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Training => First Aid => Topic started by: adi on March 28, 2013, 12:21:48 PM

Title: Advanced Casualty Assessment
Post by: adi on March 28, 2013, 12:21:48 PM
DRCABCDE

D – Danger, (SAFE TAC)

S – Shout / send / signal
A – Assess the Scene / Approach with caution
F – Find &/or free the casualties
E – Evaluate Requirement & send ETHANE report

T – Trace & Treat   
A – (ABC) Airway, Breathing & Circulation
C – Communicate findings


ETHANE Report

E – Exact Location
T – Type of incident
H – Hazards (Actual & Potential)
A – Access
N – Number of Casualties
E – Equipment Required

R – Response (AVPU)
   
A – Alert
V – Voice
P – Pain
U – Unresponsive   

C – Catastrophic Haemorrhage (CAT HEM)

Stop catastrophic bleeds

A – Airway (TWELVE FLAPS)

Trachea – Position or Deviation
Wounds – To neck
Emphysema – Escape of Air
Larynx – Position
Veins - (In neck) Venous Engorgement
Everytime

Feel – Place hands on chest thumb next to breast bone. Watch for equal left & right movement. Check collarbone and breast bone.
Look – Open wounds, bruising & abrasions 
Auscultate – Listen for chest sounds
Palpate – Check for obvious wounds and check blood on gloves.
Search – check armpits and back.

B – Breathing

Normal 12 to 20 bpm if 10 bpm & under or 30 bpm & over assist with breathing by giving 10 breaths a minute) 

C – Circulation

Check Pulse, Capillary refill, Blood Pressure, Stop Bleeding & replace Fluids)

D – Disability

Check AVPU, Pearl x 2 (Pupils Equal & Reactive to Light), Blood Glucose (4 & lower sugar/20 & higher Insulin, FAST (Face, Arms, Speech, Time)

E - Exposure & Environment

Provide shelter and insulation
Title: Re: Advanced Casualty Assessment
Post by: Callum on March 29, 2013, 09:40:31 AM
Phew, that's a big mnemonic Adi for anyone to learn, maybe a wilderness medic who is working everyday but for the rest of us I doubt I would manage. Who is it targeted at?
Title: Re: Advanced Casualty Assessment
Post by: adi on March 29, 2013, 11:38:28 AM
Callum it is not one mnemonic it is many placed together in sequence of working with a casualty from start to hand off. It is how paramedics work but as first aiders we can leave out the bits we are not trained in.

It is from my notes I typed up from my medic course.
Title: Re: Advanced Casualty Assessment
Post by: adi on March 29, 2013, 11:42:53 AM
DRCABCDE should be taught in every first aid course. I have broken down each letter further.

You may know it as DRABC, DRAB, DRSABC, Or as primary & secondary assessments. 
Title: Re: Advanced Casualty Assessment
Post by: Lyle Brotherton on March 30, 2013, 08:59:32 AM
Very comprehensive Adi (as always) For me I need to continually practice First Aid to stay proficient and I have printed your list onto a small plastic card as a memory aid. I use these even when with a casualty, and I know some of them are thinking 'Does this guy know what he is doing' ;)

Alan Mcgee who is a team member and paramedic developed a casualty assessment card which also acts as an aide mιmoire, have you done this for your list?
Title: Re: Advanced Casualty Assessment
Post by: captain paranoia on March 30, 2013, 10:18:28 AM
I've just revised my DofE aide memoire, a little A7 notelet printout of things I need to do whilst supervising DofE groups, including notes on emergency and first aid procedure.  These notes are very personal, and might not make a lot of sense to someone else, but I know what they mean.

I find checklists useful, but you have to be sure they're inclusive, and haven't missed something, especially if it's a kit list you're blindly following as you pack in a hurry...

As I've said before, I don't find the convoluted mnemonics to be very mnemonic for me, as I can never remember what they mean.  But my aide memoire/checklist serves the same purpose.
Title: Re: Advanced Casualty Assessment
Post by: adi on March 30, 2013, 10:42:51 AM
I don't Lyle although I should if I am going to asses a casualty to the standard described above. Ambulances carry aid memoirs on board. Because I get a lot of practice doing normal first aid assessments whilst I am teaching I remember how to do it.

As first aiders we don't necessarily have all the equipment we need to do all of the above nor the training. Some of the above is for very advanced first aid and only really needs to be considered if acting as a team medic on an expedition abroad and obviously you need to be trained. However if you expect to be with the casualty for any length of time because of the time it would take for evacuation to be arranged then it is worth trying to do as much of the above as possible as it helps you to build a picture of the situation and you may be able to work out what more you can do to promote recovery and of course the more information you can give to the emergency response the better prepared they will be when they get to you.

The more information you can get at the time of accident is helpful to monitor the casualties condition is worsening or improving. If capillary refill or blood pressure drops it may suggest the casualty is bleeding and if you have not found any bleed it would suggest they have internal bleeding.   
Title: Re: Advanced Casualty Assessment
Post by: Callum on March 30, 2013, 05:26:35 PM
As obvious as it seems, I had not thought about carrying an aide memoir. So your list makes sense Adi as the ultimate checklist, which I guess you could use to what extent you choose, determined by the situation.

We currently use BASP to provide our courses and 3 year refreshers, yet for some time I have felt they are a little lightweight in content. Who do you provide for Adi?
Title: Re: Advanced Casualty Assessment
Post by: adi on March 31, 2013, 02:40:10 AM
Callum what course do you do? Is it an expedition & remote medicine course? My faculty is the Lifesigns group. I teach both first aid at work and expedition & remote medicine which are recognised by the outdoor NGO's and national outdoor governing bodies such as the MLTB, BCU, RYA ect. For the uk we teach venture medicine and there are more advanced courses for over seas expeditions.
Title: Re: Advanced Casualty Assessment
Post by: adi on March 31, 2013, 03:03:26 AM
I have just looked at the BASP site and see they do an outdoor emergency first aid course which sound similar to our venture course. What do they cover? If you are interested I will send you furthure information about the expedition & remote medicine courses we do tomorrow.
Title: Re: Advanced Casualty Assessment
Post by: Callum on April 02, 2013, 07:38:30 PM
Hi Adi, busy weekend and ready for my two days off - next weekend  :o Will PM you tomorrow :)
Title: Re: Advanced Casualty Assessment
Post by: captain paranoia on May 05, 2013, 11:51:56 PM
I need to revise my aide memoire, and do some 'mental training'...

I've just completed a first aid course; yes, my first such course in 50 years.  And the content of the course was mostly familiar, and I thought I'd be fine when it came to the exercises.

Boy, was I wrong. The scenarios were pretty full-on (multiple casualties, 'tricks' etc.), but I was ashamed and dismayed at just how poorly I performed, even under this moderate stress. My brain shut down, and I got tunnel vision on my casualty ( the only good thing was that I did pick the most serious casualty, and diagnose and treat properly). But we failed to assess the scene properly, or call 999 until well into the exercise. But the worst thing was the total lack of communication between the rescuers, to the extent that when the second-most serious casualty was found in near-collapse by one rescuer, she tried to attract our attention by shouting to us at the top of her voice, but we simply didn't hear her, due to tunnel vision focus on our casualties.  The second exercise didn't go much better.

All in all, a very chastening experience.  Besides the obvious of doing more scenarios, does anyone have suggestions for mental training exercises to help stay calm, assess and, well, do a better job?
Title: Re: Advanced Casualty Assessment
Post by: Lyle Brotherton on May 06, 2013, 08:48:46 AM

An honest appraisal CP and something which we will all have encountered, to some level or other, in similar stress training exercises.

Captain paranoia said: does anyone have suggestions for mental training exercises to help stay calm, assess and, well, do a better job?

You are already doing it, in that simply recognising the problem and searching for an answer is the first major step forward.

‘Knock at the door and wait for the answer’

This phrase was given to me by a WEMT (Wilderness Emergency Medical Technician)

C&C (Command and Control) is central to your solution, normally a term associated with the military, yet it is also best practice for all first level responders (Police, Fire & Rescue and the Ambulance Service) and something which UK Mountain Rescue implements very well.

10 years ago I was at the Scottish Mountain Rescue Shell Conference held in Aberfeldy. These meetings were designed to share best practise amongst the Scottish MRTs through a series of lectures and also in practical exercises. There was a night exercise which involved a downed aircraft. Something which happens more frequently than is often known in the Scottish mountains, especially with military low-level training flights. In addition, we have had major air crash disasters, my own team, TVMRT, were in attendance at the Pan Am 103 Lockerbie incident and were some of the first responders’ on-scene.

UK Mountain Rescue teams create 'Hills Parties' for every incident, comprising of the members who turn up at the shout, meaning that the mix of responders is frequently different. Hill Parties are usually 5 responders and each person is assigned a specific role, these are:
1.   Hill party leader
2.   Navigator
3.   Safety officer
4.   First-aider
5.   Comms

Whilst thru MR training each member can fulfil each role, due to experience some people are better placed than others for specific tasks, for example a team member who in his work life is a paramedic will invariably be assigned First-aider - My role was regularly as the Navigator;)

OK, back to the night exercise at Aberfeldy and why this is so specific to your training requirements CP.

A group of around 25 volunteers were mustered on the hill and briefed as a group that there had been a reported aircraft crash in the near vicinity; we were given no other details.

The first thing that this team of people did, some of whom knew each other and others who did not, was agree the C&C. We chose an overall leader for the night (Incident Commander), a second in command (2IC) and a Runner; I will explain more about this last role later. This process took 10 minutes.

The IC & 2IC assessed the information report, then determined which areas were to be searched by each of the Hill Parties. When they had determined this the IC2 briefed the parties as a group. The first important feature is that the IC never has any direct contact with any of the Hill Parties. If he/she wishes to communicate with them or vice a versa they do so thru their 2IC or the Runner. This strategy allows the IC to have a clear head and complete situational analysis of the incident from the outset and it works excellently.

As the Hill Partys reported back their findings, from aircraft parts to casualty in a tree (a parachutist) the IC was able to coordinate the Hill Party activities and allocate resources accordingly. Similar to your training scenario, our incident contained wild cards, from un-exploded munitions near one of the casualties to an irate drunk farmer and his vicious dog.

People like structure, it is the premise of our society, and it is remarkable to observe people when they know exactly what their task is.

A few years later I was by chance the first on scene at a serious road traffic accident involving a cyclist who had been crushed by a wagon turning a corner.

I clearly remember standing still for a few moments, probably no more than one minute, assessing the situation, looking around for other casualties, where vehicles had stopped and if the area was safe (Knock at the door and wait for the answer’) and when I had established that I felt safe to enter the area of the incident I assumed control (Hill Party Leader) of the people surrounding the girl. I asked specific individuals if they could do certain tasks, could somebody call the emergency services and stay on the line to them (Comms), could some other people stop or divert the traffic past the incident (Safety Officer) were there any doctors or nurses who could help (First-aider). The system worked and the young girl, who had suffered horrendous injuries, lived.

You could write a book on this subject, and many people have, my advice would be if you feel confident assume control at such an incident and designate specific task to the individuals in attendance. You can build your confidence prior to ever having to do this by visualising how you will act, imagining what you will do at such an incident – effectively role playing it in your mind. It works for me.
Title: Re: Advanced Casualty Assessment
Post by: captain paranoia on May 06, 2013, 03:36:22 PM
Yes, working as a structured team would certainly have helped, but this wasn't covered in the course, and I think we were all focussing on doing our first aid, rather than the wider emergency skills.

Waiting for a bit to allow the scene to sink in, and come up with a quick strategy would certainly help.  As I said at the outset, I need to do some mental rehearsal, so I might have a chance of being more capable in future.
Title: Re: Advanced Casualty Assessment
Post by: Lyle Brotherton on May 06, 2013, 08:22:32 PM
I was speaking to an educational specialist about your dilemma CP and explained to her the answer which I had provided. She observed that visualisation is one of the most important ways ion which we learn to both cope and deal with stressful situations, she recommends that you actualise verbalise, out loud, your imaginary scenario, ideally explaining your proposed actions to somebody else, if possible who has expert knowledge of the particular situation.
Title: Re: Advanced Casualty Assessment
Post by: Callum on May 07, 2013, 09:11:55 AM
Clearly explained Lyle:)

The mandatory interval for our staff to attend first aid refresher courses at our centres, is every three years. This is in compliance with HSE (Health & Safety Executive) guidelines. From experience we know that skills fade can occur much quicker and as a consequence we have adopted the practice of annual formal refresher courses, where all staff are re-certificated, in addition to frequent reminders, in the form of first aid questions at staff briefings, to keep us all up to speed.

Practice makes Perfect
Title: Re: Advanced Casualty Assessment
Post by: adi on May 07, 2013, 09:31:50 PM
The recommendation is to take a refresher course one every 12 month, this is not mandatory but if your organisation has a serious incident then they best have a good excuse when questioned at the Tribunal to why the organisation did not do annual refresher courses.

When we used to do the big night exercises during our remote course we used multiple casualties spread out over a couple of acres of land. I always played the confused aggressive mild Hypothermia casualty and I would be relatively easy to find, once I was found I would start to strip of my clothing and would become increasingly difficult to handle. Soaking up man power and causing general confusion. If I found the opportunity to wonder off I did and I would keep going and never stop. I never went too fast but it was amazing how many times I got clean away with no one noticing and I would rarely be found again.   

Command and control is Key. I tell my students it does not matter if you can't remember what you are supposed to do but by appearing that you know what you are doing people will listen to you and do what you want then to. Never ask people to help, tell them to do things. You ring the Emergency Services, Tell them where, what, when, risks and danger, numbers of casualties, injury's. ect.

When I responded to a toddler under a car the other person on seen was an off duty paramedic, he made the call whilst I started first aid. I knew he the right person to make the call and pass on the correct details and he could see I knew what I was doing if things had taken a turn for the worst he could step in and assist. A Paramedic has far more experience of seen safety than I do so it made scene assessed the casualty.

If Lyle creates an area for First Aid I am happy to add relevant threads from time to time and try and answer any questions.                 
Title: Re: Advanced Casualty Assessment
Post by: Callum on May 08, 2013, 03:12:09 PM
"I always played the confused aggressive mild Hypothermia casualty"
Bet you weren't acting Adi ;)
Title: Re: Advanced Casualty Assessment
Post by: adi on May 08, 2013, 05:17:17 PM
I did find it enjoyable Callum ;)
Title: Re: Advanced Casualty Assessment
Post by: captain paranoia on May 08, 2013, 06:33:44 PM
As well as doing mental rehearsals, I'll be converting Adi's original list into a form I can understand, to add to my pocket aide memoire.  Having done the first aid course, the list makes more sense now...
Title: Re: Advanced Casualty Assessment
Post by: adi on May 09, 2013, 11:52:34 AM
CP my original list is very advanced and well beyond that of a First Aid course, Just try to remember what you was taught on your course and build on that. If you have any questions please feel free to ask, I will try and answer them for you.
Title: Re: Advanced Casualty Assessment
Post by: captain paranoia on May 09, 2013, 06:37:56 PM
Actually, there's not much in your list that wasn't covered to some extent; the detailed airway stuff, and bloods (glucose, etc), but most of the other stuff makes sense from the training we did (18 hr outdoor FA course; we also covered AED and epipen).

I don't like mnemonics, as I can't remember what they mean, but I'll use the basic information to add to my aide memoire.  I'm sure that I will need a checklist of things to do, and, given a few words that mean something to me, I'll remember what to do.  It's just something to get myself past the mental block/freeze; a prompt, or cue.  Once I've got familiar with my aide memoire, it'll stick in my head, and I'll be able to recite what I need to do without it; I think the vocalisation will be useful.  That's the way my brain works.

I know I won't be carrying the aide memoire all the time, but I will when I'm doing DofE, which is what the training was for.

I also know from past experience that I stay passive for a while, but my brain eventually wakes up and I take charge if needed.
Title: Re: Advanced Casualty Assessment
Post by: adi on May 09, 2013, 07:10:42 PM
I am crap with mnemonics too and pre hospital care is full of them. Far more than the military use. I make memory cards to help me memories them.   
Title: Re: Advanced Casualty Assessment
Post by: Lyle Brotherton on May 11, 2013, 09:40:50 AM
You First Aid knowledge is invaluable Adi and I most certainly have learned a lot from it. As requested, the new board is at http://micronavigation.com/forum/index.php?board=25.0
Title: Re: Advanced Casualty Assessment
Post by: adi on September 20, 2013, 04:33:42 PM
All in all, a very chastening experience.  Besides the obvious of doing more scenarios, does anyone have suggestions for mental training exercises to help stay calm, assess and, well, do a better job?

Practice practice practice. I can do chest compression's to the correct rhythm and depth whilst still talking to my students with no loss of performance or breath. I taught myself the correct rhythm not on a dummy but by portending to do it whilst doing other things.

Flip cards are great too.

Get some cards and write some key phrases on each. On the reverse write the answer. When testing yourself look at the phrase and try and giv the answer then check your answer.     

For instance. just a couple of examples.

Sprains & strains
R
I
C
E

Rest
Ice
Compression
Elevation 

or

Signs of Stroke
F
A
S
T

Face is it showing signs of dropping
Arms ask person to close arms help them hold arms out in front of them and let go, does one arm drop?
Speech, do they have slurred speech
Transport

and

Primery assesment
D
R
SH
A
B
999

Danger to you or cas
response, noting level off
Shouting for Help
Airway is it open?
Breathing? Are they and how effective?
999 call 999 or 112

and lastly and my favorite
F
I
S
H
S
H
A
P
E
D

Faint
Infection including temperature
Shock
Head injury
Stroke
Heart attack
Asphyxia
Poisoning
Epilepsy or any seizure
Diabetes
     
Title: Re: Advanced Casualty Assessment
Post by: captain paranoia on July 21, 2016, 06:16:05 PM
> I need to revise my aide memoire, and do some 'mental training'...

Well, three years on, and we have a refresher course. And I'm not sure I did much better in the exercises than last time... Still very focussed on me doing basic first aid, rather than dealing with the situation as a whole.

I've taken to watching the various emergency services TV programmes, and seeing how they deal with incidents. And the thing that strikes me most is the obvious (that I failed to do): say who you are, and ask who they are; ask them what happened. Then you quickly find out their basic state (AVPU), and get a clue to what injuries they may have, how many are in the party, whether there are other casualties, etc.

If only I could get my brain to react calmly like this. Back to the mental exercises to try to din this approach into my brain...