Assessing a Casualty
In the previous edition, I provided my insights into Incident Management. I now want to focus on our ‘Medical Challenges’ in paddlesport and move the discussion on to ‘Assessing A Casualty’. This article is not a substitute for attending a First Aid Course but will hopefully remind you of the framework we use to make an assessment. It will also raise issues for you to consider because of the environment we operate in, whether that’s the sea or a river.
If you go to see your GP in his or her nice warm surgery, saying that you feel poorly, you’ll be asked to give more details and a medical examination will take place.
If you hobble in to a nice warm Minor Injuries Unit or A+E department, saying you’ve injured your foot, you’ll be asked to say more about what happened and a physical examination will take place.
Medical illness or traumatic injury, the clinician will work through a checklist, to arrive at a diagnosis. A cornerstone of this process is your story of what has happened, we call it ‘history taking’.
We have a hostile environment as opposed to a nice warm consulting room, and our casualty may be wearing a drysuit and other kit that will hinder a careful patient examination, so our job is harder. We can still use our senses of sight, hearing, smell and touch, to help assess a casualty and therefore realise how urgent or otherwise the situation is.
There is no substitute for attending a quality first aid course that focuses on working in a remote environment.
Knowing what has happened can help us look for patterns of injury, and what risks the patient may be prone to. A sea-kayaker may capsize in the surf, exit the boat, tumble about in the waves and swallow some water whilst getting to the beach, but in another incident two boats could collide, with one casualty being struck in the ribs. On the beach both paddlers will appear distressed, coughing, and short of breath; but the history says they will probably have very different injuries, and have different recovery times. Patient details and the history of the event is crucial information for the rescue and emergency services who may get involved. Remember to note:
- Time of incident.
- What happened. I can’t stress enough how important this is.
- Time of any subsequent event such as vomiting, seizure, loss of consciousness, treatments given.
You want to be able to replicate the nice warm, calm, examination room of a Minor Injury Unit as best as possible, but the reality is the temperature is hovering around zero, and the casualty is still panting after their personal ‘epic’. With good Incident Management controls, your group is now as safe as they can be, and this is being continually managed. Use the next few minutes to establish what has happened, and when it happened. Get your team in close so that you can develop and share a plan, so that everyone knows what is going on, and they are close by for you to give responsibilities to as necessary. Within two or three minutes there should be some evidence that the patient is now able to control their breathing.
- Remember the Primary Survey as this will influence the urgency:
- Your priority is to make yourself safe, your peers safe, and the casualty safe.
- You can only deliver effective First Aid once everyone is safe.
- Is the casualty alert? If the casualty is unconscious, then the airway is threatened.
- If they can talk, great.
- If they are unconscious, make sure the airway is open.
- Even a partially obstructed airway (snoring may be present) can quickly prove fatal.
- Measure the rate.
- Assess the depth.
- Is the person finding it difficult to breathe? Can they talk in full sentences?
- Look for equal expansion on both sides of the chest.
- Does a deep inhalation cause pain. Pain on deep inhalation is a sign of injury or illness.
- Count the pulse (beats per minute),
- Feel the rhythm of the beats. A healthy heart should have equally spaced beats, but irregular heartbeats are quite common in older people.
- Feel for the strength of the pulse. If you are unable to feel a pulse at the wrist, trying using less pressure through your fingers. If you press too hard you simply cut off the blood supply and you don’t feel anything.
- Check the capillary refill. Squeeze a fingernail for 5 seconds and release. The colour should return to the nailbed in 2 seconds. This indicates that the heart and lungs are doing a good job in unison. But with paddlesport, we often have cold fingers and this will slow the capillary refill time! An alternative is to press on the forehead for 5 seconds and then release, does the colour return?
- Does the casualty complain of chest pain?
- Are there signs and symptoms of shock?
- Are there signs and symptoms of a heart attack?
- Remember your AVPU scale. Are they Alert, respond to Voice, respond to Pain, or are they in fact Unconscious?
- Are they being repetitive? Asking the same question several times, indicates concussion.
- Are they FAST positive? (Face droop, Arm weakness, or speech difficulties) i.e. Are they having a stroke?
Expose the injury
- Where is the pain?
- Look for irregularity and swelling. What is the range of movement like? Compare where the injury is to the healthy side.
- Dress any wounds.
- Minimise the pain as best you can.
If there are major problems with DRABCD, then you need assistance from the rescue and emergency services as soon as possible.
Real life Situation.
A paddler has capsized, hurting his arm, and has come out of his boat. We have got him out of the water and everybody is safe. Thankfully he is pretty sure it is just a muscular injury that he has sustained, as he has been able to move his arm a bit. It is winter, and he is wearing a drysuit. In this real-life case we are now close to a building where we can get shelter, otherwise we would have erected a group shelter. As I approach I get good eye-contact with the patient and he is able to talk to me normally, although obviously in pain.
Dangers: We have moved away from the water and we are now in a safe, accessible place.
Response: The patient has his eyes open, and responds to voice. The patient is alert.
Airway: He can talk, so he has a good airway.
Breathing: He can talk in full sentences, so his breathing is at least adequate. No pain on deep inhalation.
Circulation: He is conscious, so he has a pulse. His pulse is regular but fast due to pain and exertion.
Disability: He is alert. He is not confused, so that’s good.
Expose the Injury: Let’s look at this more carefully.
Expose the Injury
You have to work with the casualty. Be guided by what you have seen and what they are telling you. You can only do what they allow you to do.
In a harsh environment, there is a conflict. By exposing the injury, we will be exposing the casualty to the cold environment. A group shelter, if on land, can help minimise the impact of the cold, as can a warm drink. Choose not to expose, and you risk missing something important. For instance, an ankle injury will be painful, but an open fracture (where the bone has broken the skin) is far more serious. Only expose what the casualty allows you to expose, and only as much as is necessary to understand the severity of the injury. With a drysuit, cutting off a bootie, which is repairable, may be enough to view the injury. What is happening below the site of an injury is important too. Is the circulation system and nervous system still working below the site of the injury?
Going back to the incident of the shoulder injury, a group of us helped remove the drysuit. To control this, someone helped to support the injured arm, others undid the zip and then helped him get his head out first, then the good arm, and finally let the other sleeve slip off his injured arm. We had been able to remove the drysuit with minimal movement. It was now obviously a dislocation. He took some pain killers and we took him to A+E by car.
In a similar incident, half way down a river, the group were unable to remove the drycag due to the pain the casualty was in, but they could still compare the injured side to the good side, compare the range of movement, and come up with an evacuation plan. There is no ‘one rule fits all cases’.
Had this incident happened on the open sea, away from the shoreline, I would have contacted the coastguard, explaining the situation, and ask if they could offer assistance. A delay in treating a dislocation will lead to an increase in muscle spasm, an increase in pain, a more difficult procedure to relocate the shoulder, and a longer recovery time with greater long-term consequences. If blood vessels and/or nerves are trapped then the consequences can be even more catastrophic. The quicker you can get any type of dislocation treated the better the outcome, so rather than performing an heroic rafted tow for 4 kilometres, make use of your radio and get what assistance you can.
It’s immoral to leave someone in pain if you have the means to reduce that pain. Tools at our disposal are:-
- Cooling, splinting, bandaging, supporting.
- Pain killers
Your personal first aid kit should include some medication so that you can manage your own pain relief. Just think of all the possible injuries that you can sustain, and how many of those cause pain. Remember to read the leaflet before taking your medications.
Actions that can increase the injury, and associated pain, are moving the patient inappropriately. We’ll consider this more fully in the next issue.
If you would like me to review any incident or accident, no matter how small, I would love to hear from you. It’s not a matter of passing judgement, it’s about looking for patterns of behaviour and actions and seeing if we can learn lessons.
Andrew Barras has been paddling regularly since 1990. He has 5 star awards in both WW and sea kayaking. He works professionally as a paramedic in London and the Home Counties, and runs Aquatic First Aid Courses which are certificated by the BCU Lifeguards.