Paramedics: From Street to Emergency Department Case Book                      

Secondary Survey

By Tony Clough

Once you have verified a casualty has the ability to breathe on their own, whether responsive or unresponsive, using the Danger Response Airway Breathing (DRAB) method (Primary Survey) described in my earlier article ‘Airway Management’, it is time to continue to the secondary survey. Thorough practice of the Primary Survey will satisfy first aiders’ that the casualty is not in immediate state of dying. The secondary survey is a further priority list; a systematically examination to discover any injuries a casualty may have, life-threatening or otherwise. 

Following on from DRAB;

Circulation - once it has been confirmed that the casualty can breathe without assistance, a few seconds should be spent giving a full visual examination of the casualty, looking in particular for severe bleeds and severe burns. Anywhere that cannot be immediately seen, such as the natural hollows behind the knees and beneath the lower back, should be quickly examined; checking their gloves for fresh blood. Anywhere that may absorb or mask the blood such as hair and clothing should also be examined. Nevertheless, the examination should be brief with time only spent treating any discovered severe bleeding and burns.

Blood transports oxygen around the body and having wounds or injuries that produce heavy blood loss can quickly bring on ‘Hypovolaemic Shock’ and death. Likewise, burns produce a natural defence mechanism in the form of blisters. Blisters are filled with plasma – the fluid constituent of blood - sizeable burns whether partial thickness or full thickness will produce large volumes of plasma and if this is lost through burst or leaking blisters, blood will lose its fluidity, its ability to transport oxygen and the likelihood of ‘Hypovolaemic Shock’ increases.

Damage – This, head-to-toe-Survey is a further examination of your casualty to find anything you may have missed previously. It should be thorough but done in a firm and gentle way as not to move and exasperate any yet undiscovered injuries. You are now looking and feeling for any deformities, open wounds, tenderness to the casualty and swelling. Many discoveries may be beyond first aid care but the information gained and passed to the arriving definitive medical care can help and speed up the casualty’s on going treatment.

Head; your brain lives in a very tight box – the skull – and like any other muscle when injured, can swell. It literally has no room to swell into but can start appearing at the natural openings of the skull; eye sockets, ears, nasal and mouth. Your brain is also bathed in straw coloured cerebral fluid and if the skull is fractured this fluid may also leak into these areas.

Start by gently cupping your hands around the back of the casualty’s skull and then running your fingers down the back of the neck. The skull should feel like your own skull and the neck like your own neck – simplified; like a stack of polo’s with jelly tots between them. The nape of your neck is where the spine starts its journey down your back; protected within it runs your internet super highway – the spinal cord. If you suspect anything is not quite right, make a note and start treating your casualty as if the ‘C’ spine is injured; in other words immobilise by holding the head still and do not move them unless they stop breathing and are in need of CPR – which will take precedence over a neck injury.

Now look at the face noting the colour and temperature. Run your fingers along the forehead, down the bridge of the nose, then along the cheek bones pausing to open and look in the eyes. The pupils should react to light normally – the more light there is the smaller the pupils react – making a note any abnormalities. While looking in the eyes also look for the straw coloured fluid and look to see if the capillaries in the bottom of the eye area are a nice healthy bright pink, hinting at good oxygenated circulated blood arriving where it should. Continue your facial examination by feeling the jaw bone.

Neck and throat; any damage to this bodily area can cause severe breathing problems; look at the front of the neck for any ‘tracheotomy’. Also look to see if the casualty is wearing a ‘Medic-alert’ necklace. Medic alert is a charity based organisation that has access to the medical records of patients who have opted to have them made available to emergency services in need of medical emergency. The necklace has the symbol of first aid on one side – a cross with a snake wrapped around it – and on the other it will have a unique patient number to access a data file and a brief description of any medical problems. If one is discovered, never remove it but make a note of it and make its presence known to the emergency services. Some younger patients may wear them around the wrist or around the ankles.

Chest; you can imagine under the human chest it is rather busy. Several vital organs are within the torso and it is to here we now divert our attention. Damage to these organs can quickly become life-threatening and it is for this reason it is known as ‘the kill zone’.

We do not possess x-ray eyes and cannot see inside the chest so visually and physically we need to examine it. Start by feeling the rib cage; we all have one and it should feel like our own.

Tip: Broken ribs can be extremely painful so on conscious casualties, if you suspect broken ribs ask the casualty first; be patient led.

Press on the four quadrants of the ‘six-pack’ (tummy). Even the best athletes of this world, with abs to die for (Jessica Ennis), should have a soft springy tummy when pressed. If any of the four areas feel rigid it could be the sign of an internal bleed. Muscle is naturally soft and spongy and will soak blood up readily; once blood soaks into the muscle it will change its texture and will become noticeably rigid when touched.

Tip: When touching a casualty during an examination, especially of the opposite sex; if you use your thumbs during the examination it can be misconstrued as a grope. Using the palm of your hand or just the outstretched fingers of your hand on the casualty will gain the results you are searching for and give the correct impression to the patient.

Hips; fractured hips can very quickly become life-threatening, especially if it has become complicated with an internal bleed. Fatal blood loss in excess of 40% can occur before noticeable swelling can be seen. It is because of this dangerous consequence only a visual examination of the hips should be made by the first aider. Slight movement during a physical examination could accelerate blood loss so it is extremely important to only visually examine the casualty for hip/pelvic injuries. Nevertheless, there can be visual clues to pelvic fractures; the casualty will want to sit on the uninjured side, while the leg on the injured side can look shortened and slightly rotated. If the casualty is conscious encourage them to sit still.

Legs; the Femur is the largest bone in the body and once again can warrant enough blood loss if blood vessels are damaged to be fatal. So before moving onto the arms check the legs for deformities, open wounds, tenderness and swelling; not forgetting to look for ‘medic-alerts’ around the ankles.

Arms; the final examination of the secondary survey should be the arms. Visual and physical examination should be completed. Competent pulse checkers may also take a pulse at this point but it isn’t necessary for the lay first aider. Unless you take regular pulses this exercise can be quite difficult and daunting; a pulse can be difficult to find. A person breathing and with good colour will have a pulse. A good test to see if the casualty has circulation problems in their arms is the ‘cuticle refill test’. Pressing the bed of the thumb nails – or just beneath if they are wearing nail polish – for five seconds, this pushes blood out and makes the nail pale in colour. When you release the nail a person with good perfusion will see it regain its natural pink colour and should refill within two seconds.

Tip: If you do take a pulse the paramedic not only likes to know the pace of the heart beat but likes to know what it felt like. If you take your own pulse now you will know how a regular pulse feels and can use the phrase ‘regular pulse’ to describe a normal pulse. Other description are ‘fast and weak’ or ‘Slow and bounding’.

Once the arms have been checked you have completed the ‘Secondary Survey’ and should be in a position to tell the emergency services the complete state of your casualty and injuries they may have. If help is at hand you can send them to the telephone to call for medical help but if there is no one you may have to do this yourself. Most people these days carry a mobile phone and will be able to make this call from the side of the patient but, in the worst case scenario and you don’t have one you will have leave your patient to make the call. If this situation arises and the casualty is unresponsive but breathing you will have to place them in the recovery position. Attending a first aid course will teach you how to do this.

Until next time

Tony Clough

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R. Scott Boots

Article Contributor

After moving to Boston in 1987 and volunteering with local AIDS organizations, HCEI Founder R. Scott Boots began to compare notes about resources in his native Iowa. The Health Cares Exchange Initiative, Inc. was founded in 1992. Without formal funding, HCEI built networks and held focus groups nationwide, while the HCEI office consisted of a voicemail, post office box, and two filing cabinets.

A graduate of Interlochen Center for the Arts and the University of Iowa, Scott has studied wellness at Boston's Beth Israel Deaconess Mind-Body Clinic and massage at the Touch Therapy Institute in Cambridge. He has given HCEI Stress Management Workshops to caregivers from the Midwest to the East Coast and presented at the 1997 United States Conference on AIDS. In addition, Scott has served as Chair of the AIDS Support Committee and Co-Chair of Pastoral Ministry at Trinity Church in the City of Boston.

Comparing the Caring

by

R. Scott Boots

I sat next to David’s bed in the AIDS hospice the last week of his life and told him that he was a beautiful man.  “Thank you”, he said, and I closed the door and softly sang hymns he had in the choir.  “Take from our lives the strain and stress, and let our ordered lives confess the beauty of thy peace” I sang.  The next day David died, and I began experiencing symptoms of burnout first-hand.

Twenty years ago in Boston I volunteered for a variety of community based organizations and at one point was the chair or co-chair of three committees simultaneously at the city’s largest Episcopal church.  But the demands of meeting the needs of so many others began to take its toll and I stopped volunteering while experiencing great emotional exhaustion and a lack of any feeling of personal accomplishment.

In response to my experiences and a concept which came to me while meditating, in 1992 I began an educational public charity designed to support and educate care providers.  The Health Cares Exchange Initiative, Inc (HCEI) creates supportive networks of caregivers in diverse geographic areas and then educates them about the best ways to provide care for others and, not least important, for themselves.

HCEI created its own moderator’s guide and hosted the first-ever nationwide focus groups with both paid and nonpaid care providers.  We use a broad based definition of care provider so it could be a paid or unpaid person – anybody who cares for and about others and gives of their resources and selves.  Focus groups held from Kansas to Boston revealed, not surprisingly, that most care providers do not feel supported or celebrated.  As a result of these focus groups we developed a dynamic stress management skills building seminar which has been given for thousands of caring persons in the US and UK.  The session, which usually lasts 60-90 minutes, encourages participants about ways to identify stressors in their lives and then respond in healthy ways.  Audiences have included teachers, clergy, nurses, EMTs, research administrators, advocates, family members, and persons living with chronic conditions.

Our first paid seminar was presented to the Kansas Department of Health and Environment in 1998 using a flip chart, magic markers and boom box.  I have since spoken at a large number of conferences and I recall many successes and some challenges.  The conference where I looked out and saw an audience member inhaling a helium balloon.  The conference where, during a quiet meditation exercise, a marching band began to play in the next room.  The conference of funeral planners where I could look out beyond my audience into the exhibit hall to see rows of caskets and glass necklaces with the ashes of your cat (or spouse) inside.

Although the majority of people I come into contact with have giving and gentle hearts, some are very wounded or angry.  Some people I have invited to network on the Linked In internet networking site have “blocked” me from any future contact (am I trying to sell used vacuums?)  At one exhibit hall highlighting senior services I walked from booth to booth introducing myself and collecting business cards.  The woman who had coordinated the event called security and asked them to throw me out because I was trying to market my services and had not paid to rent a booth.  Several people, listed as designated contacts on the website of their organization, respond to emails from me asking me to take them off my spam list and never contact them again.  For a small but unmistakable group of people, something about providing support for caring people can really piss people off.  I believe the issue sometimes stirs up deep needs, fears and resentments.

And yet should I be surprised at a general lack of support and enthusiasm?  A few years ago when I began writing a book version of my workshop I realized oh my, I have chosen to advocate for a group of people whom (in general) nobody cares for.  Perhaps I should be doing stress management for professional athletes or contestants on televised talent shows?  Certainly there is great interest and support for those people.  And so, in the United States, which espouses individualism rather than collective thought, home to the highest rate of infant mortality for an industrialized nation, and which quite intentionally has no national health plan for its citizens, what sort of support can I reasonably expect?

Perhaps in the United Kingdom, where the nation cares for all residents, there would be interest and support in my efforts?

Because HCEI is a volunteer-based effort, I work at jobs for income and benefits and do this work evenings and weekends.  In September, 2011 I took a two week vacation and traveled to England and Scotland to visit relatives and see palaces.  Using email several months prior to my visit, I contacted dozens of centres for carers in a variety of cities and towns in the UK.  I introduced myself and HCEI, and asked them if I could present my seminar when I visited.  Four organizations were innovative enough (and brave enough) to build communications and invite me to present.

These pioneering groups included Northumbria University, Orkney Carers Center, Derbyshire County Council, and Lancashire County Council.  The first seminar was held for a group of family carers at the public library in Kirkwall, Orkney Islands.  I knew my seminar was “universal” when I saw heads begin to nod in understanding.  The day before I had walked the Ring of Brodgar, a 5,000 year old Neolithic stone circle, and realized this is a culture that over thousands of years has come to understand how to care about each other.

Although seminar participants in the UK were involved with supportive networks for carers, many had never been to a session about compassion fatigue or burnout prevention.  I joked that I was becoming their “airplane friend” because for 90 minutes we connected over issues which were very personal and challenging, and then the next week I would be safely 4,000 miles away!  I recall the woman whose parents had died, both unexpectedly, six weeks apart earlier that year and kept mementos from both on the dashboard of her car.  I felt admiration and also concern for the young man who moved into the house with his mother eight years ago after she had a stroke.

Surveys given to participants before and after the UK seminars indicated respondent gains of at least 20% (at least one point on a scale of 0-5) on three out of four question items.  For the question “How well do you identify stress?” the pre-presentation mean was 3.2 and the post-presentation mean was 4.9, a difference of 1.7.  Asked “How well do you understand options for responding to stress?” the pre-presentation mean was 2.8 and the post-presentation mean was 4.2, a difference of 1.4.

Similar to the hospice movement and national health care, the UK appears better coordinated, and willing, to invest resources to care for family carers and others than the US.  Seminar participants were extremely involved and appreciative, and appeared to be somewhat more self-sacrificing than those in the US.  During one exercise where I asked participants to think of the three people they cared for most, NONE of the UK participants were cheeky enough to list themselves.  And in both our Anglo cultures, we all smile through our anger and our disappointments while our leading cause of death for men and women is cardiovascular related.  One thing we have in common, in general, is that we all smile and say no I’m fine, I’m not mad, I don’t need anything, thanks.  And then our hearts break.

Following my trip I began to research the NHS, a daunting task as there is no national health policy in the US for me to compare to.  So many changes in structure, authority and leadership, plus I read the electronic Guardian’s coverage on social and health care.  I intend to continue to network and build collaboration in places where care is seen as an important necessity for all.  I will continue to give my skills building sessions to groups of paid health and social care providers, administrators and family carers in the UK and beyond in order to reduce staff turnover, medical errors and reduce hypertension in most participants.  And I have so much to learn!  But now I know what mushy peas are.  Now I know if I accidentally spill food on my trousers NEVER to complain that I’ve just soiled my pants.

My great great grandparents left Durham County, England in 1882 in search of something more.  The world and opportunities they were given were not adequate, they did not want to “settle” with the status quo and go without.  They had the restlessness and courage to look beyond what they knew and look across oceans for meaning and new life and new hope.  Ironically I am looking east at their land, eager to spend more time, eager to be part of the systems already there, eager to tell nurses and administrators and family carers “well done”.

R. Scott Boots

773-509-6402

Rsbkc@yahoo.com

www.HCEI.org

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Editor's note: please read the letters of support below to see how much appreciation Scott has had for his presentations in the UK.  Please contact Scott if you would like him to present for your organisation. Email him at Rsbkc@yahoo.com or leave your comments on this post.

Letters of Support:

Lancashire County Council - Letter of Support.pdf

Crossroads Orkney - Letter of Support.pdf

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MISSION... Founded in Boston in 1992, HCEI's mission  is to create supportive inclusive networks for caregivers, including AIDS caregivers, in diversely affected geographic areas and then foster information and personnel exchanges between them. HCEI works to encourage caregiver collaboration, enhance community-based care, and educate caregivers about stress management. 

DEFINITION  A group of chronic neurological conditions that present as seizures.

Epilepsy is a general term for a range of conditions which cause a chronic brain disorder resulting in recurrent seizures (fits), and as many as one person in 20 will experience a seizure at some point in their lives.

The flow of information within the brain is precisely controlled. A seizure occurs when brain transmissions begin to malfunction, sending rapid, uncontrolled messages. This disorganisation can last for only seconds, or can take minutes.

Seizures are classified into two main groups: partial or generalised.

Partial seizures involve only one area of the brain, and do not result in loss of consciousness. Partial seizures are divided into two groups: simple (the casualty remains fully conscious and aware of what is happening) and complex (the consciousness is impaired and the casualty is unaware of where they are, or what they are doing).

The effects of a simple partial seizure vary, depending on which area of the brain is affected. The casualty may experience visual disturbances, stiffening of one part of the body and abnormal sensations such as tingling. These may also be accompanied by a strange smell, such as burning. These sensations are described as an “aura” and in people who progress onto generalised epilepsy this aura will give warning of an imminent attack.

Those who witness the partial seizure may also see unusual movements, such as twitching of the face, jerking of an individual limb, or lip smacking. The casualty may appear to suddenly start daydreaming, even in mid sentence.

Although the effects of partial seizures are of short duration they can still cause considerable distress to the person affected, and if the seizure is complex they will have no memory of what has taken place.

Generalised seizures involve most of the brain which causes aggressive fitting, usually of the whole body. The commonest of this type of seizure causes the casualty to lose consciousness and exhibit tonic-clonic contractions, resulting in uncoordinated jerky movements which can be accompanied by emptying the bladder and/or bowels.

The tonic phase is caused by the contraction of all the muscles so the casualty becomes very stiff, and breathing becomes irregular. An audible cry may be produced by the contraction of the respiratory muscles forcing air out of the lungs and over the vocal cords.

This is then followed by the clonic phase. The muscles now independently relax and contract resulting in violent jerky movements throughout the whole body. This is accompanied by profuse salivation, bruxism and occasionally vomiting. Shortly after the clonic phase all movement ceases, and the casualty remains unconscious and unresponsive. Recovery is gradual and can take considerable time – usually between 10 and 15 minutes although it can sometimes take longer. It may take an individual up to 2 hours for their cognitive function to return to normal.

Tonic-clonic seizures are usually short, lasting less than 5 minutes.

If the casualty does not enter the recovery phase, then it is likely that they are developing status epilepticus which is a potentially life threatening condition and is a result of a generalised seizure lasting 30 minutes or longer, or can be repeated tonic-clonic convulsions occurring over a 30 minute period without recovery of consciousness between fits. This requires hospital treatment as soon as possible.

It is of utmost importance, therefore, to note the time at which the seizure starts, and in the dental practice any convulsive phase of a tonic-clonic seizure that lasts for 5 minutes or more should be treated as status epilepticus.

POSSIBLE SIGNS AND SYMPTOMS

As mentioned earlier a generalised seizure usually follows a pattern:

AURA

The warning sign that some patients experience before the tonic-clonic phase of the seizure. This is helpful if it happens, as the patient can inform the dental team of an imminent attack, giving them time to summon help, clear a safe area and lay the patient on the floor.

TONIC PHASE

Sudden loss of consciousness, the muscles become rigid, the back may arch and the patient may let out a cry (they are not in pain). The lips may go blue (cyanosis). This phase usually lasts less than 20 seconds.

CLONIC PHASE

The limbs make sudden, violent jerking movements due to the muscle contractions. The eyes may roll, the teeth may clench and frothy saliva may be seen (it may be blood stained as a result of biting the tongue). The breathing will be irregular and may be loud and “snoring”. Bladder and/or bowel emptying may occur. This phase usually lasts less than 5 minutes.

RECOVERY PHASE

The body relaxes, although the casualty is still unresponsive. Levels of response will improve within a few minutes, but the casualty may not be fully alert for 20 minutes or so. They may be unaware of their actions, uncertain of where they are, complain of tiredness and may have a headache.

REMEMBER

If the casualty is having repeated seizures or one seizure is lasting longer than 5 minutes then it is likely that they will go into status epilepticus.

“TRIGGERS”

There can be many factors that can precipitate seizures and some examples are listed here:

Forgotten or incorrect medication

Sleep deprivation and fatigue

High temperature

Stress

Infection

Photosensitivity

Menstruation

Alcohol and drugs

Monotonous tones/sounds

MANAGEMENT

All treatment must be stopped immediately. As mentioned earlier it is very important to make a note of the time the seizure started and to monitor its duration. Make the area as safe as possible - if the casualty experiences an “aura” act immediately by laying them on the floor, removing glasses if worn and clearing away all moveable objects if possible, prior to the seizure starting. Blankets or clothing can be used to cover immoveable objects on which the casualty may injure themselves, such as the spittoon. During the seizure itself, do not attempt to restrain the casualty or put anything into their mouth (such as an airway or mouth prop) whilst they are fitting. All staff must be aware of their own safety also and ensure that they keep a safe distance from the casualty to avoid being bitten, or kicked.

When the seizure has finished place the casualty into the recovery position and administer high-flow oxygen via the non-rebreathing face mask. Monitor ABC (airway, breathing, circulation). Allow the casualty to recover slowly in a private, quiet environment to ensure that their dignity is maintained. It is important that all staff appreciate the importance of gentle reassurance and understanding of the casualty’s disorientation and confusion during the recovery phase.

When the patient has recovered sufficiently they can go home with a suitable escort; they should never be discharged unaccompanied, and a competent adult should stay with them for some hours afterwards.  It is not usually necessary to send a patient to hospital following a seizure. However, the emergency services must be called for the following reasons:

• One or more tonic-clonic seizure lasts longer than 5 minutes
• One tonic-clonic seizure lasts longer than normal for the individual
• Several seizures occur with no recovery of consciousness in between
• An injury has been sustained
• It is their first ever seizure
• Difficulty monitoring casualty’s condition

As mentioned earlier, when one or more seizures continue for 5 minutes or longer, there is a danger of status epilepticus developing. When status epilepticus is suspected the emergency services must be called immediately and the casualty transferred to hospital. Other than high flow oxygen (if possible) the only other interventive treatment to be considered within the dental practice is the administration of 10mg midazolam (adult dosage) by a transmucosal route – buccally or intranasally.

(For clarification please see the pages from the Resuscitation Council (UK) Medical Emergencies and Resuscitation appendix (viii) (Emergency use of buccal midazolam in dental practice) http://www.resus.org.uk/pages/MEdental.pdf)

Intravenous diazepam/ midazolam or rectal diazepam may be administered by the paramedic.

The doses of transmucosal midazolam advised by the Resuscitation Council (UK) for children who have status epilepticus are as follows: 1-5 years 5mg, 5-10 years 7.5mg 10 years and above 10mg.

PREVENTION

As for all dental patients a full medical history is essential but it is also important to have a record of detailed information if the patient has a history of epileptic seizures. It is also worth remembering that the nature of the condition can change, so the history must therefore be updated before each course of treatment as the pattern of the illness may vary. The following information should be obtained from patients who suffer from epilepsy in order that a risk assessment can be undertaken:

• The type of seizures experienced, and normal duration
• How well the seizures are controlled including the frequency and date of most recent seizure
• Normal recovery process for the individual, including normal length of time
• Which triggers normally precipitate a seizure
• Does the patient experience an “aura” before a seizure, and if so what is its description
• Has the patient ever had status epilepticus, and if so how many times
• Has the type of anti-epileptic medication changed recently
• Has the patient taken their medication as usual before treatment

The answers to the above questions will enable the dental team to assess the likelihood of a seizure occurring at the dental surgery and how best to recognise and manage it. If the patient with a dental anxiety knows that stress is a trigger for their seizures then the team may consider it more appropriate to offer any treatment under sedation. If the patient has recently changed their anti-epileptic medication or their seizure control is poor they are more likely to be at an increased risk of a seizure developing.

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Wendy Berridge delivers CPR, Medical Emergencies and AED training to dental practices throughout Yorkshire and Lincolnshire.

Contact details:

tel: 07771590513

email: info@berridgemedicaltraining.com

Website: www.berridgemedicaltraining.com