The last E is the final review and action on the primary survey:
Environment – Consider factors within the environment which may cause further detriment to the patient:
Is the cold/rain causing the patient to become hypothermic? This can have significant detrimental effects in trauma patients and may require blankets, foil blankets, heat pads, and a higher priority extrication.
Is the weather too hot, have they succumbed to heat exhaustion? They may need to be removed from the environment into a cooler/shaded area as further heat exposure may worsen their condition.
Are there dangerous factors within the environment such as carbon monoxide, hydrogen sulphide, an entrapped space with low oxygen. If this is the case then specialist rescue resources will be required so others aren’t put in danger.
Exposure – Consider if tactful exposure of a patient may help identify potential missed injuries in trauma or other pathological medical issues. For example, a thick jacket may hide bleeding from a small puncture wound, and that bleeding could continue for some time before being identified due to being hidden by the jacket. When exposing a patient, be aware of potential causation of hypothermia and maintain their dignity.
Evaluate – Consider all your findings on the Primary survey. Is there anything you’ve missed, have you rectified all deficits where possible, what are your impressions of the patients’ condition, what route of action do you need to take moving forward.
Following your ‘E’ factors, you would have completed a Primary survey review of the patient and would have an understanding if there were any immediate life-threatening deficits putting the patient at risk. When reviewing the Primary survey as a whole, it is important to go on your clinical judgement of the situation. You may not be able to fully complete the survey due to management early on, such as in airway. Where a patient may have life-threatening deficits, early transport to hospital should be conducted so they can receive early definitive care. In these cases, you will likely only manage catastrophic haemorrhage, airway, and breathing, whilst travelling to hospital.
For example, if you had a choking patient where you were unable to manage the airway and specialist support was unavailable, you will need to rapidly transfer to hospital whilst still trying to correct Airway and Breathing. In many time critical cases, the clinician will have to provide corrective/supportive care to sustain the patient until they receive definitive treatment at hospital. Circumstances around the situation will also affect what you can and can’t do. For example, if multiple resources turned up for 1 trauma patient, then multiple managements of the Primary survey systems can be done at once whilst on route to hospital.