Wilderness Medicine and Paramedics

Continued from Page 1

Note: The American Red Cross and other medical authorities oppose the use of tourniquets, resetting dislocated limbs, incisions into snake bite wounds and other invasive procedures by anyone other than professional rescuers, since these are often done incorrectly and lead to complications.

Cuts and Lacerations

In most cases, to stop the initial bleending, apply direct pressure on the wound with a trauma pad, Kotex, clean cloth or your bare hands. Elevate the area if possible to reduce blood flow. Unless an artery has been cut (or the patient is taking a prescription blood thinner) the blood should clot up automatically from the direct pressure.

It can sometimes be difficult to access the injury beneath a victim's clothes. Adding a pair of trauma sheers to your first aid kit is one solution. However, in extreme weather conditions, keep in mind that preserving clothing intact as much as possible is crucial to maintaining body temperatures and protection from the elements.

Once bleeding is controlled, clean out the wound as much as possible to prevent infection from pathogens (i.e. bacteria and viruses). To do this, add a few drops of iodine and a dash of salt to some clean water and let it sit for 5-10 minutes. Then irrigate the wound with this concoction to flush out any dirt or debris. Use an irrigation syringe if you have one, or fill a plastic bag with the water and poke a hole into the bottom to generate a stream.

Depending on the size of the wound, you may need to pull the skin together and either apply butterfly enclosures or actual stitches. Refer to your first aid manual for instructions. Make sure pus or other discharge has a way out of the opening as the skin heals.

For smaller lacerations, apply a sterile dressing (i.e. clean gauze) over the wound. You can add a little iodine or other non-irritating antiseptic before setting it in place. Then tape or wrape it snugly. Make sure any bandaging isn't so tightly wrapped it cuts off circulation.

For an arm/hand injury that's severe, apply a sling using a triangle bandage. In the case of animal bites, puncture wounds or any dirt or foreign material entering the tissue, have the victim take antiobiotics (or an herbal equivalent like golden seal) orally for the next several days.

Fractures, Dislocations and Other Wounds

Fractures -  It's advisable to secure the victim's entire body in a C-SPINE position pending a determination of whether spinal injury is suspected. The sound of "crepitus" indicates that two bones are grinding together. Ideally a team of responders will lift the patient in unison during the physical exam, or when it's time to BEAM (i.e. move and transport). You'll want to fashion some sort of C-Collar around the neck, but initially one responder can hold the base of the skull (behind the ears) steady while the SAMPLE is conducted.

If possible, turn a fractured limb back into correct anatomical position. (The sooner the better, because muscle spasms and swelling exacerbate the situation.) Unless it's necessary to remove them, leave a patient's shoes on, since they provide warmth and protection, and you may not get them back on once the swelling starts.

If you're alone and fracture your femur (i.e. the thigh bone in the upper part of the leg), try tying your foot to a tree for traction. Then hook an arm around another tree and pull slowly but forcefully to overcome any muscle spasms and realign the bone as much as possible.  To get more traction, use your free foot and second hand and push. 

Splints - The purpose of a splint is to hold a fractured limb stationary. If the injury is to the ankle, the splint may also need to be durable enough for the victim to walk out on. Install a rigid material like bark around the limb (and any clothing), from the joint above the fracture to the joint below it. Tie it in place with Duct tape, a belt, rope, vines or gauze bandages. (A lightweight Sams Splint is a product routinely carried by paramedics for securing injured limbs.)

For wrist, hand or arm injuries, fashion a sling around the splint to hold the arm steady and aloft. You can use a triangle bandage for this purpose or fold the victim's shirt over the splint and secure it with safety pins.

If you don't have hard material to make a splint, you can create an "anatomical" splint, which refers to an adjacent body part (e.g. finger or leg) that can hold the fractured bone in place. A "Soft" splint is a blanket, towel, piece of foam or other soft material folded around the injured limb and tied into place.

In the case of a fractured femur, a "traction splint" is employed to fend off muscle spasms that cause the bone to slip out of alignment. To create traction, a long stick is set alongside the patient's leg and tied near the hip. Then an "ankle hitch" is created, so that a rope on the other end of the stick can be pulled through it and tightened. To create the hitch, simply wrap a gauze bandage or some other fabric in a figure eight shape around the ankle and extend it around the sole of the shoe (See video links.)

Whenever a splint is used, monitor it frequently to make sure blood circulation isn't cut off anywhere on the injured limb. For instance, numb, cold, tingly or blue fingers or toes indicate that the splint needs to be loosened.

Open fractures - When a bone breaks through the skin, the fracture is considered "open". In a wilderness situation (or when EMS personnel will not be available for a long time), you should try to ease the limb back into an anatomically correct position, so the bone's no longer sticking out. However, there's a risk involved in this procedure, including severing an artery or damaging tissue, so do so with caution. You can also administer a half-dose of antibiotics to guard against infection.

Dislocation -  As described above under Fractures, you want to restore the limb to its anatomically correct position pronto.  If you dislocate your own shoulder, try pressing against a tree to pop it back in place. If you're a responder, maneuver the arm back in place while the victim stands or sits. If he or she is lying down, press your bare foot into the armpit and pull the arm out slowly and steadily at right angles, turning it from side to side until it gently slips back into place through the torn ligaments.  Afterwards, monitor for swelling and circulation problems.

Severed Body Part - Stick it in a clean plastic bag or wrap it with sterile gauze then put it on ice. Avoid contact with the inner tissue and evacuate the part with the patient. In most cases, it can be reattached if surgery takes place within several hours.

Embedded Object - In most cases, it's better to let a trained professional remove anything that gets stuck in the victim. Pulling out the object can trigger excessive bleeding, damage tissue or organs, or leave a hole in the lung that causes it to collapse. In a wilderness situation, however, there are exceptions to this rule. For instance, if the object is causing the victim to freeze, it will have to come out. Extractions must be performed carefully and with precision, lest internal damage result or part of the object breaks off inside and can't be reached.

Other Illness and Injuries

Sun glare/Snow blindness – Rub charcoal above and below eyes, use sunglasses or make birch bark goggles with slits.  To treat, bandage eyes and keep in darkness for several days, even inside tent, where UV rays still penetrate.  At onset, bathe eyes with cold weak tea.  Or use compresses or antiseptic, anesthetic eye ointment.

Parasites, Infection and Fever – Giardia and other parasites usually cause intense abdominal distress, diarrhea, nausea, fever and malaise. Treat with antibiotics or golden seal 3-4 times every 24 hrs, then half dose for two days (sometimes longer) after the fever breaks.  (Note: Some people are allergic to Penicillin so always ask before providing it.) The diarrhea may last a week or more so it's essential to drink plenty of water. If the fever doesn't break after a few days, discontinue use of one antibiotic and try another.  In addition, since antibiotics destroy healthy bacteria, add pro-biotics to the patient's diet (yoghurt, sauerkraut, etc.) to prevent yeast infections.

Tetanus – Also known as lockjaw, tetanus is produced by a bacterium called Clostridium tetani, often found in soil. It enters the body through an open wound, burns, frostbite, gangrene, a contaminated intravenous injection or crush injury.   The bacterium generates a neurotoxin which causes muscle spasms (usually beginning in the jaw) and can lead to death. Emergency treatment involves administration of antibiotics and other medicine to control the muscle spasms.  Hospital care is required.

Tetanus is rare in the United States due to widespread immunization.  The booster shot is good for ten years and all prospective backcountry visitors should make sure theirs is up to date. Neonatal tetanus can be prevented by making sure pregnant women are immunized, by delivering babies in sanitary conditions, and by proper umbilical cord care.

Eye irritation – Apply eye ointment (antiseptic/anesthetic) if possible before trying to work out splinter or object.  Sterilize a needle in a blue flame of a match.  If the needle turns black, wipe it with sterile gauze before starting.  Then hold it parallel to the eye and bring it up from the side of the head. Tap the edge of the object and flick it out.

Indigestion. Use ¼ tsp of baking soda in half a glass of water.  Mint tea is also helpful, as is the homeopathic remedy nux vomica. (Note: You can also baking soda for gargling and as a mouthwash.)

Diarrhea or chronic stomach trouble – Try a purge of 1 tsp of salt in a quart of water on an empty stomach or consume cold spring water during your morning dip in a river or lake. If you have activated charcoal, dilute a little into a glass of water and have the patient drink it. Note: the charcoal soaks up any poisons or chemicals in the stomach, including other medications.

Carbon monoxide poisoning - Poisoning is treated with fresh air and stimulants like coffee, tea and chocolate.  Keep the victim relaxed and warm while their blood detoxes. In frigid weather, never sit in a car for long periods of time with the engine running and the windows shut tight. Don't cook inside a tent or other shelter without ventilation.

Epileptic seizure – Allow the victim to go through the course of the seizure, monitoring for any mucus discharge or vomit that might obstruct the airway. Don't stick a pencil or other object in the mouth. If necessary, check for a swallowed tongue and use your forefinger to hook it upward, making sure the victim's jaw won't clamp shut on your fingers. Rescue breathing and CPR are only necessary if the patient stops breathing or has no pulse.

Burns

Forest fires, cooking or gas lamp accidents commonly lead to serious injury in wilderness settings. Even too much sun can cause a first-degree burn. The skin turns scarlet red and is sensitive to touch. Cool it immediately with aloe vera gel, burn ointment or ice. (Stick the ice in plastic or wrap it in cloth first.) Aloe vera is a cactus juice that draws out heat from the body when applied to a recent burn.

Second-degree burns (a.k.a. partial thickness burns) penetrate deeper beneath the skin and can be the result of fire, acid, a scalding liquid or a lightning strike. Flush with cold water to stop the burning quickly - except, of course, in cases where a live electrical line may be active. After cooling down the burn, you may have time to cut away any clothing or dead skin with a scissors, with the objective of removing contaminants. This job is usually reserved for trained medical personnel, but if help is far away, you may have to take such a pro-active step to reduce the chance of infection or further burning.

Third-degree burns (a.k.a. full thickness burns) leave the skin white or black and can lead to shock. Nerves may be exposed and muscle tissue impacted. Don't use ice on these burns. Treat the patient for shock and remove any jewelry or clothing near the burn site, since swelling may develop. Wrap the exposed area gently with sterile gauze and elevate any burned limb. Needless to say, the patient should be evacuated to a hospital as soon as possible.

Always consult your doctor before making any changes to your health regiment. Discuss any first aid or medical issues before undertaking a wilderness expedition. Some information on this page may be inaccurate, so it's essential to verify any advice gleaned from written sources before implementation. If possible, get trained in first aid or paramedics, then purchase a wilderness first aid guide written by a physician to bring with you on trips outdoors. See also herbal medicine.

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2012 Survival Guide: A practical planner for the worst case scenario
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Recommended Books

First Responder by J. David Bergeron, Gloria Bizjak, George W. Krause and Chris Le Baudour

Comprehensive Guide to Marine Medicine by Eric Weiss and Michael Jacobs (Applicable on shore as well, this handy pocket-sized book is sold with Adventure Medical Kits.)

Wilderness Medicine, Beyond First Aid by William Forgey

Field Guide of Wilderness & Rescue Medicine by Jim Morrissey

Field Guide to Wilderness Medicine by Paul S. Auerbach, Howard Donner and Eric Weiss

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Insect and Animal Bites

Insect bites, stings or skin rashes – Make a paste of baking soda with water and apply on affected area to stop the itching and cool the skin. When the blood gets heated, it causes the rash and itch. Keep the affected areas cool. For stings, flush with water or use an extractor to remove venom. Poison oak or ivy should be immediately scrubbed off with soap and any exposed garments washed with an extra dose of laundry detergent. Avoid skin contact with dogs and horses that have followed the same trail.

The Black Widow (hourglass mark on belly) and the Brown Recluse are spiders whose bites are venomous. In the case of the Widow, excruciating adominal pain is common, as well as nausea, chills and heart palpitations and swelling. The Recluse causes the skin to turn purple, then black. Irrigate or flush the bite with clean water. Mark the area with a pen so you can track the extent of discloration and swelling. Photograph the insect if possible. Painkillers can be given if the victim's vitals are normal. Evacuate to a hospital.

Ticks – Only a few species carry Lyme disease or Rocky Mountain Spotted Fever.  The worst case scenario is an egg-heavy female burrowing into the base of the skull and depositing the eggs there.  Respiratory paralysis may ensue in this case.

Treatment involves removing all parts of the tick. Avoid killing it while it's still attached to your skin.  Apply light heat to its backside by lighting amatch, then blowing it out and holding it near the tick. (Don't tap the tick with the hot match.) Alcohol/gas/shaving cream are also used to get the tick to back out willingly.  Use pincer forceps or slide a knife between skin and tick to ease it out and remove.  Rather than smash a tick between your fingers and risk further exposure, toss it into a fire or smash it on rock with another rock. Then wash your hands and the impact site thoroughly.

For a more serious exposure, lance an area 1/8 inch deep and apply suction with an extractor, or flush the area with clean water.  A hot salt or wet-grain poultice can then be applied to the site for ½ to ¾ hours.  Alternatively, clean the site with an antiseptic or iodine, allow it to dry, then cover with a bandage. 

Mosquitoes – Like heat-seeking missiles, the insects are attracted to your body heat. For some reason, they're also drawn to the color blue. Wear loose clothes and apply cool mud or repellant to your exposed skin. Alternatively, you can use the reddish dirt from ant mounds, as it contains Formic acid. Stay close to a river breeze or walk along a cliff ledge, areas mosquitos usually avoid.

Animal Attacks - Make sure the scene is safe before intervening. If the victim is conscious, ask about the animal's behavior and appearance for possible symptoms of rabies or other illness. If there's a lot of bleeding, that flowing out will initially clear the poison, but you'll have to stop the bleeding quickly with direct pressure and other means if necessary. (See Severe Bleeding.) Flush each wound with lots of clean water before dressing it. If the attacking animal is large, the victim may also have suffered a spinal injury, so consider a C-Spine as well. Administer anti-biotics and evacuate to a hospital.

Snake bite – The only poisonous snakes in North America are rattlers (a.k.a. pit vipers), the coral, moccasin and copperhead.  In the west, rattlesnakes are the most common problem snake. They have triangular-shaped heads, rattles (unless they're juveniles), and are fat at the center. In addition, the rarely seen Gila Monster in Nevada is poisonous. In the southeast U.S., reptiles and snakes pose a greater threat, so you should check with local park service personnel in advance of a wilderness trip about precautions and treatment.

There are a mere 12 deaths per year nationwide from snakebite. Moreover, paramedics say the victims are primarily male, 14 to 28, with a stash of alcohol or drugs with them. That's why, enerally speaking, humans are more likely to be attacking the snakes than the other way around. Young children are considered most vulnerable to fatality because of their small size.

If a bite occurs, keep the victim calm and motionless in order to slow the blood absorption of the venom. Tie a constricting band just above the bite mark and keep the limb or body part LOWER than the heart. Remove the band (which is not a tourniquet) every 10 minutes for about a minute so you don't jeopardize circulation. You should also be able to slip your pinkie inside the wrap when it's tightened. Flush the wound with water as soon as possible. Although the wilderness medicine experts insist nowadays that it does no good, you can try using an extractor to suction out contaminated blood and poison. (The Sawyer brand is recommended.) Then clean the skin with iodine or soap.

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