The Collapsed Cyclist: First Aid, Consent and the Limits of Your Role
On a Saturday afternoon you are on duty at the entrance of a shopping centre. Outside, a cyclist in his sixties collides with a bollard and falls. He is lying on the pavement, conscious but confused, breathing normally, with a graze on his forehead and a swollen, deformed left wrist. He tries repeatedly to sit up and insists he is 'fine, just let me get my bike'. A small crowd gathers and one bystander starts filming with a phone. Your first-aid kit is inside the entrance, about 40 seconds away. A colleague is at the door. The ambulance service is called by the colleague and is expected within eight minutes.
1. Set out your priorities for the first two minutes, distinguishing what you know from what you are assuming.
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What is known: he fell and struck his head, he is confused, he has a deformed wrist, he is breathing normally and is conscious. What is assumed and must not be: that confusion is 'just shock'. Confusion after a head impact is a red flag, and the mechanism (fall onto a hard bollard with a head strike) means spinal injury cannot be excluded.
Priorities.
- Safety of the scene: traffic and other cyclists. Ask the colleague to divert pedestrians and cyclists around the casualty.
- Do not let him stand or walk. Kneel beside him, introduce yourself, explain what you are doing. Keep him still and support his head in the position found; do not move his neck to 'check' it.
- Airway, breathing, consciousness: speak to him, watch his chest, check that breathing is normal and not noisy. Reassess regularly; a confused head-injury casualty can deteriorate.
- Do not manipulate or straighten the wrist. Support it in the position found with something soft; the deformity is for the hospital to manage.
- Keep him warm and keep talking calmly; note the time of the fall and the changes you observe.
Consent. He is confused but not unconscious; explain and seek his agreement for what you do. If he becomes unresponsive, the duty to help continues and implied consent applies in an emergency.
2. The bystander filming steps closer and starts asking the casualty loudly whether he wants to 'sue the shopping centre'. How do you handle the bystander and the filming?
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Separate the two issues: the casualty's care and the filming.
Care first. The casualty's condition is the priority; do not get drawn into an argument over the phone camera. Ask the colleague to step in and deal with the bystander so you can stay with the casualty.
Filming. People may film in a public place, and you have no power to seize a phone or delete footage. What you can do is ask, politely and once: 'Could you step back and give him some space? He needs air and quiet.' If the person refuses, do not escalate physically; note the time, a description, and whether the footage might be relevant, and inform the police or ambulance crew on arrival.
The 'sue' question. Do not answer it, do not admit or deny liability, and do not discuss the shopping centre's responsibility. Say: 'I'm not the right person to answer that; my job right now is to keep him safe until the ambulance comes.' Anything you say about fault can be recorded and used later. Liability questions belong to the client's insurer and lawyers, not to the guard at the scene.
3. The ambulance is delayed and now expected in twenty minutes. The casualty becomes drowsy and stops answering. What changes?
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A deteriorating head-injury casualty changes the situation from 'monitor' to 'urgent'.
- Recheck airway and breathing immediately. If he is unresponsive but breathing normally, place him in the recovery position - but because a spinal injury is possible, use the modified technique that keeps the head, neck and trunk aligned as a unit while turning him, and only turn him if the airway is at risk.
- Call the ambulance control back, state that the patient's level of consciousness has dropped since the first call, and give the times. Ask whether a different unit or a first responder can attend. Update the estimate to the colleague so the entrance is cleared for the crew.
- Keep monitoring and recording: breathing, response to voice, any change in colour, and the exact times. This record is useful to the paramedics.
- Do not give him anything to eat or drink, do not try to sit him up, and do not remove his helmet if he is wearing one unless the airway cannot be managed otherwise.
Boundary of your role. You are providing basic life support and keeping him safe until professional care arrives; you are not diagnosing. If breathing stops, start CPR and send for the AED, following the dispatcher's instructions.