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I work as an emergency physician, both in the hospital environment but also with the ambulance service working in the in the pre hospital environment, regularly seeing Children in a in a pre hospital critical care environment, which is much less hazardous than where there is conflict but deals in a system that works relatively well. I also have a lot of experience trying to apply that in the humanitarian settings. So in a real variety of resource settings, but my experience of global health is also uh makes me think a lot about what really works in different settings and for different people and trying to take the learning from these other two areas and think what could be most helpful for someone in a particular environment. And so the four key areas I'd like to cover is firstly for us to think about the first responder who that is and what they do. Well, then take that on to think about what we, what we all think of as prehospital emergency care. So providing that treatment before a journey to hospital well, then move on to just talking briefly about the actual transfer, a patient hospital. Um and then finished by just talking about the important issue, particularly with Children of multiple casualty incidents and how those first three points might be different when you're dealing with multiple casualties. And so if we think about that first responder, all this uh sometimes conjures up the idea of someone being sent to an incident and being the first to arrive. But actually, this is almost always a family member, a neighbour, um or very often someone with medical training but not medical training and dealing with emergencies at the scene of an emergency. So as a as a medical professional, quite commonly, someone might know that you live nearby, someone might know you're available and request your attendance. And rather than the trauma team or the scene that we're used to on arrival in the hospital, it may be that we see a scene much more like this and actually many of our, much of our training and our experience doesn't feel so helpful in this setting. And if you were to go on any first aid course, um they will always start by telling you about safety, they will say make sure it is safe to approach. Now for many people in countries around the world, this is something that happens very quickly to make sure that you're safe in the world of prehospital responding and emergency care. This actually is incredibly important and is a much more uh important step than it's normally in in the approaching a casualty, the hazards are much greater and much more extensive. So while this seems simple, even when you're an experienced provider, you must really think through these steps and doing them the right order. And I'll just say as it says here, it's really about shouting for help, but also not just shouting, but starting the call for what emergency services you might need, making the assessment for whether you can even approach the scene and then deciding if you can only then starting to make some evaluation of a casualty. And so this is not a slide just to put in uh so that we've covered it. This is a crucial first part of that first responder role and to think through uh in what we would consider, I guess an unstable environment. So any any environment that has threats that change, uh such as it's happening in Ukraine at the moment, there are some important things that are, that are risks when there is a blast injury. There is very often other fuel, gas cylinders, cookers, it that can become extra secondary explosions. There is often ongoing threats from fire smoke. The other thing is that if it was from a aggressive device, often such weapons are still pointed at the same site. And so the chance of a second attack are very high. You never know if there is a chemical element to the attack which is not seen physically. There is also often a damage to infrastructure. So electricity will often be live or broken, there'll be loose debris. And then also one of the important things is being cautious that has a small incident been set to draw a crowd such that a second attack will happen, knowing that the crowd has been drawn with that very intentional. And as we said that so that there is, you do not want to create yourself as the second casualty because then we're into a much more complicated incident and safety is always changing. So you must be ready for the scene to become unsafe even if it was safe at first. Now, this is an important rule that I always apply when dealing with any prehospital incident as a first responder is the rule of twos. So always think what would I like to be happening in two minutes time in 20 minutes time and in two hours' time and all of those uh aims often have actions that need to happen now. So there may be things that you need to instruct or start to allow you to achieve what is going to happen in two minutes, 20 minutes and two hours. And all of your plans should keep this rule of twos in the background in the back of your mind when making plans about what you do next. And then we'll refer back to this idea as I go through the explanation of what we do and the key thing to a first responder is to recognize that you are someone with very little resource. What you do need to be very simple. And if somebody is unlikely to survive in the next few minutes, there are very few things that you can do to prevent that. And so you focus on simple interventions, you reassuring comfort people and keep progress thinking about that rule of twos. And if you have one casualty, it might be a simple that in two minutes, I want to have assessed the casualty to deal with something really simple and important. In 20 minutes, I would like to have some help and be thinking about moving. But in two hours, I would like to be in the right place that has the right facilities available. And it might be thinking how do I do that? And it might be thinking about how you assess someone, what help you ask what transport you request and where you're going to be heading. And do you have the right means to get that? So as you approach, the, the key thing is to say, people often are concerned about moving injured people that they might cause more harm. You have to just be very sensible and say if you cannot get to someone or assess them, we may need to move them very quickly out and you may need to have an idea in your mind, a picture of the scene for where is the safest place to take them, call away any casualties who are able to walk and move them away. And the first thing is to take as many bystander helpers as you can and give them all jobs that will help you with your rule of twos. So maybe somebody to secure the road and make some space, somebody to call for, help somebody to start arranging transport, somebody to provide communication and somebody to support the family. As many people as you have, it's better to have people busy with jobs and help you while you start making your assessment. And so as you approach, always being aware in blast injury, that patient's may have hearing loss from the blast or be confused and being aware. So let's talk through the key. Simple things that you will do in a few in 2 to 3 minutes, that will make a difference. The first one is really just stopping catastrophic, heavy bleeding. Now, if you have tourniquets available, they're very good to just stop heavily bleeding limbs, especially where there are amputations. The windless tourniquet is twisted to get that tightness and stop the arterial blood flow. But this can be achieved with a belt from trousers. And so as a first responder, it may be that you need to get hold of a belt to do that much more commonly. It is about direct pressure from really heavily bleeding wounds. And that is simply the same as with surgery is taking gauze pressure, direct pressure and more gauze and more gauze more materials. This may in the pre hospital area need to be t shirts, clothing and other materials that just get added with pressure to try and stop catastrophic hemorrhage. So you do not need to be distracted by the more complicated injury, do not be distracted by the initial fracture to the limb. We need to stick to just stop heavy bleeding and then moving on to making sure that the child has an airway. If you keep it very simple with a young child, you simply take a piece of clothing or a blanket and place it under their shoulders. So they're in a more neutral position in terms of an older child. So once you are a toddler or a year and older, then it is what you're more used to in an adult where you would simply tilt the chin up or give a little thrust to the jaw to try and open the airway. If you have any worry about how older child is always just look in the label in their clothing and it will tell you the size of the child fairly accurately, but it's simply stopping heavy bleeding and then positioning the airway, you have no other equipment. So this is the best and simplest thing you can do. One of the simpler things to think about as a first responder is about the patient's breathing. Often people will not want to lie on the painful, injured side of their chest. So they may lie on their uninjured good side. Unfortunately, this then restrict their main area for expansion for breathing. So actually, if a child is at all conscious, trying to set them up so that the lungs can work effectively and supporting them to be confluence, comfortable sitting and just making sure any type bags or clothes are away from the child will optimize the breathing. So really what we've talked about, there are the only situations where you will make a difference in two minutes to somebody living or dying, stopping the heavy bleeding, positioning the airway in, in an unconscious patient and optimizing the breathing of a patient who is uh either unconscious or partially conscious. And so they are simple things but the things to really concentrate on because nothing else clever will work and those initial 2 to 3 minutes to make a real difference. And really from then, it is a case of repeating your simple management of those three things as a first responder and trying to keep the casualty warm even when, even when people have been burned. So even when there are burns, you will cool the skin um that that needs to be cool but has been burned. But people forget to keep the actual patient warms. It may be that you need to put cold water onto a, onto a limb that's been burned, but you must keep the actual patient warm. One of the biggest mistakes people make is when you think of that rule of twos is if in two hours, you want to be in a hospital in a theater waiting a long time for specialist help to arrive when you have a vehicle and a patient can be critical for the patient. If there is very little more that you can do and transport is available, you're better to get moving in the right direction and an emergency service can always meet you on the way, but do not wait with this patient who is getting worse a long time thinking that specialist prehospital help will arrive now. So just to recap. So going back to our idea, we've spoke before, it might be that in two minutes, you're just doing simple things in 20 minutes, you might be moving from the scene and at two hours you might be having in the right place to have surgery. Always have that in the back of your mind and do not try to be too ambitious and what you think you can achieve, it's better to be steady and move slowly and achieve those goals. Now, the next step, we hope after that first responder is an actual trained provider arrives to provide slightly more detailed care that we'll talk through now and that may be you in this role. However, it's worth noting that this will often be in any system in the world outside of a conflict zone someone with variable equipment, variable transport that may not even have the ability to take a patient and variable ability to make decisions. And so it's just being aware that could be you coming with a pre hospital service or it could be that you're the first responder and a pre hospital provider is arriving. And so we will just look through the simple system that we've used already talking about catastrophic hemorrhage, airway, compromise breathing and then revisiting hemorrhage and shock and just talk about the things that then as a pre hospital provider, we add, you'll note that again, it is very simple. The bag of equipment we carry even with a critical care service does not require a huge amount of equipment. So let's just talk through what can really a prehospital providers add to catastrophic hemorrhage. So really one of the few things beyond the basic tourniquet pressure is thinking about pelvic injury and we're really specifically thinking about open pelvic injuries. And you might be familiar with the pelvic binder that aims to close that and at least get approximation of some of the vessels allow better clotting and less movement of the pelvis as well as reducing the amount of uh space that bleeding can occur into in the pelvis. This is really generally given where you either have an unconscious patient where the mechanism means they could have a pelvic injury uh and an element of shock or where there is obvious clinical signs of a pelvic injury and this should be applied as soon as possible. And again, may well end up being a a bedding sheet, a large item of clothing, something that can be pulled tight around and allow the legs to be tied together at the same time with another piece of material so that you use the legs to bring the pelvis together and close the pelvis. And then once our first responder has positioned the airway, really, the main intervention would be to use a simple adjunct to keep the airway open like a an oral airway. Um That is simple sort of basic airway management really that you might add as a pre hospital provider unless you're a critical care team providing intubation and uh and anesthesia. Alongside that is the simplest of interventions really around breathing are the provisions of supplemental oxygen, providing a three where a three sided dressing or sending occlusive dressing to uh to any chest wound so that you do not get further sucking chest wounds, but you allow some dispersion of air. And then considering if you have a really critical perry arrest patient with some evidence of chest injury is considering needle decompression in the child with, with a cannula into that second intercostal space as on the diagram. And they're really just the key airway and breathing interventions that your regular prehospital provider can add in addition to the first responder. And then finally, we're looking at the more developed care of shock where we're looking at intravenous access, uh ideally blood products but, but fluid in small bonuses and Children, just five mils a kilo aiming to keep it to the level where you can feel, uh feel either a break your pulse, um or, you know, at least a sort of a good peripheral pulse. Um And then really just looking at other sources of hemorrhage that we can do something about and very commonly, this will mainly be things like significant femoral fractures, um, other wounds that are, that are bleeding. And I would say if the interesting thing is if you arrive at this child that's been injured and is semi conscious from the last injury, we haven't really had to think about any clever trauma diagnosis. We have simply positioned them well, we've simply applied some oxygen, we have simply dressed wounds, we have straightened limbs and we have a binder on and any fracture as best as we can straightened. And we've already without really knowing what's wrong with them, given them the best chance of surviving any significant injury from that blast injury. And then we just finish by thinking more a little bit about prehospital pain relief. So, uh certainly in your disability, making sure that the patient is alert that you have checked to glucose level. Uh, you've thought about pain relief and then really about exposure. Uh, we, we all know that cold trauma patient's do very badly and they bleed more. And so actually, it's very important to start keeping patient's warm from the beginning. So, so getting them covered, dry and warm and into somewhere into shelter. Um And it's just to finish by saying really, uh sometimes it feels like this is not, this is an extra, this is something that we can try and do. But actually, it's so important and often you get very good clinical information from trying to think about the psychological impact of the injury. So keep parents with Children reassure everybody, always ask what you think the parents or child is going to happen next. Once you know each other's names, every time you move, remind them it is you and it's the same person looking after them for that reassurance. And I have no problem with people trying to be really positive about the outcome of injuries. It's not the time to be really brutal and honest. I think it's time to be as positive as you can be. So that as a as a team, you're getting everything moving forwards with the hope of a positive outcome. And I will then just talk very briefly about transport because you could spend many days talking about training for transferring patient's. The key thing really is that it's the most high risk and challenging stage of looking after the patient. And I would caution that once you're in a moving vehicle, it is very hard to provide clinical care So you need to enter any transfer thinking that you have a very small chance of being able to change your treatment or change what you're doing during the transfer. And that's why we would have detailed transfer checklists and we won't have time to go into all of the details of this. But trying to just think through really the simple logistics of what you might need before leaving with a patient and then providing a detailed at missed handover to the hospital that you're expecting to go to. So they know what to expect. Some of the most easily forgotten things are that people don't have details for parents or don't have um money with them so that they can make their own way back home after the hospital or they haven't communicated with the hospital that they're even arriving. So it's just worth thinking about trying to have a look in advance yourself at a transfer checklist. So you can think through their vast detail of things that you can try and remind yourself to do. But my most important point for this is that it's really challenging and do not expect to be able to have another think in transport and start to change your treatment, try to have everything organized before you leave and then be ready just to say, secure and safe for the transfer. And one of the most important things to do is call the hospital because it gives you a moment to step away from the scene, calm yourself, look around again at the scene, take in information and process yourself, what what has happened and what you plan to do. So it's incredibly important moment for the clinician to be able to step away from the patient and do that. I'll just finish them with a few slides about multi casualty incidents that unfortunately are relatively common in blast injury because of the hazards that we talked about. The important thing, multi casualty incidents is that the role of the pre hospital provider becomes much more about safety, communication and command. And so it is really rather than you'll see that treatment and triage and transport come very much further down. And actually, the expectation of the of the pre hospital provider is to achieve a lot less than you would do with with a single casualty. So we have to reset what we're going to achieve and we have to look at actually our role as the first responder or prehospital provider may not reach any kind of assessment triage or treatment and we may simply be involved in command and safety. So really when we talk about the arrival of a first responder or that the first person at a multi casualty incident, if you could literally in the first five or 10 minutes, establish a point of communication. So a place where it's obvious that people can gather, gain a quick understanding of what's happening in terms of numbers of casualties and some of the information we'll talk about in a moment and then be able to report that back to someone who has an ability to plan the response and help. That's really all that can be achieved in actually about five minutes. And so when you look even in stable environments at multi casualty incidents, the time from the moment of the incident, when patient's are arriving at any kind of imaging or surgery are often much longer than we imagine. And so I would just ask any, any multi casualty responder to, to not see this as a race to treat patient's, but to see it as a calm profess to make progress forward and think through that rule of twos. And again, what do you need to do? Now that will make that be the case in two minutes, 20 minutes and two hours. And that may involve a lot of asking for help. It may be a lot of preparation. So what I'd like to think about with that is just trying to rethink about the rule of twos we talked about. So we've now got multiple patient's. So it may be that in two minutes. Actually, all we've done is gathered some basic information and it may be that at 20 minutes, all we've done is communicate this information and maybe even just started some basic triage. And rather than being in a hospital in a theater at two hours, we may simply be starting to transport patient and have an idea of what's happening. Now, we talked there about the methane report. I'm just going to show you that you can see here just to list really the key bits of information that prehospital provider needs to provide to the healthcare service. It's to say that there has been a major incident or a multi casualty incident, the exact location, the type of incidents such as explosion, uh a car crash, etcetera, the hazards. So are there any ongoing hazards um access? What's the best way of any emergency service getting their, what is your best estimate or range of the number of casualties? And which services do you think are needed? And if you can keep to that, you can give a very understood and clear idea of what the incident is you're dealing with. And there are again, long course is aimed at being very clear about how you would set out a scene in a multi casualty incident. If I had to keep it as simple as possible, I would say you have an area where those that can walk can go to. You have some sort of area where casualties are assessed and decided on where they're going separate to this. You have a transport area. So vehicles are not in the way of patient's and you know, where patient's will be able to leave the scene and a clear center where people would come with any information or come to see where the coordination is. And I think if you keep to those logical ideas of an area to walk people to an area to look after patients who are not walking and then their transport and organization, that's all that you need. And that can be very simple in a small area and detailed triage tools that can be used. I would say that the key thing is your first guest does not have to be correct. It just allows some prioritization. And if you keep it as simple as walking, there are patient's who you believe, maybe already dead. And then in between, you simply have patient's who are critically ill that you think need very emergency care. And there are patient's, you cannot walk but may not need immediate care. Trying to take any further detailed measurements can be really challenging. And so actually, if you take it and keep it really simple and say that in Children, they either obviously have airway or bleeding problems and so are very emergency or they don't have the airway and bleeding problems. I wouldn't start trying to take too many measurements because you simply say, can they walk or not. And that allows you a really simple way of just thinking about the three key groups of casualties that you're going to act on. And I'll just finish by reminding people that this is often how the response comes to unexpected incidents. It's often much slower than we would like. And then it peaks very rapidly and then it goes off very rapidly. And I would always say that if you're involved in any kind of multi casualty incident, being prepared for that peak of resource is much better than trying to rush at the beginning. So before you know, it many people will arrive, transport will arrive. And if you can be better equipped in the early minutes to know how you will allocate that help and use it wisely. That's much better than in the early phase. Trying to fight yourself when there is very little resource available. So do not panic when there is not resource available but get yourself prepared for when that resource to help you arrives. And I would just say really that try not to send walking wounded two major hospitals where you think emergency care may be needed for more critical patient's just try to inform hospitals when people are coming. But also they will be very pleased to know if they're interventions. They need to prepare such as opening theaters, preparing blood transfusions because it's trying to put yourself in their position. I think what is it? They need to prepare and they should be ready and not giving too much information but simply allowing them to carry on the care that you're hoping to provide. And so in summary, from this talk, clearly, I hope what you have an understanding of despite being highly trained professionals in your own field is an idea of what a first responder can be. How that differs to then slightly more structured prehospital care and a sense of the hazards of transfers and how to prepare for them. The real difference in timelines and expectation when dealing with single patient's versus multiple patient's. But really the most important thing is it is not just simply part of the algorithm to tick to say safety, safety is so crucial to pre hospital medicine. Uh And, and trying to keep everyone safety is responding, communicating and re communicating and re communicating. But also being really aware that you are in an austere environment, often in a hazardous environment. And just remembering what simple interventions you have available and not seeing that as a failure yourself because actually you just have very little resource available to you and to do simple things, try to help people who have a chance that with simple things can get to somewhere where they can be treated and so remain calm and just always keep doing the next sensible thing you think that you can do and try to remember that rule of twos about what you'd like to be happening in two minutes, 20 minutes and two hours and make your plan work towards that goal.