Ten Kilometres, 38 Degrees: Three Casualties and One Stretcher
You are the senior cadet with 26 cadets on a 14 km route march in May. The temperature is 38°C and humidity is low. Each cadet carries one litre of water and the resupply point at 8 km has been passed. At about the 10 km mark three things happen almost together. Cadet A, aged 17, collapses: his skin is hot and dry, he is confused and irritable, his pulse is about 130 and the thermometer in the kit reads 40.2°C. Cadet B, aged 16, fell on a rock and has a rapidly swelling ankle; he can stand but cannot run. Two other cadets who drank from an irrigation tube well are vomiting. You have two first-aid kits, four litres of drinking water, one folded stretcher, no vehicle, and the nearest motorable road is 1.5 km away. An ambulance has been called and gives an estimated 25 minutes.
1. Give your triage order for the four casualties, with the reasoning for each placing.
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First - Cadet A. Confusion, a temperature of 40.2°C, hot dry skin and a pulse of 130 point to heat stroke, the only one of the four that can kill within the hour. Everything else can wait; this cannot.
Second - the two vomiting cadets, together. Vomiting after drinking from an unknown tube well raises two possibilities at once: contaminated water and heat illness. They can walk and are conscious, so they are not yet an emergency, but they can deteriorate quickly in this heat and they must be shaded, watched and given small sips of safe water or oral rehydration solution.
Third - Cadet B's ankle. Painful and it will end his march, but it is not life-threatening. Splint it, keep weight off it, and put him on the stretcher only if he cannot hop along with support - a stretcher party of four moves at about 2 km/h and would strip the group of its fittest carriers.
Principle: treat in the order of threat to life, not in the order of who is shouting or who is nearest. The obvious injury is not always the urgent one.
2. How will you manage Cadet A with what is actually available, and what must you not do?
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Do:
- Move him into shade at once and remove excess clothing.
- Cool him aggressively and continuously - wet the skin with water and fan him; place wet cloths at the neck, armpits and groin. Cooling is the treatment, not a comfort measure.
- Keep fanning while he is being carried and while waiting for the ambulance; do not stop because the temperature has fallen a degree.
- Check breathing and keep him under continuous observation; if he becomes unresponsive but is breathing, place him in the recovery position.
- Take the temperature every ten minutes and record time, temperature, pulse and what was done, for the ambulance crew.
Do not:
- Give fluids by mouth to a confused cadet - the airway is not protected.
- Give salt tablets, alcohol or a hot drink.
- Leave him alone, or send the only first-aider away with someone else.
- Use the tube well water for drinking; it is suspect. Use it for cooling if more water is needed, but not for drinking.
Reasoning: in heat stroke the body has lost the ability to lose heat. Water on the skin and moving air replace that function until the ambulance arrives.
3. How will you move the group, and what will you report?
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Move:
- Halt the march where it is, in the best shade available, and do not resume it. A commander who finishes the march with a heat-stroke case in the party has misunderstood the task.
- Send two fit cadets with a written note - names, numbers, position, time, casualties, ambulance called at what time - to the road, 1.5 km away, to guide the ambulance in. A written note survives a breathless messenger.
- Bring the group to the road in a controlled column, not a race: the vomiting cadets walking with a buddy each, Cadet B splinted and supported between two cadets, Cadet A carried on the stretcher with a fan and wet cloths and rotated carriers every few minutes.
- Keep everyone else in shade and sipping water while this happens.
Report to camp: time of collapse; Cadet A's temperature, pulse and conscious level at each check; that heat stroke is suspected; cooling started at what time; the tube well location and that two cadets drank from it; that an ambulance was requested at what time with what estimated arrival; the exact position of the group; and that the march is abandoned.
Reasoning: the report is what the medical officer acts on before he sees the patient, and the tube well note may protect the next company that marches this route.