Suddenly there is an explosion—an accident, a bomb, a malfunction—and there are 50 people wounded, dead, or dying in the room with you. Some have lost limbs and are bleeding profusely, others have been knocked unconscious, others have been eviscerated and their intestines, looking like pink cauliflower, are hanging out of their stomachs. Some people near the windows have punctured lungs from the shattered glass, others have awful wild burns. One woman's eye has come out of her socket and is dangling on her cheek, and another man has a metal pipe lodged through his stomach.
You are fine or have minor injuries. What do you do? What do you do first?
This month I went to an all-day emergency medical training course at the U.S. Consulate here in Montreal. I learned what to do for these situations in a systematic way designed to save as many lives as possible. And frankly, it gave me much more confidence that during an emergency, I could actually help instead of standing there helplessly.
You are fine or have minor injuries. What do you do? What do you do first?
This month I went to an all-day emergency medical training course at the U.S. Consulate here in Montreal. I learned what to do for these situations in a systematic way designed to save as many lives as possible. And frankly, it gave me much more confidence that during an emergency, I could actually help instead of standing there helplessly.
Our instructor, Lynda Graham, has seen and responded to many tragedies. She was one of the responders for U.S. Embassy bombings in Nairobi and Beirut, as well as receiving injured people flying in from places where the help they needed wasn't there. She still responds with her team, but they also do outreach classes at embassies and consulates all over the world. She told the most incredible stories, and she has my complete respect and admiration.
We learned M.A.R.C.H., a system of triage to help as many people as possible according to the severity of their injuries:
M - Massive hemorrhage
A - Airway management
R - Respiration (chest injuries)
C - Circulation
H - Hypothermia and Head and neck injuries
Massive Hemorrhage
When we talked about lost limbs and tourniquets, it de-mystified and de-sensationalized (well, at least a little—I still became lightheaded) what happens when a limb is lost. Applying a tourniquet is a serious thing—the living tissue in the limb starts dying after 4–5 minutes, and untying the tourniquet all at once can release built-up poisons and enzymes that can result in anaphylactic shock and death—but it can prevent the person from losing all their blood and dying. We practiced applying tourniquets in less than 20 seconds, because arterial cuts are deadly and the more bleeding people you can patch up quickly and efficiently, the better. Neckties, bras, pantyhose (anything about 2 inches wide) can be used for a tourniquet, and the windlass (what tightens the cloth) can be a chair leg, utensils, scissors, a metal tube.
Lynda said that clothing can be useful in all sorts of ways when there is an emergency; the way she figures, everybody will be naked but at least they'll be alive. I learned how to apply a tourniquet to my own arm if it gets blown off (and bandage and put pressure on the stump). Just thinking practically about the idea reduces the fear of such a terrible situation.
Airway
After the massive hemorrhage cases (which is different than lesser wounds that bleed—"you'll know the difference when you see it," Lynda said), you look for the people who are not breathing and you put them in a "position of comfort"—on their side, neck extended so they will have room if they vomit. Do CPR if needed.
Respiration
Then you treat chest injuries. Since lungs are like balloons, if they are punctured they will deflate, and the space that they used to take up will fill up with 1) air from the outside (from the hole where the glass or the bullet entered), 2) blood, 3) body fluids, and 4) air escaping from the lung as the body tries to breathe the normal way. You can only do something about the first, so that's what you can fix. Get down to the bare skin, find the hole (look for both entrance wounds and exit wounds). Create an air-tight seal. If there's nothing else, you can lick your hand and put it over the wound. (!!!) If you are awesome like MacGyver, my hero, and have duct tape, put two strips like a cross over the hole. You can also use foil, cellophane, credit cards, and bandages, and make one side sticky with chapstick or makeup if you don't have tape so it will stick to the skin. If you see pink, frothy blood on their lips, you know that it is a chest injury. (Other symptoms are belabored breathing, blue lips, but the pink, frothy blood is the certain sign.)
Because the lung is still filling up with the other stuff, from time to time you may have to "burp" the person—undo the dressing and let the blood and fluid geyser out. Clean it, then have the person breathe all the way out and then seal the hole up again. If the person is dotted with wounds like this, you may have to burp every single wound, one at a time. You can tell you need to burp the wound if the person starts getting very anxious, has difficulty breathing, and experiences additional chest pain or tightness in the chest (tension pneumothorax). The more severe the chest injury, the sooner you will have to burp the person.
Circulation
These are the cases where there are bleeds that don't require tourniquets. Apply direct pressure. It takes 3-5 minutes for blood to clot, so time is needed. Use clothing for bandages, but make sure that you roll it in a way that doesn't become a tourniquet. You will be faster and create a better bandage if the unrollling part of the rolled-up bandage is nearest to the skin of the patient. Don't remove the bandage if blood seeps through; apply another bandage on top. If it seeps through again, you may have to use a tourniquet. For cavernous wounds, put gauze or cloth in the depression and bandage over it. If there are clean bandages, great; but if not, use what you have.
Because shock is also a circulation problem, you treat others for shock. Shock is not like being astonished. It's a medical condition where all the blood in the vessels can only constrict for so long in response to an emergency, and suddenly all the blood goes to the extremities instead of the core. Shock can occur from about 20 minutes to 20 hours after the injury. To treat shock:
1 Control bleeding
2 Allay anxiety
3 Alleviate pain
4 Don't elevate the feet or the legs anymore—this has changed
5 Give oxygen
6 Maintain warmth (wrap them up like a burrito in a blanket)
Remember that people get ugly when they panic. Don't slap people, like you see in the movies. Use calm, direct, simple words. One guy at the scene of a car accident had his femur hanging out and he refused to get off the cell phone (he was calling his insurance company and babbling) so Lynda could treat him. Shock.
Hypothermia/Head and Neck Injuries
If the core of the body changes four degrees, it can kill you. Raise the temperature of the body slowly; otherwise the heart can stop.
Head trauma—when the brain jiggles in the cerebral spinal fluid and gets bruised. These injuries are hard to assess because it depends on what part of the brain was bruised and how deeply it was bruised. People with head trauma have moist ears (which is impossible to tell for sure, particularly if you in an African jungle at night and it's raining). If they are hit in the back of the head and the brain was bruised in the front, the person will have broken blood vessels behind the eyes and look like a raccoon from the bruising, although it takes a little while for the bruising to show. If the hit was in the front, there will be bruises behind the ears. People will often vomit because they experience vertigo from the brain sloshing back and forth. They can have unequal pupil sizes since one side of the brain is swelling. We saw the saddest picture of a baby with bruises around the eyes from Shaken Baby Syndrome.
Block and cushion the head all around it to let others—and the person—know that they need to keep still. It's okay to let them sleep, but wake them up every hour and ask what their name is (long-term memory), what the day is (short-term memory), and if they can perform a small task like tying a shoelace (specific information). If the scalp is bleeding, don't clean it—pull the edges together and duct tape it.
Neck injuries—put the person flat on a door or a tabletop. If they can't feel their legs, don't write them off—the next 48 hours will tell how bad the injury is.
Burns
We also talked about burns—run cool tap water for 15 minutes over 1st degree burns. DON'T remove clothing since it could take off the skin. Then put some remedy—people use lots of different types: aloe vera, onions, tomatoes, sour cream, egg whites, peppermint toothpaste. Never use ice, as it will burn it more.
For 2nd degree burns, with open, weeping wounds from blood plasma, the nerve layer can be exposed and be excruciatingly painful. Use the cleanest thing you have—stay away from anything fuzzy, and pat it into the burn. This will help keep the air off it and lessen chances for bacteria.
For 3rd degree burns, you also have to treat for 2nd and 1st degree burns. These burns go down to the bone, and noses, ease, fingers, toes can disappear. The skin is the color of ash; any black is soot. These burns are normally painless because the nerves have been burnt away. Cover with clean cloth or bandage and treat for 2nd and 1st degree burns. Spread fingers and toes and bandage separately so they don't fuse together. Treat for shock.
Then we talked about impaled objects. THE OBJECT NEEDS TO STAY THERE, where it will act like a cork. Removing it will start the internal bleeding. Use bandaging to secure the object in place (the blockhouse effect) and cover 3/4 of the object. If the object comes out, DON'T PUT IT BACK IN! You can't do anything about internal bleeding but you can get the person to a place where they can remove the object and control the internal bleeding better.
Eyesight
If there's something in the eye, close the good eye and bandage both, since both eyes will track light together and you don't want the injured eye moving. If the eye is evulsed and hanging on the cheek—and Lynda said that this is one injury that would definitely make her throw up—you can scoop it up with half of a water bottle and set it back in the socket, with the water bottle over it so it's sort of protected. Secure the water bottle to the head since you don't want to put any pressure on the injured eye (this goes for glass and other injuries too).
Eviscerations
There probably won't be any bleeding, but if the guts are hanging out, then they are drying out and getting cold and infected. Cover them with a clean, wet cloth to keep them moist, and take a piece of plastic and put it around the cloth to keep the heat in. Secure the cloth and plastic with two neckties or two belts, but don't tie them over the organ. Don't clean the guts and for heaven's sake, don't stick them back in.
The important thing about all this information is that I as a non-medical person can help respond during a crisis. I can only respond to what I can fix—as detailed above—but many lives can be saved if these things are known. We as a society have learned how to respond emotionally to horrible things (thank you media and terrorists) but knowing medically what to do can help us when there is an actual crisis.
Now you know . . . here's to helpful, empowering knowledge!
We learned M.A.R.C.H., a system of triage to help as many people as possible according to the severity of their injuries:
M - Massive hemorrhage
A - Airway management
R - Respiration (chest injuries)
C - Circulation
H - Hypothermia and Head and neck injuries
Massive Hemorrhage
When we talked about lost limbs and tourniquets, it de-mystified and de-sensationalized (well, at least a little—I still became lightheaded) what happens when a limb is lost. Applying a tourniquet is a serious thing—the living tissue in the limb starts dying after 4–5 minutes, and untying the tourniquet all at once can release built-up poisons and enzymes that can result in anaphylactic shock and death—but it can prevent the person from losing all their blood and dying. We practiced applying tourniquets in less than 20 seconds, because arterial cuts are deadly and the more bleeding people you can patch up quickly and efficiently, the better. Neckties, bras, pantyhose (anything about 2 inches wide) can be used for a tourniquet, and the windlass (what tightens the cloth) can be a chair leg, utensils, scissors, a metal tube.
Lynda said that clothing can be useful in all sorts of ways when there is an emergency; the way she figures, everybody will be naked but at least they'll be alive. I learned how to apply a tourniquet to my own arm if it gets blown off (and bandage and put pressure on the stump). Just thinking practically about the idea reduces the fear of such a terrible situation.
Airway
After the massive hemorrhage cases (which is different than lesser wounds that bleed—"you'll know the difference when you see it," Lynda said), you look for the people who are not breathing and you put them in a "position of comfort"—on their side, neck extended so they will have room if they vomit. Do CPR if needed.
Respiration
Then you treat chest injuries. Since lungs are like balloons, if they are punctured they will deflate, and the space that they used to take up will fill up with 1) air from the outside (from the hole where the glass or the bullet entered), 2) blood, 3) body fluids, and 4) air escaping from the lung as the body tries to breathe the normal way. You can only do something about the first, so that's what you can fix. Get down to the bare skin, find the hole (look for both entrance wounds and exit wounds). Create an air-tight seal. If there's nothing else, you can lick your hand and put it over the wound. (!!!) If you are awesome like MacGyver, my hero, and have duct tape, put two strips like a cross over the hole. You can also use foil, cellophane, credit cards, and bandages, and make one side sticky with chapstick or makeup if you don't have tape so it will stick to the skin. If you see pink, frothy blood on their lips, you know that it is a chest injury. (Other symptoms are belabored breathing, blue lips, but the pink, frothy blood is the certain sign.)
Because the lung is still filling up with the other stuff, from time to time you may have to "burp" the person—undo the dressing and let the blood and fluid geyser out. Clean it, then have the person breathe all the way out and then seal the hole up again. If the person is dotted with wounds like this, you may have to burp every single wound, one at a time. You can tell you need to burp the wound if the person starts getting very anxious, has difficulty breathing, and experiences additional chest pain or tightness in the chest (tension pneumothorax). The more severe the chest injury, the sooner you will have to burp the person.
Circulation
These are the cases where there are bleeds that don't require tourniquets. Apply direct pressure. It takes 3-5 minutes for blood to clot, so time is needed. Use clothing for bandages, but make sure that you roll it in a way that doesn't become a tourniquet. You will be faster and create a better bandage if the unrollling part of the rolled-up bandage is nearest to the skin of the patient. Don't remove the bandage if blood seeps through; apply another bandage on top. If it seeps through again, you may have to use a tourniquet. For cavernous wounds, put gauze or cloth in the depression and bandage over it. If there are clean bandages, great; but if not, use what you have.
Because shock is also a circulation problem, you treat others for shock. Shock is not like being astonished. It's a medical condition where all the blood in the vessels can only constrict for so long in response to an emergency, and suddenly all the blood goes to the extremities instead of the core. Shock can occur from about 20 minutes to 20 hours after the injury. To treat shock:
1 Control bleeding
2 Allay anxiety
3 Alleviate pain
4 Don't elevate the feet or the legs anymore—this has changed
5 Give oxygen
6 Maintain warmth (wrap them up like a burrito in a blanket)
Remember that people get ugly when they panic. Don't slap people, like you see in the movies. Use calm, direct, simple words. One guy at the scene of a car accident had his femur hanging out and he refused to get off the cell phone (he was calling his insurance company and babbling) so Lynda could treat him. Shock.
Hypothermia/Head and Neck Injuries
If the core of the body changes four degrees, it can kill you. Raise the temperature of the body slowly; otherwise the heart can stop.
Head trauma—when the brain jiggles in the cerebral spinal fluid and gets bruised. These injuries are hard to assess because it depends on what part of the brain was bruised and how deeply it was bruised. People with head trauma have moist ears (which is impossible to tell for sure, particularly if you in an African jungle at night and it's raining). If they are hit in the back of the head and the brain was bruised in the front, the person will have broken blood vessels behind the eyes and look like a raccoon from the bruising, although it takes a little while for the bruising to show. If the hit was in the front, there will be bruises behind the ears. People will often vomit because they experience vertigo from the brain sloshing back and forth. They can have unequal pupil sizes since one side of the brain is swelling. We saw the saddest picture of a baby with bruises around the eyes from Shaken Baby Syndrome.
Block and cushion the head all around it to let others—and the person—know that they need to keep still. It's okay to let them sleep, but wake them up every hour and ask what their name is (long-term memory), what the day is (short-term memory), and if they can perform a small task like tying a shoelace (specific information). If the scalp is bleeding, don't clean it—pull the edges together and duct tape it.
Neck injuries—put the person flat on a door or a tabletop. If they can't feel their legs, don't write them off—the next 48 hours will tell how bad the injury is.
Burns
We also talked about burns—run cool tap water for 15 minutes over 1st degree burns. DON'T remove clothing since it could take off the skin. Then put some remedy—people use lots of different types: aloe vera, onions, tomatoes, sour cream, egg whites, peppermint toothpaste. Never use ice, as it will burn it more.
For 2nd degree burns, with open, weeping wounds from blood plasma, the nerve layer can be exposed and be excruciatingly painful. Use the cleanest thing you have—stay away from anything fuzzy, and pat it into the burn. This will help keep the air off it and lessen chances for bacteria.
For 3rd degree burns, you also have to treat for 2nd and 1st degree burns. These burns go down to the bone, and noses, ease, fingers, toes can disappear. The skin is the color of ash; any black is soot. These burns are normally painless because the nerves have been burnt away. Cover with clean cloth or bandage and treat for 2nd and 1st degree burns. Spread fingers and toes and bandage separately so they don't fuse together. Treat for shock.
Then we talked about impaled objects. THE OBJECT NEEDS TO STAY THERE, where it will act like a cork. Removing it will start the internal bleeding. Use bandaging to secure the object in place (the blockhouse effect) and cover 3/4 of the object. If the object comes out, DON'T PUT IT BACK IN! You can't do anything about internal bleeding but you can get the person to a place where they can remove the object and control the internal bleeding better.
Eyesight
If there's something in the eye, close the good eye and bandage both, since both eyes will track light together and you don't want the injured eye moving. If the eye is evulsed and hanging on the cheek—and Lynda said that this is one injury that would definitely make her throw up—you can scoop it up with half of a water bottle and set it back in the socket, with the water bottle over it so it's sort of protected. Secure the water bottle to the head since you don't want to put any pressure on the injured eye (this goes for glass and other injuries too).
Eviscerations
There probably won't be any bleeding, but if the guts are hanging out, then they are drying out and getting cold and infected. Cover them with a clean, wet cloth to keep them moist, and take a piece of plastic and put it around the cloth to keep the heat in. Secure the cloth and plastic with two neckties or two belts, but don't tie them over the organ. Don't clean the guts and for heaven's sake, don't stick them back in.
The important thing about all this information is that I as a non-medical person can help respond during a crisis. I can only respond to what I can fix—as detailed above—but many lives can be saved if these things are known. We as a society have learned how to respond emotionally to horrible things (thank you media and terrorists) but knowing medically what to do can help us when there is an actual crisis.
Now you know . . . here's to helpful, empowering knowledge!
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