE History:

Part 6 0f 9: PAS – AMPLE History: What is their past medical history?

ACTION:
Talk with your patient or others to determine the following information:

A – Allergies:
Are they allergic to any medications, foods, insects, etc.? 
If they are what happens and how is it treated?

M – Medications:
What medications are they taking, both prescription and over-the-counter?
If they are taking medications, how often and how much do they take and have they taken their meds today?

P – Previous Injury or Illness:
Is there any recent or past injury or illness that could contribute to the current problem?
Have they ever been hospitalized over night for any medical problems, is so what?

L – Last Input and Output:
When was the last time they had anything to eat or drink?
What did they eat and drink?
When was the last they voided or had a bowel movement?

E – Events leading up to the crisis:
What lead up to or occurred just prior to the critical event?

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V. PAS – Secondary Survey – Patient Exam:

Part 5 of 6: PAS – PATIENT EXAM: What are their injuries?

PRINCIPLES OF THE PATIENT EXAM:
You are trying to discover all possible injuries by:
LOOK:
Inspect:  Is there any bleeding, wounds, impaled objects, or deformities?
Compare:  Are their body parts symmetrical?
LISTEN:
Complaints: Are they complaining of pain or tenderness, if so, isolate where it hurts?
FEEL:
Palpation: Is there tenderness in muscles, bones, or joints?
Circulation:   Are there pulses in all four extremities?
Sensation:   Is there normal sensation in all four extremities?
Motion:   Is there normal range of motion is all four extremities?

ACTION:
Keeping the above principles in mind do a hands on head-to-toe exam:
HEAD:  scalp, face, eyes, ears, nose, mouth.
NECK: cervical spine, trachea.
CHEST: clavicles, gently compress the rib cage.
ABDOMEN: compress the abdomen in all four quadrants.
PELVIS: compress the pelvis front to back and laterally.
ARMS: palpate the muscles and flex the joints.
LEGS: palpate the muscles and flex the joints.
BACK: palpate the length of the back.

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IV. PAS – Secondary Survey – Vital Signs:

Part 4 of 9: Patient Assessment System – Vital Signs:

STOP – SECONDARY SURVEY: How hurt are they?
The Secondary Survey consist of:
How well are they? Vital Signs
What are their injuries? Patient Exam
What is their past medical history? AMPLE History
What is our patient care plan?  SOAPnote

VITAL SIGNS: How well are they doing? 

Respiratory Rate and Effort:
Respiratory rate and effort shows us how well the Respiratory System, the airway and lungs, is doing at oxygen exchange and in particular, in supplying the brain with O2.
LOOK – Do they look like they are having difficulty breathing?
LISTEN – Are they complaining of shortness of breath or difficulty breathing?
FEEL – Is the chest moving properly with breathing?

Heart Rate and Effort (blood pressure):
The heart rate and effort, blood pressure, tells us how well the Circulatory System, the heart and blood vessels, are doing.
LOOK – Do they look shocky?
LISTEN – What is there heart rate, beats per minute.
FEEL – Take a blood pressure by palpation (systolic), if you do not have a BP cuff.

Level of Consciousness:
Level of consciousness tells us how well the Central Nervous System, the brain and spinal cord, are doing.

Action:
Level of Consciousness (LOC) is determined using the AVPU scale:
Awake, Verbal, Painful, Unresponsive.

Conscious: “The lights are on, is anyone home?”
Awake, their eyes are open but, are they alert oriented times 3, person, place, and time?
Person, do they know who they are?
Place, do they know where they are?
Time, to they know the day, week, and year?

Unconscious: If their eyes are closed they are unconscious, but how responsive are they?
Verbal stimuli, “Hello, anyone in there?”
Speak to them, do they react to hearing their name?
Do they follow simple commands?
Painful stimuli, “That’s got to hurt.”
A knuckle rubbed on their sternum?
Is it an appropriate response to pain?
Unresponsive, “Speak to me; say something.”
No response to verbal or painful stimuli.

Skin color, temperature, and moisture:
Skin color varies by individual and race.
Look – What is their skin color, pale, ashen, cyanotic?
Listen – Are they complaining about feeling hot or cold?
Feel – Is their skin dry, moist, clammy, hot, or cold?

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III. Patient Assessment System – Primary Survey

Part 3 of 9: Patient Assessment System – Primary Survey

STOP – PRIMARY SURVEY: Are they alive, and are they going to stay alive?

A: Approach and Assess – Are they conscious and can they speak?
A: Airway – Do they have an open airway?
B: Breathing – Are they breathing?
B: Breathing – How well are they breathing? 
C: Circulation – Do they have a pulse? 
C: Circulation – Are they bleeding?
D: Deformity – Are there any obvious deformities?
D: Disability – Is their neck or back at risk of injury?
E: Environment – Can they stay where they are?
E: Everyone Else – How is everyone else in the group doing?

A: Approach and Assess – status of the central nervous system
Are they conscious and can they speak?
Look – Are they awake; are their eyes open; what position are they lying in?
Listen – Speak to them. Do they speak back?
Feel – What is your general impression of the situation?

A: Airway – status of the respiratory system
Do they have an open airway?
Look – Is there anything in their airway?
Listen – Can you hear air moving in and out of the airway?
Feel – Can you feel air moving in and out of the airway?

B: Breathing – status of the respiratory system
Are they breathing?
Look – Is their chest wall moving as they breathe?
Listen – Can you hear any adventitious breath sounds indicating a partially occluded airway, such as wheezing, gurgling, or snoring?
Feel – Is the chest wall moving appropriately with respirations?

B: Breathing – status of the respiratory system
How well are they breathing?
Look – Is their chest wall moving as they breathe?
Listen – Can you hear any adventitious breath sounds indicating a partially occluded airway, such as wheezing, gurgling, or snoring?
Feel – Is the chest wall moving appropriately with respirations?

C: Circulation – status of the circulatory system
Do they have a pulse?
Look – Is there any bleeding?
Listen – Can you hear a heartbeat?
Feel – Can you feel a carotid pulse?

C: Circulation – status of the circulatory system
Are they bleeding?
Look – Is there any bleeding?
Listen – Can you hear a heartbeat?
Feel – Can you feel a carotid pulse?

D: Deformity
Do they have any obvious injuries or deformities?
Look – Do you see any obvious injuries or deformities?
Listen – Where are they complaining of pain?
Feel – Where does it hurt? As you touch them, where can you cause pain?

D: Disability
Is their neck or back at risk of injury?
Look – What was the mechanism of injury (MOI)? Can they move their extremities?
Listen – Are they complaining of any neck or back pain?
Feel – Do they have normal sensation in their extremities?

E: Environment
Can they stay where they are?
Look – Where are they lying?
Listen – Are they complaining about being hot, cold, or wet?
Feel – Is their skin warm, dry, cold, or wet?

E: Everyone Else
How is everyone else in the group doing?
Look – How does the rest of the group look?
Listen – Is anyone complaining of being cold, wet, hungry, or thirsty?
Feel – What is the emotional status of the group?

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II. Patient Assessment System — Scene Survey

Part 2 of 9: Patient Assessment System – Scene Survey

To survey something is to examine it closely and ascertain the condition. In this system of STOP and Survey, the intent is to take the time to STOP and take a deep breath before closely examining and ascertain the patient’s condition.  A survey is organized in a logical step-by-step process that allows you to gather the information and respond in an orderly manner. 

STOP – SCENE SURVEY: Is the Scene Safe?
 Am I OK, and am I going to stay OK?
 Are the others OK, and are they going to stay OK?
 Is the victim of this crisis OK, and are they going to stay OK?
 What happened? What was the mechanism of injury (MOI)?
 How do I safely approach the victim?
 What is my general impression of how serious this is?

To accomplish all this Scene Survey:
 
1. STOP! Stand still, take a deep breath, and ask yourself, “Am I OK?” If not, do something about it! Go

2. STOP! Tell everyone else to STOP, stand still, take a deep breath and ask themselves, “Am I OK?” If not, do something about it! Don’t allow anyone to run off to check the victim or to get help. Go

3. STOP! Is the victim OK? First speak or call out to them, even if you cannot see them or get to them. Ask them if they are alright. Hopefully, they will answer; even if they say that they are not alright, at least you know they are alive, have an open airway, are breathing, and have a pulse. Go

4. STOP! Ask yourself, “What happened?” “What was the mechanism of injury?” Go

5. STOP! Survey the victim’s situation. While figuring out how to safely get to them, keep talking to them, be positive, keep encouraging them, tell them to lie still, that help is on the way. Go

6. STOP! As you approach the victim, survey their position. Ask yourself, “Can they stay where they are, or are they in eminent danger and need to be moved?” Go

7. STOP! What is your impression of the victim. As you approach the victim (they do not become your patient until you lay your hands on them), develop a general impression of how serious the situation seems to be, based on the position they are lying in, how they look, whether they are conscious, bleeding, etc. Go

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Lower Leg Splint

Lower Leg Splint

There are many ways to improvise a splint for a lower leg for ankle injury. But few methods have the advantage of using an ensolite or foam sleeping pad to make the splint.

The advantage that ensolite (closed cell foam) has is that it is very flexible, soft, conforms easily, it is warm and insulating, and has good support when formed to the extremity and tied in place.

Technique for making a lower leg splint with an ensolite pad:

1. Remove the shoe and sock to be able to inspect and monitor the foot once the splint is in place. Fold the ensolite pad in half width wise, adjust the length to fit the length of the leg keeping the doubled over portion at the foot end. The pad should extend at least 12″ above the knee and a 12″ below the foot.

2. Roll the ensolite around the leg and tie it in place above and below the knee.

3. The section that extends below the foot can now be folded up against the sole of the foot. To aid in tying the folded-up foot support section around the leg, put a 6′ piece of tubular webbing, rope, or other material through the folded over end of the ensolite pad.

4. Take the webbing (or rope) material and cross in front of the leg.

5. Then wrap around the lower leg and cross over the top of the leg.

6. Then wrap around the folded up section of the ensolite with the foot being held at 90°, position of comfort.

7. Finish by tying off the webbing on the front of the leg.

Remember to monitor circulation, sensation, and warmth in the distal extremity every fifteen minutes.

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LOWER EXTREMITY INJURIES

Lower Leg Fracture – Tibia/Fibula:

May be an angulated fracture with impairment of circulation distal to the site of the fracture.
If angulated the fracture can be easily reduced into proper anatomical alignment with gentle Traction-In-Line (TIL).
Splint the lower leg in proper anatomical alignment with distal pulses intact.
A splint can be easily improvised with an ensolite pad or well-padded sticks held in place with cravats.
Splint with the foot held at 90 degrees.
Monitor circulation every 15 – 30 minutes.

Ankle Injuries:

“Ottawa Rules” can be used to help determine if the injury is a fracture or not.
The Ottawa Rules are:
Need to be an adult (i.e. good historian).
1. No tenderness over the malleoli (the lateral and medial aspects of the ankle).
2. No laxicity on inversion, eversion, or drawer test of the ankle.
3. They can walk 3 steps without pain or sensation that the ankle is going to collapse.
If suspicious of a fracture then treat the same way as a tibia/fibula fracture.
If a sprain then RICE the ankle and support with a sprained ankle bandage.

Video demonstration of applying a sprained ankle bandage:

Foot Fractures:

A “March Fracture” is a stress fracture of the 5th metatarsal that is caused by a long march or hike.
Diagnosis – pain and tenderness over the center of the lateral arch of the foot.
Treatment is to support the foot well with a firm boot.

Fractured Toes:

May be angulated, is so apply TIL to straighten, move into proper anatomical position.
Splint the injured to by “buddy taping” the injured toe to the adjacent toe, with padding in between the toes for comfort and support.
Support the fractured toes by wearing a stiff-soled shoe to prevent flexion of the toes.

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