BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 6. - First Aid
RADIO 4
TUESDAY 05/07/05 2100-2130
PRESENTER: MARK PORTER
REPORTER: CAROLINE WILLIAMS
CONTRIBUTORS:
NICK PIGOTT
POLLY TERRY
EMMA WILLIAMS
GREGOR HENDERSON
ALANA ATKINSON
PRODUCER: PAULA MCGRATH
NOT CHECKED AS BROADCAST
PORTER
Hello. Today's programme is all about First Aid - a surprisingly recent concept born out of the realisation, during the late 19th Century, that training soldiers how to splint and bandage battlefield wounds - instead of waiting for the surgeon - could ease suffering, and reduce casualties.
By 1878 civilians living around the military hospital at Woolwich were being taught first aid by the newly formed St John Ambulance - skills that were quickly put to the test by a disaster that occurred within months of those pioneering classes. The death toll following the sinking of the Thames pleasure boat, the Princess Alice, was well over 600 - a figure that commentators of the day believed would have been much higher had it not been for, in their words, the promptitude of the assistance thus rendered by the Woolwich First Aiders.
Despite major advances in emergency medicine, basic first aid skills remain as important today as ever. Particularly if you are a parent.
Two million children are seen in A&E departments across the UK every year - yet 8 out 10 parents admit their first aid skills aren't up to scratch, as we discovered when we visited a St John Ambulance course specifically designed for parents.
VOX POPS
If I walked in and found the baby wasn't breathing I want to know what to do that's effective rather than panic.
Just to have the knowledge perhaps of being able to deal with choking for no apparent reason or stopping breathing.
I said to someone earlier, to me it's like insurance, if you do these things you don't need them and that's all I'm looking at doing - I hope I never need to use this course.
A little while ago my baby started eating solids and I stupidly gave him a little piece of apple and also at another time some rice cracker which he choked on and I realised I had absolutely no skills and completely panicked. With the rice cracker he was in his stroller and I'd given it to him to sort of chewed on, I just crouched down and dare I say I sort of got him and shook him ever so gently and he actually got it out himself and it just literally sort of flew out.
He does fairly adept at coughing it out himself.
Well we just learned what I should have done is got him out of his stroller, tipped him down with his head down and his chest lower than his bottom and given him five sharp slaps between his shoulders. Or alternatively lain him on his back and given him chest compressions - was it five?
Yes, five times.
PORTER
Nick Pigott is a consultant in paediatric cardiac intensive care at Great Ormond St Hospital, and one of the doctors behind First Aid for Kids - a new interactive course for anyone who looks after children. So, why are so few parents trained first aiders?
PIGOTT
I think most of us hope that the worst won't happen. The nature of what I do means that I see the consequences of that.
PORTER
Presumably there's quite a big conversion there, I mean people come in and see you with one emergency, which hopefully everything's alright, and that obviously then is a major driver, isn't it, to go and do something about it.
PIGOTT
That's right, I think people feel impotent when something bad has happened and that motivates them to go and learn what to do in that type of situation.
PORTER
Can you give me an example where a lack of knowledge may have endangered a child in your own clinical experience?
PIGOTT
The types of examples I would think of are seizures - convulsions are common in young children. And in my experience the types of things that parents will do in that situation - the first thing is they think their child's going to die. And the second thing that people will often do is they will try, for some reason, to do something like put a spoon in their mouth because there is a perception that children will swallow their tongue and that may be dangerous. And in fact that will often cause harm. The types of things that one could do in those situations are very simple and could be done by anybody. The other example that comes to mind is in the rare situation where a child's heart stops, so they stop breathing, really very basic things like being able to position the head and open the airway may make a significant difference to a child's chance of survival. And those are not things that are the domain simply of experts, anybody can do that type of thing.
PORTER
So what should parents be doing about it? We heard from those parents there - they're on a Saint John Ambulance course - but obviously not enough people are coming forward for that and there's something like, if we're lucky, one in five families know how to look after their children in an emergency. How can we raise that ratio?
PIGOTT
I'm passionate about promoting this as an issue because I think that raising the awareness amongst the general public has a direct benefit for children in this country and promoting first aid skills at all levels, the organised courses, there are plenty of books that are available to read, how one encourages people to do that is difficult to know. And I think increasingly there will be computer based ways of learning.
PORTER
Well that's what you've been involved in, tell us how that works and how might it differ from a conventional course.
PIGOTT
Within my role as an intensive care specialist at Great Ormond Street I was asked to become involved in a project to develop an interactive CD-Rom centred around first aid for children. And it covers about 20 different areas, major topics in first aid, ranging from very basic things like how to remove a splinter, what to do with an insect sting, all the way up to things like what to do with anaphylactic shock and cardiopulmonary resuscitation, what to do if a child stops breathing or if the heart stops beating.
PORTER
All you need is just a normal home computer that will play a CD-Rom.
PIGOTT
It'll play on an ordinary PC or an Apple Mac, it's a standard CD-Rom.
PORTER
And people can watch at their own pace presumably, so you can back and forward to each bit.
PIGOTT
They can revisit it, there are embedded video clips, it's interactive and at the end of each chapter there are sections of multiple choice questions on which the user's marked and that ultimately produces a score at the end of - there's a test at the end of the CD.
PORTER
Dr Nick Pigott from Great Ormond Street. And you can find out more about that CD-ROM by calling the R4 helpline or visiting our website - details of both at the end of the programme.
My guest today is Polly Terry, consultant in accident and emergency medicine at Warrington Hospital, and she is in our Manchester Studio.
Polly - in these days of paramedics, helicopter ambulances, high tech emergency departments, such as yours, just how much difference can basic first aid make?
TERRY
Basic first aid makes a huge difference both to the patient but also to what happens at a later stage when they come into us in A&E. If you get it right from the word go it can often result in a better outcome for the patient.
PORTER
Presumably the opposite of that is that if you don't get it right, if you're not there applying basic first aid, such as looking after someone's airway, then it doesn't matter how much high tech support's arriving five minutes later it's too late?
TERRY
That's absolutely right and if we're first on scene then what we will do is the basics first.
PORTER
And with the best will in the world how quickly could, for instance, a helicopter ambulance be expected to get to a scene, I mean it's going to be 10 or 15 minutes at least isn't it.
TERRY
Yes, depending obviously on the locality but certainly within London it's 15 minutes before we're on scene.
PORTER
When I was training I'm sure that - I mean this is going back a long time in the '80s - that we used to have a philosophy, it was just scoop and run basically, which meant that you picked the patient up and got them to a specialist department, such as an A&E department, as quickly as possible. Whereas now the emphasis has changed, there's much more stabilising patients at the scene, why has there been that change?
TERRY
We have seen a change from the scoop and run to what's now referred to as the stay and play, whereby we stay longer on scene and do more interventions. However, what we try to do is we try to train people to identify what is the definitive treatment this patient needs? For instance does the patient require theatre to stop the bleeding or if it's a heart attack do they require the clot busting drugs? And if it's then within that provider's scope of practice they will deliver the treatment on scene. So, for example, a lot of paramedics now will deliver the heart - clot busting drugs on scene, they don't need to take you to the hospital.
PORTER
And that presumably reflects the different level of expertise of the people who are arriving on the scene, I mean in days past the ambulance crews' basic job really was basic first aid and get people in wasn't it, where now we've got very highly qualified paramedics and sometimes doctors on the scene.
TERRY
That's right. Ambulance services were developed purely for transport purposes and the paramedics have only really been about since the 1990s.
PORTER
Let's go back to first aid. What sort of examples of mismanagement have you seen, can you give us a couple of common things that you've seen in your day-to-day clinical practice?
TERRY
A common presentation to an A&E department is pain from whatever source and a lot of people won't take painkillers because they feel that'll mask the symptoms or prevent the doctor from making a diagnosis. In fact it doesn't. So I would certainly encourage everybody to be taking painkillers if they have pain. Another common one is patients with burns or any wounds and they've applied creams to the area.
PORTER
And the principle rule with burns is that we really shouldn't be putting anything on them.
TERRY
Nothing that's not been prescribed by the doctor no.
PORTER
Well I'll tell you what we'll come back to how best to manage some common emergencies a bit later.
Before that a look at who might turn up when you dial 999 - the professional first aiders. Ambulance crews now contain at least one member who has undergone further training to become a paramedic capable of dealing with a range of life threatening incidents. But emergencies make up a surprisingly small part of an ambulance's day to day to day workload - less than 10% in some cases. As I discovered when I spoke to Emma Williams, one of a new breed of emergency care practitioners, or ECPs, that are being introduced to bridge the gap between paramedic and doctor.
WILLIAMS
People we go to who've got flu, people who played football yesterday, twisted their ankle, elderly people who've fallen out of bed actually they just need a bit of assistance and not necessarily to be conveyed to A&E.
PORTER
I can understand someone who's fallen out of bed dialling 999 but why is someone with flu calling an ambulance?
WILLIAMS
I think, to be honest, there's an awful lot of people there who aren't sure where to turn. We quite often go to people and all they really want is medical advice but they feel that some people who call NHS Direct feel they don't necessarily get what they want from there, they try their own GP and are told that it could be a few days before an appointment. Very few people also think about approaching pharmacists, I think an awful lot of it is people aren't sure where to turn and so they pick up the phone and dial 999 because it's reasonably easy and they get some assistance.
PORTER
But when someone dials 999 who's got a problem that's not obviously something that needs an ambulance can you not just redirect them to the correct service?
WILLIAMS
What happens now is when you dial 999 you get what's call triage, which is you get assessed according to your clinical priority. Those calls that are acute obviously the priority is to get an ambulance to them as quickly as they possible can. But we do have a system now which is called clinical telephone advice, which is somewhat similar to the NHS Direct system. So if you do call up because you've got a slight headache or, as I said, you've a minor ankle injury or a cut finger we can actually give you some telephone advice over the phone. However, this never takes away from actually the best thing for some of these people is to have a face-to-face discussion and have a clinical assessment because we're still at the end of a phone and you can never beat that face-to-face assessment.
PORTER
Okay, so how much extra training did you have to become an emergency care practitioner?
WILLIAMS
In London we do a two year diploma, it's targeted at patient assessment, clinical decision making, minor illness, minor injury, chronic conditions, as well ...
PORTER
This is while you're working as a paramedic?
WILLIAMS
That's correct yeah, we do it sort of on the road as well as doing the education but in addition to that we take on clinical placements where we work alongside doctors and ENPs - emergency nurse practitioners - within the clinical position, so we can learn from them because obviously as ECPs we work by ourselves, we don't work in an environment where we have peer review so it's very important that we link up with local acute services and primary care services to learn from them and develop the knowledge that we have into practical skills.
PORTER
And how are you travelling around - do you travel around on your own in a car or an ambulance?
WILLIAMS
We travel by ourselves, we have a people carrier, so we have a boot full of gear, basically all the same equipment that an ambulance has without obviously the stretcher and extremely large pieces of equipment but all the critical lifesaving equipment with additional diagnostics. But we also have the back seat, so if someone does have an arm injury or a minor wound and their legs are fully functional there's no reason that they can't sit in the back of our car, and if they need to be conveyed to a walk-in centre or to an A&E then we can do that ourselves.
PORTER
So give me an example how the patient might benefit from seeing you rather than a normal paramedic.
WILLIAMS
I think when we were set up we were initially tasked to help deal with the chronic conditions and quite a lot of times these are obviously elderly people as well, so we can go to them and make an assessment, look at their medication, if they've got say for example a simple urinary infection and that's caused some confusion, maybe caused them to fall, by assessing that that is purely the problem today we can actually then get in contact with the GP, maybe get some medication, we're actually ourselves looking at getting patient group directives so we could give the antibiotic and liaise with the GP. Also if there's a social care issue, the patient needs additional carers for assistance or walking aids or things like that, rather than actually having to go to A&E and go through the sort of middle man to organise that we now have the ability to do those referrals direct.
PORTER
So you're something of a halfway house because the conventional paramedic wouldn't have the choice, they really probably would just have to take them into A&E and let somebody else sort the problem out.
WILLIAMS
Absolutely, absolutely and that's one of the key differences between us and regular road staff who are still absolutely essential with what the ambulance service are doing but what we're trying to do is by doing these less acute calls we can actually free up those crews to do the calls that they're excellent at dealing with.
PORTER
Which all sounds great if you're an additional service and herein lies my concern is that the state of out of hours services at the moment in the NHS is, shall we say, a bit shaky, the fact that there probably aren't enough doctors to cover the system, they're having difficulty recruiting doctors. The most inexperienced GP has nine years training before they're let out and about on their own. Are ECPs being seen as a cheap way, an easy way if you like, to fill the void and possibly could patients be losing out as a result?
WILLIAMS
One of the key things that we're learning is very much the scope of our practice and we must learn where our limits are, so we never go beyond that, we always - if we need assistance we'll call for the GP, we'll speak to a doctor in A&E and get advice. I think the reason ECPs were created was because the ambulance service call rate is going up 6-7% a year, we do 5 million calls across the UK and we're really getting to a situation where as ambulance services ourselves we cannot deal with this increase in call rate, particularly when the large majority of them are not acute. Personally I don't feel the patients are missing out at all. I think what's quite important to emphasise is that these are patients that we're going to, that we go to anyway, the difference is now rather than taking them to A&E we can actually give them very similar levels of treatment to the doctors but what's most important is that you guys - you doctors have got so much experience and knowledge let's keep you for what you really need to do, let's keep you for the really unwell people - the chronic conditions, the complicated situations - let's send people like myself, I've been on the road for eight and a half years I've got quite a lot of experience at dealing with minor injuries and such, let's use people like myself to deal with the less serious cases.
PORTER
But don't you sometimes wish that people use the emergency services better than they do, I mean people still dialling 999 when they've got a sprained ankle, I mean there is an education problem there isn't there.
WILLIAMS
Very much so, very much so and I think anyone you talk to in any acute trust will agree the same. We all have anecdotal stories of people who've called us because their boiler won't go on or they can't reach the remote control or they've lost their contact lens - that kind of thing.
PORTER
I mean they're funny but they're true - that's the sad thing.
WILLIAMS
And this is the tragedy, absolutely. I mean the London Ambulance Service we do try and educate people that we go out to, we did actually run a campaign a few years ago trying to educate people about what to call ambulances for and we actually ironically found our call rate went up because a lot of people who would have put granny in the car when she'd had a bit of a stroke now realise that actually the best thing to do is to call an ambulance and the target people we were trying to reach obviously didn't either take in or didn't understand what we were trying to say. I think what we have to say to everyone all over the country is we are there at the end of a phone, if you're having an acute situation - you're having a heart attack - we're tasked to get to you in eight minutes but please don't abuse the service, if you have a minor injury or a minor illness really think before you pick up the phone.
PORTER
Emergency care practitioner - Emma Williams. You are listening to Case Notes, I'm Dr Mark Porter and my guest today is Polly Terry, a consultant in accident and emergency medicine.
Polly - let's have a look at some common scenarios. We've already mentioned burns and scalds, let's start there. You said not to put butter, ointment or any other things on, so what should people be doing?
TERRY
The most important thing is to stop the burning process, so if there is still a chemical around or if there's still hot water over the area to remove that, to remove the clothes, and then to start to cool the area. By cooling the area it'll give quite a bit of pain relief as well as limiting the damage.
PORTER
Because in a big burn the burn can actually continue for some time after the insult's been removed, I mean if you put your hand in some boiling water and it's in their for a while - and it wouldn't be hopefully - but actually the burn can carry on afterwards can't it.
TERRY
That's right and by applying copious amounts of cold water for anything up to 10 minutes under a simple - cold water from the tap, nothing special, it will help to limit the damage.
PORTER
And if you need to cover it up because you're in a dirty environment or whatever what should they be putting on it?
TERRY
The best thing to cover it up with is something that's clear and what we use in hospital is we actually use simple cling film available from your supermarket.
PORTER
Okay, on to a slightly more difficult challenge - the drunken teenager, or indeed anyone who's had far too much to drink. I mention drunken teenager because I've got two teenagers myself, so an area of concern for me. It's very difficult for parents isn't it - or anybody who's looking after someone who's so drunk they can't stand up. I mean when is it a matter of putting them to bed and when should they seek further help?
TERRY
That's a difficult one. The most important thing is whether or not the patient is conscious. Quite often what we find is it's late at night, the drink acts as a depressant and they're tired anyway, there's nothing wrong with letting the patient go to sleep but it's whether or not you can actually wake them up.
PORTER
So if you can wake them up that's a good sign, if you can't wake them up you need to seek help - is that what you're saying?
TERRY
Yes, if you can't wake them up then lower the patient on their side, phone 999 for an ambulance, bring them into us at the hospital.
PORTER
Okay, moving on to road traffic accidents, now I know this covers a multitude of different types of events but are there a few dos and don'ts that people should think about? I'm thinking, for instance, a lot of people feel that they must get the person out of the car as quickly as possible before it explodes.
TERRY
Right, yes. Again the most important thing is your own safety because what we don't want to end up with, with two casualties and by you rushing in you can actually become a casualty yourself. So do no harm, leave the patient where they are, obviously unless there's imminent danger like the car is smoking or what have you, but just leave the patient where they are. Reassure them and most importantly don't give them anything to eat or drink.
PORTER
What about people on motorbikes and their helmets, if somebody you think they might be unconscious, they're in full leathers and they've got a helmet on is it alright to take the helmet off because a lot of people said oh I can't take the helmet off I might injure their neck?
TERRY
Generally we leave the helmet in place unless, as you say, there appears to be a problem where they're vomiting or a problem with the airway, in which case we do actually teach people to take the helmet off. But it is a two person job.
PORTER
Right, so best left to the experts or someone who's been properly trained. And what about animal bites - slightly different thing here? The reason why I ask is we see quite a lot of problems following animal bites and I suspect people probably wouldn't go to the casualty department unless they knew they were going to get trouble.
TERRY
Animals, if you think about their mouths, are absolutely filthy, if you think about what's contained within their saliva and when they bite, because of the fangs, they inject all those horrible nasties quite deep into the skin. So although it might not look much on inspection they are quite a deep wound, so it's very, very important with those to clean them out extremely well and there we do tend to give antibiotics.
PORTER
Okay, well so far we have concentrated on physical problems, but mental illnesses can present as emergencies too. The Scottish Executive and NHS in Scotland have started a training programme to help ordinary people help others with crises caused by mental illness. We sent Caroline Williams along to find out more.
MARY
We learned about panic attacks. If you see somebody in the supermarket how you could identify if it was a panic attack or not. And before, I must admit, if I had seen somebody in a supermarket I would probably have just jumped the queue to the checkout.
WILLIAMS
Mary is one of a new breed of first aiders, trained to deal with the crisis of the mind.
MARY
Now I've got the confidence to say, it's okay it could just be a panic attack and I would know what to do and how to act in that situation and that I would never have done before I went on that course.
WILLIAMS
The Mental Health First Aid course pioneered in Australia is now available in Scotland. The course trains volunteers to spot the signs of problems as early as possible and to guide people towards treatment. Gregor Henderson is director of Scotland's programme for improving mental health and wellbeing.
HENDERSON
We know that people do want to know what to say, how to help, how to intervene, they don't sometimes have the skills and the confidence and the abilities to make those first approaches but with this course they will have the skills to be able to do that and not just to make the first approaches but also to be able to continue in some way to provide advice and support and very much to hold people in their anxiety, particularly during their period of crisis. What we're not saying though is that we're training a whole new bunch of mental health therapists or counsellors. The services need to be in the right place at the right time.
MUSIC
WILLIAMS
To qualify as a mental health first aider volunteers do 12 hours of exercises, including discussion, role play and written tasks. The emphasis is split between an awareness of mental health issues and practical help on how to deal with an emergency. Alana Atkinson is national coordinator of the training programme.
ATKINSON
When you actually come on the sessions you'll do a range of things. In particular about how to talk with someone, how to listen non-judgementally, and you get to practise some of your skills about engaging people around some perhaps difficult or not easy subjects to talk about like is the person thinking about taking their own life. Most importantly what they'll learn is what to do in a mental health crisis.
WILLIAMS
What actually constitutes a mental health crisis?
ATKINSON
For the purpose of this course a mental health crisis is if you are concerned that someone might be thinking about committing suicide or having a panic attack or suffering from acute stress disorder or in the first stages of psychosis.
MUSIC
WILLIAMS
And in the meantime while the rest of the UK waits to catch up with this programme what kinds of things can people be looking out for in their workplace or in their family and what advice could you give them?
HENDERSON
There are lots of good things to be able to do but the first thing to be able to do is to listen, the most important thing is that human contact. If someone is being seen to listen and listen to a person as a person first and foremost. That has capacities, abilities, desires, likes, wants, hates, everything else, to treat the person as a person and to listen. To empathise with their situation and just to know that you're there to guide and support someone is the best advice anyone can give anyone else.
PORTER
Gregor Henderson talking to Caroline Williams.
Polly, presumably mental illness must make up a significant part of your workload?
TERRY
Yeah, surprisingly, it's about 1-2% of all new patients presenting to A&E present with a mental health problem.
PORTER
And what sort of mental health problems?
TERRY
Generally with A&E it's a crisis intervention, so it maybe patients that have got an ongoing mental health problem and there's a sudden crisis and they'll present with suicidal type problems. But occasionally we do get a new presentation of a psychiatric illness.
PORTER
In suicide - attempted suicide, particularly overdose I suppose and you must see an awful lot of those?
TERRY
We do see a lot of those and in fact we end up admitting quite a lot of patients - about a fifth of all acute admissions on to a general medical ward is from deliberate self harm.
PORTER
And what sort of drugs are they taking?
TERRY
There's the common over-the-counter ones like paracetamol but then there's also the antidepressant tablets. And there's the herbal tablets - I don't think people are aware of quite how dangerous some of the herbal tablets are that you can buy.
PORTER
What sort of herbs Polly?
TERRY
A particularly common one is St John's Wort and this is available over-the-counter in most health food stores and it's actually taking for depression but an overdose of that can actually cause quite significant problems, mainly because of the way that it affects the liver and it affects the way all your other medicines work that you may be on at the time that's prescribed by your doctor.
PORTER
Okay, well let's go back to our first aid scenario again. Someone that you know or someone that you discover has taken an overdose what should you do and what shouldn't you do?
TERRY
As the gentleman before was saying the most important thing is to listen to what they say they've taken and then to get help for the patient. We don't anymore make patients sick or wash stomachs out or anything like that, just reassure the patient and call for help.
PORTER
And what about windows of opportunity here because with some types of overdose you can still do quite a lot even though it's been a long time elapsed since they took the pills, I was thinking of paracetamol, if someone admits to taking paracetamol the day before they should attend for help shouldn't they?
TERRY
Absolutely, paracetamol's a classic example because it tends to cause the effects about 24 hours down the line and there is a specific antidote that we can give for that which will save lives.
PORTER
So people taking an overdose ring help, don't give them anything, do not make them sick. Let's go back to people who want to learn more about all aspects of first aid - if you're looking to join a local course what sort of criteria should you look for, are some better than others?
TERRY
Generally I would go for the accredited courses and that's through people like St John Ambulance, British Red Cross and also St Andrew's up in Scotland. These are all accredited courses, you have a manual that goes with it, the people that teach them are trained in teaching methods and it's up-to-date information.
PORTER
I was going to ask you about the up-to-date side because there's a lot of people out there who've been on one course at some stage during their life but that's not the same as being up to speed with your skills is it.
TERRY
No, that's right. And some of the courses they give you accreditation for three years and then at the end of three years you need to retake the course.
PORTER
And that's for a reason because things change.
TERRY
Things do change all the time and our practises change in hospital, quite often we'll find we're going back to what we used to do.
PORTER
And you need to keep your skills up-to-date by practising, which hopefully you won't have to do if you become a first aider. Polly Terry, thank you very much.
If you want to learn more about anything we have covered in today's programme, including details of those accredited courses and the first aid for kids CD-Rom, then do call our action line on 0800 044 044 or visit the website at bbc.co.uk/radio 4 where you can also listen to the programme again.
Next week we'll be investigating the ear, and problems with hearing and balance - including a look at an effective, but often underused treatment for tinnitus and for those of you who use MP3 players and other types of personal stereos, how spending too much time listening to them could seriously damage your hearing.
ENDS
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