Emergency Training for SM Practitioners

by Jay Wiseman

A young woman is being hoisted in suspension bondage when the winch handle slips from her Master's hand and she plummets back to the floor. A man strains at the cuffs holding his hands above his head and the overhead eyebolt pulls loose; he crashes onto the floor, and the heavy chain attached to his wrist cuffs then crashes down upon him. A woman giving an intense whipping on a hot, humid day becomes nauseated, pale, and sweaty. A man quietly waiting for a lecture to begin at an SM club meeting suddenly slumps to the floor; the people who go to his aid discover that he has no pulse.

All of the above are examples of actual emergency situations that have arisen within the SM community. Of course, many, many more incidents have also occurred. Indeed, when I'm asked to give an "SM for Beginners" talk, one of my favorite observations is "we are talking here about an activity in which it's common for two people to go off alone together, and for one of them to tie the other very securely and then proceed to beat them with various blunt instruments. Allow me to suggest the radical notion that doing this could be dangerous."

There is almost no such thing as life without risk. As long as somebody has something that they don't want to lose -- their life, their property, their reputation, whatever -- then they face at least some degree of risk. Indeed, the phrase "he's got nothing left to lose" indicates that someone could be extremely dangerous.

So the bad news is that almost all of us, no matter how quietly we live, face at least some degree of risk. For example, as I sit here in San Francisco working on this article, there is at least a small chance that an earthquake might strike. (Actually, some SM scenes were in progress when the last "big one" struck the Bay Area in 1989, and we learned a number of valuable lessons thereby. More on those lessons in a later article.) The good news is that it's possible, with only a modest amount of effort, to prepare ourselves to respond effectively to most emergency situations.

All SM play involves some risk. Indeed, exploring that risk is part of SM's attraction for many people. Exceptionally risky play, such as playing with real firearms or with strangulation, is not necessarily irresponsible play, as long as the players understand and are both physically and emotionally prepared to deal with the degree and type of risk they are taking. On the other hand, to play while ignorant or heedless of the risks involved may get you nominated for "the Darwin Award." (When all is said and done, we all bottom to Master Charles Darwin.)

Proper emergency preparation depends on having a somewhat informed understanding of exactly what an emergency is. The word "emergency" derives from the infinitive verb "to emerge" and is defined in one of my books for ambulance crews as "the sudden and unexpected appearance of a situation in which life and/or property is in jeopardy and in which the rendering of immediate assistance is essential." In other words, some set of unexpected circumstances has literally "emerged" that has placed life and/or property in danger, and somebody needs to immediately do something about that.

I've found that almost all emergencies fall into one of three categories:

1. Behaviorial emergencies which involve violence, other criminal activity, or mentally unstable behavior.
2. Environmental emergencies which involve fire, power failure, earthquake, and similar occurrences.
3. Medical emergencies which involve matters such as heart attacks, seizures, and trauma.

A well-prepared SM practitioner will have at least a fundamental understanding of all three types of emergencies, and will be both trained and equipped to respond to them. In this article, I'll mainly cover where and how to obtain the basic training and education one needs to evaluate and cope with SM-related medical emergencies. In a follow-up article, I'll cover details of how to treat common SM-related conditions.

There are three general categories of medical emergencies. Those that can be handled without professional assistance such as a minor muscle strain; those that need prompt, but not emergency, professional assistance such as a superficial laceration on the arm, and those emergencies which require emergency, professional assistance such as a heart attack. A knowledgeable SM practitioner will be able to determine which type of emergency they are dealing with, and will be able to respond accordingly.

One of the most useful concepts to keep in mind is that the goal of all emergency care is to stabilize -- to turn an unstable, dangerous situation into a stable, safe situation. Indeed, one of the most useful questions you can ask yourself in any emergency is "what needs to be done to stabilize this situation?"

Therefore, as a general rule, you should seek or call for help when the resources you have available are not adequate to stabilize the situation. For example, on one end of the severity spectrum, you would probably be able to dig out a shallowly located splinter without any help. On the other end of this spectrum, dealing with a cardiac arrest would probably be beyond your capabilities and it would be time to call 911.

There are two books in print which do a very good job of educating people regarding how to evaluate a wide range of medical symptoms, when and how to attempt self-care, when to schedule a doctor's appointment, and when to call 911. The first is the "Healthwise Handbook" (eleventh edition) by Kemper, McIntosh, and Roberts, published by Healthwise, Inc. International Standard Book Number (ISBN) 1-877930-04-0. This highly popular book has been in print since 1975 and has won an American Health Book Award.

The second book is "The American Medical Association Guide to your Family's Symptoms." It's edited by Drs. Clayman and Curry, and published by Random House. ISBN # 0-679-74128-3. This book, formerly titled "The American Medical Association Home Medical Advisor," is perhaps not as good regarding self-care measures as the first book, but contains an outstanding series of flowcharts that make it a superior aid to evaluating what various symptoms may indicate. I strongly suggest that you make at least one of these books, and preferably both of them, part of your permanent library.

You can learn a lot about self-care methods for less severe conditions from the above books, and from other resources that I'll mention later. However, to learn how to care for the more severe conditions, you'll need to take an actual class in First Aid and CPR.

Before we go into those details, let's take a look at who will show up at the scene of a major emergency. The players in this little drama are the victim, the bystanders, the first responders (typically police officers, fire fighters, lifeguards, factory medics, and others), the ambulance crew, and the hospital emergency room staff.

All emergency medicine is something of an exercise in passing the buck. The job of the bystanders is to try to keep the patient alive until the first responders get there. The first responders try to keep the patient alive until the ambulance crew gets there. The ambulance crew tries to keeps the patient alive until they reach the emergency room, and so forth.

The person who plays the biggest role in determining how this drama ends is the victim. They make most of the decisions regarding their own health, and their actions play the leading role in determining the outcome. For example, if a chest pain patient is going to suffer a cardiac arrest, they will probably do so within the first two hours after the symptoms start, yet the average chest pain patient waits over three hours before calling for help.

The person who plays the next-biggest role in determining the outcome of an emergency is anyone else who happens to be in the area when the emergency occurs. These are commonly called bystanders and, if they attempt to render aid, are sometimes more formally referred to as "citizen responders" or, in the United Kingdom, as "first aiders."

The most important tasks of a citizen responder are to recognize severe emergencies for what they are, promptly call the Emergency Medical Service (EMS), and keep the victim alive until the emergency crews arrive.

In the average urban or suburban area, the first responders will probably arrive on the scene within about five to fifteen minutes of being called, with the ambulance crew arriving soon after that. Therefore, citizen responders have the greatest need to intervene in those conditions which will kill the patient before the first responders arrive. Five such conditions account for almost all such deaths, therefore good first aid training for citizen responders will place the most emphasis on dealing with these specific conditions.

These five conditions are:

1. an airway that has been blocked due to obstruction by the tongue or a foreign object,
2. stopped breathing,
3. cardiac arrest,
4. severe bleeding
5. a severe allergic reaction.

Of these five conditions, it is cardiac arrest, usually secondary to a heart attack, that is by far the most common cause of death.

A number of resources probably exist in your community that can provide adequate First Aid and CPR training. You can get a good idea of what's available by checking your local yellow pages under "First Aid Instruction" and "First Aid Supplies." Almost all of such training will be given by instructors authorized through one of the following four agencies:

1. the American Red Cross
2. the American Heart Association
3. The National Safety Council
4. Medic First Aid.

Of these four agencies, the one most likely to offer readily accessible "off the street" training to the average citizen is the American Red Cross. (If you ask around your local SM club, you may find that there is an "in house" instructor and perhaps an "all-perv" class can be organized. I teach several such classes every year in the San Francisco Bay Area.)

The "gold standard" of training in First Aid and CPR for the average citizen is the American Red Cross class called Standard First Aid. This class is about six and one-half hours long, and covers all five topics listed above plus some additional material. Most Red Cross chapters offer it several times every month. As of this writing, the typical fee is about $50.00 per student. Reduced cost and even free classes are sometimes available. Students who successfully complete the course receive an "Adult CPR" card considered good for one year and a "Standard First Aid" card considered good for three years. (I recommend that people retake the entire class once a year.)

If you help care for infants or small children, you would also want to ask about obtaining training in infant and child CPR. The techniques used on these smaller victims are somewhat different.

Good further training would include how to do two-person CPR and how to perform mouth-to-mask breathing. These topics are covered in the Red Cross class called "CPR for the Professional Rescuer" and the American Heart Association class called "CPR for the Healthcare Provider." The latter class textbook, and maybe the class itself, also covers how to use cricoids pressure to prevent an unconscious person from regurgitating and aspirating vomit - a very useful technique to know. The textbook for this class is the American Heart Association's "Textbook of Basic Life Support for Healthcare Providers" (ISBN # 0-87493-615-2) and it does a very good job of outlining how to care for various cardiopulmonary emergencies, including cardiac arrest, heart attack, and stroke. I strongly recommend that you add this book to your library.

The Red Cross offers both basic and more advanced training. If the idea of getting some comprehensive training in managing medical emergencies appeals to you, then ask your local Red Cross chapter when their next first responder class (called "Emergency Response") is being offered. In this class, which is roughly fifty hours in length, student first responders learn how to perform a comprehensive assessment of a patient (including how to take their blood pressure), how to perform both basic and advanced CPR techniques, how to manage a wide variety of injuries and medical emergencies, and even how to deliver babies. Many first responder courses also include instruction in how to administer oxygen, and some even teach how to shock a stopped heart back into beating.

I need to make a brief advisory about instructor quality here -- namely that quality of instruction can vary wildly from one instructor to another, and entirely too many instructors do a very poor job. I've been an instructor for over sixteen years, for a number of different agencies. Based on this experience, I can tell you that, despite very strident official claims to the contrary, there is an almost complete lack of quality control in this field - and it shows. Indeed, one of the worst instructors it was ever my misfortune to co-teach with was himself a very senior instructor-trainer. This person was in charge of training instructors, and those instructors were then turned loose to teach on their own with almost no follow-up supervision, and yet he was nothing short of a babbling, rambling disaster. The quality of instructor he produced, and the quality of students that they went on to produce, do not lend themselves well to calm contemplation.

As a rule, you should try to find an instructor who has at least one year of full-time EMS experience, or its equivalent, and who has been trained to at least the paramedic level. However, I've known instructors who met both of these criteria who nonetheless did very poor quality work. I've also known (a few) instructors who met neither criteria and yet who did very good quality work.

A good instructor will explain things clearly and will not try to bluff their way through when they don't know the answer to a question you might ask. They will teach in a calm, organized, positive manner, and after you have finished taking their class you should feel somewhat more relaxed, more knowledgeable, and more confident of your ability to handle an emergency.

If, after taking their class, you feel the instructor was disorganized, dictatorial, or unduly negative in their approach, or if you now feel less confident, confused, and more tense about your ability to respond to an emergency, then you may have drawn a bad instructor and it's time to go looking for another one (and to communicate your misgivings back to the instructor's agency).

If you can't relate well to your instructor, at least concentrate on the class video and any textbook that you are given. These are generally accurate and relatively "instructor proof."

The "holy grail" of managing a medical emergency generally consists of the following steps (minor variations are taught in different programs):

1. Survey the scene. This involves making a general survey of the emergency scene before you go running in to care for obvious victims. Make sure that there are no life-threatening hazards to you before you go racing in.
2. Call for obviously needed major back-up. In the event of a large fire, multi-car crash, or similar situation, making sure that 911 really has been called may be the most important action that a citizen can take.
3. Control hazards (if possible). Putting out small fires, diverting traffic, and taking similar measures help keep a bad situation from becoming worse. If doing this is exceptionally difficult or hazardous, call 911.
4. Gain access to the victim(s). Most of the time, gaining access will be so easy to accomplish that one will hardly be aware of it being a separate step in emergency care. However, if gaining access is exceptionally difficult or hazardous, it's once again time to call 911.
5. Provide for what's called "body substance isolation" (BSI). This mostly means keeping gloves made of latex (or vinyl, or plastic) readily available so that you can put them on in hurry. This is not a good time to be getting people's blood, or other fluids, on you. (If you do get so exposed, immediately wash off, or otherwise remove, the fluids. Some emergency personnel carry foil packets containing nonoxynol-9 or a similar disinfectant for just this reason. It's also crucial to get a medical consult promptly. Additionally, please note that it's now possible to get immunized against both Hepatitis A and Hepatitis B. Ask your physician about having this done before an exposure occurs.)
6. Perform what's called a Primary Survey. This involves rapidly assessing the victim's level of consciousness, making sure that their airway is not blocked, making sure that they are breathing, making sure that they have a pulse, and checking for severe bleeding. If any life-threatening conditions are found, they are treated at once.
7. Have someone call EMS if that hasn't already been done. It's also an excellent idea to send some people outside to help flag down the first responders and the ambulance crew and then lead them to the patient.

   The above actions are the essential ones for a citizen to perform. If someone present has had more training, they might also do the following:

8. Perform what's called a secondary survey -- usually consisting of getting a history, checking the victim's pulse rate, respiratory rate, and perhaps blood pressure, and performing a head-to-toe exam. They then might give further care to any conditions that they find. The first responders and ambulance crews receive extensive training in how to conduct a secondary survey and how to treat what they find.

While you cannot properly learn emergency care from a book (CPR skills, in particular, require that you practice them on a manikin in the presence of a good-quality instructor), there is one book that makes a particularly good post-class reference. It's the "National Safety Council First Aid Handbook" (with William Shatner's face on the cover) published by Jones and Bartlett Publishers. ISBN # 0-86720-846-5. I've looked over many first aid manuals, and I'm particularly impressed with the organization and content of this one.

In summary, in this article I've described where and how to obtain the basic knowledge and skills you will need to respond effectively to a medical emergency. In my next article, I'll discuss how to deal with specific emergency situations.

Editor's Note: Jay Wiseman is probably best known in the SM community as the author of the highly regarded book, "SM 101: A Realistic Introduction." He spent eight years as an ambulance crewman, including two years as director of training for an ambulance service and four years in a ghetto. During this time, he received the Red Cross Certificate of Merit for Lifesaving Action -- their highest award. He also spent three years in medical school, during which time he worked in an emergency room, a coronary care unit, and an intensive care unit, and also became an American Heart Association instructor in Advanced Cardiac Life Support.

He currently works full-time as a writer in health, relationship, and sexuality issues, and is active in teaching various classes in basic, advanced, and wilderness emergency care. He offers classes at both the citizen and first responder level to the SM community of the San Francisco Bay Area, and has recently become one of the very rare individuals ever nominated to receive a second Red Cross commendation for lifesaving action. He can be reached by sending e-mail to oldrope@aol.com or by writing to 3739 Balboa # 195, San Francisco, CA 94121.