The Secondary is Primary

I was working with a trainee and we were sent to an assault at a discount shoe store. Dispatch told us that the manager had been beat up during a robbery, and the cops were already on scene. I was deeply hoping that the shoe store manager/patient looked like Al Bundy. I was a little disappointed when he didn't. 

Anyway, the story we were told is that a guy tried to take money from the cash register. Our intrepid patient tried to stop him, a struggle ensued, and the patient wound up with his head under the robber’s arm. Picture two men facing each other, one bends over so his head is next to #2’s ribs, and #2 wraps his arm around #1’s neck. It is the start of a jiu-jitsu guillotine choke, if that makes sense to you. From that position, the robber punched our guy in the back several times and ran away.

The shoe store manager neither had a sparkly leotard nor a mullet, but you get the idea.

By https://www.flickr.com/photos/10542402@N06/ [CC BY-SA 2.0], via Wikimedia Commons

The manager denied being hurt. He said his nose was a little sore, but not a big deal. It was the police that requested our company, based on a fight having occurred. The patient wasn’t knocked to the ground, not choked to airway closure, and not solidly struck. The trainee checked his nose, found it to be sturdy and minimally tender, not bleeding, and otherwise generally atraumatic. 

The trainee took a blood pressure and began to walk away, as though he was about to go in service. That action made me rather angry. One of the first things I tell trainees (and paramedic students, as well) is to perform a full head-to-toe secondary exam on every patient. My trainee didn’t touch the patient, outside of his nose. The proto-medic didn’t have all the information needed to make a decision, much less terminate the call.

I reminded the trainee about my desire to see a complete secondary exam on every patient. I think I was even sort-of polite and almost not hostile at all when I did so. 

The trainee returned to the patient with a sheepish expression on his face. He checked the patient’s head and face and lifted the manager’s shirt. Next, he asked the patient to spin around so he could see his back.

That was when he found twenty-two stab wounds in the patient’s back.

Apparently the punches to the back weren’t punches. Or they were punches, but there was a knife clenched in the fist as well. The story worked out that after the fight, the patient’s shirt was torn. So he changed it while he was waiting on the cops. That was why there were no bloody holes in the shirt. 

I can’t emphasize the importance of a secondary exam enough to a trainee. Everyone thinks they can cheat on a physical exam. But to me, it is all we have for physical information gathering. A hospital can shoot an x-ray, perform an ultrasound, draw labs, and even find a room quiet enough to listen to heart tones. We don’t have any of that at our disposal. All we have is the ability to perform a great head-to-toe exam. 

I think that two problems cause this. First, newer paramedics are embarrassed about the full exam. They think patients will call them out for checking their head, when we were called for an ankle problem. They think people don’t want to be groped by medics. Here is the physical exam pro-tip: People don’t notice. People even subconsciously expect an examination. It feels medical. It makes sense to patients and bystanders. It is not off-putting to patients in the least. That is especially true when you tell them that you’re going to check them out completely, starting with their head. In short, patients neither mind nor notice. Grope away.

Second, I think modern schools don’t teach primary-secondary exams anymore. I’m apparently a dinosaur for even referring to a physical exam as a “secondary exam.” Now EMTs are taught about Focused Assessments, Rapid Assessments, and Detailed Exams. At least one site says:

Many of your patients may not require a Detailed Physical Exam because it is either irrelevant or there is not enough time to complete it. This assessment will only be performed while enroute to the hospital or if there is time on-scene while waiting for an ambulance to arrive…

I strongly and emphatically disagree with that tripe. My blood pressure rises each time I read it, while editing this post. But it explains why many of my new paramedics and trainees think they can get away with half of the required information collection available to a medic.

It is amazing to me how often I find something during a physical exam that isn’t specifically related to the patient’s complaint. Other problems are found. Related issues are found. More of the story is found. I get repeated practice identifying normal breath sounds, pupillary responses, and other exam findings – to the point that abnormal alerts me on a subconscious level. I cannot understate the importance of secondary exams.

Exams are important enough that thick-ass books are written about how to perform exams. Clinicians have used physical exam to do astounding things.* And, again, it is about all we have in the prehospital setting. The only other viable way to gather information is via verbal history. 

Don’t give up half of your potential information.

Perform complete head-to-toe exams. Every patient, every time. I can’t get any more clear than that. Every patient, every time.

*Karl Frederik Wenckebach described the partial blockage of AV conduction that bears his name in 1899, based on physical exam findings and irregular pulse strength.  Willem Einthoven invented the string galvanometer that was used to create electrocardiograms in 1901.  Wenckebach described a Type I AV block before the ECG was invented!  Based on physical exam!