SOFME
Observer
Hello all. After reading through some of the threads in the medicine and SAR sections I felt a few stickies should be made. Here is my attempt at it. I will be writing based off my personnel knowledge and experience. However if anyone has genuine concerns I can reference/cite. That being said I am a military medic by trade. I spent 6 years in “dirt med” but now currently operate as a Flight Medic.
I want to make it clear from the get go, and with frequent reminders; what I will attempt to teach is: A WAY, NOT THE WAY. Most of us reading this are medical professionals of varying degree. So I will attempt to keep the teaching at reasonable level. As the thread develops feel free to ask questions, elaborations, make corrections, and add any knowledge you feel is relevant. Please keep the fluff to a minimum.
:coffeedrink:
To start I feel we need to talk patient treatment priorities. As we all know it is the “practice” of medicine. Things change frequently. A few years ago the standard was A-B-C (-D-E); Airway - Breathing - Circulation
(-Deformity - Exposure). This philosophy works fine. But there are major (needed) changes starting to surface in civilian medical teaching, specifically in Pre-Hospital Care. Ask any battlefield medic and they will tell you “rapid blood sweep then ABC”. This is largely due to the types of injuries we frequently see. Ask a civilian paramedic and the conversation may get interesting. But, civilian medicine is changing. PHTLS/ATLS teaches providers to stop life threatening bleeds first, the new NREMT (per AAOS) has disbanded the “pressure points” step in bleeding control algorithm, and the American Heart Association has now instituted “CAB” CPR.
Now when it comes to setting up treatment priorities there will always be a situation which one way is better. Everyone can “what if” anything to death to prove their point. But that helps no one. The point is: Perform within your scope of practice/knowledge, and keep it simple!
Now for the lesson (note: I will not discuss treatment of specific injuries here; as I will be following up with detailed, injury specify/body region specific write-ups soon.)
The key to successful treatment is simplicity under stress. The first acronym to remember is K.I.S.S; Keep It Simple Stupid.
Physiology quick and dirty: Blood goes round and round, Air goes in and out. Any disruption is bad. So fix it.
Your next step will be ensuring that the scene is safe for both you and the casualty. For obvious reasons this is paramount. I won’t get deep into the water about this because everyone has an instinctual will to survive. But I do need to highlight scene safety because we are frequently with people we care about during our adventures. Just remember you’re not going to be any good to your friend, wife, or child if you cannot keep yourself safe. Take a quick but detailed look at your surroundings, for example if your truck is teetering on the edge of a cliff after a roll over; you don’t want to roll in guns blazing to treat the casualty.
The first step will be securing the vehicle. The basics include: turn the vehicle off, stop any fires, and note fluid spillage.
After scene safety the next step will be your initial assessment. During this phase of care you will be assessing the big picture, creating a game plan, and finally initiating care. Keep in mind this is very rapid. Most times you will be doing most tasks simultaneously or by delegation. Your initial assessment includes:
- Mechanism of injuries
- Number of patients
- The need for and initiating transport
- Triage your patients
- CAB assessment and treatment
Knowing how your buddy was potentially hurt will aid you when it comes time to actually treat him. For example you buddy is spotting during vehicle recovery and the winch line snaps under load. He may have a number of injuries, but will be different than a friend who was involved in a roll-over.
Knowing the number of patients is the first step in setting treatment goals and aids in ensuring that your treat/evacuate everyone.
Get help, ASAP. This should be delegated if possible. If not possible at a minimum, due to your likely remote location, I recommend completing a CAB assessment first. The preferance is two way, open and continuous communication. be as detailed as possible with regards to location, number of patients and severity. I recommend learning a 9-lines request. But don’t call one in like you would on the battle field. Specify each line in communication.
Triage is simply explained, but difficult in practice. Just remember do the most good for most amount of people. You don’t want to be treating superficial cuts and abrasions on a child if dad is losing all the red stuff in his body.
Finally the CAB assessment. Circulation – Airway – Breathing.
- Circulation: Stop all catastrophic bleeding. We aren’t talking about insignificant bleeds. We’re talking about major arterial bleeds. Arterial bleeds are identified by bright red, spurting blood. Other less obvious signs:
clothing is quickly saturated in blood or large rapid pooling of blood. Expose the suspected area quickly.
Once catastrophic bleeding has been identified treat it quickly and simply (KISS). Use a tourniquet. Don’t forget tourniquets can be reversed to pressure bandages during later phases of care. But for now you simply want to stop the bleeding quickly to continue your initial treatment.
- Airway: Fix anything that my hinder breathing. Open and look into the casualty’s mouth looking for Blood, Vomit, Dirt, Rocks, Teeth, and most commonly the tongue. To keep things simple I will only highlight on one
technique for opening the airway. [video] http://www.youtube.com/watch?v=r3ckgEQEE_o [video] Remember in awkward positions this may be difficult to perform. Another techniques to perform a jaw thrust, grab the
lower jaw with your thumb and index finger and pull forward without moving the patients neck. Stabilize any penetrating item in the chest, sticks, metal shards, etc. Plug any holes in the patient’s chest or neck with a
bandage that will not let air in to the hole.
- Breathing: Check for spontaneous breathing which is adequate to support life. Not too fast, not too slow. Everyone knows what normal breathing is like. You’re doing it as you read this. If you are comfortable with mouth
to mouth, do it. CPR pocket masks are better. Just remember once you start this DO NOT BREATH FOR THEM TOO FAST. Give one breath every 6 real seconds. If you have to count it aloud; 1 Mississippi, 2
Mississippi, etc. Ensure the chest rises equally and fully. Ensure chest recoil is the same. Everyone knows what normal is. Any deviation from normal should be treated at this time IF YOU ARE QUALIFIED AND
TRAINED.
Now you have concluded your initial assessment. To recap, you have ensured the scene is safe, you have identified/prioritized all of your patients, called for help, stopped all catastrophic bleeding, opened the airway, and ensured adequate breathing. And you have repeated your CAB assessment on each patient if applicable.
Now move into a full assessment. The purpose of this phase of care is to find and resolve injuries which you may have missed, or injuries which you noticed but did not require immediate treatment. For example most bone fractures, less-than catastrophic bleeding, and any injuries, if left untreated, will comprise breathing or general survivability.
There really is no exact way to examine the entire body; however the entire body must be examined. To reiterate, this method I will describe a way, not THE way.
Start at the head. Ensure you asses every portion, highlighting the Ears, Eyes, Nose, and Mouth. Move to the Neck. Again this is a detailed look for anything other than normal. After you have cleared the neck move to the chest, abdomen, and pelvis looking for anything other than normal. After examining the trunk, I move to each leg, then follow to each arm. At this time I will check the back with an “X sweep”. Leaving the patient in the position found I will place one arm at the patient’s right shoulder, and the other hand at the patients left hip. Palms facing away from you body. Slide your hands together “hugging” the patient until your fingers touch. Pull your arms out and check for blood. If your arms are clean repeat from opposite shoulder/hip respectively. Again if your arms are clean AND there has not been any penetrating injury to the chest/abdomen postpone visual inspection of the back until you’re ready to move the patient. As a rule of thumb I will not move my patients unless scene safety is compromised, movement is necessitated by the need for an examination/ treatment/intervention, or the need for transport to definitive care. Finally after The Head, Neck, and trunk have been examined Its time to move to the extremities . I prefer to do legs first, then arms. Remember to keep your suspicion high for any injuries.
Now every portion of the body has been covered in detail. So far we have: Eliminated all apparent life threats. Completed our CAB examination/treatments. Completed detailed assessment while simultaneously treating injuries which may cause issues if left untreated AND reassessing treatments/interventions rendered during your CAB assessment.
At this time you can obtain “formal vital signs”. If you are only trained in basic first aid this may just be skin color/condition (sweating/dry/pale/pink/etc), pulses at multiple sites and respirations. Or, if you’re a high-speed medic with the Gucci-gear you can obtain a Blood Pressure, Pulse, Respirations, blah, blah blah.
Now is the critical time. You have busted you’re A** giving the best treatment at the best time to the best of your ability. But what have we forgotten?
Treat for shock! Ensure you completely cover your patient especially if touching the ground with any portion of their body. Best is a space blanket. Just remember when red stuff comes out the body’s temperature drops. DO NOT SLACK OFF WHEN IT COMES TO SHOCK.
Now you just need to reassess your patient and wait for help to arrive. Congratulations!
Please keep in mind that I will be posting follow-ups to this which will give details on specific injuries/treatments, aid bag philosophy, and a few other fun stuff to know. Also feel free to question anything you disagree with or ask for elaborations/justifications to these courses of action. And above all: K.I.S.S and This is a way, not the way.
I want to make it clear from the get go, and with frequent reminders; what I will attempt to teach is: A WAY, NOT THE WAY. Most of us reading this are medical professionals of varying degree. So I will attempt to keep the teaching at reasonable level. As the thread develops feel free to ask questions, elaborations, make corrections, and add any knowledge you feel is relevant. Please keep the fluff to a minimum.
:coffeedrink:
To start I feel we need to talk patient treatment priorities. As we all know it is the “practice” of medicine. Things change frequently. A few years ago the standard was A-B-C (-D-E); Airway - Breathing - Circulation
(-Deformity - Exposure). This philosophy works fine. But there are major (needed) changes starting to surface in civilian medical teaching, specifically in Pre-Hospital Care. Ask any battlefield medic and they will tell you “rapid blood sweep then ABC”. This is largely due to the types of injuries we frequently see. Ask a civilian paramedic and the conversation may get interesting. But, civilian medicine is changing. PHTLS/ATLS teaches providers to stop life threatening bleeds first, the new NREMT (per AAOS) has disbanded the “pressure points” step in bleeding control algorithm, and the American Heart Association has now instituted “CAB” CPR.
Now when it comes to setting up treatment priorities there will always be a situation which one way is better. Everyone can “what if” anything to death to prove their point. But that helps no one. The point is: Perform within your scope of practice/knowledge, and keep it simple!
Now for the lesson (note: I will not discuss treatment of specific injuries here; as I will be following up with detailed, injury specify/body region specific write-ups soon.)
The key to successful treatment is simplicity under stress. The first acronym to remember is K.I.S.S; Keep It Simple Stupid.
Physiology quick and dirty: Blood goes round and round, Air goes in and out. Any disruption is bad. So fix it.
Your next step will be ensuring that the scene is safe for both you and the casualty. For obvious reasons this is paramount. I won’t get deep into the water about this because everyone has an instinctual will to survive. But I do need to highlight scene safety because we are frequently with people we care about during our adventures. Just remember you’re not going to be any good to your friend, wife, or child if you cannot keep yourself safe. Take a quick but detailed look at your surroundings, for example if your truck is teetering on the edge of a cliff after a roll over; you don’t want to roll in guns blazing to treat the casualty.
The first step will be securing the vehicle. The basics include: turn the vehicle off, stop any fires, and note fluid spillage.
After scene safety the next step will be your initial assessment. During this phase of care you will be assessing the big picture, creating a game plan, and finally initiating care. Keep in mind this is very rapid. Most times you will be doing most tasks simultaneously or by delegation. Your initial assessment includes:
- Mechanism of injuries
- Number of patients
- The need for and initiating transport
- Triage your patients
- CAB assessment and treatment
Knowing how your buddy was potentially hurt will aid you when it comes time to actually treat him. For example you buddy is spotting during vehicle recovery and the winch line snaps under load. He may have a number of injuries, but will be different than a friend who was involved in a roll-over.
Knowing the number of patients is the first step in setting treatment goals and aids in ensuring that your treat/evacuate everyone.
Get help, ASAP. This should be delegated if possible. If not possible at a minimum, due to your likely remote location, I recommend completing a CAB assessment first. The preferance is two way, open and continuous communication. be as detailed as possible with regards to location, number of patients and severity. I recommend learning a 9-lines request. But don’t call one in like you would on the battle field. Specify each line in communication.
Triage is simply explained, but difficult in practice. Just remember do the most good for most amount of people. You don’t want to be treating superficial cuts and abrasions on a child if dad is losing all the red stuff in his body.
Finally the CAB assessment. Circulation – Airway – Breathing.
- Circulation: Stop all catastrophic bleeding. We aren’t talking about insignificant bleeds. We’re talking about major arterial bleeds. Arterial bleeds are identified by bright red, spurting blood. Other less obvious signs:
clothing is quickly saturated in blood or large rapid pooling of blood. Expose the suspected area quickly.
Once catastrophic bleeding has been identified treat it quickly and simply (KISS). Use a tourniquet. Don’t forget tourniquets can be reversed to pressure bandages during later phases of care. But for now you simply want to stop the bleeding quickly to continue your initial treatment.
- Airway: Fix anything that my hinder breathing. Open and look into the casualty’s mouth looking for Blood, Vomit, Dirt, Rocks, Teeth, and most commonly the tongue. To keep things simple I will only highlight on one
technique for opening the airway. [video] http://www.youtube.com/watch?v=r3ckgEQEE_o [video] Remember in awkward positions this may be difficult to perform. Another techniques to perform a jaw thrust, grab the
lower jaw with your thumb and index finger and pull forward without moving the patients neck. Stabilize any penetrating item in the chest, sticks, metal shards, etc. Plug any holes in the patient’s chest or neck with a
bandage that will not let air in to the hole.
- Breathing: Check for spontaneous breathing which is adequate to support life. Not too fast, not too slow. Everyone knows what normal breathing is like. You’re doing it as you read this. If you are comfortable with mouth
to mouth, do it. CPR pocket masks are better. Just remember once you start this DO NOT BREATH FOR THEM TOO FAST. Give one breath every 6 real seconds. If you have to count it aloud; 1 Mississippi, 2
Mississippi, etc. Ensure the chest rises equally and fully. Ensure chest recoil is the same. Everyone knows what normal is. Any deviation from normal should be treated at this time IF YOU ARE QUALIFIED AND
TRAINED.
Now you have concluded your initial assessment. To recap, you have ensured the scene is safe, you have identified/prioritized all of your patients, called for help, stopped all catastrophic bleeding, opened the airway, and ensured adequate breathing. And you have repeated your CAB assessment on each patient if applicable.
Now move into a full assessment. The purpose of this phase of care is to find and resolve injuries which you may have missed, or injuries which you noticed but did not require immediate treatment. For example most bone fractures, less-than catastrophic bleeding, and any injuries, if left untreated, will comprise breathing or general survivability.
There really is no exact way to examine the entire body; however the entire body must be examined. To reiterate, this method I will describe a way, not THE way.
Start at the head. Ensure you asses every portion, highlighting the Ears, Eyes, Nose, and Mouth. Move to the Neck. Again this is a detailed look for anything other than normal. After you have cleared the neck move to the chest, abdomen, and pelvis looking for anything other than normal. After examining the trunk, I move to each leg, then follow to each arm. At this time I will check the back with an “X sweep”. Leaving the patient in the position found I will place one arm at the patient’s right shoulder, and the other hand at the patients left hip. Palms facing away from you body. Slide your hands together “hugging” the patient until your fingers touch. Pull your arms out and check for blood. If your arms are clean repeat from opposite shoulder/hip respectively. Again if your arms are clean AND there has not been any penetrating injury to the chest/abdomen postpone visual inspection of the back until you’re ready to move the patient. As a rule of thumb I will not move my patients unless scene safety is compromised, movement is necessitated by the need for an examination/ treatment/intervention, or the need for transport to definitive care. Finally after The Head, Neck, and trunk have been examined Its time to move to the extremities . I prefer to do legs first, then arms. Remember to keep your suspicion high for any injuries.
Now every portion of the body has been covered in detail. So far we have: Eliminated all apparent life threats. Completed our CAB examination/treatments. Completed detailed assessment while simultaneously treating injuries which may cause issues if left untreated AND reassessing treatments/interventions rendered during your CAB assessment.
At this time you can obtain “formal vital signs”. If you are only trained in basic first aid this may just be skin color/condition (sweating/dry/pale/pink/etc), pulses at multiple sites and respirations. Or, if you’re a high-speed medic with the Gucci-gear you can obtain a Blood Pressure, Pulse, Respirations, blah, blah blah.
Now is the critical time. You have busted you’re A** giving the best treatment at the best time to the best of your ability. But what have we forgotten?
Treat for shock! Ensure you completely cover your patient especially if touching the ground with any portion of their body. Best is a space blanket. Just remember when red stuff comes out the body’s temperature drops. DO NOT SLACK OFF WHEN IT COMES TO SHOCK.
Now you just need to reassess your patient and wait for help to arrive. Congratulations!
Please keep in mind that I will be posting follow-ups to this which will give details on specific injuries/treatments, aid bag philosophy, and a few other fun stuff to know. Also feel free to question anything you disagree with or ask for elaborations/justifications to these courses of action. And above all: K.I.S.S and This is a way, not the way.