What should your first response be?

As members of the public, we all play a vital role in assisting a network of individuals trained and qualified to attend to medical emergencies (outside of a hospital setting). This network makes up the EMS system (Emergency Medical Services). Members of the public are often the first point of contact when a medical emergency occurs. Therefore, we all play a role in the EMS system, and we can contribute our bit in these 4 basic steps:

• Acknowledging / recognising the emergency
• Making a swift decision to take action
• Involving the EMS system (i.e. calling for medical assistance)
• Providing the correct care until EMS professionals are able to take over

EMS professionals are trained in different capacities according to specific roles. All can take over from a member of the public providing first aid, continuing to give advanced life support (where necessary), as well as transport a person to a medical facility (hospital or clinic). This network of professionals includes:

• EMRs (Emergency Medical Responders): These individuals typically have a legal duty to respond to an emergency situation and include fire fighters, police officers, national park rangers, ski patrol personnel or professionals and some athletic trainers (with certified training).
• EMTs (Emergency Medical Technicians): These individuals are qualified to provide more comprehensive life support (on a basic level) at an emergency scene (outside of a hospital environment).
• AEMTs (Advanced Emergency Medical Technicians): These individuals have qualified in additional life support training. Training also certifies an advanced technician to be able to administer medication to a patient at the scene of an emergency.
• Paramedics: These professionals are trained with the highest level of advanced emergency medical care, including the administering of medications at the scene, as well as airway support.

1. Recognising the emergency situation

Yes, time is of the essence in any emergency and when someone is choking, but it is just as important to know exactly what you’re dealing with. The wrong approach may be just as harmful as doing nothing at all. Immediate care is necessary, but must be appropriately approached, and there’s a fair amount to keep in mind.

Acknowledging an emergency situation means that you will already be taking note of what is happening, who is involved, as well as how you can potentially help. It’s important to remain calm and tune out unnecessary and distracting factors. No one is of any use in a flat panic.

2. Making the decision to take action

It may seem the obvious thing to do but deciding to take action is not entirely as simple as you might think. Many may freeze on the spot or be slow to acknowledge the situation. Others sometimes hesitate to take action, either due to personal feelings of apprehensiveness or simply thinking someone else around may know more and be in a better position to respond quicker and more effectively. These responses are human and can happen to anyone.

With minutes to work with, however, every second counts, and hesitation will matter in an emergency situation. With choking being a time-sensitive situation, it is thus important to know what should be done, as well as the risks involved. For many, knowing what steps to take can make it easier to confidently make the call to assist, and react quickly and appropriately.

Not everyone will feel confident enough to assist when unaware of what will be helpful or cause further harm. If your feelings of panic, fear or discomfort in providing aid to a person is stronger than the ability to help, rather call for emergency assistance as quickly as possible.

Once making the decision to take action (yourself or even merely calling for medical assistance), you will have already needed to assess a few factors. Certain details are going to matter to the EMS team once they arrive to take over. Before providing care yourself, you must be aware of exactly what you are approaching too.

There may be various things to be aware of, but they needn’t take up too much time. Some things to assess include:

1. Assess the scene

Is the environment where the choking incident is taking place, safe?

Choking can happen anywhere, and not always within a spot that is without hazards. If there are any noticeable hazards (like an area near a body of water, near electrical wires, or one within a confined space with no ventilation) which could pose a safety problem for the victim, yourself or any other bystanders, it is well worth noting so that an initial response can be to assist in moving the affected person away from such safety concerns.

Can you identify what may be causing choking?

As you approach, look around and use your senses (sight, smell etc.). Are there toys lying around? Is there an open medication package or a plate of food? What could a person potentially be choking on? It is also worth keeping in mind that a person may have moved a short distance away from these tell-tale signs in the moments they began to choke in an attempt to seek out assistance and is no longer in the exact spot.

Is anyone else around who may be able to assist or provide necessary information?

A bystander is technically an individual who is present as the emergency situation takes place. A bystander can also be someone who may know the patient well and can provide valuable information (about the person and or/ the choking incident) to EMS professionals once they arrive. You may decide to save time and have a bystander call for medical assistance, and request that they be available to meet EMS professionals when they arrive and direct them to where you and the patient are. A bystander can also help to control onlookers, keeping others away from the area the affected person is being assisted in, or to provide reassurance to the victim if they are particularly distressed by what is happening to them.

2. Assess the person

You may need to tailor your care approach to potentially special circumstances and or / a person’s age, as well as whether they are conscious or not.

Does the person appear alert (or responsive) even though they are visibly in distress (while struggling to breathe)? Are they experiencing an altered level of responsiveness (i.e. struggling to stay alert)? Does the person appear confused? What skin discolouration is taking place – is the person flushed, pale or turning a bluish / grey (ashen) colour? Is the person able to move or are they motionless? How old is the person (i.e. baby, toddler, adolescent, young adult or senior)?

Obtaining consent to assist:

1. A person that is conscious and responsive:

It is a good idea to obtain consent from the person experiencing choking before you take any care action. If the individual is a child (i.e. a minor), try to seek permission from a nearby parent or guardian.

The generally accepted process for obtaining consent is to state your name, mention if you have first aid training experience (including CPR / cardiopulmonary resuscitation training), and your intention to assist the person choking. From there, you can request consent to assist. This approach may also be reassuring for the patient and any loved ones nearby.

It is worth keeping in mind that some individuals may refuse care from a stranger who is a member of the public (even if they are in desperate need of it), including the parents or guardians of a minor needing assistance. In these situations, the best thing to do is to offer assistance by calling appropriate EMS personnel to assist.

In some instances, consent may be given initially and then withdrawn. In such cases, stop giving care and ensure that you wait for EMS professionals to take over when they arrive.

You will need to be mindful of your communication with a person who is choking, as well as with surrounding loved ones (or bystanders). Take care not to make statements that promise something which may contradict your actions. For instance, you may not be able to guarantee that the first aid you implement won’t cause some discomfort or physical harm (although it goes without saying that every effort should be made to avoid doing so). First aid for choking requires forceful techniques, so some injury can be expected.

If an individual is able to understand you, speak to them directly, even if they are an older child or have a loved one nearby. Gauge the situation with a clear mind and act accordingly.

2. A person that is not responsive / conscious or is mentally impaired:

These individuals are not able to provide consent due to their condition. In many countries, the law takes the assumption that in these situations, a person of sound mind (including minors without a parent / guardian present) would give consent for assistance (this is known as implied consent), and thus a person willing to assist can lawfully go ahead and provide first aid care.

You can check for responsiveness (and breathing) when you approach a person by shouting the person’s name (if you know it or can quickly find out), but for no longer than 5 to 10 seconds. A second attempt can be made by tapping a person’s shoulder (or the bottom of their foot if an infant). If they do not move, make any moaning noises or open their eyes, they are considered non-responsive. Gasping does not qualify as normal breathing ability.

Special circumstances to consider:

• If the choking victim is an older adult (senior): Assess whether there is a bystander around who knows the patient well. When speaking to the affected person, speak in a loud enough tone (but do not shout – it is even more distressing for the person). Be alert. If a conscious person appears to struggle to understand you, opt to change your wording and not the volume of your voice. If they appear to show signs of struggling to hear you (many older adults have problems with impaired hearing), then only raise your voice a little. An older adult is particularly vulnerable to a state of confusion during a medical emergency.
• An affected person has an obvious disability: As with an older adult, assess whether a bystander who knows the victim is nearby for assistance. A person may have an intellectual disability and struggle to understand what is happening or to communicate with EMS or medical professionals later on. A family member or caregiver nearby can assist with this during and after a choking emergency. Those with disabilities may have a service animal (such as a guide dog) or an assistive device (such as a leg brace, cane or wheelchair). You may need to factor in getting some assistance from a bystander with calming an anxious service animal or handling assistive devices. Service animals are trained to stay with their handlers / owners, so it is advisable to try and keep the animal nearby and have someone calm them down, should they be anxious or agitated. Both animal and owner could become more anxious should they be separated, even during an emergency. A person could also have impaired hearing, in which case, it is advisable to initially approach them from the front while obtaining consent so that if they are able, they can lip read and understand your facial expressions. It is best to use short sentences. Adjust volume or words accordingly based on the cues you determine from the patient – can they not hear you or are they merely not understanding your words? Use clear gestures if need be to help you communicate.
  A person with impaired vision can be spoken to in a normal tone. If a person is responsive and can hear you, it can often help to describe what you are doing as you provide first aid care.
• A patient does not speak the same language as you: This can be challenging, especially when trying to get consent in an emergency situation when time is of the essence. Speak in a normal tone and try to find out if any nearby bystanders can help to communicate or translate on your behalf. Non-verbal communication with clear gestures and facial expressions, which can be universally understood, may also be useful. You may have to use this method of communication if no one is available to translate. This information should also be mentioned to the EMS dispatcher when medical assistance is called for.

3. Call for medical assistance (‘activate the EMS system’)

In an emergency situation, and especially if you are handling an injured person on your own, it can be confusing as to whether you should call for emergency assistance first or attend to the person requiring help before making that all important call.

Choking is life-threatening, and there is little time to spare. You have minutes to work with. In this instance, it is best to provide care as quickly as possible once consent is received and then call for medical assistance. It’s essential to prioritise appropriate care which prevents a person’s condition from worsening further. You may need to gauge appropriate action (i.e. call or care first) according to the situation at hand.

If a bystander (like a parent or guardian of a minor) is able and willing to assist, instruct them to call EMS professionals while you administer care. If you are alone with a person choking (who is responsive), provide care first and then call. If you are alone with an unresponsive patient, whom you did not see collapse (and may be unaware that their condition is as a result of choking), provide care first (i.e. assess whether the person is breathing or not) before calling for assistance. Chest compressions could help to dislodge a potential obstruction.

The situation may require you to call for medical assistance before care is administered. One reason could be that you require verbal assistance from a trained EMS dispatcher in order to be sure how to assist. Many EMS dispatchers are trained in first aid and CPR, and thus are able to assist in providing care for a patient in these critical moments. For those alone with a patient and not entirely sure how to provide care (or simply if you require a reminder), it may be useful to call as quickly as possible and follow the instructions of the qualified dispatcher, while they arrange EMS professionals to attend the emergency call-out.

Another reason for calling before taking action could be that you are choking and alone. In this case call for assistance first while you are conscious and responsive, in the event that you may be unable to request help later. If you are alone with someone known to be experiencing choking, call for emergency assistance before providing care if they have collapsed in your presence and become unresponsive. From there you can administer appropriate care (which may involve CPR) while EMS professionals are dispatched to come and assist / take over.

When making the call, either yourself or a bystander must be prepared to provide essential information to an EMS dispatcher:

• The location of the emergency (address, and if necessary, landmarks or nearby intersections).
• The nature of the emergency and some detail about the patient (adult / child / infant etc.) experiencing choking.
• What assistance has been given so far (and by whom).
• The telephone number of the phone being used to make the call (and whom is making the call).

4. Provide care

In an emergency situation, how quickly appropriate care is given can mean the difference between permanent disability and complete recovery, or even life and death. If you opt to provide emergency care for someone experiencing choking, you must be committed to doing so until such time as qualified EMS professionals arrive.

Care not only involves physical actions to help remove the obstructing foreign object from a person’s airways, it also includes ensuring that you do not cause further harm to the person, being aware of their level of consciousness, breathing capability (if relevant), and reassuring a person (if conscious and responsive) that medical assistance will be called or is en route.

Unless an environment is identified as unsafe (i.e. there is some immediate danger that could cause further harm), a patient should not be moved. This is to prevent additional injury, which could impact their recovery. If a person loses consciousness and requires CPR, they may then need to be moved onto a flat, hard surface in order to properly administer care.

In an emergency situation such as choking, it is not a good idea to transport a person directly to a medical facility before providing care. If you are experiencing choking, it is also not a good idea to try and drive yourself to a medical facility as you may have difficulty in driving safely and could lose consciousness.