The purpose of this article is to make you consider the process of dealing with a casualty so that you make good decisions.
First of all, let’s consider safety. When we talk about safety, we’re thinking firstly of our own individual safety, secondly of the group safety and thirdly the safety of the casualty. Once the group is safe, they can start working as a team. On the sea, we may all turn our boats and paddle into the prevailing conditions to maintain our relative position to each other. Maintaining group control and communication is a group safety management strategy. We have acted as individuals to make the group as safe as possible. We are now able to help the patient.
An injury or illness sustained by a kayaker in any environment will throw up many challenges. I want to help you recognise those challenges so that you are better prepared to meet them. There are key challenges to consider.
Your location on the river bank, shoreline, portage route, roadside, pool side, or still in the water, will present you with unique challenges. Hazards will change with time. For those by the shoreline, a rising tide may enforce a move, whereas for those inland, if it’s raining, any paths will become more slippery and river levels rise. Temperatures can fall dramatically and without food or drink people will get colder. Failing light will accentuate the dangers.
Everybody in the group will be stressed by an incident, especially if someone is injured. The group leader, the most accomplished first-aider, the patient, and the rest of the group will all have different stresses to deal with, and these need managing.
In a hostile environment, assessing the casualty, who is likely to wearing a few layers of protective clothing, could nevertheless be cold and physically exhausted. This will challenge anyone. Judging the severity of the injury is crucial and establishing a baseline of where you are and will help you develop a strategy to resolve the situation.
As well as using your first–aid kit, you may have to use other equipment and personnel to ensure safety and make progress throughout the incident. This is especially the case if you have to move the patient, even if it’s a very short distance.
How are we going to move from our baseline, from where we are now, to a satisfactory resolution? How is the group going to manage the physical, psychological and technical challenges so that you have the best possible outcome?
This incident management is an interwoven process that moves from a state of uncertainty to resolution. These challenges will change with time and new ones can arise, and they will have a knock on effect. Keep on evaluating. Is the situation getting better, staying the same or getting more chaotic? Keep asking yourself, and be open to suggestions from others, as to whether there is anything you can be doing better. Think through each action. What are the consequences if it doesn’t go to plan? Stay safe. Remember the basics.
- Preserve Life.
- Prevent The Condition From Worsening.
- Promote recovery
Resolution and Reflection
The road from Incident to Resolution and Reflection is not a smooth linear process. That’s why at the centre you have constant risk analysis and re-assessment going on, what I have termed here as situational awareness. Even if the casualty is doing well, the challenges will keep on changing. For instance, as more help arrives, your physical and psychological challenges may diminish, but as you reassess the situation, you may now have more options, which could increase both your tactical and psychological challenges. As the medical challenges are overcome and you see your casualty improve, the psychological challenge may diminish for most of the group, but the new tactical challenges for those making decisions on what to do next will increase your personal psychological challenge.
Let me give you a real example where a training session was taking place on a canal. It could very easily have been a quayside, or close to a jetty.A paddler has sustained a shoulder injury, but within a few seconds he is standing waist deep in water, close to the side of the canal and the club house is nearby.
Psychological Challenge: The patient is concerned by his injury, but thinks it’s just a pulled muscle. He is probably trying to convince himself that it’s not serious. The others are concerned for his well-being but not alarmed or upset.
Tactical Challenge: How can we get the casualty out of the water and at the same time prevent the condition from worsening. The bank is man-made and is effectively 60cm vertical wall from flat ground to water level. There are no steps nearby. Railings near the edge mean we can anchor people who will lift, but then there will be a second move to get him over the railing. We’re going to have to lift him out of the water and we’ll do it in two stages, first, so that he can sit on the edge, and then we’ll help him to stand up, and step over the railings.
Physical Challenge: How can we safely lift the casualty out of the water. We’ll be lifting approximately 80kg vertically. We need to get people to help from above and below, using his dry-suit and buoyancy-aid, whilst avoiding his injured arm that he’s supporting with his good arm.
Medical Challenge: We’ll assume it’s a dislocated shoulder until proven otherwise. There is nothing we can do for him in the water. He is supporting his arm himself.
Technical Challenge: We’re not using any specialist kit, we just have to get enough hands onto his kit and clothing so that we can lift effectively. It’s essential that the lift is co-ordinated. We are now checking that everybody who is going to lift are themselves well-anchored, so that the situation does not deteriorate! At this moment, the patient mumbles that he’s ‘going’, and starts to slump. The initial adrenaline rush from a minute or two earlier has worn off. His blood vessels have dilated, blood has pooled in his legs and he has fainted.
Psychological Challenge: The group are now challenged. An unconscious person in the water, with an arm injury is scary. What’s the best thing to do? We’re ready to lift.
Tactical Challenge: We need to consider the consequences quickly and efficiently. This is where experience and good first-aid skills become crucial. Nobody is in position to protect the airway during the lift. So we have an airway problem. He is breathing, but there is circulation problem. He has fainted because not enough blood can flow to his brain. Lifting an unconscious patient vertically is dangerous. There is a condition known as ‘suspension trauma’ which can be fatal. People working at heights with ropes and in chest-harnesses need to be know how to prevent it in case they ever get suspended head-up and motionless. The other option is to lay him flat on the surface of water. There is no current. We can protect his airway, and lying flat means that his head is now level with his heart and legs and so blood can flow more easily to his brain, which will promote recovery. It’s an easy choice although to some it’s counter-intuitive.
Medical Challenge: To maintain an open airway, the patient was laid on his back in the water. The patient was supported in the water, assisted by the buoyancy aid whilst the person at the head end had one hand either side of the head and could tilt it gently back.
Physical Challenge: Because of his buoyancy we don’t have a physical challenge. The patient regains consciousness about 20 seconds later. We give him plenty of time to recover and then move slowly from horizontal to standing in the water, allowing his body to adapt gradually. We then completed the rescue.
And so the cycle of tactical, technical, psychological, physical and medical challenges continue until you reach a resolution where everyone is safely back on dry land, in the best of health possible, and able to reflect on the incident.
This model of Incident Management will appear familiar to those of you who are going through, or have been through, the coaching process. It is based on the PPTT model of coaching paddlesport. I have used the PPTT model as part of my reflective practice as a paramedic, and found it a useful tool to improve my professional performance.
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.