This was prompted by a duty a while back where I and another person ended up doing an impromptu lesson in patient monitoring to half a first aid post. Not a promising start to the duty, but we were told afterwards by quite a few of the members that they appreciated the help.
Observations. Obs. Pulse and Resps. Vital Signs.
Whatever you call them, they’re important. And too many of us (myself included) are really bad at remembering to do them.
I was checking over a report for a patient I had treated, where I had come cycling down to back someone up. Something simple, but significant enough to require a reasonable amount of writing to prove we’d tried to think of everything. As I scanned through the notes, I noted that they’d put down: “patient apparently stable”. I glanced over at the observations box: empty. Now I agreed that the patient was stable (they wouldn’t have wondered off five minutes ago if they weren’t), but if you look at that form there was nothing to back us up. Nothing showing that the patient’s obs were normal, or at least returning to normal, and not shooting off somewhere unpleasant.
Repeat after me: if it isn’t written down, it didn’t happen.
To prove that something isn’t changing significantly, you need at least two data points. One tells you nothing. And they need to be reasonably spaced out. Two sets of obs done in two minutes tells us nothing. A lot of things that could go very wrong happen over a relatively long period of time (at least at first). Getting two sets of obs should be simple: one when they arrive, and one when they leave. Obs every ten minutes or so works well, if you can (obviously life-saving stuff needs to come first). It should only take a minute or so to do, and we don’t have to be getting precise numbers every time. We just need to know what’s going on, and then use that information to help us make decisions (such as, do I take my time and finish tidying this bandage, or do I want to have a paramedic with me yesterday…)
Taking a pulse is a simple technique, anyone with a couple of fingers on one hand should be able to do it, but it does takes practice. However, in my experience, it doesn’t seem to be covered as much as it should by our training. Everyone just assumes that everyone else knows what they’re doing. I’ve been caught out a number of times in training where someone has told me they don’t know what they’re doing. And I’ve caught out a number of people trying to cheat in an assessment by making things up (and holding the wrong part of my wrist…)
This is the method I use on a conscious patient:
- Decide which wrist you’re going to use. Make sure it’s comfortable for the patient, and the arm isn’t squashed beneath them or against something (and cutting off the blood supply).
- Make sure your patient knows you’re going to do a pulse. Like with any technique, if you do this without consent you could technically be assaulting your patient.
- Take the hand as if you are going to shake hands, and gently rotate it around so that their palm is up. Don’t let go, but consider resting it on a hard surface (a leg works well if it isn’t shivering). This means you have control of the arm, and you can keep it still.
- Using the first three fingers on your other hand (never your thumb, which has its own pulse), place your fingers on their wrist, beneath their thumb, next to their radius. You are trying to (gently!) press their radial artery against a bone. Hopefully you should feel their pulse. Don’t push to hard (you may cut of the blood supply, or your patient may just hit you because it hurts), and be prepared to hunt for it. It’ll always be on the thumb side of the arm, but sometimes you’ll have to search (and sometimes it is quite hard to find).
- Count the pulse for 15, 20 or 30 seconds, and then multiply it up. You don’t need to count for an entire minute, we’re not after exact numbers here, this should give you an acceptably accurate number. A normal pulse in an adult is about 60-80 bpm1 (though remember this depends on the patient’s fitness and what they’ve just been doing), and expect a child’s to be faster (and a baby’s faster still). Also pay attention to the quality and regularity of the pulse. Are they strong or weak? Are they skipping beats? Is it a regular pulse (or regularly irregular, or just plain irregular)? All things that are important.
If you can’t find the radial pulse, try the brachial. This one is on the inside of the elbow. It can be quite challenging to find, so practicing this one is a very good idea. If you ever learn to do manual blood pressures (which I hate doing, but we can’t use automatic BP cuffs) you’ll need to know about this one, as this is the one you listen to. As a last resort you can use the carotid (in the neck, next to the trachea on both sides), but this is not very comfortable for a conscious patient (take it from someone who has played at casualty as many times as I have: it is NOT fun). The First Aid Manual has some good pictures on where you can find pulses (page 53).
Keep in mind that if you expect your patient’s blood pressure to be very low (for example when shock is starting to get bad), pulses do start to disappear (radial first). It is worth noting if you can’t find a pulse (don’t be embarrassed or afraid to say you can’t do something), and it is very important to note if a pulse disappears.
Get used to making this one of the first things you do for a patient (after your primary survey, of cause). Not only does it give you a baseline to work from later, but it starts to tell you something of what is going on, and it makes you look like you know what you’re doing (and you have a plan). Finally, if you’re patient is distressed, the act of taking their hand can be very reassuring (I know this one from experience).
Naturally, be alert for people who aren’t comfortable with you touching them (holding hands can be seen as being quite personal) and be prepared to alter your technique to fit. If they won’t let you take a pulse, note that down and move on. It’s not worth alienating someone over. First aid is all about taking the perfect solution and the real world injury and making the two fit.
And don’t do what someone did in an assessment, and move a ‘broken’ arm to take a pulse. Needless to say, they got an earful from their casualty.
The most important things are, in my humble opinion, practice, practice and more practice. Every time you get a patient who’s with you for any length of time (we’re not talking the plaster dispenser ones here), take a pulse. Every time you do a scenario in training, take a pulse. Pester your friends to let you practice on them. Develop your own method of taking a pulse, one that works for you (or pinch mine, that’s what I did). Whatever it takes to get yourself confident in taking pulses.
I’ll cover respiration rates in my next post. These are more difficult to get, but form the other part of the most basic observations we can all do as first aiders.
So, I think I should do a bit of an update.
I’m currently in the middle of my final ever exams at Uni. I’ve done one, and have another three to go. I’m a bit stressed, as you can imagine.
It goes without saying that all the depression and anxiety are acting up, with all the problems that entails, not least because I still haven’t got around to doing anything about it…
On the bright side, I have just received confirmation that I have a graduate job with a big engineering company, doing pretty much the engineering I think I want to do. How it pans out remains to be seen, but at least its something to go in to while I worry about everything else. My plan has always been to get a graduate job, and then see what happens next. I can still go into nursing (or something else) later if things don’t work out, and in the meantime I can build up my savings, ready to go back to uni if the need arises.
Typically, now I’ve got this all sorted, I’ve got my project supervisor pestering me about doing a PhD with the uni. I’ll admit, the idea is slightly attractive, but not enough to make me abandon my longterm plans. I can’t justify further expense that could be on a doctorate in something I’m not that interested in as a career ( and I have no desire to be an academic…)
With the Organisation, it feels like we’re on the verge of mutiny with the local Adults. One member (who I have already introduced as CycleGuy) has jumped ship to join my youth unit, and the feeling is growing that two more may be planning to leave. To add to this, I have heard through the grapevine that the Adult leader may want a word with me about ‘stealing’ CycleGuy, after having both of us make it clear to him that the unit he held his membership at was his choice, and neither of I nor the Adult leader minded what he chose. The fact that CycleGuy and I both found this out through a third member doesn’t help the matter. Needless to say CycleGuy is slightly miffed (and I’m far from impressed).
I also know that CycleGuy (as well as HistStudent) wants to become my 2IC. I am a little sceptical, mainly because I worry that he doesn’t have the Youth Work experience, but my alternative is HistStudent who I know (at a gut level that is difficult to explain in words) would be wrong for the position. I have been putting off re-opening the position (long story…) because I can’t really face the interviews and the stress they’ll cause, but I don’t think it can wait any longer. I could be off for good in a few months time (sad times 😦 ), and someone needs to know what to do if I go.
I think that’s a catch-up of everything that’s been going on over here. I have an exam tomorrow, so I can’t stay up too much later. Fortunately I’m reasonably confident about this one (at least, everything is making sense).
One of the most common questions I am asked (along with ‘Are you paid for this?’ and ‘What’s the worst thing you’ve ever dealt with?’) is ‘How do you do this for free?’ This usually happens about the time when I’m trying to stop a drunk student from drowning in their own vomit, while avoiding getting vomited on myself, and their friend is on the other side trying not to vomit. My stock answer is ‘Because it’s fun!’
Even more often, when I’m knee-deep in the worst of the politics and fighting against the people who are too quick to tell us what we are incapable of doing and the people who don’t care and the people who don’t want to lose their power, I wonder why I do it. I spend hundreds of hours a year doing work for a cause I passionately believe in, and in return I get people try to work against me because I want to improve things and they don’t want to leave the happy little rut that they’ve dug themselves.
A short time ago, I dealt with a patient at a Half Marathon, while working on a bicycle. They weren’t particularly unwell, but they had fainted and were a bit shaken up. They hadn’t run anywhere near that distance before, and weren’t used to all the sensations of their body saying ‘that wasn’t such a good idea, let’s not do that again’. All put together, they got a bit worried, and worked themselves up in to what I’m pretty sure was a full-blown panic attack. And I don’t just mean a bit of hyperventilation that quickly cleared up. They were genuinely terrified, kept fainting from the unbalancing hyperventilation does to your body, which just kept making things worse.
In the end, I called an ambulance for them and got them shipped off to the main treatment center, where someone would have the time to care for them and help them calm down properly. As soon as they were sent off, I was sent to another collapse, and I put the entire incident out of my mind.
After the spending the rest of the day zipping up and down the course, I was stood down and headed to the main First Aid post to grab some personal kit and help pack everything up.
While I was there, I bumped in to my patient from earlier. They had just been discharged and were going home with their mother. They both stopped when they spotted me, and my patient asked if I had been the person with them out on the course.
“Yes, I think so. How are you now?” I replied.
“Much better now, thank you.”
“Do you know what was wrong?” The mother chimed in.
“I can’t say for absolute certain, but I think you had a panic attack.” I went to explain how a panic attack was a scary condition, but usually self-limiting and nothing to be overly concerned about. My patient nodded along with my explanation, and then commented that she couldn’t really remember what happened.
“I just remember being convinced that I was going to die, but I remember you being there, and talking to me, and holding my hand, and I knew that I would be okay.” I didn’t really know how to reply to that.
To me, the treatment didn’t seem that much. A simple, non-life-threatening condition that, even if I did nothing, would most likely pass on its own, which I passed on to someone as soon as it looked like it would take a long time to deal with. Fifteen-ish minutes on scene, before moving on to the next job, patient already out of my mind.
But in those fifteen minutes, I helped out a terrified person, taking away some of their fear just by being there. And to that person, I made all the difference.
This is why I volunteer.
It is difficult to describe what it is like, the low mood and other things I’m feeling right now. It is difficult to imagine (even for me), which makes it hard for people to empathise, (or more importantly for me, understand).
It’s not just feeling sad, though that is definitely part of it. Everyone feels sad from time to time, and most people get through it without it being a problem. It’s also not just feeling lethargic, or lazy, or just not bothering to do anything. Again, everyone gets days like these.
But, in my case at least, it’s not just feeling sad all of the time. And it’s not just feeling apathetic all of the time and accepting it. It’s more than that. At least these would be something concrete to fight against.
For me, it’s somewhere in between. Some days I feel fine. If I keep myself busy, through myself in to my work with the Organisation, get lost in a good book, or am snowed under with work, it seems to go away. I don’t really want to get up every morning, but I know that if I do I’ll get out of the house, get paid, and be able to do important things like eat for another month. On a good day I’ll be full of energy, whipping around the house, tidying, finishing paperwork, generally getting things done. On a good day I can achieve a lot, and by keeping myself busy I don’t give myself time to sit and mope. Through me in to the deep end of an event, and I’ll be so busy doing things I enjoy that I won’t notice it’s been a good day until it’s over. For a while I’ll forget.
On a bad day, it goes completely the other way. I’ll sit on the sofa, mope around and do nothing. I’ll have work satin front of me, waiting for me to finish it, and I’ll just put it aside and pretend I’m busy. It’s not even just procrastination, just a complete lack of motivation. Given half a chance, I’ll spend the morning in bed, only getting up when I’m seriously hungry. I won’t eat properly, snacking on stupid things because I can’t muster the motivation to cook properly. I won’t bother to shower. I’ll generally neglect myself, leaving everything I can get away with. If I bully myself enough, and I have a close enough deadline, I might get a little work done, but only enough to scrape through. It’ll be a struggle to even get that done without putting it off.
And to top it all off, most of the time I’ll just sit and think. Mostly about how rubbish I’m being, and how I need to get stuff done. Things will go around and around like how I’m a useless Youth Leader, a rubbish engineer who’ll never enjoy his work, anything that’s getting me down. I’ll beat myself up over every little mistake I’ve ever made, agonising over how I should have done it differently, and imagining terrible consequences for it all.
Which is when the harming tends to come in. I try to keep myself away from things that can seriously hurt me. I’ve never done myself serious damage. I don’t plan to allow myself the opportunity to start. I almost allow myself the small things, as a pressure release, to stop things building up. It’s not good, it’s not a solution, but under the circumstances, I can think of worse things.
If I can muster the motivation, and I have the time, I try to go for a cycle ride at this time. A bit of mindless cycling, having to concentrate on everything going on around me and not what’s going on in my head helps a little, at least for a while.
I need someone to talk to. Someone I can sit down in front of, real out everything to, and get some honest advice (and probably a kick up the backside) in return. The problem is, everyone who really meets those requirements is an Organisation member, and so immediately I run them in to a difficult position. And of cause, even the thought of this is enough for me to not talk to them, because I don’t want to drag someone else down with me.
And so the cycle goes around and around. I am desperately trying to get myself sorted, but time and again the general lack of motivation defeats me. I’ve got to keep trying and keep trying, and hope this won’t beat me.
No, that is the wrong attitude.
This won’t beat me. I won’t let it.
I can’t let it.
- Mental Health – Continued (walkingplasterdispenser.wordpress.com)
So, it appears that putting the CBT leaflet where I can see it every morning hasn’t helped. Months have gone by and I still haven’t done anything about it…
Today has found me feeling particularly down. No particular reason, I’ve just done nothing but sit and mope and start to self-harm again.
I hate this feeling. I don’t normally have too much trouble being ill, but that’s because I normally only get colds which a healthy dose of paracetamol will handle. Being ill, and the illness making me not bother to get the help that would make it go away… This has got me feeling more sorry for myself.
It would help, I think, if there was someone to talk to. The problem is, my best friends are all members of the Organisation. This means, if I talk to them, I put them in the difficult position where our friendship has to fight with their obligation to report safeguarding concerns. I don’t want to put them in that position, and I don’t want this to have to go to the safeguarding team. The last thing I need is someone considering me to be a vulnerable adult, not least because of my leadership role (and I don’t think I am vulnerable in the way safeguarding worries about. I am perfectly capable of looking after myself…).
Now, if cause, I’m stressing, and so can’t really sleep, which really won’t help.
Tomorrow. Tomorrow I’ll call them, and make an appointment with my GP for a follow-up.
There is a thing about first aid that some people get straight away, others catch on eventually, and still more never really understand:
You can’t treat everyone.
It is a fact that some people who don’t need treatment will demand it, and others that really need treatment won’t accept it.
The former are very easy to spot, and easy to deal with. You just have to follow someone like Brian Kellett (né Tom Reynolds) on Twitter (@Reynolds) or read one of his books (which I highly recommend) to get a feel for the number of patients who turn up to A&E or call an ambulance for things that really don’t need emergency care. I’ve had plenty of this sort of patient, but let’s be honest, these are the people who should be coming to someone like me. I can patch them up and send them on their merry way without consuming the time of a professional who has better things to be dealing with.
The latter group is more difficult. These are the people who would really benefit from help, but don’t want to be a bother, or don’t want to waste your time. Their heart is in the right place, but they don’t realise that they are themselves in the group they think we should be spending our time on. I thankfully don’t see many of these, and the few times I have we’ve managed to reach an agreement that perhaps, may be, it would be worthwhile getting a nice paramedic come out and for them to have a chat.
Finally, there is a third class of person. I’ve deliberately not called them patients, because most of the time, they’re not. Often, these are the people who are most likely drunk who stagger past you at a stupid-o’clock in the evening while you’re waiting for a bus. They are the people determinedly limping past your first aid post on the half marathon. The might benefit from treatment, but they don’t really need it.
It is tempting to walk over, offer treatment, persuade them to stop. It’s easy to go charging over, first aid kit in hand, and cure their ills. Except they won’t appreciate it, and they’ll argue, and to be honest, they’re not interested. Just because you can fix something, doesn’t mean you have to. Just because you can act doesn’t mean you should.
You have to be realistic. That drunk person you want to approach in the street. Say they actually accept your help and don’t wallop you one for your trouble. What you are you going to do? They are conscious, mobile and still with it enough to make their way from A to B. If you call an ambulance, they’ll take them in (assuming the patient is still around when the ambulance arrives), and they’ll sleep it off in A&E. What would they do if you weren’t around? They’d go home, and sleep it off in their own bed. Yes, in A&E, they will be monitored by the staff and cared for. But do they need it? Perhaps it isn’t our call to make, but again, what would happen if you weren’t around?
The same goes for when I’m on duty. You see someone heading towards your post. You think about going to intercept them. Except, what if they’re headed past your post? And even if they are headed your way, what does this gain you? They still need to come to your post if you plan to treat them properly, so you’ve just had to walk too and fro to meet your patient a few seconds earlier, and gained what?
I was the same. To be honest, I have to watch myself to make sure I don’t revert. It is very tempting to think that you can go in and solve any problem. I enjoy looking after people. I think everyone in the Organisation does. But I think, slowly, I’ve learned when to get involved, and when to just stand back, watch, and wait until I’m needed.
I’m not advocating walking on by every time. Sometimes you do need to stop and asses. But you must be reasonable. Assess the situation from a distance, first. Will you getting involved achieve anything? Are you putting yourself at risk? What are you about to go charging in to?
Sometimes it’s experience. Sometimes its a judgement call. It’s not easy, but it is important. Running in to the rescue may be exciting, but when you get it wrong you just look like an idiot. And that is not fun…
So that CBT thing I was supposed to be referring myself to. The one whose leaflet I’ve had sat on my desk for more than a week now.
Yeah… That thing that I keep telling myself ‘I must sort that out.’ ‘Must do that, but tomorrow’.
I promised myself I would keep on top of this. And yet, I keep putting it off.
I think I know why. I’m afraid. It’s scary admitting that I have a mental health problem, and going to seek out help from somone I don’t even know. That’s terrifying. So I put it off, and put it off, until I forget about it. Which is a crap way of dealing with it.
‘Don’t be stupid.’ I tell myself. ‘You’ve faced down threatening patients. You’ve worked in a major incident with no second thoughts.’ Except, of cause, one way or another, I have been in control of those situations. Either by sheer force of will, or by continuous training and work. I can cope with that, because I know what will happen.
With this, I’m all at sea. I have no idea what is going to happen, and I don’t seem to be able to control my situation either. I’m terrified that everything is going to slip away from me, and I have no way of pinning these things down.
‘So’, I tell myself, ‘it’s time to take control. And that means take that first step.’
And it’s easy to tell myself that. Easy to promise myself that I’ll do it. Easy to push it back and push it back. Easy to let the leaflet get buried under everything else on my desk.
This isn’t going to be easy. I have to remember this. It’s probably going to be scary.
I’ve told patients (mainly the very young ones) that it’s okay to be scared, as long as you are brave.
I’m good at handing out advice like this. That’s the easy bit.
No comes the difficult part…
So I did it. I went to see a GP last week, and then had a follow-up appointment the week after.
After a couple of questionnaires and a LOT of questions, she told me that while it wasn’t very serious, I am displaying symptoms of minor anxiety and depression. Which is pretty much what I expected to hear.
Moving on to what I could do about it, she described counseling and Cognitive Behavioural Therapy. She quickly touched on anti-depressant drugs, but to my relief just as quickly dismissed them as not helpful in my case. After much umming and ahhing and questioning, I decided to follow her advise and go for the CBT. She told me that she would post me some information about it, and that I should make arrangements to self-refer myself to the local unit.
So I now have a leaflet from the local Psychological Therapies Service on my desk, placed where I can’t ignore it. And tomorrow, I will be calling the number on the back. Because I’ve got going now, and I am not going to let my nerves or self-consciousness hold me back.
Even thinking that I’m doing something is making me feel a bit better. I feel like I’m building up some momentum, and almost that nothing will stop me now. Time to make it happen.
I still haven’t made that appointment. Every time I’ve thought about doing it, something has come up and I’ve done something else. Mañana, mañana.
This afternoon, I received a massive kick up the backside. It appears that my particular self-harm has started being visible to my friends. To them it looks particularly innocuous. To me it was an unpleasent surprise.
Tomorrow, I have an appointment with the nurse to get my wounds checked on. Tomorrow morning, I’m going to try to get an appointment with my GP to fit in shortly after. Because enough is enough. This isn’t getting better, no matter what lies I tell myself. Today, I got home, sat down in front of my computer, and despite having a reasonably good day (aside from one rant which is going to follow), felt like crying. No real reason, I just felt really upset. And this isn’t right. I deserve better than this. I have to believe that. I do believe that.
So, it’s time to do something. Because at this rate, I’m going to hit rock bottom so hard I’ll never get back up.
It’s easy to make New Years Resolutions. Not so easy to keep them. I could make the usual ones:
- Exercise more
- Eat better
- Keep up with my studies better
The list goes on. Add in my particular circumstances and I could add:
- Come out to my parents
- Blog more regularly
Again, the list could be a mile long.
I’ll say right away, the first item in the second list isn’t likely to happen any time this decade, and the latter really depends on how much inspiration I have.
However, the first list shows some potential.
If I want to get anywhere in my ambulance work without damaging myself, I need to get fit, and I need to get stronger. I noticed that my fitness was going down when I stopped cycling to work. Suddenly, the cycle to uni, which used to be pretty average, is a nightmare. Well, the few times I’ve tried it before the snow got bad. In short, more exercise is needed. I’m at a uni that has amazing sports facilities. Shouldn’t be too hard, as long as I stick with it… That, unfortunately, will be the problem.
As a student, the eating properly think is always a problem. Hopefully that’ll get better as I get a bit more free time. More importantly on the health front, I think I need to see a Doctor.
I should explain more thoroughly… A few months ago, I had a chat with a GP about my mental health. To cut a long story short, I’ve been self-harming for quite a long time, now. In fact, I can’t really remember when I started, it was so long ago. At first I just saw it as a bad habit, but looking back, at my behaviour, my feelings, everything, I got a bit concerned.
Now don’t misunderstand. I have never done myself lasting damage. Never anything that risked my life, and I’ve never considered suicide. I have no visible scars (at least, none that were deliberately self-inflicted), and nothing that you’d see in everyday life.
I had a feeling that something wasn’t right, and when I went to the Doctor, she agreed that something was wrong, possibly depression, or it could be anxiety. She gave me a questionnaire to fill out, and told me to see her in a week.
I missed the appointment. Not intentionally. I honestly thought she had said two weeks, not one. More importantly, though, I didn’t set a new date for the appointment. I could have done. I have thought about doing it, more than once, and have seen a GP about other things since. It’s just never happened. If I’m honest, it’s probably because I’ve never worked up the courage to do it again. It was hard enough having the conversation the first time around, why would I want to do all that again…
Except I need to, because the harm hasn’t stopped, and I’ve not miraculously started feeling better. I would be lying to myself if I said I was. I have trouble sleeping, I am still harming myself (even as I write this post, and that scares me because I know what I’m doing, but still do it), I always feel run down, and am always feeling generally ‘low’.
So my New Years Resolution is simple. Look after myself better. And I can achieve it. I have to believe I can achieve it. Because if I don’t, I’ve already lost the battle.
And I can’t let this get any worse…