Turning an accident into a disaster

Hitting the fan

When it does, the actions that the people involved take, significantly affect the outcome of the event. Generally we think of disasters as affecting lots of people. Many people dead and injured. On a personal basis, you falling from a height, breaking your leg and consequently not being able to pay your mortgage is a disaster.

This is about how quality first aid training and the applied skills, alter the outcome of an accident

The points below are about what makes a bad situation worse, the mistakes that we make when faced with a very challenging situation.

People become disoriented in their environment

You plan your days work, the address of where you are working. What about your journey to and from work? The "Devon Air Ambulance Trust App" locates us within a few seconds with a six figure map reference, plots where you are and has a box to dial 999/112 straight away.  It works on all smart phones.
We are atrocious at communication. There are more studies than we can shake a stick at to say how poor we are at calling for help. The Ambulance services spend a huge amount of time and effort trying to dissuade us from using them. When it comes to an emergency, people hesitate to dial 999/112. The majority of simple first aid incidents we will sort out without complication. However, the boundary between simple and cock-up is small!

Plan for access and egress
How does the ambulance get to you off the road.?  If you are a long way off the road, does Ambulance control need to send Helimed?  Only you can tell them. Know where your equipment is - first aid kit etc. It is no good in the front of the van, half a mile away. Know where your colleagues/help are.

We fail to anticipate or plan

First aid training:- a lot of the training we receive is not fit for purpose (some is, I hasten to point out). It is up to you, the purchaser to exercise "due diligence" when organising your first aid courses. Choose companies that are experienced and understand your needs.

Failing to plan is planning to fail

First aid training, understanding how thinking around and planning for a situation going pear shaped, makes a huge difference to the outcome.

Have effective communication system 

Make sure when you leave for work your phone is fully charged. Have you got a network where you are working. That is less important for the initial 112 call, as your phone can cross network dial. However, you will not be able to get a call back from them.  I have an old phone, will a payg EE sim in it, for the odd time when I need to speak to WMAS and I have no network. 

Call the ambulance service/fire & rescue early
If you panic and call them early, then later discover that you have overreacted, ring them back and stand them down. Not a problem. Someone bleeding, and you not stopping it, is a very big problem. If the situation changes, ring them back and tell them.

Get colleagues to help early
Get all your team involved. There is plenty to do. Someone to meet the ambulance, keeping the patient warm, sorting out evacuation etc.

We become fixated on one issue 

We are often overwhelmed by the situation and obsess over one thing.  People see blood and panic, or see a broken arm and panic. We see the first part and then stop looking. We frequently see this in people in all walks of life. We miss obvious things because we are overwhelmed by the circumstances. If we have been injured in one place on our bodies, why not anywhere else. Have a good look.

We are overwhelmed by noise/alarms/people
Noise is extremely distracting.  Step back – check situation, is everything happening that should be? If you are team leader, have you got it all going? Someone on the phone, one or more doing first aid, access/egress, meeting the ambulance, keeping warm etc.

Delegate someone to be situationally aware. Last week I was dealing with a collapsed lady in the street. A bus touched my arm. I had not heard or seen it.  It scared me. I moved my car to close off the carriageway. The motorway is extremely dangerous, a number of people are killed every year just stepping onto the live carriageway.

Distribute workload

Crew resource management, one person one job.  Each crew member carries out their specific role. Apply this to the emergency situation. We loose many of the above skills when overloaded with functions, therefore, one person needs to take overall charge and delegate. This avoids many of the above faults by checking that functions are being done. Move people around to stop them becoming tired.

You should have learned all about this on your first aid training course. I teach it on all of mine. We can be contacted at www.axiomtraining.com there are links there to other blogs, facebook etc.

Communication is vital – to the patient, to the team, to ambulance control!

 By Martin Bennett

Director Axiom Training Ltd.

Humans breath air!

Drowning is death caused by submersion in a liquid. Near drowning is injury caused by submersion, but the person does not necessarily die.

To make a very distressing, large subject understandable, I have broken it down into segments.

Dry drowning

Approximately 15% of everyone who dies as a result of submersion, will dry drown after the maximum period of breath holding, which in warm water can be 20 to 40 seconds. However, in cold water this is only 5 to 10 seconds of breath holding. The individual will be unable to resist the stimulus to breath. They will make an attempt to breath, whilst still submerged. Water enters the person's mouth, they repeatedly attempt to swallow. Eventually, after a few attempts their epiglottis, and particularly their vocal cords, close off. In these patients no water reaches their lungs and they in essence asphyxiate.

Wet Drowning
In wet drowning, approximately another 15% of deaths, the person is more likely to have had an altered level of consciousness, from alcohol, a head injury or a heart attacke. They are unable to get to the surface and clear their airway. They then inhale water into their lungs. The damage this causes is catastrophic. The small globules of water readily block their bronchioles and terminal bronchioles. There is massive collapse of the alveoli and death follows rapidly.

This type of event can also happen in very cold water. When the person enters the cold water there can be a very powerful "gasp" reflex. They directly inhale the water.

Autonomic Conflict
Cold shock or autonomic conflict - As a human enters cold water cautiously, and as the water rises up our body, we experience a vastly increased heart rate, known as a reflex tachycardia. As the cold water encroaches further up our body, our heart rate increases. However, if we suddenly submerge our face into cold water, this has a dramatic and opposite effect. This stimulus, known as a vagal stimulus, aggressively slows our heart rate. This technique years ago was used to slow inappropriately fast heart rates in hospital.
When a person falls into very cold water, as the cold moves up their body, it stimulates their heart to go much faster, when their face enters the cold water, that separate stimulus slows their heart rate. The conflict between these two stimuli can be so powerful that it can stop our heart. The longer the person is in/under the water, in seconds, the stronger the conflict becomes.

The remainder
The remaining 70% of deaths occur from a combination of the above effects. Perhaps the most common being a gradual loss of consciousness, either from the cold, or hypoxia, or both, fighting to stay above the surface - exhaustion. The individual gets small amounts of water into their airway, they continue to struggle, more water enters, their level of consciousness deteriorates. There is often not enough water in their lungs to have killed them alone, it is the combination of some or all of the above factors.


Near and secondary drowning
In these cases the patient has experienced a period of submersion, and has been rescued or self rescued. They have got small amounts of water into there larger, or even their smaller airways. They have enough air exchange to survive at the moment. However, the presence of a liquid within the bronchioles, and terminal bronchioles, can alter the physiological function of the airway wall, and blood plasma can start to collect in the airway. There is a dilution of surfactant, which inhibits the movement of oxygen across the alveolar membrane. Collectively this gives rise to  pulmonary oedema, it can rapidly build up to the point where it becomes fatal. There have been a number of cases around the world where patients have been rescued alive, believed that they were ok, or others have believed that. They have then gradually succumbed to the pulmonary oedema and died either in hospital or before they have got there. A few people have been found dead in bed.

Assessment and first aid
The first aid assessment of this patient is relatively straight forward. The vast majority of people who have a minor water event are just fine. Once out of the water, they are fully conscious, with no untoward symptoms. Their breathing is clear, with no persistent coughing, no nausea, no altered consciousness and no hypothermia. Having stated that, if the patient worries the first aider, send the patient by ambulance to hospital when possible.

If the patient has any respiratory difficulty, even minor, they must go to hospital. If they have had an altered level of consciousness they must go to hospital. If they have wheezing, intercostal retractions, nasal flaring, diaphragmatic breathing, or any cyanosis.  Persistent coughing, nausea and vomiting are serious signs. Hypothermia will be a common associate of the near drowning victim, and can be a nightmare to manage. The patient will need a great deal of insulation from blankets or clothing. The only thing the shiny metal blanket will do is help to keep the patient dry, they have no insulation value.

Resuscitation
Resuscitation from drowning is almost impossible.  The causes of their cardiac arrest are complex, and often spread out over a long period of time. There are life threatening difficulties in rescuing the patient. Many people have died attempting to rescue the drowning victim. Once the patient is rescued, they are very unlikely to be in a shockable rhythm. There is often irretrievable damage to their lungs, they have been without oxygen to their brain, sometimes for very long periods. The chances, therefore, of a person surviving this are slim to non existant. However, people have survived, sometimes after very protracted resuscitation attempts. I believe that we should try as hard as we can to resuscitate the patient. The resuscitation attempt will not be pleasant. The patient is highly likely to regurgitate large volumes of vomit. There will be lung matter being ejected from their airway. The patient will probably be incontinent.

Start uninterrupted chest compressions as soon as possible. If it is possible to ventilate, do so immediately. Give 5 initial breaths. If not, start chest compressions. Do not stop for anything or anyone. When a suitable ventilation device (pocket mask) is available, do the standard 30:2 compression to ventilation ratio.
Keep going, get people to help, it is exhausting.
Do your best to keep the patient warm.
Don't stop until the paramedic tells you too.

I have painted a bleak picture of the drowning scenario. If it does happen, call for help early, give a good location. Get people to help you, keep trying.

Clip of boys on the ice/falling through it!
http://goo.gl/VxlLia

I hope that no one is ever involved in one of these situations. 441 people died from drowning in 2012.  Any comments would be welcome.

By Martin Bennett
Director -  Axiom Training Ltd.

Adult or Paediatric First Aid?

Paediatric First Aid training, do you need it?
Adult First Aid training, do you need it?

There is an easy answer provided by OFSTED - If the child being looked after is pre-adolescent, paediatric first aid is appropriate.  If the child is older, then an adult certificate is needed. I would interpret this as saying for a nursery, pre-school and first schools just a paediatric certificate is required. Remembering of course, you MUST make a provision for your staff! For Primary and Secondary Schools, the adult "First Aid at Work" is the appropriate standard.
It would seem logical to me that first aiders in all schools who have younger children should have both paediatric and adult first aid qualifications!

Why the big difference?
The HSE make numerous requirments about the course content for First Aid at Work (FAW) which are described eslewhere. The Early Years Foundation Stage guidelines lay down what should be taught on a paediatric first aid course. The syllabii are largely similar, with differences identified, such as the different resuscitation techniques.

The main differences between adult first aid and paediatric first aid are:-

Rescusitation - Adult CPR, 30 chest compressions to every two ventillations
Paediatric CPR,  5 ventillations, then,  30 chest compressions to every 2 ventillations.

Choking - everyone over 1 year old, 5 back slaps, then 5 abdominal thrusts
Under one year old - 5 back slaps, then 5 chest thrusts

Asthma - everyone over 5 years old, 4 x 100mcg salbutamol via spacer device, followed by three doses of 2 x 100mcg salbutamol.
Under 5 years old - 2 x 100mcg salbutamol via a spacer device, followed by four further 2 x 100mcg doses

Medications - the paediatric first aider is required to be able to administer a child's medicines, including epipens.

The HSE state that the giving of medications is outside the remit of the FAW course, if this is to be taught then a specific provision must be made to allow for the extra time necessary!

The Government has made provision to deregulate paediatric first aid after the 1st September, 2014. The Local Authority will no longer have any involvement in the first aid provision - its up to YOU!

"The changes now mean that the childminder training will not have to be approved
by the local authority (LA) as was previously the case. This will enable LAs to
focus their resources on early years and childcare providers who need to improve
the quality of their provision, in line with the wider changes we are making to the
role of the LA in the early years. It will also enable the market to be opened up;
improving access to training from a range of providers to offer bespoke courses.
With regard to paediatric first aid training, we have put in place additional
safeguards on what the training should cover. Providers will be able to choose
which organisation they wish to provide the training (preferably one with a
nationally approved and accredited first aid qualification or one that is a member
of a trade body with an approval scheme) but the training must cover the course
content as for St John Ambulance of Red Cross paediatric first aid training and be
renewed every three years. The 2014 EYFS now requires that “at least one person
who has a current paediatric first aid certificate must be on the premises and
available at all times when children are present, and must accompany children on
outings.”

It would seem to me that the differences between the two concepts (paediatric and adult first aid) are minimal. I get my students for three seven hour days. That's plenty of time to cover all the differences. I know we need to eat, drink etc, but there is plenty of time to cover all the nuances of the various bits, relative to age related techniques.

Is the biggest difference price? Many training companies and organisations want their staff to do a 3 day FAW course and a 2 day paediatric course. As mentioned above, the syllabii are largely the same, so why?
Charge everyone for an FAW course, then charge almost as much again for the paediatric course. NOT FAIR and NOT NECESSARY!

Axiom Training run a 3 day first aid at work course, which includes the entire of the paediatric syllabus, the giving of medications and advisory defibrillation, at NO EXTRA COST. I have shaved a bit of time off the tea and lunch breaks, and built the necessary protocols up into the full range of resuscitation techniques. The same with asthma, allergies and all the other parts!
Our courses are approved by Worcestershire County Council for Paediatric first aid, we also are approved through the First Aid Industry Body for First Aid at Work and Paediatric first aid

Our main website has all the costings and course dates etc http://www.axiomtraining.com/course-dates.php

If you can think of any other differences between the techniques, please let me know. Or indeed any other thoughts about what I have written here!

By Martin Bennett
Director Axiom Training Ltd