First of all, let’s consider safety. When we talk about safety, we’re thinking firstly of our own individual safety, secondly of the group safety and thirdly the safety of the casualty. Once the group is safe, they can start working as a team. On
the sea, we may all turn our boats and paddle into the prevailing conditions to maintain our relative position to each other. On a river we may all hit an eddy and get out of our boats. Maintaining group control and communication is a strategy to maintain safety and work towards resolution.
The road from Incident to Resolution (and Reflection) is not a smooth linear process. There will be hurdles to cross, and challenges to be met. At the centre you have constant situational awareness, re-assessment of the plan, and communication. Even if the casualty is doing well, the challenges will keep on changing. For instance, as the medical challenges are overcome and you see your casualty improve, the emotional challenge may diminish for most of the group, but the new tactical challenges for those making decisions on what to do next will increase. As you draft in more support from your group, your physical challenges diminish but your own emotional challenge may increase.
If you think about a situation you’ve been involved in yourself, you may think up more hurdles, I’ve limited them here to four. I’ve labelled five different challenges. I could have put medical challenges as a subset of technical challenges, but I think this way the model is more easy to understand. Central is the need to maintain situational awareness, and communication.
Your location on the river bank, shoreline, portage route, roadside, pool side, or still in the water, will present you with unique challenges. Hazards will change with time. For those by the shoreline, a rising tide may enforce a move, whereas for those inland, if it’s raining, any paths will become more slippery and river levels rise. Temperatures can fall dramatically and without food or drink people will get colder. Failing light will accentuate the dangers.
Everybody in the group will be stressed by an incident, especially if someone is injured. The group leader, the most accomplished first-aider, the patient, and the rest of the group will all have different stresses to deal with, and these need managing.
In a hostile environment, assessing the casualty, who is likely to wearing a few layers of protective clothing, could nevertheless be cold and physically exhausted. This will challenge anyone. Judging the severity of the injury is crucial and establishing a baseline of where you are and will help you develop a strategy to resolve the situation.
As well as using your first–aid kit, you may have to use other equipment and personnel to ensure safety and make progress throughout the incident. This is especially the case if you have to move the patient, even if it’s a very short distance.
How are we going to move from where we are now, to a satisfactory resolution? What is our exit strategy? How is the group going to manage the physical, emotional and technical challenges so that you have the best possible outcome?
This incident management is an interwoven process that moves from a state of uncertainty to resolution. These challenges will change with time and new ones can arise, and they will have a knock on effect. Keep on evaluating. Is the situation getting better, staying the same, or getting more chaotic?
Think through each action, and be open to share ideas. What are the consequences if it doesn’t go to plan? Stay safe. Remember the basics.
- Preserve Life.
- Prevent The Condition From Worsening.
- Promote recovery
A Real Life Example
Let me give you a real example where a training session was taking place on a canal. It could very easily have been a quayside, or close to a jetty. A paddler has sustained a shoulder injury, but within a few seconds he is standing waist deep in water, close to the side of the canal and the club house is nearby.
Situational Awareness and Communication. We have an injured person in the water. We need a plan to get that person out of the water so that we can carry out a thorough patient assessment. We need to communicate that plan to the team. We also need to be aware of any other dangers on the canal.
Emotional Challenge: The patient is concerned by his injury, but thinks it’s just a pulled muscle. He is probably trying to convince himself that it’s not serious. The others are concerned for his well-being but not alarmed or upset.
Tactical Challenge: How could we get the casualty out of the water and at the same time prevent the condition from worsening. The bank was man-made and was effectively a 60cm vertical wall from water level to flat ground. There were no steps nearby. Railings near the edge meant we could anchor people who will lift, but then there will be a second move to get him over the railing. We’re going to have to lift him out of the water and we’ll do it in two stages, first, so that he can sit on the edge, and then we’ll help him to stand up, and step over the railings.
Physical Challenge: How can we safely lift the casualty out of the water. We’ll be lifting approximately 80kg vertically. Once he is 60cm higher up on the ledge he will be able to help himself somewhat. We need to get people to help from above and below, using his dry-suit and buoyancy-aid, whilst avoiding his injured arm that he’s supporting with his good arm.
Medical Challenge: We’ve assumed it’s a dislocated shoulder until proven otherwise. There is nothing we can do for him in the water. He is supporting his arm himself.
Technical Challenge: We’re not using any specialist kit, we just have to get enough hands onto his kit and clothing so that we can lift effectively. It’s essential that the lift is co-ordinated. We are now checking that everybody who is going to lift are themselves well-anchored and got good posture so that they lift using strong muscle groups. No bent backs, plenty of hands on to share the load.
At this moment, the patient mumbles that he’s ‘going’, and starts to slump. The initial adrenaline rush from a minute or two earlier has worn off. His blood vessels have dilated, blood has pooled in his legs and he has fainted.
Situational Awareness and Communication. We now have an unconscious patient in the water. A decision needs to be made and communicated.
Emotional Challenge: The group are now challenged. An unconscious person in the water is scary. We were ready to lift.
Medical Challenge: We had to protect the airway. We had to restore normal blood flow to the brain.
Tactical Challenge: We had to consider our options quickly and efficiently. This is where experience and good first-aid skills became crucial. Let’s go back to our Primary Survey also known as DR ABC.
D - Dangers: we were in calm water, which was cold but we were all well dressed for the conditions. There was no one fishing nor was there any other canal traffic moving nearby.
R - Response: The patient was now unresponsive.
A - Airway: The head had slumped forward so he had an airway problem. This needed to be managed but nobody is in position to protect the airway during the lift.
B- Breathing: He was breathing.
C- Circulation: We had a circulation problem. He had fainted because not enough blood could flow to his brain.
We needed to protect the airway quickly. We all had hands on clothing, but no one was in a person to hold the patient’s airway open. We also needed to correct the circulation problem. Our plan for the lift was now massively compromised. Our tactic to resolve this new medical challenge was to lay him flat on the surface of water where we could protect his airway and assist his circulation. One person took the head end, others supported his chest and legs.
Physical Challenge: The physical challenge was to keep him as level as possible, with the airway protected well above the water. Because of his buoyancy aid we didn’t have to work very hard, just quickly organise ourselves. The patient regained consciousness about 20 seconds later. We give him plenty of time to recover and then moved slowly from horizontal to standing in the water, allowing his body to adapt gradually. We then completed the rescue.
And so the cycle of tactical, technical, emotional, physical and medical challenges continued until resolution was reached, where in this case, the patient was taken to A+E, and the rest of the group were back on dry land, changed, and able to reflect on the incident.
This model of Incident Management may appear familiar to those of you who are going through, or have been through, the coaching process. It is based on the PPTT model of coaching paddlesport. I have used the PPTT model as part of my reflective practice as a paramedic, and found it a useful tool to improve my professional performance.
If you would like me to review any incident or accident, no matter how small, I would love to hear from you. It’s not a matter of passing judgement, it’s about looking for patterns of behaviour and actions and seeing if we can learn lessons.
Andrew Barras has been paddling regularly since 1990. He has 5 star awards in both WW and sea kayaking. He has worked professionally as a paramedic in London and the Home Counties, and runs Aquatic First Aid Courses which are certificated by the BCU Lifeguards. See www.sea-stack.com for further details.