4. Initial Assessment: Judgment
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.
[(Crisis A + Setting
B) x Stressor C] divided by Strategy D = Outcome E.
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.
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
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
In such a situation, an assessment needs to be both fast and
thorough. The only way to accomplish both is to be both systematic
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
- 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
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?
All the above risk factors apply to drug emergencies, including
- 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
- 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
In the next chapter, we'll discuss
life-support techniques aimed at preventing that from happening.