EMT & Wilderness First Responder Basics

How Rescue Swimmers Save Lives

21 November 2022 | By RSM Vince

EMT & WFR Basics

The purpose of this blog is to briefly encapsulate the basic patient assessment skills used by Helicopter Rescue Swimmers, Emergency Medical Technicians (EMT) and Wilderness First Responder (WFR) professionals.

I want to thank Matthew Smith at Canadian Outdoor Medical Consulting in Squamish, BC as my WFR recertifying instructor and for providing some of this information and flow-charts.

The purpose of the skills learned in first responder qualifications is never to provide definitive treatment. It is rather an attempt to slow down the process of life-threatening injuries/diseases and keep a patient as stable as possible in the interim of more definitive care.

WARNING:

Though I have been a Nationally Registered EMT for 8 years now and a Wilderness First Responder for nearly 5, I am NOT a certified instructor of these skills. The intent of this article is to, briefly, while employing my own personal KISS model (Keep It Simple Stupid), give readers a general understanding of the basic steps a first responder goes through while assessing a patient. A proper certified course should be taken before providing any medical care to anyone.

We don't do it for the money.
We don't do it to get paid.
We don't do it for the glory.
But for the life that might be saved.

Scene Size-Up

H – HAZARDS (PPE):

Before rushing to help someone, stop, take a deep breath, and ask yourself:
“What can hurt me?”, “Is there avalanche danger above me?”, “Could a car hit me?” “What can I do to make things safe for me?”
Next, ask yourself:
“How can I best protect myself from the patient?” At minimum, one should wear surgical gloves. But eye protection and a mask can also be wise pieces of Personal Protective Equipment (PPE) to protect yourself from bodily substances and communicable diseases.

E – Environment: “Is there a storm coming?”, “How far are we from definitive care?”, “How long would it take for additional rescue resources to assist?, “What time of day is it?”, “Are temperatures dropping?”

M – Mechanism of Injury (MOI): “What happened?”, “Is this a medical or trauma-based problem?”, “What was their speed of travel, height, surface landed on, part of body landed on? Did this person fall walking in soft snow? Or did they fall off a 30ft cliff, going 50mph into rock debris on their head?”.

Note: One of the main reasons this is important is because it gets us thinking about whether or not this patient may have a spinal injury which we should immobilize (though this is not the priority just yet).

P – Patient(s):

“How many people are there?”

Note: It’s easy to get side tracked when approaching a scene. In fact, 50% of my Helicopter Rescue Swimmer class failed because they didn’t attend to the conscious drowning patients first by giving them flotation. Instead, they got tunnel vision and went directly to the unconscious, partially submerged, spinal-injured patient while letting the other victims drown.

As a ski patroller, I recall an incident where recreational skiers got swept by an avalanche. Everyone focused on digging out and attempting to resuscitate a 10ft buried unconscious skier (who was ultimately already deceased) and missed a, likely still alive, skier 15yds away. The skier was barely buried below the snow and may have ultimately survived if attended to in time.

helicopter rescue swimmer medical skills

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Push, Pull Prevent:
- Push: IMMEDIATELY apply SIGNIFICANT direct pressure to deadly bleeds (mainly arterial bleeds which either squirt or bleed profusely. Typically, bright red in color). If direct pressure doesn’t stop the bleeding, apply a tourniquet.
- Pull: Pull a patient away from a situation compromising their airway (eg. underwater, head down in snow).
- Prevent: Prevent the patient from drowning, falling, being swept away, etc.
Consciousness and Consent:
- Consciousness: Take a moment when approaching to recognize a patient's level of consciousness.
- Consent: Ask if it is ok for you to help them (if patient is a minor, ask a legal guardian).

Primary Assessment

A - AIRWAY:

Breathing is obviously crucial to our survival. That said, to breath effectively, our mouth or nose must, of course, be clear. So, Step 1 is to check for a patent airway. If the patient is unconscious, the following 3 methods can be used:

Head Tilt/Chin Lift: This is the most effective and easiest method of opening an airway. It is performed by tilting the patient's head back. This movement alone tends to open the airway, but additionally, the jaw can be lifted then opened by pressing down on the chin.
Jaw Thrust: If you suspect a spinal injury, a jaw thrust can be attempted instead of the head tilt by pulling up on the bend of the jaw with the index and middle finger and pushing the chin down with the thumbs.
Recovery Position: If a patient is vomiting, roll them to their side.

If the airway is obstructed, do your best to clear it, ideally using a suction tool, if not available, using fingers to sweep away any shallow obstructions but be cautious not to push the blockage deeper down the patient’s airway.

B - BREATHING:

Look, listen, and feel: Does their breathing sound labored? Is their chest rising and falling without strain? Put your hands on their chest and feel as they inhale and exhale.
Expose chest injuries: If something seems off, check their chest for any signs of bruising, deformities or bleeding.

If the patient is not breathing, give two slow, even breaths, then check for a pulse.

C - CIRCULATION:

Pulse: Check for the presence or absence of a pulse at the neck for at least 10 seconds (middle and index finger over carotid artery).
Note: Pulses can be hard to find even for trained professionals, so it is best to practice before emergencies.
Major Bleeding: Look and sweep your hands over and under the patient to check for severe bleeding. Control life-threatening bleeding by applying pressure. If SIGNIFICANT direct pressure does not stop the bleeding, a tourniquet should be administered at least 2 inches above the bleed but not on a joint.

If there is no pulse, start CPR. If there is a pulse but no breathing, start rescue breathing.

CPR: Briefly, CPR on an adult is provided by stacking both palms over a patient’s sternum (generally between nipples) and providing 30 compressions at a rhythm of 100-120 pumps per minute. Then providing 2 rescue breaths with an open airway (described above). Watch for a chest rise and fall. Then repeat the process. If an AED is available, try to get someone to go get it. Apply AED when 2min of CPR has been administered. CPR should not be stopped until higher care deems it fit.

D - DISABILITY:

Level of Consciousness:

Generally, Wilderness Responders use the AVPU scale to assess a patients level of consciousness:

- A – Awake and Alert: Patient responds to questions and answers appropriately.
  - Person: What’s your name?
  - Place: Where are you?
  - Event: What happened?
  - Time: What day of the week is it?

If all questions are answered appropriately, our patient is Alert and Aware times four (A&Ox4).

- V – Verbal: Patient responds to verbal stimuli (eg. you scream: “HEY!”, or clap your hands loudly) with incomprehensible sounds or movements.
- P – Pain: Patient responds to painful stimuli (sternum rub with knuckles or trap muscle pinch) by making incomprehensible sounds or movement.
- U – Unconscious/Unresponsive: No response to either verbal or painful stimuli.

Once this is assessed, we can label our patient on the AVPU scale. Eg. “Our patient is A on the AVPU scale and A&Ox4.” This should later be reported to SAR, ambulance services or the hospital.

Spinal Restriction:

At this point, based on the Mechanism of Injury and our patient's level of consciousness, we should make a decision on whether or not our patient’s spine should be stabilized. If so, we should have someone, or objects, keep the patient’s head in an in-line and neutral position with the rest of the spine.

Note: Recent research has proved that spinal injuries are almost always caused by the initial impact and are rarely severely worsened with inadequate spinal immobilization by first responders post-injury. Nevertheless, it is best to air on the side of caution and limit spinal movement before making any further assessment.

E - EXPOSURE:

Expose/ Treat Major Injuries: At this point, the chest should have already been visually examined and a quick body blood sweep performed, but if the patient is say, complaining of pain in their leg, try to expose the injury to make sure no immediate treatment is necessary (eg. major bleeding).
Exposure to Environment: Is our patient susceptible to extreme temperatures? If so, either keep them warm (blankets, heat pads, removing them from water/snow). If susceptible to heat emergencies, keep them cool (eg. removing them from the sun). In cold environments, our bodies can lose their ability to thermal regulate, which may speed up the shock process.

Note: Avoid rapid heating or cooling (eg. Hot tub or ice bath).

Unstable or Stable?

At this point, we should have a general understanding about whether or not our patient is stable or not.

Here are a few examples of an Unstable Patient:

Major loss of blood
Obstructed airway
Trouble breathing
Cardiac arrest
Signs of shock
Abdominal Pains/Deformities
Pelvis Pain/Fractures
Femur/Humerus Fractures
Decreased level of consciousness

Call for Help or Continue Assessing

If unstable, now is likely the time to call for additional resources if available and to provide them with all the findings we have found so far. Things that should be communicated are:

S – Subjective: What happened and what is the patient complaining of?

O – Objective: What have we found?

A – Assessment: What are all the problems we’ve found and vitals?

P – Plan: What is our treatment plan? What resources/equipment do we need? How quickly do we need them?

Secondary Assessment

Once we’ve attended to the major life-threatening emergencies of the primary assessment, we should move forward with what else MIGHT be happening with our patient to discover any more potentially useful clues or information.

PHYSICAL EXAM:

A head-to-toe examination should be performed, especially with patients who’s injuries are trauma based. Generally, you are assessing whether body parts that should be hard are hard (eg. skull), and things that should be squishy are squishy (eg. stomach). Here is a brief list of some things to check for:

Skull: Palpate (firmly press) all around the skull for any crepitus.
Eyes: Check that the pupils are equal and reactive to light. Check that there’s no bruising around the eye (typically present hours after a brain injury).
Ears: Check for bleeding or fluid leaking from the ears (could signify a brain injury).
Throat: Check that the throat is not deformed or out of line.
Neck & Shoulders: Palpate the neck and shoulders, note if there’s pain or crepitus.
Chest: Palpate the chest in all four quadrants as the patient exhales and inhales. Notice deformities.
Arms: Feel and press along both the arms. Have the patient squeeze your fingers with both hands at the same time. Notice if their squeeze is strong and equal. Check their brachial pulse on both wrists. Check their capillary refill on each hand (done by squeezing the finger nail and releasing. The nail should go white and return to red within 2 seconds if proper circulation is present). If these tests prove od, or unsuccessful, suspect a potential spinal injury.
Abdomen: Same as the chest except it should feel squishy.
Pelvis: Squeeze the patient pelvis, take note of any crepitus or pain.
Legs: Feel and press along both legs.
Feet: Check for a petal pulse on both feet. Without the patient looking, squeeze one toe on each foot and ask them which toe you are grabbing. Check the capillary refill. If these tests prove od, or unsuccessful, suspect a potential spinal injury.

MEDICAL HISTORY:

A medical assessment should be completed regardless of whether or not any trauma occurred. EMT’s and Wilderness Responders both use the SAMPLE acronym to help them assess the patient with the proper questions:

S – Symptoms:

               O – Onset of the Event: “What were you doing when the symptoms started?”
               P – Provocation: “Does anything (activity, body positioning, medication) that makes it feel better or worse?”
               Q – Quality: “Could you describe the pain to me?” ...you are looking for adjectives like shooting, crushing, sharp, burning, aching, dull, or throbbing, but do not feed them the adjective, let THEM describe it.
               R – Radiation: “Is the pain localized or does it radiate/hurt anywhere else?”
               S – Severity: “Can you describe the pain on a scale of 0 – 10, 0 being no pain, 10 being the worst pain imaginable?”
               T – Time: “When did the pain start? Did it happen suddenly or did it build? Has this happened before?

A – Allergies:

“Are you allergic to anything? Medication? Insects? Food? Pollen?”

M – Medications:

“Have you taken any prescriptions, over-the-counter or recreational drugs in the past 48hrs?...I'm not a cop, my only concern is your health." If not, "should you be on any medication?"

P– Past Medical History:

“Has this happened before? Have you had any prior relevant surgery? Does something like this run in your family?"

L – Last Oral Intake:

“When/what did you eat last? Have you felt nauseous or vomited? What were your last pees, and poops like?"

E – Events:
"What were you doing when/before you started to feel this way?"

VITAL SIGNS:

Level of Consciousness (LOC): Explained above.
Temperature: If a thermometer is not available, place the back of your palm directly on the patient’s belly. It should be pink, warm and dry. If it is white, cool and clammy, this could be a sign of shock.
Respirations: How many breaths are they taking per minute? An average adult at rest should have 12-20 breaths per minute.
Pulse: Check their brachial pulse. An average adult at rest should have a pulse of 60-100 beats per minute.
Blood Pressure: If a BP cuff is available, use it and note the systolic and diastolic pulse.
Oxygen Saturation (optional): Ideally assessed with a Pulse Oximeter. If not, check the capillary refill (described above).

Ongoing Assessment

Reassess: It is important to continually reassess the patient and their vitals, as frequently as every 5min if unstable. If stable, every 15min.
Treatment: Though I will not dive into the bajillion field treatments a first responder can provide to a patient, note that our resources and scope of practice is limited. Again, our main objective is to treat major injuries/disabilities in the interim of more definitive care. This usually comes in the form of:
- Stopping bleeds (applying pressure and dressing).
- Stabilizing fractures (with splints, triangle bandages, etc).
- Maintaining Spinal Immobilization (with c-collar, backboard, etc).
- Administering oxygen.
- Helping patients take their own medication.
Documentation: It is important to document your findings for yourself, as well as for the further care you pass your patient on to. It is also your liability protection as a responder to prove the proper care you provided.
Transport: Is the patient safe to walk out? Can we carry them out? Is it urgent? Do they need a helicopter? Is this safe and realistic for the rescuers?

In conclusion, though it is imperative to have this general step-by-step process in the back of your head (to avoid missing potentially life-threatening factors in moments of high stress), do not forget to use your common sense. It's worth noting that your patient often knows what their body needs better than you ever will, so communicate, ask questions and make them your ally as you provide them with the help they need.

Rescue Swimmer Mindset

Podcast

Listen as RSM Vince and Cody breakdown the step-by-step process of approaching and dealing with a real medical emergency as a Coast Helicopter Rescue Swimmer, and as a Wilderness First Responder.

In this episode you'll learn the full EMT patient assessment, from the scene size-up to the primary assessment and all the way to the patient treatment.

Audio Podcast

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RSM Vince

RSM Owner | Instructor | Nationally Registered Wilderness EMT