[Elaine:] We need you in a semicircle and the best way to do that is to push your chairs roughly around that grey line...
[speaker002:] ... There's a nice swivelly one...
[Elaine:] Erm you pass those round in either direction, from now on it's, it's bandage time. Denise is going to do bandaging and I'm going to do bandaging and so are you, so you have these packs and these packs, if you'd like to take one pack each, I don't know if there's a pin in them, you might find a pin in there please look after them and bring them back each day, you'll find a bandage and a roll of bandage in there... and... so their your own properties... In your text book you've got quite a lot of information in there about reinforcing, what we're going to do in the practical session and it's always a help I think when you have a lot of the, thrown at you to know that you can just put it up and there it is if you get a bit confusing or can't remember what's what, so on page one six nine it starts telling you all about nursing and bandages and general hygiene which we've already talked quite a lot about but it's very useful for you to know, you can go there and look, and if you just go through the pages from there on one seventy, one seven one, one seven two, one seven three and then on one seven four it's got the general rules for applying bandages... apply bandages when the casualty is sitting or lying down, you always sit your casualty down and you work from the front of, I say why do you work from the front of the thing?
[speaker002:] So you can keep So you can see how they're looking, see if they're going pale a bit or if they're going to fall off their chair and talk and reassure them.
[Elaine:] That's right, erm always make sure that the injured parts are well supported... bandages should be firm enough to do the job and large enough to cover the wound all of this is the sort of thing which you need to be referring back to if you're in any doubt. On page one seven five you've got how to check the circulation, after you've put the bandage on to make sure it's not too tight, it's not stopping all the blood supply, press a fingernail if there's only a finger nail and the, it should go white of course if you press it, then the blood should go back and it goes back pink again or an area of er skin, always check your circulation after you've put your bandage on. Now when you've actually opened your pack you'll find, what you got your triangular bandage here. Now I'm going to show you now how you going to put it away again, fold it, afterwards, opening it up...
[speaker002:] ...
[Elaine:] alright, everyone open their bandage up?... Now when it's opened it's useful as a sling, two sorts of slings we're going to do, high sling and the low sling but also if you fold it, it's very useful as a bandage too, if you put it across your knee, then you bring the point up towards you like that... and then again, fold it the base up to the top... again.... and again face up to the top and there you've got a bandage, okay? One stage before that you've got a very broad bandage which is helpful for supporting things, we'll learn about how to use that later. When you've got it to the final fold there you've got your ordinary fold bandage and if you want, pack it away like that, you bring the end in the centre, there, so and again the ends in to the centre, just so that they meet like this, like this the centre, just so that they meet there, again, start like this, ends just to meet in the centre don't overlap them too much and again bend into the centre and you've got a nice little pad, if you ever need a pad for plonking on a wound quickly, there you've got a pad, or putting against an ear or anything you want it for and you open it up quickly and you've got a bandage, two of those and you've got a but it's a very handy way to keep. When you've got your bandage in your pack, I've explained to you before, you open it up in the first aid kit it's sterile, yeah, you open it up by the one hand goes one way, one hand goes the other, break it open, put the cardboard away and you need to be ready to try before you pull the next bit off don't you because as soon as you've opened that it's not sterilized any more, so you open that up... and you find, unwrap it unwrap it as I showed you before with the first aid kit, comes out first... and then you see how the padding because this wadding is stitched onto the back, and the front is the bit you put against the wound and you put it straight against the would without or touching it and that pad should be big enough to cover the wound, so you should something, overlaps, alright, and then if you find, if you unwrap the roll a little bit further, you don't want to unroll it completely, your see that if while you're using it in practice you need to roll it up again backwards towards the back of the bandage like so, we'll roll it up again, backwards and when you get to the bandage you just fold the bandage up around the long end and wind the short end round it firmly and there it's ready for use again in practice, you wouldn't of course do that for real would you? Put away, use another one. So that's how you look after your bandages and all these things that we're going to show you you'll find in those little sections in your first aid book so if you get confused or why you've only got to look up in the book. Let's do the sling first. I thought we'd do the sling first, high sling because it's very important to get it high and not pull it, everyone, anyone gets asked to do the high sling in their exam and if you can put a good high sling on you're halfway [LAUGHTER] to passing []
[speaker002:] Mm
[Elaine:] and from that it can't be bad can it? So I'll be the casualty and at the moment we won't worry about all the various things you use a high sling for, we just want to make sure that you can actually do it, okay? Can you just come back a little further and then they'll be able to see, better if all round the side
[Denise:] Okay? Right, now then, be like this I'll pretend that I've done something that needs to be, a high sling to support me in this fashion.
[Elaine:] And I, I'm going to be working from behind Denise because you all need to see, but you would be working from the front as I've already talked about, so you need your triangular bandage, alright, and there's your long edge, and there's your point as we call it, a sort of elbow shaped, think of that as elbow shaped because it always goes towards the injured elbow. Now, that when you arrange your sling in the first place, it's crucial to the success and ease of which you finalize the bit round the elbow. You arrange it so that this long side is vertically up and down the body, right, in that direction. Don't let it come across like that, the temptation is to think that you've got to have all this bit up here, now you don't want this up here because it's very difficult to cope with once you've tied it round to get it round the elbow, you want the least amount that you can get, just cover the arm and then it makes it much easier to deal with at the end. The amount at the top that you need is just enough to tie a reef knot oh I've forgot to show you a reef knot didn't I? Tie a reef knot. We all use a reef knot in erm first aid and again it is in the book a very good illustration in the book reef knot and then nobody knows how to do it, I will show you in a bit, but that's enough to do a knot, the knot comes on just above the fingers, in the hollow of the neck, okay? So that's how you arrange it like that, the first thing you then do is to tuck the spare bit under the hand, cos the hand then there anchors it for you
[Denise:] Okay?
[Elaine:] and the hand doesn't sneak out afterwards and starts popping out and then it's useless, then the rest of all this stuff you just get it out of the way under the arm, it's all gone, right, this bit comes up between the two shoulder blades, don't make the mistake of bringing it across there, a lot of people do that, that won't do, you have to come round the back and between these two shoulder blades to get maximum support, you've got to hold this elbow up and then you tie it near the hand, now I recommend that you tie it and talk to your casualty, half tie it and say is that supporting you enough?
[Denise:] It feels okay thanks, yeah
[Elaine:] Cos then you can draw it up a little tighter if it's too loose, if it's like that and, most people do it too loose, is that tight enough?
[Denise:] No it isn't.
[Elaine:] Right I'll just draw it up a little bit tighter, is that tighter for you?
[Denise:] Better, better
[Elaine:] And now I'll do the other half of my reef knot, right, and tuck the ends in immediately, they don't like seeing ends because they're considered dangerous in first aid so don't forget to do it, do the knot, tuck it in all in one movement and then it's done, okay, how does that feel?
[Denise:] That's fine
[Elaine:] Of course you're reassuring all the time as you do this
[Denise:] Mm, mm
[speaker002:] Got a bit that's fall down
[Elaine:] Hello we haven't finished yet, haven't finished. Now you're gonna want a pin, these are rather small pins, I recommend that peop people who have got large hands try and fit their first aid kit out with large pins, they're much easier to handle, but firstly they do not put pins in their mouths for obvious reasons, either, either have it on the table open ready or just pop it in the front of shirt while you do this bit, okay? So you're going to fold this around the elbow to give support to the arm and in this one you're gonna fold first of all forward... and then back, can you see that little neat envelope? A neat little envelope that's supporting quite firm, that's supporting the elbow, now pin it, again, now you can see how important it is not to have lots and lots of bandage up here, cos what will you do with it then? It's too much, if you ever have too much you can just fold a bit down, if you have a big bandage you can fold either of those edges down first if you've got too much and then you fold it forward and back, now your pin sticks in, but all the material and out of all the material and it goes in a straight upward direction, again it must go in that direction so that if per chance it comes undone it falls out and drops on the floor, whereas if it was sideways or downwards it would open and stick in your casualty, so that's why we have it done that way. Would you like to see that again or do you think you could manage it now?
[speaker002:] See it again
[Elaine:] See it again, right, I'll just do it this time without talking it through, and you can just watch
[Denise:] Yeah
[Elaine:] and I tell you what we shall do we shall change arms
[Denise:] We'll change arms as well
[Elaine:] you'll need to practise on both arms.
[Denise:] And there's no use getting in the exam on Thursday and say ah well I'm afraid I've not done it on that arm so erm lost
[Elaine:] Okay, so there you are you see, you're, you're a first aider and you come up to the person and you hold it the way you did last time and you think ah, now that's the wrong way round of course, there's my elbow point, there's my injured elbow, so I have to be that way round, mm, so you turn it round the other way, right, your elbow shape goes to the injured elbow and your long line goes straight up and down the line of the body, you arrange it so that you only just covering the forearm there, with just enough above the hand to tie your reef knot... that would be too little and that would be too much... just enough above the hands to tie your reef knot, the first thing you do is to tuck nice, big bit of material right under the hand and anchor it into position, just keep that resting there and all the rest of this goes under the arm up between the shoulder blades there and you tie your first half of the reef knot just above the fingers in the hollow of the neck here, now that's important because round the back here if you press on that bit of muscle there, there's a big band of muscle, if you've got a knot on that it gives a great deal of discomfort very quickly so you want to get the knots round in the hollow here that doesn't hurt your casualty, there, draw it up half the knot, is that tight enough?
[Denise:] It feels fine
[Elaine:] Yeah
[Denise:] that feels fine
[Elaine:] and then do your other half of knot, reef knot and tuck it in straight away, you get your pin ready, have it on, either on the table or ready like that, now if you've got too much material ever you just fold that down, there, if that's too much, which isn't too much with Denise because it's the right size sling, sometimes you have to improvise and then you fold if forward and back, firmly, take the pin and put it, put your two fingers down between the casualty so that your fingers are apart and there's a space between your fingers so you can stick the pin in and out again without any danger, if you put the fingers apart like that, if you do stick the pin in yourself and draw blood would you please throw the pin away, as a matter of automatic hygiene, it mustn't be used again once it's been stuck into somebody
[Denise:] Or in your casualty
[Elaine:] or in your casualty, it must be thrown away
[Denise:] Do it up, discard it
[Elaine:] Alright
[Denise:] get another one from the box
[Elaine:] would you please make sure that all through these practices that you deal with different people all the time cos in the exam and for real afterwards you'll have to bandage all different shape people and if you just get, work in pairs you don't get that sort of practice, by all means start of with somebody next door to you but each time you do one go across the room and find somebody you haven't done before.
[Denise:] And if the gentleman having to put bandages on a lady and you want to put your hand underneath there just excuse me a moment, alright, because in the exam one row of you will certainly going to have a lady bandage okay, put slings on and to bandage so it's just as well not to get to you know used to bandaging up great big chaps and then you'll find you've got some little tiny five foot two or five foot nothing lady bandaging in exam, alright, so swap around, so get yourselves so you've got a partner and use your bandages and let's just see you do the high sling to start.
[Elaine:] All got safety pins by the way?
[Denise:] Yeah they had them in the little packs, okay? Right
[Elaine:] How many people know how to do a reef knot for sure?
[speaker002:] No
[Elaine:] Right, so I'm not wasting my time a reef knot then? If, if you look in your books page one seven seven, you'll see a beautifully illustrated instruction on how to do it, which you can refer to yourself this evening or later on in the course if you forget but I'm now gonna show you how to do one as well, you, if you want to know it's there for you to look up... you take the bandage and fold it into your narrow fold band... and put it round your leg, you've got something to tie a reef knot round, okay?... if you know how to do a reef knot already fine, just do it, if you don't, follow instructions. Narrow fold bandage... you've done it correctly then. The doing it the same way each time and a reef knot is the opposite way each time, alright, undo it, once again, just once again to make sure you know... are you ready? Once again, now it doesn't matter which way round you start, you can start left over right or right over left, but the second time you do it opposite to the first time, so the first time I put the left one over first and the right one over that and then tuck it through, just like tying a shoe lace really, okay? And the next, pick the ends up, I put the right one down first and the left one across it and then put that one through and then that's a reef knot... no that's a granny over there anyone not sure?... That, that's the one... you have to remember which one you put on which, that was the left on top of the right, now the right on top of the left... yes, come on which one did you do first? That's the right on top of the left okay, right on top of the left, now you've crossed over again left on top of the right, put that through there... okay... yeah...
[Denise:] All okay I think
[Elaine:] mm, yes all okay now, right. I bang my head, I cut my scalp, yeah, everybody, I bang my head, I cut my scalp, not massive bleeding none of the bandages we're doing this morning are to do with massive bleeding, they're all to do with what we call minor wounds, right so small cut, but it needs attention, okay, so I cut my scalp
[Denise:] Cor
[Elaine:] okay so I've got my pad
[Denise:] it's a bit tender
[Elaine:] alright, so I'm going to ask my casualty to hold my nice clean sterile pad that I've got folded ready over the wound, there, gently, okay?
[Denise:] Yep
[Elaine:] Then I'm going to take another triangular bandage and I'm going to open it up and make just a little fold, this is going to go on her forehead and that little fold just helps with keeping it firm and stopping the bandage slip, now, just put it around the forehead like that, okay? Cross it over, round the back, and back up to the front again, do a reef knot here... and tuck your ends in straight away of course like so and then this little bit can just be tucked up where you've crossed the two ends and make it look neater with no ends hanging out, no that, all that does is keep the dressing secure, keep infection out, okay? The difficult part about this one is that people all have odd shaped heads, now and you find that if you put them on too high they squidge off like that, and you've got to think of bandaging an egg basically, if you had an egg with a little hole in one end and you've got to put a bandage round you'd have to put it very carefully round the widest bit wouldn't you for it to stay firm and that's the secret, everyone's heads different and as you put it round you've got to see where you can get it, where, sometimes it's over the ears, sometimes it's above the ears according to the peoples' shaped, different shaped heads everyone's different, anything else?
[Denise:] Okay, have a go at it and we'll come round and correct what you're doing as you're doing it, alright, so you want to pad over the wound to keep infection out and then try to get your bandage on top of that to keep the dressing in place.
[Elaine:] Right, well we want to make sure that you can get out to lunch sort of by, that's running a bit fast that clock, we'd like to get you out to lunch by about half past twelve otherwise you'll end up being late don't you with all the other people
[speaker002:] right
[Elaine:] Right, okay, what now, erm roller bandages so you can put those triangular ones away for a minute can't you
[Denise:] Let's do the elbow
[Elaine:] and we'll do the elbow and knee... okay elbow and knee then using the roller bandage
[Denise:] And again here it is two pages further on in your book, if you forget how to do it, just look up, okay?...
[speaker002:] Roller bandages
[Denise:] Well I fell over, slipped over in the car park out there, all gravelly and gritty out there and I scraped my elbow and I've got a nasty graze all on the elbow and it's all full of grit and muck, help
[Elaine:] Come and sit down here my dear
[Denise:] help
[Elaine:] let's give us a little now if we've got a tap handy probably the best thing would be to run it under the cold tap and that hopefully would take away any dirt and extra bits and pieces that are stuck around it. If there's anything embedded in it like gravel or something and it doesn't come away easily you mustn't, it comes under the categories of what you call foreign bodies, which first aider is not at liberty to poke about, you must leave foreign bodies that don't come away easily where they are and bandage them round and send them off to hospital or a doctor, but assuming it's just a little clean graze, if I haven't got a tap to put it under, then I must use little bits of gauze to wash, put in a bowl of water and just wipe, yeah, and you always wipe obviously from the centre of a wound towards the outside, otherwise if you start to wipe across the whole thing you take dirt from one side of the wound across and drop it off in the middle somewhere, so you wipe from the centre out and throw that piece away and you take another piece and wipe from the centre out and so on until you feel happy, quite happy.
[Denise:] I mean, well if you haven't got gauze in your first aid box, but you could have something like a Mediwipe or you might be able to use, open up your bandage and you can use, you know, several pieces of this, just keep going down the bandage and then you know clean it and get rid of that bit, okay, another clean bit okay, so you can adapt with whatever you've got in your first aid box, yes, and you won't necessarily have scissors to hand so you'll have to do whatever you've got and the little Mediwipes are very useful for that, but don't use one Mediwipe for seventy five grazes, okay, one Mediwipe for one wipe and then discard, okay?
[Elaine:] Okay, so I'm going to open up my sterile dressing now
[Denise:] So I actually put my arm out straight for you now?
[Elaine:] Do you think it'd be better if you had it bent cos it'll be easier for you after I've bandaged it
[Denise:] It's better bent is it?
[Elaine:] Yes
[Denise:] Okay, alright
[Elaine:] it would be better if you can manage
[Denise:] alright
[Elaine:] to bend if it's not too uncomfortable
[Denise:] so I can bend it, I can bend it like that then?
[Elaine:] Right, you can only bend, you can only put the arm in the position that your casualty will let you of course, but it is more comfortable to have it bandaged in that position, than having it like that. So you open it up and you find which is your sterile bit and you put that over the point of the elbow and you can bring that once around and you can ask her to hold it for you, if you like
[Denise:] It goes in there
[Elaine:] right
[Denise:] yes
[Elaine:] and then you take your long end and you wind above covering the edge and overlapping and then the low, then covering the edge and overlapping, there and again you keep working your way up and... down, a figure of eight until you get to the end of your bandage then tie away from the body in your reef knot, either you tuck your ends in or if that's awkward you can just put a sticking plaster over the ends to get them out of the way like that, so just tuck the ends in and I don't think your casualty's going to need a sling for a little graze like that
[Denise:] Right, and so that she can still move
[Elaine:] and as the same thing applies to the knee exactly the same thing, wound there you keep the knee bent a little bit and you can do exactly the same bandage like a figure of eight, okay? So one person will do the bandage on the elbow and the other person with the good looking knees, you'll be the casualty for where you've got to put the knee bandage on, cos you won't, if you don't roll your trousers up a bit you're not going to have much bandage to do much bandaging with on the knee, okay, so decide amongst yourselves who's got the good looking knee Everybody okay now?
[speaker002:] Yeah
[Elaine:] Yeah?
[speaker002:] Excuse me I've got a circulation problem [LAUGHTER]
[Elaine:] Now... All okay then? Yeah? A couple more to show you then you can practise these when you have a bit more practice time so we can get you out to lunch on time. If you have to bandage a hand for example, okay?... Somebody's slipped over and they've got all the grit in their knuckles in the part of their knuckles and you want to bandage the hand or there's a cut on the hand, even on the palm, we can do that one later when it's really, when it's really a gash, gushing blood we can do this afternoon, I repeat again none of these which you've done this morning will control severe bleeding, get it into your heads this is just to cover to keep infection out, alright, these are not to control severe bleeding just covering a minor wound or a graze, right? So she's got her knuckles grazed, you've cleansed it, put it into a drop of water,ra or else we've used the Mediwipes or the end of the bandage okay, now we just cover it, okay, so it goes over, can you just straighten out your hand for me, it goes over the wound, okay and you can take this one that she can hold it for you just up there, right, now the rest of this just winds round, the only thing you really need to do is to just make sure that you leave the thumb out, cover up the bottom right and then come up towards the wrist, cover up the top of the pad, come back down again, leave the thumb out all the time, got the idea? Right, cover up again, come up towards the wrist, if you've got any more bandage, go round perhaps one more time... okay and just make sure at the end of the day that you don't tie too tightly round the wrist, why not?
[speaker002:] Stop circulation
[Elaine:] Absolutely, so really we want to tie away from this pulse point here towards the back of the hand, good enough
[speaker002:] Yeah
[Elaine:] right, tie it off in a reef knot, if you've got bits that are left dangling they're too long and you can't go round again because it's gonna make it too tight, you can either tuck them in or else you can fold them down, a nice clean plaster and put it right over the top, okay? Now that would do, that would do whether the, whether the knuckles were hurt or it was just a minor cut in the palm of the hand there, that would do and you can use the same type of bandage on the foot... alright, so that's if the hand was damaged, now supposing we didn't have the hand damaged, but we had instead a cut up here, okay, again clean it and if you clean it with lots of water always remember to dry off around the wound because bugs love a moist skin to grow in, dry the wound before you apply the dressing okay if you can, dry it off the best you can and then you're going to place that over the cut, remember you want the pad to be long enough, big enough, okay, now she can hold this for you again, she can hold it above where the wound is and now when you bandage this one you always bandage from the narrow part to the fat part of the limb, you always bandage from the narrow to the fat, so you take the bandage down
[speaker002:] Why?
[Elaine:] Because that way it stays on if you do it the other way it'll drop off it's as simple as that, okay, cover the pad and as you spiral up the arm all you need to do is to cover about two thirds of what you've just done before, just like a spiral, you find the bandages, the more you use those roller bandages of yours the worse they get to control because they lose their, you know, nice and stretchiness, so you just do, cover up the pad at the top, tie always on the top of the arm never underneath here. Check with your casualty that it's comfortable, yes? and does it feel quite firm for you? Not too tight though?
[Denise:] No
[Elaine:] And those bits again, either tuck them in out of the way or better still fold them over and put a big plaster over the top to get them right out the way so no ends are left dangling, remember for most people you're doing this for they'll probably be returning to their place of work, okay, so they need to be safe to return to work, everybody okay on that lot? So let's just recap on the ones you've done this morning, you've done a high sling yes
[speaker002:] Mm
[Elaine:] you've used a triangular bandage to cover a wound in the scalp, it's not a chopping block wound right, it's not the chopper in its wound right, it's just a minor wound in the scalp, yes, and that came round and tied at the front, tucked at the back, you used these roller bandages to cover a graze or a wound on the end of an elbow or a knee or the hand, foot and then a straight one up the arm... okay, so a lot of your bandaging is using these little roller bandages with the lint pad and don't forget when you get into the exam do it, don't do it the wrong way round, remember that you look at your bandage and you put the lint onto the wound, not the other way round right, yeah, you put the lint face down onto the wound, okay? Any questions of anything we've done?... All alright on that, yes?
[speaker002:] We get time to practise these again before the exam?
[Elaine:] Oh yes, now if by any chanc chance you do have a question in the exam where you're asked you know instead of the wound being on top of the scalp, some clever so and so decides that you're good at improvising and you've got a wound over the top of the eyebrow, the eyebrow's split, okay, so there wouldn't be much good of me going... a minute, pull that there, trying like this round there
[speaker002:] [LAUGHTER]
[Elaine:] right, okay, it's not really in the best interest of the casualty is it, right, now what dressing would you apply to that do you think?
[speaker002:] A plaster Plaster An eye plaster, an eye pad
[Elaine:] A an eye pad won't really sop up blood will it?
[speaker002:] A roller plaster
[Elaine:] One of them, of course you will, you use a roller bandage won't you again? In this instance you can put it across the eyebrow, right, across the eyebrow, ask them to hold it and if you're doing a bandage like this the way to keep it on is to have one part of the bandage going above the ear and the next time you go round go below the ear... right, go above the ear and the next time you go round go below the ear... okay and then finally just tie it off, get the idea? Okay, so they may ask you to use something which you haven't necessarily had to do before so that they're really all that the examiner's testing is that you've got a little bit of nous, a little bit of savvy and with what you've got available you can improvise a dressing or use the dressing in a sensible manner so that your casualty's comfortable and you're doing the best you can for them, okay? Lovely. Anything else to add Audrey?
[Audrey:] No that's fine
[Elaine:] Everyone alright then, okay, it's time for grub isn't it?
[Audrey:] Yes it is, quarter past one please
[Elaine:] Quarter past one back here, okay? Anyone want coffee? Anyone staying here and want a cup of coffee?
[speaker002:] Yes please
[Elaine:] Yeah we'll do one in a minute for you then So you have the heart of the centre of it, two pumps back to back yes, the major pump or the stronger pump on the left hand side, why? That's where the blood leads by, okay, on that side of the heart the left hand side of the heart it's being pumped and therefore the muscle is a bigger muscle, that's doing the contracting, the blood push out and it relaxes back again and that allows the blood to be sucked back down into the heart, okay, and the next time it's shh, that goes out and then it relaxes down again and the blood sucks back down into the heart, okay so that's what it does, all the muscle can do is that, muscle can only retract and then it relaxes, contract and then it relaxes, that's what the heart's doing all the time, how many beats a minute?
[speaker002:] Sixty to eighty
[Elaine:] Sixty to eighty you can feel it at pulse point, can't you, here, here, we'll show you so more in a minute, okay? So you know how to check whether the circulatory system is working because if it's working you'll be able to find a pulse... pounding away, yes, that's how you check it, you know the respiratory system's working because if you want to check it what do you want to look for?
[speaker002:] Rise and fall
[Elaine:] Rise and fall of chest... breath on your hand or your cheek, circulatory system working, pulse, okay? And that's what you're checking, the other side of the heart, the right hand side of the heart with a smaller pump, where's that pumping?
[speaker002:] Blood out The lungs
[Elaine:] Back up to the lungs, okay, now in that little system there, there's just one thing that's interesting to note, when you spoke about circulatory system this morning or yesterday rather with Audrey, you spoke about the blood being always leaving the heart, yes, via the arteries, yes
[speaker002:] Yes
[Elaine:] and always coming back to the heart
[speaker002:] By the veins
[Elaine:] by the veins, there's always an exception to every rule and the exception to that rule in the case of the heart and the lung connection is the pulmonary artery and the pulmonary vein, you may not get asked anything about this, but just in case you do it's as well to know, in that instance the flow is reversed, in other words the pulmonary vein takes blood away from the heart and up to the lungs, and the pulmonary artery brings the oxygenated blood back down to the heart from the lungs, if you want to have a look at the diagrams for that and look at it yourself later on, there's no need for you to get concerned or confused about this at all, there's no need. You'll find the little diagram showing you where the pulmonary vein and the pulmonary artery are on page eleven, page eleven if you want to refer to it... right, if you want to look at it in a closer detail tonight that's fine and if you want to see what I'm saying now in a diagrammatic form look on page thirteen... now if you look at that you'll see some, the blue vein blood vessels it's coming out of the right hand side of the heart and if you look at the direction of the arrows, okay, they're going away from the heart, do you agree with me? They come out of the heart and branch like a wishbone, one to each lung, do you see that, now the arrow direction is away from the heart... and that's a vein and you'd expect that to be coming back to the heart wouldn't you? And that's the only time you're going to find it when you're linking the heart and the lungs, now look at those two areas where you've got blood coming back down into the heart, can you see those two wishbones there coming back down into the heart, do you see where I mean, yes? Now those are arteries, that's the pulmonary artery... but it's coming back to the heart... okay, that's the only time you're going to find the rule reversed, arteries leave the heart, veins come back to the heart, and the only time that rule is reversed is when you're linking the heart and the lungs through the pulmonary vein and the pulmonary artery, however, they are still carrying, the arteries are still carrying oxygen charged blood, yes, because it's come fresh from the lungs so it's still carrying nice red lovely oxygenated blood, yes, even though it's coming back into the heart, that is because it's come fresh from the lungs and the vein although it's going in the opposite direction the way you normally expect it, is still carrying the old rotten, you know, used up blood, because it's going back to the lungs to be recharged, do you understand it alright? That's the only time it'll be reversed
[speaker002:] Can you just say that bit about the pulmonary in the vein and the pulmonary in the wee artery again please
[Elaine:] The pulmonary artery comes back into the heart, the pulmonary vein goes away from the heart
[speaker002:] Vein goes home
[Elaine:] back up to the lungs, they are linking the heart and the lungs
[speaker002:] Yeah, I've written that down
[Elaine:] alright and if you look at the diagram on page thirteen and you look at the little arrow diagram you'll see that it gives it quite nice and clearly there... is that alright? Just wanted to clarify that little point, so you know the organs that make up the circulatory system, you know how to check it, you know the one slight difference than what you normally expect veins and arteries to be doing... okay? Now we need to talk a little bit about what happens when the veins or the arteries or the capillaries for that matter, the veins, the arteries or the capillaries have a leak in them, they become broken, now you already know that the circulatory system is a closed system and that the blood can only do its job if it's being transported within that system, once the blood comes outside of that system then it's lost the circulation and it cannot perform its proper function any more, in other words the body's losing its blood, okay, what condition do we call it when the circulatory system stops working properly?
[speaker002:] Shock
[Elaine:] Shock, do you understand the difference between the loss of pressure and loss of volume, volume would be when liquid was leaking out, coming out of the blood vessels, okay, pressure would be when the heart itself, the pump itself had failed or was not working properly, failed completely or was not working properly, do you understand the difference? Obviously eventually if people keep on leaking blood their pressure will fall... but you could have a situation where there's not a single drop of blood yet lost to the system and yet the person's in shock because the blood's not being circulated properly off the heart, not a drop of blood lost to the system, but insufficient pressure, so shock can be caused by either of those two things, failure of the circulatory system because the pressure of the volume drops dangerously low, okay, you did a lot of work on what the person looks like, yes... you as the casu you as the first aider will see this person in front of you, what will they be like? What will their face look like? Let's start there
[speaker002:] Pale
[Elaine:] Very pale, very cold and clammy
[speaker002:] Cold and clammy
[Elaine:] okay, don't say blue, because otherwise you'll get it mixed up with asphyxia
[speaker002:] Put
[Elaine:] very pale, if you saw somebody in a hospital bed who'd just suffered shock, they'd be the same colour as the sheet they're lying on... their face is absolutely white, okay, very, very pale, very cold and very clammy, now supposing the doctor asks you why are they cold and clammy? Why are they cold?
[speaker002:] Because they've lost blood
[Elaine:] No blood near the skin, no blood near the skin, okay, why no blood near the skin? mm?
[speaker002:] Guarding er the vital organs
[Elaine:] Right, because the body is acting in order to protect its vital organs and it's drawing the blood vessels near the skin, shut down, you're not needed there, you're needed here, in the core of the body, because your blood is what warms your skin up, it's taken away from the skin, then the skin feels cold and clammy, yeah, clammy because of course if there's no heat, we sweat all the time and especially if somebody's had an accident or is seriously ill they will be sweating, yes, then there's nothing to dry the sweat off... okay, what happens when we sweat excessively in the summer time?
[speaker002:] Dehydrate
[Elaine:] You get wet, sweaty, but there's nothing to dry the sweat off, not sweating and drying off, so they feel clammy, okay, so we've looked at their colour and we've felt their skin and we've felt that it's horrible and clammy and cold, what about their pulse, we've gone down to the pulse now
[speaker002:] It becomes rapid Fast Faster
[Elaine:] Fast, anything else about it?
[speaker002:] Weak
[Elaine:] Weak, so why is it fast?
[speaker002:] The arteries are pumping harder
[Elaine:] The heart is having to pump harder, why?
[speaker002:] Try to get more air into the arteries Is trying to get more blood round the system
[Elaine:] It's trying to do the same work with the smaller amount of blood as it did with the full amount, ten pints perhaps reduced down to seven, got to keep pump, pump, pump, pump, pump, pump, pump, because that little bit of blood has got to get round and do a lot more work now, okay, so the blood's rushing round and the heart is pushing faster... because it's having to, because it's not enough of the, not so much pressure there, that's why it feels weak, weak and fast, okay? We haven't got much blood now, it's working away like mad, so now what are you lacking?
[speaker002:] Oxygen
[Elaine:] So when you hear people who are in shock, they'll be [heavy breathing] okay and that's how they are, they're panting, breath, right, very fast and very shallow, they're not calm, they're panting for breath all the time, okay, so that's how you see them. What are they going to tell you? How will they feel?
[speaker002:] Want a drink
[Elaine:] Bloody awful, in an awful, in a word, now qualified, how they bloody awful tell me?...
[speaker002:] Sick
[Elaine:] Sick, could feel sick
[speaker002:] Could have a headache Stress Cold Light headed Faint Cold
[Elaine:] Faint
[speaker002:] Restless to talk to
[Elaine:] Restless, disorientated
[speaker002:] Mm
[Elaine:] Okay, all of those things, what are you going to do for them?
[speaker002:] Lay them down
[Elaine:] You've stood and looked at them you've listened to what they've told you, now what can you do?
[speaker002:] Lay them down and raise their legs
[Elaine:] If it's humanly possible, lay them down, raise the legs, how about if they're shivering?
[speaker002:] Maintain their body heat
[Elaine:] Supposing they start sweating?
[speaker002:] Remove Take some off
[Elaine:] Okay, you want the body temperature kept at an even level, don't have it too high, don't have it too low, cos if you shiver you make use of muscles and then the muscles will call on oxygen and then you'll shiver, you don't want them there you want the blood in here, if you make them sweat you'll bring the blood to the surface of the skin again to lose heat, and that's again precisely where you don't need, you want it in the core of the body so you maintain an even body temperature. Shall we give them a nice sweet, hot cup of coffee?
[speaker002:] No
[Elaine:] Nothing by mouth at all, no brandy?
[speaker002:] No
[Elaine:] Nothing by mouth... what else can you do for them?
[speaker002:] Reassure them
[Elaine:] Reassure them, time's going by
[speaker002:] Check Get help Ambulance
[Elaine:] Ambulance, thank goodness someone's remembered, patting this person's hand, and putting blankets on and reassuring them, telling them everything's alright, and blood all over the floor, thank god someone's gone to get the ambulance
[speaker002:] Stem the bleeding
[Elaine:] Right, and stem the bleeding if you can see where it's coming from attempt to stem the bleeding, bung the hole up, okay?... Right, so now we've got round to what we can do for the casualty, let's have a look and see what the body's trying to do here and then we'll say... how you'll help them a bit more. If the person's bleeding, not just a little tiny cut now, not like the graze this morning, this is real, this is serious bleeding okay?... First of all... you've got the blood pressure falls, the body does that automatically for itself... mm, mm, the body does that for itself... how can we help it?... Falls partly because it's shutting down the ends of the arteries, the arteries themselves can actually contract because they're muscular walled, yes, the arteries can contract and that tends to shut down and reduce the pressure slightly in that area, right and also the body itself is gonna divert that blood isn't it to the core of the body taking it away from other areas, damaged areas, so how can we help to reduce the pressure any more? Supposing I've got a cut right across my wrist here, or someone has
[speaker002:] Direct pressure Elevate it
[Elaine:] Hold it up, now you're reducing the pressure to the area because the heart's got to pump harder to get it up there... okay, so we hold the hand or the limb higher than the heart and that will reduce the pressure still further, the ends of the blood vessels contract so how can we help them to contract even more?
[speaker002:] Direct pressure
[Elaine:] Direct pressure over the wound, not your hand but the casualty's if they're still conscious... blood clots yes, what's helping it to clot is a special process in the blood
[speaker002:] Plasma
[Elaine:] Not plasma
[speaker002:] Platelet
[Elaine:] Platelet, right, it's the platelet that help clot okay, so how can we help it to clot even more?
[speaker002:] Fibrous
[Elaine:] A better, put a fibrous pad over it, so a pad, pressure directly over the wound initially, that's the first treatment done, see to casualty put pressure immediately over the wound and raise the limb higher than the heart, then the first aid equipment that you'll need is a fibrous pad to bind over it, to keep the pressure on. Pad, pressure and elevation in most instances will stem severe external bleeding, pad, pressure and elevate, okay, let's just reinforce that for you... pad, pressure and elevate, right... and that should control a severe external bleeding. How will you know if the blood is coming from er an artery that's cut? pumping, yes, if I, somebody had slit me here okay, blood from my artery, it's probably quite easy, the television set, then after that it'll drop off obviously because the body is pulling the pressure down all the time, it does, okay, but if it was a vein?
[speaker002:] Blue, blueish
[Elaine:] and it'll flow out, okay, now we know that's the difference in colour and I've already told you that the arteries have got muscles in their walls, what's the difference in between the wall of the muscle, muscular wall, let's put my teeth back in, the muscular wall of the artery and the wall of the vein? the vein has got the valve to it, but only the veins in these parts, the extremities, you see, the lower abdomen and legs, arms, you don't find those veins everywhere
[speaker002:] Is that because of the distance they have to travel?
[Elaine:] with the vein's with the valves in everywhere, yes, it's because they've got to somehow or other, you've got to somehow or other get the blood back up to the heart again, it's not under pressure is it any more, cos it's lost a lot of its pressure and the way it gets back to the heart of course that is it's lying alongside the bones and the arteries and as you're walking around, okay, the arteries are still having the pressure working, the muscles are still working and the vein lies next to it and the blood is able to be milked up, it's milked back up to a non return valve, that shuts off and it can't drop back down any further and the next bit does the next bit up, okay, and then that shuts off and eventually it gets back to the heart and the capillaries... what will that look like when it's bleeding? Their bleeding capillaries
[speaker002:] Bright red Oozing
[Elaine:] Oozing, not bright red, but mixed, it's mixed bleeding really you've got from capillary and very often in any injury you'll get mixed bleeding, but are you going to be too concerned and analyze too carefully whether it's blood from a vein or blood from an artery if it's pouring out?
[speaker002:] No
[Elaine:] It's blood that's being lost at a high rate, it's dangerous whatever ver vessel it's coming from, so you will stop it by pad, pressure and elevation, you will attempt to reduce the loss of blood and assist the formation of a clot, once you've assisted in the formation of a clot, by putting the pad on it, would it be sensible to have a little peak to see how it's doing?
[speaker002:] No, no
[Elaine:] It would not would it, so leave it in position and if you need to put another pad over the top, then do that, more pressure and a bigger pad, never take the original one off, okay, leave it on otherwise you'll open up the wound again and you'll have all that problem over again, so pad, pressure and elevate, what if it don't work? Why don't you put say another pad on top, more pressure, it's still not working and you've tried it again and it's still not working
[speaker002:] Pressure point
[Elaine:] then you can go to indirect pressure and try to control the flow of bleeding by using indeed direct pressure, away from the wound, but where an artery, okay, is running near a bone, so you can compress the artery against the bone squash it hard, and for the arm you'd use this one under here called the breaking... now press, move your biceps muscle away and press underneath there, you can perhaps try to feel it for yourself, did you do that this morning or not? Or yesterday?
[Denise:] I did do it yes
[Elaine:] Mm, okay
[speaker002:] Feel the pulse
[Elaine:] so you felt that and that pulse point there if you press on it hard enough you can actually stop the one in the wrist and of course that is controlling the flow of blood to the rest of the arm and you leave a pressure point closed off like that for no more than ten minutes, because if you left it on for too long that it means not sufficient blood's getting to the rest of the, the limbs and the limb must have its blood supply, so you leave the pressure on for ten minutes and then release it, say for ten seconds just so say that the hand comes back pinkish again and if it's not slowing down, back on with the pressure again for another ten minutes and that's how you use it, tap off, ten minutes at the most, tap on for a little while, if it's leaked again reapply, ten minutes at the most, tap on again, okay and that's how you'll control it, so if you do have a sit a situation where the bleeding was bad cos you've got a, a limb severed, you couldn't perhaps put sufficient direct pressure over that limb, this done, right, to control the bleeding then you could use indirect pressure, here, breaking or here, right in the, no playing now please, no trying to find this one right now, do this one tonight, in bed and the old lady said now what are you doing to me, never you mind, go to sleep
[speaker002:] [LAUGHTER]
[Elaine:] find time
[speaker002:] Say they just going for a walk, yeah, and you come across this, say this young kid has been climbing up the trees and hurt his leg, you're the only person around, so you, you've got to get help yeah, cos he's losing a lot of blood, but you've got to stop his blood same time as you've got to get help, yeah, so what's the priority, you just stay
[Elaine:] Stop the blood
[speaker002:] you just stay with him?
[Elaine:] mm, eventually, hopefully somebody will come along or hopefully the blood will, the blood will slow down enough
[speaker002:] To slow it off
[Elaine:] will clot
[speaker002:] Yeah that's what I mean, could you put a tourniquet on just for ten minutes to try and get help?
[Elaine:] You don't put the tourniquet on at all, don't mention tourniquet in, in first aid work, it's a no no area
[speaker002:] Say if it's in such a secluded place you know if you're gonna be there for twenty, er for days, there's no help
[Elaine:] Well if he was there and you came along well that's two people, so it's not that secluded, okay, so we have to look on the positive side, if at the end of the day you're going to get to a situation where, okay, you can see that the ordinary erm true blue course of events is just not gonna work, then it's down to you, you have then got to make up your own mind what you're going to do for the casualty and your own safety, okay, if somebody had been bleeding that long and you couldn't of got help for them, what would your priority now probably be? What do you think they'd be like by now?
[speaker002:] Dead
[Elaine:] They'd probably be unconscious and they may of stopped breathing, okay, so you know, your priority changes as your time scale changes and you have to be aware of what to do and what is possible to do next... okay? If you decide at the end of the day the thing to do is to pick up this kid and run like hell for somewhere you can gain, wave for help, or put him in the car and drive like mad to the hospital, then you might just do that, even though it breaks all the golden rules of first aid
[speaker002:] That's what I mean, because if, I guarantee if someone was put in a situation with blood everywhere and that, with being the first aider they've got to stay calm, but I, I'd say fifty per cent of all people would pick that kid up and run like hell
[Elaine:] Right, they probably would especially if you could
[speaker002:] it's just a natural reaction, you know
[Elaine:] but I mean how about little Mel, wouldn't pick him up
[speaker002:] It'd break him [LAUGHTER] Start digging
[Elaine:] You'll be needing a burial won't you? [LAUGHTER]
[speaker002:] Seeing as you didn't buy me a pint today [LAUGHTER]
[Elaine:] Yeah, you might just do that, as I say all we can do is tell you what is possible, okay, there are going to be in your own instinct about what is the sensible thing to do and the right thing to do in that incident and take charge, and you will just get on and do the very, very best that you can, you know what you need to do, you need to stop the bleeding, you know what the person needs, he needs medical aid quickly... okay? But if you're in a situation where that's not possible then you'll do the very best you can, but you're always going to be on the look out for the priorities as they change, cos once the person stops breathing they become unconscious, they stop breathing, their heart stops, then everything else has to wait and you have to try and get on with that, okay?
[speaker002:] Yeah
[Elaine:] So indirect pressure, that one then is the feneral and that's the breaking, they're the only two we worry about, okay, the feneral and if they ask where it is don't sort of put two hands over and hang on to your crutch like mad because that isn't really where the feneral artery is
[speaker002:] [LAUGHTER]
[Elaine:] okay, it is where the trouser crease meets the line of the groin and it's skin deep, okay, so you'll pushing onto it you'd probably have to put your two fingers and a pad and your knuckles right in there, alright and you'll feel it yourself best when you're lying down and your knee just up like that, that's when you can feel it best because you can push in harder then, cos you've relaxed your stomach and that's another tip for putting pressure on it when you've got somebody who needs that, you need to relax the stomach muscle, but you manage to put pressure up there okay? Righto the abdomen muscles not the stomach muscles right, everyone okay so far then? Alright, so we've done all that lot and you've got your external bleeding under control... you've used indirect pressure and direct pressure, now's another topping, there's always is isn't there? You can see the person is in shock, there's no sign of any blood...
[speaker002:] Internal bleeding
[Elaine:] internal bleeding, right... so the internal bleeding sometimes shows itself externally, for example if I had damage to my lungs or severe damage to the inside of my lungs I'd cough up blood and that's in, what do you think? What colour?
[speaker002:] Frothy red
[Elaine:] Very red and frothy, frothy colour blood, okay, supposing I had er damaged the lining of the stomach, or perhaps I've had an ulcer that I've perforated, and I was coughing up blood from the stomach... what colour might that be?
[speaker002:] Mm, the fluid's gran granuled
[Elaine:] Grained, granuley, browney, coffee
[speaker002:] Coffee
[Elaine:] colour, browney, that's from the stomach okay? Supposing that the damage to the intestines was further down in, in gut area here okay, and there was bleeding in the gut
[speaker002:] Motions
[Elaine:] Motions, right, black and smelly, okay, and according to how the different colour of the motion be there, or the different colour of the grains were there would give an indication of how long this' d been going on or how far up the gut it was, and the damage was okay? Supposing then that there was water with bloodstain in it, when somebody went to the toilet, urine, pass their urine, where, where would the damage be then do you think?
[speaker002:] Bladder
[Elaine:] Bladder or the
[speaker002:] Kidneys
[Elaine:] kidneys, so it'd come out in there, okay, so those are the areas where damage int internal organs, but yet you still have some sign eventually of blood loss, but there are still some organs in the body where there is no sn nowhere at all an outlet, the liver and the spleen particularly, round here, and the liver and spleen have no outlet in, outside if they're damaged and they bleed internally, you will see the person as you say going into shock, okay, and there may be eventually, not immediately, bruising and swelling and tenderness round the area, bruising is only internal bleeding showing itself, yes, so what can you do with that person?
[speaker002:] Hospital
[Elaine:] Before they get to hospital yes all the treatment for shock, nil by mouth, all the treatment for shock and urgent need of aid, how else might you suspect that there was internal damage and possible bleeding going on?
[speaker002:] High blood pressure
[Elaine:] Well I'm thinking more of
[speaker002:] The patient might tell you
[Elaine:] The patient might tell you what if, if the casualty was still able to talk, they might be able to give you the history of how they became like they were, received a blow, got kicked, fell onto something hard, okay and so on and so on, they might be able to tell you themselves, give some indication, right, you would remove and loosen off all tight clothing, okay, loosen off the clothing for them and then treat them for shock and then refer them to urgent medical attention, nil by mouth on any account, okay? Any questions?
[speaker002:] Just one point, you said er passing water through the ur er blood through the urine is two things er
[Elaine:] It could be the bladder
[speaker002:] it could be the bladder or what?
[Elaine:] It could be the kidneys... okay... are there any questions there, is there anything that you want to ask?... No... don't forget again all the things that you recognize from somebody who was suffering from shock... right... don't forget how we treat them... okay... and we'll run a film for you now erm, no perhaps we won't we'll deal with the severe bleeding on the palm of the hand and get that out of the way
[Audrey:] Yes, okay
[Elaine:] we'll show you now how to put on a pressure bandage for severe bleeding and then we'll put the film on and you can see the whole lot again, okay, so just be in the room if you just push and push and push on the window and er the hand has gone through the window, right, and there's no glass imbedded but it's cut right across the palm and the reason that we show you this one is because the artery that feeds all these fingers comes and the thumb comes up in an arch like that... okay, so the artery comes down, up in an arch across the palm of the hand, so the fingers and thumb all get a blood supply, so when you cut the palm of your hand there is a lot of blood pumping out, okay, so what's the first thing I'd tell her to do?
[speaker002:] Elevate
[Elaine:] Yeah, what else could she do?
[speaker002:] Put her hand on top Pressure on
[Elaine:] Have I touched her blood at all?
[speaker002:] No
[Elaine:] And I have not, and I wouldn't want to unless she was in such a condition, can you manage to sit there like that for a moment while I'll manage to go and get a pad? You okay at the moment? So then I'll need to go and get my pads and my bandages so that I can put this right, you'll need two of these for this bandage, the first one, you open out so that the pad is going to go into the palm of her hand and that over the top and she is going to grab hold of the other one like that, okay, now we've got the wad in there and she's hanging on to it, but it was the sterile part of the bandage as I undid it that went on to the wound, there is no time for dressing here is there? No, okay so now we're going to actually put this bandage, sorry have I got that round the right way?
[Audrey:] No think it goes round the bottom
[Denise:] No, haven't, sorry
[Elaine:] thank you, now we're going to bind this up, you take the long edge, sorry that goes down the long edge comes first of all over the two fingers and round the base of the thumb
[speaker002:] Excuse me, we can't see
[Elaine:] Can I, can we ask you to, can I move you forward, forward, that way or would you like to stand up, stand up and come round
[Audrey:] Perhaps if you would like to go round the
[Elaine:] come round yeah
[Audrey:] Stand at the back or something
[Elaine:] yeah, come round and have a look if you want to, come and stand up here close if you want to okay, round the base of your thumb, basically what we want to do is we want to clamp these fingers in so they can't come un unstuck, we want to push them together because she can't keep them shut like that, but the next thing is that you come round to the back where the little finger is, the next time you come round here, you're gonna come round to about the first thumb joint... okay and then you're gonna go over the top... okay and if you come round again the little thumb, by, by the little finger, you come round again to the thumb joint okay, come over the top again, round, we're just making really like the figure of eight, but all the time we're keeping off of this wrist here and I'm keeping her fingers in, are you alright still?
[Denise:] Yes
[Elaine:] Yes, okay and we're still coming round yet again and the last one cos she's got quite a large fist, I'll take it over the top, round the back and this one now I can tie, tie it off, sorry tie it off on the back of her hand now, I don't want to tie it off on the front cos in a minute I want to put this into a sling... not too tight? How are your fingers?
[Denise:] Alright
[Elaine:] I've left one thing showing, this if you, you'd got, you tuck it in at the top there if you've got some room, right, I've left her thumb out, so that if this is too tight I can check the circulation, if the pink comes back it's okay, can you get your fingers out? No they're all tucked well in, now she needs it still to be up here, right, so what's the best thing that we can do to make sure it stays up in the high position?
[speaker002:] High sling
[Elaine:] A high sling, now we can put on a high sling for her, okay, that goes up there and now, are you still alright? Still okay? We're just gonna put a sling on for you, and if the blood comes pumping through that what will I do?
[speaker002:] Put another one on
[Elaine:] A bigger pad over the top, there's the sling and towards your casualty and place it on the body... down the straight and the elbow and the point at the same side, tuck this hand under and tuck all this underneath the arm and bring the rest of it round the back, tie it up as close to the fingers as you can and try to remember how to do a reef knot, at least always make sure it's firm, is that alright for you? Comfortable and firm?... Once you've done the knot put the ends out of the way, straight away and then last of all just finish off this corner here, if you've got too much material okay, tuck it out of the way, you don't want it dangling there out the way and how does this one go?