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Secrets of the Secondary Assessment

One of the biggest challenges an EMT instructor faces when working with new students is trying to teach them the sequence of a thorough patient assessment.

Some aspects are easier than others because they never change. Saying you’re going to put on proper PPE or asking if the scene is safe will always begin the patient assessment. If they’re overlooked, well, nothing like a couple of early critical fails to jar your memory.

So through sheer repetition, students seem to retain many of the aspects required to plow them through the early part of an assessment: scene size-up, general impression, and primary survey. One quick transport decision later, and the primary assessment is in the bag.

And…this is where students begin to stare blankly at the manikin in front of them, uncertain what to do next. All immediate life threats have hopefully been identified and treated to the best of their ability, and a destination has been picked out—now what?

The Truth Is Out There

The secondary assessment can be a bit confusing. With so many acronyms to learn and tasks to accomplish, the student has to take in a tremendous amount. The task is even more difficult if the student is uncertain or undecided about what they are looking for.

The secondary assessment is where first responders really start to develop critical-thinking skills that will help them formulate a logical differential diagnosis. Taking the information gathered from a proper scene size-up and primary assessment will help a student focus their treatment and expedite proper patient turnover at the hospital. Everything from the way a patient was found upon arrival to the general condition of their environment can provide valuable insight into what might be going on.

The assessment truly does start the moment your pager goes off. But the secondary assessment is where the first responder can broaden their scope of inquiry, looking for the clues that are obvious and that need to be uncovered through detailed assessment.

Think of it as a detective working to solve a crime, rather than a police officer trying to mitigate the effects of a crime in progress. The detective is looking for causes and reasons, whereas the officer may be more concerned with stopping and controlling damages.

Both professionals work toward the same goal: discovering whom the bad guy is. In EMS the villain we’re after is the differential diagnosis.

Rounding Up the Suspects

Just like a medical detective, students begin with the patient’s chief complaint, along with their signs and symptoms, to make a short list of possible suspects.

For example, a 58-year-old male with acute onset of slurred speech and altered mentation could prove to be a rather challenging scenario for the new EMT student.

Information obtained in the primary survey finds a male in his home presenting with pale skin, confused verbal responses, and staggered gait. Based on this information students are encouraged to come up with a short list of possible causes that might fit the patient’s chief complaint and signs and symptoms.

A quick list may look something like this:

  • Stroke
  • Intoxication
  • Hypoglycemia
  • Trauma
  • Heat exhaustion

Each of these possible suspects is a differential diagnosis that fits the patient’s condition. By utilizing the three P’s of the secondary assessment, a student might find enough information to rule in or out some of these suspects.

The Three P’s

To help EMT students find a starting point for their secondary assessment, one of three paths should be chosen: past, present, or patient. Each is a quick way to group some of the questions that should be asked and tasks that should be done if time allows.


Present: OPQRST;

Patient: Physical assessment; vital signs; diagnostic tests: glucose reading, SpO2 reading, temperature.

With these three roads to travel, where to start will be based on the patient’s presentation, chief complaint, and, perhaps most important, what you want to get accomplished.

The possibility of a stroke could be addressed by a stroke scale performed during a physical assessment. Intoxication, while EMS providers do not normally carry breathalyzers, could also be examined in a physical presentation, including smell and odor of ETOH and in a SAMPLE history of alcoholism. Hypoglycemia is perhaps the easiest to address by performing a diagnostic blood glucose reading. Trauma could be noted by a DCAP-BTLS assessment performed during a head-to-toe physical. Heat exhaustion could be determined by asking questions found in the OPQRST and examining for signs during a physical assessment.

Questions Lead to Questions

Questions asked in both the past and present paths could spiderweb off into other pertinent questions. Students are encouraged to explore these questions but be mindful not to be led astray. The idea is to remain focused but thorough.

A patient presenting with abdominal pain may cause students to venture off their initial path with additional inquiries.

  • “When was your last bowel movement?”
  • “Have you had any recent changes in your diet?”
  • “Is anyone else in the house also complaining of similar problems?”
  • “Do you still have your appendix?”
  • “When was your last menstrual cycle?”

All these questions are valid if they pertain to a patient’s chief complaint; however, they might not be explored if the student is unwilling to veer off the path and explore information based on what their patient tells them.


The secondary assessment has the potential to be the most challenging and most fun part of teaching the full patient assessment. It’s filled with much more color then the relatively black-and-white decisions found in the scene size-up and primary survey, and it’s more exciting to explore than the seemingly routine things seen in the ongoing assessment.

The secondary assessment should make the EMT student feel empowered to explore and discover. Critical thinking will occur when students begin to realize why they ask the questions they ask and how that information fits with possible differential diagnoses. Teaching critical thinking will change emergency medical technicians into emergency medical clinicians.

Paul Serino, NRP, CCT-P, BS, is a 19-year paramedic and a full-time faculty member in the EMS program at St. Petersburg College in St. Petersburg, Fla. In addition to an associate degree in EMS, Paul has a bachelor’s degree in journalism and has contributed a number of articles to EMS World. He is currently working on his master’s degree in education.




Submitted byHibana1389 on 03/18/2019

You make a great point that as students we may either not realize the questions we should ask or are to afraid to ask even though it could help us get to the root of the problem. Other students may not have the confidence to ver away from the what we learn in the textbook and ask the open ended questions that could help us get more clues to what is happening in the body. We sometimes don't realize that during our second assessment we should not only reassess our interventions but also keep asking questions.

Submitted byleianac on 03/18/2019

I really enjoyed this article, it made why the secondary assessment is so important more clear and even gave tips on how to approach certain situations.

Submitted bysara_terepka on 03/18/2019

I really enjoyed your article. It breaks down the key points of scene size up and discusses the secondary assessment. You thoroughly explained why students get confused and tend to miss out on important things. You then provided a scenario as an example to explain more in depth on why students have difficulty during the secondary assessment and, listed the 3 P's plus other helpful questions to ask a patient. As you say "questions lead to questions".

Submitted bygreenethemarine on 03/18/2019

Very well written. I completely agree with you, Mr. Serino. Thank you for the article, this has given me a different insight on how to approach the secondary assessment as to it just being something on a piece of paper. This example and information will help me stay on track on to tackling down my suspects within my patient.

Submitted bySNelson94 on 03/20/2019

i really enjoyed the article. I must say the whole past, present, and patient are very helpful tricks to use when practicing. The article was very helpful and informative.

Submitted byJbytautas on 03/20/2019

Great article,
Secondary assessment's are a vital source when determining the patients NOI/MOI, but when having a good foundation to go based off makes the process even more efficient. I enjoyed reading the extra tips like the three P's and the addition questions for certain situations. I would recommend this article to other fellow EMS students. Great job!

Submitted byItsCashhh on 03/20/2019

Blank stare at the mannequin, probably the most accurate statement of this year! Great article, secondary assessments are the most challenging to learn how to process and adapt to the initial assessment and narrowing down your index of suspicion. Nice insight on how to go transition into the secondary assessment, definitely a helpful way to look at it.

Submitted byjacob.laser444 on 03/20/2019

I like how you take something that most EMT students struggle with and break it down and make it easier for us to understand. I also like how you talk about how you gave a example that made learning secondary assessments so much easier by giving questions that lead to questions to avoid blanking out during test. now I know all the secrets to the secondary assessments.

Submitted byxavrich on 03/22/2019

The part of this article that i enjoyed most is the "Questions lead to Questions" section. It reminds us that sometimes were going to have to questions that are more outside the box than the routine assessment questions. I'm personally trying to get better about this, and i appreciate that part and this whole article as a whole.

Submitted byjherret88 on 03/25/2019

I can greatly appreciate this article. I do agree and have found that a major component of obtaining important information is also finding the confidence within yourself when addressing your patients and having said confidence when being "the detective" and trying to figure out what's going on to do your best in helping your patient, even if all you can do is Rapid transport. This article definitely reminded me of the many reasons why I enjoy this field of work and why I took an interest in the first place. Well done Mr. Serino. Thank you for the fantastic article.

Submitted byRyan Duart on 03/25/2019

This article really brought light to how important the secondary assessment is. It shows that it isn't something you just check off on your list of things you perform with a patient, it is asking the right questions and exploring the situation at hand.

Submitted bysamintin on 03/25/2019

This article talks about great techniques for how to handle the secondary assessment. I find that the hardest thing to do is to ask the patient questions. This breaks it down into a simplified version that gives you the basic questions needed to dig deeper. I also find it helpful to come up with a list of things that could be going on with the patient so you have a guide of questions to try to eliminate some of those choices. Great article!
-Sam Shore

Submitted byShelleyN on 03/26/2019

This is a very informative article. While wrought memorization does make up the early components of patient care and assessments the real work comes in during the secondary assessment. Likening it to being a detective is a very apt analogy (and the blank stare during that step beyond accurate). I find this article helpful in bringing all the steps together we’ve learned about assessments and making the procedure a little more cohesive in my mind.

Submitted byAbsoluteSlaughter on 03/27/2019

I believe many students will be well into their career by the time they learn to focus their secondary assessment skills efficiently. Plus, memorization of acronyms and the order of steps only gets you so far, even in the context of actually running the scenarios. Reading this has lead me to coin a phrase.

"And if thou gaze long into a manikin, the manikin will also gaze into thee."

Submitted byAnnishaP on 04/01/2019

This article is a great tool to use when understanding how to work through a patient assessment. As a student, I struggled with were to start and what do I do next when conducting my patient assessments, esp when I got to the secondary assessment. After learning about the 3 P’s, I found myself able to correctly apply the right set of questions to various real world scenarios. Instantly, I was could perform my patient assessments thoroughly & effectively with ease & confidence.

Submitted bymzarra on 04/07/2019

Great article, enjoyed reading!! This definitely helped make the secondary assessment easier to understand. I like how you explained the importance of questions during the secondary assessment to get a more thorough understanding of the issue the patient is presenting with.

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