Safety First: Primary Decision


Study Notes:

  1. 1. Does the patient need to be Defibrillated? (Medical)   If yes, do so right away.

  2. 2. Does the patient have any life threatening disabilities (Trauma) i.e. amputations, multiple major fractures, debilitating spinal injuries, etc.?  If so, transport immediately.

“Primary Decision”


“Safety First” ... Table of Contents

Safety    Use your BSI - Biological Safety

              F is for Fire - Scene Safety

I                 I is for Incident: MOI/NOI          

R                Determine the numbeR of patients

S                Send for help

T                Trauma to the C-spine?

G                General impression of the patient

E                Estimate LOAs

T                Threats to you or your patient?

1°A             1° Airway

1°B             1° Breathing

1°C             1° Circulation

1°D             1° Decision

2°A             2° Airway

2°B             2° Breathing

2°C             2° Circulation

2°D             2° Decision

Make a Decision Already!!

Now it’s decision time. 

If you have a medical patient you have to decide if your patient needs to be defibrillated.  Rapid defibrillation saves lives - the medical research is clear about this - so as medics we want to make sure that we defibrillate as soon as possible.

The first question to ask (which we’ve already answered) is ‘do they have a pulse’?  If they DO have a pulse, then they DO NOT need to be defibrillated.  Ever.  Don’t even put the automatic external defibrillator (AED) on, it’s contraindicated.

If they DON’T have a pulse, then put the AED on and do what it says.  If you understand ECGs, and it’s a part of your scope of practice, then put on the combo-pads and look for ventricular fibrillation (VF) or ventricular tachycardia (VT).  If you see either of these, defibrillate.

If your patient is a trauma patient (with a pulse), then we need to determine if the patient has any life threatening injuries that require immediate transport.  The PHTLS and BTLS courses do a good job of teaching all the injuries that might be life threatening, but the short story is that any who looks smashed up needs to be transported right away. I’ll tell you a quick story that really reinforced this for me. 

There was a famous medic working in Toronto who was a real cowboy - a total character - but an excellent paramedic.  He was one of the original medics to hit the streets in Toronto and was also a professional stunt man.

I had just started working as a medic and was kind of intimidated to be his partner for a shift. The guy was a legend.

We rushed to a ‘pedestrian struck’ call and  I started grabbing all our equipment bags. 

He yelled out ‘drop that crap, just grab the trauma bag’ (he already had the backboard and stretcher).  We skipped everything, all the ABC’s, everything.  We loaded the patient right away into the unit and I started to hop in the back.

He looked at me and said ‘Where the hell are you going’?  And I stuttered... ‘in there to help you’.

I don’t need any help – start driving cabby.  Spark ‘er up and get the hell out of here!’ So I drove lights and sirens about 7 minutes to the nearest trauma centre. 

I opened up the back to find he had the patient intubated with a large bore IVs in the AC, he had the monitor on, vitals done and had already updated the hospital that we were coming via cell phone. Honestly, it was one of the most amazing displays of technical excellence I’d ever seen.  Later he said ‘Sometimes we’re doctors, sometimes we’re drivers’.

Those are wise words to remember.

Now we’ve done the ‘first pass’ of our ABCs.  If you are a BLS provider, this is where you stop, but if you are an ALS provider you need to go back and redo the ABCD’s at the advanced level.

Let’s take a look at how to do that ...