In all first-aid situations, the rescuer must remain calm. If you panic, you will lose control of the victim, as well as of yourself. To establish authority, speak and act calmly and purposefully. Allow the victim to discuss the incident, his situation, and his fears. If you can involve the victim in his rescue and treatment, it is often good for his morale. Try not to be judgmental, and save criticism for after the event. Avoid laying any blame on people; they may get hurt emotionally or become argumentative as a result. When communicating with a victim and bystanders, remember that you are not only caring for the victim, but in many ways, for family and friends. It is important to communicate frequently, honestly, and in a manner that is reassuring and inspires cooperation and hope.
Do not endanger additional inexperienced rescuers. If you cannot get to the victim easily, send for help. Approach all victims safely; don’t allow the sense of urgency to transform a sensible rescue into a series of risky, or even foolhardy, maneuvers. If it appears that the victim is too ill to be moved, set up camp immediately. In all cases, protect the victim from the elements from above and below.
If you have paper and a writing instrument, record your observations. If you send someone for help, have him carry a piece of paper that states the victim or victims’ location, the nature of the emergency, the number of people needing help, the condition of the victim(s), what is being done to treat the victim(s), and any specific environmental conditions or physical obstacles. Accident report forms are available from organizations such as The Mountaineers.
Always assume the worst. Assume that each victim you encounter has a broken neck or has had a heart attack until proven otherwise. Always be conservative in your treatments and recommendations for further evaluation or rescue.
Never move a seriously injured victim unless he is in danger from the environment or needs to be moved for medical reasons. Don’t encourage a victim to get up and “shake it off” until you have examined him for a potentially serious problem.
If you must remain in a wilderness location for a prolonged period of time caring for a victim, remember to attend to the basic survival requirements, which include air (oxygen) for breathing, shelter, water, food, psychological support, and human waste disposal.
Never administer medicines or perform procedures if you are not sure what you are doing. The good Samaritan has certain legal protections for his actions so long as he operates within prudent limits and takes reasonable care. This book will not make you a doctor. A good rule to follow is primum non nocere: “First of all, do no harm.” If you are not certain what to do and the situation isn’t worsening, don’t interfere. Explain to the victim that you are not a physician, but will do your best to get him through whatever crisis he has encountered, to the best of your knowledge and ability. If you encounter a victim who may be seriously ill, seek an expert opinion as soon as possible. Even if your treatment seems successful, it is wise to consult a physician if you would have ordinarily done so.
Listen to the patient. The story of what happened and the medical history can be extremely important in making swift and appropriate medical decisions. Let the victim tell you what happened in his or her own words, and try not to interrupt unless it is important. If a victim has a sprained ankle, a comprehensive discussion may not be necessary, but if it is appropriate, try to elicit the following:
Current illness: What happened? When did it happen? Why did it happen? If the victim is suffering pain, describe its location, time of onset, whether it came on suddenly or gradually, whether it comes and goes, its quality (dull, sharp, cramping, etc.), how it is made worse or relieved, and whether the victim has suffered anything similar before (and if so, whether there was a medical diagnosis). Have the victim describe all symptoms, such as nausea, vomiting, diarrhea, blurred vision, shortness of breath, fatigue, cough, and so on.
Prior illnesses and preexisting conditions: Have the victim describe any previous illness (heart attack, asthma, pneumonia, meningitis, etc.) and any current conditions (diabetes, anemia, abnormal heart rhythms, etc.) and how they have been and are currently being treated.
Surgeries: Have the victim list any surgical operations, such as appendectomy or knee surgery.
Allergies: This includes allergies to food, plants, insects, and medication(s) and the nature of the allergic reaction(s).
Immunizations, exposure to communicable diseases, foreign travel, recent dietary history: Any of these may be appropriate if the victim is perhaps suffering from an infectious disease, including food poisoning or toxic ingestion.
Review of systems: This is a comprehensive questioning about each organ system to determine if the victim has or has ever had symptoms referable to each system:
Head: headache, dizziness
Eyes: blurred vision, double vision, decreased vision, discharge, pain
Ears: decreased hearing, ringing in the ears, discharge from the ears, pain
Nose: nosebleeds, difficulty breathing, nasal discharge, sinus infection
Throat: sore throat, foreign body sensation, tonsillitis, hoarseness or difficulty talking, painful swallowing, difficulty swallowing
Dental: tooth loss, abscess, dentures
Neck: pain, decreased range of motion, arthritis
General: fever, chills, weakness, unintentional weight loss or gain, dizziness, history of intravenous drug use
Chest (lungs): difficulty breathing, shortness of breath, wheezing, cough (productive of sputum or nonproductive), coughing blood, history of tobacco use
Heart: palpitations, pressure-like sensation in the chest, chest pain
Abdomen: pain, mass
Gastrointestinal: nausea, vomiting (describe what is vomited), diarrhea (describe consistency), red blood in stools or dark black stools, yellow skin (jaundice), perianal itching, constipation, excessive gas, bloating, belching
Hematologic/immune: anemia, frequent infections, exposure to human immunodeficiency virus (HIV)
Genitourinary: change in frequency of voiding, painful urination, discolored or malodorous urine, back pain, blood in urine, history of sexual contacts, penile or vaginal discharge, date and character of last menstrual period (normal, abnormal), vaginal bleeding
Neurologic: seizure, weakness in any body part, numbness or tingling of any body part, difficulty with coordination or walking, difficulty with speech or comprehension, fainting
Muscular: muscle cramps, weakness, incoordination, pain
Psychiatric: abnormal thinking, hallucinations (visual or auditory), desire to hurt self or others, inappropriate crying or laughing, depression
SECURE THE SCENE
Be certain that you, the victim, and other rescuers are protected from inclement weather, lightning, rockfall, avalanche hazard, and so on. Create a shelter or assign someone to this task as soon as you can. Retreat from a venomous snake, a swarm of stinging insects, the edge of a swiftly flowing frigid river, or the like.
EVALUATE THE VICTIM
Immediately determine if the victim is breathing, if his heart is beating, and if he has any obvious major injuries. Techniques and procedures for treatment are covered in Part Two.
Look, listen, and feel for breathing (Figure 1). Put your ear close to the victim’s mouth and nose, and try to detect if he is moving air into and out of his lungs. Watch for chest wall motion. Determine if a victim is breathing by listening and feeling for air movement around the mouth and nose and observing the chest for unassisted rise and fall. In cold weather, look for a vapor cloud or feel for warm air moving across your hand. If the victim is not breathing well (or at all), you must manage the airway (see page 22) and begin to breathe for him (see page 28), taking care to maintain the position of the neck if there is any chance of a cervical spine injury (see page 37). Observe the number of breaths per minute; normal is 12 to 18 per minute for adults, 18 to 25 per minute for small children, and 25 to 50 per minute for infants.
Characterize the nature and effort of breathing. Look to see if breathing is effective—the chest expands and air movement is appreciated. Observe if the victim is laboring to breathe. In an adult, if the breathing rate is less than 10 or greater than 30 breaths per minute, the skin color is blue, or the victim is confused or unconscious, be prepared to assist breathing (see page 28).
If the breathing is noisy, rattling, or “musical” and high-pitched, suspect an airway obstruction (see page 23), particularly if the victim is lying on his back. If the victim has a loose denture or another dental appliance, remove it. If there is no chance of a cervical spine injury (see page 37) and it appears that the victim may vomit, position him on his side. If you are concerned about a neck injury, use the logrolling maneuver (see page 39).
Near the condition of death, a person may show “agonal respirations,” characterized by infrequent mouth openings without any chest rise, sometimes accompanied by head lifting.
Feel for a pulse. Current American Heart Association guidelines advise laypersons to begin chest compressions without going through a pulse check on victims who are not breathing and who do not show any sign of life. Basic life support may also be initiated by checking for a pulse. Place the tips of your index and middle fingers (not your thumb, which can generate a “false” pulse—your own!) gently on the radial artery in the wrist (see Figure 16, C, page 33). If you cannot detect a pulse there (particularly if your fingers are cold), move your fingers quickly to the brachial artery (this is particularly useful for infants) at the midpoint of the inside of the upper arm (see Figure 16, E,page 33), the femoral artery in the groin (see Figure 16, B, page 33), or the carotid artery in the neck (see Figure 16, A, page 33). If no pulse is detected in any of these locations (and the victim is not breathing or verbalizing), begin chest compressions (see page 32). Observe the pulse rate; normal is 55 to 90 per minute for adults, 80 to 110 per minute for small children, and 100 to 130 per minute for infants. The pulse rate is faster with excitement or fear and slower in trained athletes. A rapid and weak (“thready”) pulse is a sign of impending shock (see page 60), usually due to excessive bleeding, dehydration, or heart problems. An irregular pulse may indicate an abnormal heart rhythm.
Locate brisk bleeding. Quickly survey the victim to locate any obvious sources of brisk bleeding. Quickly apply firm pressure to these areas (see page 54).
Once you have dealt with these life-threatening problems, begin a careful, complete examination of the victim.
If an injury may be extensive, examine the whole victim. Particularly dangerous situations include falls; blows to the head, neck, chest, or abdomen; altered mental status; difficulty breathing or shortness of breath; and injuries to children. In these cases, or whenever the diagnosis is not readily apparent, evaluate the victim from head to toe. Weather and appropriate modesty permitting, be sure to undress the victim sufficiently to perform a proper examination. Look around the neck or on the wrist(s) for a medical alert (such as MedicAlert) tag, and in a wallet, helmet, or pack for an information card.
Because most bodies are bilaterally symmetrical, if you are having difficulty determining if a body part is abnormal or deformed, compare it to the opposite side. Always ask a victim to move a body part before you do it for him; if he resists because of pain or weakness, you need to suspect a broken bone or spinal cord (nerve) injury. Do not “force” a motion.
Take as much time as you can afford to explain to a victim what you are going to do. This is usually reassuring. If the victim is a child, it is important to make eye contact, and to be continually supportive. If someone is doing or has done something with which you don’t agree, make any argument or criticism out of earshot of the victim. If the examiner is opposite in gender to the victim, try to have a same-gender witness (chaperone). When examining a victim, keep talking to him. Closely observe for indications of discomfort or pain.
1. Check the victim’s mental status. If he is awake, determine if he is oriented to time, place, and person. (“What is the date? Where are you? Who are you?”) If the answers are in any way abnormal, suspect a head injury, intoxication, stroke, central nervous system infection (such as meningitis), hyperthermia, hypothermia, severe altitude illness, low blood sugar, or hypoxia (insufficient oxygen to the brain). Maintain constant observation of the victim until all of his responses are appropriate.
2. Examine the neck. Without turning the victim’s head, feel each cervical vertebra from behind and note tenderness or muscle spasm. The seventh vertebra will be the most prominent. Check for swelling. Feel the Adam’s apple in the front of the neck for tenderness or a “crunching” sensation (noted by both the examiner and victim). If there is a chance of neck injury, immobilize the neck (see page 37).
3. Examine the spinal column. Run your fingers down the length of the spine to elicit any tenderness. Check for spinal cord injury by having the victim voluntarily move his arms and legs and report his sense of feeling. Ask the victim to squeeze your hand with each of his, and then to “press down on the gas pedal” with each foot against your hand. Pinch the skin on the back of the hand and top of the foot as a crude measure of sensation. If any response (hand-to-hand or foot-to-foot) is asymmetrical, suspect a spinal cord injury or stroke (see pages 37 and 144).
4. Examine the head—but try not to move it. Feel the entire scalp for raised areas or cuts. Look into the ears for drainage (clear [spinal] fluid, blood, or pus). If there is blood, capture some on a white absorbent cloth or gauze pad. If the blood forms a ring, with a faded or yellow area toward the center, this may indicate the presence of spinal fluid. Feel the nose for obvious malalignment or instability. Look up into the nostrils. If you have a flashlight, shine it into the eyes to see if the pupils constrict and are equal in size. If you don’t have a flashlight, cover the eyes and then uncover them to see if the pupils constrict. Pinpoint (constricted) pupils may be a sign of brain injury or drug overdose. Unequal pupils may represent a direct injury to an eye or a brain injury. Nonreactive and bilaterally dilated pupils may represent a severe brain injury. Ask the victim to follow your fingers with his eyes; if this cannot be done, if the eyes do not move together, or if he reports blurred or double vision, there may be a problem. If the eyes are spontaneously jerking or wandering, this may also indicate abnormality. If the victim has contact lenses, he may require assistance with their removal (see page 183).
Figure 1 Look, listen, and feel for air movement.
Have the victim open and close his mouth to see if the teeth fit properly. Check the teeth for absence, looseness, or breaks, and the tongue for cuts. Ask the victim if he can swallow. Ask him to say “Ah” and see if you can get a glimpse of the back of his throat. Smell for any unusual odor on his breath. If dentures are loose, remove them. Smell the victim’s breath to detect any abnormal odor (e.g., alcohol or “fruity” breath associated with severe diabetes).
5. Examine the skin. Look for sweating, skin color (normal may—and pale does—indicate inadequate circulation; dusky blue indicates hypothermia or shock; reddened indicates heat illness or sunburn; yellow indicates liver disease; mottled indicates low blood pressure, shock, or massive infection), bruises, rashes, burns, bites, and cuts. Note the skin temperature. Look inside the lower eyelids for a pale color that might indicate anemia or internal bleeding. If you pinch the skin on a victim’s forearm and it remains “tented” and loose, the victim may be dehydrated.
6. Examine the chest. Observe whether the chest expands fully and equally on both sides with breathing. Feel the chest wall for tenderness and inspect for deformation or embedded objects. Place your ear against each side of the chest to listen for breath sounds.
7. Examine the back and abdomen. Gently press in all areas to elicit tenderness. Examine the buttocks and genitals.
8. Examine all bones. Gently press on the chest, pelvis, arms, and legs to elicit any tenderness. Run your fingers down the length of the clavicles (collarbones) and press centrally where they join the sternum. Trace each rib with your fingers. Look for deformation or discoloration.
9. Take a temperature. Use a digital, mercury, or alcohol thermometer, if possible one that can detect hypothermia or hyperthermia, depending on the circumstance. Rectal temperature measurement is more reliable than oral or axillary (see page 167) measurement, but may be impractical in the field. Always shake down a mercury or oral thermometer, and hold it in place for at least 3 minutes to obtain a reading. Do not rely on skin temperature to accurately reflect changes in the core temperature.
Send for help early. As soon as you have determined that a situation will require extrication, rescue, or advanced life support, initiate your prearranged plan for communication and transportation. Don’t assume that someone will call for help; you must assign this task to a specific individual.
If you are in a situation where you can access the emergency medical service (EMS) system (911 or other telephone number), be prepared to provide the following information: the victim’s location, your phone number, the nature of the emergency, the number of people needing help, the condition of the victim(s), what is being done to treat the victim(s), and any specific environmental conditions or physical obstacles. Speak slowly and clearly, and don’t hang up until the dispatcher tells you he has all the information he needs.
While you are waiting for help to arrive:
1. Take an adequate history. Listen carefully to the victim; in most cases, he will lead you to the affected organ system. Inquire about allergies (especially to medications), previous surgeries (for instance, if he has had his appendix out, he can’t get appendicitis), previous illnesses, medications, and the current event.
2. Reassure the victim. Most disorders are not life-threatening and will allow you plenty of time to formulate a treatment plan. Be sure to introduce yourself to the victim, and explain what you are doing in a direct fashion. Avoid making comments such as “Oh my God,” “This is a hopeless situation,” or “Whoops!” Let the victim know that you are capable and in charge. Accentuate the positive aspects of the situation, to build a climate of hope. Do not argue with other rescuers in the presence of the victim. Be particularly gentle, parental, and reassuring with children. Always warn the victim before you do anything that might cause him pain.
3. Keep the victim comfortable and warm. Do not feed a victim who cannot purposefully swallow. If he can eat and drink, offer water, clear soups, and clear juices. Use Oral Rehydration Salts (see page 208) or an electrolyte-containing sports beverage to maintain hydration. Avoid coffee, tea, and other caffeinated beverages.
4. Keep a written record of all medications given. If possible, also record symptoms and objective measurements (such as temperature) with times noted.
5. Remove all constrictive clothing or jewelry from any injured areas. If the victim has a hand wound, all watches and rings (see page 477) should be removed before swelling makes doing so impossible. In particular, rings left in place can become inadvertent tourniquets on swollen fingers.
Always reexamine and reevaluate a victim at regular intervals. A person may not experience difficulties until after a time delay, particularly if the problem is related to a head injury or internal bleeding. If you are concerned enough about a person to examine him once, wait a while and then examine him again. The interval between examinations is determined by your level of concern. For instance, someone with possible internal bleeding (see page 59) should be examined every 10 to 15 minutes until you are confident that the severity of the situation has declined sufficiently to warrant less vigilance. If someone has an altered mental status (particularly after a head injury), he requires your constant attention.
Try to maintain reasonable hygiene. This includes handwashing with soap and water, or using an alcohol-based hand gel. This is particularly important as an interval activity between multiple victims. Be aware that alcohol-based hand gel is not particularly effective against spore-forming bacteria, such as Clostridium difficile.