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Hi, everyone. Um my name is John. I'm an anesthetics registrar and I've also done a diploma in Expedition and Wellness Medicine. Uh I also teach for Endeavor. So today we're going to cover the general approach to a casualty. We're going to use an acronym, uh which you'll hear over and over again. For good reason. Doctor C ABCD E will cover what normal vital signs or abnormal vital signs might look like in the context of this assessment. Look at basic life support and also chat about the use of oxygen. So when we're assessing someone, it's good to have an idea of what normality looks like. So have a look at these vital signs and think about what you'd expect to find for a normal value in a normal adult patient. So the respiratory rate. So how many breaths you're doing per minute? What your pulse rate is per minute, what your consciousness level is? And what might it look like if your consciousness level is dropping? How could you measure that? And what sort of temperatures would you expect to find someone in? So the normal respiratory rate is about 12 to 20 breaths per minute? At rest, the pulse rate can be as low as 4050 individuals. Um or perhaps elderly patients who might be on medicines to lower their heart rate and normally doesn't exceed 80. When someone is at rest, the consciousness level can be measured as um with an AFP scale. So we alert, confused, responsive to voice. So they may have their eyes closed and when you say their name, they open them responsive to pain. So again, they may have their eyes closed, not responding when you're calling their name. But if you give them a good squeeze on their shoulder, for example, they might then either grunt or say something, they might be completely unresponsive. So to voice and pain, they're not doing anything. Um in disability, we also look at what the pupils are doing in response to light. We also take a note of whether the pupils look equal in size and what size they roughly are. For example, three millimeters, equal pupils and reacting. So constricting a normal temperature sits between 36 to 37.5 degrees. However, it does depend on how you're measuring the temperature which we can go into when we are on site during the course. This acronym, Doctor C ABCD E uh forms the mainstay of our approach to a patient. So why is it in this order? Uh And what does it mean? So the first part, the doctor part, the danger and response is really about keeping ourselves and our team alive whilst responding to an unwell patient. The next steps are really what's going to kill the patient first. So, catastrophic bleeding will kill someone first because there's nothing to provide them with oxygen or to keep them at BP. If they have no blood in their body, the rest of it really is how oxygen gets to the patient's organs. So if your airway, which is the tube that connects your mouth to your lungs is not open, no oxygen is going to get into your lungs. There's an issue with your breathing. So your lungs expanding to draw in that oxygen through your airway and then put that oxygen into your blood. If there's an issue with that, the oxygen doesn't get into your blood. Next, most important thing is delivering that oxygen to all of your organs, which is your circulation. So composed of your heart pumping around your blood vessels. So that oxygenated blood, if it's not being pumped around and delivered to your organs, you will then die. So that's why circulation is. Next. Disability relates to the consciousness level. Um and really is uh representative of how well your brain is having oxygen delivered to it, but equally can be affected by other things affecting your brain. For example, blood glucose, if your brain shuts down and stops working, your heart will stop working and your breathing will stop working. And therefore you also unfortunately die but it sits further down the cascade here. Finally. Um and easy to miss, but very important is um the environment um which comes under exposure. So things such as extreme colds or heat uh may be a threat to the patient um and can result in them, obviously passing away as well. Um As well as exposing the patient fully being an important step in figuring out what's going on with them. So this altogether is what we call our primary survey. So it's the first thing we do. When we survey the patient later on, you'll go on to doing something called a secondary survey. Once you're happy that the patient is fundamentally alive and likely to stay alive as part of this assessment. If we're identifying any issues within the assessment, we should also treat them before moving on. Uh And I'll talk about this when we go through each step individually in the rest of the lecture, doing this primary survey also gives us some clues into how well the patient is um and helps us plan what we're going to do next. So let's go through our, our primary survey. So the doctor C ABCD E response. So the first part is danger and response. So when you're approaching the scenario, it's having a thought of what dangers are present before you approach the patient directly. Uh And therefore how should you respond to it? This is a really good stage for you just to take a few seconds or 20 seconds just to really sit back and assess it, uh, because you could be putting yourself at significant risk. Er, and then you're not of use to anyone. So I've given a couple of examples here. Um, and what I'd like you to do is just have a quick read through them, uh, and pause the video and then write down what dangers you think might be present. Uh, and how might that affect how you respond to that scenario. So, for example, someone in the water distress and had been stung, a climber who has fallen and perhaps in a position or place, um, or a cyclist who'd been knocked off their bike in the road. So hopefully that got you thinking a little bit. So, for example, uh, some of the dangers you might face and some of them in the water is distressed is if you're approaching them, they might pull you under if they're very distressed. Um, they said they've been stung, uh, which, uh, brings up a topic of the dangers still being present there for you. So it may be some dangerous jellyfish that are around, they might have actually been bitten. Um, so if you're planning to get into the water, you're putting yourself at immediate risk of just becoming another patient. Um, so you really have to think how you're going to respond to them. A climber who's fallen might be in a risk area. Er, So they might be someone who, uh, you might want to, uh, take out very quickly from that area. If there's a risk of rock fall or they're on a ledge or you may have to think about where you're taking your equipment. Do you want to take all of your equipment onto the edge of a cliff edge immediately? So, where it falls off and then you've lost it all and, or should you leave it somewhere else before you go in, cyclist being knocked off on their bike. And the road is pretty common and you don't have to travel far abroad to see this. You might just sit in your local city. Uh And there are the obvious risks of cars still being in the road as well, for example, er and therefore you need to do some management of the environment. Um So people stopping the cars, for example, before you're actually approaching the patient and putting yourself in that danger zone of becoming another patient. So take your time, think about what dangers are present, how you should respond. Uh And how the rest of your team should also responder, giving a nod to the general team safety and perhaps not exposing everyone to the same things um or putting other people in charge of evaluating ongoing dangers and ongoing responses that are therefore required whilst you're focusing on a patient. So now we're getting into the cli clinical bit to do with the patient themselves. So catastrophic hemorrhage and what do we mean by that? Um It can be slightly confusing when you're first coming across scenarios or patients who are bleeding to know what is catastrophic and what isn't generally what we mean by this is really severe blood loss uh normally coming from an artery. So spurting um or flooding everywhere that will immediately put the patient in danger of dying from blood loss uh within minutes. So, examples of this might be someone who's got a slit wrist and you can see the blood spurting out from an artery, uh the loss of a limb. So, an amputation, for example, of an arm or a leg. Um and it's important to respond to this immediately because uh time is blood. Um and people can lose blood incredibly rapidly with arterial bleeds. It's important just to have a quick look around for any blood on the floor or under the patient or coming from any clothing. Uh to see if there's any more hidden forms of blood, for example, penetrating injuries to the abdomen or especially at the back of the abdomen might not be that obvious to you initially. Yeah. So the first pause of call with, if you're suspecting it's catastrophic bleeding is to try and stop the bleeding. Um and direct pressure on the area of bleeding uh will be your ideal solution to stopping it and we'll go into this in a second. So once you put that direct pressure on and you need to put quite a lot of force on if it's arterial bleeding. Um, and it will be uncomfortable for the person who you are doing it to is the bleeding controlled. So is what you're using, probably a piece of gauze. But if you don't have anything and you're very limited resources, it could be, for example, a rolled up t-shirt, for example, is blood still really soaking through that or not. Now, you're going to expect it to get bloody. Um But you're trying to see whether it's really dripping with blood or not. If the bleeding is controlled with that, you can try and put a compression bandage around that maintaining the pressure on it or if you've got the resources for people to have another person just putting pressure on it, um Until you've got a better solution further down the line, the bleeding's not controlled by direct pressure. Uh And particularly if it's on the limb. Um You could consider using a tourniquet. Now, there are lots of pros and cons of tourniquets um that I'm sure you can discuss when you're at the course as well. Uh What you're es what you're essentially doing is cutting off the blood supply to the entire limb, obviously to save uh the patient. But if you do this for a number of hours, the limb that you've put the tourniquet on um anything that is uh further away. So distal. So for example, if you put the tourniquet on the arm, anything from the arm down all the way to the hand, um, is at risk of dying because it doesn't have any oxygen going towards it. So obviously, if tourniquets can be avoided, that is a good thing because if they are left on for er, many, many hours, er, people might end up having that limb amputated. Of course, it's a trade off. If it saved their life, then it is, of course necessary. Another thing to note with the tourniquet is incredibly painful to put on. Um, and you can go through doing this on the course, um, and maybe try and put some on yourself. So, you know, um, and they get more painful as time passes because of this risk of, um, having the limb tissue dying. If the tourniquet is on for a long period of time, it's very important to write the time. Uh, you've put the tourniquet on, on the tourniquet which you can see in this picture, someone's writing with a, with a sharpie on that little gray, um, strap the time that they put it on. Um, another thing to consider is if you're putting a tourniquet on, in the brush of treating someone, uh, and you're not quite sure it's needed but you think it is. Um, there is no harm when things have calmed down a little bit, say 1015 minutes further down the road and then reassess, uh, whether the, the tourniquet is needed, so you can slowly release it and see if the bleeding is controlled by compression, for example. Um, and then reapply it if you think it definitely is needed. And that might mean that unnecessary tourniquets don't stay on. Obviously, you can't use a tourniquet on someone's torso. Um, so, uh, you have to consider packing the wounds, um, and using compression bandages, um, to try and stop the bleeding as best possible. Er, plus or minus, er, using some manual compression. Ok. So, um, you're confident the patient isn't completely exsanguinating, losing all of their blood. So now you can move on to uh the airway, which is a, so this is all about getting the oxygen through to the bicycle organs. And the first bit, as I said is, is really getting the oxygen into your lungs, which is down your airway. So the airway comprises of everything from uh going back in your nose or going back through your mouth and then your trachea going all the way into your lungs if they're unresponsive, however, you'll need to check that the airway is open. Um, so to do this, we use uh some simple airway maneuvers, um, particularly if there's no obvious sign that the airway is open. So what are the signs that the airway is patent and open? So you might hear some breath sounds by putting your face close down to the air, to the airway, to the mouth, you might feel the breath on your cheek, um and you might see or feel the chest rising, um which shows that your air is air flowing through. Now, it's good practice in an unconscious patient to make sure the airway uh has the best possible chance of being open uh whilst you're assessing it um and checking for signs of life and which we'll go to in the basic life support. So there are two ways of doing this. There's the head tilt chin lift, whereby you just put your fingers underneath the chin and just gently pull the chin up to elongate the airway, er and mean that the soft tissues are less likely to relax and block that windpipe. If you've got a suspicion that the person might have had a neck injury, this isn't the best option to do because you're obviously moving the neck and it also might not always be effective. So the other option is to do a jaw thrust, which is particularly effective. Um and a little bit more painful, which may give you some other information of how responsive they are. So the jaw thrust um focuses on pulling the jaw forwards. Um so giving you a sort of under bite like so and you're doing that by pulling the angle of the jaw forwards, lifting it upwards and you can go through this on the course. So once that airway has the best possible chance of being open, you can do that assessment of and looking further signs of breathing, listening and feeling as well. Um The bonus points really come from the further assessment of the airway. So it's often not as clear cut as is it open or is it not there may be signs that the airway um isn't functioning uh as often as you want and may be a real risk to the patient. So just have a quick think about um what might give you some clues that there's a real risk of the airway uh closing. Now, um And then uh for some kind of extra bonus points, think about what things might mean that it might be an immediate issue pretty quickly. And this really helps your planning uh in terms of calling for evacuation of the patient and figuring out whether they're big sick or little sick and more how the whole scenario may end up progressing. Ok. So, um as well as looking for those signs of the chest moving and breathing, you may hear noises that give you an indication that the airway, uh it's partially obstructed as we call it. Um So these might be Stridor noises. So, like um um which uh is caused by airway swelling, you may also hear snoring noises, which also give an indication that the soft tissue was relaxing into the airway. Uh If the patient is conscious, they may actually describe having difficulties breathing or difficulty swallowing, uh which may be clues that there is a problem with or near the airway. So thinking forward about whether this is going to escalate very quickly to an airway issue. Um looking for signs of burning to the face, for example, signs of allergic reaction that are severe like anaphylaxis. So, swelling of the lips and swelling of the tongue and which may rapidly swell and obstruct the airway injuries to the neck, for example, which may have an immediate problem or it may actually be hours down the line. Um and other things such as decrease in conscious levels or um throat infections may actually cause airway obstruction, but they may not be the immediate threat for you. So, with all this in mind, um once you've assessed it, um if it's not open, you need to keep it open. Um and it can easily be forgotten amongst other things. And so normally, if there's a problem with the airway, you'll need to assign someone just to look after it. Um If you cannot get it to be optimized. Uh so to do this, you can do those manual maneuvers which obviously takes up one person. Um or we can insert some airway devices such as a nasal airway device, um oral pharyngeal airway device. Um and they'll have some of these on the course that you can have a look at this video just shows that head tilt, chin lift, elongating the airway. Um So I'll keep it on this slide so you can see it repeating. So the arrow is pointing to the airway and there you can see it and it was that black hole and as the head's pulled up the soft tissues elongate and stop that obstruction. Yes. So considering the cervical spine, um, is important as part of airway really. Um, and it's a real balancing act. Now, uh There's a lot of contention about how you should manage. Um, someone's cervical spine, um but it's very, very important if you've got a strong suspicion that someone has an injury to their neck. Um There is obviously the chance that they can uh get nerve compression um and a nerve injury uh that will result in paralysis um or, or death if it's particularly high. So the key things you're trying to think about when you're approaching them and assessing it is do they, do they have a high chance of having a, a dangerous neck fracture? So you consider the mechanism that they've uh potentially injured themselves or maybe this patient now has no signs of having injured themselves. Um and it may be due to something else, for example, extreme heat exposure. So, uh very high falls or traveling at high speeds, for example, and, or signs of other head injuries, a loss of consciousness, um may give you clues er, that they might have a neck injury alongside it. Um You can consider whether the patient can self extricate themselves. Um even if they've got a bit of a sore neck. Uh, patients tend to stabilize the necks themselves and only do what they're comfortable with. Um, however, this is slightly nuanced. Um and, and does involve uh further discussion um to, to considering this if you're concerned at all and uh you don't feel like you've got the capabilities and more experienced to uh make a decision on this. We advise you just not to move the neck um and you can stabilize it gently with your hands whilst talking to the person but obviously balanced er, in the environment you're in, er, and you'll need to evacuate the person. So there's got to be some pragmatism, er, if you're putting yourselves all in a high risk environment for hours on end. Um but there's a potential that you could quite easily walk 20 minutes to your, your car parked on the road rather than waiting for a helicopter evacuation. Er, that may take half a day, for example. Um It may be better on balance to consider things like that. You could consider using some improvised neck immobilization. Um I've written, however, the caution uh it is particularly hard to do um particularly hard to do. Well. Um even with our specially designed collars, there will be a degree of neck movement even if they're not fitted correctly. However, um it may provide a bit more stability, particularly if you're having to carry out an unconscious patient, for example, using a Tarpaulin where there may be a lot of head or neck movement and it might just provide you with a bit of confidence um and a bit more stability than not using something, uh just being mindful that you don't want to cause any compression to any of the neck vessels, for example, uh when you're putting it on, um and if it's going to be on for a long period of time, there's quite a high risk of getting a pressure sore or injury from it. Um So it would need some reassessment um within a reasonable time frame. For example, an hour, if you are extricating someone who is unconscious, using that, there are some tools that we can use um that will help guide us a little bit about whether we could uh rule out or be more confident that there isn't a neck injury. Er, now these things aren't fully designed for the expedition environment, of course. Uh And so we're just trying to apply some relevant data that we can use in hospital to do that. Uh If a patient doesn't have any of these features, it is more reassuring that there's no neck injury and may give you that confidence to, to move them. So a focal neurological deficit, for example, might be a numbness or tingling going down the arm. So it's something to do with the nerves, there's a deficit or they may not even be able to move something. However, that if that isn't present, that's reassuring it, it means you're more likely to consider that there's no compressions of the nerve. Uh then there's kind of the midline spinal tenderness. Um So that's going down the bone of your neck, um, altered levels of consciousness intoxication or distracting injuries. Uh may mean that a person uh cannot focus well on whether they've got a neck injury. Um So that's why if they're present, you can't really say whether the person's got a neck injury because they may not be able to tell you because they're so distracted by something else. Um They're intoxicated, they can't really focus on that. Um, or level of consciousness means that you just can't rule it out. Um So it may be a useful tool and this one is called nexus. So we've worked through the doctor, we've done the c the catastrophic bleeding, we've gone through airway. Uh And so if we're happy that the airway is open, um at present, um and there's am oxen going through, we need to check b which is breathing. So, er, to assess the breathing, we need to have a look uh and a feel for 10 seconds to see if there is breathing. So that's part of that basic life support. Um Keeping the airway open, you're looking for the chest rise and the fall, um and you're counting the respiratory rate. So part of those vital signs, you can listen for breath sounds with a stethoscope, if you've got one, but actually just putting your ear to someone's chest with their permission, uh can give you an indication of whether there is air entering the lungs and may reveal kind of big abnormalities such as no air entering on one side. That means, ok, there's a punctured lung, for example, and, but air entering on the other, you can feel the chest movement, um which may be particularly useful in cold environments, for example, uh when assessing the breathing. Um and you can just put your hands um within someone's coat and see what their breathing rate is and check that the chest is moving equally. Um which may also give you the indication that there is air entering er on both sides of the lungs. Yeah. In this little algorithm, obviously, there's no signs of breathing. Um then you need to start CPR but we'll go into this in the base of life support. At the end, you can initiate some basic treatments um Even if you're in a remote environment. Um So I'll put some examples, you may or may not have oxygen if you do and you see that there's a problem within breathing. So any of those abnormal signs, so high or very low respiration rates, no air entering on either side, for example, or unequal chest movement um or obvious chest injury, you may consider putting the oxygen on. It may be someone who's got a diagnosis of um a chest problem like asthma, for example, that may be that you can give them an inhaler to improve their breathing, simple measures as well. Um if appropriate. So if you're not trying to protect their neck, sitting someone up has a massive difference on their ability to breathe when you're lying flat, all of your abdominal organs push up on your diaphragm and stop your chest, really expanding um easily and therefore just sitting someone up will improve their breathing if that's all normal. Um, or you've initiated as much treatment as you can, um, then you can move on to see. So mo ac and so circulation comprises of the, of the system basically to deliver the oxygen to your brain and organs. So you've got the pump, uh which is your heart, you've got your blood vessels and here are the analogies that are the hosepipe. Um, that's sort of passing this, this fluid around. Uh And then you've got a fuel the machine. So yourself basically. So it's passing all the blood to your essential organs very important in your brain. Um But also all of your other organs. So in assessing circulation, we want to check that that blood is being pumped around basically. Um, so you can look at the appearance of someone. So if they look uh pale, uh for example, pale hands or pale face, uh it might be an indicator that the heart is not pumping effectively or the blood has not been distributed around through the blood vessels. Effectively, you take their pulse rate um at the wrist, uh it feels for the radial pulse. Uh and this is the most common place to feel if their BP is lower, you might not be able to feel it here. Um And you may have a better result, feeling at the neck for the carotid pulse or potentially in the groin. For the femoral pulse. You want to make a note of their pulse rate. So how many BPM? And also what the pulse rhythm is, whether it's got a regular beat or it's irregular, which may indicate some other problems to do with the heart. Uh, and an arrhythmia, a capillary refill time is something that we do regularly as well, uh, which can be taken both peripherally and centrally. So, compressing the fingernail, er, for five seconds, er, the fingernail will then go pale because you've cut off the blood to it and then you're watching to see how quickly the fingernail gets the color back. Uh And ideally, this should be less than two or three seconds. If it is prolonged, it may mean that you are what we call sort of peripherally shut down. So your blood vessels are constricted perhaps to try and maintain your, your blood volume uh within the, the core circulation. Um, or it might just be that you're particularly cold as well, um, which you can consider, you can also check the capillary refill time at the center. So over the sternum using the same technique, um and if that's decreased, that's particularly worrying. So the issues might be that the the pump stopped working um or isn't working effectively. So it might be that you're having a heart attack. Um There are limited treatments you can do in the field, but you may wish to give someone uh some aspirin, for example, if you're, if you're trained and confident to do so, um, but you can also have the pump stopping working from other things, for example, severe infection or trauma to the chest, um, which may have caused some bleeding around the heart, for example, probably more common. Um, is that you're going to be having problems with the vessels or what's in the vessels. So there might not be enough fluid within the vessels or these hosepipes and we call that hypovolemia. So for example, if you've lost a lot of blood, there'll be less uh volume within these blood vessels. Um But it may also be due to the fact that you've lost lots of fluid as well, uh from other causes. So severe diarrhea and vomiting will make you very dehydrated and will mean that there's less volume within the blood, um, as well as s severe heat exposure will also cause a lot of sweating and dehydration. So there are other things to consider, um, or it might be actually a problem to do with the structure of the blood vessels. So they may change shape or get some holes in. Um and this is normally reduces some inflammatory cause. Um for example, sepsis. So, severe infection, um or anaphylaxis, so severe allergy to something else, um And the vessels may then struggle to constrict uh and go all floppy. Um or they may become particularly leaky as well. Uh If you've identified a problem and see. So uh a rapid pulse rate with uh what you might consider a low BP, you may have the ability to measure the BP or the pulse might be really weak, for example, and you can only feel it at the neck. Um Then you want to initiate some treatment, you might have some intravenous fluids that you can give them. Uh for example, if they're very severely unwell, uh if they're more conscious, uh and you think it might be from dehydration, uh You could consider giving them some more fluids, for example, in diarrhea, vomiting or um heat exposure, uh if they're able to do so safely. Um You may not have any resources to do that. Um And simply lying someone down will improve their BP um and improve their conscious level if it's been affected by the fact, they've got such a low BP. So consider lying someone down if there's an issue, a severe issue with circulation. Um and also consider whether you raise their legs up. Um if they don't have any injuries, uh, to improve the volume of blood going back towards the heart. Um, and this can give them an immediate boost, um, of a good few 100 mils of blood. So, uh, before we go on to disability, uh, also worried about your consciousness level, uh, because you've been listening to me for about a half an hour. Uh, so just pause the video maybe, uh, if you feel like it get up, have a quick walk around. Uh and then we're gonna come back to er, chat about disability. So whilst you're walking around, uh have a think about the things you might be looking for. So, uh welcome back if you've chosen to uh do a little, little stroll around. Um So for our disability assessment, we're basically trying to check to see what the level of consciousness is, uh whether they've got any injuries to the head potentially. Um and also not forgetting glucose, which is such an easy thing to measure, but it can have catastrophic consequences if it drops too low um when it cause loss of consciousness and seizures and death at worst. So to assess the pupils, um we're looking at them to see how big the pupils are and look at both pupils. We want to see if the pupils look like they're equal in size. And then we also want to shine a bright light into them and see if they constrict to light. Um and whether they're both doing that if the pupils are unequal, uh it may be uh a sort of difference the person has uh naturally. Um if they're conscious, they might say, oh, well, one of them has always been like that. However, it's very suspicious, particularly in an unconscious patient. Uh if someone has pupils of different sizes or uh not reacting to light that they may have had a severe head injury, um assessing the conscious level can be done in a simple fashion using the AF scale. And here's the modified one, which includes confusion in there and to give you another level of consciousness level. So the green thing there is alert and then as you go down towards what the person responds to, um you have at the very lowest thing that they're not responding at all, um which is very bad if someone's only responding to pain, uh that's an incredibly worrying thing. Um And likely that their airway will be under threat uh because they're not uh able to support all of their soft tissues, for example. Um And they'll need immediate uh response by medical practitioners and will probably need intubating. Um So this is something that's making you think this person is big sick uh voice is that borderline. Uh and people may have different reactions to it if they're incomprehensible uh and only opening their eyes to voice and not responding to anything else. It's also a pretty bad sign and confusion is, is an early sign that there may be something wrong in the brain um and should be taken seriously. Uh And you should be looking for signs of things that may be causing that. So glucose is one of them exposure. Uh for example, hypothermia um as well as head injury. Now, any decrease in the consciousness level uh needs to be taken really seriously, particularly in remote environments um for the potential to deteriorate. And also if there's not an obvious cause of it, it is worrying um you should particularly pay attention to monitoring the trends of the conscious level um along with all of your other assessment, um which I will mention again. So to round off your assessment, uh you are looking to expose the patient and also looking at what they've been exposed to. So expose the patient with mind to what the environment is like. If it's an extremely cold environment, for example, Arctic and subzero temperatures, uh you may make the patient really cold rapidly. If you fully expose them all at once, you may choose to expose parts of the patient at different times. Um or if there's a very clear obvious injury, uh you may choose not to expose the patient immediately. However, really to complete your assessment, you do need to have exposed the patient at some stage. Um exposing the patient will give you uh really useful signs of what the cause of the problem might be, um for example, rashes. Uh So uh there might be a, a rash that shows meningitis or perhaps they've got severe heat rash that may also alert you to the fact that they're not well heat acclimatized and the heat might be an issue, taking their temperature. Uh If you have a thermometer also forms part of this assessment. Um and we will give you that information about whether they're particularly hot or cold, which will both cause issues. You may see injuries that you haven't initially picked up on uh particularly in unconscious patients. So for example, areas of bleeding um or uh limb injury or chest injury, for example, it may become important further down the line. Um ideally, you want to look on someone's back as well. Um In trauma patients, you've got to consider maybe not moving them, particularly if there aren't many of you to do so and to do so safely. And this is a skill that you will, will earn um on the course to log roll a patient. Um you can use your hands however, to get to areas um which you may not be able to expose and see if there's blood on your hands, for example. So as part of this, uh you may treat them under the exposure. So if you found that their temperature is particularly high or low, uh it may be an occasion to keep the patient particularly warm and actively try and warm them up, for example, with some hot water bottles and insulation, um, or to cool them down. Alternatively, if they've been particularly hot and you think that they've got a heat stroke. Um, this is also just another quick reminder to think about uh, what you're all exposed to. So, yourself and the team, er, and to make sure that you've got the team covered and the team are safe, um, and aren't all getting cold in particular. So that covers our doctor C ABCD E assessment. Uh We are making sure that we're looking after ourselves and approaching people properly. Uh We are then assessing patients in er, the order of things that may kill the patient first. Um And we are trying to identify problems and also treat things if we can as we go a little reminder of what normal looks like in the vital signs. Um And these are obviously other abnormalities along with your examination that you might pick up in your assessment. These vital signs are important to note down um and documentation, although difficult uh in different environments, er, is really key both clinically er during the time. So, er, to make sure you've noted down any problems, you've got to make sure you've noted down all the observations. This will mean that you can keep an eye on how the patient is progressing. And the trends of the patient's observations are really, really important in trying to predict how much time you've got uh to get the patient out of there. Um and whether any treatments you've initiated are being effective or not, for example. Um It's also very important to make some notes uh when looking back retrospectively. Uh unfortunately, this is important medical legally. Um but it's also good to be able to reflect on, on what's happened and then debrief as well. So, our ABCD E assessment or as part of this doctor C ABCD E er, isn't over once we've just done it once, uh we should reassess the patient from head to toe. Uh Once we, once we have done it at appropriate intervals, particularly if there are abnormalities, we need to be revisiting those as well. Er, giving a nod to all the other bits uh within that acronym uh whilst getting to it. For example, if there's a breathing problem, we really want to be reassessing whether that oxygen we've given or sitting them up or the inhaler has been effective. Um But we're going to do, just check the airways fine. First, after we've checked back in on the breathing, we are going to do the sever circulation, fever disability. Um and, and e for exposure, if we need to rules at which we're doing, these observations will vary rarely depending on the circumstance and the resources that we have and particularly with personnel. Um and also how, and well they are to begin with if there are significant abnormalities within the vital signs to begin with, you're going to be doing them at least every five minutes. Um And you may decrease the frequency of this to every 15 minutes. For example, uh if the patient stabilizes this vital str chart, um alludes the fact that there are sort of different extremes of abnormality, uh the red zones on there. Uh For example, if you look at breathing uh in red is rates from 25 to 30. Uh And above, you'll see that there are these scales of sort of abnormality in, in the rest of your observations there. Um You may have come across these if you're medical within hospitals. So there are a number of early warning scores. Uh And if you are able to add them up, for example, scores of seven or above, uh give you a, a real indication that someone's particularly unwell, for example, on some of those scoring. Um So this is worth bearing in mind. This is going to give you information if you're in. So if you're scoring and those orange and red zones um on one particularly or, or more, um you're thinking this patient is going to be going towards that big sick versus little sick as we said before. So just touching back in on this, uh there are prompt cards as well that you have in these first responder packs um that will give you key things to look for uh at the top of this. Uh They've got the seen uh safety and situation. So that's a bit like our doctor and our doctor C ABC. So, um, and then the next thing they've got is this kind of quick assessment about whether they're big sick, are they really unwell? Do I need back up here immediately? Um So you've got the, the general appearance and their conscious level. Um, you've got whether they're having a, a big effort of breathing or not. um And a quick assessment of circulation. So, are they really, really pale? Um um And you can't feel their pulse, for example. Um And then they go on to doing the rest of that assessment that we did. Um It's probably worth having a quick pause. Um And just having a look through the sections on this. Um So you can see the types of things that you are also looking at doing um and treating in each section and a little refresher for you. So we've kind of been assuming that the patient is probably on the less responsive end. Now, there's going to be a scale of patients. They might be completely unresponsive when you're doing this initial primary assessment. Um or they may be completely responsive talking to you kind of normally now you work your way through it. Um As we've done, uh the, the caveat is if they are unresponsive, you're going to be shouting for help if you're alone. Um Or with others, someone else can be shouting for help as well. And we need to assess if they're unresponsive as you said before about whether there there are signs of life or not. So that does start with opening up that airway, uh to see if there's signs of breathing and then if, if we can't see, uh, look, listening and feeling for signs of breathing for 10 seconds. Um, we, we need to then start doing our, our basic life support. So our cardiopulmonary resuscitation, we need to make sure he helps coming. So we may have shouted, but we may be in the middle of nowhere. Um So someone needs to be calling the emergency services um if we're not sure and then we need to quickly go about doing this CPR. So for Children, um and in people who've uh you suspect have suffer from drowning, we actually start off by doing five rescue breaths. Uh This is because the lack of oxygen is probably the cause of the arrest in both of these in population groups. Um So actually giving that booster of oxygen to begin with is the most important thing. We then proceed to doing our chest compressions. Um And for adults, you're doing 30 chest compressions and then doing two rescue breaths uh with the caveat um that if you feel it is appropriate to do so and you're happy to do so, Children, you're doing 15 compressions instead uh for every two rescue breaths uh as alluded to you before just because they have a high requirement for oxygen. So you, you take more pauses to give them those rescue breaths. Now, if a automatic external defibrillator is available that needs to be attached uh and used as soon as is possible. So chest compressions should continue. Um Hopefully you've got another operator there, you can get the device ready. Um And then with communication between you both, they can attach the pads um and you can continue chest compressions whilst they're starting it up. So once the device is started up, um it will tell you to uh stop doing chest compressions. Um and it will assess the rhythm and normally they'll have a verbal cue saying assessing rhythm and then it will either say uh if the shock is advised or continue CPR if the shock is advised, it will then give you the option uh to shock the patient. The it's important that people keep back uh during both the analysis and also the shocking of the patient. And then once the patient has been shocked um to continue the chest compressions, there are a number of different devices out there. Um But they're all pretty similar. They'll have a electrode pad with a sticky bag that you'll have to peel off. You need to make sure that the patient is dry before you attach the pads. Um And on the pads, it will show you where you're going to attach them over the right pectoral uh and just to the side of the left pectoral on the side of the chest wall, um they all have voice prompts. Um And it's important just to re remember to er, stay clear of the patient when you're shocking them and also in wet environments, er, to consider whether, for example, it's safe to do so if you're on a boat and everybody is wet, um obviously, because the water will conduct the electricity. Now, I'm going to talk to you about oxygen. Um You may find that you're on an expedition or in a remote environment that has a supply of oxygen. Um And so then the question really will be, when should I be using it? Now, there are a lot of caveats with this. Um And with experience and chatting through on the course, um you'll probably er develop your potential use of oxygen. However, basics of when to apply it is when you see that a patient is big sick. So they look really, really, really unwell, you should be putting the oxygen at the first opportunity or if they don't appear to be very sick initially. Um But as you're going through your A to D assessment, um if you're finding an issue in there, um particularly with breathing, um you want to be applying oxygen as well. Now, when you put the oxygen mask on which we'll show you on the course, um and attach it up to the oxygen cylinder, you have to choose a rate at which you want to deliver the oxygen. And this is in the volume of oxygen in liters per minute. So you can turn the dial on the top and the different cylinders might have different rates of oxygen that you can give. This is of course, balance with how much oxygen you have. And we'll go on to talk about this in a second. If you only have one small cylinder in the expedition environment, it might be prudent to start actually with a lower rate of oxygen than you would use if you had an abundant supply. So we suggest and obviously, with different clinical experience, you can, you can make other decisions starting off with a lower rate of around 2 to 4 L of oxygen a minute. Now, if the patient doesn't appear to be improving with that and you're not seeing an effect from it, you probably want to increase that rate of oxygen. Um And we suggest that if the saturations are low, so less than 90 you should be increasing the rate or if they appear S nos so that's very pale or blue, so pale lips. And we can go through some of these signs in the course with you as well. This is the reverse of what we probably do in hospital where we start at a very high rate of oxygen because we've got a large supply and then we come down from there. However, um as, as we'll just discuss. Now, how long will that oxygen last? And how long do you leave it on for? So, if oxygen's on a patient, you want to be continually reassessing that patient to see whether there is a need for it or not because of your limited supply. Um And some of the outputs can be how easy they find it to breathe their oxygen saturations or whether they look um pale. Now, this concept of kind of saving your oxygen supply um applies in the expedition environment. And you need to be aware of how quickly you might be using your oxygen. So you can work out how long your oxygen is going to last. Because each oxygen cylinder that you've got will have a capacity in liters and you'll also know what flow rate you're delivering it at. So it's actually quite a simple equation where you have your cylinder capacity. I've given the example here of quite a common oxygen cylinder that you'll find. And then I've got a picture on the next slide which has a capacity of 460 L of compressed oxygen. If you apply at the maximum rate, which is 15 L a minute, which is what we commonly do in a hospital. That cylinder is only gonna last you for half an hour. So you may end up in that scenario where you've blast them with oxygen. They've got a benefit of it, but maybe it was too much for them and then it's run out before the helps arrived. And then you have a situation where you've got no oxygen left, which is why we suggest starting at a lower rate. So it lasts longer. And you'll see in the second equation, if you're doing it at 2 L a minute, your oxygen lasts for 230 minutes. That's a substantial amount of time. And particularly if you've got a sort of helicopter extraction available to you, other quicker extraction options, you may actually be able to have the oxygen on the patient until helps arrived, which is giving them a continual benefit for that period of time. Now, it can be quite a lot to take in. Um and we're going to discuss it more in the course, but this is the reasoning behind perhaps using lower oxygen levels than you normally would um in a hostile environment. For example, you've also got to have considerations when you're taking it with you. So the main thing is that if you're taking it oxygen uh on an expedition or there, is it on an expedition or a remote environment that you work in? Do you actually know how to use it? And are you confident using it? Now? You might think? Oh, I'll just figure it out. But actually there are errors even with healthcare professionals use oxygen on a daily basis that I've seen. Um it's not particularly forthcoming on how to use it. There are lots of things that you can twist around and covers on things here. You can just see a picture of a very common oxygen cylinder, which is called a CD oxygen cylinder which relates to the capacity. Um And you can see them putting on the oxygen hosing onto a little nozzle on the top. You can just see the dial um that you rotate to select the flow rate and you can see the zero there. Um, and as you twist it, it will select the flow rate for you. So you see 123, up to 15 on this cylinder for actually to come out though, you need to make sure that the supply is turned on. So you can twist a dial on the top and it says 15, but no oxygen is actually coming out. So there's a black dial on the side there. Um, and you can see written on it, it says close and that's because you, er, twist that anti clockwise to open and clockwise to close it. So, unless you've opened up that no oxygen is going to come out and that's actually concealed underneath the gray peel off cover that you can't see on there at the moment that needs to be pulled off. Um, in order to access that black um, dial. Now, oxygen's a high risk. So when you're using oxygen, when it's turned on, you need to make sure you're not near any sources of ignition that might be someone smoking, for example, or there might be a fire. Um, there is the potential for oxygen cylinders to ignite themselves and this has been seen in hostile environments. So actually when you're turning an oxygen cylinder on or, or twisting a dial, there's a very small chance, very, very small chance of it igniting itself. Um And so it's good not to do it on something that is flammable and also when you're storing it, um, storing it in a safe manner, um, and we can go into that more on the course on storage or you can look it up online when you're planning the expedition or if you're involved in planning, you should really think what are you trying to achieve by taking the oxygen? And are you taking enough of it to be of benefit? So, we looked at how long oxygen might last. Uh And we talked about using low rates to preserve it. Those low rates might not be enough to give someone benefit. So you might have to use high rates and then your oxygen cylinder is not lasting very long. So, is that going to buy you time until help comes or has it actually helped so far away that just taking one cylinder might actually not be as useful as you think? Um, you've also got to consider the weight of taking it with you. Um, and how you're storing it when you're on the expedition. Um There are environments where obviously it's particularly useful and it will buy you time, for example, in high altitude. Uh And if you can't descend, then you can simulate someone descending by giving them oxygen. So that might be a very useful use of it on an exhibition. Great. Um You've done well getting through that, there's a lot of content to think about. Um But remember a systematic approach and that will help you um to find the bits from your memory as you go through it. So you remember that acronym, the doctor C ABCD E um try and get to the end of it when you highlight things, try and treat them as you go um practice the basic life support algorithm and you'll do this on the course and become familiar with it and it will give you confidence, oxygen in remote environments is a limited resource as we just discussed uh and plan before you go and think about how you might use it before you go rather than having that dilemma when you're there. Well, I hope you enjoyed it. Um And you have a great course and you get to talk more about it with the faculty when you're there.