Look, Listen, & Feel

Will he live or die? That may not always be up to you. However, the fast decisions you make will determine whether the casualty makes a full recovery or remains with a partial/total disability. The initial management of the acutely injured can and should be memorized for maximum efficiency. This guideline will shed the light needed to reveal any life saving interventions you must perform, and in turn will determine proper triage. As your competency as a caregiver grows, the number of patients you will be able to treat effectively will grow too. I will also state that for all of you pre-hospital care providers (PHCP) out there dealing with severe trauma (especially combat related), following the normal “ABC’s” won’t cut it. If you spend X amount of time on A and B only to get to C and find that your patient has bled out… well, you see where i’m going with this. That’s not to say that the ABC’s are irrational, if you know the mechanism of injury (MOI), then you can dictate what suits the situation best. As a rule of thumb, I apply the ABC’s to most civilian non-combat situations and the HABC’s (H being hemorrhage) to the war/combat related ones. Without further ado, here it goes:

1st (goal is to identify all life/limb/eyesight threats)

H. Visually assess as you rake the body with your fingers/hands to check for severe bleeding. If a bleed is found, apply direct pressure/use proper pressure points to control each leak until all are found. Use tourniquets/pressure dressings accordingly. You may have already exposed the patient during your search for the bleed(s), so palpate the carotid; if pulse is absent, begin CPR.

A. Is the patient conscious? Is he talking to you or screaming? His airway is probably unobstructed/patent. Still, treat all trauma patients as if they have C-spine injury. If patient is unconscious, expose the chest and LOOK, LISTEN, & FEEL (LLF). (A & B are concurrent, cont. below)

B. This will reveal if the airway is obstructed, if you can’t clear the airway then you may have to open it surgically, STAT. Pay close attention during your LLF, as this may reveal tension/open pneumothorax, flail chest, etc. You may have to use or improvise an occlusive dressing to seal the chest, and/or perform a needle chest decompression (NCD) to restore an air-free pleural space.

C. Palpate distal pulse to check for proper circulation (you may have to use traction in certain situations in an attempt to restore blood flow). This is also the step where you should initiate IV fluids as necessary (at the very least gain IV access).

Further evaluate and control injuries. Throughout these 1st steps you should have already established the patient’s level of consciousness (LOC). Is he awake? Responsive to vocal/painful stimuli? Or is he unresponsive? Wrap up this partial neuro evaluation by checking the pupils for PERRL (pupils are equal, round, reactive to light). After your LOC & PERRL, you need to finish exposing your patient, thus preparing him for the complete evaluation.

2nd (resuscitation & prep. phase)

This is where you really have to lock things down. If the casualty has crashed on you or loses pulse, initiate CPR. Double and triple check any interventions previously done, continue to expose the patient, establish IV access/initiate fluids as necessary, and look for/treat/prevent shock. This 2nd step is crucial for the higher echelons of care, you want your patient to prepped for a seamless transition from your hands to theirs.

3rd (complete examination)

Constant re-evaluation is crucial, which is why in this 3rd step we will address the head-to-toe complete examination. In the field things aren’t always sunshine and butterflies. Things get knocked around, dislodged, patients may go from stable to unstable in a matter of seconds, and sterility may be a far off luxury. Continually inspect, palpate, and auscultate. Check the head and neck for wounds/fractures and re-evaluate the pupils. Know/don’t know the MOI? ALWAYS assume C-spine injury, stabilize the neck. Inspect front/back of torso, palpate ribs, clavicles, spine, sternum and listen to the heart and lungs. Inspect front/back of abdomen. Observe, auscultate, percuss, and palpate all four quadrants. Inspect all extremities completely, palpate all bones and re-check for proper circulation. Finally, re-evaluate patient’s LOC.

4th (prep. for CASEVAC/MEDEVAC)

Once the patient is packaged (to prevent shock), continue to prepare for transport. This phase is especially important as this is where documentation/communication with a receiving provider/physician happens. Sometimes the situation may tunnel your vision or you may find yourself too preoccupied to document everything. This is okay and completely understandable, just be prepared to effectively communicate your findings and treatment given throughout steps 1–3. Your monitoring and re-evaluation of the casualty should be perpetual.

Remember, your primary goal is to remove the casualty from harms way without you yourself becoming one. Coming strong in second is being the calm within the storm, this will exponentially increase the odds of your casualty’s survival, and give him/her the best chance for a full recovery.