Teaching the IPPSS - Primary

The International Paramedic
Primary Survey
Marc Colbeck
Teaching Workshop

© Marc Colbeck and Paramedicine.com, used by permission of the author. See: https://creativecommons.org/licenses/by-nc-sa/4.0/
Maintaining this note in the file is sufficient attribution of authorship as per the author.

Background
• 2016: No evidence-based research on either the
primary or secondary survey found in the literature
• Formation of an international team of senior
paramedic academics and clinicians
• Systematic review of all CPGs from: Australasia, the
UK, Ireland, South Africa, Qatar, United Arab Emirates,
and of evidence-based exemplar CPGs from the USA.

Background
• Resulted in the first (and only!) evidence-based, peer-
reviewed and published, primary and secondary surveys
for paramedicine.
• Two mnemonics came from the study
• 1o Survey: Safety FIRST GET ABCDEs
• 2o Survey: I See I HAD Vitals Assessed and Treated
• “For paramedic students … memorising over 100 unique
concepts to practice in order and without omission,
under novel and stressful conditions, is a daunting
proposition. It is the author groups’ hope that this work
will assist them in that effort”.

The International Primary and Secondary Survey
Open Access article
in the
Irish Journal
of Paramedicine
Colbeck, M. A., Maria, S., Eaton, G., Campbell, C. B., Batt, A. M., & Caffey, M. R. (2018). International Examination and Synthesis of the Primary
and Secondary Surveys in Paramedicine. Irish Journal of Paramedicine, 3(2), 1–9. https://doi.org/10.32378/ijp.v3i2.91

Make sure you know the sentence…
“Safety FIRST GET ABCDE’s”

Layout of this workshop
First: Explanation of the topic
Second: What to say (sample scripts)
Third: Reinforcement activity (for some topics)
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Follow
along!

Safety
“Safety”
Means biological safety.
Wear your gloves & goggles.
Wear helmets and footwear.
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http://cache.daylife.com/imageserve/0a6HdEh1q593B/610x.jpg April 2008

To the Scenario Director
• “I’m wearing my gloves and goggles”
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To the Patient
Safety

Fear
Is there anything
that you’re worried
could endanger the
safety of you or
your team?
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http://www.27east.com/assets/news.Article/232449/main1747.jpg February 2018

• “I don’t see anything that makes me
feel unsafe”
[or]
• “I’m concerned about ______ and
would address that by ______
before entering the scene”
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To the Patient
Fear

• Discus some examples of safety concerns on things we should fear
while on the job with another student?
• How many can you think of?
• Share as a class
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Safety and Fear

Incident
What is the nature of the
incident?
Specifically, is it traumatic or
medical?
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http://img.coxnewsweb.com/C/00/29/29/image_3429290.jpg April 2008

• “This seems to be a traumatic/non-
traumatic incident” (pick one)
• “I’m considering the mechanism of
injury”
[or]
• “I’m considering the nature of illness”
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To the Patient
Incident

• What are some examples of traumatic vs medical scenarios and what
are some considerations with this?
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Incident

numbeR
How many patients are
involved?
Look for clues that someone is
missing.
Look at any bystanders – do
they need help?
Keep an eye on your team.
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http://elkgrovetribune.com/wp-content/uploads/2016/12/exercise3.jpg February 2018

• “There appears to be only one
patient”
[or]
• “I see more than one patient, there
are ______ patients”
• “I see one patient is there anyone
else I need to be concerned about”
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To the Patient
numbeR

• What are some situations where patients could be missed?
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numbeR

Send for help
Do you need any help to
manage the scene?
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E http://www.lifemedems.com/images/IMG_1581.JPG April 2008 April 2008

• “No need to send for help at this
point”
[or]
• “I’m going to request ______ for help
because of ______”
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To the Patient
Send for help

• Class discussion – who can we call for help?
• What can they do for us?
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Send for help

Triage? Trauma?
If there is more than one
patient do you need to
prioritise the most sick?
(perform ‘triage’)
If there is only one patient,
do you need to worry about
trauma to their c-spine?
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https://upload.wikimedia.org/wikipedia/commons/thumb/e/ea/Wounded_Triage_France_WWI.jpg/1200px-Wounded_Triage_France_WWI.jpg February 2018

• “I’m ruling in C-spine – partner can you
immobilise”
[or]
• “I’m ruling out C-spine – no need to
immobilise”
• “There’s only 1 patient so no need to
triage”
[or]
• “There are multiple patients so I will begin
triaging”
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To the Patient
Triage? Trauma?

General impression – Single Patient
1. Age
2. Sex
3. Position found*
4. Location
5. Level of distress*
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http://vkool.com/wp-content/uploads/2016/05/asthma.jpg February 2018
Supine
Prone
Left/right lateral
High/low fowlers
Tripod
Mild (fine)
Severe (REALLY sick)
Moderate (anything else)

• “I see a 50-year-old male standing
upright in a classroom in no
apparent distress”
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To the Patient
General impression

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General impression
• Practice making up some situations and describing the scene to
another student using the five items mentioned – in order.
• Have each student describe their own current general impression

METHANE update
• Major Incident Declared
• Exact location
• Type of incident
• Hazards
• Access
• Number and type of casualties
• Emergency services present and required
General Impression
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• “I’m notifying dispatch that I am declaring a major incident,
• Our exact location is: ______________
• The type of incident is:______________
• Be aware of the following hazards:______________
• Best access and egress are: ______________
• We have the following casualties: ______________
• On scene we have ______________, and I am requesting ______________
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General impression – Multicausality Incident

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General impression
• Practice making up some situations and describing the scene to
another student using the METHANE mnemonic.

Estimate levels of awareness
AVPU
Alert
Verbal
Pain
Unresponsive
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https://www.virtual-college.co.uk/-/media/virtual-college/news/virtual-college/guides/what-to-do-if-someone-is-
unconscious.ashx?h=288&la=en&mh=288&mw=512&w=512&hash=6CB6D638ACB8564916D5A9FEE2393180C73BEEFE February 2018

• “The patient appears to be alert, is
visually tracking me, and is responding
to verbal with normal verbal” [or]
• “Patient is responding to loud verbal by
moaning” [or]
• “Patient is responding to pain by …” [or]
• “Patient is responding to _____ by
_____”
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To the Patient
• “Hi, my name is ______ and I’m a
paramedic, are you ok?”
Estimate LOA’s

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Estimate LOA’s
• Have each student describe several patient presentations to each
other using the structure … “The patient is responding to _____ by
_____”

Threats
POPE
People
Objects
Places
Environment
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http://www.abc.net.au/news/image/7288144-3x2-700x467.jpg February 2018
Includes “life
threatening
bleeding” in
your patient

• “There are no POPE threats to
myself, my team, my patient, or
bystanders”
• There is no life threatening bleeding
in my patient.
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To the Patient
Threats

The ABCDE’s
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• Are done in sequence
• Experienced paramedics might vary the sequence, or do them all simultaneously
• Are done using a ‘Find-it, Fix-it, Move-forward’ approach

Airway
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http://cursoenarm.net/UPTODATE/contents/images/f5/60/6095.myextj?title=Endotracheal+intubation+ant February 2018
Assess:
• Is the airway patent?
• Does it need clearing?
• Are there current, or impending, obstructive difficulties?
Consider:
• Positioning
• Suctioning
• Foreign Body Airway Obstruction removal (Magill
forceps/laryngoscope/back blows/chest thrusts)
• Basic airway adjuncts (oro/nasopharyngeal airways,
supraglottic airway device)
• Advanced airway adjuncts (endotracheal intubation +/-
pharmacological assistance)
• Surgical airway (for the “can’t intubate-can’t ventilate”
patient)
Clear
Poor
Absent
Treat
from the
‘outside→in’
Ask:
‘Do I need to go
‘in’ to the patient?

• “Airway is clear/poor/absent”
• “I’m going to attempt to ventilate the
patient to see if the airway is clear”
[or]
• “Patient does/does-not require
advanced airway support”
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To the Patient
• “How’s your breathing, is it ok?”
• Explain to the patient what you are
doing
• (Be sure to get consent!)
Airway

• Have students explain the airway approach to each other
• Have students perform the entire primary survey up to this point
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Airway

Breathing
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https://www.news-medical.net/image.axd?picture=2016%2F1%2Fman_has_difficulty_getting_his_breath.jpg February 2018
Assess:
• Look, listen, feel for breathing and assess
respiratory effort
• Consider rapid 4-point auscultation (if appropriate)
• Consider oxygen saturation (SpO2) and end tidal
carbon dioxide (EtCO2) measurement (prn)
Consider:
• Establishing breathing using a bag valve mask
• Initiating oxygen administration (mask, nasal
cannula, bag valve mask) for hypoxemia
• Chest Needle Decompression or Finger
Thoracotomy (prn for life threatening tension
pneumothorax, or hemo-pneumothorax)
Clear
Poor
Absent
Treat
from the
‘outside→in’
Ask:
‘Do I need to go
‘in’ to the patient?’

• “Patient’s breathing is
clear/poor/absent”
• “I’m going to apply a non-rebreather
mask @ 15L per minute” [or]
• “I’m going to apply a nasal cannula
@ 2L per minute” [or]
• “I’m going to ventilate with a BVM”
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To the Patient
doing
Breathing

• Have students explain it to each other
• Have students PERFORM the AB assessments
• Then have students perform the Safety FIRST GET AB assessment
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Breathing

Circulation
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http://co.cheshire.nh.us/hoc/Images/cpr3.jpg April 2008.
Assess:
• If there is a pulse or not
• Pulse rate, strength, and regularity
• Perfusion estimation - adequate vs inadequate
• For uncontrolled external haemorrhaging
• Skin condition (colour, temperature, diaphoresis)
Consider:
• Direct pressure/tourniquet for uncontrolled haemorrhage
• Cardiopulmonary resuscitation if vital signs absent
• Electrocardiogram determination prn
• Intravenous initiation
Clear
Poor
Absent
Ask:
‘Do I need to go
‘in’ to the patient?

• “There is a strong radial/carotid
pulse” [or]
• “There is no carotid pulse”
• “Patient appears well/poorly
perfused”
• “Skin is pink (pale, mottled), warm
(cool, cold) and dry (clammy, wet)”
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To the Patient
doing
Circulation

• Have students summarise our approach to Circulation to each other
• Have students PERFORM the Circulation assessment
• Then have students perform the Safety FIRST GET ABC assessment
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Circulation

Decision/Disability
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https://cihparamed.files.wordpress.com/2016/10/920x920.jpg February 2018
Medical:
B: Benzo/Seizures or Aggression
A: Adrenaline/Anaphylaxis
N: Narcan/Opioid OD
G: Glucose/Hypoglycaemia
Zap: Defib pulseless patients
Push: IV fluid push for hypovolemic
hypotensive
Trauma:
Bad breaks and bleeding

• “I’m assessing for medical disabilities”
• “No treatment required at this point” [or]
• “I want to give Midazolam for seizures” [or]
• “I want to give Adrenaline for anaphylaxis”
[or]
• “I want to give Narcan for opioid overdose”
[or]
• “I want to give Glucose/Glucagon for
hypoglycaemia”
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To the Patient
• Explain to the patient what you are doing
Decision: Medical

• “I’m assessing for trauma disabilities”
• “The patient has an uncontrolled bleed/or
break – this is a load and go situation” [or]
• “Patient appears to be stable”
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To the Patient
Decision: Trauma

Learn “BANG, Zap, Push”
• Have students stand and repeat
• Explain to each other
• Then have students perform the Safety FIRST GET ABCD assessment
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Decision

Extrication
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http://rafah.virtualactivism.net/newsphotos/06/november/6/palestinian%20medical%20work
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Assess:
• Current environmental conditions (e.g. heat, cold,
wind, rain, direct sun, impending danger)
• Egress route to transportation (manual handling considerations,
obstacles, dangers)
Consider:
1. Time Criticality:
• Escape (if unsafe scene)
• ASAP (‘load and go’)
• Normal (non-critical patients)
• Prolonged (may require shelter)
2. Getting help:
• Requesting additional assistance
3. Where are you going, How will you get there?
• Appropriate transport method (e.g. bariatrics, air
transport)
• Appropriate transport destination (e.g. cardiac or trauma
bypass, paediatric centre, neuro centre, etc.)

• “This patient requires immediate extrication”
[or]
• “This patient is a load and go” [or]
• “This patient can be extricated normally” [or]
• “This is going to be a prolonged extrication,
and I’m going to consider _____”
• “I’m going to request _______ to assist in
extrication”
• “I’m going to request _______ to assist in
patient care”
• “I’m going to request _______ for transport”
• “I’m going to transport the patient to _____”
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To the Patient
Extrication

1. What are the four levels of time criticality? (exact words aren’t
important, just explain the idea.
• Have students explain the above to each other, forwards and backwards
2. Brainstorm possible destinations and why you would choose those
over another
3. Have students brainstorm alternate transport teams
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Extrication

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Scenario Time!
Have the students do the following scenario:
• 50 year old male walking in the park, bystanders saw him sit on a
bench, then slump over gently. He didn’t respond when they tried to
wake him up, so they called for help. There is no evidence of trauma to
the patient.

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The International Paramedic
Primary Survey
Questions?

About this presentation
1. This work is shared under a Attribution-NonCommercial-ShareALike 4.0
International (CC BY-NC-SA 4.0) Creative Commons License.
2. See: https://creativecommons.org/licenses/by-nc-sa/4.0/
3. This work is authored by Marc Colbeck, based on the following work: Colbeck, M. A.,
Maria, S., Eaton, G., Campbell, C. B., Batt, A. M., & Caffey, M. R. (2018). International
Examination and Synthesis of the Primary and Secondary Surveys in Paramedicine.
Irish Journal of Paramedicine, 3(2), 1–9. https://doi.org/10.32378/ijp.v3i2.91
4. Maintaining and showing the second and last slide (in their entirety) in the
presentation, is considered a sufficient statement of authorship under the License. You
may add the presenters name to the first slide of the presentation.
5. Please visit www.paramedicine.com for more information.
6. You are not obligated to, but we would appreciate hearing about where this work was
used in order to give us an idea of where it is spreading to. Feedback is greatly
appreciated!

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