Rahul WishardIn August 2014 I undertook a one week long Emergency Medical Responder Course conducted at Indian Mountaineering Foundation (IMF), New Delhi by Vivo Healthcare.
I have summarised my notes and learnings for my own quick reference which I am sharing here for the knowledge and use of anyone venturing out in the wild.
LEARNINGS AND NOTES FROM COURSE FOR QUICK REFERENCE:—
The smallest unit in the body is cell; the cells combine to form tissue. The tissues combine to from an organ. The organs together form an organ system. All together is the human body.
There are many different kind of body system like the skin, excretion, sensory, respiratory, digestion, circulatory, nervous, etc.
The course focuses on 3 systems: respiratory system, circulatory and nervous systems.
———THE RESPIRATORY SYSTEM—————————————————————
There are 2 airway tracts: Upper airway (nose, mouth, throat and voice box) and Lower airway.
Oxygen is carried by the blood to all cells and it get rids of excess CO2 from the cells.
Asthma is a problem of the lower airway.
Breathing also called Ventilation is the process of taking in air and expelling it from the Lungs.
It involves 2 processes: Inhalation (process of breathing in) + Exhalation (process of breathing out). The atmospheric normal pressure is 760 Hg. When you breathe the chest goes out and the Diaphragm goes up. This creates a low-pressure zone inside the chest of 759 Hg and the air is pulled in (like a suction pump). When the chest goes back (automatically to its normal position), the pressure in the chest increases to 761 Hg and the air is pushed out.
Concentration of air:—
| 20.86% Oxygen | 78% Nitrogen | 1% other gases including CO2 |
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The body consumes 4-5% of Oxygen (out of the 21%) and we exhale air that still contains 16-17% of Oxygen. The CO2 is equally important for us as it is used by the Brain to command inhalation and exhalation.
Sounds from the breathing:—
| Stide: caused by smoke inhalation or burn in the neck | Snoring: fallback of the tongue and blocking the airway |
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| Stide: caused by smoke inhalation or burn in the neck: Gurgling: water obstruction | Snoring: fallback of the tongue and blocking the airway: No sound: full blockage or choking |
———THE CIRCULATORY SYSTEM—————————————————————
It’s the network that circulates blood and transport nutrients (such as amino acids and electrolytes), oxygen, carbon dioxide, hormones, and blood cells to and from cells in the body to nourish it and help to fight diseases, stabilize body temperature and pH, and to maintain homeostasis (property of a system in which variables are regulated so that internal conditions remain stable and relatively constant).
The Heart:—
The 4 chambers: left and right auricle + left and right ventricle
Arteries are blood vessels that carry blood away from the heart. Arteries carry oxygenated blood; there are two exceptions, the pulmonary and the umbilical arteries.
Veins are blood vessels that carry blood toward the heart. Veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins.
Blood is a bodily fluid that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells. It is composed of blood cells suspended in blood plasma. The blood cells are mainly red blood cells (RBC) and white blood cells (WBC) and platelets. The most abundant cells in blood are red blood cells; these contain Haemoglobin (an iron-containing protein). Blood is bright red when its Haemoglobin is oxygenated.
———THE NERVOUS SYSTEM—————————————————————
This system controls the voluntary and involuntary activities of the body. There are 2 divisions of this system: Central nervous system (brain and spinal cord) and Peripheral nervous system.
There are 12 cranial nerves that emerge directly from the brain and the brainstem and 31 spinal nerves, one on each side of the human vertebral column carries motor, sensory, and autonomic signals between the spinal cord and the body.
| The brain occupies 80% of the skull and is 2% of the body weight. It metabolises 25% of the body glucose and 20% of the total body oxygen. Since there is no storage mechanism of glucose and oxygen in the body, the brain needs a constant supply. If this stops, within 4 minutes the brain starts to have irreversible damage and after which its 7-10% damage in each minute. |
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| The Neuron/nerve cells are electrically excitable cell that processes and transmits information through electrical and chemical signals and are the core components of the nervous system. |
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| SHOCK: inadequate tissue perfusion, not getting blood (glucose or oxygen) |
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There are 33 vertebrae in total. In trauma the maximum injuries occur at the 2 curves of the vertebrae.
———VITAL SIGNS OF THE BODY—————————————————————
| Skin, pulse, breathing, blood pressure, body temperature and oxygen saturation |
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COLOUR OF SKIN:— checked in nail beds, oral mucosa (under lips), conjunctiva (inside of the eyelids) and tip of nose. These areas have capillaries, maximum oxygen supply in these areas and are affected first. The normal colour is pink.
| Red (flushed) caused by heart attack, heat stroke or high fever | Yellow caused by jaundice, hepatitis b or hepatitis c |
|---|---|
| Red (flushed) caused by heart attack, heat stroke or high fever: Blue (cyanosis) caused by lack of oxygen, sometimes also in snake bikes | Yellow caused by jaundice, hepatitis b or hepatitis c: Pale (pallor) where normal skins becomes lighter, caused by anaemia, loss of too much blood in internal bleeding, loss of water in diarrhoea |
SKIN CONDITION:— the condition of the skin could be in 4 states
| Dry – normal condition | Moist caused by heat exhaustion, seizure, heart attack, internal bleeding |
|---|---|
| Dry – normal condition: Sweaty | Moist caused by heat exhaustion, seizure, heart attack, internal bleeding: Clammy (when you touch is sticky) caused by internal or external bleeding (body in shock) |
SKIN TEMPERATURE:— the temperature of the skin
| Warm | Hot | Cool | Cold |
|---|---|---|---|
| Warm: | Hot: | Cool: Hypothermia or shock (loss of water or blood) | Cold: Hypothermia or shock (loss of water or blood) |
Always check with the back of your hand
PULSE:— wave of impulses produced during contraction of the heart. It can be measured on an artery on the bone usually on 2 places.
| Radial artery (on hand) | Carotid artery (on neck) |
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It can also be measured in the pelvic area. The normal rate is 60-100 beats per minute. It has to be checked either for 1 minute or 30 seconds (multiply by 2).
To check pulse at neck, make gun with 2 fingers, trace the curve across the adam’s apple. The neck and the hand pulse should match, if not matching it could be a sign of internal bleeding.
| Regulations for doctors: if pulse is present then don’t give CPR |
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BREATHING:— rate of expansion and compression of the lungs per minute.
| Adults: 12-20/minute | Child: 15-30/minute | Infant (<1 year) 25-50/minute |
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BLOOD PRESSURE:— it is the pressure exerted by circulating blood upon the walls of blood vessels. During each heartbeat, blood pressure varies between a maximum (systolic, ventricles contract) and a minimum (diastolic, ventricles relax) pressure.
Blood pressure is measured of the pressure in the brachial artery, the major artery in the upper arm.
| Systolic | Diastolic | |
|---|---|---|
| Adult | 100-140 mm Hg | 60-90 mm Hg |
| Child | 80-110 mm Hg |
Higher than range: Hypertension and when lower than range: Hypotension.
Children usually not have problems with BP, on problem happens when loss of blood or water. Measuring blood pressure with the automatic machine. Keep one finger loose and 2 fingers above the bone joint and keep machine at level of the heart.
BODY TEMPERATURE:— It is measured under armpit or mouth
| Normal temperature is 98.6 degree Fahrenheit or 37 degree Celsius |
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Hypothermia is when temperature is below normal (35 degree) and Hyperthermia is when temperature is above normal.
OXYGEN SATURATION (SpO2):— is the concentration of oxygen in the blood. Normal blood oxygen levels in humans are considered 96-100%. If the level is below 90% then it’s dangerous.
BLOOD SUGAR LEVEL:— it is the amount of glucose (sugar) present in the blood.
| Empty stomach: 70-110 mg/dL | During the day after food: < 125 mg/dL |
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———SUPPLEMENTAL OXYGEN—————————————————————
If Pulse Oxymeter gives a reading between 90 to 95, give oxygen.
Always use away from an AED machine. Keep cylinder flat when transporting.
The cylinder comes in different sizes, used 650ml in class (refilled cylinder has a seal with filling date, expiry date, etc.), in India white paint on top of cylinder indicates that it is oxygen. Have to use with a regulator (1-15 flows).
The black knob opens anti-clockwise, keep away from body and people, open and close knob to remove any dust and this way also check if its full or has some oxygen)
| If full: 2200 | If empty: 200 |
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Never face the meter towards the patient (too much pressure the glass of the meter could shatter and cause injury) and keep always down when opening the value.
Oxygen is a dry gas and after a while causes dryness, in hospitals it is used with a humidifier.
(On Everest, mountaineers carry a portable cylinder with a de-humidifier)
The kinds of oxygen masks:—
| Simple face mask | Flow rate of 6-10L/minute 30-60% oxygen goes to the patient |
|---|---|
| Simple face mask: Nasal Canola | Flow rate of 6-10L/minute
30-60% oxygen goes to the patient: Flow rate of 1-6L/minute 24-44% oxygen to patient Can be used for heart attack or stroke patients Don’t use if hypoxaemia (lack of oxygen in tissue) or Apnea (absence of breathing) |
| Simple face mask: Non-rebreather mask (high concentration) | Flow rate of 6-10L/minute
30-60% oxygen goes to the patient: Flow rate of 10-15L/minute 80-90% oxygen to patient Used for severe breathing issues, cyanosis or asthma attack To use, open value, fill bag with oxygen, then only attach to the patient |
| Simple face mask: Ambu mask or bag-on mask | Flow rate of 6-10L/minute
30-60% oxygen goes to the patient: Flow rate of 10-15L/minute 100% oxygen to patient Used for cardiac arrest |
Make C to hold mask and E to open jaw and mouth.
———AIRWAY MANAGEMENT—————————————————————
The airway has 2 sections:— upper airway and lower airway. Ventilation is the movement of air and respiration is the exchange of gases (happens inside the body).
The upper airway can be obstructed by tongue, denture, food, vomit, blood secretion, allergy or burn. The lower could be a medical condition like Asthma.
| Noisy breathing is obstructed breathing |
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Obstruction in upper airway: gurgling, snoring, stridor or no sound (blocked or chocked)
Obstruction in lower airway: wheezing (in asthma)
A suction device is used in hospital to clear the airway (suction catheters, soft catheters (or french catheters), hard or rigid catheters or suction tubing). On the field the recovery position could be used or even a 100ml syringe can be used.
Top been the airway open 3 technique are used:
| Without trauma: head tilt shift lift | In trauma (possible neck injury): jaw thrust | External device (with or without trauma): OPA (oral pharyngeal airway) or NPA (nasal pharyngeal airway) |
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Don’t give nasal device in a skull fracture (signs of skull fracture are: colourless brain fluid, the cerebrospinal fluid (CSF) mixed with blood dripping, discoloured and enlarged pupils, discolouration behind ears).
No OPA when gagging, patient could vomit and the vomit could go in the wind pipe.
The OPA is measured from mouth to the side of mouth to the jaw bone, and the NPA is measured from the tip of the nose to the ear lobe. The NBA is used with a special lubricant that also give local anaesthesia.
The NPA:— The tube curve should face the inside of the nose wall.
OPA:—
Altered mental state happens in the following condition:—
| Hypoxia – lack of O2 |
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| Hypoxia – lack of O2: Hypoglycaemia – lack of glucose |
| Hypoxia – lack of O2: Excessive loss of electrolytes |
| Hypoxia – lack of O2: Brain injury |
———PATIENT ASSESSMENT—————————————————————
| STEP ONE: PRIMARY ASSESSMENT |
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1. SCENE SIZE UP: is the place safe for me? is it safe for the patient? is it safe for the bystander? how many patients? what possibly happened?
Wear gloves and other precautions.
2. BSI
3. INITIAL ASSESSMENT
General impression: age, sex, approx. weight, general appearance, position of patient body, bleeding or not, broken bones, mechanism of injury.
Always approach patient from the legs and tap on shoulder.
Initial level of consciousness: States of patient
| Alert: awake and talk to you |
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| Alert: awake and talk to you: Voice: responds to voice (can you hear me? what is your name? where are you?) |
| Alert: awake and talk to you: Pain: responds to pain (pinch on neck) |
| Alert: awake and talk to you: Unresponsive: not responding to any command |
4. AIRWAY MANAGEMENT: ensure open (methods discussed previously) and clear (suction if required)
5. BREATHING: check breathing rate (normal for adult between 12-20/minute)
| Look: look for rise and fall of chest |
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| Look: look for rise and fall of chest: Listen: listen to the sound of breathing |
| Look: look for rise and fall of chest: Feel: feel warmth of exhaled air on cheek |
CPR if required, mouth-to-mouth or air pump, give 1 breath every 5-6 seconds (count 1001, 1002, till 1005)
6. CIRCULATION: check for pulse (both neck and both hands if its same), colour of skin, capillary (press finger, it turns white and should go back to pink within 2 seconds)
ALERT EMS if any medical emergency
Could place in recovery position if breathing
| STEP 2: SECONDARY ASSESSMENT |
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7. If patient is conscious: Take S A M P L E
| Signs/Symptoms: sign is what you see and sample is what you don’t see but the patient feels |
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| Signs/Symptoms: sign is what you see and sample is what you don’t see but the patient feels: Allergies: patient’s allergy to certain food or medicine |
| Signs/Symptoms: sign is what you see and sample is what you don’t see but the patient feels: Medication: if patient is on a certain medication |
| Signs/Symptoms: sign is what you see and sample is what you don’t see but the patient feels: Past history: any past history of patient (medical conditions, surgery, high blood pressure, diabetes) |
| Signs/Symptoms: sign is what you see and sample is what you don’t see but the patient feels: Last oral intake: what food was taken last (important for surgery or anaesthesia, which can only be given on empty stomach) |
| Signs/Symptoms: sign is what you see and sample is what you don’t see but the patient feels: Event preceding to incident: what patient was doing when fell sick or how injury happened? |
8. Head-to-toe examination (if patient is unconscious skip step 7)
Use the DOTS technique:—
| D- deformity | O- open injury | T- tenderness/pain | S- swelling |
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Go from head, neck (put neck collar and secure it, one person still keep airway open), shoulder, chest (centre breast bone, rib cage), abdomen (divide stomach in 4 parts and use fish movement-soft is good, hard and lumpy could be internal bleeding), pelvic (push sideways and pull upwards), legs, feet and fingers (ask to move and if feel sensation) arms and finger (ask to move and clench fingers).
Next put spine board, do log roll on one side, check back, pull spine board under patient, put straps and secure the patient.
9. Check vital signs: Skin, pulse, breathing, blood pressure, body temperature and oxygen saturation.
| STEP 3: ONGOING ASSESSMENT |
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In ambulance on the way to the hospital. If critical recheck every 5 minutes, if un-critical then recheck every 10 minutes.
| 1 AMBULANCE FOR 1 PERSON, have to prioritise/triage |
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| Fall critical and possible cervical injury, if one falls from 3 times their height |
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| Total blood volume is 5L, if both legs broken and arteries ruptured then can loose upto 2L of blood, which is a critical situation. |
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———ALTITUDE + COLD RELATED PROBLEMS—————————————————————
Acclimatisation:— It is the process in which an individual organism adjusts to a gradual change in its environment. The process can take 6 weeks and continue for years. On high altitude the body increases the number of RBC to increase the oxygen carrying capacity of the blood.
| O2 is not the problem; it is the atmospheric pressure on high altitude and reduces the capacity of the blood to carry oxygen. There is a 3.8% drop in atmospheric pressure for every 1000m. |
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The process on high altitude:—
Increased heart rate
Increased fast and deep breathing
Altitude diuresis
Increased artery pressure in lungs (open capillaries in lungs)
Increased blood carrying capacity
Increased blood viscosity and RBC count
Failure to properly acclimatise to high altitude could result in:—
| AMS (acute mountain sickness) | HAPE (high altitude pulmonary edema) | HACE (high altitude cerebral edema) |
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| Lake Louise Score (LLS) for the diagnosis of Acute Mountain Sickness (AMS) |
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Diagnosis of AMS is based on:—
1. Rise in altitude within the last 4 days
2. Presence of a headache
PLUS
3. Presence of at least one other symptom
4. A total score of 3 or more from the questions below:—
| SELF-REPORT QUESTIONNAIRE |
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Add together the individual scores for each symptom to get the total score.
| Headache | No headache | 0 | |
|---|---|---|---|
| Headache: | No headache: Mild headache | 0: 1 | : |
| Headache: | No headache: Moderate headache | 0: 2 | : |
| Headache: | No headache: Severe headache, incapacitating | 0: 3 | : |
| Headache: | No headache: | 0: | : |
| Headache: Gastrointestinal symptoms | No headache: None | 0: 0 | : |
| Headache: | No headache: Poor appetite or nausea | 0: 1 | : |
| Headache: | No headache: Moderate nausea &/or vomiting | 0: 2 | : |
| Headache: | No headache: Severe nausea &/or vomiting | 0: 3 | : |
| Headache: | No headache: | 0: | : |
| Headache: Fatigue &/or weakness | No headache: Not tired or weak | 0: 0 | : |
| Headache: | No headache: Mild fatigue/ weakness | 0: 1 | : |
| Headache: | No headache: Moderate fatigue/ weakness | 0: 2 | : |
| Headache: | No headache: Severe fatigue/ weakness | 0: 3 | : |
| Headache: | No headache: | 0: | : |
| Headache: Dizziness/lightheadedness | No headache: Not dizzy | 0: 0 | : |
| Headache: | No headache: Mild dizziness | 0: 1 | : |
| Headache: | No headache: Moderate dizziness | 0: 2 | : |
| Headache: | No headache: Severe dizziness, incapacitating | 0: 3 | : |
| Headache: | No headache: | 0: | : |
| Headache: Difficulty sleeping | No headache: Slept as well as usual | 0: 0 | : |
| Headache: | No headache: Did not sleep as well as usual | 0: 1 | : |
| Headache: | No headache: Woke many times, poor sleep | 0: 2 | : |
| Headache: | No headache: Could not sleep at all | 0: 3 | : |
| Headache: TOTAL SCORE | No headache: | 0: | : |
| Total score of: 3 to 5 = mild AMS 6, or more = severe AMS |
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| Note: Do not ascend with symptoms of AMS | Descend if symptoms are not improving or getting worse | Descend if symptoms of HACE or HAPE develop |
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Classroom hands on sessions
