First Aid & Wilderness Medicine

Probably the best training to get under your belt before a long-term natural disaster is in first aid and traditional medicine. Most community colleges offer low-cost courses in paramedics, with no pre-requitistes and the opportunity to pick up a certificate as an emergency first responder. A class in wilderness medicine -- which covers extrication and treatment for hypothermia, heat and altitude sickness -- is another robust alternative to taking the typical Red Cross CPR/First Aid seminar.

One way to get comprehensive training for free is to volunteer for a local search and rescue (SAR) organization or Community Emergency Response Team (CERT) in your area. These groups provide numerous classes at no charge to participants (although you may have to buy a uniform). At any rate, here's a comprehensive guide to typical first responder skills, protocols and treatments. See the disclaimer below.

Sections covered below include:

First Aid Kit
Patient Assessment
Shorthand for Paramedics
Mass Casualty Incidents
Life-Threatening Situations
Hypothermia, Heat Sickness and Altitude Sickness
Cuts and Lacerations (Page 2)
Insect and Animal Bites (Page 2)
Fractures, Dislocations and Wounds (Page 2)
Burns (Page 2)
Other Illness and Injuries (Page 2)

First Aid Kit

In addition to a compact first aid manual and watertight case, here's a list of items and supplies to assemble:

Besides the items listed here, consider purchasing some basic surgical and dental instruments, since open wounds and oral emergencies are a distinct possibility in a long-term evacuation. In the case of a nuclear disaster, a personal radiation detector (aka dosimeter) may come in handy, along with potassium iodide pills or liquid tincture, which prevent the thyroid from absorbing radioactive iodine. Children and pregnant women are considered to have the highest risk because of the increased rate of cell division in their bodies. Popular dosimeter brands include UltraRadiac and RadEye.

An industrial disaster might require the use of a half-mask respirator with cartridges that absorb either organic vapors (i.e. toxic chemicals) or particulates like asbestos and radioactive fallout. 3M company manufactures a variety respiratory and safety products widely available on the internet. (The website allergybegone.com generally offers lower prices than other sites.)

If you know acupuncture (and have a license to practice), you could also pack a set of needles in a long-term evacuation. Besides treating chronic disease and pain, inflammations, the flu and reproductive problems, acupuncture can facilitate recovery from sprains, fractures, burns, rashes, migraines, diabetes and heart problems.

When researching first aid on the internet, check the pages of backpacking groups and wilderness outfitters. When assembling a kit, one cost-effective approach is to buy an already organized kit on sale, then supplement it piecemeal with needed supplies. (Sierra Trading Post sometimes sells Adventure Medical Kits at steep discounts, for instance, with the caviat that most of the medicines may be near or past expiration dates.) To make your own triangle bandages, buy a couple yards of unbleached muslim from a fabric store (under $1.50 yd) and cut the trianglesyourself. Check your local thrift shop for sturdy carrying bags to hold your first aid kit. A waterproof case is ideal.

Patient Assessment

To handle both wilderness and urban emergencies, paramedics are taught easy-to-remember terms and acronyms to simplify a job that's often carried out in extreme conditions. The most common is ABC, which instructs the first responder to make sure the victim always has a clear Airway, unbstructed Breathing and normal Circulation. In the backcountry, you can add Disabilities (like allergies or diabetes) and the Environment (extreme heat, high altitude, etc.). In the event of a severe injury, a patient's pulse, heart rate and temperature is measured every five minutes in the event that shock or some other obstacle to perfusion (circulation) sets in.

SOAP - This acronym represents the modus operandi for handling any rescue or medical emergency. After making sure the scene is safe, you'll start collecting information and providing medical care. Until a spinal injury is ruled out, it's also standard practice to secure the victim in a CSPINE position (i.e. immobilizing the head and neck).

Here's what each letter stands for:

Subjective info:  This includes initial observations and whatever the patient communicates about his/her condition.

Objective data: Facts that can be recorded, like pulse and breathing, reaction of pupils to light, body temperature, and the patient's response to palpitation and/or movement his/her head, torso and limbs during a physical examination. The exam (inspection and palpation) starts with the head and proceeds downward: neck, chest, abdomen, pelvis, extremities (arms and legs), and posterior.

After the exam is finished, the first responder has enough info for the following two items:

Assessment:  A diagnosis of the primary and secondary injuries, along with any complicating factors.

Plan: The steps for treating and transporting the victim.

In carrying out the SOAP, an emergency responder ask a standard series of questions - "What's your name? What time of day is it? How many fingers am I holding? What happened to you?" The answers enable you to quickly assess if the situation is more serious than it appears. For instance, in the case of a head injury or stroke, you may notice a patient slurring his or her speech. The responder may also ask his victim to squeeze his hand or follow the movement of his finger with the eyes. These tests can indicate a possible neurological injury.

If the answers to the four questions and/or tests demonstrate a satisfactory level of responsiveness, then the patient is said to be "AO times 4", meaning Alert and Oriented. This is documented on paper as AOX4.

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SAMPLE - After an initial, quick assessment is completed for ABC's, the responder conducts a comprehensive head-to-toe exam in order to collect the objective data representing the O in SOAP, as mentioned above. Here's the kind of information to look for:

Signs and Symptoms: This includes CSM (circulation, sensation and movement), PERL (are the pupils equal and reactive to light?), skin color and dampness, body temperature, pain and tenderness, range of movement for the limbs, any visible wounds, etc. Feel for dampness in clothing, as that can indicate bleeding or other discharge.

Allergies: Always ask about this while the patient is conscious. The most common allergies relevant to a wilderness setting are bee sting, pollen, peanuts and shellfish. In some patients, these can cause Anaphylaxis. Unfamiliar foods and hypersensitivity to poison oak/ivy may also trigger symptoms. And find out if the victim is allergic to latex, penicillin, or other drugs.

Medications:  Ask what pills the patient has with him/her and the last time they were taken.  If you don’t recognize a prescription name, have him or her explain its purpose, any side effects and cautions to watch out for.

Prior Medical History:  This information will help you identify complications that the initial injury could trigger.  Patients who have asthma, allergies, hypertension or another heart condition often require a speedy evacuation and shouldn’t be forced to walk out on foot.

Last Oral Intake:  Includes both food and water.  Since the body requires glucose (sugar), fluids and electrolytes (sodium, calcium and potassium), you made need to offer these in small doses every 15-30 minutes. In a wilderness situation, it's essential to "keep the tank filled".  (Note: If you're close to a hospital, the rule is not to provide any fluids or food to a patient, since immediate surgery may be required.)

Events Prior:  When responding to an emergency, make sure to collect all the details on what exactly transpired leading up to the injury or illness. Also note the weather.

When assisting a patient for several hours or days, a rescuer repeatedly takes a pulse, temperature and other measurements in order to establish a "trend". In particular, if his or her condition is getting worse, the responder may have to render a new diagnosis, treatment and/or transportation plan.

Treating Ailments and Injuries

The following overview of first aid treatments will give you an idea of how emergencies are handled in the backcountry. 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.

If paramedics are within reach, always confine yourself to basic CPR/first aid care (i.e. controlling bleeding, maintaining an open airway, monitoring for shock, etc.), and let the experts handle the rest. You are not legally required to intervene in an emergency, but if you do, provide only the level of care in which you're competent.

Make sure the scene is safe before beginning a rescue. Once you lend assistance, you must stay with the victim until other responders take over or the emergency passes. In the case of a conscious victim, obtain consent before providing care. For a child victim, obtain the consent of a parent if there's one on scene.

Mass Casualty Incidents

A three-staged approach is used nowadays by most disaster response agencies when responding to events that produce a large number of victims. These include natural disasters, infrascture or building collapses, and mass shootings. The first stage is triage, where an initial wave of searchers quickly identify and assess victims at a location. After identifying him or herself, the lead searcher on scene will call on all victims who can walk to move in the direction of his/her voice. These walking wounded are then guided to a safe spot nearby, assessed and documented.

Victims who don't walk out are assessed where they're found. Each gets no more than a 30-second check for respirations, perfusion and mental alertness and is then categorized as follows:

In a typical triage scenario, respirations are measured for 10 seconds (then multiplied by 6). More than 30 respirations per minute suggests the blood is not getting properly oxygenated. Perfusion (circulation) is checked by pressing down on a fingernail or ear lobe to see how long it takes for the redness to return. If it takes more than two seconds for capillary blood vessels to refill with blood, then the victim may be in shock. Mental alertness is tested by asking the victim to squeeze the rescuer's hand or respond to a question. If he or she fails, it could indicate a neurological injury.

If any victims are bleeding profusely, have them or someone else apply direct pressure over the wound and elevate it so gravity can pitch in to slow the blood flow.

After triaging all the victims, searchers report back to the incident command post, explaining the number of casualties in each of the categories listed above and any extrication issues (e.g. a victim is pinned under a wall). A second wave of rescuers is then dispatched to remove all the victims who weren't able to walk out themselves. Volunteer rescuers are trained to use cribbing (lever and blocks) to lift the heavy objects under which one or more victims may be trapped. As they're retrieved, the rescuers repeat the 30-second triage assessment to confirm, upgrade or downgrade the status of each victim.

The third stage of a mass casualty incident involves a crew of first responder medical personnel treating injured victims on site until emergency transport is arranged. To be eligible to give care, volunteers take a special first responder class, then get their certification through the National Registry of Emergency Medical Technicians. For more info, visit nremt.org.

Life-Threatening Situations

Severe Bleeding – In worst case bleeding scenarios, use pressure points if possible to cut the flow of blood to the limb. For head, neck and torso wounds, you can't use pressure points. With two fingers, press the artery on the inside of armpit above the bleeding arm. For a leg injury, press the arterial point in the seam between the leg and groin. Verify these points first by searching for a strong pulse in the appropriate spot. When using pressure points, relax pressure occasionally.

If pressure points, direct pressure on the wound and elevating the injury site fail to stop profuse bleeding, apply a tourniquet directly above the wound on the leg or arm. (See disclaimer above regarding tourniquets.) A 1 or 2-inch wide, 3-5 ft. length of innertube rubber, cloth, elastic bandage or blood pressure cuff can be used. If you resort to a tourniquet, loosen the stick (like a valve) slowly after 30 minutes to see if the blood has clotted. If the bleeding starts up again, re-tighten and wait 30 minutes more. 

Use of a tourniquet jeopardizes the entire limb below where it's applied, so it's employed only to save the victim's life. Tie it just above the wound to preserve as much of the limb as possible. Every 30 minutes, loosen it a little to see how the wound responds. If profuse bleeding resumes, tighten the tourniquet and wait another half hour. Never apply tourniquets to the head, face, neck or torso under any conditions, and allow professional responders to do the job if their presence on scene is imminent. See disclaimer above. If an accident has already caused an amputation, bandage the exposed limb after addressing any bleeding. Save the severed body part, if possible, by wrapping and putting it on ice.

Remember, when loosening a tourniquet, you must do so slowly. Otherwise, the sudden release of blood from the tightened area could burst through the clotting that's developed.  In an extreme case, a trained responder may try searing an open artery shut by using a knife that’s been heated red-hot.

Shock - Severe injuries lead to shock, an automatic reflex of the body to preserve the core area around the heart. A patient's pulse will become rapid and weak, the skin pale and clammy, and LOR will be minimal. Treat shock by elevating the legs and getting a conscious patient to take a little water and food every few minutes. If the situation worsens and the patient loses consciousness and vitals, you may have to provide rescue breathing and CPR - alternating 30 compressions and 2 breaths. Always insulate a victim from the cold ground with a blanket or other material.

Head Injury or Stroke - Signs and symptoms of a head or brain injury include severe headache, deformity of the scalp, bleeding, loss of consciousness, nausea, raccoon eyes, unequal pupils, amnesia and/or seizures. If the patient hasn't suffered any blunt-force trauma to the head but complains of the worst headache of his or her life, it may be a stroke. Other stroke indications include slurred speech, blurred vision, a weak and rapid pulse, and disorientation or confusion.

In either case, C-Spine the patient (i.e. immobilize the neck), keep the head elevated to reduce any cerebral edema, and be ready to log roll if he or she needs to vomit. Evacuate to a hospital immediately.

Anaphylactic shock – This is a life-threatening allergic reaction that causes the airway to constrict and prevent breathing. Most sufferers are already aware of their susceptibility to bee stings, peanuts, shellfish or other triggers, so they carry Epinephrine (a.k.a. Novacaine) syringes and Benadryl capsules. The patient's self-administered Eppy injection provides temporary, quick relief. The Benadryl kicks in more slowly and may not undo the damage that's already occurred. Continue monitoring breathing and pulse in case CPR becomes necessary.

Symptoms of anaphylaxis include dizziness, increasingly labored breathing, swelling, blueness of the skin, vomiting, diarrhea, abdominal pain and an irregular pulse. Hives commonly develop, and if you feel both sides of the neck, you'll likely find that they aren't symmetrical. Primatine Mist is an over-the-counter medication that can be included in a first aid kit for victims who forget to bring their injectors along.

Other than the victim, only trained health care personnel are authorized to administer an Eppy. The injection is commonly inserted into the leg (straight through the pants) and left in for at least ten seconds. The injector is then retracted and returned to its container. Since relief last only 25 minutes, a speedy evacuation is paramount. The patient may not recover for several days.

Guide continues on Page 2

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.

Copyright 2009-2011 TheCityEdition.com

sterile gauze pads (4x4)
roll of wrap-around gauze
2 muslin triangle bandages
(37 X 37 X 52 inches)
Band-Aids (various sizes)
butterfly enclosures (for closing up wounds)
needle and hook needle
(for stitches)
elastic bandages
trauma pads/sanitary napkins
moleskin (for blisters)
medical/electric/Duct tape
60 cc syringe (for irrigating punctures and wounds)
snake bite extractor
Cavit or candle wax
(cavity filling material)
safety pins
magnifying glass
matches
signal mirror
space blanket
notebook
Homeopathy remedies:
Rhus Toxicodendren
(poison oak/ivy)
Nux Vomica
(gas/indigestion)
aspirin/ibuprofen
antibiotic or Golden Seal
Benadryl
Iodine tincture (or Benzoin)
aloe vera or burn ointment
biodegradable soap
packets of Vit. C powder
multi-tool w/pliers
thermometer
protective gloves
pocket resuscitator
scissors
tweezers
trauma shears
baking soda
Ipapac syrup
(induces vomiting)
Activated Charcoal
(absorbs poisons and treats diarrhea)
Tiger balm or Eucalyptus oil
(muscle aches and sprains)
oil of cloves
(for toothache)
candy/mints
(for low blood surgar)
rehydration salts
antacid (e.g. Tums)
pet medicine
2012 Survival Guide: A practical planner for the worst case scenario
Home | Survival | Gear | Food | Health | Skills | Evacuation | Disasters

More Resources

Quick Links

Herbal Medicine

First Aid Primer - Page 2

Disaster Monitoring

Evacuation Gear

Disaster Supply Kit

Recommended Books

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

Comprehensive Guide to Wilderness 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

Where There is No Dentist by Murray Dickson. Text online.

Where There Is No Doctor by Carol Thuman, Jane Maxwell, et. al. Text online.

A Book for Midwives. Text online.

Army First Aid Training. Text online. (PDF)

Schools and Training

American Red Cross
Classes offered through local chapters.

Community Emergency Response Team (CERT)
FEMA's training program for responders

Emergency Services Nationwide
U.S. Search and Rescue

Community Emergency Response Teams (CERT)
citizencorps.gov

Urban Search and Rescue (US&R)
FEMA. See also: List of participating agencies.

Wilderness Medical Society

Various Training Programs
Groups affiliated with WMS

Wilderness First Aid
Limited to several eastern/southern states

Colorado Wilderness Medicine

Other wilderness first aid program links
From Open Directory

U.S. Search and Rescue Task Force
Scroll down page for lots of links.

Wilderness and Environmental Medicine Journal

First Aid Tips

Lightweight First Aid Kit Checklist
Idaho State University Outdoor Program

First aid kit list
Survival-center.com

Backcountry Health Topics
Backpacking First-Aid Checklist
R.E.I.

Home doctoring
Homestead.org

Pet first aid kit
Canismajor.com

Making a salve

Cholera Fact Sheet (PDF)
Hesperian Foundation

Respirator Fact Sheet
NIOSH

Folk remedies
KountryLife.com

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More links on Page 2

Shorthand for Paramedics

To make communication easier, many medical and other terms are reduced to abbreviations. This is also useful when documenting the patient and injury. Remember to write down times (e.g.last oral intake, vitals taken) as this help you or subsequent responders ascertain the "trend" of the patient's recovery. Here are a few examples:

C-SPINE – Secure cervical spine

CSM – circulation, sensation, movement

AOX4 – alert and oriented times 4 (i.e. patient can answer four basic questions)

RPM – Respirations - Perfusion - Mental State (used in triage)

LOR – level of responsiveness

PERL – pupils equal and reactive to light

POP – pain on palpitation

RR – respiration rate

PR – pulse rate

BP – blood pressure

DIC – disoriented, irritable, combative

RICE – Rest, Ice, Compress, Elevate
(or Rest, Immobilize, Cold, Elevate)

TIL – Traction in line

BEAM – Body Extrication And Movement

stokes – basket used for rescue and airlift

LZ – landing zone

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Hypothermia, Heat Exhaustion and Altitude Sickness

Hypothermia - When the core of the body chills, hypothermia results. The effects of moderately cold weather are intensified by wind and lack of food, so sheltering from the elements and waiting out bad weather is often the best defense. The first symptom is uncontrollable shivering, followed by the "umbles" - fumbling objects, mumbling speech and stumbling on the trail - all because of stiff muscles. Occasionally a patient may engage in what's called "paradoxical undressing". In a severe case of hypothermia, the shivering stops, the pulse diminishes and the victim loses consciousness. He may even appear lifeless, but it's still possible to revive him, so be patient.

If necessary, remove any wet clothes, build a fire or wrap the victim in a tent, tarp or sleeping bag. Stick heat packs inside bandages or towels and set these against the victim's body. (The packs can burn the skin so don't place them on the skin raw.) Another method is use the body warmth of a fellow traveler or pet. If possible, provide tea, soup or food. Professional rescuers use the adage "feed 'em and beat 'em" to treat hypothermia. Calisthenics help circulate and warm the blood, which in turn speeds up recovery. In the worst-case scenario, extreme cold causes a patient's heart to go into V-Fib, necessitating defibulization with an AED, which will likely be unavailable.

If you've just fallen through the ice, immediately undress. In this case it's not "paradoxical", since wet garments can prove the death knell of hypothermia. After undressing, rub the inside of your jacket in the snow powder, which absorbs moisture, then put it back on. Get out of the wind, apply heat packs to your body and/or start a fire. Hang or place your boots and garments near the fire to dry -- but not to close to the heat to threaten their insulating properties. The drying garments can also serve as a windbreak.

Even dry garments that soak up sweat can be deadly, which is why non-cotton underwear is recommended for cold weather.

Frost Bite - It's extremely important to keep your hands and feet warm and functioning at all times. Toes and cheeks are typically first to freeze, and you may not even realize it.   Moreover, without your hands, you can't move or function, as Jack London dramatized in his classic short story To Build a Fire.

In the most dire of circumstances, if your hands are nearly frozen and there's no other source of warmth, you may have to sacrifice an animal. Cut into its belly and shove your hands there inside.

Before frost bite sets in, you can treat its pre-cursor, "frost nip", by sticking your fingers tightly in your palms, then wrapping your hands inside your shirt or under your armpits.  Also watch out for your ears.

Don’t apply alcohol, gasoline or other fluids to a frozen limb or rub it to create friction, as these methods only make matters worse.  Don't stick frozen body parts next to a fire or exhaust pipe of an idling vehicle.

Once a body part has frozen, experts say not to start re-warming it unless you're sure there's no chance of it refreezing again. For instance, if you must transport the patient through the cold before you reach safety, leave the limb frozen. Experts say the worse part of tissue damage comes from the process of freezing, rather than being frozen for some length of time.

First degree frostbite involves numbness, discoloration and edema (i.e. swelling). In 2nd and 3rd degree frostbite, you should see blisters and mucus on the skin.

To treat the victim, replace restrictive or wet clothing with dry, loose garments or wraps. Always monitor for shock. Elevate the extremities and leave blisters intact. Once you're sure you can maintain warm surroundings and the frostbite won't refreeze, you can start "rapid re-warming" of any frozen limb. Submerge the body part in hot (but not scalding) and constantly circulating water, like a hot tub with the jets on. You can spreading Aloe Vera jel on the skin afterward, but do not massage or rub the body part. Apply a sterile dressing on any blisters and give analgesics (especially Ibuprofen) to reduce the pain and inflammation. When the skin softens, the thawing is complete.

Heat Sickness and Hyponatremia - These conditions typically begin with cramps and crankiness, followed by nausea, vomiting, a high body temperature and disorientation. If untreated, heat sickness may progress to heat stroke and seizures.

When body temp exceeds 105 degrees farenheit, sweating stops and the patient hallucinates. In the worst case scenario, blindness sets in and the heart goes into V-Fib, necessitating the use of of an AED (if you have one).

Evaporative cooling is the recommended treatment for heat exhaustion. Get the patient out of the heat, then fan the wet skin with a towel or other cloth. When he begins to shiver, stop for 2-5 minutes, then repeat the process. Give sips of water but no caffeinated drinks or alcohol.

Hyponatremia generally happens on a hot day with a hiker who drinks a lot of water but skips meals. The extra fluid dilutes an already unnourished bloodstream. Eventually, the absence of electrolytes (sodium, potassium and calcium) can cause fainting and trigger a bad heart rhythm. Implore the patient to eat some healthy food if it's available and seek medical help.

Altitude Sickness –Although the amount of oxygen in the air above 7,000 feet is the same as at sea level, the pressure is much less, so the circulatory system has to work harder to get the O2 through the alveoli in the lungs and into the bloodstream. Acclimating slowly to higher altitudes allows the body to develop more blood cells, which in turn increase the amount of oxygen delivered into the circulatory system with each breath.

Altitude sickness is more common with younger people than older. Anyone with a history of hypertension or other pre-existing conditions is also more susceptible. An early symptom is feeling out of breath while resting, or a pounding headache.

When fluid starts filling the lungs, the condition is known as High Altitude Pulmonary Edema (HAPE). The victim spits up a pink frothy sputum and can only sleep sitting up. Edema (swelling) in other parts of the body may occur, and you may wake from a sound sleep feeling as if you're drowning from the inside out.

The general rule for treating altitude sickness is "Descend, descend, descend." If you have access to oxygen, use it. The patient shouldn't be allowed to sleep during the critical period of the illness. Drugs that help include Diamox and Viagra. However, caffeinated drinks should not be given.

A related condition is known as High Altitude Cerebral Edema (HACE). Symptoms of this are Ataxia (remembered as: the victim stumbles along like they need a taxi...), headache, nausea and DIC (Disoriented Irritable Combative) behavior. HACE is treated by descending in altitude, giving oxygen and/or Decadron (a steroid).

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