Backcountry emergencies

[SAR-EMT40]

Since there seems some interest in this I will mention a few thoughts:

In any medical/trauma emergency you need to check the following things in this order.
The three first things that you do are: Make sure the scene is safe then you make sure the scene is safe and then make sure the scene is safe. Does everyone understand the first three most important things that must be done? Your patient doesn't get better because you die attempting to help him and you becoming another patient at the scene does not help the situation in any way, shape, or form either.

Now that we are sure the scene is safe we look at the patient as we approach them. Your assessment of them is already starting. Do they look OK? Do they look sick? What looks wrong about them? What is their color like? How are they breathing? Are they protecting any limbs from further injury, etc. Are they conscious? Are they looking at you as you approach and alert? Get a general overview of the scene.

Then check:

A – Airway - If it is blocked it must be cleared. If it is blocked by the tongue then do a head tilt to clear the blockage. If you suspect head/neck injury then do a jaw thrust. Note: everyone has a head/neck injury until proven otherwise. If it blocked by vomitus or other material use a gloved hand (you do have several pairs of gloves in your medical kit I hope ) to clear it after turning the patient on his side with a log roll while someone stabilizes the head. This will take at least three of you, four is better. If you cannot do this properly by stabilizing the head do it anyway. A patient without a patent airway is a dead patient. You can only do the best you can with the tools and people that are available.

B – Breathing – If they aren’t doing it then you need to do it for them. I am not putting my mouth on anyone I don’t know so carry a barrier that you can use. If their breathing is less than 12 or greater than 20 per minute then they have a problem. Try to correct it if you can. You will not have O2 and a non-rebreather so this my be difficult to accomplish.

C – Circulation – Do they have a pulse? If they don’t then you need to try to help them. You can’t learn CPR over the internet or by watching reruns of ER. Take a class. The honest truth is if they have a cardiac crisis (their heart has actually stopped) in the woods, they are probably (certainly) going to die. Make sure you understand that. You perform CPR to the best of your ability as long as you physically can, but the patient is going to die. Why bother doing CPR at all? If it was your father or wife or son, wouldn’t you want to know that the people that found them did everything they could? If a patient’s heart stops because of trauma, you are almost certainly not going to be able to restart it. Why? Trauma patients usually die of things like hypovolemia (low blood volume). They bleed internally, they bleed externally. In order to bring them back, you need to correct where they are bleeding from and then replace the blood and then restart their hearts. This is what we pay trauma surgeons for. Trauma dead is usually (always) dead, dead. Caveats: Cold people (hypothermia cases) are not dead until they are warm and dead. Do not do CPR on hypothermia patients. Do not even jostle hypothermia patients unnecessarily.

I hope that this doesn’t make me sound cynical, I’m not. I just want people who come across situations like this to realize that people die. You can do everything correct and those people will still die. Realize that you did the best you could and that was all you could do. Since for most of you a situation like this will be happenstance. You will not have the resources that professionals have to deal with a call that really bothers you, emotionally. Someone once said there are two rules in emergency medicine. Rule 1 is that people die. Rule 2 is that sadly, doctors, nurses and EMTs cannot always change rule number one.

Things that the medical responders want to know that you can find out:

AVPU – Are they Alert (Alert)? Do they respond to you talking to them (Verbal). Do they respond to pain? i.e a sternal rub or with a woman pinch on the back of the hand? (Pain) Or do they not respond at all (Unresponsive).

If they are alert. Are they oriented to Person (what is their name)? Place (where are they)? Time (what time/day is it)? And the event. (What happened)? If so then they are said to be alert and oriented times 4. If not, how alert are they. Times two or three etc. A very important question, is the question, is their mental status changing? Is it getting worse or better?

Find out what is their chief complaint. What are their Signs/Symptoms? Do they have allergies, what are they? What medicines do they take? Did they take them today? Have they had this happen before? When was the last time they ate something? What where the events that lead up to this problem? If they cannot answer you, what can his/her friends or bystanders tell you. This is called a SAMPLE history.

What caused this onset of symptoms? What makes this feel better or worse? What does the pain feel like, does it radiate? How bad is the pain on a scale of 1 to 10? When did it start?

Can this person move on his/her own? How much do they weigh?


Things you can do even if you are not a medical responder. Get a pulse rate. Learn how to properly take a pulse. While you get this you should also note what the skin is like. Is it warm and dry or cold and clammy or hot and dry? Is the skin color pink or is it red or blue or gray? Especially the finger and toe nail beds. Try to check these things every 10 minutes if you can. Write this information down with the times and also any changes in mental status.

Learn to control bleeding. Where the pressure points are on the body and how to apply direct pressure or diffuse pressure to stop bleeding. Raising the wound above the level of the heart. These measures are almost always enough to stop bleeding. Tourniquets are almost never, ever needed. Applying a tourniquet almost guarantees the loss of the limb from that point down. If you do use one make sure it is wide and as far down the limb as possible. Once applied it shouldn’t normally be removed. Doing so could release blood clots that can have very dangerous implications.

Splinting. Learn how to make a splint. Learn how to pad and apply a splint properly for both bones and joints and how to check CSM (Circulation, Sensory, Motion) before and after you apply a splint.

There is obviously more I am not mentioning. Much, much more. So much more I really wonder if I am doing a service mentioning this or if it will cause more confusion then help, but here it is. If there are any questions I will try to answer them as best I can.

Obviously taking a first responder class would be a great idea but more then that you really need to practice these learned skills often to keep all this stuff from just leaking out your ears. Like it does with me all the time.

Keith

 

[sp1936]

...I really wonder if I am doing a service mentioning this or if it will cause more confusion then help...

No, your post was not confusing at all, but clearly written and interesting. I doubt that I will remember all of this so, as you suggest, perhaps a first responder class would be in order. Hopefully, someone like yourself will be in the vicinity if I ever encounter a backcountry emergency.

Steve

 

[Waumbek]

Great info. Thanks. I'm printing this one out.

 

[mudhook51]

Safety, safety,safety, the first thing we learn as rescue, fire , emts. A rescuer in trouble is another victim, which means another rescue , which means more rescuers ,which goes on and on. Train and practice, train and practice, even the simple things like tying a knot or cpr. Hopefuly never have to use it, but if you do, do it right, and do it safely.

 

[John Graham]

I have seen CPR revive a lightning strike victim and have heard that it has a better chance with a drowning victim or a choking victim, but it rarely can revive a heart attack victim, because the underlying circulatory problems cannot be addressed in the field. For this reason I would stress that CPR has real life saving possibilities. I take a CPR refresher course every year and wilderness first aid every other year, you cannot take these courses once and think you have done enough.

If there are bystanders who can help, delegate some of the tasks to them. Anyone can hold the neck in place during CPR or apply pressure to a wound. Sometimes it is more important to function as a leader than get tied up applying simple first-aid. A group can be in shock after witnessing a nasty accident and just stepping up and taking charge can help them snap out of it. I have taken over after an accident only to later find that one of those standing there with their mouths open was an MD.

 

[SAR-EMT40]

I have seen CPR revive a lightning strike victim and have heard that it has a better chance with a drowning victim or a choking victim, but it rarely can revive a heart attack victim, because the underlying circulatory problems cannot be addressed in the field. For this reason I would stress that CPR has real life saving possibilities. I take a CPR refresher course every year and wilderness first aid every other year, you cannot take these courses once and think you have done enough.

I should have mentioned this CPR caveat also, especially since it is a likely thing to happen in a wilderness enviroment. Cardiac arrests from lightning strikes have one of the highest survival rates of all CPR events. Always start CPR on a lightning strike patient (if they are in arrest) as soon as you possibly can. Remember that this was an electrical interruption of the heart and CPR can bring them back.

Other arrests occur from things that you are less likely to correct without a defib unit. CPR generally lets the person die slower until you can get a defib unit on them.

I have taken over after an accident only to later find that one of those standing there with their mouths open was an MD.

Anyone that does this will tell you that nothing scares them more than kid calls. I am no different. I have been on kid calls that have terrified me. I am not a fan of “there I was” war stories but I will relate this one (I have many) about an MD. I was first on the scene of a child (3 year old girl) called in as a child choking call. I arrive at a Dunkin Donuts and see a man on the floor cradling a little girl who is just about unresponsive. I asked what happened and the man tells me he thinks his daughter was choking. She obviously wasn’t choking anymore and I can see she is breathing and doesn’t sound like she has any airway obstruction so I start to do my survey on her to find out what is going on. At the same time I start talking to the father and discover he is a Boston Pediatrician. The first thing that went through my mind was thank God, we are saved. What more could I ask for? You see, we practice working on kids but the truth of the matter is that kids just don’t really get sick that often, but when they do it is usually bad. So here I am getting my stethoscope out to check this little girl’s lung sounds and finding that this is a Boston pediatrician and I am thinking at any moment he is going to jump into action and start helping me figure out what is wrong with his daughter. It never happened. My belief is that his daughter wasn’t choking but had just had a seizure that she was coming out of. It was later confirmed by his wife that she thought that the child may have had seizures before but the doctor didn’t think that was what it was.


Let me make it clear I have tremendous respect for MD’s. I don’t care if they are obstetricians or oncologists or general practitioners. I have tremendous respect for them all. But, emergency medicine is a specialty also. EMT’s and paramedics train continuously for many hours and refresher courses year after year and have to recertify every two or three years over and over again. My department (like most) trains a minimum of 3 hours every week in addition to making calls at all hours of the night. I will also tell you that I didn't really consider myself to truly be competent until I did it daily for over a year. That also doesn't mean that I don't still critique myself after every call and I am not always satisfied with my performance. That is why I try to stress that not only taking the course but if you can spend the time, volunteer at your local fire or ambulance service. They will pay for your training and you will also get valuable experience. What better deal can you get than that.


Keith

 

[jwynn9154]

Excellent thread - thanks, Keith, for kicking it off.

As a general (and sometime trauma) surgeon and FORMER EMT before med school, the points listed here at right on target. Most MDs are not trained in field medicine, though that is changing somewhat. The Wilderness Medical Society has established student interest groups at several med schools - ours even sponsors a 'medical wilderness adventure race' that's a ton of fun (google MEDWAR).

At any rate, I'd take the services of a wilderness EMT over those of your average doc most all of the time in the backcountry.

On another note, does anyone if the AMC has considered placing AEDs in the huts (not sure if the power systems at the huts can generate enough 110 current to keep them charged . . .)

Jim Wynn

 

[SAR-EMT40]

As a general (and sometime trauma) surgeon and FORMER EMT before med school, the points listed here at right on target. Most MDs are not trained in field medicine, though that is changing somewhat.

Its a pleasure meeting you. Having had the privilege to see some of the trauma surgeons and other staff at our level 1 trauma hospital work. Let me say thanks for doing what you do. I can’t say anything less than incredible is the kind of things that I have seen in there. I have brought some very, very badly broken people into our trauma hospital and have rarely seen the end results, but I have seen a few and have been amazed.

As The Wilderness Medical Society has established student interest groups at several med schools - ours even sponsors a 'medical wilderness adventure race' that's a ton of fun (google MEDWAR).

My GP is a member (he may actually be on the board) of the WMS and really a great guy to work with when I go camping. I had an incident on one trip were I wound up with a respiratory infection and he gave me some antibiotics and an inhaler to use if I got myself in that situation again. I actually wanted to check about taking the WMS classes but I think they are restricted to MD’s and maybe paramedics. Looks like are really great group. I will check out MEDWAR, thanks.

At any rate, I'd take the services of a wilderness EMT over those of your average doc most all of the time in the backcountry.

I appreciate that. I have heard on more than one occasion an AMC WFR talking to someone that sounds like he is their medical control. Several times I have heard him tell the WFR that if a doctor wants to get involved the doctor won’t be allowed to take control of the scene until they know exactly who he is, what his training is and if he will ride to the hospital with the patient. That is very similar to what we would do in the field as well.

On another note, does anyone if the AMC has considered placing AEDs in the huts (not sure if the power systems at the huts can generate enough 110 current to keep them charged . . .)

Jim Wynn

I convinced my company to purchase an AED and allow training to occur on site and the unit that I picked uses a 5 years LiON battery that never needs charging or maintenance. I also picked it because we can swap the leads directly over to our 12 lead units that we run and the paramedics run in the town.


Keith

 

[BrentD22]

CPR and 1st Aid...

Just so everyone knows that courses are very cheap and do not take up too much of your time. Your local hospital most likely offers it or your local Red Cross. My local hospital offers CRP for $5 and the local Red Cross offers 1st Aid for something like $40 or so. It's well worth the money!

So skip the movie with your family this weekend and sign-up for those courses. It will cost less for your hole family (age 13+) to become CPR certified then a trip to the movies and you'll leave the training feeling good that you can save a life!

 

[nazdarovye]

I took a nine-day WFR course this past December and feel it's one of the best things I've ever done for myself and my fellow hikers.

My particular course was through NOLS/WMI in Flagstaff, AZ; we did practical scenarios outside in weather as cold as 4° F, and it really drove home the critical importance of managing environmental effects (in this case, hypothermia).

We all both treated as well as acted as patients lying out in the snow and rocks, had a nighttime scenario in a snowstorm on the slopes of Humphreys Peak (luck of the draw on that one - but perfect timing in retrospect), and it was amazing to learn how quickly one becomes chilled, especially when "injured" and immobile, and how quickly a snowstorm or other adverse event can change the equation when scene safety must come first.

Another thing they made a big point of was that what's in your First Aid Kit is only of secondary importance; it's much more important to follow procedures and treat the patient, improvising however necessary. It's pretty amazing what you can do with duct tape, hiking poles, skis, and just the things in a normal pack. Nothing wrong with a well-equipped first aid kit, but the knowledge and experience and ability to improvise materials if you don't have them are even more valuable attributes. (That said, don't leave home without gloves and some other basics!)

My other big take-away from all of it was just how quickly the knowledge will fade away if not practiced. I plan to review the course materials on a regular basis, perhaps even get involved in SAR here. I also have SOAP forms and a summary sheet tucked away in even my smallest first aid kit - no shame in following a checklist or referring to references (I'm also a pilot, and had that hammered into me over and over, especially for instrument flying).

Anyway, I highly, highly recommend this kind of course to anyone who has the time and inclination. And if you can't afford the time or money, at least consider a local wilderness first aid and CPR course.

- Steve

FYI - here's a link to the NOLS/WMI WFR information (and links to other courses):

http://www.nols.edu/wmi/courses/wildfirstresponder.shtml

There are other schools out there as well - Wilderness Medicine Academy also has some nice printed materials and references for sale.

http://www.wildmed.com/

And here's a link to a nice WFR summary card (note - giving treatment beyond your training opens you up to liability...use intelligently):

http://www.nols.edu/wmi/pdf/wfr_cheat_sheet.pdf