First aid in the field

medical rescuer Tomasz Kutycki

People practicing professions, hobbies or sports that induce the risk of an adverse incident, deterioration of health, in a place with limited or delayed availability of emergency services, should be prepared for quick and effective rescue operations. Considering the situation in which it may be necessary to wait a long time for assistance at the scene of the accident or it becomes necessary to conduct the evacuation of the injured person, it should be assumed that reliable preparation of the rescuer for such an eventuality may decide the fate of the injured person.

You must assemble a first aid kit, develop an emergency plan, acquire the necessary skills, knowledge and maintain high physical fitness. Managing a crisis may also depend on mental resilience and self-confidence. Efficiency will definitely be improved by properly selected medical equipment included in the expedition's inventory. It is important that all persons involved in the rescue operation are prepared for it according to the rule: "even the best plan will not work if nobody knows it". The rescue operation can be divided into three basic elements (Table 1): extraction, treatment, evacuate. In each of these three areas, efficient and coordinated actions increase the chance of success for the entire operation. I suggest completing our first aid kit in the order in which the acronym MARCH appears.

We start with M (massive hemorrhage) , i.e. massive hemorrhage. Considering that rapid blood loss leads the injured person to irreversible changes in the functioning of his tissues and organs, significantly reducing the chance of rescue, the first aid kit should contain equipment enabling effective identification and control of bleeding. Considering that when assessing the condition of the injured person, external injuries with uncontrolled intense blood flow should be found as soon as possible, it is worth mastering the technique of rapid trauma examination (Head-to-Toe) from experienced head to toe. Black gloves should not be used for examining victims because of poor blood contrasts on them, which may result in the injury being missed during palpation. During activities, it should also be remembered that it is very easy to upset the internal balance of the body, functioning properly in a narrow range of vital signs. The enzymes responsible for cell metabolism work best at pH 7.4 and 37 degrees Celsius. Blood loss can lead to oxygen deficiency in tissues and the start of anaerobic transformation with the production of lactic acid, which results in a decrease in blood pH that interferes with body hemostasis, as well as a decrease in body temperature. Therefore, one of the first rescue operations at the scene should be to detect heavy haemorrhage and stop it. It is invaluable in this situation to have a set for stopping heavy hemorrhages, which includes: a pressure dressing, a hemostatic dressing, a pressure bandage. Our first actions must be determined and thought out. If the injured person will have to wait a long time for the final supply of the injury in out-of-hospital conditions, let's try to limit the use of the compression band to the necessary minimum (only for situations directly saving lives), let's try to control the hemorrhage with a hemostatic dressing and / or a compression dressing. This solution is more beneficial for the patient in view of the possibility of cutting off circulation in the whole limb. If the injured person is not bleeding or the bleeding has been under control, the next step should be to keep the airway open.

A (airway) airway patency . In this action, you must stick to the principle that "air must enter and exit the respiratory tract" providing the injured with sufficient oxygen necessary for the breathing process. In the first phase of operation, make an assessment called the "5 second" test. Ask the victim what his name is. If he answers, you can assume that he is conscious, has a clear airway, breathes, maintains circulation and arterial pressure ensuring proper blood flow through the brain. This means there are no indications for maneuvers to clear the respiratory tract or use of instrumental unblocking methods. The situation changes radically in unconscious patients who are at risk of obstruction of the respiratory tract due to body position or flooding of the respiratory tract with blood, stomach contents and other secretions. The first aid kit should have a nasopharynx or oropharyngeal tube that allows instrumental airway management for the unconscious. This is especially important in situations where tilting the head back due to suspected injuries is not recommended. The solution to this problem is the possibility of using one of the mentioned tubes to maintain patency of the upper respiratory tract. Another indication for the use of instrumental airway management is the evacuation of an unconscious victim, during which it will not be possible to keep the head in a position that guarantees free ventilation. The legal aspect of the instrumental airway management is regulated by the Act on Emergency Medical Services. In connection with existing regulations, it is recommended to complete a qualified first aid course.

R (respiration) A problem in looking after a seriously injured person may be the need to support the breath. In the event of high spinal cord injury, intoxication, chest injury with concomitant pneumothorax, or flaccidity of the chest in the face of multiple rib fractures, active respiratory support may be necessary. After stopping bleeding and opening up the airways, it becomes a priority to treat chest injuries. Start by providing penetrating wounds. ERC guidelines do not recommend that first aiders apply valve dressings or seal the chest wounds. This is correct as long as there are possibilities to immediately transfer the victim to emergency services. In a situation that forces us to a long period of care for a victim with a wound penetrating deep into the chest, it seems more beneficial to perform the wound closure using a vent dressing. At this point, it is also important to answer the question whether puncture (needle) pneumothorax is a first aid treatment? A negative answer to this question arises intuitively. This fugitive belongs to the competence of persons authorized to perform medical rescue operations. It should be remembered, however, that no law prohibits the use of a method that gives a shadow of a chance to save human life in the face of inevitable death. In extraordinary situations of isolation from medical staff, the principle "Volenti non fit iniuria" may apply - the wanting person does not hurt. "I know you don't have permissions, but I also know you have equipment and skills. My life is at stake, so do everything you can to save them." If the victim requires chronic ventilation, a self-inflating bag with a face mask will be an indispensable piece of equipment. Learning to use a self-inflating bag includes practical and theoretical classes in the qualified first aid standard under the guidance of an experienced instructor.

Step four C (circulation) means circulation. Circulatory support in a situation of isolation from external help is difficult, and statistics show that cardiac arrest in such situations often results in death of the injured party. However, you should prepare for emergency rescue in the event of anaphylactic shock failure. A key action in the event of developing symptoms of an anaphylactic reaction is the rapid administration of adrenaline in the form of an automatic syringe. The use of automatic syringes with an appropriately prepared dose of medicine has been recognized by ERC as an activity falling within the competence of first-aiders. This recommendation on the basis of the Polish legal order should be understood as suggestions for administering adrenaline to persons carrying an automatic syringe previously recommended to them by a doctor. Other activities include ensuring thermal comfort and lying position. The anti-shock (Trendelenburg) position also known as auto-transfusion involving the positioning of the patient with the legs above the head as a way of gravitational displacement of a certain volume of blood lying in the upper and lower limbs to the central system is not justified by the studies conducted on it. In theoretical assumptions, the positioning of the patient with the legs above the head was supposed to support blood flow to the central system and support the centralization mechanism, for this reason this position was called auto-transfusion. Herbert Bivins (Department of Emergency Medicine, Valley Medical Center, Fresno, California) research on 10 volunteers aged 24-38 using Technet labeling technique with 99m red blood cells showed that the use of the "auto-transfusion" position with a slope of 15O resulted in a 3.2% blood shift from the lower limbs and 1.8% from the upper limbs, which in the cited study meant an average blood volume shift of 270 ml. This self-transfusion effect can certainly be considered clinically insignificant. None of the studies carried out between 1967 and 1996 demonstrated the effectiveness of Trendelenburg's position in treating shock, and the effects of increased left ventricular filling, increased stroke volume and minute capacity were transient. In the absence of the auto-transfusion effect of Trendelenburg's position and associated adverse consequences in the form of the risk of cerebral edema, deterioration of lung function, risk of retinal detachment, it is legitimate to use it only to temporarily improve the injured person's condition.

H (hypothermia) cooling down. Disorders in the energy management of the human body caused by serious injury or illness rapidly accelerate the process of heat loss. The deepening hypothermia and related changes in the functioning of enzymatic transformations and blood coagulation adversely affect the effects of rescue operations. The rescue operation must aim at preventing the loss of heat by the injured organism by cutting off four basic ways of heat escape: conduction (contact with cold objects), convection (taking away heat particles by a sweeping stream of cold air), radiation and evaporation. If possible, remove wet clothing from the patient. Then wrap the victim in as many layers of material as possible with airspaces. Protecting the patient against wind and moisture will reduce heat loss. If it is necessary to evacuate the injured person from the scene of the accident, one should be well prepared for it. When planning an evacuation operation, it is a good idea to adopt the principle that "incorrect planning is error planning". When performing manual evacuation of the injured, rescuers should provide the stretcher with four support points. The only exceptions are places where it is physically impossible (narrow passages, footbridges etc.) or actions in which a small number of rescuers participate. In such situations, it is recommended to plan frequent rests or changes of persons transporting the injured person. The most advantageous situation when transporting the injured person manually should be the possibility of using 8 rescuers for every 100 meters of difficult terrain and 6 rescuers for every 100 meters of easy terrain. Manual transport is a very demanding method. You should change your rescuers every 15 to 20 minutes or show signs of fatigue. One must not forget to appoint one of the rescuers to constantly monitor the injured person's condition in terms of basic life parameters and thermal comfort. When carrying the victim, it is worth supporting with tapes, straps, ropes transferring the load from the hands and forearms to the shoulders and backs. The injured person should be prepared carefully and carefully with maximum comfort. When preparing the patient for moving, care should be taken to protect his head and face, especially his eyes, check that the elements of the stretcher, such as straps and clamps, do not compress the patient's body, which may lead to local circulatory disorders or damage to peripheral nerves. Due to the limitation of physical activity, the injured should be protected from wind, cold and precipitation. For long transport, anti-decubitus prevention should be introduced by providing the patient with the opportunity to change position, and in the case of an unconscious or seriously injured person, change his position obligatorily every 2 hours. It should be expected that with evacuation operations lasting over 12 hours, the injured person will have to arrange his physiological needs, which may require him to leave the stretcher with the assistance of rescuers. In the case of seriously injured or unconscious persons, the use of improvised diapers and planning of care procedures should be considered in order to avoid burns and improve the comfort of the victim in a broad sense. Complete immobilization of the transported person carries the risk of deep vein thrombosis. As part of antithrombotic prophylaxis, the victim should be taught a few simple exercises to activate the lower limb muscle pump. In unconscious or non-cooperating persons, massage of the lower limbs should be performed at least once an hour. We perform these treatments on condition that they do not increase the severity of the primary injury. Improvised stretchers should be tested on a healthy person beforehand.

As part of long-term evacuation activities, care for pain control and infection prevention is important. As part of broadly understood first aid, according to its definition, the rescuer has the right to use medicines available without a doctor's prescription for its delivery. When choosing medicines for the first-aid kit, the following principles should apply:

  • broad spectrum of activity
  • speed of action
  • minimal side effects
  • resistance to storage conditions
  • simple dosage
  • minimum dimension (weight)
  • number of people to be treated.
  • Difficulties may arise in the prevention of infections, as antibiotics are usually needed. Possession and use of antibiotics should be consulted with a physician. Moxifloxacin and cefamecin are frequently recommended antibiotics for emergencies. Both active substances have a very wide spectrum of activity and are effective against atypical pathogens. Before giving any medicine, read the package leaflet or consult your doctor.

    Composition of the first aid kit:

  • Compression band
  • haemostatic dressing
  • Ready compression dressing
  • A set of nasopharynx or oropharynx tubes
  • Foldable self-inflating bag
  • Pre-filled syringe with adrenaline (prescription required)
  • Thermal blanket
  • A set of small dressings
  • Antibiotic for use on minor injuries
  • Anti-pain and fever drugs
  • Broad spectrum antibiotic (prescription required)
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