Volume 70 July 1977
503
Section of Occupational Medicine President R I McCallum MD
Meeting 28 October 1976
Specialized First Aid [Report] Certain situations dictate the need for the provision of first aid facilities which are more advanced than those more commonly in use. Examples of these are oil rigs and the operational activities of the Special Air Service Regiment
(SAS).
The requirements for an oil rig are those of a heavy engineering industry with, in addition, the problems of remoteness and of transportation of casualties to the nearest medical base. Offshore installations may be separated from hospital care by a distance of thirty to two hundred and fifty miles and, while transport of patients over this distance is usually carried out by helicopter, the weather is an important factor. Even in the most urgent emergency the helicopter may be grounded by fog or snow, and sick or injured men must then await the delayed arrival of the helicopter or endure the slower journey by ship. Most modern rigs and platforms have beds to care for such patients as well as examination tables, excellent lighting, sterilizing facilities, resuscitation apparatus and suitable diagnostic equipment, instruments and drugs. Dr Robin Cox outlined the special skills required of those looking after the sick and injured on an oil rig. As in heavy engineering industry, the injuries sustained on an oil rig range from simple hand injuries to severe crush injuries of limbs or trunk, head injuries, internal injuries and fractured limbs. The more severely injured patient needs to be prepared for the helicopter journey and the attendant must be able to set up and monitor an intravenous infusion. It may also be necessary to apply artificial respiration during transport and this is usually carried out by positive pressure artificial respiration. Unpredictable acute medical emergencies may arise in this population of carefully selected fit employees, and with these the attendant must be
able to cope; more commonly he is likely to find himself in a general practice situation where he may act as counsellor, father-confessor and confidant of all ranks on board. The skills that are required of the industrial physician in handling confficts between management and men are also necessary here. Over and above these, specialized knowledge of diving is required, for a man may receive an injury or become ill during periods of working of 28-32 days under pressure (saturation diving), or may suffer decompression sickness. As well as being fit himself the attendant must be able to diagnose and treat the patient in a pressure chamber. This involves being able to carry out a detailed examination of the patient, and to put up infusions, give injections or insert catheters in the confined, noisy and pressurized space of a recompression chamber. Dr Cox discussed the qualifications that this attendant, the 'medic', must have. For reasons such as lack of job satisfaction, lack of ancillary services and economic extravagance, the job is not suitable for a doctor. On the other hand, the acquisition of an ordinary first aid certificate is insufficient training for the job. The choice would therefore be of someone who has at least the qualification SRN but who would require additional training in casualty work and probably in dermatology, venereology and ophthalmology. Preferably he should be able to carry out laryngeal intubation, set up intravenous infusions, cardiopulmonary resuscitation and other practical procedures. To maintain his standard of skill refresher courses are needed and it was Dr Cox's personal view that this required courses of at least one month per year, which should be arranged in suitable departments of active NHS hospitals. He was further of the opinion that offshore medics should be employed by an appropriate organization which would recruit and train them and
504
Proc. roy. Soc. Med. Volume 70 July 1977
offer them a career structure and professional support. If the general practitioners who provide the back-up for the medics could take part in their training this would contribute to the efficiency of the service and to harmonious relationships. Major I T Houghton discussed first aid in the Special Air Service Regiment. This was formed in 1941 by David Stirling for operations behind the enemy lines in North Africa and the training of the regiment's medical aides in advanced first aid is directed towards its application in isolated places. Unlike the medics on the oil rigs, the medical aide in the SAS is a highly trained professional soldier with special skill in first aid and that of an advanced kind. Selection of men for the regiment is by testing physical and mental resilience in carrying out long hard marches in arduous conditions. To encompass all the skills required for operations undertaken by the SAS, patrols are grouped into troops each with specialized training. The mode of entry and operation may be dictated by the terrain and so the mobility troops may use landrovers, or be trained to use small amphibious craft, or be air troops trained in military free-fall parachuting in the frog position carrying kit, while others are trained in mountaineering. Additionally every trooper is required to have at least one advanced individual skill which may be signalling, as a linguist, as an explosive and demolition expert, or as a medical aide. Not surprisingly, Major Houghton stated that the medical aide is the man whom the patrol values most when the going gets tough. All men in the regiment attend a one-week course of basic first aid training which orientates them to using their knowledge in isolated places. Candidates for specialized training as medical aides are then chosen from these men during their first year in the regiment. The stated aims of the medical aide courses are: to save life; to prevent disease and treat minor medical conditions; to communicate the findings; to give advice to the patrol commander on health matters. The course lasts seven weeks and consists of four weeks of theoretical and practical training and three weeks attached to the accident and emergency department of selected major civilian district general hospitals. In the classroom basic anatomy and physiology are taught, and this is followed by instruction in
advanced techniques of first aid such as the assessment of blood and fluid loss and how to correct it. Training is given in the recognition of important medical signs and serious illness and the necessity for early evacuation of the patient. Emphasis is placed on the care and safe handling of medicines and instruments in the patrol medical pack. During the period of hospital training opportunity is provided to acquire experience in the practical handling of casualties. By these means the medical aide, himself a professional soldier and member of his patrol, can render invaluable assistance to any of his comrades unfortunate enough to suffer injury or illness, in even the most inhospitable areas of operation. To refrain from teaching resuscitation for the victims of a coronary heart attack seems unthinkable to those whose responsibility it is to train first aiders in industry, yet this was the message of Professor J R Muir's talk on first aid in cardiac emergencies. Professor Muir convincingly showed that the majority of sudden deaths are due to ventricular fibrillation, which calls for the use of a defibrillator and adequate correction of acidosis in a hospital unit. The management of an acute coronary incident even in the absence of ventricular fibrillation is a skilled business in the first few hours after an attack and requires a knowledge of cardiac physiology and a long training period. After an attack adequate control of pain is one of the most important aspects, and intravenous morphine or diamorphine is recommended. Bradycardia might possibly need to be treated, since it predisposes to allowing the entry of ectopic rhythms. In most cases the situation is resolved by the use of atropine. Getting the patient to hospital as soon as possible is, however, of paramount importance. Rather than teach how to resuscitate in a case of cardiac arrest it would be beneficial, Professor Muir asserted, to teach the recognition of pain which may be cardiogenic in origin, so that an early diagnosis can be made and early treatment begun. J W CUTHBERT
Senior Medical Officer, May & Baker Ltd; Section Editor, Section of Occupational Medicine
503
Section of Occupational Medicine President R I McCallum MD
Meeting 28 October 1976
Specialized First Aid [Report] Certain situations dictate the need for the provision of first aid facilities which are more advanced than those more commonly in use. Examples of these are oil rigs and the operational activities of the Special Air Service Regiment
(SAS).
The requirements for an oil rig are those of a heavy engineering industry with, in addition, the problems of remoteness and of transportation of casualties to the nearest medical base. Offshore installations may be separated from hospital care by a distance of thirty to two hundred and fifty miles and, while transport of patients over this distance is usually carried out by helicopter, the weather is an important factor. Even in the most urgent emergency the helicopter may be grounded by fog or snow, and sick or injured men must then await the delayed arrival of the helicopter or endure the slower journey by ship. Most modern rigs and platforms have beds to care for such patients as well as examination tables, excellent lighting, sterilizing facilities, resuscitation apparatus and suitable diagnostic equipment, instruments and drugs. Dr Robin Cox outlined the special skills required of those looking after the sick and injured on an oil rig. As in heavy engineering industry, the injuries sustained on an oil rig range from simple hand injuries to severe crush injuries of limbs or trunk, head injuries, internal injuries and fractured limbs. The more severely injured patient needs to be prepared for the helicopter journey and the attendant must be able to set up and monitor an intravenous infusion. It may also be necessary to apply artificial respiration during transport and this is usually carried out by positive pressure artificial respiration. Unpredictable acute medical emergencies may arise in this population of carefully selected fit employees, and with these the attendant must be
able to cope; more commonly he is likely to find himself in a general practice situation where he may act as counsellor, father-confessor and confidant of all ranks on board. The skills that are required of the industrial physician in handling confficts between management and men are also necessary here. Over and above these, specialized knowledge of diving is required, for a man may receive an injury or become ill during periods of working of 28-32 days under pressure (saturation diving), or may suffer decompression sickness. As well as being fit himself the attendant must be able to diagnose and treat the patient in a pressure chamber. This involves being able to carry out a detailed examination of the patient, and to put up infusions, give injections or insert catheters in the confined, noisy and pressurized space of a recompression chamber. Dr Cox discussed the qualifications that this attendant, the 'medic', must have. For reasons such as lack of job satisfaction, lack of ancillary services and economic extravagance, the job is not suitable for a doctor. On the other hand, the acquisition of an ordinary first aid certificate is insufficient training for the job. The choice would therefore be of someone who has at least the qualification SRN but who would require additional training in casualty work and probably in dermatology, venereology and ophthalmology. Preferably he should be able to carry out laryngeal intubation, set up intravenous infusions, cardiopulmonary resuscitation and other practical procedures. To maintain his standard of skill refresher courses are needed and it was Dr Cox's personal view that this required courses of at least one month per year, which should be arranged in suitable departments of active NHS hospitals. He was further of the opinion that offshore medics should be employed by an appropriate organization which would recruit and train them and
504
Proc. roy. Soc. Med. Volume 70 July 1977
offer them a career structure and professional support. If the general practitioners who provide the back-up for the medics could take part in their training this would contribute to the efficiency of the service and to harmonious relationships. Major I T Houghton discussed first aid in the Special Air Service Regiment. This was formed in 1941 by David Stirling for operations behind the enemy lines in North Africa and the training of the regiment's medical aides in advanced first aid is directed towards its application in isolated places. Unlike the medics on the oil rigs, the medical aide in the SAS is a highly trained professional soldier with special skill in first aid and that of an advanced kind. Selection of men for the regiment is by testing physical and mental resilience in carrying out long hard marches in arduous conditions. To encompass all the skills required for operations undertaken by the SAS, patrols are grouped into troops each with specialized training. The mode of entry and operation may be dictated by the terrain and so the mobility troops may use landrovers, or be trained to use small amphibious craft, or be air troops trained in military free-fall parachuting in the frog position carrying kit, while others are trained in mountaineering. Additionally every trooper is required to have at least one advanced individual skill which may be signalling, as a linguist, as an explosive and demolition expert, or as a medical aide. Not surprisingly, Major Houghton stated that the medical aide is the man whom the patrol values most when the going gets tough. All men in the regiment attend a one-week course of basic first aid training which orientates them to using their knowledge in isolated places. Candidates for specialized training as medical aides are then chosen from these men during their first year in the regiment. The stated aims of the medical aide courses are: to save life; to prevent disease and treat minor medical conditions; to communicate the findings; to give advice to the patrol commander on health matters. The course lasts seven weeks and consists of four weeks of theoretical and practical training and three weeks attached to the accident and emergency department of selected major civilian district general hospitals. In the classroom basic anatomy and physiology are taught, and this is followed by instruction in
advanced techniques of first aid such as the assessment of blood and fluid loss and how to correct it. Training is given in the recognition of important medical signs and serious illness and the necessity for early evacuation of the patient. Emphasis is placed on the care and safe handling of medicines and instruments in the patrol medical pack. During the period of hospital training opportunity is provided to acquire experience in the practical handling of casualties. By these means the medical aide, himself a professional soldier and member of his patrol, can render invaluable assistance to any of his comrades unfortunate enough to suffer injury or illness, in even the most inhospitable areas of operation. To refrain from teaching resuscitation for the victims of a coronary heart attack seems unthinkable to those whose responsibility it is to train first aiders in industry, yet this was the message of Professor J R Muir's talk on first aid in cardiac emergencies. Professor Muir convincingly showed that the majority of sudden deaths are due to ventricular fibrillation, which calls for the use of a defibrillator and adequate correction of acidosis in a hospital unit. The management of an acute coronary incident even in the absence of ventricular fibrillation is a skilled business in the first few hours after an attack and requires a knowledge of cardiac physiology and a long training period. After an attack adequate control of pain is one of the most important aspects, and intravenous morphine or diamorphine is recommended. Bradycardia might possibly need to be treated, since it predisposes to allowing the entry of ectopic rhythms. In most cases the situation is resolved by the use of atropine. Getting the patient to hospital as soon as possible is, however, of paramount importance. Rather than teach how to resuscitate in a case of cardiac arrest it would be beneficial, Professor Muir asserted, to teach the recognition of pain which may be cardiogenic in origin, so that an early diagnosis can be made and early treatment begun. J W CUTHBERT
Senior Medical Officer, May & Baker Ltd; Section Editor, Section of Occupational Medicine
