Last updated 19/11/23

Primary Survey - Reading The Wreckage

Before approaching any casualty, always remember that rescuer safety takes priority, always check for danger first.

In mountain rescue we can be called to a wide range of locations and circumstances. Unlike most First Responders, we can have a significant amount of time to think about potential problems and survey the scene and casualty as we approach.  Assessment starts as soon as you can see the casualty, and a huge amount of useful information can be obtained before you’ve even said hello.  Whilst approaching them think about what you can see and look for useful clues to inform and guide your assessment and management.

As some details will be contained in the alert message and possibly extra information will be available from those managing the rescue, if they’ve been able to speak to the informant, you can start thinking about what to look for whilst on the way to the scene (in the vehicle and on foot).  However you must be careful to treat the casualty you find, and not base your management on the alert, which is not infrequently wrong.

Remember – Primary Survey problems are always the priority and should always be considered, even if the casualty appears to have an isolated minor injury. Subsequent questioning and examination may show that the problem they complain about is not the most urgent issue you need to deal with.

The following section lists many of the items you can observe as you approach the casualty. Although it is a long list, almost all of these things will be immediately apparent simply by just looking, and you won’t have to think about it. The list just demonstrates how much information is available. The only time you will have to specifically ask about any of these things is in the Cas Care exam.

Information obtained from Reading the Wreckage will be used to ensure safety (rescuers, casualties and the public) as well as for the clinical management of the casualty.
 

Weather

• Weather conditions

• Sign of a recent lightning strike

Location and immediate surroundings:

• How long has it taken you to reach them?

• How many casualties?

• Near a cliff or large drop (either below, above or both i.e. on a ledge)

• Are they at the bottom of a steep slope?

• Is the ground flat, sloped or stepped?

• Surface (grass, mud, gravel, rocks)

• Are there rocks or objects nearby that they could have hit?

• Are there rocks or objects on top of them?

• What are they sitting/lying on?

• Are they in or near water?

• Are they on ice or in snow?

• Are they next to a stile or wall they could have fallen from?

• Are there bottles, pill packets and drug paraphernalia around them?

Posture and body position:

• Sitting up or lying down?

• Do they appear to have moved after they came to rest or are they lying motionless, perhaps in a very abnormal position (would suggest they failed to recover consciousness after coming to rest)?

• Are they moving spontaneously?

• Are they looking around? Do they freely orientate to you and watch you approaching?

• If sitting up, are they leaning against something? Is someone supporting them? Do they appear wobbly? Are they holding a limb protectively or grasping their chest?

• If lying down, how are they lying? Are they on their front, back or side?

• Are they curled up?

• Are their legs straight or bent?

• Are the limbs in a normal position or e.g. is a foot pointing backwards?

• Do they appear conscious?

• Is anyone administering any form of care e.g. c-spine immobilisation, airway support, chest compressions, etc.?

Gender, age and appearance:

• Is their clothing appropriate for the location, weather conditions and temperature?

• Do they appear to be a walker, climber, cyclist, motorcyclist, farmer or paraglider?

• Male or female?

• Adult or child?

• Estimate age

• Does their build imply they are regularly active?

• Do they appear alert?

• Do their eyes follow you?

• Are they focusing on you?

• Are they talking or moaning?

• Do they look unwell, pale, cold, sweaty or clammy?

• Is their face fallen or one side of their body paralysed?

• Do they look in pain, happy, sad or distressed?

• Do they have signs of long term illness (e.g. unusual skin colour)?

• Is their clothing ripped or torn?

• Is there blood or obvious wounds?

• Are their limbs in their normal alignment?

Assessing The Scene

Important information includes:

• Exact location (OS Grid, What 3 Words increasingly being used but not as accurate)

• Type of incident

• Hazards to rescuers

• Access problems

• Number of casualties

• Equipment on scene or any special equipment that could be needed

Introduction to managing multiple casualties – the Ten Second Triage (TST)

If the incident involves multiple casualties, then it is quite possible that there won't be enough rescuers and/or equipment to care for them all immediately. It will be necessary to identify which ones need the most urgent treatment and which ones are beyond help. In this situation, you must do the most for the most, and not focus all your resources trying to resuscitate those who are dead. All emergency services (from Spring 2023) now use the Ten Second Triage (TST) model (see below). This is a simple tool that allows a quick assessment and has been developed for anyone to use. The term ‘triage’ comes from the French and means ‘to sort’. Casualties are categorised, and can be prioritised for treatment using colour coded with cards, according to what treatment they will need. The Ten Second Triage has replaced the former ‘Triage Sieve’ that you will see referred to in books.

The prioritisation is as follows:-

• Priority 1 (Red) = Immediate life-saving treatment required e.g. airway management, major bleeding from pelvic fracture

• Priority 2 (Yellow) = Urgent e.g. open fracture of the lower leg

• Priority 3 (Green) = The walking wounded e.g. superficial cuts and bruises

• Not Breathing = CPR if resources allow.

Work your way down the chart from top to bottom. Use simple assessments to categorise each casualty.

For ‘severe bleeding’ (deliberate decision not to use the term “catastrophic haemorrhage” as this is often misunderstood), try to stop the bleeding using whatever is available and depending on the location of the bleed i.e. direct pressure, packing with haemostatic dressing (Celox) and pressure dressing or tourniquet. The ‘breathing’ blue diamond icon can be head tilt-chin lift, jaw thrust, OPA or NPA.

The important role of the person first on scene is to give essential details for all emergency services. The reporting system used is METHANE, this is outlined in the chart below. The Tally Chart is a recording of the assessment done by the first on scene for reporting to the Major Incident Team. NIck Wright is involved in the Major Incident work nationally and will be providing advice and training to the Team.

Consent

When you arrive at the casualty, you must remember that just because we’ve been called to an incident doesn’t mean the casualty has consented to us diagnosing and treating them.  Sometimes we may be called by third parties. If possible, it is essential to obtain informed consent from the casualty before:

• Undertaking diagnosis

• Recording medical and personal details

• Undertaking physical interventions (examination, taking blood pressure, etc.)

• Giving drugs

• Taking photographs for teaching purposes (NB you must never put any photographs of casualties on social media)

The fact that the casualty has co-operated with your care implies that they have consented. 

In order for the casualty to be able to give you informed consent you should give them the following at each stage:

• info on diagnosis

• treatment options inc. benefits

• purpose of treatment

• common/serious side effects

• remind them they can change their mind

Some casualties may not be able to give consent:

• Small children

• People with learning difficulties

• The seriously ill or injured

In these cases, consult a partner, parent or guardian if available and document that you received verbal consent from someone else.  If this is not possible, presumed consent can be assumed for interventions which can be justified as in the casualty’s best interest.

Remember – casualty’s can refuse treatment, in which case we must respect their wishes, unless they can reasonably be said to have a diminished capacity to make judgments due to:

• Serious illness

• Serious injury

• Mental health problems

If consent is refused, document this and get advice from the TL, DTL or team doctor.