First on scene at a rural motorcycle crash
You are riding on a rural 80 km/h road at dusk and come round a bend to find a single motorcycle on its side against a steel guardrail, the engine still running and fuel running across the road. The rider, a man of about 30, is lying on his right side on the verge with a full-face helmet on and the visor up. He is breathing noisily, with a snoring sound on each breath, and there is blood around his nose and mouth. His right lower leg is bent at an odd angle and his left glove is missing. Traffic is still passing at speed and the bend is blind from the other direction for about 60 m. There is no one else on the scene. You have a first-aid kit, a phone and a hi-vis vest.
1. Set out your priorities for the first minute, in order, and say why each one comes where it does.
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1. Do not become the second casualty. Stop before the scene if you can, hazards on, hi-vis on, and get warning out towards the blind approach - triangle or bike positioned to be seen, not in the carriageway. A helper struck at 80 km/h turns one casualty into two and takes you out of the equation.
2. Kill the obvious ignition risks if it is safe to reach. The engine is running and fuel is spreading. Switch off if you can do it without stepping into traffic or into the fuel; do not create sparks.
3. Call the emergency number immediately, before hands-on care, and give location, number of casualties, mechanism (motorcycle against guardrail), whether he is conscious and breathing, and the leg injury. If you are alone, speakerphone keeps your hands free. Do not hang up - the dispatcher can talk you through what you are doing.
4. Airway and breathing. Snoring, noisy breathing with blood around the mouth is a partial obstruction. Wipe blood from the mouth, support the head in line with the spine and use a jaw thrust or gentle chin lift - enough to open the airway without forcing the neck.
2. Should you take the helmet off? Explain the conditions under which the answer changes.
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Default: leave it on. A full-face helmet supports the head and offers some protection; removing it can move an unstable cervical spine and convert a breathing casualty into a dead one. With one untrained person and a casualty who is breathing, removal is the higher risk.
What you can do with it on. Open or remove the visor, take off glasses, clear blood and debris from the mouth, and use a jaw thrust from the sides of the jaw to lift the tongue away from the back of the throat. The snoring should change or stop when the airway opens - that is your check that the manoeuvre is working.
When the answer changes. If the airway cannot be kept open, or he stops breathing and you need to ventilate, the helmet has to come off. That is a two-person job: one holds the head and neck in line, the other eases the helmet off by pulling the sides apart and rolling it forward, not lifting straight up. If you are alone with no help and no airway, you do what you must and document it in the handover.
3. The fuel is still spreading and traffic is passing close by. Do you move him, and what do you monitor while you wait?
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Moving him. With a deformed lower leg and a mechanism that suggests spinal injury, movement is a last resort. Move a casualty only if staying put is more dangerous than moving - fire, an imminent second collision, or a fuel pool that is about to ignite. If you must move him because of fire risk, drag along the long axis of the body, head first, keeping the head and neck as aligned as you can, and get him well clear of the road.
Otherwise treat in place. Control bleeding with direct pressure, do not straighten or splint the leg beyond immobilising it as found, cover him to keep him warm (shock and dusk cold are a bad combination), and never give him anything to drink.
Monitor. Breathing rate and quality every minute - snoring returning means the airway is closing again. Watch for deteriorating consciousness, pale clammy skin, a weak rapid pulse: signs of shock. Note the times of any changes, and pass the mechanism of injury and your observations to the ambulance crew.