FIRST AID BASICS
The primary patient assessment is a critical step in providing wilderness first aid. It involves quickly and efficiently gathering information about the patient's condition in order to determine the appropriate course of treatment. The primary patient assessment typically includes a general survey of the patient, an assessment of vital signs, and a more detailed examination of the patient's injuries or illnesses.
The general survey of the patient involves a quick evaluation of the patient's overall condition, including their level of consciousness, breathing, and circulation. This can be done by checking for responsiveness, observing breathing patterns, and checking for a pulse. The general survey also includes a quick visual examination of the patient to identify any obvious injuries or illnesses, such as a broken bone or a severe wound.
The assessment of vital signs is an important part of the primary patient assessment. Vital signs include the patient's pulse, blood pressure, respiratory rate, and body temperature. These vital signs provide important information about the patient's overall health and can help identify any potential life-threatening conditions.
In wilderness settings, it is crucial to be able to quickly and accurately assess the condition of a patient in order to provide the appropriate care. There are several different methods and mnemonics that are commonly used in wilderness first aid to help guide the assessment process.
SCENE SIZE UP
Sizing up the scene begins a process of making sense of the situation, a process that continues as you gather more information in the patient assessment. Your observations of weather, terrain, bystanders, and the patient’s position are your first clues as to how an injury occurred, the patient’s condition, and possible scene hazards.
Follow these five steps to complete a thorough scene size-up before starting your initial assessment.
One - I'm #1
What’s going on here? Survey the scene for hazards, including immediate danger to self, other rescuers, bystanders, and patients. Your priority is your safety and that of your fellow first responders.
Things to consider:
Difficulty reaching the patient: A cliff edge may mean you can’t approach the scene without adding protection for yourself.
Imminent hazards: A falling rock or an avalanche may dictate a rapid carry of the patient out of the path of danger.
Weather conditions: For example, cold, driving rain may make constructing shelter a priority to avoid hypothermia.
Two - What Happened to You?
Determine the mechanism of injury or illness (MOI). Look around—your observations of the scene and questions of bystanders can offer clues about what happened.
Determining the mechanism provides critical information about the location and severity of injuries.
Things to consider:
Is the patient ill or injured? If ill, gather a short history of the illness. If injured, what is the mechanism?
For example, if the patient fell, find out how far and if they were wearing a helmet. Did the person land on soft ground, snow or rocks? Did they free-fall or tumble?
Three - Not on Me!
Establish body substance isolation (BSI). It’s impossible to know for sure if the patient is germ-free, so all bodily fluids and tissues are considered infectious.
Protect yourself by washing your hands; using gloves, eyewear, and face masks; properly disposing of soiled bandages, dressing, and clothing; and avoiding needlestick injury.
Things to consider:
Long-sleeved shirts, pants, and pocket masks for mask-to-mask ventilation are recommended for situations in which splashes of blood, vomit, and other bodily fluids are likely to occur.
Wear a protective mask and glasses, or at least a bandana, over your nose and mouth.
Use sunglasses or rain gear if nothing else is available.
Place contaminated items, such as gloves and bandages, in sealed plastic bags labeled as a biohazard, or incinerate these items in a hot fire.
Make a habit of packing a mask or face covering in your first aid kit for a patient to use.
Four - Are There Any More?
Determine the number of patients. Is there more than one? If so, an initial assessment may tell you who needs your immediate attention, and how best to use your companions to organize the scene and care for the patients.
Things to consider:
What’s the ratio of rescuers to patients?
What resources are available with the rescuing party or in the immediate vicinity?
For example, does anybody have a first aid kit? Is it getting dark, and if so, are headlamps and flashlights available?
Five - What's The Vibe? Dead or Alive?
Get a general impression of the patient and the seriousness of their condition. To you, do they seem very sick/very hurt, not sick/not seriously hurt, or somewhere in between?
Things to consider:
Is the patient quiet (possibly a bad sign), or are they talking and moving (often a good sign)? Does the person look seriously ill or injured, or do you perceive a mild illness or injury?
STERI is also another method to perform a scene size up. STERI is a mnemonic for Safety, Terrain, Environment, Resources, and Impressions.
The ‘S’ in STERI stands for Safety, which refers to evaluating the patient and the surrounding area for any potential hazards or risks to the patient or the provider. This includes assessing for any signs of danger, such as unstable terrain or dangerous animals, and taking steps to protect the patient and the provider.
The ‘T’ in STERI stands for Terrain, which refers to evaluating the patient's location and the surrounding area to determine the type of terrain and any challenges it may present. This includes assessing for any obstacles, such as steep inclines or rocky terrain, that may affect the patient's care or the provider's ability to access the patient.
The ‘E’ in STERI stands for Environment, which refers to evaluating the patient's location and the surrounding area to determine the type of environment and any challenges it may present. This includes assessing for any weather conditions, such as extreme heat or cold, that may affect the patient's care or the provider's ability to access the patient.
The ‘R’ in STERI stands for Resources, which refers to evaluating the resources available to provide care for the patient. This includes assessing for any equipment, supplies or personnel that may be necessary to provide care for the patient.
The ‘I’ in STERI stands for Impressions, which refers to the provider's overall impressions of the patient's condition and the environment. This includes any observations or concerns the provider may have about the patient's condition or the ability to provide care.
INITIAL ASSESSMENT
ABCDE is an acronym used in wilderness first aid to guide the primary patient assessment. It stands for Airway, Breathing, Circulation, Disability, and Exposure. By utilizing this acronym, wilderness first responders can quickly and efficiently assess the patient's condition and determine the appropriate course of treatment.
The ‘A’ in ABCDE stands for Airway, which refers to assessing and ensuring that the patient has an open and clear airway. This includes checking for any obstructions, such as vomit or blood, and taking steps to remove them if present. It also includes assessing for any signs of breathing difficulty, such as shortness of breath or stridor.
The ‘B’ in ABCDE stands for Breathing, which refers to assessing the patient's breathing rate, rhythm, and depth. This includes counting the patient's respirations for a full minute and noting any abnormalities, such as rapid or shallow breathing. It also includes evaluating the patient's chest movement and listening for any sounds such as wheezing or crackles.
The ‘C’ in ABCDE stands for Circulation, which refers to assessing the patient's pulse, blood pressure, and skin color and temperature. This includes checking for any signs of poor perfusion, such as pale or cool skin, and evaluating the patient's capillary refill. It also includes assessing for any signs of shock, such as a weak or rapid pulse.
The ‘D’ in ABCDE stands for Disability, which refers to assessing the patient's level of consciousness and any neurological deficits. This includes checking for any signs of confusion, disorientation, or loss of consciousness, and evaluating the patient's pupils for size, shape, and reactivity. It also includes assessing for any signs of weakness or numbness in the patient's extremities.
The ‘E’ in ABCDE stands for Environment/Evacuation Decision, which refers to evaluating the patient's location, surrounding environment, and resources available to determine if evacuation is necessary and the best course of action. This includes assessing for any hazards or challenges that may affect the patient's care and determining if the patient's condition requires immediate evacuation. The decision should be based on the patient's condition and the environment they are in. If the patient's condition is stable and the environment is safe, treatment can be done on-site, but if the patient's condition is critical or the environment is hazardous, evacuation becomes the priority.
HEAD TO TOE EXAM
You finish your scene size-up and initial assessment and have addressed immediate threats to your patient. Now, your next step is a focused assessment to gain a complete picture of the medical situation. A crucial part of that is a head-to-toe exam.
The head-to-toe exam is a thorough, basic physical assessment where you as the rescuer systematically check the patient’s entire body, beginning at the head and moving to the toes. It consists of looking, listening, feeling, smelling, and asking questions.
This diagram, created by NOLS graduate Tess Perrin during her Wilderness First Aid course, shares details of how to evaluate each part of the body during the head-to-toe exam.
Considerations for Performing a Head-to-Toe Exam
Making the patient comfortable should be a priority. You can do that by getting informed consent, using the patient’s name, and managing the environment where the exam takes place (ex. moving others away from where the exam is taking place, hanging a tent fly for privacy, etc.).
As you examine the patient, explain what you are doing and why. Besides being a simple courtesy, this helps involve the patient in their own care.
If you are uncertain of what is abnormal, compare the injured extremity with the other side of the body or with that of an uninjured person.
Except in cases of imminent danger, avoid moving the patient until after the head-to-toe exam is complete.
Your hands should be clean, warm, and gloved as you perform the exam.
If possible, a person of the same gender as the patient should be present during the exam.
Designate a notetaker to record what you find during the exam.
One person should perform the entire exam to avoid confusion, provide consistent results, and minimize patient discomfort. Also, the patient will only need to respond to one inquiry at a time.
VITAL SIGNS
Check Vital Signs: Check the time and write all of the vital signs down. Here’s what you’ll take notes on:
Level of responsiveness: Is the patient awake and oriented? Awake and disoriented? Or is your patient unconscious or unresponsive?
A+O, or Alert and Orientated, is a useful tool for assessing patient care in wilderness first aid. It is used to quickly evaluate a patient's level of consciousness and cognitive function. A stands for Alert, which means that the patient is awake and responsive to verbal and physical stimuli. O stands for Orientated, which means that the patient is aware of their surroundings and able to answer questions about time, place, and person. By assessing these two areas, first responders can quickly identify any potential emergencies and provide appropriate care.
The level—x1, x2, x3, or x4—is a way of measuring the extent of a person's awareness. Here's what the types of orientation mean:
Oriented to person: The person knows their name and usually can recognize significant others.
Oriented to place: The person knows where they are, such as the hospital, clinic, or town.
Oriented to time: The person knows the time of day, date, day of the week, and season.
Oriented to the situation: They can explain why they are talking to the doctor.
Sometimes a person can answer some of this information, but not all. For example, they may know their name and the date but can't say where they are or why. In that case, it would be notated as x2.
Heart rate: Using the wrist pulse, check the number of beats per minute and note whether the pulse is strong or weak; regular or irregular.
Respiration rate: Check the patient’s number of breaths per minute and note whether the breathing is easy or labored.
Skin signs: Look at skin color, temperature, and moisture. The inside rim of the lower eye or inside the lower lip are good places to check for color. Is it pink or pale? Is the rest of their skin warm and dry vs. cool and clammy? If possible, also record the patient’s temperature with a thermometer.
PATIENT HISTORY
SAMPLE is an acronym that is commonly used in first aid training as a mnemonic to help remember the key elements of taking a patient's history during a medical emergency.
The acronym stands for: Signs and symptoms, Allergies, Medications, Past medical history, Last oral intake, and Events leading up to the emergency. Collecting this information is crucial in providing appropriate first aid treatment and can help emergency responders to make informed decisions.
When providing first aid, it's important to first establish what the problem is and what the patient is feeling.
This is where the 'S' for signs and symptoms comes in. By asking the patient about any observable or reported symptoms they are experiencing, such as pain, difficulty breathing, or dizziness, we can get a better understanding of the patient's condition. This information can then be used to identify the possible cause of the problem, and determine the appropriate course of action.
The 'A' in SAMPLE refers to allergies. It is important to know if the patient has any known allergies to medications, food, or environmental substances. This information can be used to avoid administering any treatments that may cause an allergic reaction, which can be life-threatening.
The 'M' in SAMPLE stands for medications. Knowing what medications the patient is currently taking, such as prescription drugs, over-the-counter medications, and herbal supplements, can help us understand how the patient's condition may be affected by these drugs. This information can also help us determine if any interactions may occur with other treatments that are being considered.
The 'P' in SAMPLE refers to past medical history. This includes any previous illnesses or medical conditions the patient has had, such as diabetes, heart disease, or asthma. This information can be used to understand how the patient's condition may be affected by their previous medical history and can help us anticipate potential complications.
The 'L' in SAMPLE stands for last oral intake. It is important to know when the patient last ate or drank anything and what they consumed. This information can help us understand if the patient's condition may be related to something they ate or drank and can also help us make decisions about administering medication or other treatments.
Finally, the 'E' in SAMPLE refers to events leading up to the emergency. It is important to know the circumstances that led up to the emergency, such as a fall, car accident, or sudden onset of symptoms. This information can help us understand what caused the patient's condition and can help us anticipate potential complications.
Collecting this information is crucial in providing appropriate first aid treatment. It is important to note that SAMPLE is a general guideline and specific situations may require different elements to be considered. It is also important to remember that the focus should always be on the patient's safety and well-being. By collecting the SAMPLE information, first responders can make informed decisions, ensure that the patient receives the appropriate treatment, and increase the chances of a positive outcome.
OPQRST is an acronym used in wilderness first aid to guide the assessment of a patient's condition. It stands for Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, and Time. By utilizing this acronym, wilderness first responders can quickly and effectively gather information about a patient's condition, which can aid in determining the appropriate course of treatment.
The ‘O’ in OPQRST stands for Onset, which refers to the time frame in which the patient's symptoms first appeared. Knowing the onset of symptoms can help determine the cause of the patient's condition, the urgency and the type of care needed. For example, if the symptoms appeared suddenly, it is more likely to be a traumatic injury or an acute illness, whereas if symptoms appeared gradually, it may be a chronic condition or a medical condition. Additionally, it can also help to identify if the symptoms are chronic or intermittent which will help in treatment planning.
The ‘P’ in OPQRST stands for Provocation, which refers to the factors that cause the patient's symptoms to worsen or to appear. This information can help determine the cause of the patient's symptoms, and aid in the development of a treatment plan. For example, if a patient's pain increases with certain movements or actions, it may indicate a musculoskeletal injury or a repetitive stress injury. Additionally, Palliation refers to the factors that relieve or decrease the symptoms. This information can also help to identify the cause of the patient's symptoms, and aid in the development of a treatment plan. For example, if a patient's pain decreases with rest or certain medications, it may indicate a sprain or a strain.
The ‘Q’ in OPQRST stands for Quality, which refers to the nature or characteristics of the patient's symptoms. This can include descriptions of the patient's pain, such as sharp, dull, aching, burning or any other symptoms, such as nausea, dizziness, or weakness. This information can help identify the type of injury or illness, and aid in the development of a treatment plan. For example, if a patient is experiencing sharp pain in the chest, it may indicate a cardiac problem, whereas if the patient is experiencing a dull ache in the chest, it may indicate a musculoskeletal injury. Additionally, it can also help to identify if the symptoms are acute or chronic.
The ‘R’ in OPQRST stands for Region, which refers to where the patient's symptoms are located. It's important to identify any specific location of symptoms, for example, pain in the chest, back, or head. This information can help determine the cause of the patient's symptoms and can aid in the development of a treatment plan. Additionally, Radiation, refers to whether the symptoms are spreading to other areas of the body. For example, if a patient has a headache and the pain radiates to the neck and shoulders.
The ‘S’ in OPQRST stands for Severity, which refers to the intensity of the patient's symptoms. This can include information about the patient's level of pain, as well as any other symptoms, such as difficulty breathing or loss of consciousness. This information can help determine the urgency of the patient's condition and aid in the development of a treatment plan.
Finally, the ‘T’ in OPQRST stands for Time, which refers to how long the patient's symptoms have been present. This information can help determine the urgency of the patient's condition, as well as aid in making a diagnosis. For example, if a patient has been experiencing symptoms for a long period of time, it may indicate a chronic condition, whereas if symptoms are recent and sudden, it may indicate a more acute condition.
All of these mnemonics and methods will be discussed in detail and practiced during the wilderness first aid course. It is important to have a good understanding of these concepts and practices in order to provide the best possible care to patients in wilderness settings. For students taking the upcoming Wilderness First Aid Courses, please take the opportunity to familiarize yourself with the the patient care triangle, the processes contained within this structure and the terms/mnemonics that accompany the processes.