0161 731 0056

Lyme Disease

Big Sick or Little Sick!

Is the casualty “Big Sick” or “Little Sick“?

Examining the casualty’s Vital Signs allows us to assess the casualty’s state of health accurately and objectively.  The Golden Rule on all of our first aid courses is:

“If it’s not normal, it’s  could be bad!”

The above statement may sound inaccurate but whether you are a novice First Aider or a Consultant in the Emergency Department, the above statement is always true.  This is what we need to remember when assessing the casualty.

In our latest article we will look at how we can rapidly assess a casualty’s state of health, at a basic level, with no reliance on medical terminology, equipment or numbers.

The Common Mistake

Human beings are hardwired to react to the sight of blood and generally judge casualties based on their injury rather than their vital signs.

For example, which would you say are Big Sick or Little Sick?

Most people would gauge the injuries on the right as more severe – Big Sick – and the injuries on the left as minor – Little Sick.  Some injuries can be more serious than others but injuries alone do not tell you if the casualty is Big Sick or Little Sick.  Injuries alone cannot tell you if a person is going to live or die or if so, when.  Injuries can only tell you that someone has an injury.

If we look at the two casualties below, which casualty is Big Sick?

Hopefully most people would recognize the casualty displaying chest pain on the left as being Big Sick.  Even though the casualty on the right has a nasty injury and there is plenty of blood, there is nothing in the photo to suggest that the casualty on the right is going to die any time soon.  He is Little Sick.

This is worth remembering – while we judge injuries based on the amount of blood, the bruising or the shape of the limb, we cannot do the same with casualties:

  • Some injuries can look horrific but be relatively minor.  We know that superficial head injuries bleed a lot but the wound may be very small and will easily stop bleeding with direct pressure.
  • Some casualties may have no obvious injuries but the situation can be life threatening.

So how do we judge a casualty who has no visible injury but they tell you the feel ‘unwell’?   How do we judge a casualty who is unconscious or uncommunicative?

The answer is to assess their four Basic Vital Signs.

Level of Consciousness

Another common mistake is simply to ask Polar Questions; ‘Yes / No’ questions or questions which can only be answered with one of two answers.

When we want to know about the casualty’s Level of Consciousness (LoC) we tend to ask are they ‘conscious‘ or ‘unconscious‘.   This is not enough.

If you are reading this you are more than conscious, you are fully ALERT – and that is different to simply being conscious:  Someone who is fully ALERT:

  • Knows where they are
  • Knows who they are
  • Knows roughly what time of day it is
  • Knows the date
  • Can speak clearly
  • Can give appropriate answers

Anyone who is not ALERT is unconscious.

But unconsciousness is not like turning off a switch; there are various shades of unconsciousness.  If they are not ALERT, they are unconscious but can they still respond to VOICE?

  • Don’t ask them a question like “Can you hear me?”  They are unconscious and speaking requires one of the highest cognitive functions we have.  Tell them what to do – “Open your eyes!
  • Don’t suggest it in soothing, soporific tones – you want a response so try and initiate one:  Shout “Open your eyes!” in both ears, loud!
  • Remember, you are looking for ANY response.  They might open their eyes fully or they might groan, flinch or move away from the sound.  Any response would indicate they they are unconscious, but responsive to voice.

If they do not respond to VOICE, do they respond to PAIN?

Again, your assessment needs to be effective – pinching the ear is not effect.  Unfortunately, to ascertain if your casualty is able to respond to pain, you must administer genuine pain – BUT – it must be appropriate.

  • Pinch the trapezius – the muscle along the top of the shoulder, at the fleshiest bit, between your finger and thumb, HARD.
  • Look at the casualty’s face; their response maybe overt or it may be subtle but any response is a response.
  • There are other tests for pain – some are gentle and therefore ineffective, others are brutal and therefore unethical, this is an effective, appropriate assessment.
  • Obviously, if your casualty is responding to VOICE, do not check to see if they respond to PAIN!

If they do not respond to PAIN, they are Unconscious and UNRESPONSIVE.

Your casualty can now be categorised as follows – A,V, P or U:

Conscious and Alert or

Unconscious but responding to Voice or

Unconscious but responding to Pain or

Unconscious and Unresponsive

REMEMBER:  You do not want to know IF they are unconscious, you want to know HOW unconscious

These are the phrases you will use when contacting help and handing over when help arrives – it may not mean much to you but it means a lot to the person you are telling.

WAIT!  Check this out:

What about the drunk, staggering around the town centre at 2am, hugging lamp posts and singing to the moon:  He is upright, his eyes are open.  Is he conscious?

A better question is ‘Is he ALERT?’   Does he know where he is?  Does he know what time it is?  Can he give you an appropriate answer?  Is he speaking clearly?

No.  So he must be….Unconscious?

Yes.  When you shout over to him “Hey!  Are you alright?”  And he swings around, almost loosing balance, all he has done is responded to your voice.

This casualty is Unconscious but responding to VOICE.

In summary, Consciousness has nothing to do with whether their eyes are open or closed or whether they are standing up or lying down.  Their LoC is determined by their ability to respond.


In the same way that people tend to simply ask ‘Are they conscious?‘ people will also ask ‘Are they breathing?’  These Yes/No questions are not enough:

REMEMBER:  You do not want  to know IF they are breathing, you want to know HOW they are breathing.

RATE –      Is it too fast or too slow?

RHYTHM – Is it irregular?

DEPTH –   How much air is moving? Is it shallow / light / weak or is it deep / heavy / strong?

NOISE –   Breathing should be silent.  Are they Wheezing?  Gurgling?  Rasping?

None of these are normal.  All of these are bad.  Anyone whose breathing is not normal is Big Sick.


Skin colour is another obvious, intuitive Vital Sign; we all judge – consciously or not – an individual’s skin colour; we will notice when someone looks pale or flushed.  We can tell which one of the passengers is looking sea sick!

Most changes to skin colour are intuitive:

  • Pale – Blood is moving away from the skin, typically to the core, to protect us when we are cold loosing blood or short of oxygen.
  • Blue – If the cold, blood loss or lack of oxygen is not resolved, we eventually go blue, at the extremities first (peripheral cyanosis) followed by blueness around the mouth and eyelids (central cyanosis).  This is not normal.  This is Bad!
  • Red – blood is moving towards the skin, usually to help us cool.  If the person has a history of exercise and is in a hot climate this would be normal.  This would be little sick.   If the casualty is sat at their desk in an air conditioned office but is hot and red, this is not normal, this is bad.   This is Big Sick.
  • Yellow – Jaundice, for example, can have an effect of skin colour due to a build up of bilirubin which stains the blood an orangey colour, which appears yellow through the skin.
  • Green – Do people go green?  Who knows, but you can quite accurately tell when someone is going to be sick just by the look of them.


Changes in skin colour are most noticeable in Caucasian skin because the skin is contains less pigmentation making it almost translucent, a bit like grease proof paper (if you have ever peeled off the flap of skin left over from a blister).  We are able to see blood through the skin and how it is changing – whether it is moving close to the surface, further away or if there is a stain to it.

In casualties with strong ethnicities, this becomes more difficult as the greater amount of pigmentation in the skin masks the changes we would otherwise see.

Whilst it can be difficult to notice changes in skin colour when dealing with people of different ethnicities, it is not impossible:

We are all pale in the same places; everyone has pink lips and finger nails which will go pale or blue.

Colour is closely associated with temperate – blue is cold, red is hot.  This is a universal.

Jaundice will also reveal itself in staining the sclera, the ‘white’ of the eye.

While it can be harder to notice abnormal skin colours in strangers because you do not have a normal baseline reference, we are able to notice changes in the skin colour of peopl e we know because, regardless of ethnicity, we know what normal is for them.


So most first aid manuals state the human body temperature of 37°C?  Or something like that?  Great how do you measure this when you need a thermometer and if you don’t have a thermometer knowing this number is useless.

Casting you’re mind back to when you were a little boy or little girl, you Mum would usually measure your temperature by feeling your forehead with her hand.  And we know that Mums are always right.

If your casualty feels hot, they are hot.  If your casualty feels cold, they are cold.  All we have to ask is “Is it normal?”

Is it normal for:

  • The environmental temperature
  • Their levels of activity
  • Their clothing


  • It is the Vital Signs that tell us if the casualty is Big Sick or Little Sick and all we have to ask is “Are they normal?” 
  • A casualty may have horrific injuries but if they are Alert, breathing normally, with normal skin colour and at a normal temperature, they are Little Sick.  They are not going to die any time soon.  And that is reassuring because while the injuries may be disturbing we know we have plenty of time.
  • A casualty may have no injuries at all but if they have a reduced level of consciousness, their breathing is not normal, their skin colour has changed or they are not a normal temperature, they are Big Sick.  And this is important because it prompts us to act even though there is no obvious injury.
  • If we monitor the Vital Signs over time we will notice changes.  This may reveal if the casualty is improving, deteriorating or stable.

Remember as a first aider, Keep It Simple (KIS)

Keep the pressure on!

Tourniquets and Haemostatic Dressings

Following their introduction into the European Resuscitation Council (ERC) first aid guidelines, the HSE have now fully confirmed that haemostatic dressings and tourniquets can be included in workplace first aid training.

The HSE advises that when carrying out a first aid needs assessment, employers who identify a specific risk of life-threatening bleeding (e.g. those working in arboriculture, construction, glass work, agriculture or those who use dangerous machinery) should consider providing tourniquets and haemostatic dressings and ensure that their workplace first aiders are trained in their use.

Employers have to consider the use of these items when carrying out their first aid needs assessments. Where these are found to be required RemoteFirstAid can offer both training and the supply of high quality trauma dressings and tourniquets.

We can offer employers training in the use of these advanced skills within any of the first aid courses we deliver. Or alternatively our expert trainers can deliver bespoke training courses to your current first aiders at your site or venue. For a no nonsense chat drop us a line and our training manager will call you back to discuss your first aiders training needs.

Request Callback


MAT Responder Tourniquet


Individual Trauma Kits


Lyme Disease

Lyme disease, or Lyme borreliosis, is a bacterial infection spread to humans by infected ticks.

Ticks feed on the blood of other animals. If a larval tick picks up an infection from a small animal such as a vole or bird when it next feeds as a nymph it can pass the infection to the next animal or human it bites. This is how the disease is spread.

Ticks cannot jump or fly, but when ready for a meal will climb a nearby piece of vegetation and wait for a passing animal or human to catch their hooked front legs. This behaviour is known as questing. The tick will not necessarily bite immediately, but will often spend some time finding a suitable site on the skin, so it is important to brush off pets and clothing before going inside.” The Lyme Disease Action website is an accredited health information provider.

For outdoor practitioners’ such as Forest School Leaders, where their participants are potentially exposed to these ticks a high standard of understanding is required of how to reduce the chances of a tick ”questing”. Ticks can be found anywhere in the UK but NHS Choices webpage highlights the UK Hot Spots and these can be viewed here.

A strong regime of wearing long trousers and tucking these in to socks, long sleeves and ensuring the clothing is light in colour so any ticks attached can be seen clearer are a must. All outdoor clothing should be washed at a high temperature to ensure that any attached ticks are killed off during this wash cycle.

Who’s at risk and where are ticks found?

People who spend time in woodland or heath areas in the UK and parts of Europe or North America are most at risk of developing Lyme disease.

Most tick bites happen in late spring, early summer and autumn because these are the times of year when most people take part in outdoor activities, such as hiking and camping. Read the BBC press report on Mat Dawson’s battle for life after being bitten by a tick that led to heart surgery http://www.bbc.co.uk/news/health-40973709

Cases of Lyme disease have been reported throughout the UK, but areas known to have a particularly high population of ticks include:

  • Exmoor
  • the New Forest and other rural areas of Hampshire
  • the South Downs
  • parts of Wiltshire and Berkshire

    View the Tick Testing Kit HERE!

  • parts of Surrey and West Sussex
  • Thetford Forest in Norfolk
  • the Lake District
  • the North York Moors
  • the Scottish Highlands

It’s thought only a small proportion of ticks carry the bacteria that cause Lyme disease, so being bitten doesn’t mean you’ll definitely be infected. However, it’s important to be aware of the risk and seek medical advice if you start to feel unwell.

Prevention is better than cure!

There is currently no vaccine available to prevent Lyme disease. The best way to prevent the condition is to be aware of the risks when you visit areas where ticks are found and to take sensible precautions.

You can reduce the risk of infection by:

  • keeping to footpaths and avoiding long grass when out walking
  • wearing appropriate clothing in tick-infested areas (a long-sleeved shirt and trousers tucked into your socks)
  • wearing light-coloured fabrics that may help you spot a tick on your clothes
  • using insect repellent on exposed skinProtecting children from Lyme Disease
  • inspecting your skin for ticks, particularly at the end of the day, including your head, neck and skin folds (armpits, groin, and waistband) – remove any ticks you find promptly
  • checking your children’s head and neck areas, including their scalp
  • making sure ticks are not brought home on your clothes
  • checking that pets do not bring ticks into your home in their fur


How to remove a tick correctly and how to test the tick for being a Lyme carrier?

View the Tick Out Here

View the Tick Out HERE!

Remote First Aid sell inexpensive tick removal devices, which are useful if you frequently spend time in areas where there are ticks, such as Forest Schools Practitioners & Climbing Instructors working and operating in high risk areas mentioned before. If you find a tick on you or your child’s skin, remove it by following the guidance given that comes with the tick remover supplied. We recommend that the removed tick is tested for Lyme disease using the CarePlus Tick Testing kit we also sell.  Wash your skin with water and soap afterwards, and apply an antiseptic cream to the skin around the bite.


Useful links relating to this subject:









Peter J Cook FRGS London

Peter holds a range of outdoor qualifications in climbing and mountaineering. Peter was awarded a Fellowship of the Royal Geographical Society, London in 2008 for his work in expedition leadership. Peter has organised and run expeditions to many parts of the developing world, with recent climbing and trekking expeditions to, Jordan, Morocco, Greece, Belize and Malaysia.




Tick Information

Ticks are not insects, rather they are arachnid arthropod parasites, loosely related to the spider family, and like spiders they have 8 legs rather than the 6 of insects. There are more than 800 species of tick, some have a hard carapace (hard ticks) whereas others have a leathery exoskeleton (soft ticks). The tick has three life stages, larva, nymph and adult – nymphs are often no larger than the head of a pin.

There is a common misconception that Ticks live in trees and drop down onto their victims from above, the reality is that they live in long grass, low-lying bushes and foliage, scrub and heath. Ticks are active all year round, but are most active from May to September (although this can vary considerably depending upon weather trends). Ticks can be found across the world, but are a particular problem throughout Europe, the United States, China and Japan. Within the UK Ticks are a particular hazard in certain areas, such as the New Forest, Thetford Forest and the Yorkshire / Cornish moorlands.

Tick Mouthparts

Ticks are parasites and live off the blood of humans and (more commonly) other animals including small rodents, pets, sheep, deer and birds. A Tick detects its victim through vibration and changes in temperature. Because of their habitat the first place that they will come into contact with humans is around the feet and lower legs. Ticks do not have teeth, but they attach themselves to their host by embedding their mouth into the skin – with hard ticks they will burrow their whole head into the skin where they can remain feeding for up to 72 hours. Unlike with other parasites there is no pain attached to the tick bite, and therefore this makes it very important to check yourself for ticks after leaving a high risk area.

A tick can cause serious problems – however these are more related to what the tick might be carrying rather than the tick itself. Through feeding ticks can transfer viruses, bacteria, smaller parasites or even poison to their hosts. This danger is increased if a tick is shocked or stunned in the process of removal – burning a tick off, stunning it with alcohol or smoothering it with vaseline can cause the tick to regurgitate saliva, greatly increasing the risk of transfer. Roughly pulling a tick out can also sometimes leave the head of the tick embedded in the skin – this also greatly increases the chance of infection.  The safest way to remove a tick is to use a Tick Remover – these will grip the tick without shocking it and, (generally with a twisting motion) will remove the tick with the head intact.

Possibly the most dangerous bacteria that a tick can transmit to its host is the Borrelia burgdorferi bacteria which is responsible for Lyme Disease. Lyme Disease is becoming more common across much of northern and central Europe, the northern United States and southern Canada, and in parts of Russia, China and Japan, it is a potentially debilitating disease that can lead to serious health problems or, in the most extreme cases, even death.

The Three Stages of Lyme Disease

Bullseye Rash1) A red ring-shaped rash (Erythema migrans), often known as a bullseye rash, appears around the site of the bite in approximately a third to a half of cases. Over the course of around three weeks this rash will slowly expand and then fade from the middle.

2) Flu-like symptoms may appear: headaches, exhaustion, joint and muscle pains in the arms and legs. These symptoms may last for a while, may come and go, and may eventually disappear

3) Severe joint pain, cardiac arrhythmia (irregular heartbeat) and nervous system disorders may appear, often months after the initial bite.

There is no vaccine against Lyme Disease, however, early treatment with antibiotics is generally successful at preventing any escalation or severe symptoms. Safe removal of a tick within 8 hours of being bitten gives the best chance of avoiding infection in the first place – however when bitten it is always sensible to record the date / time of the bite in case this information is required by a medical professional at a later time. Testing the tick for Lyme bacteria is another sensible step. If you are bitten and as soon as possible.