Alphabetical Disorder

   Do you remember the first time you learned about the ABCs? After grammar school, I mean. For me it was 1991. I was taking a first-aid course--the one that teaches 101 uses for cravats--so I could join the local rescue squad. Airway, breathing and circulation were introduced after the "Responding to Mushroom Clouds" lecture and before "Poisonous Creatures You'll Never Encounter." How fortunate, I thought, that our three most important physiological needs happen to align with the beginning of the alphabet.

   With practice I mastered mandible manipulation, pocket-mask management and chest compressions--on Rescue Annie, at least--and started to feel like a lifesaver. That lasted until my second call, a diabetic whose needs, within my nascent spectrum of caregiving, fell somewhere between defibrillation and sling-and-swathe. My efforts to forcibly examine the airway of our combative hypoglycemic patient clearly entertained the crew. Were the ABCs intended only for patients with the mental status of manikins? I figured a real cardiac arrest would show me.

   I didn't have to wait long. Shortly after receiving my original AHA card, I responded with an ALS crew just before dawn to a female "not breathing." We found our elderly patient supine and motionless in bed. Her husband had suspected something was wrong because she was "too quiet." I waited in the background as one of our team probed first for a radial, then a carotid pulse. After 30 seconds or so I was summoned to the patient's side to begin chest compressions. That didn't seem right: We were starting with C...unless the dispatch information counted as B, but then we should have been using the mask with the push-button thingy (it was a long time ago). And I wasn't sure about A; I hadn't seen anyone open the patient's mouth.

   My initial impressions of our care seem naive now. I was technically correct about emergent priorities, but clueless about practical application of those principles. I began to realize that the ABCs shouldn't be treated as a protocol, but rather as a checklist of mission-critical items, the order of which depends on logistics. It's a matter of acknowledging the obvious. During our cardiac arrest case, for example, we began by observing that the patient was supine and not moving--signs that the dispatch information ("not breathing") might be accurate. It was. That heightened our suspicion of pulselessness, which was easy to check. There was no reason not to begin chest thrusts while the BVM was retrieved and attached to our O₂ tank. As for airway, the time and place made it unlikely the patient had choked to death--an assumption that needed to be verified, but not as the first order of business. Intubation confirmed the woman hadn't inhaled a hot dog in her sleep.

   Later I considered other reasons why our alphabetically arranged airway-breathing-circulation sequence might be more convenient than appropriate. What about severe bleeding? Not only do we almost always spot it before evaluating airway or breathing, but it also overrides other treatment priorities. I mean, it's bad form to be staring at someone's tonsils while they're exsanguinating. And in the absence of life-threatening hemorrhage, breathing, not airway, should be next, because speech and chest movement make breathing much easier to detect than pharyngeal foreign bodies. Might as well leave the airway alone unless breathing is a problem.

   I think we just coined "the CBAs." For those of you uncomfortable about field-stripping the alphabet, here's a contrived but accommodating CBA-to-ABC translation:

   That's a start, but there are other details we detect even before bleeding--noise and odors, for example. By assigning more than one key word per letter, we can broaden the ABCs to better fit real-world assessments:

A: Unless we're wearing headphones and SCBA gear (might be a gift idea for the firefighter who has everything), we'll notice prominent sounds and smells even before we see our patient. Can't help it. Let's acknowledge reality by beginning with aromas and...uh...auditory cues. Next we'll observe the patient's posture and appearance, followed by his/her affect--verbal or silent, animated or sedate. There's nothing revolutionary about the new As; they give us important clues about presenting problems, and are usually part of the doorway survey we do without thinking.

B: This is where we begin those CBAs--our earlier draft of an acronym upgrade--by checking for severe bleeding and breathing. Remember, our assumption is they're hard to miss, and their absence or presence dictates what to do next.

C: Circulation and choking complete the CBAs. Notice we've separated bleeding and circulation; the former we see easily, the latter we have to confirm with a pulse check.

   As long as we're reassembling the alphabet, let's not forget D and E:

D: By now we've theoretically spotted and corrected immediate threats to life. Disability reminds us to finish evaluation of mental status (a task started at A), note pre-existing deficits and consider mechanisms of injury. A good medical history alerts us to disease and chronic illness.

E: By now we should be en route to someplace with doctors.

   Different? Sure. Radical? I don't think so. For most prehospital cases, you'd have to force yourself not to follow that sequence.

   It's as easy as AAAABBCCDDE.

   Mike Rubin, BS, NREMT-P, is a paramedic at Opryland in Nashville, TN, and a member of EMS Magazine's editorial advisory board. Contact him at mgr22@prodigy.net.