Trauma First Aid

Someone is bleeding. Badly. A piece of shrapnel from a blast, a deep cut from collapsed glass, a crush injury from rubble. You've called Rescue 1122 but the line is busy. You try Edhi, and they say 45 minutes. Or nobody answers at all. You're looking at someone who is losing blood faster than you're comfortable with, and everything you've pressed against the wound is soaking through.

You have what's in this room and what you know. Right now, the second one matters more.

This guide isn't a substitute for professional medical training. If you can take a first aid course, do it. The Pakistan Red Crescent, St. John Ambulance, and several private organisations run them in Karachi for Rs. 2,000-5,000. What this guide gives you is enough to keep someone alive until help arrives. That's the goal: not surgery, not diagnosis, not treatment. Just keep them alive.

Scene safety

Before you touch anyone, stop. Look around. Is the scene safe for you?

This is not selfishness. If you get hurt, there are now two casualties and zero helpers. You are no use to anyone if you become a patient.

Check for:

• Ongoing threat. Are there more blasts expected? Is the building still collapsing? Is there active firing? If yes, wait or move the casualty to safety before treating. If you can't do it safely, don't.
• Structural danger. Cracked walls, hanging debris, exposed wiring, gas leaks (smell it). Don't enter a building that might come down.
• Electrical hazards. Downed power lines, flooded areas with live wiring. Stay clear.
• Blood exposure. If you have gloves, use them. If you don't: a plastic bag over your hands, a folded plastic shopping bag, even a clean dupatta between your hands and their wound. You're protecting yourself from bloodborne infections. Manage this if you can.

If the scene is not safe, don't go in. Call for help, direct others, wait for the scene to be secured. The most dangerous thing a first responder can do is become a second casualty.

The ABCs: what to check first

When you reach someone who's hurt, you need to assess quickly. Not a full medical exam, just enough to know what's killing them fastest.

A: Airway. Are they breathing? Can you hear it? Is anything blocking their mouth or throat? If they're talking or crying, their airway is open. If they're unconscious, tilt their head back gently, lift the chin, and check for breathing. If something is visibly blocking the airway, clear it with a careful finger sweep.

B: Breathing. Watch their chest. Is it rising and falling? If they're breathing, move on. If they're not breathing and you know CPR, start it. See the FCCPR Field Card for the technique. If you don't know CPR, focus on getting help.

C: Circulation. This means bleeding. Where is the blood? How much? How fast? This is what kills most trauma patients before they reach a hospital: blood loss. Everything below focuses on this.

Stop the bleeding

Blood loss is the number one preventable cause of death in trauma. Severe arterial bleeding can become life-threatening within minutes. You don't have time to debate what to do. The priority is always: stop the bleeding first, figure out the rest later.

Direct pressure: start here

Put pressure on the wound. Hard. With whatever you have.

• Your hand, with a cloth between it and the wound (a dupatta, a shirt, a towel, anything reasonably clean)
• Press hard. Harder than feels comfortable. You're trying to compress the blood vessel.
• Don't lift the cloth to check. Every time you lift, you break the clot that's trying to form. Press, hold, wait.
• If the cloth soaks through, don't remove it. Put another cloth on top and press harder.
• Hold for a minimum of 10 minutes. Set a timer if you can. It will feel much longer than it is.

Direct pressure stops most bleeding. If it's working, keep going. Don't switch to fancier techniques unnecessarily.

For a step-by-step reference, see the FCPressure Bandage Field Card.

When direct pressure isn't enough

If you've been pressing hard for several minutes and blood is still flowing freely (the wound is too deep, the vessel too large, or the location makes pressure difficult), you need to escalate.

For arms and legs: Apply a tourniquet (next section).

For wounds on the torso, neck, groin, or armpit: Pack the wound (section after tourniquet).

For chest wounds with a sucking sound: Apply a chest seal (further below).

Tourniquet basics

A tourniquet is a band that wraps tightly around a limb to completely cut off blood flow below it. It is for life-threatening bleeding from arms or legs only. Not for scrapes, not for minor cuts, not for anything that direct pressure can handle.

When to use one

• Blood is spurting or flowing in a way that direct pressure cannot control
• A limb is partially or completely amputated
• You can't reach the wound to apply pressure (trapped limb under rubble)
• There are multiple casualties and you need to stop one person's bleeding quickly so you can help others

How to apply

With a commercial tourniquet (CAT, SOF-T, or similar):

If you have one, you already know it's the gold standard. They cost Rs. 3,000-8,000 on Daraz. Worth every rupee if you ever need it. Follow the manufacturer's instructions. The general process:

1. Place it 2-3 inches above the wound, not on a joint (elbow, knee). If the wound is on the lower arm, the tourniquet goes on the upper arm. If you're not sure where the wound is, go high: upper arm or upper thigh.
2. Pull the strap tight and secure it through the buckle.
3. Twist the windlass (the stick/rod) until the bleeding stops. This will hurt the casualty. That's expected. Keep twisting until the bleeding stops.
4. Secure the windlass so it can't unwind.
5. Write the time on the tourniquet or on the patient's forehead. Use a marker, a pen, anything. Write "TQ" and the time, e.g. "TQ 14:30." This tells medical staff how long the tourniquet has been on.

With an improvised tourniquet:

You won't always have a commercial one. Here's what works:

• A belt. Wide leather or fabric belt. Not ideal (most belts are too stiff to tighten enough) but better than nothing.
• A dupatta or chunni. Fold it into a strip about 5-7 cm wide. Wrap it around the limb twice.
• A shirt or trouser leg. Tear or cut into a wide strip.

Whatever you use:

1. Wrap it around the limb, 2-3 inches above the wound
2. Tie a half-knot (like the first step of tying your shoes)
3. Place a stick, pen, wrench, or any rigid object on top of the half-knot
4. Tie a full knot over the rigid object
5. Twist the rigid object until the bleeding stops
6. Secure the rigid object by tying it to the limb with another strip of cloth

Width matters. A tourniquet that's too narrow (like a shoelace or wire) will cut into skin and cause tissue damage without effectively stopping blood flow. Use something at least 4-5 cm wide.

For the complete step-by-step, see the FCTourniquet Field Card.

Common fears about tourniquets

"Won't they lose the limb?" Modern evidence says a tourniquet can stay on for 2-4 hours without significant risk of limb loss. The person will lose the limb if they bleed to death. The tourniquet buys time for hospital care.

"It's too painful." Yes. A properly applied tourniquet is very painful. That's how you know it's working. A pain-free tourniquet isn't tight enough.

"Should I loosen it periodically?" No. Once applied, leave it on. Only medical professionals should remove or adjust a tourniquet. Loosening it can release a clot and restart fatal bleeding.

Wound packing

Some wounds can't be tourniqueted. Wounds to the neck, groin, armpit, or torso can't have a tourniquet applied around them. For deep wounds in these areas that are bleeding heavily, you pack the wound.

This sounds brutal. It is. But it's the most effective way to stop deep bleeding in areas where a tourniquet won't work.

How to pack a wound

1. Get material. Clean gauze is ideal. If you don't have gauze: a clean cotton dupatta, a t-shirt, strips of any clean cotton fabric. Avoid synthetic materials that don't absorb well.
2. Open the wound. You may need to use your fingers to hold the wound open so you can see inside and pack effectively.
3. Push the material into the wound. Not on top of it, but into it. You're filling the cavity. Pack it tightly. Use your fingers to push the material down into the deepest part of the wound first, then pack on top.
4. Keep packing until the wound is full. The material should be in firm contact with all the bleeding surfaces inside.
5. Apply direct pressure on top. Once packed, press hard on the packed wound. Hold or bandage tightly over it.

For the visual step-by-step, see the FCWound Packing Field Card.

Chest wounds

A penetrating chest wound from shrapnel, glass, or a stabbing is immediately life-threatening for a specific reason: air enters the chest cavity through the wound, collapses the lung, and the person can't breathe.

How to recognise it

• A wound to the chest that makes a sucking or hissing sound when the person breathes
• Bubbles forming in or around the wound
• The person is struggling to breathe and getting worse rapidly
• Coughing blood

Improvised chest seal

The goal is to seal the hole so air can't enter through it. The person's airway and remaining lung function does the rest until they get to a hospital.

1. Find plastic. A clean plastic bag, cling wrap, the wrapper from a bandage or cigarette pack. It needs to be large enough to cover the wound with at least 5 cm extra on all sides.
2. Place the plastic over the wound. As the person exhales, press it firmly over the hole. This creates a seal during the exhale when there's the least pressure.
3. Tape three sides. Tape the top and two sides of the plastic to the skin. Leave the bottom side untaped. This creates a one-way valve: when the person inhales, the plastic seals against the wound. When they exhale, trapped air can escape through the untaped bottom edge.
4. If you don't have tape: Have someone hold the plastic firmly in place. The priority is the seal, not the method.

Check both sides of the torso. An object that enters the front may exit the back. If there's an exit wound, seal that one too.

For the full walkthrough, see the FCChest Seal Field Card.

Shock

Shock is what happens when the body isn't getting enough blood flow to its vital organs. After significant blood loss or trauma, the body starts shutting down non-essential functions to protect the brain and heart. Without treatment, shock kills.

How to recognise it

• Skin: Pale, cold, clammy. Sometimes greyish. In darker skin, check the lips and nail beds, which will look pale or bluish.
• Pulse: Rapid and weak. If you press the inside of the wrist and the pulse feels fast and thready, that's a warning sign.
• Mental state: Confused, anxious, agitated, or unusually quiet. The person may say they feel like something is wrong, or they may not make sense.
• Breathing: Rapid, shallow breaths.
• Thirst: Intense, persistent thirst (the body signalling that it's lost fluid).

What to do

1. Treat the cause. If they're bleeding, stop the bleeding first. Shock from blood loss won't improve until the bleeding stops.
2. Lay them down. Flat on their back if there's no spinal injury concern. If they're vomiting or you're not sure, put them in the recovery position (on their side). See the FCRecovery Position Field Card.
3. Elevate the legs. If their legs aren't injured, raise them 20-30 cm (a folded blanket or bag under the ankles). This helps blood return to the core.
4. Keep them warm. Shock causes the body to lose heat rapidly. Cover them with whatever you have: a blanket, a chador, a jacket. Underneath them too, since cold ground pulls heat away fast.
5. Don't give food or water. Even if they're begging for water. If they need surgery, food or water in the stomach is dangerous. Wet their lips if they're desperate, but don't let them swallow.
6. Keep talking to them. Maintain eye contact. Tell them help is coming. Ask their name. Keep them conscious and as calm as possible. A person in shock who becomes unresponsive is deteriorating rapidly and needs immediate medical attention.

For a printable quick reference, see the FCShock Management Field Card.

Fractures and immobilisation

If someone has a broken bone (sometimes visible as a deformity, or indicated by extreme pain and inability to move the limb), don't try to set it. That's a hospital job. Your job is to stop it from moving and causing more damage.

Improvised splints

A splint immobilises the bone so it can't shift and cause more bleeding, nerve damage, or pain. You can make one from almost anything rigid:

• Rolled-up newspaper or magazine
• A piece of cardboard
• A wooden spoon or ruler
• A straight stick or branch
• A rolled-up towel (provides some structure)

To splint:

1. Pad the rigid object with cloth (a towel, dupatta, or clothing) so it doesn't press directly on skin
2. Place it along the limb, extending past the joints above and below the break
3. Tie it in place with strips of cloth, dupattas, or belts: above and below the fracture, not on it
4. Check circulation below the splint: can they feel their fingers or toes? Are they warm? If not, loosen slightly

For arm injuries: A dupatta or chunni makes an excellent sling. Fold it into a triangle, support the arm, tie behind the neck. See the FCArm Sling Field Card.

For the complete splinting guide, see the FCImprovised Splint Field Card.

What NOT to do

This section might save more lives than everything above. Bad first aid kills people.

Don't remove embedded objects

If glass, metal, wood, or anything else is stuck in a wound, leave it in. It may be plugging a blood vessel. Pulling it out can cause massive, uncontrollable bleeding.

Instead: build up padding around the object to stabilise it. Bandage around it, not over it. Let the surgical team remove it in a hospital.

Don't apply a tourniquet to the neck or torso

This sounds obvious but panic makes people do strange things. Tourniquets are for limbs only. For neck wounds, apply direct pressure carefully, avoiding pressure on both sides of the neck at once (that blocks blood flow to the brain). Press on the bleeding side only.

Don't use home remedies on wounds

This is critically important in Pakistan. Common home practices that cause infections and worse outcomes:

• Toothpaste on wounds: causes tissue irritation, traps bacteria
• Ghee or butter on burns: traps heat in the tissue, dramatically worsens the burn
• Turmeric (haldi) on open wounds: no evidence of benefit, introduces contaminants
• Applying soil or ash: this is how you get tetanus and gangrene
• Kerosene or petrol on wounds: causes chemical burns on top of the injury

Clean water and pressure. That's it. If you have Pyodine (povidone-iodine), use it to clean around the wound, not inside deep wounds. If you have Dettol, dilute it properly. If you have nothing, clean water is better than any of the above.

For proper wound cleaning, see the FCWound Cleaning Field Card.

Burns: a quick note

Burns are extremely common in blast and fire scenarios. The full treatment protocol is covered in the FCBurns Field Card, but the essentials: cool running water on the burn for 10-20 minutes. Not ice, not butter, not toothpaste, not ghee. Just clean, cool water. Cover loosely with cling wrap or a clean, non-fluffy cloth. If the burn is larger than the person's palm, blistered, or on the face, hands, feet, or joints, they need a hospital.

Don't move someone with a suspected spinal injury

If someone has fallen from height, been in a vehicle crash, or been thrown by a blast and has:

• Neck or back pain
• Numbness or tingling in limbs
• Inability to move arms or legs

Don't move them. Keep them still. Support their head so it doesn't turn. Wait for medical help. Moving someone with a spinal injury can cause permanent paralysis.

Exception: If the scene is immediately life-threatening (fire, collapsing structure, ongoing blast), move them. A paralysed person alive is better than a person with an intact spine who died in a fire.

Don't give aspirin or blood thinners

If someone is bleeding, giving them aspirin or similar medications makes the bleeding worse, as it prevents clotting. If they're on blood-thinning medication (common in older adults), tell the medical team when they arrive. It's important information.

Basic triage: multiple casualties

If you arrive at a scene with multiple people hurt (a blast, a building collapse, a vehicle crash), you can't help everyone at once. You need to decide who to help first.

This is ugly. It's the part nobody wants to think about. But not deciding is itself a decision; it just means you help whoever is closest or loudest rather than whoever needs it most.

Simple triage framework

Help first: People who are bleeding severely but conscious and breathing. They're dying right now but they can survive if you stop the bleeding. These people get your attention first.

Help second: People who are hurt but stable: broken bones, moderate bleeding that's not immediately life-threatening, burns. They need help but they have time.

Help last (or not at all): People who are not breathing and have no pulse despite clearing their airway. In a mass casualty situation where you are the only responder, spending 20 minutes on CPR for one person means three others bleed to death. This is the hardest call in first aid. In a hospital, they'd get full resuscitation. On a street with one responder and five casualties, the math is different.

Don't forget: Walking wounded (people who are up and moving, even if they're bleeding) can often help. Direct them. "Press here and don't let go." "Hold this person's legs up." "Go call for help." People who are given a task stay calmer than people who are left standing in shock.

Hospitals in Karachi

When you or someone nearby gets the casualty to a vehicle, you need to know where to go. Not every hospital handles trauma well. Here are the ones that do:

• Jinnah Postgraduate Medical Centre (JPMC): Rafiqui Shaheed Road. The largest trauma centre in the city. Government hospital: free treatment but extremely busy. If it's a mass casualty event, this is where most people will be taken.
• Aga Khan University Hospital: Stadium Road. Private. Excellent trauma care. Expensive, but in a life-or-death situation, they will stabilise first and bill later.
• Indus Hospital: Korangi. Free, high-quality care. One of the best charity hospitals in the country.
• Liaquat National Hospital: Stadium Road. Private, good emergency department.
• Civil Hospital: Baba-e-Urdu Road. Government, large emergency department.

Know which one is closest to your home, your workplace, and your children's school. In an emergency, "take them to the hospital" isn't a plan. "Take them to Jinnah, left from the main road, 8 minutes from here" is a plan.

Building a first aid kit

You should have one at home and one in your car. Here's what to buy; everything is available from a Pakistani pharmacy.

Total cost: approximately Rs. 1,800-3,500. Keep it in a labelled container or bag. Check it every 6 months and replace anything that's been used or expired. Tell your family where it is.

Optional upgrade: A commercial tourniquet (CAT or SOF-T) for Rs. 3,000-8,000 on Daraz. If you can afford it, buy one and learn to use it. It is the single most effective piece of emergency equipment a civilian can own.

Tonight

1. Learn one thing. Just one. Direct pressure: how to press on a wound hard and keep pressing for 10 minutes. You now know the technique that stops most bleeding.
2. Check your home for supplies. Do you have Pyodine? Gauze? Even a roll of bandage and a bottle of antiseptic is a start. If not, add them to your next pharmacy run.
3. Know your nearest trauma hospital. Not the nearest clinic, but the nearest hospital with an emergency department. Know the route from home. Know the route from work.
4. Save the numbers. Rescue 1122, Edhi 115, Chhipa 1021, Aga Khan Emergency (021-111-911-911). Put them in a contact group on your phone called "Emergency."
5. Talk to your family. "If someone is bleeding, press hard with a clean cloth and don't let go. Call 1122. If 1122 doesn't answer, call Edhi." That's enough to start.

The skills in this guide take an afternoon to learn and a lifetime to (hopefully) never use. But if you need them and you have them, you will save a life.