Station Title & Timing

  • Title: Primary Survey of a Multi-Trauma Patient (Post-MVA)
  • Duration: 10 minutes (2 minutes reading time + 8 minutes performance)

Learning Objective(s)

  • Examination Skills: Demonstrate a systematic DRS-ABCDE Primary Survey with manual in-line stabilization (MILS).
  • Clinical Reasoning: Prioritize life-threatening injuries over distracting secondary injuries.
  • Communication: Maintain professional running commentary to the examiner and empathetic communication with a conscious trauma patient.

Patient Profile

  • Name: Mr. David Miller
  • Age: 29 years old
  • Occupation: Construction Foreman
  • Relevant Social History: Married, two children. Non-smoker.

Presenting Complaint

David was the front-seat passenger in a high-speed motor vehicle accident (MVA). He was restrained by a seatbelt but the vehicle sustained significant frontal impact and lateral intrusion.

Contextual Information

  • HPC: Paramedics found David conscious but confused. He was extricated with a cervical collar and a spinal board (since removed for transfer).
  • Injuries noted in transit: Obvious deformity to the right lower leg, chest wall bruising, and complaining of neck pain.
  • PMH: Fit and healthy.
  • Medications: Nil.
  • Allergies: NKDA.

Exam Instructions

Candidate Instructions

You are the Trauma Registrar in the Emergency Department. David has just been wheeled into the trauma bay.

  1. Perform a Trauma Primary Survey (DRS-ABCDE) with a running commentary.
  2. Maintain C-spine protection throughout the assessment.
  3. Address any findings as the examiner provides them.
  4. Briefly summarize your findings and immediate priorities at the end.

Standardised Patient (SP) Instructions

  • Affect: You are frightened, shivering, and in significant pain. You keep asking about your wife, who was driving.
  • Interaction: * If asked your name, answer: “David… is my wife okay?”
    • If the candidate tries to move your head or remove the collar, complain of sharp pain in the back of your neck.
    • If they check your leg, moan in pain.
  • Neurology: Tell the doctor your hands feel “tingly” if they check sensation in your arms.

Examiner Checklist Items

  • Danger/Response: Checks for safety and assesses patient responsiveness.
  • Airway: Assesses patency by speaking to the patient; inspects the mouth.
  • C-Spine: Verbalizes manual in-line stabilization while assessing airway and does not remove the collar.
  • Breathing: Inspects expansion, palpates for trachea position/crepitus, and auscultates lungs.
  • Circulation: Checks pulses (rate/volume), CRT, and skin temp.
  • Disability: Checks GCS (or AVPU), pupils, and a brief motor/sensory screen of all 4 limbs.
  • Exposure: Verbalizes undressing the patient and preventing hypothermia.
  • Prioritization: Correctly follows ABCDE sequence without skipping steps for the leg injury.

Key Clinical Findings

  • Vitals: HR 115 (Tachycardia), BP 105/75, RR 24, SpO2 96% on RA.
  • Airway: Patent (patient speaking). No secretions.
  • Breathing: Equal air entry bilaterally; bruising noted over the right 4th-6th ribs.
  • Circulation: Thready radial pulses; CRT 3 seconds (sluggish). Skin is cool and pale.
  • Disability: GCS 14 (Confused). Pupils 3mm, equal and reactive.
  • Spine: Midline tenderness at C4-C5 level. Sensation diminished in a “glove” distribution in both hands.

Communication Triggers (Murtagh-Aligned)

  • Open-ended questions: “David, can you tell me exactly where you are feeling the most pain right now?”
  • Summarising/Empathy: “I understand you’re worried about your wife. My team is checking on her right now. I need to finish checking you from head to toe to keep you safe.”
  • Lay Language: “I’m keeping your neck still with this collar just to protect your spinal cord while we check for injuries.”

Assessment & Marking Guide

DomainCriteria for Pass
A – AirwaySecured airway and maintained C-spine protection simultaneously.
B – BreathingSystematically checked for life-threats (Tension pneumothorax, flail chest).
C – CirculationIdentified signs of compensated shock (tachycardia/prolonged CRT) and requested IV access/fluids.
D – DisabilityCorrectly assessed neurology and identified C-spine tenderness.
ProfessionalismUsed running commentary effectively; handled the SP with care.

Global Rating:

  • Pass: Sticking to ABCDE logic, verbalizing all steps, and recognizing shock/spinal risk.
  • Fail: Removing the collar without clearance, ignoring the “B” or “C” to look at the leg, or failing to communicate with the patient.

Sample Answers / Model Performance

The Running Commentary (Sample):

“I am beginning the Primary Survey. I am maintaining manual in-line stabilization of the C-spine.

  • Airway: ‘David, can you tell me your name?’ The patient speaks, so the airway is patent. I see no blood or vomit in the oropharynx.
  • Breathing: I am looking for chest expansion; it is symmetrical. I am feeling for the trachea; it is midline. I am auscultating… breath sounds are equal. I note some bruising on the right.
  • Circulation: I am checking the radial pulse; it is fast and thready. CRT is 3 seconds. The patient is likely in early shock. I would request two large-bore IV cannulas and a liter of warmed saline now.
  • Disability: The patient is confused (GCS 14). Pupils are equal and reactive. I am checking the 4 limbs… David, can you wiggle your toes? Good.”

Management Summary to Examiner:

“This is a 29-year-old male involved in a high-speed MVA. Primary survey reveals:

  1. Airway: Patent with C-spine tenderness at C4/5.
  2. Breathing: Stable, but high risk for rib fractures/contusion.
  3. Circulation: Tachycardic and poorly perfused, suggesting Class II hemorrhagic shock.
  4. Disability: GCS 14 with bilateral upper limb paresthesia.

Immediate Priorities: Hemodynamic resuscitation, urgent trauma series X-rays (Chest/Pelvis), and CT Pan-scan (including C-Spine) once stabilized. I will maintain the collar until radiologically cleared.”