Royal Army College

Lesson Overview

Not every casualty bleeds. The environment itself injures and kills, and in a Principality with a cold climate and a coast it does so often. A soldier on a winter welfare task, on a hot summer exercise, at a fire, or beside someone pulled from the sea will meet these injuries, and the right first response is usually simple and decisive. This lesson covers four: cold injury and hypothermia; heat illness; burns; and drowning, including the discipline of rescuing safely from water.

These four belong together. None is a wound you can see and dress; each is a fault of temperature or of breathing, done to the whole casualty by the world around them. Each turns on the same few decisions: read the danger early, act simply and within your training, avoid a short list of things that do harm, protect the rest of the casualty from the same environment that injured them, and call for more help before you need it rather than after. Get those right and you save lives with little equipment. Get them wrong, or wait, and the slowest of these injuries can still be the one that kills.

This is the knowledge layer. The hands-on skills, cooling, warming, dressing a burn, resuscitation, water rescue, are taught and certified in person under qualified instruction, and you do only what you are trained and currently authorised to do. The clinical detail is confirmed by the College's medical staff and follows current internationally recognised practice. Remember always what you are: a trained first responder, not a medic. Your task is to recognise, to give safe first response, and to keep help coming until those with more training and equipment arrive. That care is owed to anyone who needs it, soldier or national, friend or stranger, judged by need alone.

Three cross-references run alongside this lesson. The Caring for Those in Need course, Lesson 05 (Cold-Weather Welfare and First Response), teaches cold injury in welfare work in fuller depth, with the at-risk groups and the welfare setting. The Cold-Weather Operations and Survival course teaches what the cold does to the body, and the shelter and warmth that prevent it. Basic Training Module 12 sets the casualty drill these injuries fit within. And earlier in this course, Lesson 05 taught shock, which several of these injuries can cause; keep it to hand. By the end you will be able to recognise and give first response to cold injury, heat illness, burns, and drowning, and to judge when the casualty needs more than you can give.

Key Terms

Hypothermia: a dangerous fall in the body's core temperature below about 35°C, in which the body can no longer keep itself warm; it clouds the mind as well as the body and can be fatal.
The umbles: the cluster of early warning signs of hypothermia, when a casualty stumbles, mumbles, fumbles, and grumbles, body and mind both starting to fail in the cold.
Afterdrop: the further fall of core temperature that can follow rapid or rough rewarming, when cold blood from the limbs is driven back into the core; the reason a very cold casualty is rewarmed gently and from the centre, not the edges.
Frostbite: the actual freezing of the skin and the tissue beneath it, most often at the fingers, toes, ears, nose, and cheeks.
Non-freezing cold injury: damage to the feet or hands from being cold and wet for a long time without the tissue freezing; also called trench foot or immersion foot.
Heat exhaustion: the milder, earlier form of heat illness, in which the casualty is hot and still sweating but weak, headachy, and faint; recoverable with rest, cooling, and fluids.
Heatstroke: the severe, life-threatening form of heat illness, in which the body can no longer control its temperature; the casualty is dangerously hot and often confused or collapsed.
Burn depth and extent: how deep into the skin a burn reaches and how much of the body it covers; together they decide its severity.
Drowning: harm from being unable to breathe because the face is in or under water; it may be survived (near-drowning) or fatal, and it is a process to be interrupted early.
Reach, throw, don't go: the order of safe water rescue, help from land or by throwing a line before ever entering the water yourself.

Cold injury and hypothermia

In the Principality's winters the cold is a killer in its own right, working fastest at night and made far worse by wind and wet. Hypothermia is the whole-body danger: as the core cools, the casualty shivers, stumbles, mumbles, fumbles, and grumbles (the "umbles"), then grows confused and drowsy. A grave and misleading sign is that the shivering stops; this usually means worsening, not recovery. Cold injury is more local, most often frostbite of the fingers, toes, ears, nose, and cheeks, where the skin turns white, grey, or waxy and feels hard or numb.

Recognising hypothermia. Cold climbs a ladder, and your task is to catch the casualty on the lower rungs. Early, the casualty is cold and shivering, hands fumbling, speech slurred, mood withdrawn or irritable, the "umbles" beginning. They may insist they are fine, because the cold has already clouded the judgement that should warn them. As the core falls further the shivering becomes violent and then, ominously, stops; the skin is cold even under clothing, and movement and thinking grow clumsy and muddled. In the severe stage the casualty is drowsy or unrousable with slow, faint breathing and pulse, and may appear lifeless while still alive, which is why a very cold casualty is never written off in the field. The single most important recognition point is this: when the shivering stops, assume the casualty is getting worse, not better. Shivering is the body's own heater; its silence means the body has run out of fuel to run it.

Acting on hypothermia. Stop further heat loss and warm gently. Work through it in order:

Stop the heat loss first. Get the casualty out of the wind and wet, into shelter of any kind. Wind and water strip heat far faster than still cold air, so breaking their contact with the casualty is the single most valuable, and often quickest, thing you do.
Get them off the cold ground. The ground draws heat out of a lying casualty greedily. Put insulation underneath, a roll-mat, poncho, dry vegetation, packs, before you worry about cover on top.
Replace wet with dry, gently. Remove wet clothing, cutting it away rather than dragging a stiff casualty about, and replace it with dry layers. Then insulate from above with blankets, a sleeping bag, or a foil casualty blanket over warm material rather than bare skin. Cover the head, which loses heat fast.
Warm gradually, from the centre. Add gentle warmth to the core, the trunk, armpits, and chest, not to the cold hands and feet first. Warm, sweet drinks help a fully alert casualty who can hold a cup and swallow safely, for the warmth and the sugar that fuels shivering. A casualty who is drowsy, confused, or not fully alert is given nothing by mouth, because they may choke.
Handle gently throughout. A very cold heart is irritable and can be tipped into a dangerous rhythm by rough handling. Move a severely cold casualty smoothly and as little as you can, and never make them walk or exercise to "warm up".

The cautions are firm: never give alcohol, never rub frostbitten skin, and never apply fierce or direct heat to cold flesh. Alcohol feels warming because it flushes the skin, but it opens the very blood vessels that should be staying shut to protect the core, and it speeds the fall in temperature while clouding judgement further. Fierce or direct heat, a fire held close, a heat pack on bare cold skin, hot water on a frozen hand, scalds numb flesh that cannot feel it. Worse, it can drive a sudden afterdrop: rewarming the cold limbs too fast opens their vessels and sends a wave of cold, acid-laden blood rushing back into the core, dropping the core temperature further and straining the heart at its most fragile moment. This is why the rule is gentle, gradual rewarming of the core first, and why a severely cold casualty's full rewarming is a medical task, not a field one.

   HYPOTHERMIA: read the rung, and remember the warning sign

   Rung        What you see                          What it means
   ---------   -----------------------------------   --------------------------
   Early       Shivering, fumbling hands, slurred     The body is fighting and
               speech, withdrawn or cross ("umbles")  still winning; act now
   Worsening   Violent shivering THEN shivering       Danger: the body's own
               STOPS; cold skin, clumsy, muddled       heater has failed
   Severe      Drowsy or unrousable, slow faint        Life-threatening; handle
               breathing and pulse, looks lifeless     very gently; keep helping

   GOLDEN RULE: shivering stopping is a sign of getting WORSE, not better.

Call medical or emergency help for any casualty who has stopped shivering, is confused, drowsy, or hard to rouse, who has more than superficial frostbite, or who is not improving. This is taught in fuller depth, with the at-risk groups and the welfare setting, in the Caring for Those in Need course, Lesson 05, and in Basic Training Module 12; treat those as the companion to this section. The Cold-Weather Operations and Survival course treats what the cold does to the body, and the shelter and warmth that prevent all of this.

Cold injury to the extremities

Hypothermia is the whole-body danger; the extremities have their own injuries, and their own handling. Two matter most in the Principality's climate: frostbite, the actual freezing of tissue, and non-freezing cold injury, the slower damage of being cold and wet for a long time.

Recognising frostbite. Frostbite strikes the parts furthest from the warm core and most exposed to the wind: the fingers, toes, ears, nose, and cheeks. It begins as frostnip, where the skin is cold, pale, and numb but still soft, a stage reversible if warmed promptly. True frostbite goes further: the skin turns white, grey, or waxy, feels hard, stiff, or wooden, and loses sensation, so the casualty often does not feel the injury happening. As it thaws it may blister, redden, swell, and become very painful.

Acting on frostbite. The rule that prevents the worst harm is short and absolute: do not rub, and do not let it refreeze.

Stop the cause. Get the casualty and the affected part into shelter and out of the wind and wet, and remove anything constricting, rings, a tight boot, a watch, before swelling traps it.
Do not rub the part. Frozen tissue holds tiny ice crystals; rubbing, or the old remedy of rubbing with snow, tears the tissue from within and turns a recoverable injury into a destroyed one.
Rewarm appropriately, and only if a refreeze is impossible. Rewarm gently, ideally by the body's own warmth, a hand tucked into the casualty's armpit or against a warmer companion, or by warm (not hot) water under qualified guidance. Because warming and refreezing does far more damage than staying frozen a little longer, if you cannot keep the part warm afterwards (for instance if the casualty must still walk out on a frostbitten foot) it is safer to leave it frozen and get them to care.
Never refreeze. Once a part is rewarmed, protect it absolutely from the cold for the rest of the evacuation; a second freeze is one of the surest ways to lose the tissue.
Do not pop blisters, and pad the part. Dress it loosely, separate frostbitten fingers or toes with soft padding, burst no blisters, and keep the part still and slightly raised. Treat the casualty for hypothermia too, since a frostbitten casualty is usually a cold one.

Non-freezing cold injury (trench foot, immersion foot) comes not from freezing but from feet or hands being cold and wet for many hours: the skin becomes pale, wrinkled, numb, and cold, and later, as it warms, red, swollen, and painful. It is prevented by keeping the feet dry and changing wet socks, and treated by warming, drying, and elevation, again without rubbing. Any frostbite beyond the mildest frostnip, and any significant non-freezing injury, needs medical review.

Heat illness

Heat is the opposite danger, and the Principality's summers and hard physical training both bring it on. It runs along a scale. Heat exhaustion is the milder, earlier form: the casualty is hot but still sweating, with pale, clammy skin, headache, thirst, cramps, dizziness or faintness, nausea, and a fast, weak pulse. Heatstroke is the emergency: the body's control of its temperature has failed, the casualty is dangerously hot, the skin may be hot and, ominously, the sweating may have stopped, and there is confusion, strange behaviour, collapse, seizure, or unconsciousness. Heatstroke can kill and can cause lasting harm.

The line you must draw. The single most important judgement in heat illness is which of the two you are looking at, because the treatment and the urgency differ. The line is drawn by the mind and the skin. A heat-exhausted casualty is still sweating and, above all, mentally clear, distressed and weak but answering you sensibly. A heatstroke casualty has crossed a line: the brain itself is overheating, so the casualty becomes confused, behaves strangely, slurs, collapses, fits, or loses consciousness, and the skin is very hot, often dry because the sweating has failed (though in exertional heatstroke it can still be sweaty). An altered mind in a hot casualty is heatstroke until proven otherwise, and is a true emergency.

   HEAT EXHAUSTION  vs  HEATSTROKE  (draw the line on the MIND)

                 HEAT EXHAUSTION              HEATSTROKE  (EMERGENCY)
   Mind          Alert, makes sense,          Confused, odd behaviour,
                 distressed but clear          slurring, collapse, fit, out
   Skin          Hot, sweaty, pale, clammy    Very hot; often dry (sweat
                                                has stopped), can be sweaty
   Temperature   Raised                       Dangerously high
   Body's job    Struggling but coping        Temperature control has FAILED
   You do        Rest, cool, give fluids,     Cool FAST and HARD, call help
                 watch closely                 AT ONCE, give nothing to drink

Acting on heat illness. The first action for any heat casualty is to stop the activity and move them to a cool, shaded place, and loosen or remove excess clothing. For the milder, alert casualty, cool them by any means to hand, fan them, wet the skin, apply cool packs to the neck, armpits, and groin, encourage rest, and give fluids to drink (water, or a salty or sweet drink if available). Lay them down and raise the legs a little if they feel faint. A casualty handled this way usually recovers within half an hour or so; if they do not improve, or get worse, treat it as heatstroke and call for help.

For heatstroke, cool fast and call for help at once. Pour or spray water over the casualty, fan hard to drive evaporation, and lay cold wet cloths or ice packs at the neck, armpits, and groin, where big vessels run near the surface; immersion in cold water, where it can be done safely, is the most effective cooling of all. Aim to bring the temperature down without overshooting, and keep cooling continuously while you wait for help; do not stop because the casualty looks a little better. Give nothing to drink to a casualty who is confused, drowsy, or not fully alert. Summon emergency help for any casualty who is confused or behaving oddly, who has a seizure or becomes unresponsive, who has stopped sweating, or who does not improve quickly with cooling and rest. Prevention is part of the soldier's discipline: dress for the heat, pace the work, take shade, and drink before thirst forces it.

Burns

A burn can come from heat (flame, steam, hot liquids, hot metal), from chemicals, from electricity, or from radiation including the sun. Its severity is judged by depth, how far into the skin it reaches, and extent, how much of the body it covers; a large or deep burn, or one in a dangerous place, is serious whatever its cause. The burning also continues in the skin after the source is removed, which is why the first action matters so much.

Recognising the burn, and how bad it is. A burn's depth shows in its look and feel. A superficial burn, like mild sunburn, is red, dry, and painful, with no blisters. A partial-thickness burn is red or mottled, weeps, blisters, and is very painful. A full-thickness burn destroys the full depth of the skin, may look white, waxy, brown, or charred, and is often painless in its deepest part because the nerves themselves are burned; this is deceptive, since painlessness here means worse, not better. You judge whether a burn is serious by four things together: its size, its depth, its site, and any involvement of the airway.

Size. The larger the burned area, the more serious, both for the wound and because a large burn loses fluid and heat through the lost skin.
Depth. A deep, full-thickness burn is graver than a superficial one of the same size.
Site. A burn to the face, hands, feet, genitals, or a joint, or one that runs all the way round a limb or the chest, is serious out of proportion to its size, because of the function or the swelling involved.
Airway. Signs of a burned airway, soot around the mouth or nose, singed nasal hairs, a hoarse voice, a burn to the face, or any history of fire or hot smoke in an enclosed space, are an emergency, because the airway can swell shut. Get help at once and watch the breathing closely.

Estimating size simply. You do not need precise figures, only a quick sense of how much skin is burned. A handy rule is that the casualty's own palm, fingers together, is roughly one per cent of their body's surface, so you can estimate a patchy burn by counting palms. As a rough threshold, a burn larger than the casualty's whole hand deserves to be treated as significant and shown to medical care.

Acting on a burn. The first response to a heat burn is to cool it with cool running water, for at least ten minutes and ideally twenty. Cooling limits the depth of the injury and eases the pain, and it is worth doing even some time after the burn. Work the sequence in order:

Stop the burning. Remove the casualty from the source, smother flames (drop the casualty and roll them, or wrap them in a non-flammable blanket), turn off the power for an electrical burn, brush off dry chemical, and douse smouldering clothing. The burn cannot be treated while it is still burning.
Cool the burn. Hold the burned area under cool running water for about twenty minutes (at least ten). Use cool, not ice-cold water, and do not apply ice; over-cooling a large burn can chill the whole casualty into hypothermia, so cool the burned area while keeping the rest of the casualty warm.
Remove what is loose, leave what is stuck. While cooling, remove clothing and jewellery, watches, rings, and belts from around the burn before swelling traps them, but never pull away anything stuck to the skin; cool over it instead.
Cover the burn. After cooling, cover the burn loosely with cling film laid on (not wrapped tightly), a clean plastic bag, or a clean non-fluffy dressing, to keep it clean and reduce pain. Cover rather than wrap a limb, as a wrap that tightens around a swelling limb can cut off the circulation. Never use cotton wool or anything that sheds fibres into the wound.
Do no harm. Do not burst blisters, do not peel away stuck material, and put nothing greasy, no butter, ointment, cream, or old remedy, on a fresh burn; these trap heat, invite infection, and only have to be cleaned off again later.

   BURN: the order that does most good

   STOP  ->  COOL  ->  STRIP  ->  COVER
    |          |         |          |
   stop the   cool       remove     cover loosely with
   burning;   running    rings,     cling film laid on,
   smother    water      watch,     or a clean non-fluffy
   flames,    ~20 min    loose      dressing.  Keep the
   power off  (>=10);    clothing;  REST of the casualty
              not ice;   leave      WARM while you cool
              keep rest  anything   the burn.
              warm       STUCK
                                     NEVER: burst blisters,
                                     peel stuck material, or
                                     apply any cream or grease.

Three kinds of burn need a particular word:

Chemical burns are rinsed, not soaked briefly: flood the area with plenty of clean running water and keep rinsing, taking care that the run-off does not harm healthy skin or the rescuer. For a chemical in the eye, rinse the open eye with clean water at once and keep going while help is summoned. Avoid contact with the substance yourself.
Electrical burns can be deceptively small on the surface while injuring deeply along the path of the current, and electricity can stop the heart. Make sure the power is off and the scene is safe before you touch the casualty, treat the burn as above, and treat the casualty as potentially seriously injured, watching their breathing.
A large or deep burn, a burn to the face, hands, feet, or genitals, a burn that encircles a limb, and any chemical or electrical burn, all need medical care. A burn can also cause shock through fluid loss, so for a large burn lay the casualty down, keep them warm, and manage shock as in Lesson 05.

Drowning and the safety of rescue

The Principality's coast and waterways make drowning a real danger, and it is a quiet one: a drowning person can slip under with little splash or cry. The most important truth about water rescue is that a would-be rescuer who jumps in unprepared often becomes the second casualty. The order is therefore fixed: reach, throw, don't go. First try to reach the person from land or a firm hold, with a pole, branch, oar, or your arm if you are anchored and safe. If you cannot reach, throw something that floats or a line they can grasp. Entering the water is the last resort, undertaken only by those trained and equipped for it, never alone, and never on impulse. Calling for help and keeping the person in sight are themselves rescue acts.

Recognising the danger. Real drowning rarely looks like the thrashing and shouting of films. A drowning person is usually silent, upright in the water, head tilted back, mouth at the surface, arms pressing down as if to climb out, unable to wave or call because every breath is spent staying up, and can slip under in seconds. The rescuer's first instinct, to go straight in, is the very thing that kills rescuers, who tire, are pulled under by a panicking casualty, or are caught by the same cold, current, or surf that took the first person. Hold to the ladder:

Talk and direct. Shout encouragement and instruction; a person told firmly to grab a float or kick towards a fixed point may save themselves.
Reach. From a firm, anchored position on land or a solid edge, extend a pole, branch, oar, towel, or even your arm if you are braced and cannot be pulled in.
Throw. If you cannot reach, throw anything that floats (a ring, a buoyant bag, a sealed container) or a line the casualty can grasp, and haul them in.
Row, only if equipped and able. A boat or board may be used by those competent to do so.
Go, only as the last resort. Entering the water is for those trained and equipped, never alone, and never on impulse; an untrained rescuer who enters the water more often adds a casualty than removes one.

Throughout, calling for help and keeping the person in sight are themselves rescue acts; a drowning person who is watched and marked can be found again, while one lost from sight in surf or murky water may not be.

Acting once the casualty is out: the focus is breathing. Once the person is out of the water, the danger is that they cannot breathe. Open the airway and check breathing. If they are unresponsive but breathing normally, place them on their side (the recovery position) to keep the airway clear, keep them warm, and get help. If they are unresponsive and not breathing normally, they need resuscitation at once. Drowning starves the body of oxygen, so for a drowned casualty rescue breaths matter alongside chest compressions; this is one case where breathing into the casualty is especially important, and is taught and certified in your practical training. Indeed, where the rescuer is trained to do so, a drowned casualty is one of the few for whom rescue breaths come first, before compressions, because the heart has usually stopped for want of oxygen rather than circulation, so getting air in is the most urgent thing. Do not waste time trying to clear water from the lungs by pressing the abdomen or holding the casualty upside down; that delays the breaths and can cause vomiting. A casualty pulled from cold water may be hypothermic as well, so warm them and handle them gently, and remember that severe cold can make the pulse and breathing so faint that the casualty appears dead when they are not. Anyone rescued from drowning needs medical assessment even if they seem to recover, because harm to the lungs can appear later; do not let an apparently recovered casualty simply walk away.

In Practice: One Cold Coast, Many Injuries

A winter coast can present all four of this lesson's dangers in a single difficult night, and the discipline holds throughout: keep yourself safe first, act simply and early, and call for more when the casualty needs it. Picture a stretch of shoreline on a cold, blowing evening, a small RKA party assisting the civil rescue service.

A walker pulled from the cold sea is both a drowning casualty and a hypothermia casualty, and the order of your actions reflects it. You open the airway and check breathing first, you give rescue breaths and resuscitation as you are trained, and only then do you warm them, gently, off the wet ground, out of the wind, replacing the soaked clothing with dry. But the lesson reaches back before that moment: you reach or throw before you ever go in, and you do not become the next casualty in the same cold water. Once the walker is breathing, you handle them gently, knowing the cold heart is fragile, and you treat the apparent recovery with suspicion, because the lungs may declare an injury hours later, so this casualty goes to medical care whatever they say.

Further along, a national has been burned at a shoreline fire, a sleeve caught alight while feeding the flames. You stop the burning, then cool the burn with water for the long minutes it needs while a companion keeps the rest of the casualty wrapped and warm, so that treating the burn does not turn into a second hypothermia. You take off a ring before the hand swells, you leave the scrap of sleeve that has stuck, and you cover the burn with the cleanest non-fluffy cover to hand, putting nothing greasy on it. Meanwhile a welfare team watches an unsheltered person for the umbles and for the moment the shivering stops, and a soldier of the party, working hard in heavy waterproofs, can overheat and tire even on a cold coast, so you watch your own people for heat strain as carefully as you watch the casualties for cold.

In every case the foundation holds: recognise the danger, give the right first response within your training, protect the rest of the casualty from the same environment that injured them, avoid the few actions that do harm, and summon those who can do more.

Check Your Understanding

Why is it dangerous when a hypothermic casualty stops shivering, and what are the firm "never" rules when treating cold injury? In your answer, say what the afterdrop is and how it shapes the way you rewarm a very cold casualty.
Describe the correct first response to a heat burn step by step, and explain why you cool the burn but keep the rest of the casualty warm. What four things tell you a burn is serious, and what must you never do to a fresh burn?
What does "reach, throw, don't go" mean, and why is it the rule for water rescue? Once the casualty is out of the water, why are rescue breaths so central for a drowned casualty, and why does a casualty rescued from drowning need medical assessment even if they appear to recover?

Reflection (write a short paragraph): You see someone struggling in cold water and your instinct is to jump straight in. Using this lesson, explain what you would do instead and why, and what it tells you about the difference between courage and recklessness in a rescue.

Summary

The environment kills on its own: in a cold climate and on a coast, cold injury, heat illness, burns, and drowning are all real dangers, and each turns on the same discipline, recognise early, act simply within your training, protect the rest of the casualty, avoid the few harmful acts, and keep help coming.
For cold injury and hypothermia, recognise the umbles and the warning sign that shivering has stopped, stop the heat loss, get the casualty off the cold ground, replace wet with dry, and rewarm gently from the core; give warm sweet drinks only if fully conscious, handle a very cold casualty gently to avoid the afterdrop, and never give alcohol, rub frostbite, or apply fierce heat. Never let frostbite refreeze. See the Caring for Those in Need course, Lesson 05, the Cold-Weather Operations and Survival course, and Basic Training Module 12.
For heat illness, stop the activity, move to shade, and cool; the dividing line is the casualty's mind, heat exhaustion is hot and sweating but clear-headed (rest, cool, fluids), while heatstroke is hot with an altered mind (confusion, collapse, sweating perhaps stopped) and is an emergency needing rapid, hard cooling and urgent help.
For burns, stop the burning, cool with cool running water for ten to twenty minutes (not ice), strip loose clothing and jewellery but not anything stuck, and cover loosely with cling film or a clean non-fluffy dressing; do not burst blisters or apply grease, judge severity by size, depth, site, and airway, estimate size by the casualty's palm being about one per cent, keep the rest of the casualty warm, and get medical care for large, deep, facial, encircling, chemical, or electrical burns.
For drowning, reach and throw before you go and never enter the water on impulse; once out of the water, manage airway and breathing, with rescue breaths central, and even first, for a drowned casualty, and have every rescued person assessed even if they seem well, because the lungs can declare an injury later.

Cold, Heat, Burns, and Drowning