Within Ambulance Service roles, you never truly know what you might face when responding to a medical or traumatic event. The range of emergency presentations and scenarios can be near limitless. Medicine and trauma pathologies can present in a huge number of variations, with specialities to each certain section such as Cardiology, Neurology, Oncology, and so on. Yet as a clinician responding to an emergency event, you need to have the knowledge and skills to be able to deal with whatever scenario presents itself until you can get that patient to further care. 

Primary Survey: 

The Primary survey is a rapid and structured approach to assessing a patient for any immediate life-threatening deficits and should take no longer than 90 seconds to complete. The primary survey assesses the elements of: Catastrophic Haemorrhage, Airway with consideration for C-spine, Breathing, Circulation, Disability, Environment/Expose/Extricate… (CABCDE). The survey is completed in this order as it aims to identify and manage life threatening deficits that will likely cause death to the patient first.  

Working through the Primary Survey allows you to assess for the life-threatening deficits that may or may not be immediately obvious. On identifying any, you need to manage and rectify it as quickly and effectively as possible to try and stop the patients’ condition worsening. When you have been able to identify and manage the deficit, you can then continue through the rest of the survey. For example, a patient may have low blood sugar and that is the reason they have been involved in an RTC. From the crash, they have an airway obstruction and cannot breathe. By treating the airway and breathing deficit, the patient has a better chance of survival compared to if you were to ignore those deficits and try and manage the low blood sugar first. 

If you come across a deficit you cannot effectively manage or maintain, you will have to act quickly and look to rapidly transport to hospital managing Catastrophic Haemorrhage, Airway and Breathing as best you can. Many Ambulance Services and regions have specialist clinicians and support which can also be called upon to help manage an advanced/difficult deficit. Depending on your situation and location, a combination of both may be required to provide the best care for the patient. For example, with the RTC patient with airway and breathing deficits, you may have tried to manage the airway to the maximum of your clinical ability and scope, but you are still having difficulty getting sufficient access and oxygenation. You quickly start making your way to hospital while continuing your best to rectify the airway, and advanced clinical support will meet up with you on route. 

Where there are multiple clinicians/responders on scene, you can divide the management of the patient so multiple assessments and deficits are being managed at one. For example, on arrival of the RTC, this time 2 Ambulances arrive at the same time. Between the 4 clinicians, you quickly divide roles so one is managing catastrophic haemorrhage, one is on airway, one is assisting with breathing, one is on circulation… Every scenario will be different, and you will need to review, adapt, and manage the situation in front of you. 

Each element deficit of the Primary Survey will have varying effects and consequences on the homeostasis of the body (homeostasis being the body’s constant self-regulation of systems to maintain stability and dynamic equilibrium): 

• Catastrophic Haemorrhage (C) – If the patient is rapidly losing a large volume of blood their condition will quickly deteriorate through a cascade of negative pathophysiological events: lack of oxygen and nutrient carrying/perfusion capability, increase in cell anaerobic activity causing acidosis, lack of ability to maintain organ perfusion and blood pressure, and overall negative/catastrophic impact to the body’s haemostatic balance. Blood can be difficult to replace within the pre-hospital setting due to its availability, access, maintenance, and often only being carried by specialist clinicians. 
• Airway with considerations for C-spine (A) – If the patient has lost their airway, Oxygen is unable to enter the lungs to help metabolise cellular activity and Carbon Dioxide cannot leave. This hypoxic and hypercapnic state quickly starts causing cellular disruption and death, affecting organ function and pH levels, and creating an overall negative pathophysiological outcome. Consideration and action where possible for spinal protection comes here, particularly in trauma incidents, as spinal cord injury in the C1-7 region may result in a disruption or stoppage of life sustaining functions such as breathing. 
• Breathing (B) – Similar to Airway, with reduced or no respiratory effort from the patient, gaseous exchange is severely affected or unable to happen in the lungs, causing cellular disruption and death, affecting organ function and pH levels, and creating an overall negative pathophysiological outcome. 
• Circulation (C) – If circulation supply is disrupted to certain parts/all of the body either through medical and/or traumatic means, then perfusion of the cells/tissues/organs can be affected. The severity of the circulatory problem will affect the level of negative outcome. For example, a patient may have lost a small amount of blood, but they can continue to maintain normal homeostasis. A patient who has a limb amputation and has had a catastrophic haemorrhage will have serious circulation disruption and will be at risk of significant consequences such as organ failure and cardiac arrest.    
• Disability (D) – Looking at the effects of reduced level of consciousness (LOC) and its’ cause may have increased detriment to the patient. For example, a gradual hypoglycaemic event will affect the patients’ level of consciousness and homeostatic level. As this worsens, further issues may develop, such as the patient becoming unconscious and putting their Airway at risk. In trauma, a head injury may result in traumatic brain injury, and they may be unconscious because of life threatening swelling occurring in the skull. The only treatment for this will be in hospital, giving you greater need to get the patient to definitive care. 
• Expose/Environment/Evaluate/Evacuate (E) – The last assessment of the primary survey encompasses different elements of surrounding and situational circumstances. The clinician will need to consider and question a number of factors surrounding ‘E’ such as: Will exposing the patient through clothing removal reveal further injury, is the environment a factor to their ill health (such as Carbon Monoxide poisoning) or will it further adversely affect the patient (such as hypothermia), is there a need for further evaluation, and is it time to evacuate the patient to hospital.