September 9, 2008
The Real First Aid Guide
By Simon Cameron
Would you know what to do in a medical emergency? You might think so, but a little knowledge can be a dangerous thing, says A&E doctor Simon Cameron
A little knowledge is widely recognised as being a bad thing. Nowhere does this apply more than in medicine, and emergency medicine in particular. While pre-hospital treatments can be life- or limb-saving if carried out correctly, occasionally the best thing that can be said about some first aid is that it didn't actually kill anyone. The sketch of the first-aiding characters from Little Britain who treat their patients with a variety of minty sweets is, of course, far from the truth, but not quite so far as to be completely unrecognisable.
I'll furnish an example. A man had passed out at work, and was brought in by ambulance. It turned out that he'd just fainted. Two work colleagues accompanied him on the way in, one of them the trained "first-aider" for that shift. He was looking very pleased with himself as he told me the story, one part of which was "we held him down in the recovery position until the paramedics arrived". And they had. Not "placed" him in the recovery position but actually forcibly held him down in that position as he tried to get up, having come round very quickly from his faint.
The recovery position does not actually aid recovery - it is just designed to stop things getting any worse. It is specifically for people who are unconscious, but who are breathing on their own and have a pulse. Lay them on their back and there's a chance they could obstruct their airway either with their own tongue or with vomit. That's why the recovery position has people on their side, with the head supported. The enthusiastic first-aider hadn't realised that someone who can actually express a will to stand up, and has to be restrained from doing so, needs to be in the recovery position as much as a fish needs to arrange bicycle lessons.
Or there was the woman injured with a hockey stick a week before, who still had a sore bruise on her chest. The workplace first-aider told her to go to hospital in case she'd "damaged her solar plexus", in which case she would "need it X-raying". Difficult to know where to start with this one; suffice to say no X-ray was required.
And, of course, it's "the bigger the bandage, the smaller the cut", when it comes to first aid. Someone in a triple-layer gauze dressing and an expertly applied high-arm sling usually has a torn cuticle, whereas someone who has lost most of their hand in the hydraulic limb-mangler will arrive with a few small sticking plasters dangling from the stump.
Home "first-aid" recipes can be especially dangerous, and the elderly seem to be most at risk here, following advice based more on folklore than science. I've seen one lady nearly bleed to death from a nosebleed, because her way of managing it was to drape a towel over her head, and hang over the kitchen sink. Another patient was close to death from a varicose leg vein nicked in the garden. He had simply wrapped the leg in towels, adding more layers as the blood seeped through. Towels seem to have a lot to answer for.
Different cultures have different responses to medical emergencies. In some, it is common advice to put turmeric or coffee powder on cuts; others put toothpaste on burns. Neither is recommended.
All workplaces nowadays are supposed to have someone who is trained in first aid, a term originally coined by the order of St John and in use from the late 1800s. There are plenty of courses available, which must be accredited by the Health and Safety Executive. They do sometimes attract people with an over-developed sense of drama, which is where problems can start. But there is no denying that knowledge gained from them, but always applied with an extra layer of common sense, can occasionally come in very handy.
The first job is to make sure they are breathing, and have a pulse. You test if someone is breathing by feeling for air going in and out of their mouth. Don't watch for the chest rising and falling. The chest of a child who is struggling and failing to get air past a peanut lodged in their windpipe will rise and fall - but it doesn't mean they are breathing.
Feel for a pulse, usually at the carotid artery in the neck - to one side or other of the Adam's apple. It is worth finding your own carotid pulse so you can find it on someone else in an emergency. But please don't panic if you can't find it right now - I'd really hate anyone to call 999 and say they were reading the newspaper and haven't got a pulse.
Cardiac massage and artificial respiration are probably the most useful things you can learn on a first-aid course. Properly and swiftly applied, they can save someone's life (although what we really need is more defibrillators in the community, and people trained to use them). If the thought of applying the kiss of life to a complete stranger covered in vomit puts you off, take heart. Resuscitation guidelines are changing to reflect the fact that many people simply cannot bring themselves to do this.
Many have heard of the Heimlich manoeuvre, but you need to know how to do it properly, and most importantly, have the courage to go ahead and do it when needed. The Heimlich manoeuvre is designed to force air suddenly out of the chest, and dislodge the particle which is causing the choking. Standing behind the victim (who is also, hopefully, still standing), place both arms around them and lock your hands just underneath the bottom of their ribcage. Then pull inwards and upwards sharply, a few times if necessary. Although you can break ribs and damage internal organs by doing this, either is preferable to the probable alternative outcomes - brain damage or death.
Choking is more common in young children, in whom the Heimlich is sometimes not effective. Firm blows to the back of the chest, with the child draped over your knee, are recommended as the alternative in very young children.
There is a darkly humorous saying which states that all bleeding stops eventually, which it does. The trick is to stop the bleeding well before enough blood has been lost from the circulation to start causing problems - probably something like half a litre or so in a fit adult; much less in children.
Nearly all bleeding can be stopped by simply pressing firmly directly over the bleeding point or area. Use a piece of clean material of some kind; it does not have to be sterile. Keep the pressure applied for at least 15 minutes, or until someone in a fluorescent yellow jacket tells you to let go. Tourniquets are hardly ever necessary, and can be dangerous, especially if left in place too long.
Most nosebleeds have their origin just inside the nose, and can be halted by pinching the nostrils together - exactly the same action as if there was a bad smell. Do not try to compress the "bridge" of the nose - it's made of bone.
Keep them clean and cool, but don't put them in direct contact with ice. Don't put fingers in your pocket (I kid you not) - the fluff gets everywhere. Teeth knocked out can be put in milk. The sooner re-implantation of limbs, digits or teeth is attempted, the better the chance they will "take".
People who faint need to be laid down. Flat. Not propped up against the wall with their "head between their knees". Their blood pressure has temporarily dropped, and unless blood starts to reach the head pretty quickly, they may have a full-blown seizure. You can raise the legs slightly to "empty" blood into the rest of the body.
FITS AND SEIZURES
Often people who are known to have the occasional fit will have made this known to their colleagues and family. While fits can look distressing, most have no serious consequences. The vast majority of problems are caused by injuries which occur during the fit. Make sure the person is in a position - the floor is the obvious place - where they cannot hurt themselves. Don't try to force their mouth open or put anything between their teeth. This is pointless and dangerous. Nearly all seizures will stop on their own after 10 minutes or so.
FIRST AID KITS
None of them contain anything that you can't improvise in a real emergency, but they do look good on the back shelf of your car.
Dr Simon Cameron is a pseudonym. The author is a doctor working in A & E
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