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July 14, 2007

Trauma and You, Part One: The Basics
Posted by Jim Macdonald at 09:30 PM * 118 comments

Trauma is a surgical disease. It is cured with bright lights and cold steel.

Okay, everyone, it’s time to talk about trauma in general. Between the ages of one and forty, trauma is the number-one killer of Americans. (After age forty trauma drops to number four, after heart attack, stroke, and cancer.)

As a citizen on the street, what you need to know about trauma:

If you get your patient into the back of an ambulance, and the ambulance headed to an emergency room, you have done right.

I’m still going to do future posts going into more detail on diseases and injuries, I’m sure of it. Head injuries by themselves could (and do, believe me) fill volumes, and the crossover point between trauma and disease can sometimes be obscure.

What I’m looking at here is more the First Aid side of things. I’m not going to make anyone into an EMT (that takes a 140 hour course, memorizing a thousand-page book, and passing a test), but instead just chat about Dreadful Things. I’ll give you aphorisms and guidelines, mnemonics and cookbook recipes that you can follow without knowing all of the ‘why’ and still get to a good outcome. Sometimes.

Here’s an example of the Dreadful Thing from the patient’s point of view. Notice the patient going into shock. That’s good for the patient—being in shock means that it doesn’t hurt any more. Bad from the responder’s point of view: Shock is what kills people. More on that in a bit.

So, what’s trauma? It’s the physical world impinging on your tender body. Not to be confused with biology happening (in the form of bugs and germs), or chemicals (poisons, overdoses) happening, or your body breaking down and wearing out and going mysteriously wrong. No, this is more the Force of Gravity sort of stuff. Big classifications: Penetrating trauma (where something went through the skin), Blunt trauma (where the skin isn’t broken) and Burns (which I sorta discussed already at Stop, Drop, and Roll and may breeze right by here). I’m also assuming that you aren’t in a Multiple Casualty Incident (MCI) situation. If you are, it’s triage time and the game is really different. (See Triage For Fun and Profit for more on that.)

Now, what you’ve been waiting for! Everything you need to know about Trauma in just thirteen words:

Air goes in and out. Blood goes around and around. Variations are bad.

For reasons that I hope will become clear, to give your patient their best chance you want the operating room doors closing behind them no more than one hour after the injury. Therefore, the first and most important thing you can do when you see trauma is:

Get help rolling. Now.

How to get help rolling: Turn to the nearest bystander. Look them in the eye. Point to them. SayYou. Go call 9-1-1. Now. Come back and tell me when you’ve done it.”

If you’re alone, go and call 9-1-1 yourself. Nothing else you can do is more important.

Great! You’ve got help on the way. Next (and some authorities place this ahead of calling for help, but I don’t agree with those authorities), make sure the scene is safe. There is something over there that munches people. You are a people. Don’t get munched yourself. If you do get munched what you’ve accomplished is this: you’ve incremented the patient count by one and simultaneously you’ve decreased the responder count by one. On a scale from good to bad this is bad.

In order of priority here’s who you care about on scene:
1) Yourself.
2) Your partner.
3) Other public-safety personnel (police, fire, highway department, utilities, etc).
4) Random bystanders.
5) The patient.

Reason for this is: Maximize the number of responders and minimize the number of casualties. That poor suffering SOB with tire tracks across both thighs? He’s already hurt.

This leads us to the next general principal: No matter how bad things are, make sure that after you arrive that’s as bad as they’re going to get. This goes back to the very earliest days of medicine: “First, do no harm.” Primum non nocere.

My adage:

Hold what you’ve got.

If the scene isn’t safe, make it safe. You wouldn’t run out into the middle of the street on a normal day, would you? Having a kid and a car tangled in the middle of that street doesn’t change things. Don’t run into the middle of that street without taking steps to make it safe. Grab a couple of bystanders and say, “You. Go there. Stop traffic.”

Myself, I carry highway flares in the trunk of my car, and more in my Bag Of Tricks. Depending on where you live you might get fold-up reflective triangles. Here’s where to place them: 100 feet from the scene, two hundred feet from the scene, and three hundred feet from the scene. Here’s how to do that: Walk away from the scene. Every time your left foot hits the ground, count “one.” Drop a flare or a triangle at 20, 40, and 60.

Pay special attention to power lines down, smell of gas, fire, smoke, and other hazards. When a phone pole is down the danger zone extends to the second intact pole from the point of impact.

Now let’s get to the good stuff: Bleeding bodies. We’re inching away from personal safety. Last note: Wear gloves (latex, nitrile, vinyl). You don’t want what the patient has, and the patient doesn’t want what you have. The two things I have on my keychain (besides keys) are a pocket mask and a whistle. And when everything is over, wash your hands in hot soapy water.

With the scene safe and help on the way, walk up to the poor suffering SOB on the ground and say, “Hi! My name is [your name here]. Can I help you?” If the patient says “Yes,” you’re golden. If the patient doesn’t say anything at all, silence implies consent. If the patient says “No!” and a) is unimpaired by drugs or alcohol, is b) of legal age, and c) understands what’s going on (“Are you aware that your arm is off at the shoulder?”) then just back off until the help (that you already have rolling) arrives.

As long as you’re doing the best you can the Good Samaritan laws that most states have in place shield you from liability.

Now you’re at your patient’s side and have permission to proceed. Emergency medicine is really simple. It’s totally kindergarten stuff. If you can remember the letters ABC you have it.

ABC stand for Airway, Breathing, Circulation. If you ever get lost, if you can’t figure out what to do next, drop back to ABC.

The first, most important thing to deal with is Airway. If you don’t have an airway, you don’t have a patient. Get an airway (a connection from the lungs to the outside atmosphere via the trachea (i.e. windpipe)) any way you can. A human being can last from four to six minutes without air. That’s how long you have to get that airway.

The most common thing that’ll block a patient’s airway is his own tongue. An unconscious person loses muscle tone; if he’s on his back the tongue slumps down and occludes the airway.

These days the American Heart Association (in their First Aid course) teach lay responders to use head tilt/chin lift for opening all airways. I’m not sure I agree with that. Sure, it’s easy to teach, and easy to perform, but if your patient has a broken neck it could cause problems down the road (like severing the spinal cord, turning the poor suffering SOB into a quadriplegic, which probably isn’t what he had in mind for how to spend the rest of his life).

So: when you suspect a neck injury (an automobile accident, a fall, any time you see injury north of the collarbone), I’d say open the airway with a jaw thrust. That is:

Kneeling above the patient’s head, holding his head stable with the heels of your hands, push up on the angle of the jaw with your fingers, moving the chin up. This will lift the patient’s tongue out of his airway. Video of How To Do It.

If you’re in front of the patient, put your thumbs on his cheekbones, your fingers behind his jaw, and kinda do a scissors maneuver to move his jaw forward. Do this without twisting his head around.

When you hear gurgling in the airway, that’s fluid. If you don’t have a vacuum pump (or a big ol’ turkey baster) to suck the stuff out, remember that you’re standing on top of a 6.0 x 10^24 kg suction machine. While holding the patient’s head in line with the rest of his body roll him onto his side and let the fluid drain out.

You may need to use your (gloved) fingers to sweep out big chunks, broken teeth, mud, blood, and vomit.

If you don’t have an airway, you don’t have a patient.

Bottom line: Do what you have to in order to get an airway. Be as creative as you need to be. Let your conscience be your guide.

After A for Airway comes B for Breathing. Put your ear right next to the patient’s nose and mouth (if you can’t find the patient’s nose and mouth you’re in a whole different area of challenge—be creative) and Look, Listen, and Feel for air exchange. Occasional gasping breaths don’t count. That’s called Agonal Respiration for exactly the reason you’d think.

If the patient isn’t breathing, breathe for him, using that pocket face mask (see above, you don’t want what he has). The rate is one breath every five seconds, how much is until you see chest rise. You should be able to feel the air going in—that’s called Compliance. You don’t want to blow too fast or too hard because that’ll put air into the stomach instead of the lungs which a) doesn’t get any oxygen into the bloodstream, and b) makes it more likely that the patient will puke. A puking patient can lose his airway real fast, knocking you right back to step A.

The rule is you don’t go on from A to B until you have A. You don’t go on from B to C until you have B. So you’re going to be breathing for this guy until a) he starts breathing on his own, b) you grab another bystander who isn’t doing anything worthwhile and give him the job, c) the pros take over (which is why you got help rolling as Act One, Scene One in this whole comedy) or d) you fall over exhausted.

C is Circulation. Is the guy’s heart beating? If not, pump on his chest (hard, fast, deep, rate of 100 per minute, one and a half to two inches). You’re now doing full CPR, and the success rate for CPR in the case of traumatic arrest is abysmal. But you might as well, right? You aren’t going to just stand there waiting for the ambulance. But let’s say the guy’s heart is beating, and you know this because he’s breathing, he’s moving, and you see blood spurting in bright red arcs. Circulation also covers those ten-foot arcs of blood. The pools of blood. Anything to do with blood.

Check the patient’s skin temperature, color, and condition. You’re going to find out if internal bleeding is going on that way. If you find external bleeding, control it.

How to control external bleeding: put the heel of your hand against the bleeding spot and press, hard. Take the cleanest cloth you can find and press it onto the bleeding place. If it soaks through, put on another cloth and press, hard. Keep adding cloth and pressing, hard, until the bleeding stops, or, if that doesn’t work, in addition to pressure, raise the bleeding spot above the patient’s heart. (Be aware of where the patient’s heart is, particularly if he’s lying on a slope.) If that still doesn’t work, find a pressure point (anywhere an artery passes next to a bone, where you can feel the pulse) between the injury and the heart, and press there.

Tourniquets are the next step, but if you’re using a tourniquet it means that your technique with direct pressure, elevation, and pressure points was lousy. If you absolutely, positively have to use a tourniquet, a) use a wide, soft piece of cloth (wire and fishing line are right out), put it over solid bone between the injury and the heart (not over a joint, not over a fracture), make sure the tourniquet is visible (don’t cover it with blankets or dressings), and write the letter T and the time on the patient’s forehead.

Don’t be stupid about any of this: If the bleeding is coming from the head and you feel broken skull bones under it, you don’t need to press those bone fragments into the patient’s brain. That would be bad. Nor do you want to find pressure points in his neck. There aren’t any pressure points for the chest and abdomen, and raising those above the patient’s heart isn’t going to happen.

Special cases of bleeding include Sucking Chest Wounds (those sorta fall under breathing, as in, if you don’t fix this breathing will be affected) and Sucking Neck Wounds.

Remember how Air Goes In and Out? You want it to go inside the lungs, not anywhere else. In a sucking chest wound, there’s an opening from the chest out to outside, and as the patient’s chest expands air gets sucked in through that hole. If you’re lucky this just gives you a simple pneumothorax—a collapsed lung on that side. If you’re unlucky, this gives you a tension penumothorax—everything starts squishing over toward the other side, collapsing not only this lung but the other one, compressing the heart, and generally making life difficult.

How to tell the difference between simple pneumothorax and tension pneumothorax: look for tracheal deviation. Run your fingers down the patient’s trachea in his neck. If it’s shifted over toward the injured side, you have simple pneumothorax. If it’s shifted toward the uninjured side you have tension pneumothorax. These are both late signs, but they’re neat to know.

Luckily, the basic first-aid treatment for both kinds of sucking chest wounds is the same: Use an occlusive dressing. That is, something that air won’t go through. If you have tape, tape it down on three sides (forming a one-way valve—air goes out but can’t come in). If all you have is plastic wrap, use that. Other things include the wrappers that Tastykakes come in, the patient’s credit cards or driver’s license. Remember to check the patient’s back as well as his front. Holes can be anywhere.

If you have the occlusive dressing in place and the patient starts to go downhill (increasing difficulty breathing, tracheal deviation to the opposite side) you may have induced tension pneumothorax. Take off the occlusive dressing, burp the wound, and reapply.

Sucking neck wounds, now: If the major veins in the neck are open to the air, they can actually suck air into the circulatory system, creating an air embolism. This stops the Around-and-Around part of Blood Goes Around and Around. The fix for this: Occlusive dressing. (Other occlusive dressings can include petroleum jelly on gauze, bandage wrappers, and playing cards.) Be creative.

Sucking Wounds Imply Occlusive Dressings.

When you’re dealing with trauma, your life is pretty easy. You have 1) Things that’ll kill your patient in the next five minutes, 2) Things that’ll kill your patient in the next hour, 3) Things that’ll kill your patient today, and 4) Things that you don’t really care about.

When you’ve hit the ABC steps, you’ve taken care of the things that’ll kill your patient in the next five minutes. EMS is easy: If you ever get lost and can’t think of what to do next, drop back to A and go from there. You should be re-doing the ABCs every five minutes anyway, regardless of what else you’re doing and what else is going on. Patients who had an airway lose ‘em. Patients who were breathing stop.

You can perform all the steps in an ABC survey in under thirty seconds.

Do something else for four-and-a-half minutes. Then do ‘em again.

There are some cases when, once you’ve called for help and secured the scene, all you do is stand around waiting for the ambulance. Those are: decapitation, bisection, incineration, rigor mortis, dependent lividity, and decomposition. For everything else there’s something you should be doing.

At the minimum, if you suspect neck injury (falling off the swings at the playground, falling off the roof, a tiny little motor vehicle accident, the patient says “my neck hurts”) you should be holding c-spine. That is, keeping the patient’s head and neck from moving by using gentle pressure with your hands to keep his head in a normal in-line position. You can turf this off to a random bystander because you can teach this skill in under a minute, then move on to the next step.

The Boy Scout First Aid merit badge requirements

My personal first aid kit

Medical Emergency Response Team (MERT) training

Trauma and You will return in Part Two: Shock.

Copyright © 2007 by James D. Macdonald

I am not a physician. I can neither diagnose nor prescribe. These posts are presented for entertainment purposes only. Nothing here is meant to be advice for your particular condition or situation.

Creative Commons License
Trauma and You, Part One: The Basics by James D. Macdonald is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 License.

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Comments on Trauma and You, Part One: The Basics:
#1 ::: MikeB ::: (view all by) ::: July 15, 2007, 09:03 PM:

I've diagnosed your server problem: it was scared to death.

(Not I, however - these posts are awesome. Every time I read one I feel the strange urge to go to EMT school.)

#2 ::: Avram ::: (view all by) ::: July 15, 2007, 09:10 PM:

I could have happily lived out my days without encountering the phrase "burp the wound".

#3 ::: Joyce Reynolds-Ward ::: (view all by) ::: July 15, 2007, 09:15 PM:

I found the Medic Aid First Aid course taught by the volunteer fire department that serves our school district to be a *lot* more helpful than the Red Cross version. Of course, our schools also got AEDs donated this past year, so now I've been trained on the AED (automated electric defibrillator) as well.

Paramedics tend to be more graphic about educating folks in first aid, as well as more practical. "Secure the site" was the second thing we were supposed to do, after calling 911.

Nice thing, our school is right behind the fire department...

#4 ::: Teresa Nielsen Hayden ::: (view all by) ::: July 15, 2007, 09:16 PM:

Great post, Jim.

We pause to remember Ajay's comment #85 in the metacomments thread.

#5 ::: Steve Taylor ::: (view all by) ::: July 15, 2007, 09:27 PM:

Interesting as always, and timely: my sister just got hit in the head by a falling tree while helping her tree-lopper husband. Unconscious at the scene, concussed and three days in hospital. I feel keenly aware that she got off easily. She has scary scary black eyes at the moments - I suspect more a result of all the soft bits inside the head moving around suddenly than of a direct impact.

One thing:

> Kneeling above the patient’s head, holding his head stable with the heels of your hands, push up with your fingers moving the chin up. This will lift the patient’s tongue out of his airway.

Do you know of any youtube or similar videos showing how this is done? I don't think I'm visualising it well.

#6 ::: Jon ::: (view all by) ::: July 15, 2007, 09:28 PM:

This is great. But I won't remember it in the actual event, because I won't have had practice to the point where it becomes second nature, and I'm sure as hell not gonna pull out my laptop and surf over to Making Light to read up on what I should do.

So, got any advice for the layman, besides trying to remember 'A-B-C'?

#7 ::: Diatryma ::: (view all by) ::: July 15, 2007, 09:40 PM:

Looking at my own probable reaction, anything that results in me *doing* something, rather than standing there wondering if I'll get in trouble for taking action, is good. Even if I can't remember everything, these posts act as a sort of standing order to do something. For that, Jim, you have my thanks.

Teresa, you forgot the haiku at the beginning of the last open thread.

#8 ::: janine ::: (view all by) ::: July 15, 2007, 09:50 PM:

A timid, Piglet-like question: how does one burp a wound?

I'm sure I don't really want to know the answer.

#9 ::: Teresa Nielsen Hayden ::: (view all by) ::: July 15, 2007, 09:54 PM:

Diatryma: No, I'm sure I remember it.

If you're at the scene of an accident and you don't know what to do, the single most important thing to bear in mind is that EMTs would lots rather get called out to an accident where the injuries prove to be fairly minor, than have you wait twenty or forty minutes before calling 911 because you're not sure you're doing the right thing.

#11 ::: Victor S ::: (view all by) ::: July 15, 2007, 10:02 PM:

Jon @6 -- I'll risk a recap and summary:

1. Call 911. Stay on the line.

2. Make that whatever caused the injury doesn't get anybody else, especially you.

3. Everything else.

#12 ::: Lizzy L ::: (view all by) ::: July 15, 2007, 10:03 PM:

With regard to calling 911 -- Every semester at the ceramics studio I frequent -- it's at the local community college -- we have fire training. It's important to do this regularly in a place with many toxic chemicals and large gas ovens (kilns) that get hot enough to turn sand to glass and clay to stone. The training's pretty basic. The idea is to simulate a sudden fire in the studio. The fire department lights a fire. (They have a nifty little portable ring set up, with a sand barrier and a propane torch. We do it in the parking lot.) Each student wears an insulated yellow coat and gloves. There's a pile of fire extinguishers. When the fire lights, the student yells: "Help! Fire! Call 911!!" Then the student picks up the extinguisher and sprays the fire.

I've done it now about 4 times. It's interesting. Some people forget to yell. The fire department stresses the yell part. You must yell first, before you try to put the fire out, so that while you are spraying the fire, someone else is calling 911. Some people can't bring themselves to approach the fire. If that happens to you, hand off the extinguisher and get out, you won't do any good standing around. If one extinguisher doesn't put the fire out, drop it and get out, don't look for another extinguisher. Don't throw water on the fire: it's too late for that. Don't stand next to the fire while you wait for the fire department. They'll find it, and they'll know what to do when they do. They won't need your advice.

Help! Fire! Call 911! Kind of like ABC...

#13 ::: James D. Macdonald ::: (view all by) ::: July 15, 2007, 10:06 PM:

So, got any advice for the layman, besides trying to remember 'A-B-C'?

Stay inside your own comfort zone.

Get help rolling then make the scene safe. If you can't think of anything else to do, call 9-1-1. Then go stop traffic.

Or, just keep other bystanders, all the looky-loos, from running over and getting munched. Accident scenes are dangerous.

Taking a first-aid course now, before you need it, is never a bad idea. American Heart Association and American Red Cross both have first aid courses they teach the public. SOLO has a wonderful wilderness first aid course; many of the things they teach you are applicable in urban areas too (a broken leg doesn't know if it's in a cow pasture or a shopping mall).

Call for help and stay safe. Be ready to direct the responders to the right place.

#14 ::: CosmicDog ::: (view all by) ::: July 15, 2007, 10:14 PM:

Lizzy, I would add that, if you have the time, you tell a specific person to call 911. Saves some confusion on the scene and with 911. Of course, it has to be better that ten people call 911 than none.

#15 ::: Steve Taylor ::: (view all by) ::: July 15, 2007, 10:23 PM:

CosmicDog at #14 writes:

> Lizzy, I would add that, if you have the time, you tell a specific person to call 911. Saves some confusion on the scene and with 911. Of course, it has to be better that ten people call 911 than none.

Also I'd imagine that avoids the unfortunate group of crowd dynamic where a group of people stand around waiting for someone elseto act. The larger the crowd, the worse this can be.

#16 ::: Erik V. Olson ::: (view all by) ::: July 15, 2007, 10:25 PM:

Trauma is a surgical disease. It is cured with bright lights and cold steel.

I've always heard that as "Treat trauma with diesel."

#17 ::: James D. Macdonald ::: (view all by) ::: July 15, 2007, 10:26 PM:

#8 A timid, Piglet-like question: how does one burp a wound?

It's easy, really.

While the patient's chest is fully expanded, take off the occlusive dressing. Let the patient breathe out. Air should come out of the wound. When the patient has breathed all the way out, put the occlusive dressing (taped down on three sides, or with a corner untaped, to form a flutter valve) back over the wound.

You can buy commercial devices that are occlusive dressings with built in one-way valves. One such is the Asherman Chest Seal. You probably won't see enough sucking chest wounds in your life to make it worth your while to buy one and put it in your supplies, then throw it out when it expires (the adhesive gets old, the plastic gets stiff and cracks) and buy a new one.

#5 Do you know of any youtube or similar videos showing how this is done? I don't think I'm visualising it well.

Your wish is my command: Jaw Thrust Maneuver

#18 ::: Victor S ::: (view all by) ::: July 15, 2007, 10:31 PM:

Another failure mode for fire response -- the first time, almost everybody forgets to pull the pin before trying to use the extinguisher.

#19 ::: Lizzy L ::: (view all by) ::: July 15, 2007, 10:33 PM:

CosmicDog and Steve: all I can say is, that's not how the local Fire Department teaches it. I've been through this training four times now. See fire, yell "Help -- Fire -- Call 911." Not: "Hey Joe, call 911." I assume there's some good reason for this.

#20 ::: CosmicDog ::: (view all by) ::: July 15, 2007, 10:42 PM:

Lizzy, it probably has to do with the need to start acting right away and/or if no one is close by. A fire gives you limited options.

#21 ::: Mary Dell ::: (view all by) ::: July 15, 2007, 11:07 PM:

Lizzy L @#19: Yep, when I took infant CPR last year it was "help, someone call 911." If you're busy choosing a specific 911-caller, you're not busy clearing the baby's airway.

I call 911 pretty frequently for stuff I see when I'm driving, and they never seem irritated to take the call, no matter how many fire engines or whatever are already on the way. They'll want to know where you are and what you actually see. "I'm on I-57 headed south, we just passed the 42-mile marker, and there's a lot of smoke coming from the grass in the median" for example. Not "the highway's--oh my gosh--is that a brush fire? What the?" which is always my initial reaction. Giving them a clear, fast description lets them say "thanks, trucks already en route" and end the call.

#22 ::: James D. Macdonald ::: (view all by) ::: July 15, 2007, 11:17 PM:

The trouble with saying "someone call 9-1-1" is that no one will call 9-1-1.

It's just as quick, and far more reliable, to say "You call 9-1-1."

(With infant CPR you're going to do a couple of minutes of CPR before you call 9-1-1 -- but this is getting far afield from trauma. Traumatic cardiac arrest has a very poor prognosis.)

#23 ::: Naomi ::: (view all by) ::: July 15, 2007, 11:22 PM:

My first aid courses were all a while ago. On the handful of occasions when I've been present for an emergency, here's what stuck with me:

1. YOU, GO CALL 911 NOW.
2. Airways are key.
3. Keep patient warm. (One incident involved an asthma attack in the woods on a January night in Minnesota.)
4. Keep patient calm.
5. Get the heck out of the way once the people who know what they're doing show up.

I think I've told this story on one of these threads, but I'll mention it again here: in 2001, my sister had a bad car crash on her way to work one morning. She lost control on the highway, probably due to a blown-out tire, and rolled her car. She broke her arm, her wrist, and two vertebrae in her neck -- but when her car came to a stop, she had no idea that she'd broken her neck. She tried to dig her cell phone out, and when she couldn't find it, she crawled across the passenger seat to try to get out of the car and flag someone down for help.

Several people had pulled over when they saw her go off the highway, and they came running down the embankment shouting that they'd called 911 and she shouldn't move. One brought blankets. That's all they did for her -- reassured her and kept her calm. But that was what mattered. And despite chipping C2 and shattering C7, she didn't injure the spinal cord, and she made a full recovery.

#24 ::: C.E. Petit ::: (view all by) ::: July 15, 2007, 11:24 PM:

One last point:

Observation is extremely important. While you are checking the airway and for obvious wounds, check for MedAlert tags. You may not be able to do anything for a patient whose tag notes "Anaphylactic: Peanuts" or "Diabetic"... but if it's important enough to get onto a tag, it's important enough to tell the EMTs as they arrive (and, better yet, during the 911 call).

I'm not suggesting strip-searching the victim; I'm suggesting keeping your eyes/ears open while doing whatever initial evaluation you need to do. Don't get tunnel vision!

#25 ::: James D. Macdonald ::: (view all by) ::: July 15, 2007, 11:30 PM:

Observation is extremely important. While you are checking the airway and for obvious wounds, check for MedAlert tags.

You're anticipating Trauma and You Parts Two, Three, Four ....

One thing at a time.

#26 ::: Julia Jones ::: (view all by) ::: July 15, 2007, 11:36 PM:

Jim, can we have the link to the video of the jaw thrust maneuvre in the body of the main article? I did First Aid At Work for nigh on a decade, and I don't recall ever being shown how to do that -- I dare say I'm not the only one in that position.

To repeat what Jim and others have said -- your first priority is to call 911 or your local equivalent. Make sure that someone who knows what they're doing knows that there is a problem and where it is. One of the non-fatal Awful Warning stories at my former place of employment was about the guy who was in an inspection pit when the argon feed wasn't properly shut off. Argon's not poisonous, but it's not a good substitute for oxygen, and it's heavier than air. He wasn't wearing an oxygen meter. The first person to walk past the pit and see someone unconscious rushed to help him, and didn't stop to call the emergency number first. The person who saw two unconscious people in the pit... Fortunately someone stopped and thought and headed for the phone, somewhere around the third or fourth iteration; and the rescue team came along with breathing apparatus and dragged them all out soon enough for there to be no real harm.

The trainers for the local First Aid At Work courses had *much* nastier stories about why to stop and think, lest you become a casualty yourself. I'm sure Jim has as well.

#27 ::: abi ::: (view all by) ::: July 15, 2007, 11:43 PM:

Julia Jones @26:
your first priority is to call 911 or your local equivalent

Travellers in Europe should be aware that, although there are locally traditional emergency numbers (eg 999 in the UK), there is also a Europe-wide standard emergency number: 112.

(By this I mean the use of 112 is standard across Europe. It will connect you to your local emergency responders. Nobody's running two call centres or anything.)

#28 ::: janine ::: (view all by) ::: July 16, 2007, 01:22 AM:

#17: It's easy, really.

Several of my friends have babies and "burping" in my normal context just wasn't translating as something useful in the horrible sucking chest wound context. Thank you for clarifying.

#29 ::: bbrugger ::: (view all by) ::: July 16, 2007, 01:49 AM:

On the 'You- call 911' I was taught a slighly longer version.

'You- call 911, and then come tell me when you've done it'.

'You-' is accompanied by eye contact or pointing or saying 'you- in the blue shirt'. The idea, in those long ago days pre-dating the ubiquitous cell phone, was to get the call for help rolling and to build in a confirmation it had been done.

Now days my default is make eye contact. If they don't have a cell phone and there are other bystanders someone will either offer their phone or make the call. 911 will likely keep them on the line.

True story. My first day living in Oregon we were driving to get lunch. Services were just ending at the local parish church.

We saw the elderly gentleman stagger into traffic one block ahead of us and drop like he'd been thwacked over the head. My husband pulled over and we both ran to him. I said the magic 'You- call 911!' to a specific bystander.

Swear to the diety of your choice, there are in fact people who, when directly addressed and told to call 911, while holding their cell phone in their hand will ask 'Are you sure we need 911?'. In one of the proudest moments of my life, I did not swear even a little bit while telling her yes, actually I was sure.

(Turned out he was diabetic and had skipped breakfast and the service had run long. He ended up spending a night in the hospital but was all right.)

Having been one of the first at an accident scene several times, I have to say that an EMT saying 'Okay, ma'am, we'll take it from here. Thank you.' is one of the sweetest sounds in the world.

#30 ::: Dave Bell ::: (view all by) ::: July 16, 2007, 02:07 AM:

Having done the call-911 when somebody collapsed, I have to say that it gets frustrating when they guy taking the call didn't know where "Scunthorpe Bus Station" was, and kept asking what street it was on.

I know, there are a lot of landmarks that aren't much use to the dispatcher. Street name and number are good, when they're available. But the main bus station for the town?

#31 ::: Dave Bell ::: (view all by) ::: July 16, 2007, 02:17 AM:

Just to add, I was flustered. It looked very like the times my parents had been affected by strokes (very minor for my father, more serious for my mother). Just because I'm not doing the gabble and panic thing, doesn't mean I'm thinking straight.

Which is why training is important.

#32 ::: Dave Bell ::: (view all by) ::: July 16, 2007, 02:17 AM:

Just to add, I was flustered. It looked very like the times my parents had been affected by strokes (very minor for my father, more serious for my mother). Just because I'm not doing the gabble and panic thing, doesn't mean I'm thinking straight.

Which is why training is important.

#33 ::: Kathryn from Sunnyvale ::: (view all by) ::: July 16, 2007, 02:33 AM:

Meta-knowledge about preparing for emergencies:

You will always do better in a Situation if you've mentally rehearsed what you'll do at least once.

This is known from studies*.

Cool thing is you don't have to repetitively, constantly, or obsessively rehearse. Just one or two times for a new situation.

For instance, when you sit down on an airplane, just quickly run through how you'd evacuate. "I'll get up, I'll NOT touch or take any of my possessions, I'll move forward 7 rows or back 15 rows." People who do a thought exercise like that just once are much less likely to freeze-in-fear if they do need to evacuate.

So go ahead right now and imagine yourself in a group of strangers. Imagine yourself pointing to one person and saying "You, call 911, come back and tell me when you're done."

And then imagine the same situation, but it's a group of non-strangers.

Just with those two imaginations, you'll be better off when you need to do it for real.

* don't immediately have the references, sorry.

#34 ::: mk ::: (view all by) ::: July 16, 2007, 02:37 AM:

I think I'll get my First Aid/CPR refresher before I start classes this fall. State of Hawai'i Dept. of Commerce and Consumer Affairs requires that all applicants for a license to practice massage therapy have current First Aid/CPR Infant/Adult certification, but it's not required to maintain the license. A shame, that. Last two times I went to the Red Cross for the certification; this time maybe I'll take the class taught by a friend's mother - a retired RN who got her start in the Vietnam War and spent most of the rest of her career in emergency rooms. I hear she has a teaching style aimed at making darned sure you remember *something* from the training during an actual emergency. I have Oldest of Four Rambunctious Children With A Mother Who Gets Faint At The Sight of Blood Syndrome and I turn into a loud, commanding, checking for blood person when the screaming starts. I have found that I am in a minority in that respect. Humans and pack/mob mentality is pretty interesting, and I hope that if/when I'm the one who needs help, I won't have to dial 911 myself.

#35 ::: Rachel Brown ::: (view all by) ::: July 16, 2007, 02:40 AM:

I love Jim's posts. Has anyone collected them, or the links to them, in an archive?

That's a tension pneumothorax in Steve Brust's "Athyra," right?

#36 ::: Kathryn from Sunnyvale ::: (view all by) ::: July 16, 2007, 03:03 AM:

Anecdotal information on what percentage of people call 911 on seeing a Situation:

Over the past 8 years- since I've owned a cell phone- I've taken to calling 911 when I'm on the highway and I see a potentially dangerous problem. For example, there's a large object on the road that could cause an accident via direct damage or swerving.

I'll report it as efficiently as I can as soon as it's safe to call: "Has anyone reported the lumber in the number 1 and 2 lanes of southbound 280 1/2 mile north of Page Mill?" If it's already been reported, they'll tell me.

I think I've now got a reasonable sense of when a potential problem is reportable. Back when I started, though, I'd worry about contributing to a 911 overload: all cellular 911 calls go to California Highway Patrol call centers.

I quickly learned not to worry, because I'd be the first to report it at least 2/3rds of the time. And again, these were for really obvious problems- mattresses, thick lumber, carpet rolls- things cars cannot drive over. Or a drunk driver- someone weaving crazily.

All to say that you should never assume that 911 has been called.

Also, don't assume cellular 911 is e911 (location tracking) ready. i.e. in California, if you don't want the CHP first, then tell at least one person to call 911 using a landline.

#37 ::: Teresa Nielsen Hayden ::: (view all by) ::: July 16, 2007, 07:44 AM:

While you're waiting for the ambulance to show up, please don't stand around discussing the patient(s)'s injuries, appearance, prognosis, et cetera. I've lost count of the times I've personally observed bystanders (and medical personnel, once or twice) making that mistake.

If you're dealing with a person who gets agitated during emergencies, and they're already injured, upsetting them can do them real harm.

#38 ::: Epacris ::: (view all by) ::: July 16, 2007, 07:50 AM:

Checking that my memory of the UK Emergency Number being 999, I ran into this story from 2004. I hope that more of it than is obviously satire and untrue is actually satire and not true. Privatized emergency number(s)?!? Emergency numbers all longer than 5 digits!!?? But it looks like the European 112 works in the UK as well.
In Australia the single emergency number is 000. The service has had various problems, including problems with locating mobile phone callers who say they're in 'Yarrawonga', for instance, which could be in several different cities or States. One new problem with users has been that they are picking up the US number from watching American TV shows (like ones who try to claim "the fifth amendment" in court), so there was an idea to get the number 911 to divert straight to 000.

#39 ::: Teresa Nielsen Hayden ::: (view all by) ::: July 16, 2007, 08:10 AM:

Epacris, I hope that entire story is a hoax. They'd have to be insane to privatize the general emergency number.

#40 ::: Charlie Stross ::: (view all by) ::: July 16, 2007, 08:15 AM:

Epacris: the Rockall Times is a satire mag, like the Onion. (This particular satire is taking the piss out of the privatization of Directory Enquiries in the UK. YHBT. HAND.)

Note that the UK mobile phone networks don't feed location data to the 999 call centre, so if you dial 999 from a mobile about the first thing you need to be able to tell them is which town you're in, so they can re-route your call. (NB: as 98% of the population of the UK live in urban areas, I say "town". YMMV if you're out hill-walking.)

#41 ::: Roy G. Ovrebo ::: (view all by) ::: July 16, 2007, 08:45 AM:

Charlie @40

I think I heard once that Rockall is so small it shouldn't actually show up on a map but it's a major landmark in the otherwise empty sea - it's 570 square metres (6100 square feet). But there's a great need for emergency dial-an-orgy or dial-a-kebab hotlines, I'd bet.

But yes, say your street and town. They don't necessarily know your location. Even if your emergency services do get location data, it's not necessarily correct - your cellphone may be getting a connection from a tower across a municipal border or something. Even what looks like a regular landline just might be a VoIP phone that someone took with them on holiday...

#42 ::: abi ::: (view all by) ::: July 16, 2007, 08:54 AM:

Epacris @38
That story is a parody of the introduction of competing directory enquiries services, which actually did happen, and left me wanting a directory enquiries enquiry service. Or a directory enquiries directory.

In the end, I gave up and fled the country. Now I can't ask for phone numbers in the local language anyway, so I don't have to worry about it.

#43 ::: ajay ::: (view all by) ::: July 16, 2007, 10:14 AM:

A few addenda (just going through similar training myself):

Once you get on to C, you will need to check the casualty for bleeding. Pat them down gently, like you're searching for weapons. Pat down everywhere, and check your hands in between sections. So check the head and neck - check your hands - check the chest - hands - stomach - hands and so on. Be careful around pockets where they could be carrying a needle or other sharps. If you just pat them down all over without checking your hands in between, you will be left looking at your hands thinking "Blood. Hmm. I wonder where I picked that up?"

Remember that someone could have more than one sucking chest wound. If they've been shot, for example, they could have entry and exit wounds. Patch one with an occluding dressing as described; seal the other.
Once you've dealt with them, we were taught, roll them onto the injured side to help the intact lung work.

Facial injuries and burns to the face or throat all mean that you could have a compromised airway. Pay attention. (Also: burns to the face or throat could be chemical. Watch out for this if you're breathing for them.)

#44 ::: Debra Doyle ::: (view all by) ::: July 16, 2007, 10:14 AM:

Dave Bell@#30:
Having done the call-911 when somebody collapsed, I have to say that it gets frustrating when they guy taking the call didn't know where "Scunthorpe Bus Station" was, and kept asking what street it was on.

Rural EMS gets even stranger locations than that sometimes -- "Remember where the kid swallowed the quarter last summer? It's the same place" or "Turn left where the old schoolhouse used to be." And this is after Enhanced 9-1-1 came in and the town renamed and renumbered all the streets and houses for greater consistency.

#45 ::: Greg London ::: (view all by) ::: July 16, 2007, 10:40 AM:

The one time I've been close to needing the ABC's, was when a motorcycle went down a couple cars in front of me. By the time I got out, two people were on cell phones, I checked that they were calling 911. One guy was kneeling over the rider, looked like the rider was conscious. A woman came running up saying she was a doctor. She seemed to know what she was doing. When I heard the sirens, I looked back and saw traffic backed up as far as you could see in a tunnel, with no break down lane. So, my contribution was to herd everyone just standing around back in their cars and get them out of the way so the ambulance could get to the scene.

#46 ::: Sisuile ::: (view all by) ::: July 16, 2007, 10:54 AM:

Touting my employer:

An American Heart Association program for the basics of CPR at home or work- 22 min.

Or, for those who like the traditional classes, AHA CPR, AED, and First Aid Near You!

Now you really don't have an excuse.

#47 ::: Victoria ::: (view all by) ::: July 16, 2007, 11:19 AM:

When my father had his accident, my brother, who had seen it happen, called 911 right away. He also had to correct my sister, the dispatcher, who was giving directions to our cousin, the ambulance driver, who had no clue where to go. The accident happened in a field a quarter mile from the nearest road in a very rural area and "the east edge of the old bean patch" doesn't mean anything outside my immediate family. (The ambulance couldn't make it across the plowed field so they used my brother's truck as a temporary ambulance once the ABCs were done.)

This was at the beginning of enhanced 911. Even though the roads in the county were IDed, they were not all labelled and people were still making the switch from landmark navigation to street and road directions.

My sister and her fellow dispatchers have to work to get useful address out of callers. A lot of people only use landmark navigation.

#48 ::: Julia Jones ::: (view all by) ::: July 16, 2007, 11:20 AM:

Picking up from something mentioned up-thread -- don't stand around discussing the patient's injuries in front of him/her, and don't be a screaming bystander.

I've only had someone go down right in front of me twice, both times in a group of my colleagues. The second time there happened to be two of the first aiders present, which was a good thing. Because once we'd checked that we weren't about to put our CPR training into practice, and the restaurant manager came over and quietly told us that he'd already phoned 999, the other first aider watched the patient and I dealt with the person who was panicking and repeatedly saying," He's going to die!"

It took a few repetitions of "No, he's not, he's breathing normally, his pulse is steady, the ambulance is on its way, and there are two trained first aiders here" to get her to calm down so that the patient wouldn't hear her if he started to come round.

One of the things good first aid training does is help you not be someone who make things worse. If you know that you know how to do CPR, you're less likely to panic when someone drops.

#49 ::: R. M. Koske ::: (view all by) ::: July 16, 2007, 12:06 PM:

I'm almost afraid to ask, dangerous is shock, really?

I fell on some steps at the beginning of June. Landed on the tops of my feet, and my shins, and from there to hands and knees. It was intensely painful, but I was certain* that no major damage had been done. Only bruising and scrapes.

I was shocky for what seemed a very long time. Nauseated, hot, dizzy, and insisting that I wasn't really hurt, that I'd be okay, no need to call paramedics. Stupid? Potentially fatal? I did stay at the scene with my head down and my feet up, at least. I was too dizzy for anything else.

*I suppose there was every chance that there was significant damage I was too shocky to feel, but I was right. Extremely severe bruising that took four days to stop swelling, and scrapes that are still healing. No pulled muscles, no torn ligaments, no broken bones.

#50 ::: James D. Macdonald ::: (view all by) ::: July 16, 2007, 12:27 PM:

#49: I'm almost afraid to ask, dangerous is shock, really?

I'm glad you asked that question....

I've just put up Trauma and You, Part Two: Shock. You'll learn far more than you wanted to know.

#51 ::: Lori Coulson ::: (view all by) ::: July 16, 2007, 12:29 PM:

R. M. Koske @49:

Untreated, shock can, and does, kill. Jim McDonald can explain the mechanics better than I can, and I think he's planning to do so, in a later post.

If I take a fall, and sustain an injury, I get it checked out. Last time this resulted in a trip to the ER and a few stitches...

#52 ::: R. M. Koske ::: (view all by) ::: July 16, 2007, 01:20 PM:

I guess my problem, Lori, was that I wasn't sure if bruises counted as an injury, and I'm pretty susceptible to psychogenic shock. I almost expect to go into psychogenic shock if I take a sharp blow, regardless of actual damage.

(Most embarrassing thing ever, and how I discovered this tendency - I bit my own finger eating a hot dog in middle school. Got it pretty hard, and passed out at lunch. Hard to explain without losing face, to say the least.)

I'm pretty off topic, so I'll stop now.

#53 ::: John L ::: (view all by) ::: July 16, 2007, 02:12 PM:

The one time I came upon a vehicular crash right after it happened, a semi truck had taken a curve too fast on I-40 east of Asheville NC and overturned right into the median barrier. The trucker ended up pinned in the cab with his shoulder to the pavement as the truck slid across the interstate.

My assistant and I stopped the car downhill from the crash site (big trucks and everyone else had stopped uphill) and ran to see what we could do. We helped get the smashed windshield out of the way and spoke with the trucker, who was seriously stuck in the cab thanks to the seatbelt and steering wheel. He said he didn't feel much pain but thought his leg was hurt. People were already calling 911; truckers on their CB's and motorists going up the mountain on the other side of the barrier.

The trucker, a dark black man, was covered in diesel fuel and motor oil (cargo was motor oil in quart containers; it shifted and flipped the trailer on the curve), but his left shoulder was curiously red, shading to bright pink and white in the center. Couldn't see any blood, probably because it was mixed with the fuel.

The EMS teams were there within 5 minutes and we left at that time. Not until later did we realize his shoulder had been abraded by the pavement right down to the bone; that's what we had been looking at and wondering what was so white on his shoulder...

#54 ::: Terry Karney ::: (view all by) ::: July 16, 2007, 02:37 PM:

One of the best things to come from being in the Army is a raft of first aid training, all repeated ad nasuem which combine to make the list of things needed almost reactive; and detailed.

The only thing which changes is the call to 911 (we tend to end with, "seek medical attention") because the context is different.

I will say that getting a few of the Army's field dressings isn't a bad idea (4x6 pad, sterile, with long tails to tie off). With a bit of training/practice, they are bandages, pressure dressings, or tourniquets (and the transistions can be done after they've been put on).

I've patched up a few trauma victims and the thing which always astounds me is how training takes over. So I commend a first aid course; even a little training can make a world of difference in how the first reaction goes. If you can't get past the shock/horror of what you are seeing you can't help.

If you see it and the hind-brain kicks in with, "needs a bandage" then you can deal with it.

Kathryn from Sunnyvale: We were driving south on 101, truck hauling a trailer. Traffic got very weird. Then we saw the Saturn, with a very confused looking driver, heading north.

When we called, they asked, "Are you calling about a car travelling the wrong way on 101?"

Shock, as I am sure the post I've not seen yet will go into great detail about, is deadly serious.

It's high on the list of things to look for, and treat.

#55 ::: dcb ::: (view all by) ::: July 16, 2007, 05:21 PM:

abi @ 27

911, 999, 112 ALL work to get you to the local emergency services in most countries (anywhere with a modern telephone system) - probably 000 as well.

The Powers That Be had the sense to realise that this was sensible because (a) with e.g. Trans-Atlantic TV shows (particularly for kids - Sesame Stree being shown in the UK comes to mind), children may first learn the "wrong" i.e. foreign emergency number; (b) international travellers in an emergency may not remember what country they are in, never mind what the emergency code is for that country - they ARE likely to remember their own country's emergency number.


#56 ::: Xopher ::: (view all by) ::: July 16, 2007, 05:28 PM:

Vulnus pectoris sugens ne properetis mos naturae dicendi est.

#57 ::: Tania ::: (view all by) ::: July 16, 2007, 07:39 PM:

dcb @ #55: I just tried in Fairbanks, and 999 and 112 did connect me to 911 dispatch.

999 and 112 had a delay, but they worked.

That's actually pretty neat.

#58 ::: Marilee ::: (view all by) ::: July 16, 2007, 09:12 PM:

Dave Bell, #30, I was in a Pizza Hut once when an elderly lady lost consciousness and I called 911 while moving over to check her. I told the dispatcher that it was the Pizza Hut in Wellington Shopping Center in Manassas and she insisted on an address. I asked an employee and repeated it back to dispatch and then hung up. The lady was breathing, her heart was beating; she was unconscious. As I looked up, an ambulance went right by the Pizza Hut and I called dispatch again and told her that. I said "tell them to come back into the shopping center and to the Pizza Hut" and as they were getting out of the ambulance, she regained consciousness. She refused to go to the hospital, which is her right, but I've wondered if she woke up while the EMTs were working on her if maybe she'd go.

What if it'd been worse? Why didn't dispatch add that it was the Pizza Hut as well as the address? The Pizza Hut is out near the road, away from the line of shops and apparently the ambulance guys didn't think to look there.

#59 ::: Jacob Davies ::: (view all by) ::: July 16, 2007, 09:24 PM:

What's the tone needed for that "CALL 911" instruction? I have this problem that I tend to phrase even imperative instructions as polite and optional requests. Elevating beyond that feels like I'm shrieking and panicking. I'm sure there's some middle ground.

I fell in a snow-filled crack in the top of a granite dome in the Sierras quite a few years ago, and found myself with my arms supporting me on the edge of the stone but nothing under my feet, and with nothing to brace myself against to climb out. So I was actually in Extreme Peril and couldn't help myself, but it looked like a very calm situation.

I was with a friend who was perhaps 60 feet away, and there were a couple of other tourists about 20 feet away. So I tried yelling, in a kind of moderate tone "Um, help?" They kinda looked at me. I tried a little louder. "Help!" No response. Even a little louder. Nope. And I just couldn't bring myself to go to full-on screaming and yelling mode since I knew all I needed was a quick hand out.

I only got out once my friend started looking around for me, saw what was going on and walked over to pull me out (on her own). At that point the other people wandered over and were like, "Oh... are you okay?"

I think I lack the Command Tone skill. I don't think those people were unusually oblivious; I crashed my bike very hard in front of dozens of people at Fisherman's Wharf one day a few years ago, and as I was lying dazed on the sidewalk for a minute or two, no one even walked over to ask me if I was okay. (An expression of concern would've gone a long way in making me feel better.)

I think it's just that people seem to have this conditioned response not to "make a fuss" about potential-emergency situations. To the point where they won't even look at what's happened, or they'll mock people who do. There's obviously some tone and volume level that breaks through that without them assuming you're panicking, I just dunno what it is.

#60 ::: P J Evans ::: (view all by) ::: July 16, 2007, 10:00 PM:

Jacob @ 59

Maybe you need to think loudly about how visible you are and how much trouble you're in. Not a joke - I'm usually pretty 'invisible' to people, so they don't notice me, maybe don't even really hear me. If I start thinking 'visible and conspicuous' I get a lot more attention.

#61 ::: Xopher ::: (view all by) ::: July 16, 2007, 10:07 PM:

Jacob 59: I'm sure you have friends who can help you with that. Practice by having them demonstrate, and repeating it back. Imitate them as exactly as possible, including their voice and accent. That's easier than trying to sort the tone out and imitate only that.

As a first approximation, try using the lowest part of your vocal range, at the highest volume. It's natural to pronounce high volume at high pitch, but that sounds like panic (because it's natural to get loud when you're panicking).

In the situation you describe, a panicky tone would have gotten them to come running. Don't knock a panicky tone. Sometimes it's your friend.

#62 ::: Greg London ::: (view all by) ::: July 16, 2007, 10:21 PM:

people seem to have this conditioned response not to "make a fuss" about potential-emergency situations

when I did my EMT training, I remember during the part for the heimlich maneuvar, the instructor went through the script: approach the person, ask if they are choking. If they can say anything at all, leave them alone, cause your help might make it worse. If they can't speak, go for the heimlich. And then the instructor said option 3: if they say nothing and then go into the bathroom, then you follow them, because they might be choking and can't deal with "making a fuss".

So, you're talking about a very real response. But being aware of it means you can change it if you want.

I think I lack the Command Tone skill.

This is probably more a function of conditioning than any sort of inherent character trait. i.e. how you were brought up, what your parents told you, etc. In short, it's how you've been trained.

And people react the way they've been trained, so the thing is to train yourself to do something different. The best way to do this depends on what conditioning you need to override. You might find Kareoke helps. Try it a couple times. If you can't sing, even better. If the conditioning is about not being in the spotlight, the center of attention, take the spotlight. If it's about being in control, then find an "improve theater" that you can try out. Most of improve is out of your control and you have to respond in a spur of the moment way. perfect training against freezing up. If it's specifically about talking to people, strike up conversations in public places with a dozen strangers over the next couple of weeks. Or maybe there's something else that would let you practice and condition yourself so that you're used to a command voice.

There's obviously some tone and volume level that breaks through that without them assuming you're panicking, I just dunno what it is.

For me, the tone is one of leadership rather than authority. which means it really isn't a command, but compelling. You're leading them to somewhere they're willing to go. If you think they're not willing, that they won't follow your lead, then that's probably what will happen. So, it is fundamentally a tone of confidence. You aren't worried about them saying "No" or ignoring you, because even if they do, you are confident that you'll find another way. If they don't call 911, you know you will get someone else to do it.

The way to find what the tone means for you is to practice and condition yourself to take on those kinds of situations.

#63 ::: Lila ::: (view all by) ::: July 16, 2007, 11:05 PM:

Jacob @ #59: the same tone you would use to tell your dog to stop tearing open the garbage bag, or tell your toddler not to step on the rattlesnake.

Community theater is a useful forum in which to practice trying on voices other than your own; stage fright is also useful as "artificial danger"--it gives you practice in remembering what to do, and doing it, even when you're terrified.

#64 ::: Xopher ::: (view all by) ::: July 16, 2007, 11:19 PM:

Leadership is the ability to get others to do what you want them to do, because they want to do it.

#65 ::: Diatryma ::: (view all by) ::: July 16, 2007, 11:25 PM:

I'm one of the people who wouldn't call 911 even if it were appropriate*. If you want me to do something besides stare worriedly and wish I were brave enough to do something instead of being afraid of getting in trouble**, I think the best way would be to point firmly, make strong eye contact, and say in a dog-training voice-- low, forceful, I Know What I'm Doing-- "You. Call 911." The easiest way to get me to do something it often to put yourself firmly in charge and give orders. As with babysitting children, don't end sentences with, "Okay?"

Of course, not everyone has my particular response to something going horribly wrong. I hope I don't have this particular response for too long. It's not the reaction I want to have.

*source of great shame and resolve to do better if it ever happens again.
**I know this is not the response that will save lives.

#66 ::: Xopher ::: (view all by) ::: July 16, 2007, 11:43 PM:

I suspect that part of the effectiveness of the commanding voice is to make it seem that the person employing it is taking not only charge, but responsibility. "Call 911," they say, and you hear "...and if it's the wrong thing to do, I'll take responsibility."

#67 ::: Jacob Davies ::: (view all by) ::: July 17, 2007, 12:16 AM:

Yeah, no doubt. I don't have a problem (so far as my experience indicates) in the responsibility, just in getting anyone else to assist. I think it's just that us introverts lack the practice in bossing people around.

(Sorry, now I am having this vision of practicing the command tone with my roommate. "No... more volume... I'm just not feeling the compulsion to obey here.")

#68 ::: dcb ::: (view all by) ::: July 17, 2007, 04:06 AM:

Tania @ 57

Thanks for the confirmation. Comforting, isn't it?

Jacob Davies @ 67
I'm often not very good at calling attention to myself - particularly if it's me that needs the help (social conditioning, yay!). But I'm great at standing up for other people - so if someone else needs help, I'll call loudly - and if nobody else is taking charge, or I'm sure the person who is doing so has absolutely no clue (standing up the person who is fainting, for example), then I'll step in and take charge, complete with authorative tone of voice - I just wish I could use it when I wanted to!

#69 ::: Jakob ::: (view all by) ::: July 17, 2007, 09:43 AM:

ajay #43: We were taught to 'glide, not pat', i.e. run our hands over the casualty, as you might skip over a bit if patting. We were also told to use the back of the hand when doing so if possible, as it seems less like copping a feel if the person comes to. Keeping up a running commentary of what you're doing can help there as well, as well as refreshing your memory and reassuring bystanders that you know what you're doing.

#70 ::: Terry Karney ::: (view all by) ::: July 17, 2007, 11:19 AM:

Eye contact, and a slight furrowing of the brow. The first makes sure the person knows it's them, not the guy next to them, the second gives a sense of importance. A pointed finger can help too... it shows the person doing th talking has, as others have said, assumed the right to tell you want to do.

We don't, as a culture, point at our equals. We point at employees, servants and children.

Invoking a sense of being in one of those categories helps to make people respond; esp. when they are at a loss.

A case of someone doing things really well.

I was riding with a friend. We were heading back to the barn. Guy across the wash called out to ask if either of us had a cell phone.

Yes, we did, but back at the barn (about 1/3 of a mile).

"I think I'm having a heart attack."

I told Matt to go back to sit with him, and took off (I was the better rider).

Matt, of course, had the key to the gate. I hopped it (trusting Leus to not run off), climbed back over, while dialing, and was gallopping back while talking to 911.

The guy didn't get worse (so Matt wasn't doing solo CPR, waiting for me to show up and start team), and the ambulance came to take him away.

But the guy didn't just give up when we said we didn't have one on us; he told us what was wrong. He was willing to make a, small, fuss.

#71 ::: Lexica ::: (view all by) ::: July 17, 2007, 01:27 PM:

Periodically a news story around here will mention that 911 calls from cell phones get routed through the CHP and so may take longer to get to the right agency than it would if you were calling from a landline. One of the first things I do when I get a new cell phone is to program in the non-911 emergency numbers for all the agencies around here that seem to make sense: Oakland PD, Berkeley PD, BART Police, and Oakland Fire Dispatch are the ones I have now. (Probably wouldn't hurt to add UC Berkeley Police, now that I think about it.)

I also enter the non-emergency numbers, for when it's a matter of "my drunken neighbors are singing karaoke at the tops of their lungs" rather than "we just saw a car burst into flames on the freeway in rush-hour traffic". Having made both those calls, I'll not-quite-gladly take the drunken neighbors, any day.

#72 ::: Caroline ::: (view all by) ::: July 17, 2007, 02:10 PM:

I just wanted to thank Mr. MacDonald for this.

I won't give details in order to preserve privacy, but a couple hours ago I was in a situation where I saw that someone pretty clearly needed emergency help. I wasn't physically present to do any kind of first aid, but having read these posts about the importance of calling 911 instead of fckng around, I grabbed my cell phone and called 911.

By nature I'm in the "not make a fuss" crowd, and it was kind of scary dialing 911 when my mind kept saying "Maybe everything is okay, you're just wasting their time." I wasn't even thinking about these posts at the time but later I realized that doing that mental rehearsal was what got me off my butt and calling.

It turned out that by the time I got through, someone else had called and the situation had been taken care of. But I didn't know that, and the details I did know strongly implied that everything was not okay and it wouldn't be a waste of their time.

I hadn't called 911 ever in my life before this. It had been drummed into me that you don't call 911 unless someone is visibly, obviously dying right there in front of you, like with their arm or leg chopped off, or something, and since that wasn't quite the situation, I was pretty freaked out about calling. But they were really nice to me and took care of things very professionally.

So, let me tell you guys, you won't get in trouble for calling 911 if you have reason to believe medical help is needed. People don't have to be actually dismembered before you call.

#73 ::: Fragano Ledgister ::: (view all by) ::: July 17, 2007, 02:56 PM:

I've phoned 911 precisely three times in the past three years:

Twice to report a car accident that occurred right in front of me.

Once to report a man standing against the median wall of an interstate highway.

I think of it as a reflexive deed.

#74 ::: dcb ::: (view all by) ::: July 17, 2007, 04:14 PM:

Caroline @ 72 & #73, from Fragano @ 73: Back before mobile 'phones, I seemed to make a habit of finding large objects in the middle of the motorway (folding bed, mattress, ladders - in separate incidents). I'd stop at the next emergency telephone (we have these quite frequently along motorways in the UK) and report the location and the object - I always figured it was better for the police to know about and remove the object before the multi-vehicle pile-up happened.

On one of these occasions - ladders on the M1 heading into London - I was told that yes, they'd already been reported, but thanks anyway. A colleague spoke to me a couple of days later, having apparently driven past and seen me, and told me off for, as a lone female, putting myself at risk of attack. Actual risk of getting attacked, with lots of traffic going by and a 20 ft concrete wall by the road? Approaching zero. Risk of getting hit by a car, admittedly greater than zero, but how could I have lived with myself if I'd heard of a pile-up with fatalities and known I'd not done what I could to prevent it?

#75 ::: Naomi Parkhurst ::: (view all by) ::: July 17, 2007, 05:15 PM:

I need to refresh myself on first aid (it's been a long time since I had that course).

On the other hand, I had occasion to call 911 a couple of times on behalf of other people, which made it much easier to overcome that reluctance for more personal emergencies.

Practice (useful, nonetheless): I called when I saw a city bus go by whose electric sign said "please call police". (Never did find out what that was about; 17 years later, I'm still curious.) That was my first call ever, and I was intensely nervous: fifty people would have called before me and my call would be extraneous and I would be wasting their time. But no, they wanted all the details, and nobody else had called first. I called when I saw tree branches smoldering where they were touching electric wires.

I've never been told that I shouldn't have called; when I asked, I was told I made the right decision. When family medical emergencies came up, the 911 operator talked me through what to do while waiting for the ambulance to turn up. It's all been highly reassuring.

#76 ::: Mark Z. ::: (view all by) ::: July 17, 2007, 05:31 PM:

I had AHA training last year, and they were teaching head tilt/chin lift for opening airways except when there might be a spinal injury (car accident, fall from a height, neck clearly at a funny angle, or generally any trauma where we didn't see what happened). They taught the jaw thrust for those cases.

I'm not sure about that approach. The general mindset of the training was to learn procedures by rote, making as few decisions as possible, because dithering over whether there might be a spinal injury does not help open the airway. Seems like a single well-practiced technique would be more useful than two methods and a delicate judgment call.

#77 ::: Carrie S. ::: (view all by) ::: July 18, 2007, 09:23 AM:

Tell you what, nothing gets a response like calling 911 and telling them you have a fire on a utility pole.

Came out of my house one evening to get in the car and go out, smelled smoke that didn't smell like a fireplace. After a few moments of messing around getting stuff in the car, happened to see the sparks from the broken wire where it was dangling against the pole the car was parked by. Called the fire department. They showed up very very fast.

We got in the car and went out, as planned, because it got the car out of their way.

#78 ::: James D. Macdonald ::: (view all by) ::: July 18, 2007, 10:58 AM:

Generally speaking your friends the nice EMTs would rather be called out and have the run canceled enroute a dozen times than arrive on scene and find that the patient would have been salvageable if anyone had called an hour earlier.

#79 ::: fidelio ::: (view all by) ::: July 18, 2007, 11:54 AM:

In talking with a friend who dispatches in a town nearby, I was told the "Don't call 911 for every little thing" meme is an effort to keep people from calling because thy've locked ther keys in the car, or have a cat (n no particular danger) up a tree. The rule of thumb he teaches his kids: "It's better to feel silly for making a fuss than to feel guilty because you didn't do enough".

#80 ::: Annie G. ::: (view all by) ::: July 18, 2007, 01:25 PM:

My husband is a ski patroller and was an EMT (his cert. has lapsed but fairly recently, so he still remembers his training), so we end up stopping at many roadside incidents and accidents if emergency personnel is not already at the scene.

Since I have only very minimal first aid training, my Designated Role is to call 911. Most recently, I called to report an accident at the Berlin exit on a particular highway in Connecticut, to find it had obviously already been reported-- as soon as the dispatch picked up they asked if I was calling to report the accident at the Berlin exit. But they didn't seem upset to have yet another report-- just informed me that emergency services were on their way. So I'll add to the chorus that, even if you think somebody has already called, call 911 yourself. Can't hurt, might help.

#81 ::: Seth Breidbart ::: (view all by) ::: July 18, 2007, 02:05 PM:

I think that if you're telling a stranger to call 911, it's better to say "Call 911, and tell me what they said." That makes them part of the treatment.

#82 ::: Andy Repton ::: (view all by) ::: August 16, 2007, 05:41 AM:

"You don’t go on from B to C until you have B. "

We have new protocols in the UK: if the patient is not breathing, we go straight to chest compressions.

#83 ::: James D. Macdonald ::: (view all by) ::: December 03, 2007, 09:57 AM:

An example of someone who failed to make the scene safe:

1 Dead, 27 Hurt In 6-Car Crash

Good Samaritan Killed Aiding Stranded Motorist

MESA, Ariz. -- A good Samaritan was killed and 27 other people were hurt after he stopped to help a motorist whose hood had popped open on U.S. 60 in east Mesa, police said.

The incident started when a dark sedan, its hood up, stopped in the road two lanes from the shoulder.

The victim came to his aid. But soon after, five other vehicles struck the Xterra, the victim or one another, said Department of Public Safety Sgt. William Rogers said.

Three people were seriously injured, Rogers said.


The good Samaritan was a 61-year-old man from Laveen whose wife witnessed the incident from their sport utility vehicle. He was pronounced dead at the scene by emergency workers, Rogers said. The unidentified man was partially pinned underneath another vehicle.

#84 ::: Debbie VanAllen ::: (view all by) ::: March 14, 2009, 12:26 AM:

I broke the 5th vertibrae in my neck in a diving accident 24 years ago and I've been suffering from low back pain and I mean PAIN. for years now and recently I have been having seizures three of them sense 2/3/09 to 3/13/09 I also suffer from fibormyelgia, surgeries on both knees that still are painful. And many other surgeries on my back My neuro doctor said that the seizures might be coming from the diving accident I had 24 years ago. I've tried Dilantin,Keppra XR and now Tegretol for the seizures I was taking Trammadol for all my pain but they said that can be causing the seizures to,So they took me off of it. What else can I use for pain besides over the counter meds (I tried then all) Dr.s really don't want to listen to me when it comes to the painful parts of all this. Please help or give input

#85 ::: Paula Helm Murray ::: (view all by) ::: March 14, 2009, 01:13 AM:

Debbie, a friend of my had, unknowingly, suffered some fractured vertebra in an accident some 30 years ago. This year he started having intractable pain, went to the ER because of it and they discovered the fractures. And could fix it with a way that the only way he could tell us about it was 'they injected something into the vertebra that was like a cement to fix the fractures'. What we know for sure is that as soon as the procedure was done and he was awake, he was no longer in pain.

The downside is that the x-rays discovered he has lung cancer (he's a long time smoker). It's treatable but his long-term survival is questionable.

#87 ::: James D. Macdonald ::: (view all by) ::: September 02, 2009, 04:24 PM:

The unhappy adventures of German fork-lift operator Klaus.

A factory training safety film, in German. No, you don't have to speak German to ... heh heh ... get the point.

#88 ::: David Harmon ::: (view all by) ::: September 02, 2009, 05:11 PM:

James D. MacDonald #87: Here's an English dub of that.

#89 ::: James D. Macdonald ::: (view all by) ::: July 04, 2010, 09:47 AM:

Happy Fourth of July!

In the interests of safety, here is a totally NSFW video (showing What Not To Do With Fireworks, Part #28574). (NSFW, but, surprisingly, Safe for Teresa.)

And here's a news story:

NY man blows off arm with firecrackers

The Consumer Product Safety Commission's annual warning.

And the reason why such warnings are needed. Annually.

#90 ::: James D. Macdonald ::: (view all by) ::: November 12, 2010, 04:37 PM:

"Thrown clear" in a roll-over. Wear your seatbelt.

Beginning at 4:42.

#91 ::: abi ::: (view all by) ::: November 12, 2010, 05:25 PM:

Jim @90:

Whoever was searching for any ejected children (before they confirmed there weren't any) has my sympathy. That will not have been a pleasant thing to be doing.

#92 ::: James D. Macdonald ::: (view all by) ::: November 12, 2010, 05:52 PM:

Those were firefighters from Beecher Falls (Vermont) Volunteer Fire Department. In their boots, shoulder-to-shoulder in a line, walking through dark, cold, swamp water. The rule is, if any windows on the vehicle are broken, search 200 feet in all directions (including up, into trees and phone lines).

What's worse than searching is finding.

#93 ::: abi ::: (view all by) ::: November 12, 2010, 06:22 PM:

Not entirely peripherally, Jim, I'm conscious of how lucky I am to live in a world containing people like you and those volunteer firemen.

#94 ::: TexAnne ::: (view all by) ::: November 12, 2010, 07:01 PM:

What abi said. (As usual.)

#95 ::: albatross ::: (view all by) ::: November 12, 2010, 09:37 PM:


#96 ::: Xopher ::: (view all by) ::: November 12, 2010, 09:46 PM:


#97 ::: David Harmon ::: (view all by) ::: December 22, 2010, 05:33 PM:

And one on the lighter side: Despite several errors (like continuing with the show!) she apparently was OK in the end:

Big Slingshots are Dangerous

#98 ::: James D. Macdonald ::: (view all by) ::: December 22, 2010, 07:45 PM:

A fuller version of the video here.

#99 ::: David Harmon ::: (view all by) ::: January 29, 2011, 10:17 PM:

Hey Jim, what's your take on this gadget purporting to Extend the Golden Hour? (Found a couple links away from FailBlog.)

#100 ::: James D. Macdonald ::: (view all by) ::: January 29, 2011, 10:38 PM:

That's a standard IO (interosseous) drill, with really neat styling (lots prettier than the clunky-looking ones we carry on the ambulance. And those are a ton easier to use than the old Jamshidi needles.

It's unlikely to have been something that people could carry routinely themselves to self-administer.

As for the drug Tamiasyn itself, it had made it all the way to animal trials, but the company went into Chapter 7 bankruptcy in February of 2010.

If it ever works, it'll be really neat.

#101 ::: David Harmon ::: (view all by) ::: January 29, 2011, 11:13 PM:

So, a hard sell on a standard gadget loaded with a half-tested drug, for an unlikely application. <Sigh>

Just out of curiosity, what do you guys use the IO drills for?

#102 ::: James D. Macdonald ::: (view all by) ::: August 21, 2011, 09:23 PM:

#102 David Harmon Just out of curiosity, what do you guys use the IO drills for?

To get vascular access when we can't get a vein. Used in multi-system trauma and cardiac arrest when the one thing that's worth diamonds and pearls is a way to get fluids and drugs into the body, and finesse and comfort aren't really high priorities.

#103 ::: David Harmon ::: (view all by) ::: August 22, 2011, 04:54 AM:

James D. Macdonald #103: Ow. So, meant to be a tool of last resort, rather than first recourse. Figures....

#104 ::: Ginger ::: (view all by) ::: August 22, 2011, 09:34 AM:

Oh, yes, interosseous is not a primary means of treatment, except in birds. They have fragile veins and nice light bones, so it makes sense to deliver high volumes of fluids into the IO space there.

#105 ::: fidelio eyes spam ::: (view all by) ::: February 10, 2012, 08:37 AM:

spam, spam, spamity spam.

#106 ::: Jeremy Leader ::: (view all by) ::: November 28, 2012, 01:01 PM:

Dave Harmon @99, Jim Macdonald @100: The first thing that struck me about the UniTam, compared to the EZ-IO and Jamshidi needles, is that the designer of the UniTam seemed very concerned to conceal the site of the puncture (and the "part that touches the body has a green undertone to make blood less noticeable"). The EZ-IO and Jamshidi needles on the other hand seem designed to make it easy to see what you're doing. Somehow, I think if you're driving a needle or drill into someone's tibia, they're not going to care about the drill's color, but they're going to care whether you've actually placed the drill bit correctly to hit the interosseous space.

Also, the UniTam looks more complicated (with a hidden drill bit that advances and retracts), and much harder to sterilize between uses. The EZ-IO looks like a sealed unit, to which a disposable bit is attached, making sterilization relatively simple.

The UniTam gave me a very strong "design school project" feel, a product design based on a list of requirements that ignored a vital part of the product's life-cycle (in this case, what happens to the device after you've saved someones' life, and need to get ready for the next incident?).

#107 ::: P J Evans sees spam ::: (view all by) ::: June 04, 2014, 11:44 PM:

The invasion has arrived!

#108 ::: Mary Aileen sees spam ::: (view all by) ::: October 24, 2014, 10:47 AM:

spam at #108, of the ineptly trying to be friendly variety

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#110 ::: SunflowerP sees spam ::: (view all by) ::: May 06, 2017, 06:29 AM:

Some bot is trying to sell boots @ #109, and needs to be on the receiving end of a boot.

#111 ::: Mary Aileen sees spam ::: (view all by) ::: June 23, 2017, 09:01 PM:

Spanish boot spam at #111, and an undeleted one from May at #109.

#112 ::: Tom Whitmore ::: (view all by) ::: June 23, 2017, 09:33 PM:

Note: the "Holding c-spine" link now goes to a 404. Because this is (literally) a life-saving link: you may want to change that.

I'm glad this has been brought back up to the top of the comments: it's really good to re-read this material. Jim, I don't think I can say often enough how vital what you've done with this series is. I speak as someone who's been in a couple of situations that this information would have been/was vital. The one thing I'd add here: if what you've done doesn't work, and you've followed this advice: it's not your fault. You did what you could. It's not your fault. Praise: no blame.

#113 ::: Ludens sees spam ::: (view all by) ::: December 18, 2017, 11:53 AM:

Shoe spam @ 109

Also, thanks to Jim for writing this series; and for working as EM. This work saves lives.

#114 ::: Ludens sees spam ::: (view all by) ::: December 20, 2017, 05:13 AM:

Old spam @ 109

Also, I'd like to say that these 10-year old posts are still being read and valued. Thank you for writing them, and for your service as an emergency responder.

#115 ::: Medical Depot ::: (view all by) ::: March 01, 2018, 05:57 AM:

Sometimes a single mistake in life become a trauma of life and we have to suffer it until death. Thanks for the article I like reading it.

#116 ::: Buddha Buck sees link spam ::: (view all by) ::: March 01, 2018, 07:01 AM:

spam at @115

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spam at @115

#118 ::: Mary Aileen sees undeleted spam ::: (view all by) ::: August 02, 2018, 11:41 AM:

Old spam still hanging on at #109 and #115.

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