In the case of ingested substances, do not induce vomiting in a patient who is not awake and alert. For specific treatment of ingested substances, refer to the section on poisons in chapter 5.

There are numerous other psychiatric conditions that would require volumes to expound upon. In almost all cases, appropriate first aid treatment consists of a calm, professional, understanding demeanor that does not aggravate or agitate the patient. With an assaultive or hostile patient, a "show of force" may be all that is required. Almost all cases of psychiatric emergencies will present with a third party3/4]often the family or friend of the patient3/4who has recognized a distinct change in the behavior pattern of the patient and who is seeking help for them.

DERMATOLOGIC EMERGENCIES
Most dermatologic cases that present as emergencies are not real emergencies. The patient perceives them as such because of the sudden presentation and/or repulsive appearance or excessive discomfort. Treat most dermatologic conditions symptomatically. The major exception to symptomatic treatment is toxic epidermal necrolysis (TEN).

Toxic epidermal necrolysis is a condition characterized by sudden onset, excessive skin irritation, painful erythema (redness of skin produced by congestion of the capillaries), bullae (large blisters), and exfoliation of the skin in sheets. TEN is also known as the scalded skin syndrome because of its appearance. TEN is thought to be caused by a staphylococcal infection in children and by a toxic reaction to medications in adults.

Since skin is the largest single organ of the body and serves as a barrier to infection, prevention of secondary skin infection is very important. Treatment of skin infections consists of isolation techniques, silver nitrate compresses, aggressive skin care, intravenous antibiotic therapy and, in drug-induced cases, systemic steroids.

EMERGENCY CHILDBIRTH
Every Hospital Corpsman must be prepared to handle the unexpected arrival of a new life into the world. If the Corpsman is fortunate, a prepackaged sterile delivery pack will be available. This pack will contain all the equipment needed for the normal delivery of a healthy baby. If the pack is not available, a Hospital Corpsman will require imaginative improvisation of clean alternatives.

When faced with an imminent childbirth, the Hospital Corpsman must first determine whether there will be time to transport the expectant mother to a hospital. To help make this determination, the Corpsman should try to find out

if this will be the woman's first delivery (first deliveries usually take much longer than subsequent deliveries);
the time between contractions (if less than 3 minutes, delivery is approaching);

if the mother senses that she has to move her bowels (if so, then the baby's head is well advanced down the birth canal);
if there is crowning (bulging) of the orifice (crowning indicates that the baby is ready to present itself); and
how long it will take to get to the hospital.
The Corpsman must weigh the answers to these questions and decide if it will be safe to transport the patient to the hospital.

Prior to childbirth, a Corpsman must quickly "set the stage." The mother must not be allowed to go to the bathroom since straining may precipitate delivery. Do not try to inhibit the natural process of childbirth. The mother should lie back on a sturdy table, bed, or stretcher with a folded sheet or blanket placed under her buttocks for absorption and comfort. Remove all the patient's clothing below the waist, bend the knees, move the thighs apart, and drape her lower extremities with clean towels or sheets. Don sterile gloves, or, if these are not available, rewash your hands.

In a normal delivery, your calm professional manner and sincere reassurance to the mother will reduce her anxiety and make the delivery easier for everyone. Help the woman rest and relax as much as possible between contractions. During a contraction, deep, open-mouth breathing will relieve some pain and straining. As the child's head reaches the area of the rectum, the mother will feel an urgent need to defecate. Reassurance that this is a natural feeling and a sign that the baby will be born soon will help alleviate her apprehension.

Watch for the presentation of the top of the baby's head. Once the head appears, take up your station at the foot of the bed and gently push against the head to keep it from emerging too quickly. Allow it to come out slowly. As more of the head appears, check to be sure that the umbilical cord is not wrapped around the neck. If it is, either gently try to untangle the cord, or move one section over the baby's shoulder. If neither of these actions is possible, clamp the cord in two places, 2 inches apart, and cut it. Once the baby's chin emerges, support the head with one hand and use the bulb syringe from the pack to suction the nostrils and mouth. Before placing the bulb in the baby's mouth or nose, compress it; otherwise, a forceful aspiration into the lungs will result. The baby will now start a natural rotation to the left or right, away from the face-down position. As this rotation occurs, keep the baby's head in a natural relationship with the back. The shoulders appear next, usually one at a time.

NOTE: From this point on, it is essential to remember that the baby is VERY slippery, and great care must be taken so that you do not drop it. The surface beneath the mother should extend at least 2 feet out from her buttocks so that the baby will not be hurt if it does slip out of your hands. Keep one hand beneath the baby's head, and use the other hand to support its emerging body.

Once the baby has been born, suction the nose and mouth again if breathing has not started. Wipe the baby's face, nose, and mouth clean with sterile gauze. Your reward will be the baby's hearty cry.

Clamp the umbilical cord as the pulsations cease. Use two clamps from the prepackaged sterile delivery pack, 2 inches apart, with the first clamp 6 to 8 inches from the navel. Cut the cord between the clamps. For safety, use gauze tape to tie the cord 1 inch from the clamp toward the navel. Secure the tie with a square knot. Wrap the baby in a warm, sterile blanket, and log its time of arrival.

The placenta (afterbirth) will deliver itself in 10 to 20 minutes. Massaging the mother's lower abdomen can aid this delivery. Do not pull on the placenta. Log the time of the placenta's delivery, and wrap it up for hospital analysis.

Place a small strip of tape ( 1/2 -inch wide), folded and inscribed with the date, time of delivery, and mother's name, around the baby's wrist.