First aid: Prehospital care

In the first of a series about first aid, Martin S Roth and colleagues concentrate on prehospital assessment

It is Friday night. After a long, hard week of studies you think that you deserve a break and want to have a good time with friends. While walking along the road, you come across a crowd of people staring at a motorcyclist who is lying on the ground after a crash. Your friends look at you--a medical student. They are obviously under the impression that you know exactly what to do in an incident like this. Do you?

First aid is the immediate care given to an injured or ill person before they are attended to in a hospital or clinic. Traditional under-graduate teaching in management of trauma begins in the emergency department. But medical students are just as likely as anyone to come across an incident such as the one described above. Trauma is the commonest cause of death in the 1-39 age group and has a trimodal distribution (see table).

To reduce deaths in the second and third phases, early treatment must be given. This early period is known as the "golden hour" and is the time before irreversible patho-logical changes begin. The golden hour is usually from the time of injury to definitive management--for example, surgery. In prehospital management, the "platinum 10 minutes" are most important in all emergencies where the victim is not trapped (box 1). The basic principles of treatment in prehospital care are based on a systematic approach (box 2).

Approaching with caution

The first aspect to be taken into account is without any doubt the most important--your personal safety. If you overlook this, you run the risk of injuring yourself. This is why you must evaluate the scene as a first measure.

Before approaching the patient, you must check the situation carefully. If the person is in the middle of a road, try to divert the traffic before attending to them. Is there more than one injured party? Are there vehicles involved? Is there fuel leakage? Are there any fallen electricity wires? Is the person trapped? In this case firefighters should be called.

You do not run risks only in the street, however. You must also make sure you are safe when you go into a house. What if there is more than one injured person inside and nobody answers? It is probably not advisable to go in for a number of reasons. Or if there are any dogs, you should wait for the owner to tie them up.

You must ask yourself if the conditions are safe enough for you. If the answer is no, you must first take the necessary measures to make it safe. By observing the scene, you will also have a better idea about the possible injuries.

Quite often, when someone has been injured or collapsed, a crowd of onlookers will gather. Make use of them and ask them to alert the emergency medical services. Choose one of the onlookers by pointing to them and ask them to call an ambulance. You should also ask them to tell you if they were successful. You must also move the prying crowd away from the injured person. You can now approach the person. But try to keep calm at all times, and think before acting. If you do not know what to do, then do nothing.

Other important points are not to move the injured person unless it is absolutely necessary; if the person is inside a vehicle do not take them out; watch out for airbags--they might have not been activated; do not give the person anything to drink; keep them warm to avoid temperature loss; and use disposable gloves.

Patient assessment: the primary survey

The primary assessment of the patient allows you to identify life threatening disorders systematically using the "ABCD concept." Once a threat is recognised, it must be treated before the next stage is started. As with any physical examination, it should be thorough and methodical.

Check if the person is conscious. If they do not move then exert pressure on the supraclavicular cavity to find out if they respond to pain. Never shake the person. If they respond, introduce yourself and calm them down, speak to them constantly, and ask them to move their limbs. Examining a conscious and lucid person is much easier because they can indicate any pain.

Observe the person's attitude. Are they in pain, anxious, or hostile? Observe their skin complexion, lips, and mouth. Are they normal, cyanotic, erythematous? If the person is unconscious, do ABCD:

• Airway--Check the airway is patent. The neck in the injured patient can be controlled at the same time by gentle inline stabilisation. Open the mouth to check that there are no foreign bodies. If the victim is not breathing and there is no hint of cervical damage, hyperextend their head
• Breathing--Put your ear close to the person's nose, and observe their thorax, check if it heaves, check breathing, and feel their breath. Give oxygen if available
• Circulation--Check the pulse. Look for haemorrhages, and stop them if you find any
• Disability--This is a quick assessment of the neurological status. Use the "AVPU system" in the primary survey: A=alert, V=responds to voice, P=responds to pain, U=unresponsive.

Secondary survey

This is E for exposure. A limited quick top to toe survey can help to identify life threatening fractures and occult bleeding points. Verify pos-sible existence of broken bones or any other injuries from head to toe leaving the details of minor fractures, lumps, and bruises for the emergency department. If you find any, clothes should be taken off to enable closer examination. If a critical emergency has been identified during the primary survey there may not be time to do this part - there should never be a hold up in a prehospital situation for a secondary assessment.

Eyes--Observe the size of their pupils, their symmetry, and their response to light.

Nose and ears--The presence of blood or cerebrospinal fluid are signs of fracture of the base of the skull. The other two signs that show this diagnosis are "raccoon" eyes and haematoma in the mastoid region.

Mouth--You should have already examined the victim's mouth in step A, but now in a thorough examination you should check for blisters, burns, or spots. The existence of the latter can be a sign of poisoning.

Head--Haematomas and skull asymmetry can indicate the presence of fractures. Trauma of the skull increases the possibility of vomiting, with which the person risks compromising their airways.

Thorax--Explore the ventilation symmetry and explore their rib cage to check for possible fractures.

Abdomen--Painful or hard regions can be an indication of haemorrhages or organ damage.

Pelvis--Hip fracture is indicated if you press the iliac crest from lateral to medial between your fists and the distance between them decreases. Its presence should alert you to a pos-sibility of a haemorrhage--the person may lose more than one litre of blood.

Once you have examined the person and if there are no signs of bone damage, you should lie them down on their side to avoid a possible accumulation of secretions or blood in their mouth.

During the secondary survey it is also important to get medical details of the person briefly using the "AMPLE pneumonic"--allergies, medication, previous medical history, last meal, events leading up to the emergency.

JOHN CALLAN/SHOUT PICTURES
Managing an injured person at the scene can be dangerous

It is important to take into account that this is a dynamic process. A conscious breathing person may cease to be at any time. That is why you have to be especially careful if the person is unconscious--check them. And remember that all information gained in the prehospital environment must be passed on to the receiving hospital.

These articles only intend to introduce first aid--they cannot and do not replace a complete course.

Martin S Roth, first year anaesthesia resident, Hospital Italiano de Buenos Aires, Argentina
Email: martinsroth2828@hotmail.com

Fabian J Garcia, resident instructor, Isabel Pincemin clinician, Hospital Municipal de San Isidro

Anabella Fernandez, medical student,

Matias Garcia, medical student,

Alejo Texo, medical student,

Nicolas Roth, medical student, Universidad de Buenos Aires

Dr Samena Chaudhry, SHO in Accident and Emergency, University hospital North Staffordshire


studentBMJ 2005;13:45-88 February ISSN 0966-6494

       

           

Responses published this month Articles Responses EDUCATION First aid: Prehospital care       Martin S Roth et al. (February 2005) Awad Al-Beshray (February 18, 2005) Read this response EDUCATION First aid: Prehospital care       Martin S Roth et al. (February 2005) Pumi Senaratne (March 11, 2005) Read this response EDUCATION First aid: Prehospital care       Martin S Roth,Fabian J Garcia,Anabella Fernandez,Matias Garcia,Alejo Texo,Nicolas Roth,Dr Samena Chaudhry (February 2005) Henry Sullivan (May 15th, 2006) Read this response EDUCATION First aid: Prehospital care       Martin S Roth et al. (February 2005) Awad Al-Beshray (February 18, 2005)       2nd year medical student, Al-Qassim Medical School awa733@hotmail.com Editor, One day, my neighbour asked me for a medical counsel. He showed me his indix finger which was burned and said I have a cream (and he showed me that cream)and I want to put some on my finger, what do u say about it? He knew I'm a medical student but the problem is that at that time I was not even acquainted with the anatomy of hand! Thankfully, he got my point when I said u better visit the dermatologist in the neighboring PHC. In medical school, the first three years are far from medicine and patients' needs. All what you study is some preparing subjects so that once you go to clinical phase you can handle it. But, unfortunately, people do not understand this and once you are admitted to a medical school then you have to know everything related to medicine! The only way, in my opinion, to deal with such embarrassing situations is to prepare yourself by self-education with the concept in mind that I'm just a medica student and it's not shame to say I don't know whenever you are faced with unexpected accidents. EDUCATION First aid: Prehospital care       Martin S Roth et al. (February 2005) Pumi Senaratne (March 11, 2005)       A level student, Colchester County High no_boundaries4me@hotmail.com I have only once come across an actual emergency and I was successful in handling the situation. Yet I always feel unsure whether or not I should help if I encounter another situation because, although I am a qualified First Aider, I am only an A level student. The fact that worries me is that there have been several incidents where First Aiders have helped yet failed to save lives. This, to the casualty's family/friends appears to be the First Aider's fault, even though it was unavoidable. I feel confidence itself is insufficeint in these situations. Yet I'd rather not leave with a guilty feeling that I could have helped. EDUCATION First aid: Prehospital care       Martin S Roth,Fabian J Garcia,Anabella Fernandez,Matias Garcia,Alejo Texo,Nicolas Roth,Dr Samena Chaudhry (February 2005) Henry Sullivan (May 15th, 2006)       A-level, Truro College, Truro hsullivan16@msn.com This was a very informative article - being clear and straight to the point. This is mainly in response to the feedback aimed at the other A level/first aider. I have been a First Aider for St. John Ambulance for several months. I have also been in the same situation as you a few times and, also feel that if someone did need resusitation I might think twice. You should never feel forced or pressured into acting just because you are a First Aider, especially when it comes to a person's life. Yes, we have the skills, but that doesn't always mean we have to use them if we don't feel confident. There are professional people who are paid to do this type of thing.