NOLS WMI Wilderness First Aid Part 2 (PAS)
The WMI Patient Assessment System (PAS) was the core of the course. It’s laid out as a pyramid starting at the most important and time critical, down through the stages where you clarify and dig deeper, until you get to a stabil(ish) patient and can deal with the long term “what now” at the bottom.
You get a copy of a pocket sized card, showing the pyramid, that turned out to be really handy. I picked up another copy for my “other” first aid kit.
The top of the PAS pyramid is scene assessment. This is supposed to take 30 seconds to a minute while you’re walking up to the [whatever is going on]. It has five steps which you can count down on your fingers as you go and rhyme to yourself:
- Who’s #1, I AM: Which means your #1 priority is to make sure you’re safe too.
- What happened to you?: Which means ball parking what probably just happened (avalanche? bike fall? blacked out? etc.)
- Don’t get any on me: Which means making sure all their body fluids won’t get on you (gloves at least and maybe more)
- Are there any more?: Is there anybody else hurt we aren’t seeing yet?
- Dead or alive?: If this person is gone, move onto that other person.
The next level of the pyramid is the approach. Once you’ve got an overview of the scene and have your gloves on, you get involved.
First you introduce yourself and ask if they want your help. This is also the best time, based on the scenarios we ran, to ask how old they are. It’s hard to remember to do this later but it’s really good info to have.
Assuming they do, and you can assume that if they’re unconscious, you go through your ABCs:
- A - Airway
- B - Breathing
- C - Circulation/Bleeding
- D - Decision about c-spine injury
- E - Expose all known injuries
“Hi, I’m Aric. I’m Bob. Hey Bob. I’ve got some first aid training. Can I help? OK. How old are you Bob? Got anything in your mouth? …”
These are the big hitters. If at any point something isn’t good here you fix it ASAP. Choking on the teeth they just broke? Get those out of there. Can’t take a deep breath? Figure out what’s up. Bleeding out? Compression. Etc.
Some notes I made around this:
- If they have anything in their mouth ask them to spit it out. But let them do it. Digging around in there is to be avoided.
- Ask if they can take a deep breath to cover breathing.
- There’s a technique for blood checking where you go down the trunk, each arm, and each leg, putting both (gloved) hands on each section and pulling your hands away to look for blood at each spot. You don’t want to wipe down the person because if you have blood at the end it could’ve come from anywhere on that wipe.
C-spine is a big decision. If you decide they may have a spinal and immobilize their head, you’re immobilizing their head for the duration. You can’t take this one back. Hope you have a competent partner with you because doing everything else you need to do while you’re holding their head is going to be hard.
On the other hand, if you can’t convince yourself they for sure could not have hurt their spine you should immobilize it (hold their head).
There aren’t a lot of hard rules they could give us here. The wilderness is pretty variable. But if they fell less than their body height, low speeds, and didn’t loose consciousness, they’re probably fine. Tipping over on your bike probably isn’t but coming down the mountain into a tree probably is. Vehicles - snowmobiles, ATVs, etc. - are good ?candidates for spinals.
Rounding Things Out
The next step down the PAS pyramid, it’s getting wider, is made up of three parts:
- Head to Toe
- Vital Signs
At this stage you’re making sure you didn’t miss anything, getting more info and details, and making sure you didn’t miss anything. At this point you should really be writing stuff down.
Head to Toe
You’re going to touch the patient on every part of their body looking for blood, feeling for stuff moving that shouldn’t, noting if the patient is in pain, etc. This is where you really get into their space. It’s going to be awkward. Push hard on stuff.
Check their brow and nose. Back of their head. Push down on their hips with your full body weight (these are strong bones). You can check their sternum by putting the edge of your hand along it (karate chop style) and asking them to breath deep. They’ll need to deep breath to check ribs too.
Roll them over and check their back. Run your hands down their spine. Everything solid and in line? No wet spots (blood)? This is tricky if you’re holding their head because of a possible c-spine in the ABCDE phase. We got some techniques here but it’s really easiest if there’s two people helping.
While you’re going along keep checking your hands for blood spots.
If you find anything, expose it. You need to see everything you think might be an injury.
This is your last chance to find anything life threatening so be thorough.
Write down what you find.
As you finish up your head to toe:
- Note brain state: are they awake/oriented, awake/disoriented, or unconscious?
- Take a look at the skin on their upper chest near their neck. It’s protected so usually a good general indicator of overall state. Is it pink and warm or pale and clammy? The inside of their lower lip is another good spot to check.
- Have them grab your hands and ask them to squeeze. Are both sides strong and even?
- On each hand pinch a finger. Ask them which one you’re squeezing. Did they get it right?
- Move to their feet. Have them push down like a gas pedal on both sides. Strong and even? Have them push up on both sides. Strong and even?
- On each foot squeeze either their big or little toe (most people can’t tell individual toes like they can fingers). Did they get it right?
You’re looking for SCTM (skin color, temperature and moisture), LOR (level of responsiveness), and control differences side to side. If one hand isn’t as strong as the other, but you haven’t noted an injury on the weak side, you might have found something new.
Write all this down.
Now you’re going to find their heart and respiratory rate. You have a watch right? I didn’t. I’m looking for one now. Doing this with a phone sucks.
Find their radial pulse (it’s less intrusive than going for their neck but, honestly, I’m not sure that’s worth the trade for finding the damn thing after you’ve touched them all over). Tell them you’re taking their heart rate. Take it for 30 and remember the number, then start counting chest rises to get breath rate. Remember that. Then double both of them to get the per minute values.
They’ll think you’re taking pulse for a minute and hopefully won’t think about their breathing. If you tell somebody you’re checking their breathing they’ll do it wrong. ;)
If you’re having trouble seeing their chest rise ask them to lay their arm across their chest. That makes it easier to see movement.
Is their pulse strong or week? Is their breathing easy or labored?
You’re hoping for 50-100 beats per minute and 12-20 breaths per minute.
Write these values down and the date and time. (I need to add a waterproof notebook to my going out kit along with the watch.) Something like:
Time: 11:40 Brain: awake/oriented Heart: 78 bpm strong Resp: 14 rpm easy Skin: pink/warm/dry (chest)
You’ll probably be checking these on intervals so you can tell if the patient is stable, getting worse, or getting better. You need the running log to tell this. A single set of numbers doesn’t tell you all that much. This might be every 5 minutes, hour, or half hour depending on what’s going on. If you’re waiting for evac what else do you have to do?
Now that you’re getting to know each other, and you’re sure they’re not about to bleed out, you can finish up with Q and A. SAMPLE stands for:
- S, Symptoms: How are they feeling? Dizzy? Nauseous? Short of breath?
- A, Allergies: Foods? Animals? Plants? Medicines? Stings? What happens when you’re hit with your allergy? Have you been stung today? Do you have an epi pen with you?
- M, Medicines: Prescription? Over the counter? Herbals/vitamins? Recreational? When was the last time? How much (dose)?
- P, Past/Pertinent: Old back injuries? Heart problems? Longs? Diabetes? Pregnant? The “big stuff.”
- L, Last in/Last out: When was the last food/drink in? What was it? How much? When was the last time they urinated and defecated (yeah, embarrassing). Clear or dark? Normal or ? How much?
- E, Events leading to the incident: Prior to injury> Afraid of a bee so you lost track and fell off the cliff? Got dizzy and tripped?
You’re trying to find any last details that might help figure out what’s going on with this person. If they had a granola bar and a bottle of water on the way out here 6 hours ago and they’re dizzy, dehydration?
Recreational drugs are a relatively new one. Pot is legal in a few states and many people don’t think of alcohol as a drug/medicine. You might need to work around to asking about weed and that flask you found during the head to toe…
That’s in the next part…