Basic Emergency Care Skills Manual PDF

Basic Emergency Care Skills (BECS) 1  Foreword Immediate access to basic life support care can save many lives in life threating emergencies. Formal training on essential knowledge and skills in basic emergency care will ensure early recognition, a...

Basic Emergency Care Skills (BECS) 1  Foreword Immediate access to basic life support care can save many lives in life threating emergencies. Formal training on essential knowledge and skills in basic emergency care will ensure early recognition, alerting emergency medical services system and accessing hospital based care, in addition to the provision of timely basic life support (BLS) which is significant gap in India. India being a nation of majority in younger age group, introduction of Basic Emergency Care Skills (BECS) module to undergraduate university students is a step towards bridging access gap to emergency victim. Starting a six-month BECS module at UG level and being a joint collaboration between EMRI Green Health Services, a pioneer in emergency services in India and University of Hyderabad, a premier academic institute recognized as an Institute of Excellence, is expected to set a benchmark. These trained human resources will strengthen the adage that a “system saves lives” in emergency. Basic Emergency Care Skills (BECS) course learning module is developed by medical and paramedical professionals with national and international expertise and unique experience in education-care & research dimensions of EMS and Emergency Medicine. All the team members involved in designing and developing the module are acknowledged for their professional contributions. Every effort is taken to reflect evidence based practices in a simple language. Relevant support and guidance extended by the authorities of EMRI GHS and UOH are acknowledged. BECS module will serve as a resource during and after the course. With regards Dr G V Ramana Rao MD Director - Emergency Medicine Learning Centre and Research EMRI Green Health Services, Hyderabad, India 2  Chapter 1: Scene Safety Scene size-up is a common phrase used to describe observations made and actions taken at the scene of a medical emergency or trauma before actually approaching the patient. It is a critical part of handling an emergency and begins before one approaches the patient. Failing to perform the preliminary steps of scene size-up, may jeopardize rescuer safety as well as the safety of the patient. Scene size-up includes taking standard precautions to prevent exposure to blood and other potentially infective material, evaluating the scene for dangers, determining the total number of patients, determining essential equipment needed for the particular scene, and identifying the mechanisms of injuries or the nature of the illness. Scene size-up includes the following steps 1. Standard precautions (personal protective equipment) 2. Scene safety 3. Initial triage (total number of patients) 4. Need for more help or equipment 5. Mechanism of injury or Nature of Illness Standard Precautions Medical or Trauma scenes are among the most likely to subject the emergency care provider to contamination by blood or other potentially infectious material. Personal protective equipment (PPE) is necessary for emergencies. Protective gloves are always needed, and many situations will require eye protection. In highly contaminated situations, impervious gowns with masks or face shields may be needed as well. In a toxic environment, chemical suits and gas masks may be needed. Remember to protect your patient from body fluid contamination by changing your gloves between patients, if there are multiple patients. Personal protective equipment (PPE): Equipment that an emergency care provider dons for protection from various dangers that may be present at a scene. At a minimum that entails wearing protective gloves. At a maximum, it is a chemical suit and self-contained breathing apparatus. 3 Scene Safety Begin assessing the scene for dangers as you approach. Consider whether or not the scene poses a continued threat to the patient. If there is a danger of fire, water, structure collapse, toxic exposure, and so on, the patient may have to be moved immediately. This does not mean that you should expose yourself or your partners to unnecessary danger. You may need to call for special equipment or specialist help (e.g. Police, fire, disaster team, etc.) If the scene is unsafe, you should make it safe or try to remove the patients from the scene without putting yourself in danger. Sometimes there is no obvious way to do this. Use good judgment. Remember that you are there to save lives, not give up your own. Total Number of Patients Next, determine the total number of patients. If there are more patients than your team can effectively handle, call for additional resources. You may have to call the emergency number again to notify the same. (108 and/or 100) Mechanism of Injury Once you determine that it is safe to approach the patient, begin to assess for the mechanism of injury (MOI) like Fall from height, Road traffic accident, assault, building collapse Etc. This may be apparent from the scene itself, but it may require questioning the patient or bystanders. Injuries are caused by the transfer of energy. This may give clue to the type of injuries you could expect. Do not delay patient assessment to get this information if you can’t gather all the information in the beginning. Nature of illness or a general impression of the patient: Just looking at the patient may provide some information about the nature of the illness. For example, if the patient is putting effort into breathing & using his neck muscle, indicates nature of the illness is likely respiratory (related to lungs and breathing), if you find the patient squeezing his stomach Indicates nature of the illness could be related to the abdomen. If you find the patient holding his neck with cross hand & unable to speak, this may indicate a case of choking (discussed later in another chapter in detail) Cleaning and decontamination Infectious disease exposure is a significant risk. Use PPE and wash your hands before and after every patient contact. At the scene, hand washing may not be immediately possible; carry an alcohol gel cleanser if possible. Decontamination may be required after exposure to pesticides or other chemicals (dry or wet) and, depending on the chemical, may include washing or brushing to remove the substance. Not all chemicals can be safely washed away, and some must be removed in specific ways to avoid further injury. You must wear appropriate PPE for this. Refer to local decontamination protocols for people and equipment. Ask the healthcare professional in case of any doubt. 4  Section 2: Chapter 2: Standard precautions Standard precautions are the basic level of infection control measures at minimum, which are meant to reduce the risk of transmission of blood-borne and other pathogens from both recognized and unrecognized sources. They’re based on a risk assessment and make use of common sense practices and personal protective equipment use that protect healthcare providers from infection and prevent the spread of infection from patient to patient. “Minimum infection prevention practices that apply to all persons, regardless of suspected or confirmed infection status, in all healthcare settings.” – CDC (Centre for Disease Control and Prevention, USA) What’s Included? Hand Hygiene PPE (Personal Protective Equipment) Respiratory etiquette Sharps safety and Equipment safety Hand hygiene is a major component of standard precautions and one of the most effective methods to prevent the transmission of pathogens associated with healthcare. Perform hand hygiene through hand rubbing or hand washing. Perform hand washing with soap and water if hands are visibly soiled, or after using the restroom. Otherwise, perform hand rubbing with an alcohol-based preparation. General precautions: 1] For handwashing, remove the jewellery and rinse your hands under clean running water. 2] Lather with soap and using friction, cover all surfaces of hands and fingers as shown below. Wash thoroughly under running water. 3] Dry hands with a single-use towel or by using forced air drying. Pat skin rather than rubbing to avoid cracking. If disposable towels are used, throw them in the trash immediately. Hand RUB Hand sanitisers strip the outer-most layer of oil from your skin, including the bacteria. Depending on the anti-septic base of the hand sanitiser, the effectiveness of killing bacteria will vary. Unlike hand washing with soap and water, hand sanitizing is a “waterless” product 5 and should not replace hand washing permanently. If there is visible dirt on your hands, it is recommended to use traditional soap and water to cleanse your hands. The correct steps of handwashing as described by WHO (World Health Organisation) is as below: (Source: WHO: www.who.int) Not all hand sanitisers are the same. Certain features make certain hand sanitisers more effective. Make sure that any hand sanitiser you use has at least these aspects to guarantee 6 a clean hand after use. Make sure the hand sanitiser has an alcohol base. The alcohol-based hand sanitisers are antiseptic products that can be used to avoid the transmission of pathogens. A level of alcohol of at least 70% kills 99.9% of the bacteria on the hands 30 seconds after application. The correct method of hand rub is shown below: (Source: www.who.int) Personal Protective Equipment Personal protective equipment (PPE) refers to wearable equipment that is designed to protect from exposure to or contact with infectious agents. These include gloves, face masks, protective eye wear, face shields, and protective clothing (e.g., reusable or disposable gown, jacket, laboratory coat). Examples of the appropriate use of PPE for adherence to Standard Precautions include— 7  Use of gloves in situations involving possible contact with blood or body fluids, mucous membranes, non-intact skin Use of protective clothing (e.g. Gown) to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated. Use of mouth, nose, and eye protection during procedures that are likely to generate splashes or sprays of blood or other body fluids. (e.g. Masks, goggles, face shields) It is always safe to use at least gloves and a mask whenever possible as a minimum when dealing with any patient. The correct steps for using gloves are described below: Donning and doffing of gloves: The official term for putting on and taking off disposable gloves is ‘don’ and ‘doff’. If not done correctly, the donning and doffing of disposable gloves can expose the wearer to harmful substances. According to WHO, PPE such as disposable gloves aims to prevent or minimize exposure to certain hazards. These include biological hazards, chemical hazards, radiological hazards, electrical hazards, mechanical hazards Best Practices while using gloves include using durable gloves which are of correct fit made of vinyl, latex, or nitrile, that are disposable/single-use, clean or Sterile Remember gloves are not an acceptable alternative to hand hygiene Steps to don (put on) gloves: Knowing and following the steps for donning a disposable glove could be the difference between a safe practice and a health and safety risk. Maximum protection is crucial, and following these instructions will help ensure you’re protected against injury and illness in the workplace. Step 1: Thoroughly wash hands as described above. Step 2: Select the appropriately sized gloves. Step 3: Hold with one hand and Insert the other. When the base of your thumb reaches the cuff of the glove begin to spread your fingers and insert your hand into the glove. Step 4: Pull the glove cuff towards the wrist to cover as much skin as possible and secure the glove. Step 5-Check to make sure there are no holes or tears. 8 Repeat steps 3-5 for your other hand. STEPS TO DOFF DISPOSABLE GLOVES Proper doffing is essential for protecting yourself against hazards, arguably even more so than when donning a glove. When it’s time to take the glove off, there’s likely to be biological or chemical substances on the external material. Without doffing and disposing of the glove correctly, the risk of contamination is extremely high. Step 1: Pinch one glove on the wrist Step 2: Remove the glove by pulling it away from your body Step 3: Continue holding the glove you just removed in your gloved hand. Slide a few fingers of your bare hand inside the cuff of the glove you are still wearing. Step 4: Pulling away from your body, peel off the second glove, turning it inside out and leaving the first glove wrapped inside as you remove it. Step 5: Dispose of gloves safely and wash your hands before touching any other surfaces. 9 Key Points - Limit surfaces touched - Keep hands away from the face - Change gloves when torn, contaminated, or when moving from a dirty body site to a clean body site. - Perform hand hygiene Respiratory Hygiene/Cough Etiquette Respiratory hygiene/cough etiquette infection prevention measures are designed to limit the transmission of respiratory pathogens spread by droplet or airborne routes. The following measures to contain respiratory secretions are recommended for all individuals with signs and symptoms of a respiratory infection. Cover your mouth and nose with a tissue when coughing or sneezing Use in the nearest waste receptacle to dispose of the tissue after use Perform hand hygiene (e.g., hand washing with non-antimicrobial soap and water, alcohol-based hand rub, or antiseptic hand wash) after having contact with respiratory secretions and contaminated objects/material Sharps Safety Sharps are devices or objects with corners, edges, or projections capable of cutting or piercing the skin or regular waste bags. Examples of sharps include: − Hypodermic needles, syringes, tubing 10 − Blunted needles − Pasteur pipettes − Blades (scalpels, razors, microtomes) − Broken lab glassware, microscope slides, glass capillary tubes Precautions: 1. Careful management of needles and other sharps is of primary importance. Needles must NOT be bent, sheared, broken, recapped, removed from disposable syringes, or otherwise manipulated by hand before disposal. 2. Used disposable needles and syringes must be carefully placed in conveniently located puncture-resistant containers used for sharps disposal. 3. Non-disposable sharps must be placed in a hard-walled container for transport to a processing area for decontamination, preferably by autoclaving. 4. Broken glassware must not be handled directly. Instead, it must be removed using a brush and dustpan, tongs, or forceps and placed in a glass disposal box. Plastic ware should be substituted for glassware whenever possible. DO NOT force sharps into containers DO NOT bend or try to break needle using your hand DO NOT recap needle or put fingers inside the sharps container Equipment: Some instruments like BP cuffs, stethoscopes, thermometers, etc may be generally shared between many people. Make sure that this equipment is cleaned and disinfected as directed when used between patients. Summary: 11 References and further reading: CDC: https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html WHO: https://www.who.int/docs/default-source/documents/health-topics/standard- precautions-in-health-care.pdf CDC Infection prevention guidelines: https://www.cdc.gov/oralhealth/infectioncontrol/summary-infection-prevention- practices/standard-precautions.html 12  Section 2: Chapter 3: Good Samaritan Law India is an unfortunate victim of a large number of road crash fatalities. Every minute one road accident occurs in India and one fatal road accident occurs every fourth minute. As per statistics of the Ministry of Road Transport and Highways, 1317 crashes and 413 deaths, every day or 55 crashes and 17 deaths every hour happen due to road crashes in India. More than 50% of accident victims die because they don't receive medical attention during the Golden Hour. In reality, bystanders don't often come to help accident victims, fearing legal intervention. Good Samaritan laws exist in many countries to provide legal protection to bystanders who assist accident victims Introduction to Good Samaritan Laws: Good Samaritan laws offer legal protection to people who give reasonable assistance to those who are, or who they believe to be, injured, ill, in peril, or otherwise incapacitated. In essence, these laws protect the “Good Samaritan” from liability if unintended consequences result from their assistance. Its purpose is to keep people from being reluctant to help a stranger in need for fear of legal repercussions should they make some mistake in treatment. Good Samaritan laws take their name from a parable found in Bible, attributed to Jesus referred to as the “Parable of the Good Samaritan” which is contained in Luke 10:25-37. It recounts the aid given by a traveller from the area known as ‘Samaria’ to another traveller of a conflicting religious and ethnic background who had been beaten and robbed by bandits. Duty to assist, imminent peril and reward or compensation, obligation to remain and consent are the common features of Good Samaritan Law. The furnishing of medical assistance in an emergency is a matter of vital concern affecting public health, safety and welfare. Prehospital emergency medical care, the provision of prompt and effective communication among ambulances and hospitals and safe and effective care and transportation of the sick and injured are essential public health services. Only first aid provided without the intention of reward or financial compensation is covered. Medical professionals are typically not protected by good Samaritan laws when performing first aid in connection with their employment. In a landmark ruling on March 4, 2016, Supreme Court stated that it would pass an order on the recommendations of a three-member committee, chaired by its former Judge K.S. Radhakrishnan and comprising former Secretary of Road Transport Ministry S. Sundar and scientist Nishi Mittal, which had demanded protection for those saving accident victims. The Chronology of Good Samaritan Law in India is as follows: 13  i. 2012: Public Interest Litigation (PIL) filed by Save LIFE Foundation. ii. October 29, 2014: The Supreme Court directed the Centre to issue the necessary guidelines concerning the protection of Good Samaritans until appropriate legislation was not made by the Union Legislature. iii. May 13, 2015: In a gazette notification, the Ministry of Road Transport and Highways (MoRTH) notified the said guidelines. As per the guidelines, the disclosure of personal information by a Good Samaritan who brings an injured person to the hospital was made voluntary. They also provided that a Good Samaritan would not be liable for any civil or criminal liability. iv. January 22, 2016: MoRTH issued Standard Operating Procedures (SOPs) for the examination of Good Samaritans by the police or during the trial. v. March 4, 2016: The Supreme Court reserved the judgment making the guidelines and SOPs binding on all states and union territories of India. vi. March 30, 2016: The Supreme Court approved the guidelines issued by the Centre. The guidelines lay down the following: 1. The Good Samaritan will be treated respectfully and without any discrimination on the grounds of gender, religion, nationality and caste. 2. Any individual, except an eyewitness, who calls the police to inform them of an accidental injury or death need not reveal his or her personal details such as full name, address or phone number. 3. The police will not compel the Good Samaritan to disclose his or her name, identity, address and other such details in the police record form or log register. 4. The police will not force any Good Samaritan in procuring information or anything else. 5. The police will allow the Good Samaritan to leave after having provided the information available to him or her, and no further questions will be asked of him or her if he or she does not desire to be a witness. Even when Good Samaritans agree to become witnesses, the guidelines accord them protection and comfort. They ensure that: 1. If a Good Samaritan chooses to be a witness, she will be examined with utmost care and respect. 2. The examination will be conducted at a time and place of the Good Samaritan’s convenience and the investigation officer will be dressed in plain clothes. 3. If the Good Samaritan is required by the investigation officer to visit the police station, the reasons for the requirement shall be recorded by the officer in writing. 4. In a police station, the Good Samaritan will be examined in a single examination in a reasonable and time-bound manner, without causing any undue delay. 5. If a Good Samaritan declares himself to be an eyewitness, she will be allowed to give her evidence in the form of an affidavit. 14 The guidelines also specify that the concerned Superintendent or Deputy Commissioner of Police are responsible for ensuring that all the above-mentioned procedures are implemented throughout their respective jurisdictions. Extraordinary Gazette Notification No. 126, published by the authority of the Government of India, on May 13th 2015, highlights that: Central Government considers it necessary to protect the Good Samaritans from harassment on the actions being taken by them to save the life of the road accident victims and, therefore, the Central Government hereby issues the following guidelines to be followed by hospitals, police and all other authorities for the protection of Good Samaritans, namely: A bystander or good Samaritan including an eyewitness of a road accident may take an injured person to the nearest hospital, and the bystander or good Samaritan should be allowed to leave immediately except after furnishing an address by the eyewitness only and no question shall be asked to a such bystander or good Samaritan. The bystander or good Samaritan shall be suitably rewarded or compensated to encourage ether citizens to come forward to help the road. accident victims by the authorities in the manner as may be specified by the State Governments. The bystander or good Samaritan 'shall not be liable for any civil and criminal liability. A bystander or good Samaritan, who makes a phone call to inform the police or emergency services of the person lying injured on the road, shall not be compelled to reveal his name and personal details on the phone or in person. The disclosure of personal information, such as the name and contact details of the good Samaritan shall be made voluntary and optional including in the Medico-Legal Case (MLC) Form provided by hospitals. The disciplinary or departmental action shall be initiated by the Government concerned against public officials who coerce or intimidate a bystander or good Samaritan for revealing his name or personal details. In case a bystander or good Samaritan has voluntarily stated that he is also an eye- witness to the accident and is required to be examined for investigation by the police or during the trial, such bystander or good Samaritan shall be examined on a single occasion and the State Government shall develop standard operating procedures to ensure that bystander or good Samaritan is not harassed or intimidated. The methods of examination may either be by way of a commission under section 284, of the Code of Criminal Procedure 1973 or formally on affidavit as per section 296, of the said Code and Standard Operating Procedures shall be developed within a period of thirty days from the date when this notification is issued. Video conferencing may be used extensively during the examination of bystander or good Samaritan including the persons referred to in the guideline above, who are eye witnesses in order to prevent harassment and inconvenience to good Samaritans. 15  The Ministry of Health and Family Welfare shall issue guidelines stating that all registered public and private hospitals are not to detain bystander or good Samaritan or demand payment for registration and admission costs, unless the good Samaritan is a family member or relative of the injured and the injured is to be treated immediately in pursuance of the order of the Hon'ble Supreme Court in Pt. Parmanand Katara vs Union of India & Ors 4 sec 286. Lack of response by a doctor in an emergency situation pertaining to road accidents, where he is expected to provide care, shall constitute "Professional Misconduct", under Chapter 7 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulation, 2002 and disciplinary action shall be taken against such doctor under Chapter 8 of the said regulations. All hospitals shall publish a charter in Hindi, English and the vernacular language of the State or Union territory at their entrance to the effect that they shall not detain bystander or good Samaritan or ask for depositing money from them for the treatment of a victim. In case a bystander or good Samaritan so desires, the hospital shall provide an acknowledgement to such good Samaritan, confirming that an injured person was brought to the hospital and the time and place of such occurrence and the acknowledgement may be prepared in a standard format by the State Government and disseminated to all hospitals in the State for incentivising the bystander or good Samaritan as deemed fit by the State Government. All public and private hospitals shall implement these guidelines immediately and in case of noncompliance or violation of these guidelines, appropriate action shall be taken by the concerned authorities. A letter containing these guidelines shall be issued by the Central Government and the State Government to all Hospitals and Institutes under their respective jurisdiction, enclosing a Gazette copy of this notification and ensure compliance and the Ministry of Health and Family Welfare and Ministry of Road Transport and Highways shall publish advertisements in all national and one regional newspaper including electronic media informing the general public of these guidelines. The above guidelines in relation to protection of bystander or good Samaritan are without prejudice to the liability of the driver of a motor vehicle in the road accident, as specified undersection t 34 of the Motor Vehicles Act. 1988 (59 of 1988:). Though the law is applicable all across, Karnataka State was the first state to pass the bill in the Legislative Assembly (2016) with the title Good Samaritan and Medical professional (protection and regulation during an emergency) where in definition of Good Samaritan used was ‘a person who, in good faith, without expectation of reward and without any duty of care or special relationship, voluntarily comes forward to administer emergency care to an injured person. In addition, protection for good Samaritan from civil and criminal liability; Rights of the Good Samaritan; establishment of Good Samaritan Fund; educational institutions to impart training on first aid and emergency to students; organization of awareness programs and workshops are clearly mentioned. In addition, no person shall detain a Good Samaritan for any purpose in a hospital where such Good Samaritan has brought the injured person, in accordance with the rights granted under the act. 16 Multiple choice questions 1. What is the purpose of good Samaritan laws? A. To punish people who do not help others in need B. To punish people who help others in need C. To protect people who help others in need from liability D. To identify a witness for the accident who can be used in court. 2. Which of the following is NOT typically covered by good Samaritan laws? A. Providing first aid or medical assistance to someone who is injured or ill B. Reporting a crime or suspicious activity to law enforcement C. Rescuing someone from a burning building D. Assisting a person who’s pregnant and has suffered an injury with no other help to reach the hospital 3. In general, good Samaritan laws offer protection from liability to individuals who: A. Intentionally cause harm while trying to help someone B. Negligently cause harm while trying to help someone C. Act with reasonable care while trying to help someone D. Act recklessly while trying to help someone 4. Under a Good Samaritan law, which of the following is true? A. A person who provides medical assistance to someone in need is not protected from liability for any harm caused by their actions. B. A person who provides medical assistance to someone in need is protected from liability for any harm caused by their actions, as long as they act in good faith. C. A person who provides medical assistance to someone in need is protected from liability for any harm caused by their actions, regardless of whether they act in good faith. D. A person who provides medical assistance to someone in need is not protected from liability for any harm caused by their actions unless they are a licensed medical professional. 5. Which of the following is a requirement for good Samaritan laws to apply? A. The person providing aid must be acting in good faith B. The person providing aid must be trained in first aid or a healthcare provider C. The person providing aid must be paid for their services D. The person providing aid must be willing to pay the emergency hospital fee 17 References and further reading:  Good Samaritan - Ministry of Road Transport and Highways (www.morth.nic.in)  SaveLife Foundation: https://savelifefoundation.org/  Indian Red Cross First Aid manual 18  Section 2: Chapter 4: Communication in an Emergency As a person trained in first aid, your communication skills during times of crisis are extremely important. Be it a scene of an accident or a medical emergency, the way you speak to the patient and others may create a huge difference in the outcome. A person with good communication skills can convert a chaotic situation where everyone is panicked to a calm and controlled environment where safe and effective first aid is delivered to the patient. Aims of effective communication:  To reassure the patient and others and carry out first aid appropriately.  To call for help in a specific and concise way.  To allocate roles if necessary for people willing to help and guide them appropriately.  To be the leader of the team performing first aid and rescue efforts.  Understand the principles of ‘closed-loop communication’  Preventing an emergency scenario from becoming chaotic and preventing further harm to the patient until advanced help arrives. Principles of effective communication and tips for effective communication in an emergency: A professional attitude sets the tone of an effective communication strategy. Make sure that the scene is safe. Assess the situation from a distance and make a general impression (e.g. does the patient look conscious or unconscious? Are there any immediate environmental hazards? Are there people around who can help? Quickly assess the patient and check if the patient is responsive. Call for help early – Call 108 in case of an emergency. Try to provide the most accurate location and concise details of the type of emergency. Introduce yourself to the patient and family if around and explain that you are trained in first aid and are willing to help. Ask what happened and listen carefully without interrupting for at least the first minute. You may be able to get much important information useful for first aid just by listening carefully to the patient’s history. You can also ask specific questions if you have any once the patient has finished speaking. Ask about any regular medications that they take. Also, ask about allergies. Think ‘’can I need to do anything immediately to help the patient?’’ (For ex. Checking patients' blood sugar levels if they are drowsy or confused, helping with inhalers in case of asthma, etc). Use your knowledge of first aid to help the patient. Ask if anyone is willing to help if you think you need more hands. Allocate specific roles to them after explaining and check if they are comfortable doing that. (This may be necessary especially if the patient is in cardiac arrest – It can be tiresome to 19  do CPR alone). You can also allocate 1-2 people if needed to manage the crowd in a calm and non-confrontational way to keep the patient safe. Please let your team know that you will lead the team and all communication should happen through you so that you can maintain an awareness of the entire situation. Be open to suggestions from your team members. Closed-loop communication: Closed-loop communication is a communication technique used in healthcare settings and teamwork to avoid misunderstandings. When the sender initiates a message, the receiver repeats this back. (Source: Centre for Disease Control and Prevention www.cdc.gov) Always maintain patient confidentiality and do not disclose the details the patient might have told you to anyone except the healthcare providers who would take on the patient’s care. Maintain a nonjudgmental attitude. Avoid making judgments about the patient’s behaviour Communication is the process that involves the sending and receiving of messages through both verbal or non - verbal means. Always be empathetic towards the patient. Try to prevent family/others from giving anything that you know is likely to further harm the patient. Example: Giving water to a patient who’s not fully conscious. Explain the rationale for your advice in a non-confrontational manner. Be honest: Many times you may be uncertain about the cause of symptoms and when this happens be honest about the uncertainty and explain that you may be only able to do limited things before advanced healthcare providers take over. Communication cycle : Communication is the process that involves the sending and receiving of messages through both verbal or non - verbal means. 20  The process of communication is a system in which one individual delivers a message, which is then passed down through a barrier chain. Step 1: Idea Formation – The communication process begins when the sender has an idea to be communicated. The idea will be influenced by complex factors surrounding the sender. The sender must begin by clarifying the idea and purpose. What exactly does the sender want to achieve? How is the message likely to be perceived? Knowing this information provides a higher chance of successful communication Step 2: Message Encoding – The idea must be encoded into words, symbols, and gestures that will convey meaning. Because no two people interpret information in the same way, the sender must be careful to choose words, symbols and gestures that are commonly understood to reduce the chances of misunderstanding. Therefore, a sender must be aware of the receiver’s communication skills, attitudes, skills, experiences, and culture to ensure clear communication. This may be difficult to achieve in an emergency but having this in mind will help you tune your communication as the scenario progresses. Step 3: Message Transmission: Choosing the medium to transmit the message is the next step in the communication process. Messages can be transmitted in a verbal, written, or visual manner. This is most likely to be verbal in an emergency. Step 4: Decoding – When the message reaches the receiver, the message must be decoded into its intended meaning. Therefore, the receiver must translate the words, symbols, and gestures as the sender intended. Because no two people interpret information in the same way, incorrectly decoding a message can lead to misunderstanding. Successful decoding is more likely when the receiver creates a receptive environment and ignores distractions. Alert receivers strive to understand both verbal and nonverbal cues, avoid prejudging the message, and expect to learn from the communication. This step might get affected slightly by the patient’s medical condition and it is important that the person communicating keeps it in mind. When such a situation arises the family and relatives may be able to help to a certain extent. Step 5: Feedback – A vital part of the communication process is feedback. Feedback occurs the sender and receiver check to ensure the message was understood as intended. Feedback is a shared responsibility between the sender and the receiver and can be verbal or non-verbal. For example, the sender can elicit feedback by asking, “Do you have any questions?” The sender can also improve the feedback process by only providing as much information as the receiver can handle. Receivers can encourage clear communication by providing clear, timely, descriptive, and non-judgmental feedback. For example, the receiver can shake his/her head up and down to confirm “yes” I have a question. Again, this step might vary depending on the medical condition of the patient. 21  Handing over: When the ambulance arrives or when you reach the hospital through some other mode of transport, you need to hand over the care of the patient to the advanced healthcare providers. The clinicians will find it very useful to know about all the first aid you have done and all the information about the patient that you have gathered. Healthcare providers use a mnemonic called SBAR to hand over patients. While you may not have all the information still you might find SBAR useful too for handover. Barriers to Effective Communication: Recognising the most common communication barriers and understanding how they impact effective communication is very important. Removing barriers is one of the easiest ways to improve communication. Some of the principal barriers to communication are: Noise (interruptions, physical distractions) Physical - geographical considerations, time and space Mental barriers (perceptions, stereotyping, prejudice, personal beliefs, status, the relationship between communicators, culture and emotional state) Poor feedback Poor listening skills Selection of inappropriate medium or language used Poor body language (non-verbal communication) 22 Multiple choice questions: 1) Which of the following shows a positive facial expression? A) Frowning while concentrating B) Maintaining eye contact C) Laughing continuously D) Rolling up your eyes 2) By what method we can know what the receiver understood or got the message A) Transmitting B) Feedback C) Message D) Shouting 3) The communication cycle does not include....... A) Sender B) Message C) Receiver D) Programming 4) The process in which the receiver interprets and understands the message is called............. A) Decoding B) Encoding C) Feedback D) None of these 5) SBAR stands for a. Situation, Background, Assessment and Recommendation b. Situation, Bias, Act, Refer c. Situation, Breathing, Assessment and Recommendation d. None of the above References and further reading: - Strategies for Effective Communication in Health Care https://publichealth.tulane.edu/blog/communication-in-healthcare/ - SBAR https://asq.org/quality-resources/sbar - Closed loop communication: AHA guidelines. 23  Section 2: Chapter 5: DNAR (Do Not Attempt Resuscitation) What does DNAR stand for? DNAR stands for Do Not Attempt Resuscitation. It is sometimes also called DNACPR (Do Not Attempt Cardio-Pulmonary Resuscitation) or DNR (Do Not Resuscitate). What is CPR? What does DNACPR mean? Normally when the heart stops beating, to revive the heart and restore blood supply to the brain, a process called CPR (Cardio-Pulmonary Resuscitation) is initiated - This is discussed in your curriculum elsewhere and you will practise this too. CPR may or may not be ‘successful’ depending upon many variables, including but not limited to - the cause of cardiac arrest, age of the patient, pre-existing medical conditions, etc. Sometimes even if the heart starts beating again after CPR, the brain might be permanently damaged which might result in a state of prolonged suffering and unnecessary medical procedures instead of a ‘meaningful life’ making the patient dependent on life support systems like ventilators. This is often described as a ‘vegetative state’. ICMR (Indian council of Medical Research) which has formulated consensus guidelines on DNAR in India has described it as follows - “It is a medical decision to not initiate or perform CPR on a patient suffering from an incurable disease/condition/terminal illness where medically meaningful survival is not expected” When and who should decide about CPR and DNAR directives? Although the treating physician takes the lead in making the decision, the decision is generally explained in detail to the patient or the family (if the patient is unconscious, confused or not in a state to understand the decision). Ideally, the discussion about CPR should happen early in the course of illness when the patient can understand fully if someone is known to have a serious medical condition with chances of quick deterioration. Does DNAR mean that we stop all treatments? No. DNAR is very specific and refers ONLY to what you should (or shouldn't) do if there’s a cardiac arrest. None of the other treatments would be stopped just because there’s a DNAR decision made prior to or during an acute illness. Below is a flowchart developed by the ICMR which aids in making a DNAR decision (Source: ICMR consensus statement on DNAR 2020) 24 Is Do Not Attempt Resuscitation (DNAR) same as an Advance Directives (Living Will)? No. DNAR is different to a will and is a physician-initiated decision, whereas advance directives or living will is a patient-initiated action. 25 How is this decision recorded/documented? Different countries may have slightly different processes to do this but generally, the principle remains the same. In India, ICMR has recommended the below format to record DNAR decisions (Source: ICMR consensus statement on DNAR 2020). Multiple Choice Questions: 1) What is the purpose of a Do Not Attempt Resuscitation (DNAR) directive? 26  a) To instruct medical professionals to perform CPR in all circumstances b) To instruct medical professionals to not perform CPR in certain circumstances c) To instruct medical professionals to perform CPR only if the patient is unconscious d) To instruct medical professionals to perform CPR only if the patient is conscious 2) Who is typically responsible for deciding to initiate a DNAR directive? a) The patient b) The patient's family c) The medical team d) The patient's lawyer 3) In what situations might a DNAR directive be considered? a) When the patient is suffering from a terminal illness b) When the patient has a poor prognosis for survival c) When the patient has a history of unsuccessful CPR attempts d) All of the above 4) Who should be involved in the decision-making process for a DNAR directive? a) The patient b) The patient's family c) The medical team d) All of the above 5) Can a DNAR directive be reversed? a) Yes, at any time by the patient or their representative b) Yes, only in specific circumstances only with the approval of the medical team c) No, once it is in place it cannot be reversed d) Yes, if the patient’s lawyer requests. 6) Is it possible for a DNAR directive to be overruled by a medical professional? a) Yes, if the medical professional believes it is in the best interests of the patient b) No, a DNAR directive must always be followed c) Yes, if the medical professional believes it is in the best interests of the family d) Yes, if the medical professional believes it is in the best interests of society 27  7) Which organisation framed the consensus guidelines about DNAR in India? a) ISRO b) ICMR c) DRDO d) AIIMS 8) CPR is always successful a) True b) False 9) Following are the indicators of poor outcomes following CPR except: a) Pre-existing debilitating medical conditions b) Advanced age and frailty c) A young healthy patient who had a cardiac arrest following an electric shock d) Cardiac arrest in a patient with heart failure and kidney failure. 10) It is not necessary to discuss DNAR decisions with the patient although they are conscious and able to understand the discussion as this may scare the patient. a) True b) False References and further reading: 1. ICMR Consensus Guidelines on ‘Do Not Attempt Resuscitation’ 2020 consensus statement. Published on Indian J Med Res 151, April 2020, pp 303-310 DOI: 10.4103/ijmr.IJMR_395_20 2. https://www.nhs.uk/conditions/do-not-attempt-cardiopulmonary-resuscitation- dnacpr-decisions/ 28  Section 2: Chapter 6: Systemic approach to a patient in an emergency Approach To The Emergency Patient The BECS course is intended for a wide range of frontline providers and offers a basic approach to life-threatening presentations. Emergency conditions often require urgent intervention long before a diagnosis is established, and a presentation-based approach is essential to manage patients effectively. The modules in this course teach the elements of a general approach that can be used for any emergency patient. The ABCDE approach allows rapid assessment and intervention for life threats using a systematic approach. What kills first is identified first and treated first. As an example, any problem with the airway like an obstruction due to choking kills the patient first although there may be co-existing problems in breathing or circulation. So, unless the airway problem is dealt with and fixed, moving on to the next problem in breathing or circulation will be useless as the patient will likely side due to the airway problem. ABCDE as an order of priority stands for the following: A – Airway: Check and correct any obstruction to the movement of air into the lungs B – Breathing: Ensure adequate movement of air into the lungs and the person is breathing adequately. C – Circulation: Evaluate whether there is adequate perfusion to deliver oxygen to the tissues; check for signs of life-threatening bleeding D – Disability: Assess and protect brain and spine functions E – Exposure: identify all injuries and any environmental threats and avoid hypothermia (Low body temperature) This stepwise approach is designed to ensure that life-threatening conditions can be identified and treated early, in order of priority. If a problem is discovered in any of these steps, it must be addressed immediately before moving on to the next step. The ABCDE approach should be performed in the first 5 minutes and repeated whenever a patient’s condition changes or worsens. Essential ABCDE considerations are listed in the next modules for each of the components. The goal of the ABCDE approach is to rapidly identify life-threatening conditions; ensure the airway stays open; and ensure that breathing and circulation are adequate to deliver oxygen to the body. The goal of the SAMPLE approach is to rapidly gather history and additional information critical to the management of the acutely ill patient. 29 Once the ABCDE assessment is done, the SAMPLE history is a method of rapidly gathering the history critical to the management of the acutely ill patient. The SAMPLE history includes: S: SIGNS AND SYMPTOMS A: ALLERGIES M: MEDICATIONS P: PAST MEDICAL HISTORY L: LAST ORAL INTAKE E: EVENTS SURROUNDING ILLNESS Brief description of the ABCDE assessment and management: Imp note: Before proceeding with the full assessment, if you think there’s an emergency, call for help – Call 108 – So that help can arrive quickly while you perform assessment and first aid. DO NOT delay this as most patients in an emergency would need to be in a hospital for definitive management of the problem. Airway: 1) Check if the patient is talking – A patient who’s able to speak has a patent airway. It means that he’s able to move the air in and out of the lungs through the vocal cords producing speech. 2) If the patient is not speaking, check if they are responsive or not. (If they are unresponsive, not breathing and have no pulse, follow the BLS algorithm and start CPR – Later described in another module). If they have a pulse proceed with the assessment. 3) In case of trauma, also think about stabilising the spine along with managing the airway. 4) Check for abnormal sounds from the mouth – You could hear gurgling sounds, snoring sounds, stridor or musical sounds which might be indicating an obstructed airway. 5) Check if you see any obstruction in the mouth – Any objects? Vomit? Secretions? Blood? If you see any obvious solid foreign body, you can remove it with fingers or forceps. If there are secretions, you may need a suction device to clear them. In cases of choking, perform ‘The Heimlich manoeuvre’ and follow the choking algorithm (described in another module) 6) You can also perform ‘head tilt and chin lift’ or ‘jaw thrust’ (Both described in another module) to keep the airway open. 7) If these measures fail to keep the airway open, you will probably need additional help – The patient may need something called airway adjuncts to keep the airway open or an advanced airway (Tubes that go upto or down the throat which help in oxygen transport and ventilation – e.g. Laryngeal mask airway or LMA, Endotracheal tube) 30 Breathing: 1) Check their breathing and see if they are breathing normally. Rapid breathing or slow breathing are both abnormal. Normal breathing rate per minute is between 12 and 20. Anything beyond this range is considered abnormal. 2) Check if they are complaining of difficulty in breathing if responsive and check if they are retracting their chest and appear to be struggling 3) Check if there are any open wounds or wellings on the chest. Management of a penetrating injury is later described. 4) Check if you can hear any noisy breathing. Patients with conditions like asthma can have audible wheezes (Musical noises prominent during breathing out) 5) You can also check their oxygen saturation levels if you have a device to do that. Normal levels are above 94% generally. 6) You can start them on oxygen if they have any at home. You can also help them to use their inhalers or nebulisers if they have been prescribed some (Steps to use described later in another module) Remember - If they are not breathing or gasping, check pulse and if there is no pulse follow BLS (Basic Life support) algorithm and start CPR (described later in another module) Listening to the chest (auscultation) and tapping on the chest (percussion) would also help to identify different problems like pneumothorax (air leaking out into the space between the lining of the lung and chest cavity) or haemothorax (blood in the same space), especially in cases of trauma but diagnosis of that and treatment of the same is beyond the scope of these modules and would need a trained healthcare provider for the same. Circulation: 1) You can check for a radial pulse and count it for a minute. A normal pulse rate is said to be between 60 and 90 and anything beyond that is considered generally abnormal. 2) You could also check the blood pressure and hypotension or low blood pressure (less than 90/60mmHg ) is considered to be more dangerous than high blood pressure in an emergency. You would need the help of a healthcare provider for definitive treatment of this but you can lift the legs of the patient as a temporary measure. 3) In cases of trauma, check if you can see any bleeding that might be responsible for this and to stop the bleeding apply direct pressure using cotton gauze if you identify an area of bleeding. 31 4) In cases of anaphylaxis or severe allergic reaction, ask the patient if they have an EpiPen (Adrenaline/Epinephrine autoinjector) that they can use. Disability: 1) Check the neurological status of the patient. You can use a method called the AVPU scale: 2) Check blood sugar levels if you have a glucometer. If you find low blood sugar levels and if the patient is conscious and able to swallow give them an oral glucose solution or a sugary drink/chocolate 3) Check pupils and see if the pupils are equal or unequal and if they are reacting to light. Exposure & Environment: 1) Check the patient’s temperature and look for any other injuries from head to toe. 2) Cover the patient up if their temperature is low. Call 108! Once you recognize an emergency, you must decide to take action. In an emergency, deciding to act is not always as simple as it sounds. Some people are slow to act in an emergency because they panic, are not exactly sure what to do or think someone else will take action. But in an emergency, your decision to take action could make the difference between life and death for the person who needs help. Your decision to act in an emergency should be guided by your skills and limitations and by your knowledge of the risks that may be present. However, even if you decide not to give care, you should at least call 108 or the designated emergency number to get emergency medical help to the scene. 32 Multiple Choice Questions: 1. A 25-year-old man was involved in a road traffic accident and has blood all over his hands and face. How will you approach this patient? a) Make sure the scene is safe b) Call 108 c) Wear appropriate PPE. d) Follow ABCDE approach. 2. A 40-year-old asthmatic has sudden worsening shortness of breath. How will you approach it? a) a)Call for help b) Follow ABCDE approach c) Use oxygen if available d) Use inhalers or nebulisers if the patient has e) All of the above 3. All the following stands for components of ABCDE assessment EXCEPT a) Airway b) Breathing c) Chest assessment d) Disability 4. In cases of trauma with a suspected neck injury, the cervical spine is stabilised after completion of a full ABCDE assessment a) True b) False 5. In the assessment of disability what is being checked? a) Difficult airway b) AVPU scale, sugar levels and pupils c) Head wounds d) Temperature References and further reading: - Resus Council UK https://www.resus.org.uk/library/abcde-approach - American Heart Association guidelines - Advanced Trauma Life Support guidelines - ABCDE assessment: https://oxfordmedicaleducation.com/emergency- medicine/abcde-assessment/ 33  Section 2: Chapter 7: Importance of First Aid kit and description The aims of first aid include preserving life, preventing injury from getting worse, aiding recovery, relieving pain, and protecting the unconscious. The main objective is to save lives. first aid training is therefore vital to delivering correct first aid to the person in need. A first aid kit is a systematic collection of tools that may come in handy to perform first aid when necessary which can also be carried around without much hassle. (Sample representation of contents of a first aid kit) The international standard for first aid kits is that they should be identified with the ISO graphical symbol for first aid although many kits do not comply with this standard, either because they are compiled together by individuals or they predate the standards. First aid kits may vary depending on the manufacturer and the geographical location. However, most first aid kits have many things in common. Some of the common items found in first aid kits are listed below: 1. Antiseptics & Cleansers Every first aid kit or cabinet should be well stocked with antiseptic wipes such as benzalkonium chloride (BZK) and alcohol for cleaning and sterilizing a wound and instruments used in treating the wound. Hand sanitisers are included as well to disinfect the rescuer before and after first aid treatment as well. 2. Adhesive Bandages Band-Aids are frequently used in any first-aid situation, make sure your first-aid kit has plenty of first-aid bandages and a variety of sizes for different purposes. Some, such as knuckle, fingertip and butterfly bandages may seem odd but are very handy when you know how and why to use them. 3. Gauze Rolls / Gauze Pads / Trauma Dressings A complete first responder first aid pack includes items for stopping severe bleeding and 34 protecting an injury. Sterile gauze pads and rolls should be abundant. Many first aid kits have gauze, but no way to secure it. Make sure your first aid kit or cabinet is well stocked with appropriate latex-free first aid tape. 4. Wraps & Bandages Latex-free elastic wraps and triangular bandages or triangle slings are a must. These are used for splinting and binding. 5. First Aid Instruments - Scissors / Tweezers. What’s the use of having great first aid tapes and gauzes if you can’t trim them to apply effectively? 6. Gloves / PPE A first aid kit must have personal protective equipment for the safety of the rescuer as well as the patient. Gloves should always be latex-free in consideration of latex-sensitive users. 7. Cold Packs / Instant Cold Compresses Cold treatment is needed for sprains, strains, bumps and bruises. Consider an ice-securing wrap too these are very convenient for holding a cold compress in place for the recommended 10-15 minutes so neither the rescuer nor the casualty has to hold the pack in place. 8. Medications A complete first aid set-up needs pain medications that can be used to treat pain before strong pain medications can be given in the hospital. Some of the commonly used medications include Paracetamol and Ibuprofen. Aspirin is also commonly found in a first- aid kit and can be used in patients suspected to have a heart attack. You may also find Silver Sulfadiazine ointment which can be used in cases of burns. 9. Eye Injury First Aid If there is a chemical spill to the eye, an eye wash kit and some eye pads will be useful until the patient reaches the hospital. The method of irrigation of the eye is described elsewhere in this manual. 35 10. Guide Not everyone has attended a first aid course, nor remember what was taught if they did attend. Any first aid kit or first aid cabinet needs a quick reference first aid guide booklet. 11. CPR A thorough first aid kit list should include some sort of CPR barrier device or CPR mask to protect the rescuer and encourage the administration of CPR. 12. AED No, an AED will not fit in your first aid kit, although they do keep getting smaller, more efficient and more affordable. You should, however, consider the lifesaving value of placing an AED in your workplace. 13. Glucose powder and ORS powder When low blood sugar levels are suspected glucose powder will come in handy. You can also add a glucometer to your armoury of equipment now that you will be able to use that after this course. ORS powder can be reconstituted with water and is used in patients with symptoms of gastroenteritis (Loose stools/Diarrhoea and Vomiting) to prevent or treat dehydration. References and further reading:  Indian Redcross Society – First Aid Manual  www.who.int  National Health Portal of India: https://www.nhp.gov.in/miscellaneous/first-aid 36  Section 2: Chapter 8: Orientation on ambulance equipment While there may be slight structural and functional differences between various ambulances, generally they have similar equipment and drugs aimed at immediate lifesaving measures to stabilise and provide comfort and care to the patient until they reach the hospital for definitive care. Here we have briefly outlined the equipment available in ambulances operated by EMRI Green Health Services across many states in India. They use a single toll-free number 108 for call activation across the country. 108 ambulance operated by EMRI is also one of the world’s biggest ambulance networks. What happens when someone calls 108? As soon as someone calls 108, the call reaches the central command and control centre of the respective state. The trained operator receives the call and obtains the necessary details which include details of the patient, the exact location and a brief description of the problem. Our ambulances are stationed at different base locations across cities, towns and villages and the call is then transferred to the nearest ambulance that’s available at the caller's location and dispatched to the designated location as early as possible. Details of the caller/patient are also transferred to the EMT (Emergency Medical Technician) in the ambulance so that he/she will be able to contact the patient/family directly. TYPES OF AMBULANCES: ALS – Advanced Life Support ambulances BLS – Basic Life Support ambulances An advanced life support ambulance contains advanced life support equipment like Ventilator and Defibrillator. A basic life support ambulance is a similar ambulance with the same medical and surgical stock except for advanced equipment. 37 A list of some of the most commonly used equipment in the ambulance  Different types of stretchers  Splints  Defibrillator (ALS Only)  Ventilator (ALS Only)  Oxygen Cylinder and Oxygen delivery system  Ambu bag / Bag-Mask Valve (BMV) ventilation  Suction apparatus  Glucometer  Pulse Oximeter  Nebuliser  BP Apparatus  Stethoscope  Torch  Thermometer  Drug Chiller  Airways - Different types  Laryngoscope (only in Advanced)  Tongue depressor  Sputum cup  Cervical collar  Syringe  Needle destroyer  IV (Intravenous) cannulas  IV Fluids and IV Set  Medications that are used in an emergency  Scalpel, blade and scissor  Forceps  Dressing, cotton roll, bandage  Tourniquets  Bedpan and Urine cans  Multiple chargers  Extrication equipment (For rescuing victims stuck inside the vehicle/buildings, etc) The general use of many of these pieces of equipment is self-explanatory. Explaining the specifics of every piece of equipment above in detail is beyond the scope of this curriculum. Thus this manual briefly describes some of the equipment mentioned above, especially the ones that are not very commonly known. 38 Moving and lifting the patient from their location to the ambulance and then to the hospital could be challenging due to various reasons (e.g patient factors like age, weight, disability, illness affecting movement or environmental factors like terrain, location of house, etc). To overcome this problem, and to carry out correct moving and lifting, an ambulance has five different types of stretchers designed for different scenarios: 1. Collapsible Stretcher: Easy to carry a patient and can load easily inside the ambulance. These are one of the most commonly used stretchers. The legs of the stretcher get folded inside and it is easy to push inside the ambulance Height is appropriate to load inside the ambulance Can be operated by a single person for loading and offloading a patient. Comfortable bedding for patients with a facility to strap with the help of belts for the safety of patients. Side rails to prevent accidental falls. Head-end of the stretcher can also be elevated which might be a more comfortable position for many patients. 2. Scoop Stretcher: Useful in shifting patients with multiple injuries and spine injuries. In spine injuries, it avoids movement of the spine during stretcher transfer. 39  The two joints at both ends can be split open and the patient can be comfortably scooped into and carried easily also shifting the patient to bed becomes easier. 3. Wheel Chair Easy to carry the patient through narrow gates, and staircases safely. Have wheels for easy movement on the ground. Straps and safety belts to hold the patient intact. Can be carried by two persons. Mounted on the sidewall when not in use, and has a locking system for wall mounting 4. Pedi Board: Full body immobilization with Velcro straps for easy and comfortable transportation of pediatric patients. 5. Air Lifting Jacket: Full body immobilization with Velcro straps for easy and comfortable air transportation for serious patients. Ventilators and Defibrillators: 40 Only our Advanced Life Support (ALS) ambulances have this equipment. Ventilators may be necessary when the patient can not breathe on their own and their breathing has to be supported externally using a machine. The machine (ventilator) essentially takes over the function of the lung delivering enough oxygen and air that is required for normal oxygen transfer between the lungs and the blood. There are multiple modes and settings on a ventilator which can be tuned based on various parameters based on the patient’s clinical condition. A trained healthcare professional like an advanced paramedic or a trained doctor is necessary to operate a ventilator. Defibrillators are devices used in certain problems of the electrical conduction system of the heart. When a patient is very unwell, if left untreated these conditions can lead to rapid deterioration and death. It is also used in cardiac arrest situations arising due to electrical disturbances in the heart rhythm (Called Ventricular Fibrillation and pulseless Ventricular tachycardia described later in this manual). The machine is used to deliver an external electric shock to the heart with abnormal electrical conduction. As with the ventilator, the usage of this machine requires a trained healthcare professional. Splints: In cases of fractures, immobilising the affected limb reduces pain and also prevents further blood loss and complications. Temporary immobilisation is achieved by splinting the limb. Commercially available foldable/malleable splints are used for this. The ambulances are also provided with a special splint called a vacuum splint which moulds well with the limb without much effort. (Splints which can be used for arms or legs) (Vacuum splints that can be moulded) 41 Interiors of an ambulance: Seat for EMT /Doctor & Attenders with straps. The space on the right is where the patient stretcher goes. Space for storing life-saving medicines, resuscitation kits and IV fluids Wash basin with foot-operated switch and waste disposal bins 42 Ambulance lighting system: It has Flashing lights which indicate the emergency nature from a distance. There are flood lights two on either side and one on the back help in providing lights in the dark if there is an Emergency in a dark place and the ambulance reaches there. Public addressing system and siren: Helps in intense traffic with the help of 10 Modes Unique Siren. Volume can be increased or decreased Can address the traffic in front of the vehicle and crowd for clearing the way. Easy to operate, handy for the pilot. AMBU Bag:  Artificial Mechanical Breathing Unit,  Also called Bag Valve Mask (BVM)  This is used to provide ventilation to patients in respiratory failure/ arrest  Different sizes available Oxygen: Since oxygen is extremely important, every ambulance has an oxygen cylinder attached to an oxygen delivery system. This is regularly maintained and is replaced when the cylinder is about to be empty. Regular checks after patient transfer and before transfer ensure that there is always enough oxygen available. EMTs and Pilots maintain a record of these. Suction apparatus: A suction apparatus creates negative pressure and is connected to the tubing. This essentially works like a vacuum cleaner. The end of the tubing is used to clear secretions from the mouth/nose like blood, saliva or vomit if necessary to keep the airway clear. 43 Syringe/Needle destroyers: This device is used to destroy used needles as the name suggests. This minimises the risks of needle stick injuries and helps in the appropriate disposal of needles. Drugs: Not all the drugs available in a hospital are available in the ambulance. But ambulances stock those drugs which are very important in case of an emergency. Some of the very commonly used drugs in an ambulance are noted below. This isn’t an exhaustive list and is shown only as an example.  Adrenaline (Also known as epinephrine) – Used in cardiac arrest and severe allergic reactions (anaphylaxis)  Atropine – Used in conditions where heart rate is very low and also in cases of organophosphorus compound poisoning.  Hydrocortisone – This is a steroid used in asthma, COPD, etc.  Pain medications: Diclofenac, Paracetamol, Tramadol, etc.  IV fluids – Normal saline solution, Ringers Lactate solution  Salbutamol and Ipratropium bromide – Used for nebulisation in cases of asthma or COPD.  Chlorpheniramine – Used in minor allergic reactions  Midazolam – Used for sedation or in cases of seizures. Further reading and references:  Specifications of medical equipment for ERS Ambulances under National Health Mission and type of ambulances – Govt of India https://nhm.gov.in/images/pdf/programmes/ERS/Specification_of_Equipments_ for_ERS_Ambulance.pdf  EMRI Green Health Services www.emri.in 44  Section 2: Chapter 9: Role of volunteer in case of a disaster What is a disaster? The International Federation of Red Cross and Red Crescent Societies (IFRC) describes disasters as “serious disruptions to the functioning of a community that exceeds its capacity to cope using its own resources. Disasters can be caused by natural, man-made and technological hazards, as well as various factors that influence the exposure and vulnerability of a community” Disasters are sometimes also described as ‘Major Incidents’ and with reference to healthcare it can be defined as ‘any incident where the location, number, severity or type of live casualties requires extraordinary resources’. What are some of the terminologies used by emergency services in the event of a major incident or disaster? The acronym METHANE is used to communicate information between services. M Major incident standby or declared E Exact location T Type of incident (chemical, terrorist, rail, natural disaster, etc) H Hazards present at the venue and potential hazards A Access to the site N Number and severity/type of casualties E Emergency services present and required Who are the responsible officers in a disaster situation? There will be different commanders during a disaster situation and all of them would have designated roles and responsibilities. Some examples are - Police commander - Fire commander - Medical commander 45  - Ambulance commander. There may also be commanders from disaster response units from the state or the centre assuming different roles. What is the role of a volunteer in a disaster situation? Volunteers play a vital role in the management of disasters and many of the volunteers come with their own unique set of skills which may be useful for the team managing a disaster. The role of a volunteer in a disaster can vary depending on the specific needs of the affected community and the skills and abilities of the individual volunteer. Some common roles that volunteers may play in a disaster include: 1. Providing immediate assistance: This may include providing - First aid - Triage - Distributing supplies - Helping to evacuate people to safety. 2. Assisting with clean-up and recovery efforts 3. Providing emotional support: Disasters can be emotionally traumatic for those who have been affected. Volunteers may provide counselling and support to help people cope with their experiences and recover emotionally. 4. Supporting long-term recovery: Some volunteers may be involved in longer-term efforts to rebuild communities and help them recover from the disaster. This may include working with local organisations to develop and implement recovery plans. In general, volunteers play a critical role in helping communities affected by disasters to recover and rebuild. They provide much-needed assistance and support to people who have been affected and help to ensure that affected communities can recover as quickly and effectively as possible. How should I volunteer in a disaster? You can get in touch with different organisations that respond to disasters like NDRF (National Disaster Response Force) which also conduct volunteer training programs and they can let you know if they want your services during a disaster. If you find yourself in a disaster situation without any preparation and if you want to help, try to speak to the incident commander and introduce yourself. Explain your expertise and if you are trained in first aid. The incident commander would be able to allocate roles to you depending on the situation and your expertise. Always think of safety first and keep yourself safe while helping others. 46 What are the NATO Phonetic alphabets? To prevent miscommunication due to different accents and spellings an international standardised format of the alphabet has been developed by NATO. This is used in most emergency response systems, military and generally during radio communications. Learning these alphabets will improve your communication during a disaster as you will speak in a standard globally understood lingo as a part of the team. Further reading and references: 1. National Disaster Response Force https://ndrf.gov.in/ 2. SALT mass casualty triage https://www.ndlsf.org/salt 3. National Disaster Management Authority of India https://ndma.gov.in/ 47  Section 2: Chapter 10: Field Triage Definition: The term triage originates from the French word trier which means ‘to separate’. Triage is the sorting of patients, by priority, for treatment or transport. Triage can also be described as the preliminary assessment of patients or the right prioritisation of casualties to determine the urgency of their need for treatment and the nature of treatment required. The goal of triage is to get the right patient to the right place at right time and to the right healthcare provider. Types: Triage can be broadly classified into - Non-disaster triage: The goal here is to provide the best resource-appropriate care for each patient and this is done usually in hospital settings. Different hospitals and healthcare systems use different systems of triage appropriate to the clinical setting. - Disaster triage: The goal here is to provide the most effective care to the greatest number of patients. This is usually done in disaster or mass casualty situations. Field triage generally refers to this as it is usually an out-of-the-hospital setting. Below is a description of different levels of non-disaster triage systems used across the world. In most developed countries a 5-level triage is used for categorising patients in the emergency department. In many developing countries including India, more commonly a 3- level system is being used. The categories are based on various criteria including the symptoms, ABCDE assessment and vital signs (Pulse, BP, temperature, Oxygen saturation levels, etc.). Different countries and systems have different time criteria within which different categories of these patients must be seen by a doctor. For example, anyone categorised as ‘resuscitation’ or ‘life threatening’ in a level 4 or 5 system should be seen immediately or within a minute and anyone categorised as emergent should be seen in about 2-10 minutes. These criteria may have slight changes depending on the various factors. 48 A 3-level system often uses these categories (exact time in minutes is not mentioned here as this may vary depending upon the setting): - Red or Priority 1 (P1): Should be seen immediately. Any delay would likely result in death within minutes. - Yellow or Priority 2 (P2): Should be seen urgently within a few minutes but not in immediate danger of death within minutes. - Green or Priority 3 (P3): Not an emergency. Needs care but is fit to wait until the above two categories of patients are dealt with. Can also be sent to another doctor in an outpatient department if appropriate. Disaster triage slightly differs from hospital triage in the fact that one may have to triage a large number of people with very limited information. We also may not have all the equipment necessary to check all the vital signs and even if we do have the equipment, doing so needs lots of manpower and time consuming and would leave the people in immediate help unattended. Therefore, different methods of triage are used across the world for managing mass casualties which use less information but help the maximum. Sometimes the triage in these situations is also classified as primary triage (based on limited information) and secondary triage (detailed triage by a healthcare professional once primary triage is done) MPTT 24 (Modified Physiological Triage Tool), Triage Sieve, START and SALT mass casualty triage are the commonly used primary triage systems across the world. MPTT 24: This chapter discusses MPTT 24 in detail. The triage sieve is a new simple reproducible triage method for use as a primary triage tool. The triage sieve is very similar to this with slight changes. The only vital parameters used here are respiratory rate and pulse rate both of which can be measured quickly without the help of any special equipment. Triage categories here are as follows: Priority 1: Immediate priority - These casualties require immediate life-saving intervention. Priority 2: Urgent priority - These casualties require significant intervention within 2–4 hours Priority 3: Delayed priority- These casualties require intervention, but not within 4 hours. 49 Note that triage is a continuous and dynamic process – Which means that a patient categorised as priority 3 may become priority 1 if his condition suddenly changes. These categories are not permanent and are subject to change with time and evolving situations. Also note that normally when a person is not breathing, you would start CPR in a non- disaster scenario but during disaster triaging (as you can see on the flow chart) CPR has no role (You do no intervention if the person is unresponsive and not breathing at all) as initiating CPR would take up a lot of resources in an already resource-limited setting with multiple casualties and would likely cause harm to people who are alive and are needing immediate interventions to stay alive (P1 and P2 patients). The flowchart above is for adults only and in children the method of triage is slightly different due to different physiological parameters although the principle remains almost the same. Allocation of roles: - There will be designated persons allocated for dealing with each category of these patients and patients would also need visible labelling. - The person in charge of the triage will allocate roles and will communicate with the medical commander and the incident commander. - Communication plays a key role in managing mass casualty situations. The diagram shows the entire process of triage and how it fits into the situation: Multiple choice questions: 1. Once labelled into a category during triage, this can never be changed e) True f) False 50 2. Triage is a process of a) Categorisation of patients b) Treatment method c) Method of identifying the dead d) Method to give an injection in a clinical trial 3. Triage methods are the same in disaster and hospital settings a) True b) False 4. Following are the commonly used triage systems in hospitals EXCEPT a) 3 level system b) 5 level system c) Single level system 5. A patient in a disaster zone is walking and breathing but his respiratory rate is 45. What would be his triage category? a) Priority 1 b) Priority 2 c) Priority 3 d) Non-urgent References and further reading: - RCEM Learning: https://www.rcemlearning.org/modules/triage-in-mass-casualty- situations/lessons/triage-categories/topic/primary-triage/ - Oxford Handbook of prehospital emergency Medicine - National Guidelines for the Field Triage of Injured Patients – American College of surgeons https://www.facs.org/quality-programs/trauma/systems/field-triage- guidelines/ 51  Section 3: Chapter 1: Breathing problems Breathing difficulties can also be described by patients as Being short of breath Being unable to take a deep breath and gasping for air Feeling like you are not getting enough air Breathing difficulty is almost always a medical emergency until proven otherwise. Causes There are many different causes of breathing problems. Common causes include some health conditions and sudden medical emergencies. Breathing problems can arise due to a primary problem in the lungs or the surrounding area/covering of the lungs, a problem in the heart causing a secondary problem in the lungs or as a result of problems else where in the body. Some health conditions that may cause breathing problems: Asthma Chronic obstructive pulmonary disease (COPD) Lung cancer, or cancer that has spread to the lungs Lung infections, including pneumonia, acute bronchitis etc. Heart disease or heart failure Drowning Allergic reactions A severe form of diabetic emergency called Diabetic Ketoacidosis (DKA) Kidney failure High altitude We will briefly describe some of the common conditions that cause breathing difficulties. ASTHMA Asthma is a common long-term condition in which the air passages in the lungs become narrow due to inflammation and tightening of the muscles around the small airways. This can cause coughing, wheezing, chest tightness and breathlessness. The severity of these symptoms varies from person to person. Asthma can be controlled well in most people most of the time, although some people may have more persistent problems. Occasionally, asthma symptoms can get gradually or suddenly worse. This is known as an 'asthma attack' 52 Severe attacks may require hospital treatment and can be life-threatening. Causes Asthma is caused by inflammation of the small tubes, called bronchi, which carry air in and out of the lungs. The bronchi will be inflamed and more sensitive than normal. Many factors have been associated with an increased risk of developing asthma, although it is often difficult to identify a single, direct cause. Some of these may be genetic. However, several environmental factors are thought to play a role in the development of asthma. These include air pollution, chlorine in swimming pools, dust, smoke, pollen from plants etc When a person comes into contact with something that irritates the lungs – known as a trigger, airways become narrow, the muscles around them tighten, and there is an increase in the production of sticky mucus (phlegm). Triggers that make asthma worse vary from person to person, but can include viral infections (colds), dust, smoke, fumes, changes in the weather, grass and tree pollen, animal fur and feathers, strong soaps and perfume. Asthma affects people of all ages, including young children and elderly people. Risk Factors Although the cause of asthma is unknown, several things that can increase the chances of developing the condition have been identified. These include: A family history of asthma or other related allergic conditions (known as atopic conditions) such as eczema, food allergy or hay fever Having bronchiolitis (a common childhood lung infection) as a child Childhood exposure to tobacco smoke Being born prematurely, especially if there was a ventilator to support breathing after birth Having a low birth weight as a result of restricted growth within the womb Children and adults who are overweight or obese are at a greater risk of asthma Some people may also be at risk of developing asthma through their job Triggers Asthma symptoms can have a range of triggers, such as: Respiratory tract infections – particularly infections affecting the upper airways, such as colds and the flu Allergens – including pollen, dust mites, animal fur or feathers 53  Airborne irritants – including cigarette smoke, chemical fumes and atmospheric pollution Medicines – particularly the class of painkillers called non-steroidal anti- inflammatory drugs (NSAIDs), which includes aspirin and ibuprofen, and beta- blockers sometimes given for high blood pressure or some types of heart disease Emotions – including stress or laughing Food containing sulphites – naturally occurring substances found in some food and drinks, such as concentrated fruit juice, jam, prawns and many processed or pre- cooked meals Weather conditions – including a sudden change in temperature, cold air, windy days, thunderstorms, poor air quality and hot, humid days Indoor conditions – including mould or damp, house dust mites and chemicals in carpets and flooring materials Excessive exercise in some people Food allergies – including allergies to nuts or other food items Symptoms The symptoms of asthma can range from mild to severe. Most people will only experience occasional symptoms, although a few people will have problems most of the time. The main symptoms of asthma are: Wheezing (a whistling sound when you breathe) Shortness of breath A tight chest – which may feel like a band is tightening around it Coughing These symptoms are often worse at night and early in the morning, particularly if the condition is not well controlled. They may also develop or become worse in response to a certain trigger, such as exercise or exposure to an allergen. Signs of a particularly severe asthma attack can include: Your reliever inhaler (which is usually blue) is not helping symptoms as much as usual, or at all Wheezing, coughing and chest tightness becoming severe and constant Being too breathless to eat, speak or sleep Breathing faster A rapid heartbeat 54  Feeling drowsy, exhausted or dizzy Your lips or fingers turning blue (cyanosis) Classification - Mild Mild symptoms up to two days a week and up to two nights a month intermittent - Mild Symptoms more than twice a week, but no more than once in a single persistent day - Moderate Symptoms once a day and more than one night a week persistent - Severe Symptoms throughout the day on most days and frequently at night persistent When there is a sudden worsening of asthma, it is classified as follows. This is a classification system generally used by trained healthcare providers and therefore you may find there are many technical terminologies (e.g PEF, PaCO2, etc) which are beyond the scope of this module but this classification system has been included just to give you an idea about how quickly the patient can deteriorate from having a moderate asthma attack to a life- threatening state. Also, note some of the clinical signs of life-threatening asthma which can even be recognised by a non-healthcare professional. 55 Emergency warning signs or red flags of a severe asthma attack may include: These are the conditions that need early recognition and early treatment in a hospital for preventing further complications. These patients may also need further tests in the hospital. Call for help (108) early if you identify any of these: Severe shortness of breath or gasping for air, chest tightness or coughing or wheezing that is ‘unusual’ for the patient. Symptoms that fail to respond to the use of a quick-relief inhaler. Any symptom that is unusual for the patient when compared to previous asthma episodes. Unable to complete a sentence or any other symptoms or signs described above that fall under the category of acute severe asthma, or life-threatening asthma. Unresponsive patient. Pale or blue lips or fingernails (cyanosis) Medications The right medications depend on many things — age, symptoms, asthma triggers etc Long-term asthma control medications- Generally, these are taken daily and are the cornerstone of asthma treatment. These medications keep asthma under control on a day-to-day basis and make it less likely to have an asthma attack. Types of long-term control medications include: Inhaled corticosteroids. These medications include fluticasone propionate, budesonide, beclomethasone, mometasone and fluticasone furoate Leukotriene modifiers Combination inhalers: Salbutamol/Ipratropium Quick-relief (rescue) medications are used as needed for rapid, short-term symptom relief during an asthma attack. Most patients with asthma may have these medications with them at home and would be comfortable using an inhaler or a nebuliser. Please ask the patient or the family for these medications and help the patient take these.  Oxygen: If oxygen is available, oxygen can be started at the earliest using a face mask available. Inhalers: Salbutamol/Levosalbutamol: These inhaled, quick-relief bronchodilators act within minutes to rapidly ease symptoms during an asthma attack. In an adult or anyone aged more than 6 years, you could use 10 puffs at once or within 30 mins if you are using an inhaler. This helps in bronchodilation and symptomatic relief. Inhalers: Ipratropium bromide: These medications also work in combination with the above bronchodilators and are used in acute asthma attacks. Use this as advised. 56  Both these medications can be taken using a portable, hand-held inhaler or a nebulizer, a machine that converts asthma medications to a fine mist. They're inhaled through a face mask or mouthpiece. Many patients, especially if they have had a previous acute attack, may have something called an acute asthma action plan – A set of instructions given by the doctor/hospital describing what exactly to do in case of another attack which also includes dosing of the inhalers. You can follow that if available. Oral steroids: If the patient has been using a medication called prednisolone, they can take a dose of 40mg (adult) orally which might help with the asthma attack. The only exception to this would be a patient specifically told NOT to do this by their doctor for whatever reason or a patient who can not swallow/drowsy. While these medications may help, a patient with persistent symptoms or worsening symptoms would still need assessment in the hospital and may also need supplemental oxygen and other treatment once assessed. The doctors may repeat a few nebulisers and also consider intravenous medications and if all this fails and if the patient’s clinical condition does not improve, they may also need mechanical ventilation as a last resort. So, always get the patient assessed by a doctor in case of an acute asthma attack. First Aid: Follow these steps systematically to help the patient having an acute asthma attack. - Assess the symptoms - Check if there are any red flags as described above, if any immediately call for help (108) - Sit the patient upright which might be more comfortable for the patient. - Help the patient with Oxygen if available and inhalers/nebulisers. - Check the response to medications. - Collect a SAMPLE history from relatives/family if you can - Check breathing and pulse and follow the BLS algorithm if the patient becomes unresponsive at any point. - DO NOT give anything orally if the patient is drowsy or unresponsive. - Transfer the patient to the hospital as soon as possible. Prevention 1. Follow your asthma action plan: Your doctor can write a detailed plan for taking medications and managing an asthma attack. Then be sure to follow your plan. Asthma is an ongoing condition that needs regular monitoring and treatment. 2. 2. Identify and avoid asthma triggers 57  3. Monitor your breathing 4. Identify and treat attacks early 5. Take your medication as prescribed 6. Avoid smoke of any type How to use an inhaler? Take the cap off. Look inside the mouthpiece and make sure there is nothing in it. Shake the inhaler hard 10 to 15 times before each use. Breathe out all the way. Try to push out as much air as you can. Breathe in Slowly Hold the inhaler with the mouthpiece down. Place your lips around the mouthpiece so that you form a tight seal. As you start to slowly breathe in through your mouth, press down on the inhaler one time. Keep breathing in slowly, as deeply as you can. 58  Hold Your Breath Take the inhaler out of your mouth. If you can, hold your breath as you slowly count to 10. This lets the medicine reach deep into your lungs. Pucker your lips and breathe out slowly through your mouth. If you are using inhaled, quick-relief medicine (beta-agonists), wait 1 to 2 minutes before you take your next puff. You do not need to wait between puffs for other medicines. Put the cap back on the mouthpiece and make sure it is firmly closed. After using your inhaler, rinse your mouth with water, gargle, and spit. Do not swallow the water. This helps reduce side effects from your medicine. Keep Your Inhaler Clean Look at the hole where the medicine sprays out of your inhaler. If you