Secrets of the Secondary Assessment

One of the biggest challenges an EMT instructor faces when working with new students is trying to teach them the sequence of a thorough patient assessment.

Some aspects are easier than others because they never change. Saying you’re going to put on proper PPE or asking if the scene is safe will always begin the patient assessment. If they’re overlooked, well, nothing like a couple of early critical fails to jar your memory.

So through sheer repetition, students seem to retain many of the aspects required to plow them through the early part of an assessment: scene size-up, general impression, and primary survey. One quick transport decision later, and the primary assessment is in the bag.

And…this is where students begin to stare blankly at the manikin in front of them, uncertain what to do next. All immediate life threats have hopefully been identified and treated to the best of their ability, and a destination has been picked out—now what?

The Truth Is Out There

The secondary assessment can be a bit confusing. With so many acronyms to learn and tasks to accomplish, the student has to take in a tremendous amount. The task is even more difficult if the student is uncertain or undecided about what they are looking for.

The secondary assessment is where first responders really start to develop critical-thinking skills that will help them formulate a logical differential diagnosis. Taking the information gathered from a proper scene size-up and primary assessment will help a student focus their treatment and expedite proper patient turnover at the hospital. Everything from the way a patient was found upon arrival to the general condition of their environment can provide valuable insight into what might be going on.

The assessment truly does start the moment your pager goes off. But the secondary assessment is where the first responder can broaden their scope of inquiry, looking for the clues that are obvious and that need to be uncovered through detailed assessment.

Think of it as a detective working to solve a crime, rather than a police officer trying to mitigate the effects of a crime in progress. The detective is looking for causes and reasons, whereas the officer may be more concerned with stopping and controlling damages.

Both professionals work toward the same goal: discovering whom the bad guy is. In EMS the villain we’re after is the differential diagnosis.

Rounding Up the Suspects

Just like a medical detective, students begin with the patient’s chief complaint, along with their signs and symptoms, to make a short list of possible suspects.

For example, a 58-year-old male with acute onset of slurred speech and altered mentation could prove to be a rather challenging scenario for the new EMT student.

Information obtained in the primary survey finds a male in his home presenting with pale skin, confused verbal responses, and staggered gait. Based on this information students are encouraged to come up with a short list of possible causes that might fit the patient’s chief complaint and signs and symptoms.

A quick list may look something like this:

• Stroke
• Intoxication
• Hypoglycemia
• Trauma
• Heat exhaustion

Each of these possible suspects is a differential diagnosis that fits the patient’s condition. By utilizing the three P’s of the secondary assessment, a student might find enough information to rule in or out some of these suspects.

The Three P’s

To help EMT students find a starting point for their secondary assessment, one of three paths should be chosen: past, present, or patient. Each is a quick way to group some of the questions that should be asked and tasks that should be done if time allows.

Past: SAMPLE;

Present: OPQRST;

Patient: Physical assessment; vital signs; diagnostic tests: glucose reading, SpO₂ reading, temperature.

With these three roads to travel, where to start will be based on the patient’s presentation, chief complaint, and, perhaps most important, what you want to get accomplished.

The possibility of a stroke could be addressed by a stroke scale performed during a physical assessment. Intoxication, while EMS providers do not normally carry breathalyzers, could also be examined in a physical presentation, including smell and odor of ETOH and in a SAMPLE history of alcoholism. Hypoglycemia is perhaps the easiest to address by performing a diagnostic blood glucose reading. Trauma could be noted by a DCAP-BTLS assessment performed during a head-to-toe physical. Heat exhaustion could be determined by asking questions found in the OPQRST and examining for signs during a physical assessment.

Questions Lead to Questions

Questions asked in both the past and present paths could spiderweb off into other pertinent questions. Students are encouraged to explore these questions but be mindful not to be led astray. The idea is to remain focused but thorough.

A patient presenting with abdominal pain may cause students to venture off their initial path with additional inquiries.

• “When was your last bowel movement?”
• “Have you had any recent changes in your diet?”
• “Is anyone else in the house also complaining of similar problems?”
• “Do you still have your appendix?”
• “When was your last menstrual cycle?”

All these questions are valid if they pertain to a patient’s chief complaint; however, they might not be explored if the student is unwilling to veer off the path and explore information based on what their patient tells them.

Conclusion

The secondary assessment has the potential to be the most challenging and most fun part of teaching the full patient assessment. It’s filled with much more color then the relatively black-and-white decisions found in the scene size-up and primary survey, and it’s more exciting to explore than the seemingly routine things seen in the ongoing assessment.

The secondary assessment should make the EMT student feel empowered to explore and discover. Critical thinking will occur when students begin to realize why they ask the questions they ask and how that information fits with possible differential diagnoses. Teaching critical thinking will change emergency medical technicians into emergency medical clinicians.

Paul Serino, NRP, CCT-P, BS, is a 19-year paramedic and a full-time faculty member in the EMS program at St. Petersburg College in St. Petersburg, Fla. In addition to an associate degree in EMS, Paul has a bachelor’s degree in journalism and has contributed a number of articles to EMS World. He is currently working on his master’s degree in education.