Only the rocks know, maybe a couple of trees, but they aren't talking. Summer warms the air, and the trail you and three friends hike under loaded backpacks, the trail that passes beneath a high granite cliff, has led you to a young man sprawled on the ground just below the trail, face up, unmoving, a smear of blood from mouth to ear. What happened? What do you do? There are clues everywhere, but where is Sherlock Holmes when you need him?

Imagine the ineffable Mr. Holmes, pipe clamped with determination between his teeth, eyes missing nothing, mind shifting into high gear. This is not Baker Street, Dr. Watson. His first concern, and yours, is safety. At the scene of any emergency the last thing you want to do is create a second victim. You take a deep breath. You look for obvious dangers to you and others with you (rockfall?). You become aware of subtle dangers (chill from a sudden wind?). Humans are resources who can think, help tend the patient, participate in carrying an injured person out of the woods. A second victim not only doubles the trouble, but also reduces the resources. In the outdoors, two patients are more than twice as serious as one. Precious moments taken to stand apart and survey the scene for safety are often the most valuable of the rescue.

Well, well. There are no apparent dangers, but your quick survey of the scene reveals a backpack about 30 feet away leaning against a tree. The pack is open. Beside it stands a pair of hiking boots with wool socks stuffed into them. Your eyes flick to the patient's feet. Sure enough. He wears climbing shoes. You have uncovered a highly probable Mechanism of Injury. With better understanding, you move to the patient's side.

INITIAL SURVEY
The goal, Sherlock would say, in an Initial Survey is to identify and treat any immediate threats to life. Immediate loss of life will be from 1) loss of AIRWAY, 2) inadequate BREATHING, 3) loss of adequate CIRCULATION because the heart has stopped or too much of the patient's blood is in the wrong place (e.g., on the ground), or 4) extensive DISABILITY from damage to the cervical spine (the neck). The letters ABCDE are reminders of what to do in an Initial Survey. The E stands for EXPOSURE and ENVIRONMENT. Read on.

Airway
An airway starts at the nose and mouth and ends deep in the chest where oxygen is exchanged for carbon dioxide. If it's not open all the way, it won't work. In an unconscious victim, the most common airway obstructions are the back of the tongue and the epiglottis. By tilting the head back and lifting the chin--the head tilt-chin lift maneuver-- most airways can be opened. With concern for cervical spine damage, which could result from a fall, the head tilt-chin lift is not used since it may cause further injury. You would opt for the jaw thrust: securing the patient's head and pushing the jaw straight up by lifting the corners of the jawbone. Movement of no more than one-half inch should open the airway.

If you find a victim that appears unconscious, check immediately for responsiveness by placing your hand gently but firmly on his forehead and asking in a loud voice: "Are you OK?" If he does not respond, open his airway with the jaw thrust and place your ear near his mouth to LOOK, LISTEN and FEEL for air movement. LOOK in the mouth for blood or vomit and, if it's there, sweep it out as best you can.

Breathing
If he's breathing, move on to circulation. If no breathing can be detected, you should attempt to breath for him with mouth-to-mouth ventilations. If your first two ventilations go in, and the chest rises as you breath in showing that air is getting into the lungs, that means the patient has an adequate airway but is not using it. You must keep breathing for this person, but you should check for a pulse before continuing.

NOTE: Any rescue breathing is a safer bet in terms of your personal health and well-being if you use a pocket rescue mask.

Circulation
Place two or three of your fingers over the carotid artery, in the valley between the windpipe and the large neck muscle, just below the angle of the jaw. If you find a pulse, continue rescue breathing, if necessary, by giving one ventilation at least every five seconds. (If the victim is a child, give breaths faster--at least once every 4 seconds.)

Rescue breathing is useless if the victim does not have a beating heart to push around the blood you're oxygenating with your breath. Cardiopulmonary resuscitation (CPR) is a necessary skill for a rescuer, a skill that involves airway management as well as artificial ventilations and chest compressions that simulate the patient's basic life processes. CPR needs to be seen and practiced to be learned well. Courses are offered regularly by either the American Heart Association or the American Red Cross in most communities.

Bleeding
Life-threatening arterial bleeding pulses or spurts from a wound each time the patient's heart beats. Venous bleeding, which can also be serious, flows smoothly and rapidly.

A quick visual scan of the patient is often enough to detect serious bleeding--but not always! Check inside the clothing of someone wearing bulky winter gear or raingear. Check beneath someone who is lying in sand, rocks, or any terrain that might disguise blood loss. Severe blood loss can also be internal.

To control any bleeding, apply pressure from your hand directly on the wound. If the wound is on an arm or leg, elevate the injury above the level of the patient's heart to reduce blood flow even more.

Note: Before contacting blood, or any other body fluid, it's best to put on disposable protective gloves. Without gloves, you can protect yourself at least partially by applying pressure over a folded T-shirt or some other clothing. Wash your hands thoroughly when you finish even if you wear gloves.

Disability
Down through the cervical vertebrae runs the all-important spinal cord. If its nerve messages are impeded by damage, the result is often permanent paralysis or death. In the primary phase of treatment any patient who might have a cervical spine injury should be kept still with calm words and hands on the head until secondary treatment can be applied.

Highly suspect injuries include:

1) those that leave the patient unconscious.

2) those that are produced by potentially neck-breaking mechanisms such as sudden forceful stops from any high speed movement, falls from a height, and diving from a height accidents.

3) those that cause the patient to complain of neck pain.

4) those that produce tenderness in the neck (it hurts when you touch there).

5) those that produce altered sensations in the extremities (tingling, numbness, the inability to move hands or feet).

Expose and Environment
To adequately check for serious injury you may need to expose parts of the patient's body by removing or cutting away clothing. Blood-soaked arms or legs, a chest that heaves in gasping attempts to breath, these anatomical regions must be seen to be properly assessed. And in the outdoors the environment itself can become a threat to a patient's life if he is exposed long enough to cold and wind and rain.

FOCUSED SURVEY
Observe closely, Dr. Watson. Your Initial Survey indicates the young man has no immediate threats to life. Now the search for clues becomes more focused, a complete field examination of the patient. Its goal is to find everything that is not in perfect working order. It includes three phases, but they seldom fit into neat little groups of things to do. The three phases are presented here in tidy order for simplicity. In the end you want to make sure you've overlooked nothing relating the patient's well-being. Sherlock would now remove his famous magnifying glass from his voluminous coat pocket

Vital Signs
Vital Signs are measurements of the physiological processes necessary for normal functioning. They do not tell you what is wrong, but they do tell you how the patient is doing. They include:

1. Level of Consciousness: A prime indicator, a check on how well the brain is communicating with the outside world. Use the AVPU scale for quick reference. (A) Is he Alert, able to tell you who he is, where he is, when it is, and what happened? (V) Does he respond to Verbal stimuli but inappropriately? Does he grunt or moan in response to questions? (P) Does he respond only to Painful stimuli, such as a pinch to the back of the upper arm? (U) Is he Unresponsive? As his level of consciousness decreases, his condition worsens.

2. Skin: Normal skin is pink (in non-pigmented areas such as the inner surface of the eyelids and the fingernail beds), warm, and very slightly moist. As skin color, temperature, and moisture changes, the patient's condition changes.

3. Heart Rate: Count the number of heartbeats per minute. For speed, count for 15 seconds and multiply by four. Note the quality of the pulse. Is it weak or strong, regular or irregular? Normal heart rates are strong and regular, and approximately 60-80 beats per minute.

4. Breathing Rate: Count the number of breaths per minute. Normal lungs work about 12-20 times per minute at any easy, regular pace. If no one has a watch, check anyway. At least you can get a rough idea of how well the patient is doing.

Physical Exam
Check the patient from head to toe in order to find any damaged parts. LOOK for wounds, swelling or other deformities. ASK where it hurts, if the patient can respond. FEEL gently but firmly, a massage-like action with your hands spread wide to elicit a pain response but without causing further damage. Even unconscious patients will typically flinch in response to a painful stimulus.

Patient Interview
More information is usually gathered by subjective questioning that by objective checking. Hopefully, the patient will be able provide the answers. Sometimes witnesses are sources of important information. Sometimes you're up a medical creek without an interviewing paddle.

The SAMPLE Questions:
S for Signs and Symptoms: pain, nausea, lightheadedness, etc.

A for Allergies: any known allergic reactions?

M for Medications: anything legal or illegal?

P for Past History: anything like this ever happened before?

L for Last Oral Intake: when was food or drink last consumed?

E for Events: what lead up to the accident or illness?

S.O.A.P.
In an emergency your brain tends to become a sieve instead of a bowl. The acronym SOAP reminds you to write everything down as soon as possible. Retention of information for medical and legal reasons is important.

S for Subjective information: who, what, where, when, how, SAMPLE.

O for Objective information: vital signs, results of patient exam.

A for Assessment: what you think is wrong.

P for Plan: what you're going to do.

Despite the absence of Mr. Holmes, your Sherlockian approach to assessing the young man has allowed you to deduce that no real injury has occurred. Indeed, by the time your assessment has ended, he has regained consciousness and denies any injury. The fall knocked him out for a few minutes. The smear of blood resulted from a bite to his lip. You stay with him for a couple of hours, enough time for signs of hidden injuries to show up, and you leave with peace of mind. But what if problems had shown up. By following future issues of this column you will learn how to deal with emergencies that you might uncover during other assessments of other patients. It will become, Mr. Holmes would say, "Elementary, my dear Watson."

QUICK RESPONSE

1. Insure the scene is safe.
2. Perform an Initial Survey:
   • Insure an Airway in the patient.
   • Insure the patient is Breathing.
   • Insure the patient has adequate Circulation.
   • Stop serious Blood Loss.
   • Prevent Disability.
3. Perform a Focused Survey.
   • Check Vital Signs.
   • Perform a Physical Exam.
   • Interview the patient: the SAMPLE questions.

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