cABCDE

 

cABC(DE), or

Let's Make People Care, Together.

Having a well-stocked (and well-thought-out) first-aid kit in your car, bag or on your person can mean the difference between life and death, but having the bare minimum found in pre-built hardware store/pharmacy kits or even just a gauze roll can be enough to save a life.

But a car full of fancy tools won't help anyone if you don't have the knowledge how to use them and aren't confident in your own abilities.

Take courses, train with a friend, self-educate, gradually work your way up to more high-stress scenarios, take courses, build a kit according to your means and needs, take courses.

The world is horrible and uncaring sometimes, but we can't change that, at least not alone. What we can do is care. We can be the right person in the right place for the people that aren't.

It's a harsh and unfair world out there, and it doesn't care how wonderful a person is to you, doesn't care how much good you see in them – horrible things can happen to everyone. But that doesn't mean that you can't make a difference.

Tools, theory, training.

You can combine those three things, so that when bad things happen to good people, you can be the good thing that happens in response.

You can help.

cABC(DE), or xABC(DE) is a flowchart of sorts used for on-site injury/casualty treatment in both military and civilian contexts. Each letter corresponds to a certain “check” and course of action taken. This will not be a comprehensive education on the matter. This will be a rough guideline to remember and use.

Training should be both theory and hands-on, held by medical professionals. The Red Cross provides basic first aid training and certification. Self-education and training with friends or family is a great way to introduce more stress and become more confident after you have all learned the basics, or become certified. Avoid training scars, it takes roughly 3-6 times longer to relearn something you initially learned incorrectly. Building your kit as you learn will help you save money and avoid poor-quality products.

Rolled gauze is incredibly versatile, cheap, and easy to acquire – most people likely have one or two rolls at home already. The C.A.T – Combat Application Tourniquet – is durable, easy to use and takes a second to deploy when folded correctly. If you're not a C.A.T. person, the SOF-T is a good alternative. A “space blanket” fits almost anywhere and is excellent at retaining body heat. Sterile compression bandages are for intermediate bleeding anywhere on the body. A pair of trauma shears for cutting your way through clothing, boots and gauze. Finally, multiple pairs of latex/nitrile gloves to guard against infection and protect you from blood-borne diseases – I'd recommend going a size too large, since they're easier to pull on even while sweaty and shaky, and also allow for stacking multiple pairs of gloves since the outer pair gets contaminated eventually, especially if you have multiple patients to tend to.

This “kit” in itself consists of high-quality, easy-to-use, combat-proven products, and is similar in philosophy to a stripped-down IFAK (Individual First Aid Kit), covering the most bases for the least bulk and weight possible. If you live in the U.S.A., you'll likely find the stuff far cheaper, as well.

c or x – Catastrophic/critical bleeding.

Large, open, visible wounds that pose an immediate threat to survival. An open artery in the thigh can lead to unconsciousness in 30-60 seconds and death in 2 minutes. Remember to check pulse regularly throughout repeated cABCDE.

For extremities, a tourniquet is applied. It can be improvised or bespoke, the latter being strongly recommended due to ease of use and build quality.

Do not loop the tourniquet over a joint, too close to the wound. Personally, most of my first aid knowledge comes from a military context – I was taught to tie it as close to the trunk of the body as possible in case of further unnoticed damage to the limb, like small shrapnel wounds (Roughly 70% of battlefield casualties are caused by indirect fire – artillery, mortars, bombs, and so on.) Make sure there isn't any thick clothing between the tourniquet and the skin. A light shirt or hoodie can be fine and reduce chances of nerve damage from the pressure of the tourniquet, but a thick winter coat will hamper your efforts to control the bleeding. If nothing else works, cut off the pant leg or sleeve.

Looping a sturdy strap, for example, a nylon/cordura MOLLE-compatible strap (roughly 1½” wide) with a durable non-slip cam through itself and around the limb twice and tying a knot around a strong bar (like the handle of a claw hammer) to serve as a windlass can work, as long as the wound is observed to not leak and the windlass is properly secured in place, like with another, identical strap. These are multi-purpose items, costing roughly 6€ each for the FDF-issued ones. Another possible use is securing a field-expedient (improvised) splint to a broken limb.

If using improvised equipment, check back every few minutes to ascertain end of leakage.

The tourniquet – whether purpose-bought or improvised – must be marked with the time of application, since tissue will begin necrotizing in approximately 12 hours without blood flow.

Untying tourniquets depends on the time of application – however, removal should be done in a critical care setting, not by a layperson. If you – for whatever reason – have to remove the tourniquet yourself, do it slowly. The blood trapped in the tied-off limb will rush back into the patient's system violently, possibly leading to cardiac arrest or a stroke, or even septic shock if the blood has begun decomposing.

Remember to write down the time of application.

For the torso and head, compression bandages, purpose-made chest seals, Quik-Clot or hemostatic powder, even plastic wrap can work, depending on the injury and how quickly the patient can be evacuated. Multiple layers of plastic wrap secured with duct tape or something of equal or higher adhesive strength can be enough to keep the patient's internals where they belong, assuming the patient reaches a critical care setting quickly enough and transport is stable.

For neck and throat injuries, raising the arm opposite of the wound and tying a compression bandage around the package helps prevent asphyxiation (this has saved at least one life that I personally know of.)

If in a public place and nobody has taken charge of the situation, take charge. This will be a very high-stress situation. Don't say “Somebody call an ambulance!” – say “You, the guy in the white shirt! Call an ambulance!” Singling out a person and assigning a specific task to them is a nifty way to avoid “bystander syndrome” since there's no “somebody else” to do it, they were told to call an ambulance. Instead of standing around and gawking or filming, spare people can be sent to different street corners to flag in emergency vehicles. Hi-vis vests are a great car trunk accessory for this. Filming in general should be dissuaded – there's a wounded person on the ground, and as you proceed down the checklist you might – depending on the type of trauma sustained – have to at least partially undress them in order to make sure there's no further damage. If you find the time, double-check the address with the ambulance caller, and don't hang up.

If there is someone better trained than you on site, defer to them, but do not interrupt treatment to bicker about who's in charge – you're all on the same team here, and your objective is to keep the patient alive.

 

A – Airways.

Ensure that the airways are free, tilt the patient's head back, physically reach into their mouth and dig if you have to. Breathing can be labored, but as long as patient is breathing, you're on the right track. A nasopharyngeal airway is a nifty and very uncomfortable tool that makes sure at least one airway is open.

This is not the time to start doing CPR, A.K.A. mouth-to-mouth or thorax compression, since those are meant to artificially maintain blood flow to the brain, and require enough force to usually break the ribs. Still, a good rule of thumb for chest compressions is doing it to the beat of "Stayin' Alive" by the Bee-Gees, or roughly 100-120 compressions/minute.

If CPR is necessary at this point, then treatment may have begun too late, or the wounds are still leaking due to improperly applied tourniquets, bandages, chest seals, etc.

 

Vomit aspiration is a risk if alcohol or other intoxicants are present, and after going through the checklist an improvised recovery position wouldn't be a bad idea, ex. with the wounded limb elevated but otherwise laying on the side.

Still, you should (hopefully) have enough time to intensively monitor the patient, and take immediate action even if vomiting occurs. Remember to change your gloves after digging out the puke from someone's mouth if there are further injuries you have to treat.

 

 

Usually tilting the patient's head back is enough, if injuries have been sustained sober. As long as there is no damage to the spine, an improvised pillow under the trapezius makes sure their head is tilted back.

Depending on where you live, having a naloxone nasal spray kit can be very useful, especially considering the opioid crisis in the U.S. Naloxone blocks the opioid receptors in the brain for up to two hours – normal breathing should be restored within 2-3 minutes. While it is prescription-only in some parts of the E.U., U.S. pharmacies sell Narcan over-the-counter.

More modern (and dangerous) drugs like fentanyl and carfentanil have half-lives of 7-8 hours, and if one nasal spray was enough to bring the patient back to consciousness, you might want to save the other spray on the off chance that EMS takes too long to arrive to your location. Please note that the patient is likely to be irritable, emotionally unstable, perhaps even aggressive, since naloxone triggers near-instant withdrawals due to the rapid onset of action.

 

B – Breathing.

Is the patient breathing? How well? If their breathing is labored and painful, and if there has been major damage to the torso a lá sucking chest wound, then you may have a case of tension pneumothorax on your hands; the chest wound has allowed air to build up within the chest cavity, but the loose tissue in the wound prevents air from escaping (the flap of loose skin lets air in but doesn't let it out) This causes a rise in air pressure inside the thorax which makes breathing more difficult and puts direct physical pressure on the heart, among other very bad things. Too much pressure buildup – apart from being intensely painful for the patient – will lead to difficulty breathing, the heart having to work harder to maintain blood flow.

DO NOT attempt any form of thoracostomy without proper training.

Improper use of a thoracostomy needle can injure, or outright KILL.

If the patient's state has deteriorated from A – lucid to B – incoherent or further (see AVPU p.6), this would imply insufficient oxygen supply to the brain, ex. due to intrathoracic pressure making it harder for the heart to pump properly. There could be a cardiac arrest and a collapsed lung waiting around the corner if the issue is not quickly resolved, and then CPR would be required. Still, as long as there's a pulse and some breathing, CPR will only hurt the patient.

Also, excessive blood loss would also decrease the brain's oxygen supply significantly, which is why it is imperative to ensure that there is no continued hemorrhage after step c/x (p.2). Be sure.

Probably the easiest method of treatment – that is, if you have the required tools in your first aid kit – is a needle thoracostomy, where a large hollow needle (10-16 gauge, 3” or 2” long, the former being more consistent in decompression but also increasing the risk of underlying tissue damage) wrapped in a thin plastic catheter is pushed through the cartilage between the ribs, after which the needle is retrieved and the catheter left in place – there's different ways of doing this. 

 

“Quick and dirty” is roughly three splayed fingers down from the armpit, aimed centrally through the rib towards an imaginary point in the center of the thorax.

A more exact specification would be the 4^th – 5^th intercostal space, midaxillary line: trace a line down the patient's chest ½” out from the beginning of the armpit or where the pectoral muscle swoops to connect to the front deltoid, stopping once you reach the bottom of the pectoral muscle. If you feel a slight “valley” extending sideways when you push your finger into the chosen spot, that's the cartilage between ribs #4 and #5. The right side is preferable, and I think you know why.

Another alternative is the 2^nd intercostal space, midclavicular line: with the patient's shoulders relaxed, trace a line from the left shoulder joint to the right, stopping above the right nipple, roughly 3” above the nipple. Again, try to find a “valley” – although ALTS (Advanced Traumatic Life Support) recommended the 4^th – 5^th intercostal midaxillary for adults in 2018 due to the chest walls being thinner at that spot. Another problem with the 2^nd intercostal is reliably finding it – if the patient has enough muscle mass the “valley” between the ribs indicating cartilage is very hard to find due to muscle fibers not compacting as easily as fat. With all three methods, the needle and catheter should be aimed towards the same imaginary point in the very center of the thorax, not towards the spine. If using the 2^nd intercostal, ALTS recommends using a 2” needle, presumably to avoid piercing the lung.

Penetrating the cartilage might feel extremely off-putting to you, and will be temporarily painful for the patient, but it is far better than allowing the pressure to increase. After penetration, push catheter deeper, withdraw and dispose of needle in a medical sharps or other sealed container ASAP to minimize the chance of contact with you, the patient, or a curious onlooker/assistant. Blood-borne diseases are not a joke. While a sharps container is by far the most fool-proof, glass jars also work.

One tube should be enough, a hissing sound and gradual return of normal breathing indicates decompression and success. Tubes can clog with blood, however, in which case another is necessary. Use the spots you've been taught. Be sure. If you can't do it, there might be someone else present who knows how to perform a thoracostomy, and if nothing else, EMS definitely knows how to.

Again, do NOT attempt a thoracostomy without proper training.

If piercing the 2^nd intercostal, use a 2” needle, and never use the left side.

Using needles above 2” in a thoracostomy increases the likelihood of tissue damage.

 

C – Circulation/Hemorrhagic shock.

 

If only doing cABC, this would encompass Consciousness as well (see D – Disability, p.6). Is the patient in shock? Treat non-life-threatening bleeding. Band-aids, saline rinses, smaller wounds that still bleed, but not at a rate that would be instantly life-threatening.

Low blood pressure, pale skin, blue lips and cool skin temperature are all indicators of shock. This is when transfusions should start – if possible – along with – if possible – transportation.

Naturally, if medical staff is on-site or has been on-site for a while, you will have deferred to them. Leaving the patient in their care as soon as possible maximizes the chances of the patient's survival, as will any information about the patient's injuries you've noticed up to this point.

Cannulae should be applied into veins (bright red, top of arm) instead of arteries (dark red, underside of arm). As a layperson, you will likely never have to do this.

You can remove your gloves, and check the patient's body for wounds that may have gone unnoticed initially – if plausible – a quick once-over from head to heels, making sure to both touch and observe.

This part depends on the situation, the patient, their state of consciousness, the incident that lead to the physical trauma, so on. As cABCDE is also used in a military context, the once-over is often necessary to find shrapnel wounds that have gone unnoticed or other complications masked by adrenaline killing the pain too well for the casualty to notice that they have, in fact, been shot.

Still, even if the situation demands it, you must remember to allow them their basic human dignity – cameras are everywhere today. Clothing should be removed, but only to the point where you make it faster and easier for yourself to once-over your patient, and unless the clothing is actively constricting the patient's airways or blood flow, it should be put back on as soon as possible to conserve body heat. Even then – opening a hoodie zipper for a quick check could be enough – a hitherto-unnoticed bleed would be easy to feel through a thin shirt or something similar, and easy to see on lighter-colored clothing.

Unless absolutely necessary – ex. patient lost his left testicle in a chainsaw accident – intimate areas are to be avoided (unless wounds in those areas are likely and, if aware, consent is given), so if the situation isn't catastrophic and the patient is lucid, explaining the procedure and asking for consent before going ahead would be a reassuring gesture to the patient – you are there to increase their odds of survival, watch over them until trained personnel can take over, and provide compassion and care – not trigger memories of SA. Most people don't mind... but safe beats sorry.

 

D – Disability.

Is the patient responsive? Discussion should be maintained throughout cABCDE to gauge responses. My personal go-to is asking about the patient's childhood, maintaining discussion throughout without getting too distracted. Ask about how they're feeling, their memories, their families, their jobs, anything that comes to mind. Fully lucid patients can small-talk just fine, but more shocked ones might need a bit more verbal legwork.

Maintain human contact throughout, talk to them even if they're silent, reassure them. Try to stay positive and kind, no matter what. Maintain a safe atmosphere – any wound large enough will flood their nervous systems with adrenaline, and heavy exsanguination might lead to actions and statements that might seem strange at first.

Remember, you're here to help them.

Refer to AVPU:

1. Aware – the patient is responsive, but can range from fully lucid to delirious. The latter is a sign of shock. Even if delirious, the patient's speech is garbled, but mostly consists of actual words.

2. Verbal or vocal – the patient is not coherent, but reacts to stimuli (at worst, to pain) with noise. Vocalizations do not sound like language, there is no intentional message being conveyed.

3. Pain – the patient reacts to painful stimuli by instinctively pulling back (retreating) from it, but is otherwise unresponsive. No vocalization.

4. Unconscious – the patient is wholly unresponsive. Remember, the patient's state can go from better to worse and vice versa, monitor them closely. A notebook is always handy for recording observations. Be thorough – write the time next to the observation.

E – Exposure/Evacuation

With everything done for now, close the patient's clothing back up, drape a blanket over them, or use whatever you have handy that can maintain normal body temperature. This can include your own outer layers – you have the option of moving to maintain body heat during colder months.

Continue monitoring, prepare to go down the checklist again. A foil "space blanket" doesn't cost much, fits pretty much anywhere when folded, and reflects the patient's body heat back onto them. I usually carry two in my bag, one in a small accessory pocket, another in the kit strapped to the bottom of the backpack.

If the ground is cold, sweeping away snow and making a "bed" out of evergreen branches helps with insulation. However, moving a patient alone can be incredibly tricky and possibly dangerous, depending on the type of trauma sustained.

If you arrive on the scene of a car crash, please do not move the patient of your own accord – fractures in the neck or spine are quite common in these situations, and moving the patient yourself instead of waiting until EMS and the local fire department arrive to cut the roof off the car and lift the patient out can mean the difference between a lifetime of neck-down paralysis and just some occasional shoulder pain and stiffness for the patient.

TAKE COURSES.

In addition, the patient is (hopefully) your only priority, and while comfort is a large part of well-being, do not neglect the focus on the patient's survival – sometimes things will be painful, scary and uncomfortable, and while you can help distract them with discussion and repeating the checklist now and then, gritting their teeth and bearing it can end up being the only solution.

Use your own judgment re: weather, temperature, likely response time, patient's condition.

If needed, a tarp or a foil blanket can be used to construct a shelter to protect from wind chill.

This is where the earlier questions like “is the patient responsive” come in handy, since they're a good guideline for reporting the state of the patient when they finally – hopefully – are evacuated.

Depending on the situation, training and tools available, this could be very in-depth (your notebook detailing changes in the patient's responsiveness, what first aid you've performed at what time), or it could encompass the bare necessities in a verbal report – “Laceration in right thigh, tourniquet applied and timed, breathing fast but steady, in shock. Patient aware but incoherent.”

Please note that while I'd recommend putting on 2-3 pairs of nitrile/latex gloves so the now-contaminated gloves can be discarded if you're doing something else and return to repeat the checklist, most wounds are generally considered "dirty" by default, doubly so if they were sustained outdoors.

You can rinse them with saline, but this might not always be necessary since professional care and decontamination is – hopefully – imminent. Still, trying to pull a fresh pair of gloves on while your hands are sweaty and shaking with adrenaline will make the task much harder and more time-consuming. Also, sterile gloves are generally to be removed for the once-over, if it's deemed necessary. Even a thin layer of plastic can mean the difference between finding a laceration, bullet hole, etc. and missing it entirely. Be thorough, be professional, be calm, and reassure the patient.

Remember to repeat the checklist again and again (and again...) Monitor the patient's condition closely. A previously stable patient can suddenly decline due to any number of factors. Only stop cABCDE when trained personnel arrive to treat the patient. Give them as much information as possible and – finally – breathe a sigh of relief. Water, snack. Realize that you just saved a life.

You will be stressed. You might – one day – have someone's life in your hands.
Your ability to act under duress and in adverse conditions is the most vital tool in your arsenal.
But confidence only comes with repetition. So, once your first few courses are done, train.
“Train as you fight” is commonly associated with military forces, but it carries over into first aid as well. Research typical accidents, simulate them with your friends, keep up the pressure, and remember that the absolute worst thing you can do in any situation is to freeze up.
If you lock up, move. It doesn't matter what you do, as long as you are doing something. Even a misguided action takes you one step closer to regaining control of the situation.

TRIAGE:

You, dear reader, will hopefully never have to do this. Triage is a tool in the medical arsenal often associated with desperate times, but has plenty of use outside of them as well. It is not necessarily trustworthy unless performed by a medical professional, although time constraints, resource scarcity and stress can all warp one's judgment to an extreme level, doctor and layperson alike. This usually entails allocation of limited resources to a large amount of patients, whether in wartime or during natural disasters, large-scale triage usually means something has gone horribly wrong.

1. GREEN: Low priority, survival likely. Wounds are relatively light, yet hinder everyday activities to some extent. Can be as innocuous as a sprained ankle. Or a bullet in the butt.

2. YELLOW: Medium priority, survival likely if given care. Deep wounds requiring surgery, bullets hitting muscle without severing too many blood vessels – ex. being shot in the leg.

3. RED: High priority, survival only possible if care is given quickly. Severed limbs, lacerated femoral artery, slit throat, anything entailing catastrophic bleeding and a need to act as quickly and efficiently as the current situation permits.

4. BLACK: No priority, whether due to no hope of survival whatsoever, insufficient resources, or simply being impossible to stitch back together again. Nerve gas exposure without timely application of atropine. Exploding shell in the stomach. Administer analgesics, stay with them until the end, comfort them – even if you can't provide care, you can always provide comfort and reassurance, stay beside them as a fellow human being until their time is up, let them pass away peacefully and with dignity, next to someone that cares, that remembers.

The examples listed are ideal examples, assuming a well-stocked, powered, staffed hospital – the point of triage is to assess what you can treat based on the current situation, your supplies, the amount of staff able to help and their skill-set, if some form of mass evacuation is feasible, if you are currently under threat of attack, if there is a constant stream of casualties coming in, if communications lines are functional, if the building has power... you could probably fill in another five restricting factors quite easily just based on personal experience, and writing a comprehensive list of every single one would likely take up some 700 pages. Having to ration supplies, for example, would probably mean a lot less red cards and a lot more black. No power, and an inconsequential surgery suddenly becomes impossible.
No surgeons? Oh dear.

The point of this – rather grim – page is to remind you that no matter how hard you try, how much you sweat and bleed and cry, overwhelming outside factors can decide if the patient survives long before you get to the scene. The world is harsh and unfair – terribly so at times.

It's not your fault, no matter how guilty, terrible or shocked you feel.  

You tried your best.

Always remember that.

A popular pro-gun argument in the USA is that to stop an active shooter situation, all you need is "a good guy with a gun". Now, I personally love shooting, so I should agree, right? No.

A high-stress situation nobody has prepared for can turn a range sniper into a shaky first-timer, a deer in the headlights of an oncoming truck, or likely even into another separate threat to public safety, whether due to indiscriminate fire, ricochets or an itchy trigger finger.

The reason I wrote this quick-and-dirty introduction or taste test is because I don't believe in "good guys with guns" making the world a safer place – I believe people with training and first aid kits and the capacity to push back against apathy, ignorance and bystander syndrome are what we actually need more of, no matter where we live.

I believe in people that care.

Whatever country it is shaped by, whatever city block or farm it was raised in, whatever unique form it takes with time, whatever heartbreak and happiness it gets to experience, life will always be horrible and wonderful and priceless and so painfully fragile.

So let's rage against that fragility. Let's use our hands to heal and our voices to soothe, even while the world around us swings hammers and spews hate.

Let's not be the "good guy with the gun" that spits “safety” out of a rifled barrel.

Let's not be the bystander filming another human being's suffering for the world to see.

Let's be the hand that staunches the bleeding and ties the mitella around the broken arm.

Let's be the smiling mouth that says everything is going to be okay, and actually means it.

Because every time we do our best, every time we interrupt our 24/7 feed of apathy, greed and wanton cruelty with a story of selflessness and empathy and a fragile life pulled back from the brink, every time another person decides they want to help as well... then I'd say that the world gets just a little bit more okay, as well. It's not going to happen overnight...

...but even a baby step is a step in the right direction.

You are free to distribute this document wherever you may so feel, as long as the credits below are in place. If you are well-trained in first aid, or even a medical professional, please add, improve or update as much as you want to, and add your handle, nickname or whatever onto the lines below.

Let's make people care, together.

Thank you for reading.

2023, TKU, FIN, original document by uwusmeg/noko