23.1 — The First Sixty Seconds

Most people who come across an emergency do nothing useful for the first two or three minutes.

Not because they do not care. Because they do not know what to do first, and in the absence of a first step they stand still, or they do something that feels active and is not — shaking the person, shouting their name repeatedly, running for water, searching for a pulse they will not find.

This Part is the answer to that. It is the most important Part of this volume, and this page is the one to read first, because it is the framework that all the others hang on.

One structure covers every emergency, from a road crash to a collapse in a kitchen. Learn it once and you always have a first move.

Before anything: are you safe

You cannot help anyone if you become the second casualty.

And this is not caution for its own sake. Rescuers are injured and killed at scenes regularly — by traffic, by electricity, by fire, by fumes, by water, by collapsing structures, and by violence.

Look for, in this order:

Traffic. Approaching a road scene, look for oncoming vehicles before you look at the casualty. Get others to warn traffic, use hazard lights, and stay off the carriageway where you can.

Electricity. If someone is in contact with a live source, do not touch them. Switch off at the source or, for domestic current only, push them clear with something dry and non-conducting — a wooden broom handle, a plastic chair. For high voltage — overhead power lines, railway lines, substations — stay at least 25 metres away and wait for the power to be confirmed off. Electricity can arc, and the ground itself can be live (Chapter 23.7).

Fire and smoke. Do not enter a smoke-filled space. Smoke inhalation incapacitates within a few breaths.

Gas and fumes. A person collapsed in a confined space — a grain silo, a tank, a cellar, a manhole — is a trap. The commonest cause of multiple deaths in confined spaces is rescuers going in after the first casualty. Do not enter. Call for specialist help.

Water. Reach, throw, row — do not go. Reach with something, throw something that floats, use a boat if there is one. Entering the water is the last resort and only if you are trained (Chapter 23.10).

Violence. If there is any possibility the situation is still dangerous, wait at a distance and call for police.

Blood and body fluids. Use gloves if you have them, and a barrier for rescue breaths. The risk from a stranger's blood is low and not zero, and a plastic bag over your hand is better than nothing.

And a rule that sounds cold and is correct: if the scene is unsafe and you cannot make it safe, your job is to call for help and keep others out. That is not failing to act. It is preventing more casualties.

The primary survey — DR ABC

This is the sequence. It works for every emergency, and it works because it deals with the things that kill fastest, first.

A blocked airway kills in minutes. Absent breathing kills in minutes. Catastrophic bleeding kills in minutes. Everything else can wait.

D — Danger

Covered above. Check before you approach, and keep checking.

R — Response

Kneel beside them. Speak loudly and clearly: "Are you all right? Open your eyes."

Then shake their shoulders gently. Shoulders, not the head, and gently — if there could be a spinal injury you do not want to move the neck.

Grade what you find, because it tells you how urgent this is:

Alert — eyes open, talking. A person who can speak clearly has an open airway and is breathing. That is a lot of information from one sentence.

Responds to voice — opens eyes or moves when you speak.

Responds to pain — only reacts to a firm pinch of the earlobe or trapezius muscle.

Unresponsive — nothing. This is the emergency.

If they respond: leave them where they are unless there is danger, find out what is wrong, and get help as needed.

If they do not respond: shout for help immediately. Do not leave them yet — shout first, so someone else can call while you continue.

A — Airway

In an unresponsive person, the commonest cause of a blocked airway is their own tongue.

Muscle tone is lost, the tongue falls back against the throat wall, and the airway closes. This is why unresponsive people die who would otherwise have survived — not from the original problem, but from simple mechanical obstruction.

The head tilt and chin lift opens it:

Place one hand on their forehead and tilt the head back gently.

Place two fingertips of your other hand under the point of the chin and lift.

Fingertips under the bony chin, not under the soft tissue beneath, which pushes the tongue backwards and makes it worse.

That single movement lifts the tongue off the back of the throat and opens the airway in most people.

If you suspect a neck injury — a fall from height, a road collision, a dive into water — use a jaw thrust instead: from behind the head, place your fingers behind the angles of the jaw and push the jaw forward without tilting the head.

And if you cannot open the airway with a jaw thrust, tilt the head anyway. An open airway takes priority over a possible spinal injury, every time. A dead person's spine does not matter.

Look in the mouth. Remove anything visible and loose — dentures only if they are displaced, vomit, food, blood. Do not sweep blindly with a finger, which pushes objects deeper.

B — Breathing

Keep the airway open. Put your cheek near their mouth and look along the chest.

LOOK for chest movement.LISTEN for breath sounds.FEEL for air on your cheek.

For up to 10 seconds. No longer.

And this is where the single most consequential mistake in first aid happens.

In the first minutes after a cardiac arrest, many people take slow, irregular, noisy gasps. This is agonal breathing. It looks like breathing. It sounds like breathing — snoring, gurgling, sighing. It is not breathing.

It occurs in a large proportion of witnessed cardiac arrests, and it is why bystanders and even emergency call handlers sometimes conclude the person is alive.

The rule: if breathing is not normal — not regular, not quiet, not effective — treat it as absent.

Occasional gasps every few seconds are not breathing. Start CPR.

If they are not breathing normally: this is cardiac arrest. Call an ambulance, get a defibrillator, and start chest compressions (Chapter 23.2).

If they are breathing normally but unresponsive: put them in the recovery position and continue to monitor.

C — Circulation

Look for catastrophic bleeding.

And in specific situations — a stabbing, an amputation, a major open fracture, an industrial injury — bleeding is checked and controlled before anything else, because someone can bleed to death from a major artery in under three minutes while their airway is perfectly fine.

This is why some services teach "C-ABC" for trauma: catastrophic haemorrhage first.

Look for pooling blood, blood-soaked clothing, and blood underneath the person. Blood soaks into dark clothing and into carpet and can be far greater than it appears.

Control it with direct pressure (Chapter 23.3).

Do not check for a pulse to decide whether to start CPR. Trained professionals are unreliable at it under pressure, and untrained people more so. The decision is made on breathing, not on pulse.

The recovery position

For anyone unresponsive but breathing normally.

Why it works: it keeps the airway open by gravity, and it lets vomit drain out of the mouth rather than into the lungs.

Aspiration of vomit is a real and common cause of death in unconscious people, including in ordinary alcohol intoxication, and this position prevents it.

How to do it:

1. Kneel beside them. Straighten both legs.

2. Place the arm nearest you out at right angles to the body, elbow bent, palm facing up.

3. Bring the far arm across the chest and hold the back of that hand against their cheek nearest you.

4. With your other hand, grasp the far leg just above the knee and pull it up, keeping the foot on the ground.

5. Keeping their hand pressed against their cheek, pull on the far leg to roll them towards you onto their side.

6. Adjust the upper leg so both hip and knee are bent at right angles, which stops them rolling further.

7. Tilt the head back to keep the airway open, and adjust the hand under the cheek to maintain it.

8. Check breathing regularly.

If they must stay in it for more than 30 minutes, roll them onto the other side, to prevent pressure damage to the lower arm.

And do not use it if you suspect a spinal injury and they are breathing safely — unless you need to protect the airway, in which case the airway wins and you roll them with as much support to the head and neck as you can manage, ideally with help.

The secondary survey

Once the immediate threats are dealt with, and only then.

A rapid head-to-toe check for anything else:

Head and face — bleeding, swelling, fluid from the ears or nose. Neck — deformity, and a medical alert necklace. Shoulders and chest — deformity, symmetry of chest movement, wounds. Abdomen — rigidity, tenderness, distension. Pelvis — do not rock or press a possibly fractured pelvis; look rather than push. Legs and arms — deformity, swelling, wounds, and a medical alert bracelet. Pockets and bag — for medication, an insulin pen, an adrenaline injector, a medical card.

And take a history if they can talk, or from anyone who saw it:

Signs and symptoms — what do they feel. Allergies.Medication.Past medical history.Last food and drink — which matters for surgery and for diabetes. Events — what exactly happened, in order.

Write it down, or type it into a phone. You will forget details under stress, and the ambulance crew will ask.

What to do while waiting

Keep them warm. A blanket or coat, and something underneath them if the ground is cold, because the ground draws heat faster than air.

Do not give food or drink to anyone who might need surgery, who has swallowing difficulty, or who is not fully alert. A sip of water for someone fully alert with a minor problem is fine.

Reassure them, and keep talking. Say who you are, that help is coming, and what is happening. Unresponsive people may still hear, and there are accounts from survivors who remember what was said around them.

Send someone to meet the ambulance — at the gate, the lobby, the entrance to the field. Minutes are lost to crews looking for the address.

Clear a path. Move furniture, unlock doors, and put the dog in another room.

Gather their medication — the actual boxes, not a list from memory.

And stay with them.

Deciding how urgent it is

Call an ambulance immediately for:

Unresponsiveness.Breathing difficulty, or noisy or absent breathing.Chest pain lasting more than 15 minutes.Any sign of stroke (Chapter 23.4). Severe bleeding that will not stop.Seizure lasting over 5 minutes, or a first-ever seizure.Severe allergic reaction.Serious injury, major burns, or suspected spinal injury.Suspected poisoning or overdose.A baby under 3 months with a fever.And a non-blanching rash with fever (Chapter 17.4).

And a rule that removes the hardest part of the decision: if you are not sure, call. Call handlers are trained to work out what is needed, and no ambulance service is annoyed by a call that turns out to be minor. The calls that cause harm are the ones not made.

Two things worth knowing about the law

Good Samaritan protection exists in most jurisdictions. Someone acting in good faith, within their competence, to help in an emergency is protected in law in the large majority of countries. Legal action against a bystander who tried to help is vanishingly rare.

Doing nothing from fear of doing the wrong thing is the actual risk.

Consent: ask a conscious person before touching them. For an unresponsive person, consent is implied — the law assumes a reasonable person would want help.

The one paragraph to remember

Check for danger. Check for a response. Shout for help. Open the airway with head tilt and chin lift. Look, listen and feel for normal breathing for up to 10 seconds. If breathing is absent or abnormal, call an ambulance, get a defibrillator, and start chest compressions. If breathing is normal, put them in the recovery position. Control any severe bleeding with direct pressure. Then keep them warm, keep talking, and wait.

That sequence covers almost everything, and the rest of this Part is what to do differently in specific situations.

What the next page fixes

Chapter 23.2 covers CPR and choking — the two procedures where a bystander acting immediately makes the largest difference to whether someone lives, with exact technique for adults, children and babies.