text:
Horticulture/Ranunculus ficaria

Lesser celandine, (Ranunculus ficaria, syns. Ficaria grandiflora, Ficaria verna), is a low-growing perennial native to Eurasia, but introduced into other parts of the world where it has escaped from cultivation.

Description
Lesser Celandine is a low-growing, hairless perennial plant, with fleshy dark green, heart-shaped leaves. It is a spring ephemeral, meaning that the foliage dies down after seeds are set in early summer.

The flowers are yellow, turning white as they age. Ranunculus ficaria exists in both diploid and tetraploid forms which are very similar in appearance. However, the tetraploid type prefer more shady locations and frequently develops bulbils at the base of the stalk. These two variants are sometimes referred to as distinct sub-species, R. ficaria ficaria and R. ficaria bulbifer respectively. The plant is found throughout Europe and west Asia and is now introduced in North America. It prefers bare, damp ground and in the UK it is often a persistent garden weed.

Ecology
In many parts of the northern United States and Canada, lesser celandine is an invasive weed. It can be a difficult weed to eradicate both in gardens and in woodlands or meadows.

Uses
According to Gilbert White, a diarist writing around 1800 in the Hampshire village of Selborne, the plants came out on February 21st, but it is more commonly reported to flower from March until May, and is sometimes called the "spring messenger" as a consequence. It is sometimes planted (or at least tolerated) for the early flowers and the glossy foliage.

The plant used to be known as Pilewort, as it was used to treat hemorrhoids. Supposedly the knobbly tubers of the plant resemble piles, and according to the Doctrine of signatures this resemblance suggests that pilewort could be used to cure piles. The German vernacular Scharbockskraut (Scurvywort) derives from the use of the early leaves, which are high in vitamin C, against scurvy.

title: Horticulture/Ranunculus ficaria


text:
Statistics/Point Estimation

Introduction
Usually, a random variable $$X$$ resulting from a random experiment is to follow a certain distribution with an unknown (but ) parameter (vector) $$\theta\in\mathbb R^k$$ ($$k$$ is a positive integer, and its value depends on the distribution), taking value in a set $$\Theta$$, called the parameter space.

For example, suppose the random variable $$X$$ is assumed to follow a normal distribution $$\mathcal N(\mu,\sigma^2)$$. Then, in this case, the parameter vector $$\theta=(\mu,\sigma)\in\Theta$$ is unknown, and the parameter space $$\Theta=\{(\mu,\sigma):\mu\in\mathbb R,\sigma>0\}$$. It is often useful to those unknown parameters in some ways to "understand" the random variable $$X$$ better. We would like to make sure the estimation should be "good" enough, so that the understanding is more accurate.

Intuitively, the (realization of) $$X_1,\dotsc,X_n$$ should be useful. Indeed, the estimators introduced in this chapter are all based on the random sample in some sense, and this is what mean. To be more precise, let us define and.

In the following, we will introduce two well-known point estimators, which are actually quite "good", namely and.

Maximum likelihood estimator (MLE)
As suggested by the name of this estimator, it is the estimator that some kind of "likelihood". Now, we would like to know what "likelihood" should we maximize to estimate the unknown parameter(s) (in a "good" way). Also, as mentioned in the introduction section, the estimator is based on the random sample in some sense. Hence, this "likelihood" should be also based on the random sample in some sense.

To motivate the definition of maximum likelihood estimator, consider the following example.

Intuitively, with these particular realizations (fixed), we would like to find a value of $$p$$ that maximizes this probability, i.e.,, makes the realizations obtained to be the one that is "most probable" or "with maximum likelihood". Now, let us formally define the terms related to MLE.

Now, let us find the MLE of the unknown parameter $$p$$ in the previous coin flipping example.

Sometimes, there is constraint imposed on the parameter when we are finding its MLE. The MLE of the parameter in this case is called a MLE. We will illustrate this in the following example.

To find the MLE, we sometimes use methods other than derivative test, and we do not need to find the log-likelihood function. Let us illustrate this in the following example.

In the following example, we will find the MLE of a parameter vector.

Method of moments estimator (MME)
For maximum likelihood estimation, we need to utilize the likelihood function, which is found from the joint pmf of pdf of the random sample from a distribution. However, we may not know exactly the pmf of pdf of the distribution in practice. Instead, we may just know some information about the distribution, e.g. mean, variance, and some moments ($$r$$th moment of a random variable $$X$$ is $$\mathbb E[X^r]$$, we denote it by $$\mu_r$$ for simplicity). Such moments often contain information about the unknown parameter. For example, for a normal distribution $$\mathcal N(\mu,\sigma^2)$$, we know that $$\mu=\mu_1$$ and $$\sigma^2=\mu_2-(\mu_1)^2$$. Because of this, when we want to estimate the parameters, we can do this through estimating the moments.

Now, we would like to know how to estimate the moments. We let $$m_r=\frac{\sum_{i=1}^{n}X_i^r}{n}$$ be the $$r$$th, where $$X_i$$'s are independent and identically distributed. By (assuming the conditions are satisified), we have In general, we have $$m_r\;\overset{p}\to\; \mu_r$$, since the conditions are still satisfied after replacing the "$$X$$" by "$$X^r$$" in the weak law of large number.
 * $$\overline X=m_1\;\overset{p}\to\; \mathbb E[X]=\mu_1$$
 * $$m_2\;\overset{p}\to\; \mathbb E[X^2]=\mu_2$$ (this can be seen from replacing the "$$X$$" by "$$X^2$$" in the weak law of large number, then the conditions are still satisfied, and so we can still apply the weak law of large number)

Because of these results, we can estimate the $$r$$-th moment $$\mu_r$$ using the $$r$$-th sample moment $$m_r$$, and the estimation is "better" when $$n$$ is large. For example, in the above normal distribution example, we can estimate $$\mu$$ by $$m_1$$ and $$\sigma^2$$ by $$m_2-(m_1)^2$$, and these estimators are actually called the.

To be more precise, we have the following the definition of the :

Properties of estimator
In this section, we will introduce some criteria for evaluating how "good" a point estimator is, namely, and.

Unbiasedness
For $$\hat\theta$$ to be a "good" estimator of a parameter $$\theta$$, a desirable property of $$\hat\theta$$ is that its expected value equals the value of the parameter $$\theta$$, or at least close to the value. Because of this, we introduce a value, namely, to measure how close is the mean of $$\hat\theta$$ to $$\theta$$.

We will also define some terms related to bias.

Efficiency
We have discussed how to evaluate the unbiasedness of estimators. Now, if we are given two unbiased estimators, $$\hat\theta$$ and $$\tilde\theta$$, how should we compare their goodness? Their goodness is the same if we are only comparing them in terms of unbiasedness. Therefore, we need another criterion in this case. One possible way is to compare their , and the one with smaller variance is better, since on average, the estimator is less deviated from its mean, which is the value of the unknown parameter by the definition of unbiased estimator, and thus the one with smaller variance is more accurate in some deviation sense. Indeed, an unbiased estimator can still have a large variance, and thus deviate a lot from its mean. Such estimator is unbiased since the positive deviations and negative deviations somehow cancel out each other. This is the idea of.

Actually, for the variance of unbiased estimator, since the mean of the unbiased estimator is the unknown paramter $$\theta$$, it measures the mean of the squared deviation from $$\theta$$, and we have a specific term for this deviation, namely (MSE).

Notice that in the definition of MSE, we do not specify that $$\hat\theta$$ to be an unbiased estimator. Thus, $$\hat\theta$$ in the definition may be biased. We have mentioned that when $$\hat\theta$$ is unbiased, then its variance is actually its MSE. In the following, we will give a more general relationship between $$\operatorname{MSE}(\hat\theta)$$ and $$\operatorname{Var}(\hat\theta)$$, not just for unbiased estimators.

Uniformly minimum-variance unbiased estimator
Now, we know that the smaller the variance of an unbiased estimator, the more efficient (and "better") it is. Thus, it is natural that we want to know what is the efficient (i.e., the "best") unbiased estimator, i.e., the unbiased estimator with the smallest variance. We have a specific name for such unbiased estimator, namely. To be more precise, we have the following definition for UMVUE:

Indeed, UMVUE is, i.e., there is exactly one unbiased estimator with the smallest variance among all unbiased estimators, and we will prove it in the following.

Cramer-Rao lower bound
Without using some results, it is quite difficult to determine the UMVUE, since there are many (perhaps even infinitely many) possible unbiased estimator, so it is quite hard to ensure that one particular unbiased estimator is relative more efficient than every other possible unbiased estimators.

Therefore, we will introduce some approaches that help us to find the UMVUE. For the first approach, we find a on the variances of all possible unbiased estimators. After getting such lower bound, if we can find an unbiased estimator with variance to be exactly equal to the lower bound, then the lower bound is the minimum value of the variances, and hence such unbiased estimator is an UMVUE by definition.

A common way to find such lower bound is to use the (CRLB), and we get the CRLB through. Before stating the inequality, let us define some related terms.

For the regularity conditions which allow interchange of derivative and integral, they include We have some results that assist us to compute the Fisher information.
 * 1) the partial derivatives involved should exist, i.e., the (natural log) of the functions involved is differentiable
 * 2) the integrals involved should be differentiable
 * 3) the support does not depend on the parameter(s) involved

Sometimes, we cannot use the CRLB method for finding UMVUE, because We will illustrate some examples for these two cases in the following.
 * the regularity conditions may not be satisfied, and thus we cannot use the Cramer-Rao inequality, and
 * the variance of the unbiased estimator may not be equal to the CRLB, but we cannot conclude that it is not an UMVUE, because it may be the case that the CRLB is not attainable at all, and the smallest variance among all unbiased estimators is actually the variance of that estimator, which is larger than the CRLB.

Since the CRLB is sometimes attainable and sometimes not, it is natural to question that can the CRLB be attained. In other words, we would like to know the for the CRLB, which are stated in the following corollary.

We have discussed MLE previously, and MLE is actually a "best choice" asymptotically (i.e., as the sample size $$n\to\infty$$) according to the following theorem.

Since we are not able to use the CRLB to find UMVUE in some situations, we will introduce another method to find UMVUE in the following, which uses the concepts of and.

Sufficiency
Intuitively, a $$T(X_1,\dotsc,X_n)$$, which is a function of a given random sample $$X_1,\dotsc,X_n$$, contains all information needed for estimating the unknown parameter (vector) $$\theta$$. Thus, the statistic $$T(X_1,\dotsc,X_n)$$ itself is "sufficient" for estimating the unknown parameter (vector) $$\theta$$.

Formally, we can define and describe as follows:

Let us state the above remark about transformation of sufficient statistic formally below.

Now, we discuss a theorem that helps us to check the sufficiency of a statistic, namely (Fisher-Neyman).

For some "nice" distributions, which belong to, sufficient statistics can be found using another alternative method easily and more conveniently. This method works because of the "nice" form of the pdf or pmf of those distributions, which can be characterized as follows:

Now, we will start discussing how is sufficient statistic related to UMVUE. We begin our discussion by.

To actually determine the UMVUE, we need another theorem, called, which is based on Rao-Blackwell theorem, and requires the concept of.

Completeness
When a random sample $$X_1,\dotsc,X_n$$ is from a distribution in exponential family, then a complete statistic can also be founded easily, similar to the case for sufficient statistic.

Consistency
In the previous sections, we have discussed and. In this section, we will discuss another property called.

license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/

title: Statistics/Point Estimation


text:
Radiation Oncology/Sarcoma/DFSP

Dermatofibrosarcoma Protuberans

Epidemiology

 * Cutaneous, locally aggressive, primarily low grade sarcoma
 * ~10% may contain a high-grade fibrosarcoma component
 * Low rate (<5%) of metastasis; higher if fibrosarcoma component
 * Rare, 2-6% of soft tissue sarcomas
 * Adults in 30's
 * Risk factors: pregnancy, arsenic exposure, acanthosis nigricans

Clinical Presentation

 * Plaque-like areas of cutaneous thickening
 * Skin-colored, red-brown, or violaceous, particularly at the margins
 * May arise within pre-existing scar or tattoo
 * As it slowly enlarges, becomes raised ("protuberans"), firm, and nodular (fixed to dermis, but moves over deeper structures)
 * At diagnosis, >75% are superficial and <5cm diameter
 * Slow, indolent growth, such that the lesion may be present for years
 * Distribution:
 * Trunk ~50%
 * Lower extremity ~20%
 * Upper extremity 15%
 * Head and neck 15%

Work Up

 * MRI helpful to estimate extent of deep extent
 * CT not routinely necessary, unless bony invasion suspected
 * Metastatic workup not routinely necessary, unless suspicion from H&P

Histology

 * Cell of origina is not well understood
 * Histochemistry and electron microscopy suggest fibroblast lineage
 * However, the cells are CD34 positive, suggesting possibly dendritic lineage
 * In comparison, dermatofibromas and desmoid tumors are CD34-
 * The tumors show benign-appearing spindle cells, in an irregular patterns resembling a straw mat. In early lesions there is a tumor-free zone with epidermis
 * >90% have a t(17;22) translocation, resulting in a fusion of PDFG-B driven by a highly expressed collagen promoter (COL1A1)
 * Results in PDFGRb activation, which is tyrosine kinase receptor

Staging

 * AJCC 7th Edition (2010)
 * First edition to include DFSP
 * Please see the Soft Tissue Sarcoma staging page

 * American Musculoskeletal Tumor Society Staging for DFSP
 * Stage IA - Low or intermediate grade within the subcutaneous compartment
 * Stage IB - Low or intermediate grade extending outside anatomic compartment
 * Stage II - High grade histology

Natural History

 * Tends to recur locally after excision alone
 * Recur locally multiple times before metastasis; significant interval before development of metastases.
 * Fibrosarcomatous changes predict for metastatic potential.

Treatment Overview

 * Surgical resection is the primary treatment approach
 * Historically, wide local excision with 3cm margins was recommended, down to and including fascia
 * Mohs mapping reveals fine tentacles of tumor, and is becoming favored due to preservation of cosmesis
 * Some recommend modified Mohs to include a final path margin for permanent section
 * Pooled local recurrence rate with adequate margin WLE or Mohs' is <2%
 * Recurrences tend to occur within 3 years of surgery
 * Definitive RT not routinely; only couple reports available
 * Adjuvant radiation is typically indicated if positive or close margins, further resection anatomically not possible if recurrence happens, or recurrent disease
 * Given the high rate of t(17;22) leading downstream to a tyrosine kinase activation, efforts are under way to use Gleevec and other TKIs in this disease

Adjuvant Radiation Therapy

 * MD Anderson
 * 2013 (1972-2010) PMID 23628134 -- Dermatofibrosarcoma Protuberans: Long-term Outcomes of 53 Patients Treated With Conservative Surgery and Radiation Therapy. (Castle KO, Int J Radiat Oncol Biol Phys. 2013 Jul 1;86(3):585-90. doi: 10.1016/j.ijrobp.2013.02.024. Epub 2013 Apr 26.)
 * Retrospective. 53 consecutive patients. Surgery and preoperative (13%) or postoperative (87%) RT. Median tumor size 4 cm (1-25 cm). Preop dose 50 Gy, postop dose 60-66 Gy. Gross disease 7%, positive margin 30%. Median F/U 6.5 years
 * Outcome: Recurrence 4%. 5-year and 10-year OS 98%. Fibrosarcomatous change not associated with risk of LR or DM
 * Toxicity: 13%; moderate/severe complications 9% at 10 years
 * Conclusion: DFSP is radioresponse with excellent local control after surgery and RT. Adjuvant RT should be considered if large/recurrent tumor or where attempt at wide surgical margins would result in significant morbidity
 * 1998 PMID 9531366 -- "The role of radiation therapy in the management of dermatofibrosarcoma protuberans." (Ball MT, Int J Radiat Oncol Biol Phys. 1998 Mar 1;40(4):823-7.
 * Retrospective. 19 patients receiving adjuvant xrt. 60 Gy given for +microscopic margin; 65 Gy given for gross residual disease.  Local control at 10 yrs was 95%
 * Conclusion: adjuvant xrt should be considered for +margins or if adequate wide excision would lead to major cosmetic defect.

 * Soft Tissue Tumours Working Group, The Netherlands Cancer Institute; 1997 PMID 9376187 -- Haas RL et al. "The role of radiotherapy in the local management of dermatofibrosarcoma protuberans."
 * 38 consecutive pts w/ DFSP. 21 tx'd surgically, 17 tx'd w/ combined modality.
 * Surgery alone had local control of 67%
 * Combined modality had local control of 82% (many of these who had xrt already had multiple local recurrences.

 * Harvard; 1996 PMID 8708729 -- Suit H et al. "Radiation in management of patients with dermatofibrosarcoma protuberans."  J Clin Oncol. 1996 Aug;14(8):2365-9.
 * 18 patients treated with postop (n=15) or definitive (n=3) xrt. Population was +/close margins or xrt alone.
 * Local control at 10yrs was 88%.

title: Radiation Oncology/Sarcoma/DFSP


text:
User talk:203.124.210.98

Thanks for experimenting with Wikibooks. Your test worked, and has now been removed. Please use Sandbox for any other tests you want to do, since testing material in modules will normally be removed quickly. Please see the welcome page if you would like to learn more about contributing to our project. Thanks. -- Jim Thomas (aka Jomegat) 12:22, 28 March 2007 (UTC)

title: User talk:203.124.210.98


text:
Algorithm Implementation/Strings/Dice's coefficient

WARNING
Please check, if the implementation in the progamming Language you want to use meets your needs !

Some implementations (example: new unrevised javascript implementation) count equal bigrams only once, which is inadequate for string similarity (similarity of "ggggg" and "gg" will be "1" etc. ) Read the comment inside the Java Implementaion (which in my opinion seems to be correct) for this ! Could someone, who is really a specialist on this topic, review this to clarify the problem, and do this warning in a correct way ? See Discussion !

Algorithm
Dice's coefficient measures how similar a set and another set are. It can be used to measure how similar two strings are in terms of the number of common bigrams (a bigram is a pair of adjacent letters in the string). Below we give implementations of Dice's coefficient of two strings in different programming languages.

From the Dice coefficient Wikipedia page, when taken as a string similarity measure, the coefficient may be calculated for two strings, x and y using bigrams as follows:

$$d = \frac{2n_t}{(n_x + n_y)} $$

where nt is the number of character bigrams found in both strings, nx is the number of bigrams in string x and ny is the number of bigrams in string y.

An alternative multiset-oriented description of d is as:

2 × |AB| / (|A| + |B|)

where A, B and AB are to be understood as multisets, with A and B corresponding to the bigrams in x and y respectively, and where AB is defined as the multiset such that, if an item, x, has multiplicity a in A and b in B, then it will have multiplicity min(a,b) in AB. Also for a multiset X, the notation |X| signifies the count of items in X.

Haskell
a naive, non-optimized version

C
A possible problem with the above example is that it considers the position of the bigrams as well as their presence/absence. An alternative implementation which is independent of bigram position is given below:


text:
Talk:Algorithm Implementation/Strings/Dice's coefficient

These algorithms kind of work, but I'm not 100%. - Francis Tyers 15:01, 28 March 2007 (UTC)

Thanks for your code, it was very helpful. Two notes about the C++ code:

 The  loops shouldn't use "unsigned" because the code hangs on empty strings. The code is easy to read and perfect for illustrative purposes. However, for production code comparing large numbers of strings, performance can be dramatically improved by removing all memory allocations. This is possible because the bigram analysis can be done directly on the source strings by using raw pointers to either a 16-bit value (for a pair of single byte characters) or to a 32-bit value (for a pair of Unicode characters.) There is no need to create the arrays  and  .  - Jim Beveridge 23:59, 20 August 2007 (UTC)

 * Thanks for the feedback. Yes, I agree that an optimisation would be to use pointers instead of actually calculating the bigram arrays, but as you say it is more for illustration than actual production use :)

 * Second point (your point 1.), I hadn't realised that, and actually it might make sense just to check the input strings first for zero lengths, and then return 0 if either string is 0 length. - Francis Tyers 15:42, 14 November 2007 (UTC)

 * I would like to note that these implementations are quite incorrect (at least the Python version is, and I assume it is derived from the C++ version). Try using it with two strings where multiple occurrences of a element exist and you'll see what I mean: ('aaa', 'aaa') gives you 2.0, while a number between 0.0 and 1.0 is required. A fixed Python version can be found below:

The text on Wikipedia isn't very clear on what should be done with multiple occurrences of an element, but as a set can have only one occurrence of an element and the text mentions the intersection being done between sets the above code should be closer to the algorithm. Alex de Landgraaf 12:33, 25 May 2008

 * You're right, it should be done on sets. I've changed the code to reflect this. The C++ version appears to have already been updated to fix this. - Francis Tyers (talk) 14:22, 7 June 2008 (UTC)

 * I used something close to the Simon White variant. Basically a pair is removed from the bigram list (not set) as it is matched. This avoid a problem where "gc" vs "gcgc" evaluates as 100%, instead of the correct 50%. My Javascript implementation fakes the removal by setting the bigram array element to null. I have not yet experimented with a fast "proper" Array removal (e.g. something derived for the John Ressig Array.remove) yet. Maybe that could be faster. Stormrose (discuss • contribs) 11:58, 6 March 2012 (UTC)

 * No, the wiki page is incorrect. According to Adamson and Boreham, Brew and McKelvie and Kondrak , the set of bigrams is actually a multi-set of bigrams. Adamson and Boreham make it perfectly clear that "Multiple occurrences of the same [bigram] in one word were treated as distinct, ...". This can easily be seen if one looks at the similarity between "GG" and "GGGGG", which should obviously not be 1. I suggest all implementations are adapted. Jfresen (discuss • contribs) 17:46, 10 December 2012 (UTC)

I've added a Javascript implementation. It relies on Array.push and String.substr which are standard. I did try a version that used Array.indexOf instead of the inner "j" loop but that performed slower for the size strings used and Array.indexOf requires more recent Javascript libraries. Stormrose (discuss • contribs) 11:58, 6 March 2012 (UTC)

PHP Implementation
I'm new to wikibooks and I couldn't figure out how to add this to the actual page. This is a PHP implementation taken from the second Python implementation:

function dice_coefficient($a, $b) { if (!strlen($a) || !strlen($b)) return 0.0; if (strlen($a) === 1) $a .= '.'; if (strlen($b) === 1) $b .= '.';

$a_bg = array; $b_bg = array; for ($i=0; $i < strlen($a)-1; $i++) $a_bg[] = substr($a, $i, 2); for ($i=0; $i < strlen($b)-1; $i++) $b_bg[] = substr($b, $i, 2);

$overlap = count(array_intersect($a_bg, $b_bg)); return $overlap * 2.0/(count($a_bg) + count($b_bg)); }

Clarify what the algorithm should do, before implementing
Shortly the Javascript implementation was changed to "sets", which changes the functionality with multiple occurences of the same substring (this may be true in other language impementations). For comparing strings, an Implementation with sets is not useful, as we have to count eqal bigrams each time they occur. Try the current (26. July 2021) Javascript implementation, and the revised (21. November 2020). They produce different output for example for the arguments "gg" and "ggggg", or "aaaaaaa" and "axaaaaa", I add a warning in the header ! Perhaps some "Test cases" with correct results should be added in the wiki. -- See comment of User Jfresen ! --Rilaf (discuss • contribs) 04:30, 26 July 2021 (UTC)


text:
First Aid/Authors

Among many others:

title: First Aid/Authors


text:
First Aid/What Is First Aid?

What is First Aid?
First aid is the provision of immediate care to a victim with an injury or illness, usually effected by a lay person, and performed within a limited skill range. First aid is normally performed until the injury or illness is satisfactorily dealt with (such as in the case of small cuts, minor bruises, and blisters) or until the next level of care, such as a paramedic or doctor, arrives. First aid may help the person to survive till the doctor comes and saves his/her life.

Guiding principles
The key guiding principles and purpose of first aid are often given in the mnemonic "3 Ps". These three points govern all the actions undertaken by a first aider.
 * Prevent further injury
 * Preserve life
 * Promote recovery

Limitations
The nature of first aid means that most people will only have a limited knowledge, and in emergency situations, first aiders are advised to FIRST seek professional help. This is done by calling, or assigning an able bystander to call, an emergency number, which is 9-1-1 in many places. There is no worldwide common emergency number. The European Union has established 1-1-2 as the universal emergency number for all its member states. The GSM mobile phone standard designates 1-1-2 as an emergency number, so it will work on GSM systems to contact help, even in North America. In the United Kingdom and Republic of Ireland, the numbers 999, 112 and 911 all work in parallel. In emergency situations, it is important that the responder seek help immediately, seeking professional help by other means, if telephone contact is unavailable. The risks of inadvertently doing further injury to a victim, and/or the responder sustaining injury themselves while applying aid, can often outweigh the benefits of applying immediate treatment.

title: First Aid/What Is First Aid?


text:
First Aid/First Aid Training

First Aid Training
Reading this manual is no substitute for hands-on first aid training from an instructor qualified by a recognized organization.

Training programs vary from region to region, and we will highlight some of the main programs here.

North America

 * Lifesaving Society: The LSS, Canada's lifeguarding expert, provides first aid training geared toward both lifeguards and public
 * Red Cross: The RC has been a leading first aid training organization throughout North America
 * St. John Ambulance: provides first aid courses to the public, as well as more advanced training
 * Canadian Ski Patrol: provides first aid training for their ski patrollers as well as the public
 * Heart and Stroke Foundation of Canada
 * Corporate training programs: there are various corporations which provide their own programs
 * Many ambulance and fire services offer basic first aid courses to those who are interested, contact your local Emergency Services Station for more information.

United Kingdom

 * British Red Cross: The British Red Cross is part of the worldwide organization, and provides personal and commercial first aid training
 * St John Ambulance: SJA is the other main voluntary provider of first aid training in the UK

Professional Levels Beyond First Aid
Professional pre-hospital care is provided by local or regional Emergency Medical Services. It is feasible for interested persons to undertake further training. Higher levels of training include:

 * First Responder - The first responder level is often aimed at professionals, such as police officers, although in some areas, laypersons can become first responders, designated to reach emergencies before an ambulance
 * Emergency Medical Technician - Most ambulance services worldwide qualify their staff as EMTs or an equivalent. The additional skills they have vary between services, however most cover areas such as more advanced spinal care, resuscitation and patient handling.  In many countries, first aiders can attain this level of training through voluntary organizations or through private training.
 * Paramedic - Paramedics are often the most highly qualified of the ambulance personnel, usually with a range of intravenous drugs and items such as intubation kits. It is unlikely that any non-professional could achieve paramedic level.  In many countries, the title is protected, meaning that an unqualified person calling themselves a paramedic could face prosecution.

title: First Aid/First Aid Training


text:
User talk:212.219.171.150

Thanks for experimenting with Wikibooks. Your test worked, and has now been removed. Please use Sandbox for any other tests you want to do, since testing material in modules will normally be removed quickly. Please see the welcome page if you would like to learn more about contributing to our project. Thanks. -- Jim Thomas (aka Jomegat) 16:55, 28 March 2007 (UTC)

title: User talk:212.219.171.150


text:
User talk:87.164.240.102

Thanks for experimenting with Wikibooks. Your test worked, and has now been removed. Please use Sandbox for any other tests you want to do, since testing material in modules will normally be removed quickly. Please see the welcome page if you would like to learn more about contributing to our project. Thanks. -- Jim Thomas (aka Jomegat) 16:56, 28 March 2007 (UTC)

title: User talk:87.164.240.102


text:
User talk:142.163.245.214

Thanks for experimenting with Wikibooks. Your test worked, and has now been removed. Please use Sandbox for any other tests you want to do, since testing material in modules will normally be removed quickly. Please see the welcome page if you would like to learn more about contributing to our project. Thanks. -- Jim Thomas (aka Jomegat) 16:57, 28 March 2007 (UTC)

title: User talk:142.163.245.214


text: First Aid/Introduction

title: First Aid/Introduction


text:
First Aid/Consent

Importance
Most people and cultures involve a certain amount of respect for a person's personal space. This varies with cultural and personal attitude, but touching another person is generally considered to be rude, offensive or threatening unless their permission is gained.

As most first aid treatment does involve touching the victim, it is very important that the first aider gains their permission, so as to avoid causing offense or distress. In most jurisdictions, it may be considered battery if a first aider touches the victim without permission.

Gaining consent
The simplest way to gain consent is to ask the victim if they will allow you to treat them. Talk to the victim, and build up a rapport with them. During this conversation, it is important to identify the following key points:
 * Who you are - Start with your name, and explain that you are a trained first aider.
 * Why you are with them - They are likely to know they have an injury or illness (although you can't always assume this in the case of patients in emotional shock, children or those with learning difficulties), but explain to them that you would like to help with their injury or illness.
 * What you are going to do - Some first aid procedures can be uncomfortable (such as the sting which accompanies cleaning a wound with saline), so it is important to be honest with the patient about what you are doing, and if necessary, why it is important.

Implied consent
There are some cases where you can assume that the victim gives their consent to you treating them. The key, unequivocal reason for assuming consent is if the patient: In these cases, you can perform any reasonable treatment within your level of training, and your position is protected in most jurisdictions.
 * Is unconscious
 * Has a very reduced level of consciousness

Judgment of consent
There are also some cases where the first aider may have to exercise a level of judgment in treating a victim who may initially refuse. Cases like this include when the victim is:
 * Intoxicated
 * Irrational (i.e. delusional, insane or confused due to the injuries)
 * A minor (parent or guardian must give consent if present and able; otherwise consent is implied)
 * Suffering from learning difficulties

In these judgment cases, the first aider must make a decision, even if the victim is refusing treatment. If this occurs it is very important to make a note of the decision, why it was taken, and why it was believed that the person was unfit to refuse treatment. It is advisable to summon professional medical assistance if you believe the victim should be treated and is refusing, as medical professionals are experienced in dealing with people reluctant to accept treatment.

Wishes of relatives
In some cases, relatives may object to the treatment of their relative. This can be a problematic area for the first aider, with several important factors to be considered.

In the first instance, it may not be any decision of the relative to choose to consent to first aid treatment. In most countries, the only time this decision can be definitively taken is if the person requiring treatment is a child.

In other cases, the presumption for the first aider must be towards treating the victim, especially if they are unconscious.

The other main consideration is if the person claiming to refuse consent on behalf of the victim is in fact a relative, or if they have the victim's best interests at heart. In some cases, the person may have caused harm to the victim. If in this case, you fear for your safety, or the person becomes aggressive, you should look after your own safety as a priority, and call for assistance from the police.

Advance directive
Some victims may have a statement recorded, called an advanced directive or living will, that they do not wish to be treated in the case of life threatening illness. This can be recorded on a piece of paper, or on wearable items such as a bracelet.

The legal force of these items may vary widely between countries. However, in the majority of cases they should follow a certain format, and be countersigned by a solicitor or notary public.

In any case, as suggested above, the first aider should always presume towards treating a victim, allowing health care professionals to make the final decision. Almost every first aid treatment will only extend life, rather than definitively save it, meaning you are usually not breaking the advance directive. This includes actions such as CPR, which simply extend the time until which definitive treatment will work - usually delivered by a health care professional, who can make their own clinical decision on any advance directive.

title: First Aid/Consent


text:
First Aid/Protective Precautions

Awareness of Danger
The first thing that anyone providing first aid should be aware of when entering a situation is the potential for danger to themselves. This is especially important in first aid, as situations which have been dangerous to others carry an inherent risk of danger to those providing first aid.

Danger consists of:
 * Environmental danger - A danger in the surroundings, such as falling masonry, broken glass, fast vehicles or chemicals.
 * Human danger - Danger from people at the scene (including the victim) which can be intentional or accidental.

Barrier Devices
Keeping yourself protected is the first priority of any first aider. The key is to always be aware of your surroundings and the situation, and be alert for any changes therein.

Once you are aware of the hazards, you can then take steps to minimize the risk to oneself. One of the key dangers to a first aider is bodily fluids, such as blood, vomit, and urine, and feces, all of which pose a risk of cross contamination. Body fluids and feces can carry infections and diseases, including, but not limited to, HIV and hepatitis.

Gloves
The main tool of the first aider to avoid this risk is a pair of impermeable gloves. Gloves protect the key contact point with the victim (i.e. the hands) and allow you to work in increased safety. They protect not only from bodily fluids and feces, but from any dermatological infections or parasites that the victim may have.

The first thing a first aider should do when approaching, or on their way to, a victim is to put on their gloves.

Remember GO to the victim (Gloves On) They are generally of three types:
 * Nitrile - These gloves can come in any color (often purple or blue) and are completely impermeable to bodily fluids and feces. These are the gloves most recommended for use during victim contact. This material is also rated for dealing with chemical spills. If you ever need to deal with chemical burns, these are the gloves to use (you can brush off dry chemicals with gloved hands if you use nitrile). Nitrile gloves, however, are also the most expensive.
 * Latex - Usually white gloves, often treated with powder to make them easier to get on or off. These are not used as widely as they once were due to a prevalence of allergies to latex. Latex allergies are rarely life-threatening; if you must use latex gloves, ask the victim if they have a severe allergy to latex.
 * Vinyl - Vinyl gloves are found in some kits; they should not be used for contact with body fluids or feces, though they are far better than nothing. They should primarily be used for touching victims who do not have external body fluids or feces due to the glove's high break rate.  For this reason, some organizations recommend that they not be kept in first aid kits due to the risk of confusion.

CPR Adjunct
The other key piece of protective equipment that should be in every first aid kit is an adjunct for helping to perform safe mouth-to-mouth resuscitation.

With mouth-to-mouth resuscitation, there is a high probability of bodily fluid contact, especially with regurgitated stomach contents and mouth borne infections. A suitable mask will help to protect the rescuer from infections the victim may carry (and to some extent, protect the victim from the rescuer). It also makes the performance of CPR less onerous (not wishing to perform mouth to mouth is a key reason cited for bystanders not attempting CPR).

CPR adjuncts come in a variety of forms, from small keyrings with a nitrile plastic shield, up to a fitted rescue 'pocket mask' complete with oxygen inlet, such as the one pictured.

Other equipment
Larger first aid kits, or those in high risk areas could contain additional equipment such as: Oftentimes, all of these will be included as a part of a larger kit. The kit should have a list of instructions on how to properly don/don off the equipment. Follow these instructions and familiarize yourself with their use to prevent exposing yourself.
 * Safety glasses - Prevents spurting or pooled fluid which could spray from coming in contact with the eyes.
 * Apron or gown - Disposable aprons are common items in larger kits, and help protect the rescuers clothing from contamination.
 * Filter breathing mask - Some large kits, especially in high risk areas such as chemical plants, may contain breathing masks which filter out harmful chemicals or pathogens. These can be useful in normal first aid kits for dealing with victims who are suffering from communicable respiratory infections such as tuberculosis.

Improvisation
Many first aid situations take place without a first aid kit readily at hand and it may be the case that a first aider has to improvise materials and equipment. The flexibility required in such situations is referenced in a common saying among rescue workers - "Adapt, improvise, and overcome!" As a general rule, some help is better than no help, especially in critical situations, so a key first aid skill is the ability to adapt to the situation, and use available materials until more help arrives.

Some common improvisations include:
 * Gloves → plastic bags, dish gloves, leather work gloves (wash your hands with soap and water especially well after using these)
 * Gauze → clean clothing, bedding or towel (but not paper products, such as paper towels or toilet paper)
 * Splints → straight sections of wood, plastic, cardboard or metal
 * Slings → the victim's shirt's bottom hem pinned to the center of their chest will immobilize a forearm or shoulder injury nicely
 * Stretcher → a heavy blanket can be used to move a victim

title: First Aid/Protective Precautions


text:
First Aid/Primary Assessment & Basic Life Support

A quick summary of Basic Life Support/Cardiopulmonary Resuscitation (BLS/CPR) is available!

The first thing you should do in any situation requiring first aid is to follow the three C’s: Check, Call, and Care.

Survey the scene
Before you approach the victim, take a moment to survey the scene and prioritize your safety. Look for any potential hazards that could endanger you or others. Remember, safety should always come first.

Primary Survey
As you approach the victim, pay attention to their position and watch for any automatic red flags. Your safety is essential, and getting hurt while trying to help could make matters worse.

Next, perform a primary survey, which can be done while walking or running to the scene. This involves checking for:
 * 1) Consciousness: Determine if the victim is conscious or unconscious.
 * 2) Breathing: Observe if the victim is breathing and if their airway is clear.
 * 3) Pulse: Check for a pulse to assess their circulation.

Assessing an Unconscious Victim
When you approach an unconscious victim:
 * Look, listen, and feel for signs of breathing.
 * Place your ear over the person's mouth and observe the rise and fall of the chest.
 * Feel for breath on your face and listen for any moving air or signs of a blocked airway.

If the victim is not breathing, start CPR immediately. If they are breathing but unconscious, call 911 and continue monitoring vital signs until help arrives.

Suspected Head or Neck Injury
In case of suspected head or neck injury:
 * Maintain the C-spine position until EMS (Emergency Medical Services) arrives.
 * If you determine a head or neck injury, assume the C-spine position to prevent unnecessary movements.

Always prioritize CPR if the individual is not breathing. If you suspect a head or neck injury and the person stays down, call EMS for immediate assistance.

Remember, quick and accurate assessment is crucial in providing effective first aid. Properly evaluating the situation and taking appropriate actions can make a significant difference in the victim's outcome.

Call
After checking the victim, the first and most important step is to call Emergency Medical Services (EMS). If you are the only person present, you must make the call yourself. Remain calm and follow these steps to provide essential information to the 911 operator:

 * 1) Designate a Caller: If there are multiple people around, designate someone to call EMS. If you are alone, take charge and make the call.
 * 2) Dial Emergency Number: Dial 911 or the local emergency number immediately.
 * 3) Provide Essential Information: When speaking to the 911 operator, ensure you provide the following information:
 * 4) Location: Clearly state your precise location, including any landmarks or nearby streets.
 * 5) Situation Description: Briefly explain the nature of the emergency. For example, state if the victim is unconscious, injured, or experiencing a specific medical issue.
 * 6) Patient Description: Provide any relevant details about the patient's condition, age, and any visible injuries or symptoms.
 * 7) Personal Information: The 911 operator may ask for your name. Be prepared to provide it.
 * 8) Facility Access: If you are in a secure facility or building, inform the 911 operator of any access codes or instructions to enter the premises.
 * 9) Stay on the Line: Do not hang up the phone until the 911 operator instructs you to do so. They may need additional information or provide you with essential instructions.
 * 10) Update on Location: If you need to change locations or move the victim before EMS arrives, inform the operator of the updated location.

Remember, staying calm during this process is crucial, as it allows you to communicate effectively and provide the necessary information for a prompt and appropriate EMS response.

Care
After calling the EMS, provide appropriate Care until EMS arrives and takes over. Continue monitoring the vital signs of the victim until EMS arrives.

It is important to do your best to stay calm and stay focused so that you will be able to provide the best care possible for the injured individual.


text:
First Aid/Emergency First Aid & Initial Action Steps

Protecting yourself

First aiders are never required to place themselves in a situation which might put them in danger. Remember, you cannot help a victim if you become a victim yourself. When a first aider is called upon to deal with a victim, they must always remember to safeguard themselves in the first instance and then assess the situation. Make sure the scene is safe, and remember that your own personal safety is above all else. Before you enter a scene, put on personal protective equipment, especially impermeable gloves. Only after these steps are completed can treatment of the victim begin.

As you approach a scene, you need to be aware of the dangers which might be posed to you as a first aider, or to the victim. These can include obviously dangerous factors such as traffic, gas or chemical leaks, live electrical items, buildings on fire or falling objects. While many courses may focus on obvious dangers such as these, it is important not to neglect everyday factors which could be a danger. (ex. Gas fires, where in getting close to a victim could result in burns from the heated vapor.)

There are also human factors, such as bystanders in the way, the victim not being co-operative, or an aggressor in the vicinity who may have inflicted the injuries on the victim. If these factors are present, retreat until the police are able to control the situation.

Once you have assessed the scene for danger, you should continue to be aware of changes to the situation or environment that could present danger to you or your victim until you have left the scene.

If there are dangers which you cannot mitigate by your actions (such as falling masonry, an assailant, or a structure fire), then STAY CLEAR and call the emergency services. Always remember to  never put yourself in harm's way .

What has happened?
As you approach the scene, your goal to gain as much information as possible about the incident. Try and build a mental "picture" of the situation in your head. Details you observe can help you care for your victim, especially if the injury or illness is not obvious.

Assess the Scene - Where are you? What stores, clubs, public buildings, etc. are nearby? Has anything here caused the injury? Does this area have motor vehicle traffic? Is this area known for violent crime? What time of day is it? What are the weather conditions?

Look for Clues - Things that could help you determine the reason for the patient's illness or injury may be obvious (such as an empty pill bottle between the patients legs) or subtle (shellfish - which many people are allergic to - in the victims food).

Get some History - If there are witnesses, ask them what's happened "Did you see what happened here?" and gain information such as how long ago it happened "How long have they been like this?", but be sure to start your assessment and treatment of the victim simultaneous with your history taking.

Be sure to Listen - While working on a victim you may overhear information from witnesses in the crowd. An example of this would be an old man falling on the sidewalk, as you approach the scene you can hear someone say "He was just walking and his legs went out from under him." But you may not see the person saying this. Everything should be taken into account should no witnesses want to become involved or you cannot ask questions. Note what is said and continue treatment.

Responsiveness

Once you are confident that there is minimal danger to yourself in the situation, the next step is to assess how well (if at all) your victim responds to you.

This can be started with an initial responsiveness check as you approach the victim. This is best as a form of greeting and question, such as:

"Hello, I'm here to help you. Are you alright?"

The best result would be the victim looking at you and replying. This means that the victim is alert at this time.

In an emergency setting, the level of responsiveness is categorized by using what is called the AVPU scale, AVPU stands for the four possible categories they can fit into. They are either "Alert", "Verbal", alert to "Pain", or "Unresponsive"'

If the victim looks at you spontaneously, can communicate (even if it doesn't make sense) and seems to have control of their body, they can be termed Alert.

Key indicators on the victim are their:
 * Eyes - Are they open spontaneously? Are they looking around? Do they appear to be able to see you? Do they look "glassed over"?
 * Response to voice - Do they reply? Do they seem to understand? Can they obey commands, such as "Open your eyes!"? Do they know where they are or what happened to them?

If the victim is not alert, but you can get them to open their eyes, or obey a command by talking to them, then you can say that they are responsive to Voice - that is, they became alert upon you speaking to them.

If a victim does not respond to your initial greeting and question, you will need to try and get a response from them by carefully delivering pain.

The word "pain" is a bit misleading - it refers to anything physical you do to elicit a response from your victim. The first, and most gentle stimulus to use is a tap/shake of the shoulder. There are other, more painful stimuli that can be employed should this be unsuccessful, but all of these have their downsides, especially if overused.

Of these, the three most commonly used ones are:

 * Sternal rub - This is performed by grinding the knuckles of your clenched fist vertically up and down the victim's sternum (or breastbone).
 * Nail bed squeeze - Using the flat edge of a pen or similar object, squeeze in to the bottom of the victim's fingernail or toenail.
 * Ear lobe squeeze - using thumb and forefinger, squeeze or twist the victim's ear.

If any of these provoke a reaction (groaning, a movement, fluttering of the eyes), then they are responsive to pain. It is important to note that different trainers have different opinions on the efficacy of these, so ask your trainer before employing any of these on a first aid course.

Any of the responses A, V or P, mean that the victim has some level of consciousness. If they are not alert, you should always summon professional help - call an ambulance.

If they are only responsive to Voice or Pain, then consider using the Recovery position to help safeguard them if they need to vomit.

If they do not respond to voice or pain, then they are Unresponsive and you must urgently perform further checks on their key life critical systems of breathing and circulation (informally known as the ABCs). A victim who is unresponsive will often require special attention, both due to the injury or illness causing their unconsciousness, and the fact that they are unable to provide any reason for them being sick or injured.

DRSABCD D-Danger check for danger R-Responce check for responds S-Send for help A-Airway clear B-Breathing check C-CPR 30 chest compressions D-Defibrillation 2 rescue breaths

Summary
To this stage the first aider, on approaching a victim should have:
 * GO - Put their gloves on
 * D - Checked for danger
 * R - Checked for responsiveness
 * S - Looked at the scene for clues about what has happened
 * H - Gained history on the incident
 * AVPU - Assessed to see how responsive the victim is.

This can be remembered as the mnemonic "GO DR SHAVPU" (Go Doctor Shavpu)

We use a formula to handle a patient DRABC D for Check danger R for Response A for Airway B for breathing C Cardic Mean plus

Next Steps
If the victim is unconscious, the first aider should immediately call an ambulance - you will need professional help regardless of whether they are breathing or not. Waiting would endanger the victim's life unnecessarily, and any time wasted in summoning help is time lost. If you are alone with an adult victim, call immediately, even if you must leave the victim. Placing them into the recovery position will help prevent them from choking if they should vomit while you are calling the ambulance. If you are alone with an unconscious child, continue your primary assessment; you will call once you have confirmed that the victim is breathing, or after 2 minutes of CPR. If you are not alone, have a bystander call the ambulance immediately while you continue your assessment and care of the victim.

If there is more than one person injured the rescuer must determine the order in which victims need care. In general, rescuers should focus on the victim with the injury that is the greatest threat to life. Simple triage techniques should be applied to make sure that those in greatest need of care receive support quickly.

Treatment
The last step is to actually provide care to the limits of the first aider's training -- but never beyond. In some jurisdictions, you open yourself to liability if you attempt treatment beyond your level of training.

Treatment should always be guided by the 4Ps:
 * Preserve life
 * Prevent further injury
 * Promote recovery
 * Protect the unconscious

Treatment will obviously depend on the specific situation, but some situations will always require treatment (such as shock). The level of injury determines the level of treatment required.

The principles first, do no harm and life over limb are essential parts of the practice of first aid. Do nothing that causes unnecessary pain or further injury unless to do otherwise would result in death.


text:
First Aid/A for Airway

A for Airway
The complex structures of the human body leading from the lips to the lungs are often referred to simply as the patient's "airway". The airway of the human body is one of the more important parts to be checked when providing first aid, and is typically the first item given attention in the seriously sick or injured patient. The airway is the entrance point of oxygen and the exit point of carbon dioxide for the body. Should this become blocked, the victim will have no way to obtain fresh air, and death will eventually result.

We are normally able to keep our airway a clear path for fresh air subconsciously. Depending on the severity of the victim's condition, an unconscious person's airway could be blocked when their tongue relaxes and falls across their throat, blocking airflow. A common example of this is the sounds made by a snoring person. The technique used to open the airway and keep the tongue out is referred to as the "head-tilt chin-lift" technique.

For this to work properly, the patient will be placed on a flat surface, lying on their back. Kneeling at the level of the victim (easiest when the rescuer is on one side of the injured individual) the rescuer places one palm, open handed, on the victim's forehead. The rescuer then places the index and middle finger of their other hand under the bony part of the victim's jaw (mandible). The fingers and palm are used to gently tilt the victim's head backwards, and lift their chin upwards, extending the victim's neck. Ideally, once you have done this, the victim's jawline will be perpendicular to the ground allowing the airway to be open the maximum amount.

This technique is typically not necessary for conscious victims, as they can typically maintain an open airway. Simply, if the victim is talking or has no respiratory distress, their airway is adequate.

Even if you suspect that your victim may have sustained a spinal neck injury, open the airway as normal, but with caution. Life over limb - the potential for keeping the victim alive outweighs the risk of aggravating the spinal injury. If you absolutely must roll a person suspected of head, neck, or spinal injury because he or she is vomiting, choking on blood or in danger of further injury, use at least two people. Work together to keep the person's head, neck and back aligned while rolling the person onto one side.

You may also check the victim's mouth for visible, removable obstructions in the mouth which can obstruct airflow. The common items found obstructing the victim's airway include partially chewed food, hard candy, and balloons. You may attempt to expel any items in the mouth which can be easily withdrawn with a finger swipe but do not waste time trying to remove fixed or lodged items such as dentures. Also, be alert to the status of your victim, as you could be injured if your fingers are in the mouth of a person regaining consciousness.

If a conscious victim's airway is obstructed by a foreign object (such as someone who is choking), the object must be removed via other means. Abdominal thrusts are the standard method for conscious adult and child victims. Refer to Obstructed Airway for unconscious procedures.

title: First Aid/A for Airway


text:
First Aid/B for Breathing

Principles
Humans breathe by inhaling fresh air into the lungs, exchanging part (but not all) of the oxygen in it with unneeded carbon dioxide, and exhaling the spent air. Blood vessels located in the lungs distribute oxygen throughout the cells of the body. Human beings typically have a lung capacity of 4 to 6 liters.

When someone stops breathing, this is a life threatening condition known as respiratory arrest. Occasionally when a victim stops breathing, their breathing can restart if stimulated by a rescuer blowing air into their lungs. However, a victim in respiratory arrest is likely to fall into cardio-respiratory arrest, which means that they are no longer breathing and their heart has also stopped.

Without their lungs receiving oxygen, a victim will suffer permanent brain damage after only a few minutes. Because of this, it is crucial that rescuers provide rescue breathing (ventilation) quickly and correctly.

Checking the respiration
After opening the victim's airway, check to see if the victim is breathing. To do this, place your cheek in front of the victim's mouth (about 3–5 cm away) while looking down their chest (towards their feet). If desired, you can also gently place a hand on the center of the victim's chest. This allows you to observe whether the victim is breathing in the following ways:
 * 1) You may Feel the victim's breath against your cheek.
 * 2) You may Hear the air entering or escaping your victim's lungs.
 * 3) You may See the chest rise and fall with each breath.
 * 4) You may Smell the breath of the victim as they exhale.

If you have placed your hand on the victim's chest, you may also feel their chest rise and fall against your hand. Search for these signs for 10 seconds. If there is no breathing (or it is slower than 6 times per minute), your victim is not adequately moving air in and out of their body. In order to help them, you must perform rescue breathing.

Calling For Help
If a bystander has not already summoned assistance, now is the time to make sure that emergency personnel are enroute (known as EMS, Ambulance Service, Rescue Squad, or Paramedics depending on the region). Ideally, someone else will be able to make the call while you continue aid. If you're alone, you must stop and call yourself.
 * Europe: 112
 * USA & Canada: 911
 * Australia: 000
 * United Kingdom: 999 or 112

You will need to give the emergency services:
 * Your exact location (including apartment number, suite, building, etc.)
 * The illness or injury that the victim is having (to the best of your knowledge).
 * A telephone number you can be contacted back on (for instance, if they have difficulty finding you)

In some cases, the person taking your call will run through a list of questions with you in order to make sure the proper resources are sent to you. Also, some localities will give the caller instructions on what to do before help arrives.

Sometimes, the victim must be left unattended while the first aider leaves to seek help for them. If the victim is unconscious they should be left in the recovery position so they do not choke if they vomit. However, if you suspect the victim has an injury to their neck or back, they should not be moved and their head kept stationary, with two exceptions. One, if the victim is in immediate danger (such as from a fire), they should be moved regardless. Two, if the victim is unconscious, the threat of choking outweighs the potential injury to their neck or back, and they should be placed on their side anyway. There are alternative methods for safer positioning available to those with more advanced training.(See Suspected Spinal Injury for more information.)

Rescue Breaths
Rescue breaths must be provided to victims in a state of respiratory arrest; do not provide them to a weakly breathing victim. If you cannot detect the breath of the victim, or they are breathing slower than once every ten seconds, begin rescue breathing.

If you have a CPR mask or other barrier device, you can use it to protect yourself and the victim from exchange of body fluids. Cheap, keyring-sized CPR masks are available in most pharmacies. Be sure to read the instructions and practice with any equipment you buy. In the event you do not have a barrier device, the rescuer should perform as best they can, given the situation and abilities. If you are uncomfortable performing direct mouth-to-mouth on a stranger, or you find blood or other bodily fluids present, you are not obligated to. You should, however, perform the chest compression portion of CPR, as it is better than doing nothing.

The 2010 CPR guidelines changed CPR so compressions are started first, after checking for breathing.

To give two rescue breaths:
 * Kneel at the level of the victim, perpendicular to and facing them.
 * Maintain an open airway using the head-tilt chin-lift.
 * Squeeze the nose of the victim with your free hand to seal it shut.
 * Put your mouth on the mouth of the victim in an airtight manner, and blow into the mouth of the victim so that their chest beings to rise. Never blow forcefully, as this may cause the air to enter the stomach and not their lungs. Instead, exhale smoothly over 1–2 seconds.
 * Remove your mouth, and let the victim exhale completely (watch for their chest to fall).
 * Repeat the above steps for your second breath.

If your breaths do not go in easily, or the victim's chest did not rise, the airway could have again become closed. Open the airway once again with the head-tilt chin-lift technique and try again, making sure the victim's neck is extended and their head is rocked back fully.

Continue with CPR compressions.

title: First Aid/B for Breathing


text:
First Aid/C for Compressions

Principles
The human heart is an electro-mechanical pump, circulating nourishing blood throughout the body. If beating stops, the brain, lungs and even the heart itself stop receiving oxygen and perish. Rescuers can use a technique called chest compressions to squeeze the heart from outside the patient's chest, helping to circulate blood around. When performing chest compressions during CPR, you are helping move the oxygen you delivered through rescue breathing where it is needed.

Chest compressions are often started before any other intervention in an emergency setting, because even blood that has already passed through the body has oxygen remaining to be used. Using compressions to pump that existing blood around can help buy the patient more time. This is the reason that CPR can be done "compression only", or without rescue breathing. Once compressions start, they must continue for as long as possible.

Technique
The goal is always to compress in the center of the chest, regardless of the shape or size of the patient. This means that compressions are to performed on the sternum or breastbone of the patient, in line with the casualty's armpits or nipple line.

 * For adults (>8) - place the heel of one hand in the centre of the chest, approximately between the nipple line (on adult males - for females, you may need to approximate the ideal position of this line due to variations in breast size and shape). You may also use the bottom of the casualty's armpits as a reference mark. Bring your other hand to rest on top of the first hand, and interlock your fingers.  Bring your shoulders directly above your hands, keeping your arms straight. You should then push down firmly onto the heel of the lower hand, depressing the chest 5–6 cm (2-2.5inches).
 * For children (1-8) - place the heel of one hand in the centre of the chest, approximately between the nipple line. Bring your shoulder directly above your hand, with your arm straight, and perform compressions to at least one third (1/3) the depth of the chest with one arm only.
 * For infants (<1yr) - Use your forefinger and middle finger only. Place your forefinger on the centre of the child's chest between the nipples, with your middle finger immediately below it on the chest, and push downwards using the strength in your arm, compressing the chest at least one third (1/3) of its depth. For newborns and small infants, you can hold the child in your opposite arm (head in your palm, feet at your elbow) for easier access.

Give 30 compressions in a row, and then two (2) rescue breaths.

Then restart your next cycle of compressions

Making compressions effective
You MUST allow the ribs to come all the way back out after each compression, followed by a brief pause. This allows the heart's chambers to refill. Spacing compressions too close together will lead to them being ineffective.

You are aiming for a rate of 100 compressions per minute, which includes the time to give rescue breaths. In practice, you should get just over 2 cycles of 30 compressions in along with breaths per minute.

Almost everyone compresses the chest too fast - Experience shows that even well trained first aiders tend to compress the heart too fast. The rate you are aiming for is only a little over one per second. The best equipped first aid kits should include a Metronome with an audible 'beep' to match your speed to. Many public access defibrillators have these included in their pack. If one is not available, count the number of compressions with the word 'and' between them. When you press down on the chest, say the number, when the chest rises say 'and'. this way, you will be saying 'one-and-two-and-three...'

The patient should be on a hard surface - If the patient is in bed or a similar cushioned area, moving them to the floor will help assure you are compressing their chest and not the mattress or couch cushions. If moving the casualty is impractical, a hard, flat board can be placed behind them to make compressions more effective.

Keep your arms straight - A lot of television and films show actors 'performing CPR' bending their elbows. This is not effective - you should always keep your arms straight, with your elbows locked and directly above your hands.

It often helps to count out loud - You need to try and get 30 compressions per cycle, and it helps to count this out loud or under your breath. In such a stressful situation, you will be anxious and unable to count out loud for the duration, but ensure you keep counting, even if it's in your own mind.

If you lose count, don't stop, just estimate - It is important to carry on once you've started, so if you lose count, don't panic, and simply estimate when 30 compressions is over, and do 2 breaths, then start over counting again. Avoid any interruptions in CPR.

You are likely to break ribs - When performing compressions, especially on the elderly, you may find yourself breaking the patient's ribs. This often feels like flicking the finger of one hand against the palm of another. This is to be expected during CPR, and you should carry on regardless. It is a sign that you are performing good, strong compressions. Oftentimes the cracking sound you will hear is just the cartilage of the ribs and sternum breaking, and not the bones themselves. If bystanders are concerned about injury to the patient, you may want to remind them of the life over limb principle and assure them that it is a normal occurrence, and what you are doing is critically important.

Chest compressions are tiring - This is especially true if you are performing both rescue breathing and compressions by yourself. Studies show that the efficacy of CPR drops when one rescuer performs compressions for an extended time. Hospital emergency rooms switch personnel performing compressions often for this reason. If you are with someone else trained in CPR, rotate between compressions and rescue breaths.

When to Stop
You should continue giving the patient CPR until:
 * The casualty starts breathing spontaneously - This occurs very infrequently, and does not include gasping, called agonal breathing. Patients are also likely to make sighing noises or groans as you perform chest compressions - this is just the sound of air trapped in the lungs being forced out, and you should not stop CPR if these noises are heard.
 * The patient vomits - This is an ACTIVE mechanism, meaning the patient moves and actively vomits. Not to be confused with regurgitation, where stomach contents make their way passively in to the mouth. If the casualty vomits, roll them to their side, clear the airway once they're done vomiting and reassess ABCs. Vomit is obviously undesirable for the person performing CPR. Attempt to clear the mouth with your fingers (preferably while wearing a barrier device) and continue CPR. If you are without barrier device and feel uncomfortable giving rescue breaths, give chest compressions only.
 * Qualified help arrives and takes over. This could be a responder with a defibrillator, the ambulance service or a doctor.  DO NOT STOP until instructed to.  They are likely to require time to set up their equipment and evaluate the patient (as you did at first) and you should continue with CPR until instructed to stop.  The emergency medical personnel are used to working around people, and may do things like place defibrillator patches while you continue. By continuing CPR, you are keeping the medical personnel free to perform other tasks.
 * You are unable to continue - CPR is physically very demanding, and continued periods can be exhausting. Try to change places frequently with another trained rescuer to lessen the chance of exhaustion.
 * You put yourself in danger by continuing - Hazards may change, and if your life is endangered by a new hazard, you should stop CPR. If possible, remove the patient from the hazardous situation as well, but never at the risk of your own life or health.

title: First Aid/C for Compressions


text:
First Aid/External Bleeding

Introduction
Bleeding is a common reason for the application of first aid measures and can be internal or external. The principal difference is whether the blood leaves the body – external bleeding can be seen, whereas in internal bleeding, no blood can be seen.

There are many causes of external bleeding, which fall into seven main categories, which are:
 * Abrasion
 * Also called a graze, this is caused by transverse action of a foreign object against the skin, and usually does not penetrate below the epidermis

 * Excoriation
 * In common with Abrasion, this is caused by mechanical destruction of the skin, although it usually has an underlying medical cause

 * Laceration
 * Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth

 * Incision
 * A clean “surgical” wound, caused by a sharp object, such as a knife

 * Puncture Wound
 * Caused by an object penetrated the skin and underlying layers, such as a nail, needle or knife

 * Gunshot wounds
 * Caused by a projectile weapon, this may include two external wounds (entry and exit) and a contiguous wound between the two

Recognition
Recognizing external bleeding is usually easy, as the presence of blood should alert you to it. It should however be remembered that blood may be underneath or behind a victim. It may be difficult to find the source of bleeding, especially with large wounds or (even quite small) wounds with large amounts of bleeding. If there is more than 5 cups of blood from a wound, then the wound is life-threatening.

Treatment

As with all first aid situations, the priority is to protect yourself, so put on protective gloves before approaching the victim.

All external bleeding is treated using three key techniques, which allow the body's natural repair process to start. These can be remembered using the acronym mnemonic 'RED':

 * Rest
 * Elevation
 * Direct pressure

Rest
In all cases, the less movement the wound undergoes, the easier the healing process will be, so rest is advised. Rest will also reduce the pulse rate, thus the severity of the bleeding, especially in the case of arterial bleeding.

Elevation
Direct pressure is usually enough to stop most minor bleeds, but for larger bleeds, it may be necessary to elevate the wound above the level of the heart (whilst maintaining direct pressure the whole time). This decreases the blood flow to the affected area, slowing the blood flow, and assisting clotting.

Elevation only works on the peripheries of the body (limbs and head) and is not appropriate for body wounds. You should ask the victim to hold their wound as high as possible. You should assist them to do this if necessary, and use furniture or surrounding items to help support them in this position. If it is the legs affected, you should lie them on their back (supine), and raise their legs.

Direct Pressure
The most important of these three is direct pressure. This is simply placing pressure on the wound in order to stem the flow of blood. This is best done using a dressing, such as a sterile gauze pad (although in an emergency, any material is suitable).

If the blood starts to come through the dressing you are using, add additional dressings to the top, to a maximum of three. If you reach three dressings, you should remove all but the one in contact with the wound itself (as this may cause it to reopen) and continue to add pads on top. Repeat this again when you reach three dressings. The reason for not simply adding more dressings is that it becomes harder to apply the direct pressure which is clearly needed if this much blood is produced.

Where an articulate area of the body is wounded (such as the arms or hands), it is important to consider the position of the area in keeping pressure on the wound. For example, if a hand is cut 'across' from the thumb to halfway across the palm, the wound can be closed with direct pressure by simply clasping the victim's hand shut. However, if the hand was wounded from between the two middle fingers down to the wrist, closing the hand would have the effect of opening the wound, and so the victim should have their hand kept flat.

In most cases, during the initial treatment of the bleed, you will apply pressure by hand in order to stem the flow of blood. In some cases, a dressing may help you do this as it can keep pressure consistently on the wound. If you stop the flow by hand, you should then consider dressing the wound properly, as below.

Dressing
Once the bleeding is slowed or stopped, or in some cases, to assist the slowing of the blood flow you should consider dressing the wound properly.

To dress a wound, use a sterile low-adherent pad, which will not stick to the wound, but will absorb the blood coming from it. Once this is in place, wrap a crepe or conforming bandage around firmly. It should be tight enough to apply some direct pressure, but should not be so tight as to cut blood flow off below the bandage. A simple check for the bandage being too tight on a limb wound is a capillary refill check; to do this, hold the hand or foot (dependent on what limb is injured) above the level of the heart and firmly pinch the nail. If it takes more than 2 seconds for the pink color to return under the nail, then the bandage is likely to be too tight.

If the blood starts to come through the dressing you have applied, add another on top, to a maximum of three. If these are all saturated, remove the top two, leaving the closest dressing to the wound in place. This ensures that any blood clots that have formed are not disturbed; otherwise, the wound would be opened anew.

Nosebleeds (epistaxis)
If a person has nosebleed, have them pinch the soft part of the nose firmly between thumb and forefinger, just below the end of the bone. If necessary, do this yourself, but it is preferable to have them do it themselves if they are able to do it effectively.

The victim should lean their head slightly forward and breathe through their mouth. You can also leave the head in a neutral position, but never tilt the head back. Tilting the head forward ensures that blood isn't ingested (as it can cause vomiting) or inhaled (choking hazard).

If you are unsuccessful at stopping the bleeding after 10 minutes of direct pressure, you should assess the blood flow. If the blood flow is minor, you could consider using an ice pack on the bridge of the nose to help stem the flow.

If the nose continues to bleed with a fast flow, you should seek medical assistance, probably from an ambulance.

Embedded Objects
If there is something embedded in the wound, do not remove it. Instead, apply pressure around the object using sterile gauze as described above. Rolled bandages are perfect for this. Be careful not to disturb the object, as moving it may exacerbate the bleeding. This doesn't apply to superficial splinters and such. A useful rule of thumb: if it's causing bleeding, don't remove it. If it isn't, feel free. Apply pressure and secure with bandages then get medical aid.

Stab, puncture or gunshot wounds to the body
These wounds are life threatening, and after assessing the ABCs of the victim, you should immediately summon an ambulance. As always, you should check that you are not in danger when approaching these victims (from someone with a knife or gun, for instance). As with all embedded objects, ensure you do not remove the item from the body.

If possible, you should sit the victim up (as blood in the body will go to the lowest point, allowing the heart and lungs to work as efficiently as possible). You should also lean them to the injured side, keeping the healthy side free from incursion by blood.

Assess the victim for open chest wounds or abdominal injuries, and treat accordingly.

Amputations
If a body part has been amputated, immediately summon ambulance assistance, and treat the wound for bleeding first as above. Cover the amputated part with a moist dressing and place it in a clean plastic bag, and place this bag into a bag of ice and water, sending it with the victim to the hospital (it should be labeled with their name, and where it belongs). You should avoid putting the part in direct contact with ice, as this can cause irreparable damage, meaning that surgeons are unable to reattach it.

If the body part is partially amputated, do not detach, but treat as a wound.

title: First Aid/External Bleeding


text:
First Aid/Heart Attack & Angina

Introduction
Heart attack (myocardial infarction) is when blood supply to the heart or part of the heart is cut off partially or completely, which leads to death of the heart muscle due to oxygen deprivation. Heart attacks usually occur after periods of rest or being recumbent, and only rarely occur after exercise (despite popular portrayal).

Angina (angina pectoris) is a 'miniature heart attack' caused by a short term blockage. Angina almost always occurs after strenuous exercise or periods of high stress for the victim.

The key differentiation between a heart attack and angina is that, in line with their typical onset modes, angina should start to relieve very shortly after resting (a few minutes), whereas a heart attack will not relieve with rest.

Pain in the chest can have many different causes and you should not attempt to distinguish between them. Always err on the side of caution and call for help when encountering a person with chest pain. This is absolutely crucial if the victim has had heart problems in the past.

Recognition

 * Chest pain: tightness, pressure, or pain in the chest (often described as "crushing")
 * Back pain: above or between the shoulder blades, often radiating into the left arm, and the jaw
 * Nausea or indigestion (especially in women)
 * Pale, cool, clammy skin
 * Ashen grey skin
 * Denial
 * History of a similar episode earlier that "just went away"

While some people will show typical signs of a cardiac emergency, others will show none at all. This is especially true of women in general, and both men and women with diabetes.

Treatment
Call for assistance. A possible cardiac problem is serious, and should never be ignored or passed of as insignificant. Assist the victim with medication, only if it is prescribed to them. People with angina will often have medication to control it; either as pills or a spray. This medicine (nitroglycerin) is commonly referred to as “nitro”. The pills should never be touched with bare skin by the rescuer, as they will be absorbed directly through skin. These pills are placed directly under the tongue for absorption, never chewed or swallowed, and while the victim is seated. The spray should be taken on the bottom of the tongue, and should also be kept away from bare skin. Only the victim should administer his medication. This includes over the counter medications such as aspirin. Giving medication to someone in an emergency is much more complicated than handing the victim a pill, and should only be done by medical professionals. If he is unable to do so, then the rescuer should not do it for him. Helping to take the lid off or handing the bottle to the victim is acceptable. The names of the medications and times taken should be documented if the patient is transferred to other rescuers.
 * Loosen tight clothing, especially around the neck to help the victim relax, and help medical personnel access the chest.
 * Help the victim sit reclined, with the body leaned back at about 45 degrees, with feet on the floor, but knees raised – this puts the patient in a “W” position. Getting the victim comfortable without straining is more important than the position.
 * Avoid giving food or drink which can complicate some treatments. If the victim complains of thirst, small sips of plain water or ice are acceptable.
 * Be vigilant for any changes in condition which can occur rapidly and without warning.
 * Be prepared to do CPR should the victim go into cardiac arrest.

title: First Aid/Heart Attack & Angina


text:
First Aid/Anaphylactic Shock

Anaphylaxis is a life-threatening medical emergency because of rapid constriction of the airway, often within minutes of exposure to the allergen. It is commonly triggered by insect stings and foods such as shellfish or peanuts. Call for help immediately. First aid for anaphylaxis consists of obtaining advanced medical care at once. Look to see if a device such as an epinephrine autoinjector (“Epi-pen”) is available – most people who know they have anaphylactic reactions will carry such a device with them. First aiders in many jurisdictions are now permitted to administer epinephrine in the form of an Epi-pen if the victim is unable to do so themselves. Check what the law says in your area.

Recognition

 * Hives or rash all over accompanied by itchiness
 * Swelling or puffiness of the lymph nodes, especially around the neck and mouth
 * Swelling of the airway and tongue
 * Difficulty breathing, wheezing or gasping

Treatment

 * Call EMS immediately
 * Have the victim administer their epinephrine autoinjector if possible
 * If available, administer an antihistamine to decrease swelling
 * Encourage the victim to breathe slowly; calm them
 * The victim should rest until EMS arrives
 * Monitor ABCs and begin CPR if required
 * If the victim is unable to administer their epinephrine autoinjector and it is legal to do so, administer it for them

Administering an epinephrine autoinjector
Epinephrine autoinjectors are designed for ease of use. There are instructions in the tube with the auto-injector, but you should know how to use one ahead of time. They're designed to inject through clothes, so you don't have to remove the victim's pants - even if they're wearing a heavy material like denim. Whenever possible, the victim should inject themselves, but if they're unable to do so, you may be legally permitted to inject the victim.

Remove the auto-injector from the protective tube. One end has a black tip - this is where the needle will come out. Do not touch this tip! The other end has a grey cap. Remove the grey cap, hold the autoinjector in your fist, and press it firmly against the outside of the victim's outer thigh. There should be an audible click. If there is not, try again but pressing harder. Hold the auto-injector in place for 10 seconds. When you remove it, massage the area for 10 seconds, then reinsert the applicator into its protective tube needle end first to avoid any danger. When EMS arrives, they can dispose of it for you.

title: First Aid/Anaphylactic Shock


text:
First Aid/Burns

A burn is the exposure of tissue to heat (thermal burns), chemicals (wet or dry), by electricity, or by radiation.

Recognition
There are 4 degrees of burns:
 * 1) Superficial Burn - First-degree skin will be dry, red, may swell and will usually be painful. An ordinary sunburn is a common example.
 * 2) Partial thickness - Second-degree skin will be red and may swell, usually very painful, has blisters that may open and release a clear fluid. This will make the skin appear wet.
 * 3) Full Thickness - Third-degree may destroy underlying tissues such as fat, bones, nerves, and muscles. Skin may be brown or black and will look charred. Tissue underneath may appear white. It may not be painful due to nerve endings being destroyed.
 * 4) Severely Full thickness - "Fourth-degree" may severely destroy underlying tissues. Skin will be black and will look severely charred. Tissue underneath will appear white. It will not be painful due to nerve endings being severely destroyed.

Thermal burns
You must stop the burning by removing the person from the source of the burn, being careful not to endanger yourself. Check for any life-threatening conditions by checking the Airway, Breathing, and Circulation. Cool the burn with copious amounts of pure water until the pain is relieved (in case of dry chemical burns, brush off residue first).

After the victim feels some relief, cover the burn loosely with a sterile, dry (preferably non-adhesive) dressing, such as "cling film". Do not use butter, oils, creams, etc.; they can trap heat and increase risk of infection. They will also need to be cleaned out by the hospital later, which only increases the pain the patient must endure. Also do not use antiseptics that may aggravate sensitive skin. Treat for shock. Burns affect the body's ability to regulate temperature. Ensure the person does not become over-heated (very rare) or chilled (very common). Cool the burn wound not the burn patient.

Aloe vera extract, silverdene (Silver Sulfazdiazine), topical analgesics, and NSAIDs (such as ibuprofen or aspirin) are commonly used medications. Consult a doctor before use.

Chemical burns
If there is a dry chemical, brush it off the skin using paper, cloth, or with a gloved hand. Be sure not to get any on yourself or more on the patient. Once the bulk of the dry chemical is gone, flush with running water as above. Call EMS immediately. If the burn is caused by a wet chemical, flush with plenty of water for 15 minutes and while flushing, call EMS immediately.

Electrical burns
Electrical burns look like third-degree burns, but are not surrounded by first- and second-degree burns. They always come in pairs: an entry wound (smallest) and exit wound (larger). Call EMS immediately if a person has been shocked as electrocution can cause cardiac and respiratory problems. Be prepared to give CPR or defibrillation. Care is the same for thermal burns.

Radiation burns
Radiation burns, though typically caused from a nuclear source, can also include ultraviolet radiation, in the form of sunburn, which should be treated as a thermal burn. The most common radiation burn is due to radiotherapy treatment, and are usually epidermal or superficial dermal burns. Burns caused by a nuclear power source, though rare, are still possible. Radiation burns can not be treated by a lay rescuer, but the usual principles of burn 1st aid apply. Individuals working in high-risk environments for possible radiation exposure, such as radiotharapy departments or nuclear power facilities, are trained in the management of radiation burns. The rescuer may unknowingly put himself/herself at risk of radiation exposure by treating someone with a radiation burn. For all nuclear radiation burns, call your local emergency number immediately.

Radiation burns also come in the form of snow blindness (or other intense light burns to the retina). Cover the eyes with sterile gauze, and contact EMS immediately. Do whatever you can to keep the victim comfortable, monitor ABCs, treat for shock, and keep the victim calm.

Critical Burns
The following burns require medical attention as soon as possible. They may be life-threatening, disabling, and disfiguring. Call the local emergency number if:

 * The burns are to a child younger than five years old or to an elderly person.
 * The patient is having difficulty breathing.
 * The burns are on more than one body part.
 * There are burns to the head, neck, hands, feet, or genitals.
 * There are burns to the mouth or nose (these may be signs of burns to the airway).
 * The burns result from chemicals or electricity.

title: First Aid/Burns


text:
First Aid/Immobilization

The proper method of slinging depends on where the injury occurred on the arm. After applying a sling, ensure circulation to the arm has not been compromised by doing a distal circulation check. Remember also that moving an arm into a position where you can put a sling on it may be painful for the victim. If that is the case, simply immobilize in the position found. You will have to improvise something based on the victim’s position of comfort.

The arm sling – for injuries to the forearm

 * Support the injured forearm approximately parallel to the ground with the wrist slightly higher than the elbow.
 * Place an open triangular bandage between the body and the arm, with its apex towards the elbow.
 * Extend the upper point of the bandage over the shoulder on the uninjured side.
 * Bring the lower point up over the arm, across the shoulder on the injured side to join the upper point and tie firmly with a reef knot.
 * Ensure the elbow is secure by folding the excess bandage over the elbow, securing it with a safety pin.

This can be accomplished by using the victim’s shirt or sweater as a sling. Simply pin the bottom hem to their chest using multiple safety pins, going over the arm. This works surprisingly well!

Elevated sling – for injuries to the shoulder

 * Support the victim’s arm with the elbow beside the body and the hand extended towards the uninjured shoulder.
 * Place an opened triangular bandage over the forearm and hand, with the apex towards the elbow.
 * Extend the upper point of the bandage over the uninjured shoulder.
 * Tuck the lower part of the bandage under the injured arm, bring it under the elbow and around the back and extend the lower point up to meet the upper point at the shoulder.
 * Tie firmly with a reef knot.
 * Secure the elbow by folding the excess material and applying a safety pin, and then ensure that the sling is tucked under the arm giving firm support.

Collar and cuff – for upper arm or rib injuries

 * Allow the elbow to hang naturally at the side and place the hand extended towards the shoulder on the uninjured side.
 * Form a clove hitch by forming two loops – one towards you, the other away.
 * Put the loops together by sliding your hands under the loops and closing with a “clapping” motion. If you can tie a clove hitch, simply tie it on the wrist.
 * Slide the clove hitch over the hand and gently pull it firmly to secure the wrist. Extend the points of the bandage to either side of the neck, and tie firmly with a reef knot.
 * Allow the arm to hang naturally.
 * It is especially important for this sling that you ensure that circulation to the hand is not compromised – do distal circulation checks often.

Femoral fractures
The femur is the largest bone in the body, and has a large artery, the femoral artery, directly beside it. Because a mechanism of injury which can fracture the femur is likely to also displace the fracture, it is possible that the femoral artery will be damaged internally. Damage to the femoral artery is likely to cause massive internal bleeding, so it is a major emergency; Call EMS immediately. Be sure to maintain as much immobilization as possible and monitor ABCs until EMS arrives.

title: First Aid/Immobilization


text:
First Aid/Musculoskeletal Injuries

Sprain or Fracture?
Sprains, strains, dislocations, and fractures can all present with the same symptoms. It is very difficult to determine what the injury may be. It is not necessary to know which injury the victim has as the treatment will be the same for all of them. Sprains only occur when a ligament is stretched past its normal limits. Strains occur when a muscle or tendon is stretched past its normal limits. Dislocations are when a bone comes out of its normal joint. Fractures are actual breaks in the bone.

When assessing an injury, the history will inform the practitioner almost as good as anything. The anatomy, the way it feels, hearing a "pop," loss of function, and what the pain feels like are good indicators to having a musculoskeletal injury. If the patient has any of the following symptoms, you should treat for a possible muscle or skeletal injury.
 * Deformity at the injury site
 * Crepitus - A grinding or cracking sound when the affected area is moved (usually accompanied by extreme pain). (Do not test for this! It should be reported by the patient.)
 * Bruising and swelling
 * No pulse below injury site
 * Inability to use the affected body part normally

''If the injury appears to be severe, EMS should be activated as soon as possible. These injuries include open fractures, shoulder/hip dislocations, and any injury that compromises nerve or circulatory function.''

Treatment
The acute treatment for muscle, bone or joint injury can follow the simple acronym "RICE".

 * Rest - Rest is very important for soft tissue injuries, both in the short term and for longer term care.
 * Immobilize - Sprains, strains and dislocations can be slinged; fractures should be splinted and slinged.
 * Cold - Ice should be applied periodically, for around 10-20 minutes at a time. After the 10-20 minutes, you need at least a 20 minute off period before you ice again. Any person sensitive to cold should have a layer of clothing between the skin and the ice.
 * Elevation - Where appropriate, the injury should be elevated above the heart, as this may help reduce the localized swelling which occurs. Do not elevate if this causes more pain to the victim.

If the injury is bad enough, the victim should be referred to a physician.

title: First Aid/Musculoskeletal Injuries