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Head-to-toe, Secondary Survey, Top-to-toe
MJLCOOKE Offline
#1 Posted : 15 September 2011 21:41:13(UTC)
MJLCOOKE


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Hi



I'd like some real help with this - i've read loads of posts and no-one really bottoms this!



Weather the 'secondary survey' is done after or before the recovery position is not my issue, my issue is that in performing the physical secondary survey you are asking a First Aider to apply enough pressure and have enough knowledge to evaluate weather the casualty has any other injuries. I have not yet trained someone who can say they would know if a pelvis was fractured or not, let alone any other part of the body. At the time of the incident they are usually stressed and we need them to concentrate on the important breathing.



I thought the emphasis was on 'Simplicity' - is it not better to ensure that we concentrate on DRAB, make a good judgement of a casulaties breathing and deliver the appropriate First Aid (recover or CPR). After the services have been called, a First Aider can 'Look' for other injuries and deal with them - the touchy/feelie approach will probably reveal nothing. Life threatening bleeding/breaks/burns may/will be seen but its the Paramedic who will deal with it.



Remember if the emergency services have been called, they are not going the take a First Aiders analysis as fact they are going to check themselves - and that would usually be in the Ambulance.
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wavey Offline
#2 Posted : 15 September 2011 22:20:19(UTC)
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As a medical proffessional I DO NOT spring the pelvis anymore to accertain if it is fractured of not, we consider the mechanism of injury and treat appropriately. I would not expect a first aider to go anywhere into this. If you are considering that a pelvis may be fractured then a C-spine injury cannot be ruled out at this stage and a recovery position should not be adopted.

First aid is simple, just remember D A B C and 999 and your almost there, Life threatening bleeds and not felt they are seen, life threatening breaks are felt but mostly are also seen, burns are not felt they are also seen and a history will sugest these anyway. A secondary survey for a first aider, may well not be as indepth as mine, but looking/feeling for further injury is not going to harm the casualty, it will assist in the further treatment and will make the first aider feel like they are doing something rather than sitting and watching.

However, if you consider a C Spine injury and there are no other obvious life threatening injuries,you should just take manual imobilisation and await the cavalry. Afterall there is only so much you can do on your own. (Ask a rapid response Paramedic)

speckles Offline
#3 Posted : 15 September 2011 22:42:54(UTC)
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Welcome to the forum MJLCOOKE. There are a couple of schools of thought on secondary survey.

You are right in whether a a person having only done a one day course would have the skills (or even been taught) to do a  proper secondary survey. Some of us would question how well they would actually do the primary survey.



A head to toe survey is always a good idea what you call it and when it is done (Before or after moving them into a "recovery position") is not so important. As far as  basic first aid goes does it really matter if a patient has a broken lower leg or not?

Bleeding on the other hand a first aider can do something about, so getting them to check for that is important.



Whilst the ambulance crew will do there own survey it does no harm to point them in right direction.  
JonAcc Offline
#5 Posted : 15 September 2011 22:53:25(UTC)
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I continue to be horrified at the number of requal candidates I have to re-educate because on their last course they spent ages learning TtT/2ndry Survey, having been taught to lift the head and feel all around it (and many turn the head to look in both ears), then feel around the neck and palpate "to see if it is OK", then try to push their hands under the supine patient to "see what they can feel along the spine" and then come down and press on the ileac crests, then press around the hips and then palpate the abdomen "to see if that is OK or feels strange".



When you tell them the latter few actions can precipitate a catastrophic bleed, for which they can do nothing but hold the patient's hand as they die, rather quickly, we often get some real-life examples of what a shocked patient can look like





As Wavey so rightly says, in today's world if MoI says they might have a spinal complication, then they do until disproven professionally. If MoI says they have a hip/pelvic injury, then they do until disproven professionally





If anyone is teaching any different, please, I beg you, PLEASE get your training updated to present-day procedures





We are not in the village hall any more (my previous posts refer)
NWEMS Offline
#6 Posted : 15 September 2011 23:03:26(UTC)
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Again Backing up what has just been said. We used to check the pelvis by rocking it and listen for crepatis, that nice little cracking sound you get from 2 bones rubbing together, But it is not advised as you can cause major injury to the bladder given the right circumstances.

 However in your turning of the patient if you hear this then you can report your findings as this will help in further treatment of the patient and protection of the area.

Also to note Bladder incontinence can also be a pointer to a fractured pelvis and this you can find on your primary and secondary survey without causing any undue trauma to the area.



Welcome By the way..



Mike
kevwilson Offline
#4 Posted : 16 September 2011 07:01:21(UTC)
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Originally Posted by: speckles Go to Quoted Post
A head to toe survey is always a good idea what you call it and when it is done (Before or after moving them into a "recovery position") is not so important.  





I don't agree personally with the above statement, in that the secondary survey MUST be done before a decision is made to place a patient in the recovery position. What if the patient has a fractured pelvis or 2 fractured femurs? if this patient is placed in the recovery position then a secondary survey is then carried out to discover the injuries which a MOI also suggest are present, then you can hold their hand and watch them die ......



Yes I agree that it should be done quickly and effectively (by first aider standards) I also agree that the pelvis should not be sprung, just checking the MOI, position of the feet, is the groin a bit wet and/or smelly with the other signs are usually enough to point to the distinct posibility of a fracture and should never be turned into the recovery position if so. Finding a severe bruise developing on one side of the abdomin would indicate which side to place the patient on as well, i.e. injured side down.



Please correct me if I am wrong troops, but common sense also tells me this is the correct way.

   
speckles Offline
#8 Posted : 16 September 2011 07:46:59(UTC)
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My apologies, perhaps I shouldn't post when I am tired. (Mind you I am not sure I am fully awake know) I did say there was a couple of schools of thought but only really explained one.

The other is that a survey is important before you move the casualty, as explained by others. 



The problem remains that with the limited time on FAAW/EFA courses how much of an understanding these first aiders will actually have of how to do a patient survey. Whilst Method of Injury (MOI) is also important it to does need some understanding and again I question how much time is spent on this on FAAW/EFA courses.
admin Offline
#9 Posted : 16 September 2011 08:36:05(UTC)
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I think this is a great post and one that comes up again and again. What actions you carryout is dependent on what you find. However, what overrides all of this, is experience and that is one thing the majority of first aiders do not have.

The recovery position can however be a lifesaver especially if the casualty vomits lying on the back.
Dave
These Kitchen people are back, so i am not sure what you next plan is with these people.
wavey Offline
#7 Posted : 16 September 2011 08:45:22(UTC)
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Originally Posted by: NWEMS Go to Quoted Post
Again Backing up what has just been said. We used to check the pelvis by rocking it and listen for crepatis, that nice little cracking sound you get from 2 bones rubbing together, But it is not advised as you can cause major injury to the bladder given the right circumstances




Its not just injury to the bladder, you can bleed out from pelvic fractures, if you think of the pelvis as a polo and try to break it in one place - its impossible - therefore a fractured pelvis (we are not talking chipped ilium/iliac crests here)  will have at least 2 fractures.   Thes will bleed, and will clot.  When/if you disturb this clot it will bleed again, if the first aider, the paramedic(s), the nurse, the doctor all spring the pelvis thats an awful lot of blood lost into the pelvic cavity.



Originally Posted by: admin Go to Quoted Post


The recovery position can however be a lifesaver especially if the casualty vomits lying on the back.





I quite agree, but would only advocate moving a patient that really really needs it.  Any form of long bone/C spine/pelvic complication I wouldnt move the patient, unless theyre iminantely going to vomit, by which time most patients would have moved themselve, unless theyre unconcious, in which case IF you can rule the trauma out then move them.  If not then a jaw thrust would be nice to keep a patent airway.



There is a tendancy for everyone to be put into the recovery position because its the bit people remember fomr thier course, when the cavalry will always manage a patient flat on thier back, or sat up. 
MJLCOOKE Offline
#10 Posted : 19 September 2011 19:23:47(UTC)
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..... And i think i have the answer to my question.



Many thanks for everyone's input .... it's quite plain to see that as there is no definitive way of doing this survey (before of after the Recovery Position) and there is so much 'What if' - it is a pointless procedure to carry out!



Lets consider the First Aider here, not the experienced tutor - First Aiders should complete DRAB, make a decision on the breathing (consider if someone else can get help, whilst the First Aider maintains the airway until the Paramedics arrive or until the airway starts to be compromised - and then put them in the RP). Or go on to Help/CPR.



If the casualty is in the recovery position or someone else can keep an eye on the breathing, then i fully agree that other obvious injuries should be dealt with - but leave the emphasis on obvious.



I believe that this is reasonable and practical - although I'd love to hear from you



Ta



Matt
speckles Offline
#11 Posted : 19 September 2011 19:45:39(UTC)
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I tend to agree with you. We always seem to get bogged down with the "what if's" 

Unless you are in Afghanistan then it is ABC  
wavey Offline
#12 Posted : 19 September 2011 20:12:32(UTC)
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Originally Posted by: speckles Go to Quoted Post
I tend to agree with you. We always seem to get bogged down with the "what if's" 

 




Surely that should be the mentality though, because if you only expect things to go how it does in the classroom, and by the book, when things change or complicate then thats when people panic.



Thinking what ifs and whats next and what else should make everyone better at what theyre doing and further prepared to deal with things.
speckles Offline
#13 Posted : 19 September 2011 21:44:35(UTC)
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Yes for the experienced first aider I would tend to agree. But for the the 3 day FAW course or 1day course?



A) if you spend time on "what if's" how do you teach the other bits.

B) By not having the time to underpin a lot of knowledge a lot of people just revert to, "You can't do that because you will hurt, kill, paralyse them (take your pick)




wavey Offline
#14 Posted : 19 September 2011 22:18:57(UTC)
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That experienced first aider has to start somewhere.



Im meerly suggesting teaching black and white is fine, but being sugestive of the grey areas and the fluidity of first aid situations is perhaps more important. Those you are teaching have no or little experience to draw on and thats where the trainers experiences and knoweldge should be passed on is it not?!
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#15 Posted : 20 September 2011 08:28:34(UTC)
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Intersting topic that mentions a number of issues ie When to or not to put someone in the recovery position.



Surely the first aider must place someone in the recovery position as soon as possible as their training is emphasis on Primary Survey securing the airway.



They (first aiders) have no skills to make an assessment of a spinal injury, however if it is obvious that a neck injury may be suffered by the casualty (and this could be a matter of debate as different first aiders may make different personal decisions on that) and they are breathing effectively then they should maintain the line of the casualties head as found by the first aider and only place in the recovery position if the casualty has to be left; airway difficulties developing or vommiting.



In relation to putting injury side down surely a serious bleed needs to be above the heart and pressure can be better applied by a first aider by having the bleed on the topside of the casualty, I appreciate that chest injuries and CSF are different



I tend to agree the secondary survey should be looking for the obvious serious conditions that the first aider or his/her assistant may have to control until the ambulance arrives if they have time
MJLCOOKE Offline
#16 Posted : 22 September 2011 12:22:44(UTC)
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Again, thanks for your continued support on this topic.



It's really difficult to put everything down in writing and to get it across the way its meant - without going into a long winded rant - oh well!



I understand that First Aid is not Black and White, that every situation will be different. But you should start with the facts DRAB - if the casualty is unconscious but breathing normally > recovery position, if the breathing is Not Normal > Help & CPR. The conundrums are endless, but working on the worst case scenario (First Aider and Casualty ONLY) I believe the above is correct. When help is available or if a mobile phone is with you, then BRAB - Breathing Normal, get someone to call for help/use mobile and maintain the airway until help arrives or the airway starts to be compromised. If Breathing Not Normal > Help CPR.



Continuing with the rest of the course, you are able to apply alt of 'What if's' to the situations, i.e. if some one has broken a bone/bleeding/burnt/shock - what would you do ..... what if they are unconscious? what would you do now? .... This way the candidates get all the building bricks for First Aid treatment and then use them to deal with the situation effectively.



In this way candidates understand their priorities without getting confused and wasting time on a full Secondary survey - do the basics and look for anything else thats obvious.
wavey Offline
#17 Posted : 22 September 2011 20:34:09(UTC)
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Originally Posted by: MJLCOOKE Go to Quoted Post
if the casualty is unconscious but breathing normally > recovery position,




Which begs the question................



If theyre maintaining their airway in thier current position, why move them?







because the book says so....  apparently.
speckles Offline
#18 Posted : 22 September 2011 22:15:36(UTC)
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Yes it is partly because "the book" says so. Bear in mind we are talking mainly about basic first aiders, who by and large don't have access to airway management adjuncts nor suction.  




MJLCOOKE Offline
#19 Posted : 23 September 2011 07:59:43(UTC)
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Hi



Sorry to confuse .... but as i said - IF the First Aider in on their OWN, BRAB>Breathing Normally>Recovery Position>Help. Obviously, if you have a mobile with you, just maintain the airway and phone.



Getting back to the original point, very few, if any, are confriming that the Secondary survey - done texted book style, is pointless and First Aiders should be tought to 'look for any other obvious signs of injury'
sitrep Offline
#20 Posted : 23 September 2011 09:42:04(UTC)
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personaly i think secondary survey as per the book is a waste of valuble training time. most of my students have difficulty remembering primary survey. I teach them to look for other obvious signs of injury quickly befor turning into the recovery position taking into acount of course The MI.
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