4. Initial Assessment: Judgment Calls

In discussing ways of sizing up and responding to drug emergencies, it's hard to resist the temptation not to present things in a simplistic way -- with neatly-drawn borders around clearly defined problems, each inviting a can't-miss response from a too-cool-to-fool crisis worker.

But if things were that easy, we could just throw all the variables into a laptop or handheld computer and let it sort things out.

[(Crisis A + Setting B) x Stressor C] divided by Strategy D = Outcome E.

The problem is that most drug emergencies aren't so clear-cut.

Things get even dicier when you're presented with an unconscious or hysterical victim. Then it can be tough to pin down precisely what a specific problem even is, much less figure out how to proceed.

The range of complicating variables in the drug world today is too vast to do much more, in a booklet of this type, than present a basic guide for thinking on your feet -- and sorting things out quickly with your head and heart. But learning to do that is possible -- and necessary, if you ever plan to apply the information in this book.

In this chapter, we'll create a basic context for all the specific interventions and crisis-management methods that follow.

We'll begin with basic assessment techniques and move on to more advanced life-support procedures that are essential to effective crisis aid.

The old saying that you can't build on a shaky foundation was never more true: Because if you encounter someone in a crisis who needs life-support and you can't provide it, it doesn't matter what else you may know.

Because no one's going to be around to take advantage of it.

Making An Assessment

Whenever you encounter someone who is either unconscious or otherwise impaired, your initial inspection of the person and his/her condition assumes critical importance.

In such a situation, an assessment needs to be both fast and thorough. The only way to accomplish both is to be both systematic and prepared.

The American Red Cross calls the following "Emergency Action Principles." You can call them whatever you like -- as long as you can call them to mind when you need them.

1. Survey the scene.
2. Do a 'primary survey' of the victim.
3. Phone the emergency medical services (EMS) system for help.
4. Do a 'secondary survey' of the victim.

1. Survey the scene. The first principle is as simple as it sounds. Quickly look over the entire scene. Decide whether or not it's physically safe for you to be there. Look for any cues that might give you an insight into the emergency -- signs of a physical struggle, suicide notes, pills or syringes, etc.

If the person is conscious or if others are present, take charge of the situation. Identify yourself as someone with crisis training and ask specific questions to determine the problem.

If others are present, decide whether they may be of value in the intervention. Ask if they know the victim or are aware of any medical problems. Ask if they can help, if help becomes necessary.

If the person is conscious, ask for his or her consent before you go any further. The Red Cross recommends simply saying, "Hi, my name is ______. I know first aid and can help you until an ambulance arrives. Is that okay?"

If the person is unconscious, a minor, or emotionally upset, get permission from a parent or guardian, if one is present. If a legal guardian isn't present or if the person is unconscious or impaired and consent cannot be obtained, assume that consent would be given, and proceed with the intervention.

2. Do a primary survey of the victim. The "primary survey" is a fast check of the person's basic life systems. It's as simple to learn -- and recall in an emergency -- as ABC. And it's as fundamental to everything else that follows.

With an unconscious or unmoving victim, check their degree of responsiveness by gently tapping them on the shoulder and asking, "Are you OK?"

If there's no response, repeat the process. If there's still no response, call for help. Ask a partner or anyone else nearby to phone for help, while you continue the primary survey.

If no one is available to make the call, continue the primary survey by checking the victim's ABC's: airway, breathing, and circulation.

  • Airway. If the person is lying on the ground, make sure the airway (the passage from the nose and mouth to the lungs) is clear. If it isn't or it's obstructed in some way, use the head-tilt/chin-left method to re-establish a clear breathing passage. (Figure 1, p. 16.) [Ed. Note: For illustrations listed in this document, see http://www.doitnow.org/pdfs/208.pdf] Place one hand on the victim's forehead, and place your other hand under the victim's chin. Tilt the forehead back as you lift up on the jaw. Lifting the chin reduces the possibility of further injury, if the person has suffered a neck or back injury.
  • Breathing. Check for breathing. Place your ear over the victim's mouth and nose. (Figure 2) As you look for chest contractions, listen and feel for the movement of air through the nose and mouth. If the person is breathing, count the number of breaths for 30 seconds and multiply by two.
  • Circulation. Find out if the heart is beating by checking the carotid artery at the left side of the neck for a pulse (Figure 3). Hold one hand on the person's forehead, and slide your middle and index fingers into the groove alongside the Adam's apple.

3. Phone emergency medical services (EMS) for help. Getting help isn't always as cut and dried in an emergency as it sounds. Essential information can be easily omitted, addresses jumbled, ambulances dispatched to the wrong city.

That's why it's as important to be as prepared here as in any other area of crisis response.

For starters, be aware of who to call in your community for EMS back-up. If you're unsure, call 911 or '0' for operator assistance. Even better, have a crisis partner or bystander call for you, while you continue to monitor the victim.

But if you do transfer responsibility for the call to someone else, make sure that person handles the call correctly.

Give as much information as possible to the EMS dispatcher. Include

  • Exact location (include street, number, city, landmarks, etc.)
  • The phone number being used
  • Description of person
  • Drug(s) involved
  • Physical condition, including breaths per minute and pulse.

4. Do a secondary survey of the victim. The purpose of the primary survey is to identify and respond to any immediate life-threatening problems. The purpose of the secondary survey is to gather additional information and respond to other problems that may be present.

There are four main things to focus on at this stage in a crisis involving drugs:

1. Identify drug(s) involved.
2. Check for other danger signals and "red flags."
3. Continue to monitor vital signs.
4. Provide emergency care and support.

1. Identify drug(s) involved. Question the person or others present. Be friendly, but firm. Find out: How much of what when?

If the person is unconscious or no one else knowledgeable (or communicative) is present, look for evidence of use, such as prescription containers, syringes, pipes, pills, or bottles. Look in the medicine cabinet or the night table, if necessary. Evidence of combination drug use could be vitally important.

2. Check for other danger signals and "red flags." Is the person diabetic? Hypoglycemic? Hypertensive? Epileptic? Suicidal?

All the above risk factors apply to drug emergencies, including the following:

  • Unconsciousness. Person is completely unresponsive and can't be roused or drifts in and out of consciousness when awakened.
  • Respiratory problems. Unusually fast, slow, or irregular breathing. Lack of oxygen is indicated if person's skin takes on a blue or purple coloration, particularly around the mouth and lips. In dark-skinned people, this condition (called cyanosis) is best seen in the discoloration of gums and nails.
  • Heartbeat irregularities. Rapid pulse (more than 120 beats per minute) or slow pulse (less than 60 beats/minute). Irregular or unsteady pulse is another danger signal.
  • Fever. Body temperature above 102° can mean trouble. Sweatiness or detectable warmth on the forehead is a signal of possible trouble.
  • Pupil size. Dilated pupils may mean shock or overdose on cocaine or amphetamines. Constricted pupils may signal an overdose of heroin or another narcotic. Unequal size pupils may indicate head injuries or a stroke.
  • Vomiting. Can be particularly serious if the person is unconscious or semi-conscious.
  • Convulsions. May signal overdose or withdrawal.
  • Shock. Very fast or slow pulse rate; fast or slow breathing; cool, moist, and pale (even bluish) lips, skin, and nails.

3. Continue to monitor vital signs. Compare with earlier results. Things to look for: speeded up, slowed, or irregular pulse rate; breathing rate changes or problems (wheezing or otherwise noisy breathing); skin tone or body temperature changes.

Repeat every five minutes -- or more -- until help arrives. If vital signs are extreme, write down measurements and reading times, if possible, or have someone else write them down for you. General terms will do: "sweaty," "cold and clammy," "flushed," etc. are fine.

4. Provide emergency care and support. In a drug crisis, any of the above "red flags" can signal serious problems. Still, the two most vital signs are B and C in the ABC checklist.

Because when breathing and heartbeat are suppressed, oxygen flow to the brain stops. And when the brain is cut off from a constant supply of oxygen, it starts to die. Then so does the rest of the person.

In the next chapter, we'll discuss life-support techniques aimed at preventing that from happening.

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