Extended Field Care

You have dealt with the casualty’s initial injury or illness but you are still several hours (or days) from help.  What do we do now?

This is where most First Aid courses end but there is still much to do to ensure the best possible outcome for the casualty.  As the casualty has yet received definitive medical care, they may still be vulnerable to long term problems, including but not limited to dehydration, infection, heat stroke, hypothermia…

A FIT ARSE is a useful mnemonic which prompts us how to continue care for extended periods of time.

A – Ask

F – Fluids

I – Infection

T – Tubes & Wires

A – Analgesia

R – Records

A – ASK the casualty how they are feeling.

Compare this to how they were before treatment.  Has there been an improvement or are they deteriorating?  Are there any new symptoms or has the pain radiated to a different area?  This sounds obvious but simply talking to the casualty and listening is often overlooked.

F – Fluids

Monitor the casualty’s fluid intake and urine output.  Hydration is incredibly important; many casualties die (in urban and remote environments) not because for their initial injury or illness but through dehydration following the incident.

In traditional, urban First Aid we are still often taught “never give the casualty anything to drink”.  Unless the casualty is in hypovolaemic shock this obtuse statement should be ignored at all costs in remote environments.  Decide what is needed:

  • If the casualty is saying they are thirsty, they are thirsty.  Encourage small sips.
  • If the casualty vomits or deteriorates – their body is saying it does not want it.

Hydration should be maintained to ensure a urine output of 0.5-1ml / kg / hour.

Water is appropriate but a rehydration solution is preferred as the casualty will be missing important salts and sugars.   This may be a commercially available Oral Rehydration Solution (ORS) such as Dioralyte, a sports supplement such as SIS Hydro or the WHO ORS formula of:

  • 20g glucose
  • 3.5g salt
  • 5g sodium bicarbonate
  • 1.5g potassium chloride.
  • 1 Litre clean water.

If the ingredients are not available, a simple ORS can be made from:

  • 8 level teaspoons of sugar
  • 1 level teaspoon of salt
  • 1 Litre of clean water

If the casualty is not able to tolerate water orally, consider rectal rehydration.

I – Infection

Wounds should be properly cleaned, dressed and monitored and the casualty treated with a course of appropriate antibiotics if available and trained – Administering Medicines article.

T – Tubes & Wires

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Some invasive techniques administered by the advanced practitioner (including airways, IV tubes, catheters, chest drains or needle decompression, for example) must be regularly checked to ensure they are still patent, fixed, clean and clear.

Tubes and wires including airways, IV lines, axillary thermometers or pulse oximeters should be taped to the casualty to ensure they are not dislodged, especially if the casualty is to be moved.

A – Analgesia

Pain relief if commonly thought of as drugs but can also be accomplished to a degree with other techniques including:

  • Emotional support and reassurance
  • Dressings are regularly cleaned and checked
  • Heat or cold packs to treat sprains and strains
  • Distraction – engage the casualty in their own treatment or keep them occupied with low-stress job around camp.  The best way to make someone helpless is to treat them as though they are.
  • Splinting injuries and avoiding unnecessary movement or rough handling.

Many Over The Counter drugs are available which provide effective relief for simple or moderate pain.  If prescription drugs are available for severe pain they should be administered legally and appropriately.

Further Reading - Musculoskeletal injuries and The Medicine Cabinet

 

R – Records

Document your initial findings; history, Signs & Symptoms, baseline vital signs and the treatment given.  Continue to record your observations and any treatments given as you go rather than attempting to do so at the very end.  You will forget and you will not be prepared for  ‘the end’ when it comes.

There are several reasons for creating records; to protect yourself legally, to aid post-incident investigations and also to assist handover of the casualty from your care to that of another.

The format is not as important as the content.  It should be clear and legible; take the time to write – or rewrite – things clearly as records which cannot be read are useless.  Avoid abbreviations, slang, jargon or complex terminology unless they are universally recognised.  Ask yourself:

If I were to receive these records, would I know exactly what had happened and what has been done in order to confidently take responsibility of this casualty and continue to give appropriate care?”

S – Sanitation

The casualty will need to be cleaned and washed as you would.  Consideration must also been made for the collection and measuring of urine output as well as toileting the casualty.

For all members of the team, camp hygiene must be ensured considering including hand washing facilities, disinfecting if available, water collection and treatment, food storage, cooking and washing-up processes, waste disposal and latrines.

E – Environment

The casualty must be protected from the environment.  Recognised that their illness or injury may compromise their normal temperature regulation.

In hot environments they should be shaded and cooled with localised cold compresses.  In cold environments they must be adequately protected – especially extremities.   If they are immobile they will have reduced peripheral circulation.

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Any casualty immobilised on a stretcher will also be more susceptible to heat or coldthey should be packaged appropriately.

Use a fridge thermometer with the probe positioned in the casualty’s armpit to take an axial temperature (typically 1oc lower than an oral temperature, e.g. 36oc ± 1oc) with the display on the outside of the casualty’s clothing / sleeping bag.   This avoids having to disturb or expose the casualty to take their temperature or placing anything in their mouth.

Further reading:   Hypothermia Guidelines for Remote Environments