Chapter 10: Initial Assessment

The importance of the initial trauma assessment cannot be overstated as it sets the tone and conduct for the successive steps in the patient’s overall care. Missed or delayed identification of injuries during the initial assessment can lead to adverse outcomes and complications later in a patient’s hospitalization. Although, there have been multiple studies demonstrating the effectiveness of trauma center care on outcome, in reality, the optimal approach to a trauma patient should be universal regardless of the center. Prompt evaluation and treatment are cornerstones of modern trauma systems, which all starts with the initial assessment.

The initial assessment begins with an understanding of which patients need an evaluation by a trauma team. After successful field triage (see Chapter 7), the injured patient should be seen in a setting that can accommodate both the patient and the full trauma team. The basic principles of Advanced Trauma Life Support (ATLS) are then utilized with the primary goal of identifying and treating life-threatening injury. Adjunctive tools of evaluation are often employed to help with the assessment. Finally, ongoing evaluation and training of the trauma team should be utilized to maintain readiness.

While the definition of trauma can be easily defined as injury, the patient with an injury requiring the resources and expertise of a trauma team is less clear. The ability to triage or “sort” trauma patients to the appropriate level care can be examined from several different aspects. These include (1) prehospital triage (ie, does this patient require a trauma center?), (2) trauma center designation (ie, in a region where there are several levels of trauma centers which one is most appropriate?), and finally (3) in-hospital triage tiered response (who is going to see and treat the patient upon arrival?). The best outcomes will be generated by a system that is seamlessly connected.

The most recent Resources for Optimal Care of the Injured Patient recognizes that inclusive regional trauma systems should optimally place the right patient in the right place at the right time.¹ Ideally the only difference between hospitals should be related to their resources and not their commitment to provide the best care for the injured patient (see Chapter 4). Trauma patients should be taken directly to the most appropriately equipped center to handle their needs. As such, there are many factors that have been examined to provide field triage to the injured patient which include anatomy, physiology, mechanism, comorbidities, and field triage scores. Of these indices, physiologic parameters provide the most accurate single criteria for triage but ideally a combination of physiologic, anatomic, mechanism, and comorbidities provide better triage than any criteria taken in isolation.^2,3 Levels of trauma center designation range from I to IV, with level I centers providing the most comprehensive trauma care and level IVs the least (see Chapter 4). Decisions to transport an injured patient to a specific trauma center will be based on multiple factors that are regionally dependent and ultimately on the severity of the patients injuries. Finally, utilizing a tiered response system in the hospital has been shown to be safe, cost effective, and can even potentially reduce over triage.^4,5,6,7

Although, there is no “official” standard for the amount of space needed for the optimal evaluation of the trauma patient, an understanding of the needs and composition of the team will help to dictate the space required. The room and equipment should be designed to optimize trauma team performance. A space large enough to accommodate the trauma team (see below) and ancillary staff is absolutely necessary. When considering size, one must also take into account the need for monitoring and resuscitation equipment, bedside radiographic studies and ultrasound as well as crowd control. In ideal situations, the room or rooms should be solely dedicated to the evaluation and initial management of the trauma patient. This dedicated room will allow the staff to become acquainted with the dynamics of the space. Having a readily available resuscitation room allows for rapid assessment and the ability to keep the appropriate equipment stocked in one easily accessible space. The room should also have telephone access for communication with the operating room, blood bank, and other important locations.

The room should have a standard set of equipment that can be utilized by the trauma team for all trauma patients. Personal protective equipment (PPE) in the form of fluid resistant gowns, head covering, face shield, and gloves (both sterile and nonsterile) should be made available to the entire trauma team. Depending on how x-rays will be performed, protective lead shielding should be provided. A radiographically compatible stretcher so as to obtain x-rays without having to move the patient would be ideal. Cardiac and vital sign monitoring equipment that includes dynamic ECG, oxygen saturation, and blood pressure should be permanently available in the room. Quantitative end tidal CO₂ monitoring is a nice adjunct to have as part of the monitoring system. A manual blood pressure cuff should also be immediately available.⁸ Flat panel monitors placed within the resuscitation room, which can display radiographic images and laboratory data, is an excellent adjunct which can allow the team to remain at the bedside of critically injured patients. Other basic equipment should include dressings/bandages, IV and phlebotomy equipment, thermometer, scalpels, suture material, and a needle driver. It does help to create a “universal” instrument set that would include standard equipment that can be utilized a broad spectrum of needs. The “other” equipment available in the trauma bay can be divided into categories based on injury need (Table 10-1).

Although, many iterations and variations are found as it relates to the optimal makeup of the trauma team, there are no hard recommendations as to the proper number and formulation of the team involved in the initial assessment. The key to formulating the makeup of the team lies in understanding the goals that need to be achieved. Quite simply, the goal of the initial assessment of the trauma patient is to identify significant injuries and initiate lifesaving measures. This can be further divided into the immediate evaluation and management of life-threatening injuries and subsequent identification and management of non–life-threatening issues. These concepts are commonly referred to as the primary and secondary surveys. As such, the ideal team to evaluate the trauma patient should include the personnel necessary to perform these tasks. Based on industrial and psychological research, team efficiency has been divided into horizontal and vertical organizations, which can be translated into horizontal and vertical resuscitations for trauma patients. A horizontal approach is preferred and is one in which each team member is carrying out their individual tasks simultaneously. Studies have demonstrated the effectiveness of this approach in improving resuscitation times.⁹ Conversely, the less efficient approach would be a vertical resuscitation where each task is performed sequentially.

Frequently seen as the “ideal” environment, the level I trauma center has a dedicated team for the initial evaluation of the trauma patient. This will often include a senior surgeon, residents and/or advanced practice providers, nursing staff, medical students, EM and anesthesia staff, respiratory and radiology staff. This team is clearly not attainable in all institutions and should only be used as a template. Trauma center designation should not factor into the proper evaluation of the trauma patient. With the goal to efficiently perform evaluation and management simultaneously, the minimum team numbers should include personnel to perform the primary and secondary survey (1 or 2 team members), procedures (1 or 2 members), and a team leader (1 member, usually the most experienced surgeon). The nursing staff will be working to help with intravenous access, providing medications, transfusions, and monitoring. Although not well studied, the importance of a well-experienced nursing staff as part of the trauma team cannot be stressed enough.

Trauma team leader: The leader of the trauma team should be the most experienced provider in the room with an understanding of the priorities in the evaluation and care of the injured patient. In a trauma center, this should be the trauma surgeon.¹ The team leader should provide direction and assign tasks to individual team members prior to arrival of the patient. With the goal of conducting the “trauma team orchestra,” they should situate themselves with a view of the entire proceedings. While this is often best accomplished at the foot of the bed, the geography of the resuscitation room will dictate the optimal position which affords the team leader the “big view.” Once the patient arrives, the team leader should keep the team on track and offer prompts as needed to bring the initial evaluation and management to an appropriate conclusion. Decisions as to the next steps in care should be made by the team leader. If trainees are present, opportunities should be made for them to be team leader under the close supervision of the attending.

Primary surveyor: This individual is responsible for the actual evaluation of the trauma patient. Based on ATLS algorithms, this individual will work through the ABCD/primary survey of the evaluation and report these findings to the team. Depending on available personnel, this individual can perform the secondary survey as well.

Procedures: Depending on the severity of the trauma, the patient may require many procedures or none. It is however imperative to pre-identify who is going to perform that procedure should it be needed. At the very minimum, someone should be designated to provide airway care. While in some institutions this has been traditionally performed by anesthesia personnel, no difference exists in endotracheal intubation success rates between emergency medicine and anesthesia in level I trauma centers.^10,11 Local protocols with appropriate quality assurance should dictate control of the trauma patient’s airway. All other procedures can be addressed using the most appropriate member of the team.

Ancillary team members: Because the extent and severity of a patient’s injuries are often not clear at the beginning of the initial assessment, a mechanism needs to be in place for bringing ancillary staff into the team. These may include extra nursing personnel, respiratory therapists, and x-ray technologists. Additionally, there needs to be a method for activating operating room or interventional radiology personnel if you are in a center that will be providing operative intervention or angiography. Appropriate and up-to-date contact information for relevant consultants (ie, neurosurgeons, orthopedic surgeons) will also need to be readily available.

EMS Handoff

The communication between prehospital providers and the trauma team provides the initial information that helps to paint the picture of the real and potential injuries the patient has sustained. Because communication errors have been shown to be a common cause of preventable disability or death, transmission of information between emergency medical services (EMS) and the trauma team should be afforded dedicated time. The EMS report ideally begins in the prehospital environment. Mature EMS systems will have a mechanism through which the prehospital providers can notify receiving teams about the incoming patient using radio, cell phone, or landlines. Creating a centralized center for dissemination of this information is an ideal way to minimize the need for multiple steps in communication, which could otherwise lead to misinformation. The report need only be brief, containing information as it relates to age, mechanism, hemodynamics, injuries, and estimated time of arrival (ETA). Prenotification then allows the trauma team to make the appropriate preparations prior to patient arrival. This can include mobilizing the appropriate personnel and obtaining the equipment necessary for the particular type of injuries that may be presenting.

Once in the hospital, EMS providers should be afforded dedicated time for their report. There have been multiple studies demonstrating difficulties in the handoff between prehospital providers and a receiving team.^12,13 The reasons for this have been shown to be multifactorial but include difficulties in communicating between teams with different views, the need to perform multiple simultaneous tasks, and relaying fragmented bits of information.¹⁴

Additionally, there does not seem to be a focus on educating EMS providers as to the information deemed important to the trauma team. Because of this disconnect, trauma teams often do not demonstrate a willingness to listen and EMS providers continue to provide information that may not be beneficial for the hospital providers. Several studies demonstrate the effectiveness of educating all the involved parties in a more “formal” handover using specific data points. At the current time there are several of these with one of the most common being MIST (mechanism, injuries suspected, signs [vitals] and symptoms, treatments). MIST has been adopted by many EMS systems internationally and is also being utilized by the military for their handovers.^13,15 Other studies have shown that better data and more timely handovers occur when a more formal handover is performed.¹⁶ From a practical standpoint and unless the patient is in extremis, the prehospital handover should ideally take place prior to the patient being transferred to the hospital stretcher. This allows the entire team to focus on the EMS provider without jumping into an assessment that precludes listening. The report should be prompted to start and finish by the team leader who should be cognizant of the information being given and limit extraneous stories. Ultimately, the prehospital report should not take more than 45 seconds to 1 minute. The team leader, who can utilize a tool such as MIST to ensure that the appropriate information has been conveyed, would then direct the transfer of the patient and beginning of the assessment.

With the overarching goal of trauma care to minimize mortality and improve outcomes, the primary assessment is designed to systematically allow the team to achieve this objective (Fig. 10-1). In fact, the term “primary assessment” or “survey” is somewhat a misnomer in that the goal is not only to identify (using the ABCDE moniker) potentially life-threatening injuries but also to intervene and correct these problems as soon as they are diagnosed. With the exception of those patients with external or compressible life-threatening hemorrhage where the circulation evaluation and treatment will come before airway, the provider should follow the airway, breathing, circulation, disability, and exposure/environment approach. One can rapidly obtain a general picture of the patient’s condition by merely asking them one or two questions. Appropriate answers to “What is your name?” and “Can you tell me what happened?” will provide the team with information regarding the first four (ie, ABCD) elements of the primary survey. If the patient is not awake and alert, tactile stimulation (ie, painful stimuli) in addition to questioning may result in the patient verbalizing answers to questions. A more complete description of assessing disability and altered metal status is outlined below.

Although, the importance of physical examination is stressed continuously throughout training, what data exist demonstrates that it unfortunately has significant limitations and should take place along with the appropriate adjuncts to the primary and secondary surveys. However, while the negative predictive value of physical examination may be limited, positive findings are likely secondary to serious injuries and should be acted upon.^{17,18,19,20,21}

The airway exam begins with assessment of patency. In general, a patient who is able to speak in their normal voice does not have airway obstruction. Significant maxillo-facial bleeding into the airway or destruction in the area of the oropharynx or neck should prompt urgent airway stabilization. In the setting of penetrating trauma, where cervical spine precautions are unwarranted, merely placing the patient into an upright sitting position and allowing them to spit or suction the blood can turn an airway emergency into a situation that can be treated in a more controlled fashion. Airway stabilization should also be performed in the patient with a significant alteration in mental status (GCS ≤8). On occasion, combative patients either due to intoxication and/or head injury may require intubation in order to facilitate or complete their trauma assessment (see Chapter 16).²² If there is an early decision made to intubate a trauma patient, a brief neurologic exam should be performed prior to the administration of paralytics and sedation. Securing an airway will generally involve endotracheal intubation via rapid sequence intubation (RSI) but the team should always be prepared for a potentially difficult airway with other methods such as video laryngoscopy, flexible fiber optic intubation, or surgical airway.

The assessment of a patients breathing will depend on the severity of the injury and presentation. Auscultation of each hemithorax for absence or presence of breath sounds is a rapid easy way to begin the assessment. A prolonged multilocation exam is not necessary, as your only goal should be to identify the presence of potentially life-threatening injury such as hemo- or pneumothorax. Continuous pulse oximetry can disclose occult hypoxemia but provides no information on the status of ventilation. In the intubated patient, absence of breath sounds on the left should prompt assessment of the depth of the endotracheal tube and the possible withdrawal of the tube a centimeter or two before other interventions. Other physical findings of chest trauma, such as significant deformity, bony crepitus, subcutaneous emphysema, tachypnea, or desaturations, should prompt further study (ie, chest radiograph) or intervention, most commonly tube thoracostomy. Expanding the FAST (eFAST) exam from the traditional abdominal views to examine and screen the chest for significant pneumothoraces or pleural blood can be a useful bedside adjunct to traditional chest radiography. In the patient who presents in extremis, triage of the chest cavity needs to be more rapid and invasive. Placement of bilateral chest tubes will not only diagnose but also treat most life-threatening chest injury. Lastly, in the patient who presents in cardiac arrest, the chest can be definitively assessed via a thoracotomy (see Chapter 14).

Circulation can be rapidly assessed by palpation of central and distal pulses. Although not well studied, each location is associated with a minimal threshold systolic pressure; carotid (60–70 mm Hg), femoral (70–80 mm Hg), radial (90–100 mm Hg), and pedal (>100 mm Hg) pulses. Traditionally, this is also the time the patient would be placed on a cardiac monitor. Historically, blood pressure measurement has not been part of this portion of the assessment and as long as there is evidence of palpable radial or femoral pulses, an immediate blood pressure is not needed. If a blood pressure is to be taken, it should be done manually as the use of noninvasive BP devices may be erroneous in those patients in shock.⁸ Simultaneously, intravenous access with large bore catheters should be initiated. In the situation where intravenous access is not immediately obtainable, consideration should be made to performing intraosseous access. The intraosseous line has become more commonplace in the adult patient population and permits transfusion as well as all necessary medications (Fig. 10-2). Treatment for active external bleeding identified through these exams should begin with direct pressure. Bleeding not taken care of by direct pressure should be considered for whip-stitching or placement of a tourniquet in case of extremity arterial bleeding. Blind clamping of deep wounds is discouraged because of the proximity of nerves. Adjuncts to the circulatory exam include a rapid search for intracavitary bleeding using plain chest and pelvic radiography, FAST and diagnostic peritoneal aspirate or lavage (DPA or DPL). Identification of intrathoracic or intra-abdominal injury in unstable patients should prompt a trip to the operating room. The treatment for pelvic fracture bleeding is beyond the scope this chapter but a pelvic binder should be immediately placed in high risk patients (see Chapter 35).

The disability exam focuses on the patient’s neurologic status. The Glasgow Coma Score (GCS) should be assessed immediately upon presentation and sequentially during the resuscitation. As outlined above, a persistent GCS less than or equal to 8 should prompt endotracheal intubation. Pupillary response and overall neurologic status (movement and sensation) should be examined and abnormalities noted for early intervention. In those patients with an adequate blood pressure, presumptive osmotherapy (ie, mannitol) can be considered for lateralizing signs (see Chapter 19). It should be also remembered that generalized agitation and combativeness is also classic symptom of class III and IV shock which demands rapid evaluation and treatment. Patients who present with signs of spinal cord injury should have rapid assessment of their likely injury level. A more detailed neurologic exam, including assigning an ASIA level, should be performed in the secondary assessment (see Chapter 23).

The key to a full examination is appropriate exposure. All clothing should be removed to facilitate a complete 360-degree exam. This is recommended for all trauma cases as it contributes to standardization. Equally important, concern for keeping the patient warm should be paramount once the full exam has been completed. This includes the use of warm blankets and IV fluids.

Once the primary assessment for life-threatening injury is completed, the team should begin a more thorough and detailed examination of each body region. This “secondary assessment” is actually a complete history and physical examination whose aim is to identify all other injuries. After obtaining a full set of vital signs that should include pulse, respiratory rate, blood pressure, pulse oximetry, and temperature, the patient’s medical history should be obtained. ATLS suggests utilizing AMPLE (allergies, medications, past illnesses, last meal, events/environment/mechanism) to accomplish this.²³ Providers should then perform a complete head to toe examination that should follow the standard inspection and palpation model. Specific details on the exam of each body region can be found in ATLS and many of the issues and controversies in physical examination pertaining to specific body regions can be found in their respective chapters.

Although, the physical examination is an important component in the initial assessment, its limitations make it necessary to utilize adjunctive tests to fully identify serious and potentially life-threatening injuries. Adjuncts to the primary survey should be quick, reliable, be able to be performed in the trauma resuscitation bay and provide a high degree of specificity that positive test results are of unequivocal importance that demand attention. The primary adjuncts remain: chest and pelvic radiography, FAST or extended FAST (eFAST), and DPA (Fig. 10-3). While CT scanning revolutionized trauma care and is of undisputed importance in the complete identification of injures, we believe that physiologically unstable patients should not go to CT and therefore we consider it an adjunct to the secondary survey. While a complete review of all of these primary adjunctive modalities is beyond the scope of this chapter, the following outlines the major issues.

Chest Cardiography (CXR)

Although, not yet relegated to the historical scrap heap, the role of routine CXR has been questioned.^24,25,26 While chest CT is superior for the total identification of thoracic injuries, lost in the debate is the true purpose of the plain CXR,²⁷ which is a screening tool to quickly evaluate a patient for life-threatening conditions. In the patient with an abnormal chest physical examination (ie, tachypnea, desaturation, significant chest deformity) or hemodynamic instability, the CXR provides a rapid means of identifying hemo- or pneumothoraces, a ruptured diaphragm or the suggestion of aortic injury. Additionally, pulmonary contusions or multiple rib fractures that can be seen on the screening CXR may predict later respiratory failure and the need for admission to a monitored bed for more comprehensive care.²⁸ Lastly, the CXR confirms placement of both endotracheal and chest tubes. Thus, while routine CXR may not be warranted in every hemodynamically stable patient with a normal physical examination, it remains an integral and invaluable part of the primary survey in patients with physiologic derangements or positive physical examination findings.

Pelvic X-Ray (PXR)

Similar and possibly to a greater extent than the discussion on screening CXR, there are multiple studies demonstrating lack of utility for routine pelvic x-ray (PXR) as a standard adjunct to the primary survey.^29,30,31 This conclusion was reflected in the most recent edition of ATLS, where PXR is no longer considered a mandatory adjunct to the primary survey.²³ In our own practice, we have now focused our efforts in those patients with unexplained hypotension in which a simple intervention such as pelvic binding might be beneficial or those with obvious skeletal injuries where a hip dislocation may be considered.

Focused Assessment of Sonography in Trauma

The standard FAST exam (four views examining the pericardium, right and left upper quadrants and the bladder) has been shown to be a useful adjunct in the hemodynamically unstable blunt trauma patient (see Chapter 36).^32,33,34 Its use has essentially replaced (DPA/DPL) as the prime adjunct for triage of the abdomen in the unstable patient. Recently, however, there have been questions as to the role this modality plays in certain subgroups such as those with penetrating trauma or the hemodynamically stable patient. Multiple studies have demonstrated that sensitivity and specificity decrease significantly in the patient who is stable or may have other injuries.^35,36,37 Unlike plain radiography, the reliability of the FAST exam is related to operator experience, patient’s body habitus, underlying bowel gas, or the machine itself. The inability to get the critical views makes the scan unreliable and the examination should not be considered “negative.” Thus, in the hemodynamically unstable patient without external signs of bleeding and a “clean CXR and PXR” a negative FAST should be interpreted with caution.

The last decade has seen an expansion in the use of ultrasound to include evaluation of the thorax for pneumothorax.³⁸ The eFAST has been shown in multiple studies to be equal or more reliable in detection of pneumothoraces than CXR.^{39,40,41,42,43} Although, operator experience always comes into play with ultrasound, the eFAST has the advantage of rapidity and decreased ionizing radiation. However, the true role for eFAST in the trauma patient has not yet been clearly defined. Because the eFAST can detect occult pneumothoraces that might not be found on CXR, caution should be utilized in making decisions about a tube thoracostomy in those patients.

Diagnostic Peritoneal Lavage

Though the diagnostic peritoneal lavage (DPL) has been utilized for nearly 50 years in evaluation of the trauma patient with suspected intra-abdominal trauma, the adoption of FAST as a noninvasive means of evaluation has called some to question whether it still has any role in trauma care.⁴⁴ However as the use of FAST has become widespread, potential limitations due to patient, machine, and operator factors have become more apparent and the role of the DPL in the hemodynamically unstable patient has re-emerged.⁴⁵ We would submit that there is no longer a need for the actual lavage portion of the procedure and as currently practiced it is a direct aspirate of the peritoneal cavity designed to look for gross blood in the face of hemodynamic instability. Eliminating the lavage mitigates some of the reported disadvantages to the DPL including lack of ability to repeat the study, possibility of altering/skewing CT or ultrasound results with installation of fluid and high negative laparotomy rate due to its inherent sensitivity. We strongly believe that DPA should not be eliminated from the trauma surgeon’s armamentarium. In those instances where the FAST is “negative” in a patient with unexplained hypotension, a DPA should be strongly considered a part of abdominal triage.

CT Scanning

With significant improvements in technology, CT scanning of the trauma patient has become ubiquitous. As an adjunct to the secondary survey, for the hemodynamically stable patient, there is no doubt that modern CT scanning provides the most accurate means of injury identification over a broad spectrum of possibilities. There is some evidence that the liberal use whole body scanning identifies clinically significant abnormalities.^46,47 An additional advantage of the “pan-scan” is the ability to discharge patients safely when the scan is negative.²¹ There should however be some caution in liberally and routinely prescribing total body CT scans for all trauma patients. In addition to the cumulative radiation over a patient’s lifetime, there is risk for contrast-induced nephropathy, especially in the geriatric trauma patient.⁴⁸ The provider should take into account all factors, such as mechanism of injury/suspected injury, cooperation of the patient, clinical exam findings, and patient flow, when making decisions as to what scans are needed.

Laboratory

Although, there are multiple studies that demonstrate a low utility for certain standard screening laboratory panels in trauma patients, there may be some tests of value depending on the nature of the trauma.^49,50,51 Although, decisions as to appropriate testing can be made based on the severity/perceived severity of the patient, it is often useful to have a “trauma panel” that includes a CBC, coagulation profile, and alcohol level. Point of care testing should be considered as the results are more rapidly available. All patients should have a type and cross match sent. After that, there may be some utility in obtaining an arterial blood gas in those patients meeting the highest level of trauma activation.^52,53,54,55 This should ideally be able to provide the standard values like pH and base deficit but lactate as well. A venous lactate may also provide similar information.⁵⁶ For those in shock, TEG/Rotem have shown some promise in helping guide resuscitation.^57,58

Medical Record and Performance Improvement

With increasing emphasis on short- and long-term outcomes, clinicians taking care of trauma patients should create performance improvement methodology which allows for a thoughtful analysis of each trauma encounter. It should include review of the team’s performance during the initial assessment and management of the trauma patient and can begin with identification of appropriate triage of the trauma patient. Flow in the trauma bay, specifically evaluating times to accomplish certain tasks (ie, movement to the operating room or interventional radiology) and timely response of consultants can also be measured. While there is no perfect system of recording the events in the trauma bay, the backbone of most PI programs is the trauma flow sheet. These should be completed in sufficient detail that allows the trauma center staff to do a thorough review of any case. As the primary individuals responsible for charting are the trauma nursing staff, seeking their input in the creation of an institution’s trauma flow sheet is invaluable.

First described in 1988, Trauma Video Review has been utilized in many institutions (Fig. 10-4) and found to be an effective performance improvement tool.^59,60,61 Although, there are medicolegal considerations to its use, trauma video review provides an opportunity to improve performance by highlighting team cooperation, error identification, and educating the entire trauma team.

The importance of the initial assessment cannot be overstated in that it sets the tone for the entire encounter. Recognition and treatment of life-threatening injury form the basis of the initial assessment of the trauma patient. Understanding the multiple elements that go into the successful performance of the initial encounter with the trauma patient will result in optimal outcomes.