Secondary Survey

Abstract

Secondary Survey"Make sure your patient walks away smiling," the old sur¬ geon opens the lunchtime skull session, the weekly conference that trails journal club. "Make sure a grin warms his face as he waves good-bye. See joy lighten his step when he turns to greet you. Ensure that your patient leaves happy. This is the most important lesson to learn in medicine." What is next most essential? one intern asks. Second in importance? a student in the group queries. The doctor speaking this afternoon is nearly deaf; most words seem to touch down then deflect from the pink shells of his ears. It takes three repeats for him to re¬ alize our prodding. As he considers the question, his voice fal¬ ters for one moment, then from the lull comes out swinging. "The second most important skill to acquire in medicine," he calls out, "is vigilance. Vigilance!" He hesitates for a moment to allow this word time to settle. "Care, for example, in completing the secondary survey-that scouring with a clear eye, hardy ear, and sure hand of every curve and surface of a patient's skin."The doctor plows onward: "In the hours flanking huge trauma, this careful sweep detects minor faults, slight injury. These points if missed later lead to distress. A good second look doesn't take skill. A complete follow-up check with a ma¬ rauding eye and steady palm doesn't really even require intel¬ ligence. The healer in this instance simply needs vigilance." Silence once more follows this thought. Then the voice starts again. "Missing a small finding on the secondary survey will get you sued. Overt signs like a wound squirting blood or an open mouth gasping for breath won't get you in trouble. Everyone sees these big things and most realize the steps of proper treatment. And poor outcome emerging from the ash of wicked injury is always a fair possibility. But missing a subtle finding will trip you. Detecting covert signs through the wan¬ ing haze of catastrophe separates the slick from the crude.