Chapter 2.docx

Emergency Scene Management Chapter 2 Emergency scene management Emergency scenes generally begin with confusion as people realize there is an emergency unfolding in front of them. No one knows what to do first, who should be in charge, or how they can help. In this situation, the first aider needs t...

Emergency Scene Management Chapter 2 Emergency scene management Emergency scenes generally begin with confusion as people realize there is an emergency unfolding in front of them. No one knows what to do first, who should be in charge, or how they can help. In this situation, the first aider needs to follow a sequence of actions that ensures safe and appropriate first aid is given and everyone's safety is protected. First aiders use emergency scene management (ESM) to do this. Emergency scene management is the sequence of actions you should follow to ensure safe and appropriate first aid is given. Steps of ESM Scene survey-during the scene survey you take control of the scene, find out what happened and make sure the area is safe before assessing the casualty. Primary survey-assess each casualty for life-threatening injuries and illnesses, call or send someone to call 9-1-1, and give life-saving first aid. Secondary survey-the secondary survey is a step-by-step way of gathering information to form a complete picture of the casualty's overall condition. Ongoing casualty care-during ongoing casualty care you continue to monitor the casualty's condition until medical help takes over. These steps are generally done in the order above. The initial scene survey, primary survey and the start of life-saving first aid usually happens within one or two minutes. The secondary survey is not always necessary. Scene Survey Take charge of the situation Call out for help to attract bystanders Assess hazards and make the area safe Find out the history of the emergency, how many casualties there are and the mechanism(s) of injury Identify yourself as a first aider and offer to help, get consent Assess responsiveness Send or go for medical help as soon as you identify a serious problem and then begin the primary survey. If you have a mobile phone, you can dial 9-1-1 or your local emergency number, and put the device on speaker phone, if possible. This allows the first aider to remain with the casualty. Primary Survey Check for life-threatening conditions, the ABCs: A= Airway B = Breathing C = Circulation The sequential steps of the primary survey should be performed with the casualty in the position found unless it is impossible to do so. The primary survey should begin immediately after the scene survey. Check the airway If the casualty is conscious, ask "what happened?" How well the casualty responds will help you determine if the airway is clear. Use a head-tilt-chin-lift to open the airway of an unresponsive casualty. If you suspect a head or spinal injury, and have been trained, use a jaw-thrust without head-tilt. Check for breathing If the casualty is conscious, check by asking how their breathing is. If the casualty is unconscious, check for breathing for at least five seconds, and no more than 10 seconds. If breathing is effective, move on to check circulation. If breathing is absent or ineffective (gasping and irregular, agonal), begin CPR. Check circulation Control obvious, severe bleeding Check for shock by checking skin condition and temperature Check with a rapid body survey for hidden, severe, external bleeding and signs of internal bleeding Rapid body survey The rapid body survey is a quick assessment of the casualty's body which is performed during the primary survey. By running your hands over the casualty's entire body from head to toe (and under heavy outwear), you are able to feel for severe bleeding, internal bleeding and any obvious fractures. When performing the rapid body survey: Wear gloves when possible, and check gloves for blood every few seconds Be careful not to cause any further injuries while performing the survey Look at the casualty's face to notice any responses to the rapid body survey Provide first aid for life-threatening injuries or conditions. Maintain an open airway with a head-tilt chin-lift or by placing the unresponsive breathing casualty into the recovery position Provide CPR if the unresponsive casualty is not breathing or not breathing normally (gasping) Control severe bleeding Provide support for obvious fractures Give first aid for shock by providing first aid for life­ threatening injuries and maintaining the casualty's body temperature Evaluate the situation and decide whether to do a secondary survey Do a secondary survey if: The casualty has more than one injury Medical help will be delayed more than 20 minutes Medical help is not coming to the scene and you have to transport the casualty If you do not do a secondary survey, steady and support any injuries found and give ongoing casualty care until medical help arrives. How to turn a casualty face up You should give first aid in the position in which the casualty is found as much as possible. But sometimes you have to turn a casualty over to assess for life-threatening injuries or to give life­ saving first aid Extend the arm closest to you over the head. Tuck the far arm against the casualty's side. Cross the far foot over the near foot. Support the head and neck. Firmly grip the clothing at the waist. Roll the casualty over Position the casualty for giving first aid ESM when a head or spinal injury is suspected If you suspect a head or spinal injury, protect the head and neck from any movement. Head or neck movement could result in life­ long disability or death. Adjust your first aid to this situation as shown below As soon as you see there might be a head or spinal injury, tell the casualty not to move Once you have consent to help the casualty, steady and support the head and neck. Keep elbows firmly supported on thighs or ground. Then, assess responsiveness. If there is a bystander to help, show them how to support the head and neck so you can continue your assessment. Continue your assessment. If a second bystander is available, show them how to steady and support the feet to prevent movement. Keep the head and neck supported (and the feet if possible) while giving further first aid until handover to medical help. When moving a casualty with a suspected head or spinal injury, move them as a unit as much as possible. This means rolling the head, trunk and legs together, or lifting the whole body at the same time. Do what you can to prevent movement. Turning a casualty face up when a head or spinal injury is suspected You should give first aid in the position in which the casualty is found as much as possible. But sometimes you have to turn a casualty over to assess for life-threatening injuries or give life-saving first aid When you suspect a head or spinal injury, turn the casualty as a unit so the head and spine stay in the same relative position The first aider at the head supports the head-placing the right hand along the right side of the casualty's head and the left hand along the left side The other first aider extends the casualty's near arm over their head and gets a good grip on the casualty at the shoulder and waist. At the same time, the two first aiders roll the casualty towards the second first aider. If extra help is available, have the third first aider support the legs to prevent twisting of the neck and spine. With a fourth, put one first aider at the shoulders and another at the waist. Secondary survey A secondary survey follows the primary survey and any life-saving first aid. It is a step-by-step way of gathering information to form a complete picture of the casualty. In the secondary survey, the first aider is looking for injuries or illnesses that may not have been revealed in the primary survey. You should complete a secondary survey if: The casualty has more than one injury Medical help will be delayed for 20 minutes or more You will transport the casualty to medical help The secondary survey has four steps: History Vital signs Head-to-toe exam First aid for any injury or illness found History A SAMPLE history is used to gather a brief medical history of the casualty. This information may be useful for health care professionals who will continue to assist the casualty. If the casualty is unable to respond, some of the SAMPLE history could be answered by a close family member. S = symptoms - what the casualty is feeling (such as pain, nausea, weakness, etc.) A= allergies - any allergies, specifically allergies to medications M = medications - any medications or supplements they normally take, have taken in the past 24 hours, or any doses they may have missed P = past or present medical history - any medical history, especially if it is related to what they are experiencing now. Ask if they have medical alert information L = last meal - last meal they ate and when, anything else taken by mouth E = events leading to the incident - what was happening before the injury/illness? How did the injury occur? Vital signs There are four vital signs to check on the casualty Level of consciousness (LOC) Breathing Pulse Skin condition and temperature Check your applicable workplace legislation/ regulations Level of consciousness (LOC) A common method of obtaining a casualty's LOC is using the acronym AVPU. When using AVPU to indicate LOC, it is a scale which ranges from good (A), to not as good (V), to bad (P), to worse (U) A= Alert -An alert casualty will have their eyes open and will be able to answer simple questions. An alert casualty is oriented to person, place and time. V = Verbal - The casualty will respond when spoken to, but may not be able to effectively communicate. They may not be oriented to person, place or time. P = Pain - This casualty will only respond when a painful stimuli is delivered, such as pinching them or rubbing your knuckles on their sternum. They may move or make noise, but they will not communicate. U = Unresponsive - the unresponsive casualty will not respond to any stimulus. Please note that an alternative to quickly estimate a casualty's LOC is to evaluate their eye, verbal and motor skills. If their eyes are open, they can clearly speak, and obey a command such as "squeeze my fingers," they are alert Breathing To assess the breathing rate, watch the casualty closely for a total of 30 seconds. It is OK to place your hand on their upper abdomen to feel the rise and fall. Check the quality of the breathing. Carefully count each breath over the 30 seconds and multiply that number by two for breaths per minute. Pulse The pulse rate is the number of beats your heart takes in one minute, and it is an essential skill for assessing all casualties. The most common places to assess a pulse is at the wrist or neck, and for infants, the inside of the upper arm. To assess the pulse, use two fingers and gently place them on either the inside of the wrist Gust below the hand on the thumb side), or on the side of the neck (carotid artery), or for infants, the inside of the upper arm, on the brachia! artery. Press just gently enough to feel the pulse. You may have to feel around the area until you find it. Once you have found the pulse, count the number of beats over 30 seconds and multiply that number by two. Normal pulse rates Age Normal pulse range Infant 120-150 Child 80-150 Adult 60-100 Skin condition and temperature When assessing the skin we look for the temperature (warm or cold), the colour (normal skin tones or pale) and whether the skin is dry or wet. Use the back of your glloved hand to feel the casualty's forehead and cheeks. If their skin normal, they will have normal skin colour, and their skin will be warm and dry. If the skin is pale, cold and wet (sweaty), this could be an indication of shock. Head-to-toe exam The head-to-toe exam is a complete and detailed check of the casualty for any injuries that may have been missed during the rapid body survey. Do not examine for unlikely injuries. You may need to expose an area to check for injuries, but always respect the casualty's modesty and ensure you protect them from the cold. Only expose what you absolutely have to. Ask the casualty if they feel any pain before you start. Note any responses. Speak to the casualty throughout the process. Explain what you are checking for as you proceed. Always watch the casualty's face for any facial expressions that may indicate pain. Do not stop the exam. If you find an injury, note it and continue. Do not step over the casualty. If you need to, walk around them. During a detailed exam, you are looking for all bumps, bruises, scrapes, or anything that is not normal. If the casualty is unconscious, look for medic alert devices during your survey, such as a tag, bracelet, necklace, watch, or other indicator. Look, then feel Check the skull for anything abnormal Check the ears for fluid Check the eyes, are the pupils the same size? Check the nose for drainage Check the mouth, are the teeth intact? Are the lips blue or pale? Check the neck: Are the neck veins bulging? Is there a medical alert necklace? Check the collarbones Check the shoulders on both sides Check the arms: Check each arm completely Check the fingernails for circulation by squeezing and watching the blood return Ask the casualty to squeeze two of your fingers in both hands at the same time. Do they have an adequate strength and is the strength equal? Check the chest and under: Does it hurt the casualty to breathe? Does the chest rise and fall with breaths as it should? Reach around the back as far as you can With flat hands, check the abdomen carefully Do not push into the abdomen. Gently feel for pain, tenderness, or rigidity Place a flat hand on their abdomen and ask the casualty to push against it. Does this cause pain? Reach around the back as far as you can Check the pelvis: Place your hands on top of the pelvic bones and very gently squeeze for stability Check the legs, ankles, and feet: Check each leg completely one at a time Is one leg shorter than the other? Carefully check the stability of the kneecap and under the knee Squeeze or pinch a foot. Ask the casualty what you just did to see if they answer correctly. Place both hands on both feet. Ask the casualty to push and then pull against you. Feel for equal strength. Ask the casualty to wiggle their toes and watch for the response. Check circulation First aid for injuries found When you have completed your exam, give appropriate first aid for any injuries or illnesses found. If the casualty has more than one injury, give first aid to the more serious injuries first. Document Upon completion of the secondary survey, document your findings as accurately as possible. This information may be valuable to medical professionals who will continue to assist the casualty. Documentation is also important in a workplace emergency as it may be used as part of an investigation. Documentation of the incident and the first aid given should be completed on pre­ printed forms and maintained as required by provincial regulations/ legislation for reference by investigators. Ongoing casualty care Once first aid for injuries and illnesses that are not life threatening has been given: The first aider will hand over control of the scene to the casualty, or someone else, and end their involvement in the emergency The first aider will stay in control of the scene and wait for medical help to take over, or The first aider will stay in control of the scene and transport the casualty to medical help The first aid must maintain the casualty in the best possible condition until handover to medical help by: Giving first aid for shock Position the casualty based upon their condition Monitoring the casualty's condition Recording the events of the situation Reporting on what happened to whoever takes over Instruct a bystander to maintain manual support of the head and neck (if head/spinal injuries are suspected). Continue to steady and support manually, if needed. Recovery Position This position protects the casualty and also reduces bending and twisting of the spine. This position protects the airway if you must leave the casualty. Position the arm closest to you at 90 degrees in front of the casualty, keeping it out of the way when rolling them. Position the arm furthest from you on the casualty's chest. Bend the far knee. Reach behind the casualty's shoulder and roll casualty towards you by pulling on the far knee. Adjust the position of the arms and leg so the casualty is in a stable position. Place the far arm at 90 degrees to the casualty with the palm down. Give ongoing care. After the handover In first aid, we prepare ourselves to care for an injured or ill person. We don't often think about what happens after the casualty has left our care. Immediately following the handover of the casualty you may have a number of practical details to attend to. These details can include cleaning up after the emergency, correcting any unsafe conditions that caused the injury, or making a report on the incident and your involvement. Once these practical matters are out of the way, we expect things to "return to normal." However, you will likely find yourself thinking about the situation and the details of what happened while you were involved. Following a stressful event, many people review the details and try to evaluate what they did and how they could have done it better. This reviewing of the events is completely normal and you can expect it to happen. But if thoughts of the incident continue for many weeks, or if they affect your day-to-day life, you may be experiencing the negative effects of critical incident stress (CIS). Critical incident stress is a common reaction to a stressful emergency situation. The effects of CIS can interfere with your daily life-your job, your relationships, your peace of mind. If this happens to yourself, you need to do something about it, and help is readily available. Start by talking to your family doctor or a doctor at a walk-in clinic. A doctor will understand what you are going through and will suggest a course of action. The effects of critical incident stress can appear many weeks, months or years after the event. Shock Shock is a circulation problem where the body's tissues don't get enough oxygenated blood. Shock is a danger because any physical injury or illness can be accompanied by shock, and it can quickly progress into a life­ threatening condition. Pain, anxiety and fear do not cause shock, but they can make it worse, or make it progress faster. This is why reassuring a casualty and making them comfortable is important. Medical shock should not be confused with electrical shock or being shocked and surprised. Medical shock is life-threatening, as the brain and other organs cannot function properly. The following information provides some causes of shock. Severe shock can also result from medical emergencies such as diabetes, epilepsy, infection, poisoning or a drug overdose. *For casualties with dark skin colour, the colour changes may be observed in the following areas of the body: lips, gums and tongue, nail beds and palms, earlobes, membrane of the inner eyelid. The following actions will minimize shock: Give first aid for the injury or illness that caused the shock Reassure the casualty often Minimize pain by handling the casualty gently Loosen tight clothing at the neck, chest and waist Keep the casualty warm, but do not overheat- use jackets, coats or blankets if you have them Moisten the lips if the casualty complains of thirst. Don't give anything to eat or drink. If medical help is delayed many hours, give small amounts of water or clear fluids to drink- make a note of what was given and when Place the casualty in the best position for their condition Continue ongoing casualty care until handover The above first aid for shock may prevent shock from getting worse. Whenever possible, add these steps to any first aid you give. Positioning a casualty in shock Putting the casualty in the right position can slow the progress of shock and make the casualty more comfortable. The position you use depends on the casualty's condition. The casualty should be as comfortable as possible in the position you use. No suspected head/spinal injury; fully conscious Place the casualty on their back, if injuries permit. Once the casualty is positioned, cover them to preserve body heat, but do not overheat. No suspected head/spinal injury; less than fully conscious Place the casualty in the recovery position. When there is decreased level of consciousness, airway and breathing are the priority-the recovery position ensures an open airway. Conscious with a breathing emergency and/or chest pain If a conscious casualty is experiencing chest pain or is having difficulty breathing, have them sit in a semi-sitting position, or any position that makes breathing easier for them. Suspected head/spinal injury If you suspect a head or spinal injury, steady and support the casualty in the position found. This protects the head and spine from further injury. Monitor the ABCs closely. As injuries permit A casualty's injuries may not permit you to put them into the best position. Continue to support the head and neck and, if needed, use a head-tilt chin-lift to maintain the open airway. Always think of the casualty's comfort when choosing a position. Fainting Fainting is a temporary loss of consciousness caused by a shortage of oxygenated blood to the brain. Common causes of fainting include: Fear or anxiety Lack of fresh air Severe pain, injury or illness The sight of blood An underlying medical problem Fatigue or hunger Long periods of standing or sitting Overheating A person who has fainted is unconscious. Place them in recovery position to protect the airway and prevent possible choking. Place the casualty in a comfortable position as they regain consciousness. Ensure a supply of fresh air and loosen tight clothing at the neck, chest and waist. Make the casualty comfortable as consciousness returns and keep them lying down for 10 to 15 minutes. Continue to monitor breathing and consciousness. Do not assume a person has "just fainted," unless there is a quick recovery. If the recovery is not quick or complete, stay with the casualty until medical help takes over. If you have to leave to get medical help or you have to give first aid to other casualties, turn the casualty into the recovery position being as careful as you can if there are any injuries. Feeling faint or "impending faint" Sometimes when a person is about to faint, there are warning signs. The person: Is pale Is sweating Feels sick, nauseous, dizzy or unsteady First aid for an impending faint Place the casualty on their back. Ensure a supply of fresh air-open windows or doors. Loosen tight clothing at the neck, chest and waist. Stay with the casualty untill they has fully recovered. Decreased level of consciousness (LOC) Consciousness refers to the level of awareness one has of themselves and their surroundings. There are different levels of consciousness ranging from completely conscious to completely unconscious. Many injuries/illnesses can cause changes in a casualty's level of consciousness, including: A breathing emergency A heart attack A head injury Poisoning Shock Alcohol or drug abuse Medical condition (epilepsy, diabetes, etc.) Semi-consciousness and unconsciousness are breathing emergencies for casualties lying on their back, because the tongue may fall to the back of the throat and block the airway. Saliva and other fluids can also pool at the back of the throat and choke the person. A progressive loss of consciousness means the casualty's condition is getting worse. Always monitor a casualty's level of consciousness and note any changes. A first aider can use the acronym AVPU (alert, verbal, pain, unresponsive) to assess and describe levels of consciousness. Decreased consciousness is always an urgent situation. The person can quickly become unconscious, and this is a breathing emergency. When you recognize decreased consciousness, get medical help as quickly as possible. First aid for unconsciousness Start ESM. Perform a scene survey. Call or send for medical help as soon as unresponsiveness is determined. Do a primary survey. Do a secondary survey if necessary. Turn the casualty into the recovery position, if injuries permit. Give ongoing care. If injuries make it necessary for the casualty to be face up, monitor breathing continuously. If necessary, hold the airway open. Always ensure an open airway. Loosen tight clothing at the neck, chest and waist, and continue ongoing casualty care until handover. Record any changes in level of consciousness and when they happen. A decreased level of consciousness also requires urgent medical help. Multiple casualty management (triage) The process of making decisions at an emergency scene where multiple people are injured is called triage. In triage, first aiders quickly examine all casualties and place them in order of greatest need for first aid and for transportation. The idea is to do the most good for the greatest number of casualties. Casualties are categorized into three levels of priority: Highest priority-casualties whoneed immediate first aid and transportation to medical help Medium priority-casualties whoprobably can wait one hour for medical help without risk to their lives Lowest priority-casualties who can wait and receive first aid and transportation last, or casualties who are obviously dead Note: in the event of a lightning strike, where more than one person is injured, the principles of multiple casualty management are reversed. Give first aid to unresponsive non-breathing casualties since the casualties that are still breathing are recovering. Begin ESM Determine how many casualties there are in the scene survey. Start with the nearest casualty, and move outward Do a primary survey Give first aid for life-threatening injuries If the person is obviously dead, go to the next nearest casualty Repeat step 2 for each casualty Always move to the next nearest casualty Categorize Decide which casualties have the highest priority, second priority, and lowest priority. Arrange transportation Arrange for the highest priority casualties to be transported to medical help as soon as possible Perform secondary survey Begin with the highest priority. Give appropriate first aid, and move on Give ongoing care for each casualty until transported In a multiple casualty situation, constantly assess the casualties and the situation and make changes to priorities. Lifting and moving Always try to give necessary first aid where the casualty is found, then wait for the paramedics to move the person. However, there are times when this is not possible. You may have to move a casualty when: There are life-threatening hazards to yourself or the casualty e.g. danger from fire, explosion, gas or water Essential first aid for wounds or other conditions cannot be given in the casualty's present position or location The casualty must be transported to a medical facility If life-threatening hazards make it necessary to move a casualty right away, you may need to use a rescue carry. In urgent and dangerous situations where casualties are moved with less than ideal support for injuries, the casualty's injuries may be made worse by improper movement and handling. The chance of further injury can be reduced with proper rescue carry techniques. Always move the casualty the shortest possible distance to safety and to provide essential first aid. Use bystanders to help you and support any injuries the best you can during the move. Keep the risks to the casualty, yourself and others to a minimum. Rolling Cots {Stretchers) If your workplace uses rolling cots to transport injured workers, it is crucial that you have proper training on how to operate and handle the cot before you use it. Failure can result in the cot tipping or dropping, and causing further injury. Occupational Hazards When working in and around occupational hazards such as confined spaces, trenches, machinery, and hazardous gases, workers should know the proper response protocols. Ensure you have the appropriate training for the type or rescue you will be undertaking as well as the proper equipment to keep yourself safe while rescuing another worker. In some locations, a helicopter may be sent to transport an injured worker to hospital. Anyone working around helicopters should have proper training and everyone should follow these guidelines: Never approach without permission of the pilot or crew chief Always follow directions from the pilot or crew chief on from which direction to approach the aircraft Know the restricted and danger areas around the aircraft and remain outside these areas unless you need to enter The tail and tail-rotor of the helicopter poses a significant danger and should be avoided Transporting a casualty Generally speaking, first aid providers will not transport casualties to the hospital, leaving that to ambulances. However, there are instances where you may choose to transport someone to the hospital yourself. The injuries are minor and the casualty is stable The response time for EMS to arrive is prohibitively long (i.e. remote areas) If the above conditions are met, and the casualty is a family member or close friend-do nottransport strangers to the hospital in your own vehicle whenever possible Care during transport Every effort must be taken to ensure that injuries are not made worse while transporting a casualty to a medical facility. Take steps to keep the casualty comfortable and in a position that will not cause unneeded movement of injured limbs. Have another person accompany you to monitor the casualty if possible. Do not drive fast. If a casualty needs to be transported quickly, an ambulance should be called. Follow all local traffic laws. Find the smoothest route possible to make the ride as comfortable as possible. Meeting an ambulance crew enroute Some work locations are isolated and response times of EMS are extended. In these instances, where provincial regulations permit, casualties can be transported toward medical help with the plan to meet an ambulance part way. When selecting a meeting point, be sure the location is clear to both sides and it is easily found. Identify any landmarks or businesses that can aid in finding the location. In the event you arrive before the ambulance, contact EMS and get an update on the ambulance location before moving the meeting location. Lifting techniques and proper body mechanics Moving any casualty from an emergency scene poses dangers to the rescuer as well as the casualty. If the casualty must be moved, select the method that will pose the least risk to the casualty and to you. You can be of little help to a casualty if you injure yourself in the rescue. Using incorrect body mechanics in lifting or moving a casualty may leave the rescuer suffering muscle strains. Use the following lifting guidelines: Stand close to the object to be lifted. Bend your knees, not your waist. Tilt the object so that you can put one hand under the edge or corner closest to you. Place your other hand under the opposite side or corner, getting a good grip on the object. Use your leg muscles to lift, and keep your back straight. When turning, turn your feet first; don't twist your body. When lowering the object, reverse the procedure. Rescue carries A rescue carry is an emergency method of moving a casualty over a short distance to safety, shelter or to transportation. Select the type of carry based on the circumstances. The size and weight of the casualty relative to the rescuer The number of rescuers available to assist The type of injury The distance to move the casualty Whenever possible, ask one or more bystanders to help you. When help is available: Remain with the casualty Give instructions to the bystanders about what to do and what safety precautions to take Fully coordinate the rescue activities Drag carry This carry is used by the single rescuer to drag a casualty who is either lying on their back or in a sitting position. The drag carry provides maximum protection to the head and neck, and therefore should be used when you are moving a casualty with this type of lnJUry. If time permits, tie the casualty's wrists together across their chest before dragging. To perform a drag carry: Stand at the casualty's head facing their feet. Crouch down and ease your hands under the casualty's shoulders. Grasp the clothing on each side. Support the casualty's head between your forearms to stop movement. Drag the casualty backward only as far as necessary for their safety. As an alternate method, the first aider and drag the casualty. Because of the risk of aggravating any injuries, only use drag carries in the most extreme cases when there is an immediate threat to life. Human crutch If a leg or foot is injured, help the casualty to walk on their good leg while you give support to the injured side. Take the weight of the casualty's injured side on your shoulders by placing the casualty's arm (on the injured side) around your neck and grasping the wrist firmly. Reach around the casualty's back with your free hand, and grasp the clothing at the waist. Tell the casualty to step off with you, each using the inside foot. This lets you, the rescuer; take the casualty's weight on the injured side. Chair carry The chair carry enables two rescuers to carry a conscious or unconscious casualty through narrow passages and up and down stairs. Do not use this carry for casualties with suspected neck or back injuries. Specially designed rescue chairs are available and should be used for this type of carry. If the casualty is unconscious or helpless: Place an unconscious casualty on a chair by sliding the back of the chair under their legs and buttocks, and along the lower back. Strap their upper body and arms to the back of the chair. Two rescuers carry the chair, one at the front and one at the back. The rescuer at the back crouches and grasps the back of the chair, while the rescuer at the front crouches between the casualty's knees and grasps the front chair legs near the floor. The rescuers walk out-of-step. Going down stairs The casualty faces forward The front rescuer faces the casualty A third person should act as a guide and support the front rescuer in case they lose their footing Extremity carry Use the extremity carry when you don't have a chair and do not suspect fractures of the trunk, head, or spine. One rescuer passes their hands under the casualty's armpits, and grasps the casualty's wrists, crossing them over their chest. The second rescuer crouches with their back between the casualty's knees and grasps each leg just above the knee. The rescuers step off on opposite feet-walking out-of-step is smoother for the casualty. Blanket lift with four bearers Roll the blanket or rug lengthwise for half its width. Position bearers at the head and feet to keep the head, neck and body in line. Place the rolled edge along the casualty's injured side. Kneel at the casualty's shoulder and position another bearer at the waist to help log-roll the casualty onto the uninjured side. Turn the casualty as a unit so the casualty's body is not twisted. Roll the casualty back over the blanket roll to lay face up on the blanket. Unroll the blanket and then roll the edges of the blanket to each side of the casualty. Get ready to lift the casualty-have the bearers grip the rolls at the head and shoulders, and at the hip and legs. Keep the blanket tight as the casualty is lifted and placed on the stretcher. Before using a blanket, test it to ensure that it will carry the casualty's weight. Do not use this lift if neck or back injuries are suspected. Stretchers There may be times when medical help cannot be contacted, or for other reasons, cannot come to the scene. When this happens, transport the casualty to medical help. If the casualty can't walk, or if the injury or illness allows only the gentlest movement, a stretcher should be used. Principles for stretcher use Complete all essential first aid and immobilization before moving the casualty onto a stretcher. Bring the blanketed and padded stretcher to the casualty, rather than moving the casualty to the stretcher. As the first aider in charge, take the position that permits you to watch and control the most sensitive area of the body, usually at the head and shoulders, or the injured part. Tell the bearers what each is expected to do. If the move is difficult, and time permits, it's a good idea to practice with a simulated casualty. This reduces risks and reassures the conscious casualty. Test an improvised stretcher with someone equal to or heavier than the casualty to ensure that it will hold. Check the clearance of an improvised stretcher to ensure that it will pass through hallways, doors and stairways without harm to the casualty. Use clear commands to ensure smooth, coordinated movements. Commercial stretchers The most common of the commercial stretchers is the rigid-pole, canvas stretcher. It has hinged bracing bars at right angles between the rigid poles at either end that must be locked in the extended position before the stretcher is used. Improvised stretchers If a commercially prepared stretcher is not available, you can improvise one by using two rigid poles and a blanket, clothing or grain sacks. Do not use non-rigid stretchers for casualties with suspected head or spinal injuries. Improvised blanket stretcher Place the blanket flat on the ground and place a pole one­ third of the way from one end. Fold the one-third length of blanket over the pole. Place the second pole parallel to the first so that it is on the doubled part of the blanket, about 15 cm (6 inches) from the doubled edge. Fold the remaining blanket over the two poles. The casualty's weight on the blanket holds the folds in place. Improvised jacket stretcher A non-rigid stretcher can also be improvised from two jackets and two or four poles. Button and zipper the jackets closed and pull the sleeves inside out so that the sleeves are inside. Lay the jackets on the ground so that the top edge of one jacket meets the bottom edge of the other. Pass the poles through the sleeves of the two jackets on either side to complete the stretcher. If the casualty is tall, prepare another jacket as before and add it to the stretcher with the head of the jacket towards the middle. All bearers kneel on their left knees, three on one side of the casualty and one on the other, as shown below. Bearer 4 helps in lifting and lowering the casualty, and also places the stretcher under the casualty. Bearer 4 joins hands with bearers 1 and 2. When assured that each bearer has a firm hold on the casualty, bearer 1 directs the others to "Get ready to lift" andthen gives the command "Lift." Lift the casualty smoothly to the height of the raised knees. On bearer 1's command "Rest," the casualty is gently laid on the raised knees of bearers 1, 2 and 3. Bearer 1 tells bearer 4 to position the stretcher. Bearer 4 then resumes their position supporting the casualty by linking their hands with one from each of bearers 1 and 2. Position the stretcher. When everyone is in position, bearer 1 instructs the team to, "Get ready to lower" and then, "lower." The team lowers the casualty gently onto the stretcher. Secure the casualty to the stretcher. Three-bearer method, no blanket The three-bearer method is essentially the same as the four-bearer method, except the first aider and one bearer share the weight on one side of the casualty. The third bearer links hands with the first aider from the opposite side to take up the weight of the trunk. The casualty is lifted and rested on the bearers' knees while the stretcher is positioned and bearer 3 links hands again with the first aider to help lower the casualty to the stretcher. Carrying a stretcher A stretcher should be carried by four bearers. As the first aider in charge, decide on the carrying method and give clear instructions to the bearers. After the casualty has been strapped to the stretcher, position yourself so you can watch the casualty and at the same time give direction to the other bearers. Assign the remaining bearers (depending whether you are two or four) to respective corners or ends of the stretcher. Bearers crouch by the carrying handles of the stretcher, facing in the direction of travel. When the bearers have a firm footing and a good grip on the stretcher, give the command, "Get ready to lift," and then, "Lift." Ask the bearers if they are ready. When they are, give the command, "Go forward." When it is necessary to stop, give the commands "Stop," Get ready to lower," and then, "Lower." To ensure the smoothest carry for the casualty: Four bearers carrying a stretcher step off together on the foot nearest the stretcher and keep in step Two bearers step off on opposite feet and walk out-of-step Although stretcher casualties are usually carried feet first, certain conditions call for a head-first carry: Leg injuries during a long downhill carry or when descending stairs, a head-first carry decreases pressure on the lower limbs and minimizes discomfort Uphill carries and going up stairs if there are no injuries to the legs-a head-first carry decreases blood flow to the casualty's head and is more comfortable Loading an ambulance or transferring the casualty to a bed-it is safer to do this head first, and easier to watch the casualty Obstacles When crossing uneven ground, a stretcher should be carried by four bearers and kept as level as possible. Bearers must adjust the height of the stretcher to compensate for dips and rises in the terrain. Crossing a wall Avoid crossing a wall, even if it means a longer carry. Where a wall must be crossed, follow these steps: Lift the stretcher onto the wall so that the front handles are just over it. The rear bearers hold the stretcher level while the front bearers cross the wall. All lift together and the stretcher is moved forward until the rear handles rest on the wall. The front bearers hold the stretcher level until the rear bearers have crossed the wall and resumed their positions at the rear of the stretcher. The stretcher is then lowered to continue the journey. Extrication Extrication is the process of freeing casualties who are trapped or entangled in a vehicle or collapsed structure and cannot free themselves. Provide as much support as possible to the casualty during extrication. Whenever possible, give essential first aid and immobilize the injuries before the casualty is moved. When there is an immediate danger and you are alone and must move a casualty from a vehicle, proceed as follows: If necessary, disentangle the person's feet from the vehicle and bring the feet toward the exit. Ease your forearm under the person's armpit on the exit side, extending your hand to support the chin. Ease the person's head gently backward to rest on your shoulder while keeping the neck as rigid as possible. Ease your other forearm under the armpit on the opposite side and hold the wrist of the casualty's arm which is nearest the exit. Establish a firm footing and swing around with the person, keeping as much rigidity in the neck as possible. Drag the casualty from the vehicle to a safe distance with as little twisting as possible.