CAVRA Service Materials

N O T E : Because of our special situation, these notes at various points go beyond what is taught in a First Aid course for the general public. But in 'normal' circumstances it is often best, after checking that there is no immediate danger, to follow the usual advice: ''Call for the ambulance,'' and then make the casualty comfortable, deal with a crowd that may be gathering, and so on.

There are different ways of teaching First Aid: rather than treat it as a set of procedures to be learnt by heart (and quickly forgotten,) I prefer to approach it as a subject most of which should actually 'make sense' to the student.

These notes were last updated on 6 December 2000. Should you notice any omissions, or points at which these notes don't follow present standard practice at the appropriate level, please let me know, either using the web's form-mail or using your e-mail program (if set up.) Thank you.

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Priorities

When nearing the scene of the accident slow down to catch your breath and compose yourself. On arrival you will be the focus of attention of your team, any bystanders and possibly the patient himself, so try to act decisively and confidently. [Words like ''he'', ''his'', ''himself'' should be replaced by ''she'', ''her'', ''herself'', as appropriate ...]

While approaching, ensure both your own and the patient's safety, bearing in mind that you will want to devote your entire attention to the examination and treatment. At the same time try to assess the situation. Tell the patient to lie still, that help is at hand, and that you have come to give first aid.

Difficulty from either breathing or bleeding should be attended to immediately. If he is conscious, ask the patient what happened and where the pain is, (and possibly also if there was anyone else.) Note any damage to clothing. (Based on notes by D.T. Roscoe.)

As the first-aider approaches the scene of an accident, it is important that he has in his mind a clear set of priorities, determined by various risks:

1. threats to himself or to any casualty from the environment,
2. danger to the casualty/ ies from their heart not beating, or from not breathing, or their airway being obstructed,
3. danger to the casualty/ ies from major bleeding.

If any of these are encountered they must be dealt with immediately. These priorities will also determine the sequence of actions in a multi-casualty situation. Examples:

• Even if an unconscious casualty has a suspected broken spine, he must not be left lying on his back.
• If there are two casualties, one loudly complaining of pain holding his leg, the other lying still, then after checking that the scene is safe, the first-aider should check the second casualty's breathing and if necessary commence resuscitation, or turn him into the recovery position, before attending to the first casualty.

The next step is to conduct a full casualty examination. Once the first-aider has a full understanding of the condition(s), he can decide on the most appropriate treatment(s), and on the most suitable way of disposing of the casualty/ ies: some conditions are more urgent, while others require greater care in handling.

It is not uncommon that the injuries a casualty has, or may have, require conflicting treatments. In such cases, too, the first-aider has to establish priorities. Example:

• If a casualty has a broken rib, which may have punctured the lung, and a broken collar bone, both on the left side, then he should still be placed in a half-sitting position leaning towards the injured side.

First Aid can be a very worrying topic, but all we can do is the best we can, on the basis of what we have learnt -- and to remember that even doctors, after years of studying and with long experience, will often come across situations where they are unsure, or unable to help.

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Resuscitation, plus

Oxygen is required by all tissues, and the processes by which it normally gets from the outside air to the cells in the body are something as follows:
• breathing in and out (usually at a rate of about 15 /min) brings air (usually containing about 20 % of oxygen) into our lungs, and the millions of little airsacks called alveoli, where it gets transferred to the red cells in the blood;
• the oxygenated blood flows to the left, larger side of the heart, which pumps it (usually at a pulse rate of about 60 to 80 /min for an adult at rest, faster for children) through arteries into the rest of the body;
• the arteries branch into smaller and smaller blood-vessels, and eventually into the capillaries, from which the cells absorb the oxygen; meanwhile the blood picks up the cells' waste products, carbon dioxide and water;
• the de-oxygenated blood then is collected again, in larger and larger veins and flows back to the heart: not carrying oxygen, venous blood is darker in colour than arterial blood, and the pressure is lower in veins;
• the right, smaller side of the heart pumps the blood back to the lungs, where it gives up carbon dioxide and water, which are breathed out, and the red blood cells pick up oxygen again.
This process can 'go wrong' at many different points, eventually leading to hypoxia (= low blood oxygen, or asphyxia);
-- signs/symptoms:
if there is a lack of blood under the surface, the skin looks pale, even grey; if the blood lacks oxygen, the skin will turn bluish (cyanosis,) especially the lips; (these signs will be less obvious in a person of darker skin of course;)
-- main dangers:
brain tissue is most in need of oxygen: unconsciousness will result after 1 or 2 mins without oxygen, and after 3 mins there may already be permanent damage;
other tissues start dying after 10 to 15 mins without oxygen; (so in a crush injury, cutting off circulation in a part of the body, the crushing object must not be removed -- unless specialised medical help is present -- more than 10 to 15 mins after the accident.)

lack of oxygen in the environment, due to smoke, a plastic bag over the head, suffocation by a pillow, etc.	-- immediate action: remove the cause and provide fresh air, of course, giving proper regard to one's own safety.
strangulation, hanging	most people attempting suicide by hanging themselves do not break their neck, but end up suffocating slowly, so ... -- immediate action: support the person's weight before trying to cut them down.
the airway being blocked by swelling, after a bee sting in the throat, say, or due to an extreme allergic reaction (anaphylactic shock)
choking, i.e. an object, such as a particle of food, going down 'the wrong tube' and blocking the airway	-- signs/symptoms: ability to breathe, cough or talk is impaired; congested blood vessels on neck and face as the casualty strains, panic, flaring of nostrils; -- first check: if the person can breathe, cough or talk, even a little, there is no need for the first-aider to do anything but keep the person under observation; -- treatment: first, encourage casualty to cough; then alternate between 5 hard slaps between the shoulder blades, with the casualty leaning forward (but supported, in case they fall unconscious,) and 5 abdominal thrusts, from behind, to try to dislodge the object; continue, with the casualty on the ground, once they have become unconscious, but include a visual check: if the obstruction can be seen, it may be possible to remove it.
drowning
breathing interrupted	-- causes: breathing is completely controlled by the brain, so compression (after a head injury,) or a stroke (usually in an older person,) or a broken neck, or electric shock, can stop the breathing; some poisons, such as barbiturates and alcohol, are CNS (= central nervous system) -depressants and can lead to the breathing stopping.
damage to the lung	-- causes: punctured lung due to a broken rib, or from an external wound, stabbing; -- signs/symptoms: fast breathing, gasping for air; coughing up bright red, frothy blood; possibly surgical emphysema (= escaped air from the lung collecting under the skin;) in an external injury, a 'sucking' wound; -- treatment: rest casualty in half-sitting position, leaning towards the injured side, (to avoid blood affecting the other half of the lung,) apply an elevation sling on the injured side; if the casualty becomes unconscious and has to be placed in the recovery position, it is the injured side that should be down; a sucking wound must be sealed airtight immediately; a foreign object in the chest should be left.
asthma attack, usually in younger people who suffer from the condition long-term	-- cause: constriction of the air passages in the lungs, sometimes due to an allergic reaction or to psychological tension; -- signs/symptoms: short, quick breaths; wheezing sound when breathing out; anxiety, which may be making the attack worse; -- treatment: calm the casualty, help them breathe slowly; give them their medication (usually an inhaler) if they have it; sit them down leaning slightly forward, allow them to grasp a table in front of them.
fainting, i.e. temporary lack of blood to the brain	-- signs/symptoms: the casualty turns pale, may see black before their eyes, then 'blacks out' and sinks to the ground; -- treatment: keep lying down, with legs raised to improve blood supply to the brain, open tight clothing, talk calmly -- the casualty may well be able to hear; let them rest for a while; if they have not 'come around' after 1 or 2 mins, treat as unconsciousness.
shock, i.e. loss of blood, or lack of blood in circulation
carbon monoxide poisoning	-- cause: breathing in a space with carbon monoxide in the air, (like a closed garage with a car engine running;) the haemoglobin in the blood will bind the carbon monoxide rather than oxygen; -- signs/symptoms: blooming, ruddy (reddish) complexion; drowsiness leading to unconsciousness (-- the body has no organ to sense lack of oxygen: it is excess carbon dioxide in the blood that makes us feel we are suffocating;) -- treatment: bring casualty into fresh air, give oxygen if available.
heart attack, usually in older people, the heart not pumping	-- causes: interruption of blood supply to part of the heart, hence eventually chaotic fibrillation replacing the organ's effective pumping action; possibly by electric shock; certain poisons paralyse the heart muscles; -- signs/symptoms: very severe, gripping pain in the region of the heart, spreading down the left arm; weakness, sweating, extreme anxiety; -- treatment: sit the casualty down comfortably, in a semi-recumbent position (= half leaning back;) put some support under the knees, open tight clothing; give them an aspirin to put under their tongue; -- related condition: angina, a long-term condition of a narrowing of the arteries in the heart, resulting in an indigestion-like pain when physical effort is being made; to treat, rest the casualty and help them take their medication if they have it.

When one comes across a casualty who may be unconscious or not breathing or whose heart may not be beating, it is essential to act quickly and efficiently, so there is a set procedure, as follows:

As you approach, check for your own and the casualty's safety, and if necessary take steps to make sure it is safe; check if the casualty is conscious -- say loudly: "Open your eyes," and tap them on the shoulders; if they are conscious: ask them what happened, and proceed with a body-check if appropriate (-- check for major bleeding first, and deal with it,) if they are not conscious: check if the casualty is breathing -- extend the neck (so that the tongue does not block the airway,) and look (for the chest rising and falling,) listen (for the breathing) and feel (for air coming out of their mouth,) for 10 secs; after checking the breathing, send someone for help: instruct them to give the precise location and details of the casualty's condition, and to return; if you are on your own, and the casualty is older (and has probably had a heart attack,) go for help now; on your return, re-check the casualty and continue; if they are breathing: place the casualty in the recovery position (so that the stomach is above the level of the lungs: otherwise the casualty might drown on their vomit -- every unconscious casualty must be placed in the recovery position;) proceed with a body-check if appropriate. if they are not breathing: give two 'rescue breaths': keep the casualty's neck extended, close their nose with the fingers of one hand, support their chin with the other hand, make a seal around their mouth, and give two breaths (-- the air we breathe out still had 16 % oxygen in it;) then check for the carotid pulse on the casualty's neck, for 10 secs; if there is a pulse: perform EAV (= expired air ventilation): give one breath every 5 secs, turning your head sideways each time to see the chest fall; re-check after every minute that the casualty still has a pulse. if there is no pulse: give CPR (= cardio-pulmonary resuscitation): move down to the side of the casualty's chest, place the heel of one hand on the sternum (= breastbone,) three fingers from the lower end, and the other hand on top, and lean straight down, with straight arms, 15 times at a rate of 80 to 100 /min; use your weight to compress the chest by about 4 cm each time, but do not take the hands off the chest between compressions; move back to the head and give two quick inflations, as before, then return to the compressions; (if there are two first-aiders, after one may have gone for help, they should then take turns performing CPR.) if you are on your own, and the casualty is younger (and has probably not had a heart attack,) go for help after one minute, i.e. after four cycles of inflations and compressions. If the resuscitation is effective, the casualty should regain some colour, and dilated pupils should become normal size. Continue with the resuscitation until the casualty shows signs of life, such as a twitching of the face (or sometimes throwing up ...,) at which point they should be re-checked, (and turned into the recovery position if their pulse ad breathing have returned;) or until more qualified help arrives; or until the first-aider(s) is/are too exhausted to continue. The procedure needs to be adapted for infants and children. For an infant, use mouth-to-mouth-and-nose, give only puffs of air for the inflations, and do the compressions with two fingers; compressions and inflations can be done at the same time, in the ratio 5-to-1, at a rate of 120 compressions/min.

The first-aider should be aware that the chance of the casualty 'coming back to life' as a result of the resuscitation efforts are very small: the purpose of resuscitation is to keep the casualty's body tissues alive until help arrives with better equipment etc. -- such as, in the case of a heart attack, an ambulance with a defibrillator.

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Bleeding, Shock

Blood, of which the body of an adult has about 5 l, serves all kinds of purposes in the body, one of which is to carry oxygen around the body. The loss of about 500 ml from the circulation, which is the quantity taken when one donates blood, can already lead to problems; losing 2 l is life-threatening.

1. Internal Bleeding:
   sometimes it is not obvious that there has been bleeding, because the blood is still inside the body, but any blood that has been lost from the circulation cannot be recovered by the body;
   while there is usually nothing that the first-aider can do, it is important to recognise these conditions and give the transportation of the casualty to hospital a high priority, as well as protecting them from further problems;
   there are two main dangers associated with internal bleeding:

   1. Damage to other organs;
      
      in two areas of the body, even a small amount of bleeding can be very serious.
      1. head:
         bleeding in the closed box of the skull will affect the working of the brain ('compression';)
         -- causes: fracture of the skull, stroke;
         -- signs/symptoms (-- these may develop only very slowly, even 24 hrs after the injury):
         drowsiness, casualty difficult to rouse, may become unconscious;
         pupils of unequal size, may react only slowly to light, casualty may complain of double-vision;
         feeling of nausea, skin hot and flushed, pulse slow and bounding; breathing may become laboured and noisy, like snoring;
         -- main danger: breathing may stop;
         -- treatment: as for an unconscious casualty: place in recovery position, keep monitoring the airway, breathing; resuscitate when necessary;
         -- distinguish from: concussion, where the brain has only been shaken, but is not injured;
         the most typical symptom is loss of recent memory; the casualty may briefly lose consciousness, and feel dizzy or nauseous; he may suffer from a head ache, and be sensitive to bright light or noise;
         a casualty with concussion will gradually improve, but should be watched for signs of compression developing, which may happen as long as 24 hours later.

      2. chest:
         bleeding into the lung may interfere with effective breathing;
         -- causes: lung punctured by a broken rib, stabbing;
         -- signs/symptoms: fast breathing, gasping for air; lack of oxygen leading to cyanosis (= blueness;) coughing up bright red, frothy blood; possibly surgical emphysema (= escaped air from the lung collecting under the skin;)
         in an external injury, a 'sucking' wound, with air going in/coming out;
         -- treatment:
         rest casualty in half-sitting position, leaning towards the injured side, (to avoid blood affecting the other half of the lung,) apply an elevation sling on the injured side;
         if the casualty becomes unconscious and has to be placed in the recovery position, it is the injured side that should be down;
         a sucking wound must be sealed airtight immediately; a foreign object in the chest should be left.

   2. Major blood loss:
      
      In other areas it is the amount of blood lost that is dangerous, leading to shock.
      1. abdomen:
         -- signs/symptoms: sometimes pain, or marks on the skin from an impact;
         some time after the injury, abdominal muscles may become rigid;
         but often no sign other than deepening shock, in the absence of other serious injuries.
      2. fractures:
         notably fractures of the pelvis or femur (thigh bone) may result in major blood loss;
      3. bruising:
         a bruise is internal bleeding under the skin; while this will usually be minor, in some injuries a large amount of blood may be lost.

2. External Bleeding, Wounds:
   1. Severe bleeding:
      -- treatment:
      1. direct pressure, use the casualty's help if possible;
         a dressing, which should be absorbent and preferably sterile, held in place by a bandage, will also help to seal the wound, by the blood clotting;
         (if blood comes through a dressing/bandage, do not remove but put another on top, up to three;)
         -- caution: make sure a bandage is not too tight, as would be indicated by
         1. the casualty complaining of discomfort,
         2. white skin below the bandage, slow capillary refill;
         3. bluish, slightly warm appearance below the bandage;
         4. loss of sensation;
      2. in he case of an arm or a leg, elevation;
      3. only in extreme cases: indirect pressure, using a pressure point, but release pressure after ten minutes; (and do not use a tourniquet!)

   2. Foreign object in a wound:
      -- treatment: if at all practicable, do not remove; apply pressure, and dressing and bandage around the object.

   3. Amputation:
      -- treatment: if a part of the body is severed completely in an accident, treat as a severe wound, but in addition take the following ...
      -- action: place the severed part in non-adherent clean material, but don't try to clean it off, keep it cold but avoid direct contact with ice, label it with the time and the patient's name if possible, and send it with the patient to the hospital.

   4. Particular cases:
      1. nosebleed:
         -- treatment: have casualty leaning forward, pinching the lower part of their nose;
         do not put anything in the nose, advise them not to blow their nose for some time, and to seek medical help if bleeding persists or is frequent;
         -- caution: after a head injury, blood or a straw-coloured fluid coming from the nose or ear may indicate a fracture of the base of the skull;
      2. burst varicose vein:
         -- cause: varicose veins are a long-term condition suffered mostly by older people, where the transport of blood, mostly in the legs, back to the heart is slow, so that the veins swell up;
         bleeding can be major when a varicose vein bursts:
         -- treatment: direct pressure, elevation, dressing and bandage;
      3. abdominal wounds:
         -- treatment: a vertical wound may close if the casualty is laid down flat, a wound across the abdomen if his legs are supported;
         if there are intestines protruding, do not attempt to put back, but cover sterile with something that won't adhere, like plastic.

Shock:

Shock is a potentially very serious condition in which there is insufficient blood in circulation in the body ('body volume loss';)
-- causes: blood loss, through major external or internal bleeding;
or sudden pain, as in even a minor fracture, or (psychological) shock, when the body pulls back blood to the liver, intestines, and so on (-- this latter kind is reversible;)
-- signs/symptoms: the casualty is pale, even grey, their skin cold and clammy, they feel dizzy and nauseous, they may complain of thirst, breathing is fast and shallow, and the pulse is fast and weak;
-- treatment: reassure the casualty, lie them down, keep them warm, (underneath as well as above;)
except in the reversible kind of shock, do not give anything to drink, just moisten the lips, as the casualty may fall unconscious or require an operation.

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Casualty Examination, plus

Often when one comes across a casualty, some injury is most obvious, and there is a natural tendency to treat this injury immediately, especially if the casualty is in severe pain. This may lead you to overlook other, less obvious but possibly more serious injuries. To avoid this trap, work to a predetermined and practised routine which is applied to all casualties. (The routine of examination in this section is based on notes by D.T. Roscoe.)

On the basis of your examination and diagnosis, priorities of treatment and of removal will have to be established, especially in multiple-casualty situations. The following system is logical and satisfactory, and very little will go unnoticed if it is adhered to.

1. Check first if the patient is conscious, and if he is not, that he is breathing and has a clear airway; if he is not breathing, check that he has a pulse. Treat immediately if there is any problem with these. Then check if there is any severe haemorrhage (bleeding,) and treat immediately if you find any.

   After this, complete the whole of the body check, so that you have a full picture of the casualty's condition, before carrying out any treatment.

2. Check for major fractures before attempting to move the patient if he is in a difficult situation. Should major injuries be found, do not attempt to move him, unless there is an immediate danger (rockfall, avalanche, etc.) but carry out the examination as best you can on the spot.
3. Detailed examination: always start at the head and work methodically down the body to the feet, using both hands at once on opposite sides of the body for comparison: this will help to reveal discrepancies between injured and normal limbs etc., i.e. swelling, deformity, etc. Talking to the patient will help considerably (and will also reveal the level of consciousness;) however, even an unconscious casualty may react to pain and such reactions must be observed. Assuming that the patient is lying on his back, proceed as follows:
   1. Slip a hand under the lowest point of the head; if blood is found, a further check for head wounds should be made. If no blood is found, it is unlikely that there are scalp wounds of any significance.
   2. Run your fingers firmly over the scalp, feeling for depressions etc., and on over the bony promontories of the cheeks, nose and line of the jaw. Bruising behind the ear (''battle signs'') and swelling over part of the vault of the skull are also signs of fractures.
      treatment: (fracture of skull) lay the casualty down, with head and shoulders raised.
   3. Look for blood or clear, straw-coloured (''cerebro-spinal'') fluid emerging from the ears or nose. Bleeding from within the ear is a sign of a fracture of the base of the skull, and from the nose a sign of a fractured front of skull.
      treatment: (fluid/bleeding from the ear) cover with sterile dressing, rest casualty with affected side down to allow blood to flow from the ear.
   4. Look at the eyes and compare pupil sizes. Unequal pupils and no (or slow) reaction to light are signs of compression. Black eye or bleeding into the white of the eye are further signs of a fracture of the front of the skull.
   5. Run your hands firmly over the cheekbones; check for a broken jaw, from in front of the ears to the chin. A fracture here indicates that there has been a major force to the head, so keep checking for signs and symptoms of compression.
      treatment: (broken jaw) since swallowing and speaking can be painful, give the casualty a cloth to support their lower jaw against the upper jaw, and encourage them to let their saliva run into the cloth.
      possible complication: (in all head injuries) compression.
   6. Try to feel the bony prominences of the neck from the base of the skull to the shoulder line. Swelling or pain may indicate a broken neck.
      treatment: (fracture of neck) minimise any movement, in particular turning and forward; tell casualty not to move; use a ready-made or improvised neck-splint, but hold the head while putting it on;
      main danger: nerves in the spinal chord being affected, resulting in the breathing stopping.
   7. Place your hands flat on the rib cage and try to feel and see the motion of the chest when breathing. Reciprocal, or paradoxical, breathing (one part of the chest going down when the rest is coming up, or the chest going down when the abdomen is rising for a breath) is an indication of a flail segment.
      Frontal pressure on the rib cage will, in a conscious patient, indicate any areas of pain, which may be bruises or fractures. If fairly firm pressure inwards from the sides gives rise to pain in the same spot, a fracture may be assumed.
      treatments:
      1. broken rib(s): arm sling on the injured side, place casualty in half-sitting position leaning towards the injured side;
      2. flail segment, paradoxical breathing: try to minimise movement of (the affected part of) the chest;
      possible complication: punctured lung, (in which case it is an elevation sling that should be put on the injured side.)
   8. Run your fingers along the clavicles (collar bones,) from the sternum (breastbone) to the shoulders; at the same time check for puffiness of the tissue, especially around the neck, which would indicate surgical emphysema (i.e. air escaping from an injured lung.) Then pass your hands over the shoulders and down the arms, checking the humerus (upper arm), bony points of the elbows, and forearms.
      
      treatments:
      1. broken collar bone: support the arm in an elevation sling on the injured side, with some padding between the upper arm and the chest;
      2. dislocation of the shoulder: support arm in the position most comfortable for the casualty, which may be with the lower arm resting on top of his head; do not attempt to reduce (= put back;)
      3. fracture of humerus: splint arm in the position in which it was found, by tying it to the body; transport as a stretcher case;
      4. fracture of lower arm, wrist: support in an arm sling;
      5. fracture in the hand, of finger(s): apply padding, put on elevation sling; do not attempt to splint;
      possible complication: a fracture of the humerus just above the elbow (supracondylar fracture) can interrupt the blood supply to the lower arm, by the bone pressing on the artery; if there is no pulse below the fracture, gently straighten the arm until there is a pulse.
   9. Take the pulse at the wrist, for at least 30 secs. A very slow pulse ( < 60) is a further indication of cerebral compression. A fast and feeble pulse indicates a state of shock. Clench the hands lightly in your own to check for broken fingers.
   10. Gently depress the four quadrants of the abdomen with the flat of the hand. Normally it is fairly flaccid (= soft,) but in the event of an internal abdominal injury it may feel very rigid and possibly tender (= painful when touched.) Such injuries are not easy to detect, as there is little pain and this may be masked by other, more painful injuries. If suspected, check for clothing- or rope-marks on the abdomen indicating a forceful blow. There is a great deal of haemorrhage from an internal abdominal injury and the patient will quickly become deeply shocked: signs of shock with no other major serious wounds to account for it should lead one to suspect this type of injury.
   11. Press gently on the pubis. If there is pain or tenderness, assume a pelvic fracture and do not proceed further with the pelvic examination. Otherwise, apply a hand to the crest of the ilium (to the hips) on either side and spring the pelvis lightly, diagnosing a fracture if there is pain or movement.
       treatment: (broken pelvis) warn casualty not to urinate, in case the bladder has been punctured; if you have to transport the casualty, put wide and firm padding between legs and tie the legs together.
   12. Observe any shortening of a leg or unusual position. Run the hands down the thighs, feel above the knee caps, the knees themselves and just below for swelling, which would indicate fracture of the lower end of the femur (thigh bone,) damage to the knee joint or to the patella (knee cap), and fracture to the upper end of the tibia, respectively. Continue down the lower leg to the ankle, feeling the bony prominences on either side. Check inside shoes or boots for blood.
       treatment: (especially fracture of femur) put plenty of padding between the legs, move the uninjured towards the injured leg, and tie legs together firmly with broad bandages, starting with a figure-of-eight bandage around the ankles, but avoiding a bandage on top of the fracture;
       (fracture of the ankle, also bones in the foot) rest, apply ice, elevate; loosen shoe/ boot, but don't remove unless there is serious bleeding;
       possible complication: (fracture of femur) contraction of the muscles around the fracture, resulting in further damage to tissue.
   13. Tap the bottom of each heel. Pain here could indicate a fracture of the heel bone, from the casualty having fallen from a height onto his feet, and should lead one to suspect a fracture of the other heel, and possibly also of the spine, or the pelvis, or the base of the skull.
   14. If the patient is conscious, ask if there is any loss of sensation or power (paralysis) in the lower part of the body. They may also be complaining of pain in the back, or a feeling of ''being cut in half.'' There is then no need for further examination.
       Otherwise, to examine the spine, turn the patient away from yourself, taking great care to prevent rotation between the shoulder girdle and pelvis. Unless familiar with this technique, obtain assistance in moving the patient. Try to feel the bony prominences from the neck down to the pelvis. Areas of swelling or displacement may be felt, coupled with pain or tenderness, if a fracture is present. While the patient is in this position, check for fractures of the shoulder blades and tenderness over the kidneys.
       treatment: (broken spine, or suspected broken spine) though not urgent, this is a very serious injury because of the possible consequences; there is no First Aid treatment, but any movement of the casualty -- if absolutely necessary -- requires the greatest care;
       an unconscious casualty with a broken spine, lying on his back, should be placed in a modified recovery position: the body is turned half-way, until the casualty is resting on his side, and needs to be propped up front and back; meanwhile the head is supported in line with the body at all times.
4. Every ten minutes, check and record the casualty's levels and rates.

Injuries of bones and joints:

• Fractures:
  
  general signs/symptoms: severe pain, to the point of causing nausea; swelling and possibly bruising; deformity, inability to move;
  principles of treatment: avoid movement, elevate if appropriate, prevent further damage by immobilising (-- if an injured limb is bent at an angle, you may apply traction to gently pull it straight;) watch out for shock developing.
• Special cases:
  • Open fracture:
    cause: a broken end of bone has pushed through the skin; the bone may still be protruding, or not;
    or a force has both broken through the skin to the bone, (e.g. skull fracture;)
    treatment: cover the wound sterile, and apply a dressing and bandage, but avoid applying pressure at the site of the fracture; then treat the fracture;
    if the bone is protruding, arrange padding around the wound and bandage in place, without applying pressure to the bone.
  • Broken collar bone:
    signs/symptoms: the casualty may be supporting the elbow on the side of the fracture, and incline their head towards the injured side;
    treatment: support the arm on the injured side with an elevation sling, with some padding between the upper arm and the chest.
  • 'Broken hip':
    cause: fracture of the neck of the femur, a typical injury in older people, after taking even a small fall;
    signs/symptoms: casualty lies on the ground, holding the painful hip, foot on the affected side turned outward.
• Sprains:
  causes: overstretching of ligaments in a joint, most commonly the ankle, thumb or shoulder;
  signs/symptoms: swelling and possibly bruising; pain when attempting to use the affected joint;
  treatment: rest the affected joint, apply ice to reduce swelling and pain, compress and support using an elastic bandage, elevate to reduce swelling (= rice;)
  treat a sprained shoulder like a fractured clavicle.
• Dislocations:
  causes: displacement of a bone at a joint, most commonly the shoulder, a finger, or the jaw;
  signs/symptoms: pain, even sickening pain; deformity, inability to move the joint;
  treatment: support in the position most comfortable for the casualty; do not attempt to reduce (= put back;)

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Effects of Heat and Cold

	local	global
heat	Burns: -- causes: fire, hot gases, steam ('scalding',) chemicals, electricity, friction (rope burns;) -- appearance: 1st degree (e.g. sunburn): reddened skin; 2nd degree: blisters, very painful; 3rd degree: whitish charred skin, but no pain, (due to nerve endings having been damaged;) with electricity, there may be burns both where the current entered the body and where it left; -- treatment: flush area with plenty of cold water, for at least 10 mins, longer for chemical burns; avoid spreading a chemical to unaffected areas; near electricity, remember that water is a conductor; don't pop blisters, don't apply creams etc., don't remove clothing stuck to a burn; cover with non-stick dressing, a burn dressing if available.	Heat Exhaustion, Heat Stroke: -- causes: being in the sun, working in hot environment, fever; -- signs/symptoms: at first sweating, skin is cool and clammy, possible head ache and dizziness, or muscle cramps (heat exhaustion;) sweating stops as the body runs out of water and salt, the skin is hot and dry, head ache and possible hallucinations, convulsions as enzymes in the brain start to degenerate at about 41 ºC (heat stroke;) -- treatment: cool down the body quickly, with cold water (but don't leave alone in a shower,) etc.; give drinks, water with small amounts of salt.
cold	Frost Bite: -- causes: water in the tissue freezes, most commonly in the extremities: toes, ears, fingers, nose; especially in windy conditions, when wearing not enough clothing, shoes that are too tight, (which reduces circulation,) when the body lacks energy; -- signs/symptoms: whitish, waxen appearance and feel, loss of sensation, inability to move; -- treatment: protect from pressure, avoid rubbing or massaging: tissue damage can lead to gangrene, hence must seek medical attention; thaw slowly -- the process can be very painful; don't thaw but leave frozen if there is a danger of the part refreezing; don't use heat to warm affected part: the skin might get burned without the patient feeling it; use a warm part of the patient's (or another person's) body.	Hypothermia: -- causes: core temperature < 35 ºC, either (i) slowly, through lack of energy, in windy conditions, due to lack of protection, (this can even happen in the home,) or (ii) quickly, when the body is immersed in cold water; -- signs/symptoms: paleness, initially shivering, which stops as the body runs out of energy; as the brain gets affected: confusion, bad mental and physical coordination, irritableness, lack of motivation; eventually loss of consciousness; -- main danger: heart attack; -- treatment: warm slowly, don't give alcohol (-- to avoid expansion of blood vessels on the surface, possibly resulting in further cooling of the core;) insulate well, and use the patient's own (or another person's) body heat; -- see below for more details.

Hypothermia:

• Hypothermia can develop in very different situations: a casualty may be in the water, and for someone without protective gear in the sea in our cold season, the situation may become serious within ten minutes; he may be exposed to the elements, wind and rain or snow, in the hills; or he may just have been sitting at home without heating for too long. The effects depend purely on how far the core temperature has fallen below the optimal 37 ºC.
• Initially when the temperature is low, shivering sets in as the body attempts to generate heat. As the body cools, it begins to protect the core by shutting down functions and reducing blood flow to the surface and extremities: the sudden pooling of blood in the core which results when someone becomes immersed in cold water may overload the heart and precipitate a heart failure.

  At about 34 ºC, the working of the brain begins to be affected and a casualty will start to get confused, to forget even important matters, to act irrationally, and eventually even to lose the will to make an effort to survive. Shivering will have ceased when the temperature reaches about 33 ºC.

  At 30 ºC the casualty will have lost consciousness, and when the core temperature has fallen below 28 ºC, death from heart failure may occur at any time, as the heart is unable to maintain its coordinated beat and the muscle starts fibrillating without pumping any blood. At 24 ºC then, the situation will have become irreversible.

• The aim of First Aid is of course to restore the casualty's core temperature to its normal 37 ºC, but it is essential to bear in mind what is called the 'afterdrop': as the body becomes warmer and blood begins to circulate more fully again, the core actually cools further before warming, because of the inflow of cold blood from the outer parts of the body - and this may lead to a critical situation. So whereas a conscious casualty may be warmed quite quickly, even in a bath of 40 ºC and with warm drinks (but under close supervision,) an unconscious casualty must only be allowed to warm very slowly, using only the heat generated by the body itself: he should be protected from further heat loss, ideally by being wrapped in a 'space blanket', but must be protected from a warm environment.

  If there is no pulse or breathing, or these are so slow and shallow as to be unobservable, resuscitation must of course be attempted, and this should not be discontinued before the body temperature is normal again. (This is especially the case with children, who if they have become immersed very suddenly in icy water can survive without breathing for as long as one hour and a half or more.)

• It is a recent insight that when a casualty is in the sea, the hydrostatic pressure of the water on his legs helps to reduce the circulation to the extremities and to protect the core: such a casualty must be rescued in a horizontal position and be kept with legs slightly elevated, so as to avoid heart failure due to the blood flow to the legs being restored too suddenly. Any casualty who has suffered from hypothermia may experience serious after-effects and must receive medical attention immediately and be kept under close observation for a few days.

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Medical Conditions

1. Angina

   (= angina pectoris, not the same as angina in German, which is an infection):
   in older people, a long-term condition leading to occasional attacks;
   -- cause: narrowing of the arteries in the heart, especially due to smoking;
   -- signs/symptoms: indigestion-like pain, usually when physical effort is being made; feeling of 'pins and needles' spreading to the left arm;
   -- treatment: rest the casualty and help them take their medication if they have it.

2. Asthma:

   usually in younger people, a long-term condition leading to occasional attacks;
   -- cause: temporary constriction of the air passages in the lungs, sometimes due to an allergic reaction or to psychological tension;
   -- signs/symptoms: short, quick breaths; wheezing sound when breathing out; anxiety, which may be making the attack worse;
   -- treatment: calm the casualty, help them breathe slowly; give them their medication (usually an inhaler) if they have it; sit them down leaning slightly forward, allow them to grasp a table in front of them.

3. Diabetes:

   a long-term condition in which the body does not produce (adequate amounts of) insulin, which is needed to store or use sugar in the blood;
   -- cause: temporary imbalance of the amounts of insulin and sugar in the blood:
   whereas in hypoglycaemia (= low sugar) there is too much insulin for the amount of sugar, in hyperglycaemia (= high sugar) there is too much sugar for the amount of insulin;
   -- signs/symptoms:
   (hypoglycaemia) pale, cold and clammy skin; strong, bounding pulse; shallow breathing; patient may feel faint or hungry, show strange behaviour, appear drunk, and become less responsive;
   (hyperglycaemia) dry skin; rapid pulse; deep breathing, a faint 'fruity' smell on their breath; eventually sliding into unconsciousness;
   patient may have a bracelet with medical information, or sugar in their pockets, or be carrying syringes;
   -- treatment:
   (hypoglycaemia) if the casualty is conscious, give sweetened drink, food; otherwise, place in recovery position and dispatch to hospital;
   (hyperglycaemia) urgently remove to hospital;
   in case of doubt, give a small amount of sugar, and see if the patient's condition improves.

4. Epilepsy:

   long-term condition affecting the brain, giving rise to occasional attacks, but usually completely controlled by drugs;
   -- cause: electrical disturbance in the brain, sometimes set off by flashing light (stroboscope) or shortness of oxygen;
   -- signs/symptoms:
   (minor fit) loss of awareness, automatic behaviour, possibly localised twitching;
   (major fit) patient falls to the ground, breathing may stop, leading to cyanosis (= blueness of lips etc.,) then arching of the back, violent convulsions;
   -- treatment:
   protect casualty from injuring themselves, but do not try to constrain; move objects away, place something soft under their head;
   (if a fit lasts more than a few minutes, seek medical help urgently;)
   after the fit, reassure and allow to rest; check for injuries;
   if the patient was not aware of their condition, advise them to see a doctor soon.

5. Anaphylactic Shock:

   an extreme allergic reaction, in which the condition of the patient can deteriorate very quickly, to the point of death;
   -- cause: eating a particular food, or being stung by a particular kind of insect, or being given a particular drug, etc., leading to swelling of tissues;
   -- signs/symptoms:
   swelling of face and neck, puffiness around the eyes, skin may show red blotches;
   casualty may gasp for air, breathing may stop;
   heart beats rapidly, may stop;
   -- treatment:
   remove casualty to hospital with extreme urgency;
   monitor level of consciousness, breathing and heart beat, and place in recovery position or resuscitate as necessary;
   casualty may be carrying an antidote, which a qualified person can administer.

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Self-Assessment: Multiple Choice Test

You can take a multiple-choice self-assessment quiz on some of the above material. The same test is available in different formats.
There are 20 questions with 4 answers each, of which one is correct. You start with 20 points, selecting a correct answer adds 3, and a wrong one subtracts 1, (so there is no point in random guessing.) If you are able to eliminate at least one answer, though, you should choose one of the remaining ones -- like in the SATs.
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