Assessing a Patient in an Austere Situation

Disclaimer.  I am not a licensed health practitioner.  This is just another post on knowledge and understanding you might wish to acquire in advance of a disaster in case no higher care is available.  As long as our society is functioning, you should leave anything more substantial than applying a Band-Aid to the professionals.  No medication, including those available over the counter, should be taken without consulting a physician.  Information shared here is for educational and entertainment purposes only.  It is not medical advice nor a substitute for licensed medical care. 

So let's say we're a few weeks into TEOTWAWKI and you're happily situated at your BOL.  And all is well, until some child drops out of the sky into your front yard.  Yeah, that's not really likely, but it avoids having to discuss the wisdom of treating an adult who stumbles into your area, whether there are threats following him or observing you, whether he's faking and you're putting yourself in danger, etc.  Also, imagining that it is your child you are treating may not work so well, either, for other reasons.  Keeping this as someone else's child helps keep you detached and rational in your approach.

Before rushing to the child's side, take a look around and above, just to make sure no one else is dropping out of the sky and on top of you.  As you approach the child, put on your gloves and make a mental note of your initial impressions and the time.  In other situations you might also note the location and number of other patients.

There are a number of different initial mnemonics for this as well, to help you remember everything.  Some use DR ABCDE, or ABCDE, or ABC.  You can Google the first two; both doctors my husband, daughter, and I took classes from taught us to use ABC.  This is to stop and fix immediate threats to life:

• A--airway
• B--breathing
• C--circulation

CIRCULATION

There is some debate among medical personnel about the order in which these threats are addressed, and you may disagree as well.  That's ok.  We probably won't be working on each other or each other's family members.  Lots will say to go in alphabetical order here:  first, airway; then, breathing; finally, circulation.

The American Heart Association changed the order in 2010 to CAB, because, as both doctors teaching our classes also pointed out, a body can survive a blocked airway and/or no respiration for three to five minutes without permanent damage.  But a person can bleed out in less than 60 seconds, and there's no comeback from that.  Bleeding (circulation) gets controlled first.

The next part of this is chest compressions, part of CPR.  Except that most times when CPR is being performed, it has to be continued until the patient arrives at the hospital.  We're talking about a time when there is no hospital, no advanced care, no diagnosis or treatment for whatever has caused the cardiac arrest.  As both docs teaching our off-grid medicine courses shared, you don't do CPR post-collapse.  Those people have underlying medical conditions that are not going to be fixed without advanced care.  Yes, it's hard to accept.

There are a few exceptions to this rule, all for people who were otherwise healthy before needing resuscitation--those who have drowned, or been electrocuted (lightning strike--yeah, it's possible to survive that), or choked.  CPR may bring those people back without the need for additional hospital support. 

AIRWAY

If the patient is conscious, one way to judge the airway is by how much the patient can speak.  Can he say a sentence, a phrase, a word, or nothing?  Is the patient able to make any sound?  The absence of any breathing sounds indicates total obstruction of the airway.  Gurgling or snoring sounds suggest partial airway obstruction.

In an unconscious person, the head is tilted and the jaw thrust forward so that the tongue can't block the airway.  Look, listen, and feel for air movement.  Does the chest rise and fall?

In both groups of patients, vomit and foreign objects need to be scooped out of the mouth so that they cannot block the airway or be aspirated.

• Turn the patient to the right or left before scooping out the mouth so that gravity can help.
• Make sure to scoop carefully so that you do not further impact material into the airway.  
• Semi-conscious patients may bite down on your fingers.  A bite block may help prevent injury to the caregiver.
• Be prepared for the patient to unexpectedly vomit.

In a survival situation, if necessary, you can safety pin the tongue to the lower lip to keep it out of the airway.

Oral and nasal airways are a simple way of maintaining the airway in an unconscious patient.  They're really cheap on Amazon, like $6-12, and each set has a wide variety of sizes to accommodate infants to adults.  It doesn't require any particular training to use them.  They aren't perfect; there is no protection from aspiration of foreign objects or vomit.  However, all the other methods of keeping an airway open--supra-glottic airways, intubation, and a surgical airway--require skill and training.


BREATHING

After the airway is open, check to see that the patient is breathing.  If not, you have to do it for him.  This is done either by mouth-to-mouth (or face mask) or using a bag-valve mask.  Neither of these are long-term solutions.  A patient requiring prolonged ventilation in a remote situation or societal collapse is unlikely to survive.

After, and perhaps even during, taking care of the ABCs above, it's also important to assess the patient's level of consciousness (LOC).  Most providers use the following AVPU scale:

A--alert and oriented to:

• person, place, time, and events (AOx4)
• person, place, and time (AOx3)
• person and place (AOx2)
• person (AOx1)

V--verbally responsive--responds to questions
P--painfully responsive--responds to pain like pinching fingers or toes 
U--unresponsive--no response to any stimulus

Care providers usually conduct the AVPU assessment while doing other things, like you see on TV.  You know, the questions you might find annoying.  "Do you remember what happened?  Do you know what day it is?  Do you know where you are?  Do you know who I am?"  Stuff like that.

In all likelihood, you'll never be faced with any of this.  Even trained physicians, other than those working in the ER or trauma departments, rarely see anyone in a life-threatening situation.  But things like this are always good to know.

For further reading:
Survival and Austere Medicine, 3rd Edition, pp 88-93.
(Articles accessed 16 September 2019)
https://www.americanpartisan.org/2019/02/first-aid-in-a-wilderness-environment-part-1-patient-assessment/
http://www.emergencymedicalparamedic.com/assessing-abc/

 17 september 2019