I teach a lot of First Aid Courses these days but, bizarrely, I don’t actually do a lot at the minute. Recently, while I was out and about in Cumbria, I came across a casualty on the street, and it was an encounter that reminded me of a few things I’d forgotten.
I was on my way to town with my toddler in the car when I saw a group of people on a pavement gathered around somebody collapsed on the ground.
I parked the car in a way that allowed me to see both my son and the casualty, and I approached the huddle.
“I’m a First Aid instructor. Can I help?”, I asked.
Indeed, I could. An elderly lady had fallen and had what I suspect turned out to be a fractured hip and wrist, and possibly (but probably not) a lower leg injury too.
It was a fairly straight-forward one to deal with – the casualty was clearly responsive and breathing and an ambulance had already been called.
I made sure the casualty was warm (it was a cold day), made sure she was being properly monitored, and ruled out anything immediately life-threatening like major bleeds and so on. Then, it was just a case of immobilising the potential fractures, reassuring the casualty and wondering when the bloody ambulance was going to get there!
Other than teenage aches and pains, it was the first serious First Aid casualty I had dealt with for a while. It reminded me of a few things that I thought were probably blog-worthy:
Thing One: Too many Chiefs, not enough Indians!
When I arrived there were three or four people gathered round. None of them seemed to have that much training, although they had had the presence of mind to reassure the casualty, call 999, and get a load of blankets to keep the her warm.
Once I turned up, they were happy to defer to me, which made sense. Likewise, when the two nurses turned up with their kit, I was happy to defer to them. The person with the most expertise should always call the shots. I gave them a quick hand-over summary of the situation and stood back in case they needed me, which they didn’t.
Because I had my son with me, I asked the nurses if they were okay with me leaving. They were, so I did.
In between the nurses arriving and me leaving, an off-duty copper turned up, flashed his badge and started doing his own thing independently of the two nurses. All rather odd
The situation required no law enforcement, no peace-keeping, and no major incident management. In short, much as I like the police, the situation really didn’t need Old Bill, and the guy in question, though he clearly had some First Aid, had nothing like the skill-set of the two nurses who were already managing the scene. He didn’t even seem to have my level of knowledge, and I was already standing well back.
(Some coppers – e.g. firearms – have a good level of First Aid knowledge – often FPOS/ FREC3 – but most just have fairly basic training)
The Nurses were on the phone to Ambulance Control and were getting good direction from them. They too (and I say this presuming they’re not trauma/ emergency specialists) also knew when to defer.
I got a little annoyed at them for not reining in the copper though, but I do realise that telling a policeman to wind his neck in is easier said than done.
It reminded me that at every scene there is a need for the most experienced, skilled person to take charge and to (politely) let everyone know that it’s not a free-for-all.
If a paramedic, doctor or nurse is on scene, they are in charge. If not, ambulance control are in charge and the most experienced person on the scene takes the lead on the ground. If nobody on scene has any real skills then the person on the phone really should call the shots, relaying advice from the Ambulance Service.
I say all that, of course, realising that if you don’t have any First Aid training, then it’s unlikely you’ll also be able to think about managing the wider incident, but for First Aiders, there’s a useful lesson:
Anyone with skills and training needs to make sure that everyone knows who is calling the shots and needs to make sure that other people aren’t just independently doing their own thing.
When you arrive at a scene where other people are already trying to help, tell people what your training is and ask if you can help. If you’re the person with the most experience, take charge. Be polite, but be firm. If not, support the most experienced person.
Thing Two: Don’t Panic – Remember Your Training!
When I got to the scene I initially made a rookie mistake!
One of the people already attending the casualty told me that the lady had fallen and hurt her hip, so immediately, I thought “okay right… possible broken hip… err… yes… immobilise… call EMS… okay, EMS is called… What next?”
Then I remembered!
The Primary Survey always comes first.
For a moment – really only about five seconds – I forgot the very basics! Luckily my brain soon caught up:
“Okay, danger? No dangers. That’s good. Response? She’s clearly alert. Good again. What about Airway? And breathing? Okay, they’re good too. Any major bleeds? Not that I can see. Okay…”
Then, I could start to move on to the secondary stuff, including treating the presenting condition.
The problem is, doing something for real is different to doing it theoretically in your head, or acting it out in a classroom. Even, it turns out, for instructors. And even though this was by no means my first time at the dance, so to speak, that distinction still remained.
Point being – remember your training.
Primary Survey first. Depending on skill levels, it will be different for different people, but for most people, it’s DRABC.
If the patient is unresponsive and not breathing normally, call EMS, send for an AED, and start CPR.
If the patient is unresponsive and breathing normally, do a secondary survey, treat what you can, and put the casualty in the recovery position. Monitor them. Especially the breathing. Monitor the breathing constantly. Really, constantly.
If the primary survey shows the patient to be responsive and breathing normally, ask for their consent and then treat as appropriate, again doing a secondary survey to the extent that it’s appropriate.
In all cases, remember infection control (gloves, barrier devices for CPR breaths), monitor, reassure, and get some information together – even if only in your head – so you can hand over to EMS.
Take a breath. Take a moment to remember your training. Don’t just dive in.
DISCLAIMER – the actions noted above are not an exhaustive list and this blog post is not a First Aid course designed to teach you! It’s here to make a few points to already qualified First Aiders.
Thing Three: Ambulance Response Times are Annoying, but There’s Not a Lot You Can Do!
The man who called the Ambulance was told that there would be a two hour wait. Since the patient was breathing, she wasn’t a priority, and resources had to be allocated accordingly.
The Ambulance Service operates a system of response categories, designed to sift out the most urgent calls from the less urgent ones, and despatch resources appropriately.
Basically (and this is the very rough version) Category 1 is for those who are going to die within minutes if they’re not attended to. Cardiac arrests, for instance. Category 2 is for those who are still in danger of death, but not so imminently. Strokes, and chest pain. Categories 3 and 4 are for people who need hospital care, but aren’t in immediate mortal danger.
The lady on the pavement wasn’t in any immediate danger of death (they probably put her as Cat 3) so we had to wait. I say ‘we’, but since I had my son with me, I didn’t end up seeing the ambulance.
It’s always tempting when something is taking a long time to try to game the system. It was tempting to find a reason to hurry the ambulance up. Was her breathing suspiciously laboured? Did she mention a pain in her chest? Was her level of responsiveness deteriorating?
None of those things were the case, of course, but it was tempting to tell Ambulance Control that they were.
One thing I’ve learned over the years is how to make the Emergency Services hurry up. But here’s the thing – it’s not a very nice thing to do!
The response categories are there for a reason, and if I pretend that somebody is in category 1 or 2 when they’re not then I might divert resources away from a real Cat 1 or 2, and those are the folks who could well die if they don’t get an ambulance quickly.
So, don’t tell porkies to Ambulance control. Tell the truth and, if you have to wait, wait!
Doesn’t stop you writing to your MP about the terrible Ambulance waiting times, mind!
Thing Four – Sometimes First Aiders Can’t Give the Situation 100%
For a few minutes, until the nurses turned up, I was the most competent person on scene, but I also had my son with me.
He was quite happy in his car seat, and he wasn’t in any danger, but as a parent, he has to be my priority when I am responsible for him. His needs at that moment were less acute, so he didn’t get more attention than the casualty, but his presence did mean that I couldn’t give her my full-and-undivided.
How many times have you been in a First Aid class and been told “okay, we’re going to practice the Primary Survey, but this time I want you to imagine that you’ve got a small toddler with you who is in your sole care. Off you go…”
Doesn’t really happen in classes, but it does in real life.
Classes are great, but they can’t teach every scenario, and one thing that we don’t teach is that sometimes you can’t give 100% to a casualty.
At JRA, we talk a little on our paediatric courses about how to respond to an incident when you’re in charge of other children, but only fairly briefly.
So, what do you do if you already have an important responsibility?
Well, there’s no clear formula. As the First Aider, you need to figure it out for yourself. You need to balance the needs of one thing over the other.
As a parent or teacher, for instance, you have a clear responsibility which must come first. As a passer-by who knows some First Aid, you might feel you have a moral responsibility to help, but you don’t have a legal one.
On the other hand, if somebody needs CPR and nobody else around is able or willing to do it, can you really pass that up? What could happen to the children in your charge if you get involved?
Obviously that depends on the ages of the children, their specific needs, the dangers of where you are, and so on.
As I say, there’s no precise formula. You need to make your own assessment of what you see in front of you.
I chose to position my car so I could see my son. I then locked the car. With him secure, he wasn’t going to come to any harm, and he could see me so he wasn’t going to get upset. Happily, that meant I could attend to the casualty quite well, and my son didn’t seem to mind the slight detour to his day.
And, So… What’s My Point?
Real life First Aid is different to the classroom in some ways. In other ways, not so much. The next time you’re with a real casualty, just stop, take a breath and think things through. You’ll get there!
John, Lead Trainer