A guy climbing a rock in front of you totally decks...

[skichica]

Not sure if I should be posting here or at a rock climbing forum, but here goes...I'm a neurosurgery resident, former ski patroller and EMT. One of the reasons I went into surgery is because I witnessed a terrible skiing accident in high school and hated the helpless feeling I had.

Flash forward 15 years...this weekend, I'm out rock climbing, having lunch 30yds away from the base of a popular climbing spot and watch someone rappel off the end of their rope and fall 30 feet to a rocky ledge, then ragdoll down the rest of the crag, unhelmeted of course. Magically, he was conscious and not spinal cord injured. Meanwhile, everyone is shouting for a doctor. I grabbed my first aid pack and did what I could, and thankfully there was a well seasoned fire fighter to help as well. EMS was not too far away and the guy didn't have a neurologic decline by the time EMS arrived (my biggest fear). However, I was pretty shaken up by the whole thing and became acutely aware of my rusty wilderness medicine/EMT skills and inadequate first aid pack. Having been surrounded by CT scanners and ORs for several years, I found the situation a lot more unsettling than I thought I would.

So, questions for you: what should I keep in my first aid pack in my car? which wilderness med textbook should I get? and any suggestions in keeping up with this stuff? What would you do in that situation if someone did have a neurologic decline in front of you?(besides get on the phone to get the chopper in more quickly)

I do a lot of outdoorsy stuff and by default frequently become the team medic, despite the fact that a paramedic would be more qualified than a neurosurgeon in most settings. And, I plan on doing global health/wilderness med stuff when done with residency as a 'hobby' of sorts. So, this will likely not be a one time scenario for me. Anyone else in a situation like this?

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[GorillaPanic]

incoming MS1, aspiring emergency med doc here... Very interested in people's answers to this question.

Cheers.

Sent from my DROID RAZR using Tapatalk 2

 

[The White Coat Investor]

It all depends on how far you've got to carry it. If I'm backpacking, I carry far less than if I'm in a boat or a car. I also take more for a longer trip.

In your case, maintain an open airway, c-spine stabilization, and a cell phone. What else could ANYONE do? Maybe some pain meds.

I've taken two wilderness meds courses, and after a while you realize there's just only so much you can do in teh boondocks, and you become comfortable with that fact. Yeah, there are some little tricks (safety pin a tongue to a cheek to open an airway, or making a litter out of a climbing rope, a tarp, and a sleeping bag) but for the most part, it's just bread and butter EM.

If you really want to save a life, carry an epipen. It just sucks they're so expensive and have such a short shelf life. A roll of tape, a couple of safety pins, a SAM splint, some leftover lortab, some needles (for FBs), some non-stick dressings (great for burns), go a long way and don't weigh that much. Just keep in mind that even a minor wound will eat up A TON of dressings over just a few days.

 

[strongboy2005]

As for a textbook, Auerbach's Wilderness Medicine is the gold standard. It is included in the MDConsult library if your residency program has access to it.

 

[dchristismi]

Yep, although the "baby Auerbach" is a lot more portable. (The Field Guide to Wilderness Medicine.)

Not a whole hell of a lot you can do in the field - even medics have their toys. A phone is your best tool, honestly. Agree with the epipen comment, and if you can keep the patient calm, that's going to go a long way. (And prevent others trying to "help" from worsening any injuries.)

 

[joeDO2]

I would concentrate on items for the few things that are emergent....

MI- ASA
Asthma- Albuterol MDI
Anaphylaxis- EpiPen x2
Diabetic- oral glucose
Bleeding- tourniquet, quikclot
Airway- OPA, pocket mask

IMO splints, etc take up a lot of space and aren't going to save a life

in the non-emergent but commonly useful and easily carried category, consider adding benadryl, zofran dissolving tabs, oral pain meds

 

[Cynic]

How are you guys getting your hands on the prescription meds, like epipens and MDI's. Do you just write yourself an Rx or have a colleague do it or does it vary by state?

 

[The White Coat Investor]

I would concentrate on items for the few things that are emergent....

MI- ASA
Asthma- Albuterol MDI
Anaphylaxis- EpiPen x2
Diabetic- oral glucose
Bleeding- tourniquet, quikclot
Airway- OPA, pocket mask

IMO splints, etc take up a lot of space and aren't going to save a life

in the non-emergent but commonly useful and easily carried category, consider adding benadryl, zofran dissolving tabs, oral pain meds

Aspirin in less than 4 hours doesn't make a difference. I guess if you're WAAAAYYY out there it's reasonable. But as a general rule, people with CAD aren't WAAAAY out there.

A SAM splint fits nicely into a camelback. Broken forearms are pretty common way out there. A SAM also makes a nice C-collar.

If you want stuff you'll actually use, concentrate on bandage stuff. But most of the time, you can make bandaging stuff out of the clothing you're already carrying. I like the tourniquet idea. That would be worth carrying.

If weight and space isn't an issue, I carry enough stuff to suture wounds as well (and have used it 50 miles away from the nearest trailhead/marina.)

 

[Spinach Dip]

OP - If you go out with the same people frequently, perhaps you can ask for some "donations" to help keep the first aid kit up to date?



And also:

safety pin a tongue to a cheek to open an airway,

I'd rather just carry around a couple of these:

 

[gro2001]

I think the best thing you can do medically for a party you are part of is make sure anyone with medication needs brings enough of their own meds and then some. Multiple MDIs to be carried by the asthmatic, multiple epi pens by the guy with allergies, etc. Agree with splinting material. Also, communication equipment (phone?) and redundant equipment (second phone, second battery, etc). Be aware of people's medical conditions. Be aware of evacuation routes and options. C-collar stuff seems potentially high yield. Skin stapler or suture stuff may be for longer trip. Duct tape. Gauze. Sharp knife.

 

[skichica]

Thanks for the advice SDN! I think I might try to get involved with the search and rescue group out here for those moments when we're out of cell phone service. The epi pen seems nice to have, but I may reserve that for the times when I go on specific trips with minimal access to medical care.

 

[The White Coat Investor]

OP - If you go out with the same people frequently, perhaps you can ask for some "donations" to help keep the first aid kit up to date?



And also:





I'd rather just carry around a couple of these:

Are you going to size them on your party before going out?

The benefit of the safety pin is you can just throw it in the bottom of your pack and forget about it. Plus you can use it for other stuff (like turning their t shirt into a sling.) If you just throw a "couple of these" into your bag for everything you could possibly use, you won't take the bag except in your trunk. My first aid kit is bigger than my sleeping bag. That doesn't cut it if you have to carry it any significant distance.

 

[jbar]

There are wilderness medicine courses for medical professionals (SOLO has one, WMI might too).

The medicine is pretty similar but it's much easier to make a splint out of a sleeping pad if you've seen a few examples and practiced a few times then trying to re-invent the wheel in a stressful situation.


As far as medical gear goes, I'd echo what others have said. There is the kit you make if you are going to go into the woods to provide medical care (working a BMX race, or an adventure race or for search and rescue.) This is most of the same stuff you'd find on an ambulance, minus the really heavy stuff. So you'd have c-collar, IVs, maybe meds, bleeding control, airways, maybe BVM, BP cuff etc.

Then there is the "I'm going on a extended trip/big group and will be the medical person if called on, but have to stay mobile." I had a nice waterproof one for kayaking from Adventure Medical. This tends to be 4x4, gauze, SAM splint, gloves, blister supplies, tylenol, ASA, maybe tweezers, tape, steri-strips, iodine etc)

The last is the "I'm going out to play by myself/with a friend" this is what I always have with me kit. This should be super light. Mine is mainly stuff for survival, most of the medical stuff I'm going to improvise. Mine mainly fits in a metal cup, wrapped in a bandana. (The cup can be used to melt snow, or heat up the packet of jello that is in there, mixed with water good for the hypothermic/exhausted patient.) There is a candle and matches, for heating the cup. I have a small knife, small headlamp, bottle of iodine pills to purify water, a small compass, batteries for the headlamp. Duct tape in there or wrapped around the water bottle. A length of paracord, And a pair of latex/nitrle gloves.


Some wilderness medicine rules that I like:

1: Don't cut down jackets, the feathers go everywhere.

2: Take care of the rest of the group first, make sure they are safe, get them busy making shelter, setting up camp etc.

3: Slow down. Most wilderness situations are more than an hour from the hospital. So 5 minutes isn't going to make a difference of life or death in terms of getting the patient out. Have a plan, know where you are before someone runs off for help. Better to figure out what is going on if it's going to be an hour hike out to get help.

4: Take care of yourself and your gear first. You can't help anyone if you are dehydrated, hypothermic or injured. Have enough gear to survive 24 hours on your own, good if you get lost or have to stay with a patient.

5: Get the patient onto a sleeping pad (ie log roll with help). They lose a lot of heat into the cold ground.


And speaking of the OPs case, remind people you climb with to tie a figure 8 knot at the end of their rappel ropes. Better to be stuck at the end of your rope then fall off the end.

Man this is making me miss search and rescue/ski patrol

 

[The White Coat Investor]

The last is the "I'm going out to play by myself/with a friend" this is what I always have with me kit. This should be super light. Mine is mainly stuff for survival, most of the medical stuff I'm going to improvise. Mine mainly fits in a metal cup, wrapped in a bandana. (The cup can be used to melt snow, or heat up the packet of jello that is in there, mixed with water good for the hypothermic/exhausted patient.) There is a candle and matches, for heating the cup. I have a small knife, small headlamp, bottle of iodine pills to purify water, a small compass, batteries for the headlamp. Duct tape in there or wrapped around the water bottle. A length of paracord, And a pair of latex/nitrle gloves. \

Now we're talking. It's easy to leave the gloves behind. I just refuse to climb with anyone with HIV/HEP C.

My "camelback" kit contains a very thin space blanket, lighter, water tablets, a roll of athletic tape, a safety pin, a leatherman, a SAM splint, an epi pen and one pill bottle with Aleve, Lortab, and Benadryl in it. All of that fits in a ziploc sandwich bag (except the SAM which fits nicely in a camelback BTW) and you can do an awful lot with it.

 

[Apollyon]

One or more folks alluded to it above, though - if you have anything that requires a prescription, and you are not licensed in the state in which you are using it (if you do), Murphy's law states someone will somehow get someone else to clip you for practicing medicine without a license.

Has it happened? I don't know. I've heard anecdotal stories about similar rescues, but haven't looked for confirmation. At the same time, you want to be the first one?

 

[deleted109597]

My "camelback" kit contains a very thin space blanket, lighter, water tablets, a roll of athletic tape, a safety pin, a leatherman, a SAM splint, an epi pen and one pill bottle with Aleve, Lortab, and Benadryl in it. All of that fits in a ziploc sandwich bag (except the SAM which fits nicely in a camelback BTW) and you can do an awful lot with it.

Benadryl, the wonder drug. For itching, insomnia, headaches, motion sickness, you name it.

Space blankets are funny though. It's not bad as a lean to, or windbreak, or to gather water, or to signal rescuers. But it is pretty terrible as a blanket.

 

[Spinach Dip]

Are you going to size them on your party before going out?

Hey Jim, come over here. Turn your head to the side.... Okay, That's about a 9. Hey Carol, you're next! No need to be shy.

 

[mehc012]

There are wilderness medicine courses for medical professionals (SOLO has one, WMI might too).

The medicine is pretty similar but it's much easier to make a splint out of a sleeping pad if you've seen a few examples and practiced a few times then trying to re-invent the wheel in a stressful situation.


As far as medical gear goes, I'd echo what others have said. There is the kit you make if you are going to go into the woods to provide medical care (working a BMX race, or an adventure race or for search and rescue.) This is most of the same stuff you'd find on an ambulance, minus the really heavy stuff. So you'd have c-collar, IVs, maybe meds, bleeding control, airways, maybe BVM, BP cuff etc.

Then there is the "I'm going on a extended trip/big group and will be the medical person if called on, but have to stay mobile." I had a nice waterproof one for kayaking from Adventure Medical. This tends to be 4x4, gauze, SAM splint, gloves, blister supplies, tylenol, ASA, maybe tweezers, tape, steri-strips, iodine etc)

The last is the "I'm going out to play by myself/with a friend" this is what I always have with me kit. This should be super light. Mine is mainly stuff for survival, most of the medical stuff I'm going to improvise. Mine mainly fits in a metal cup, wrapped in a bandana. (The cup can be used to melt snow, or heat up the packet of jello that is in there, mixed with water good for the hypothermic/exhausted patient.) There is a candle and matches, for heating the cup. I have a small knife, small headlamp, bottle of iodine pills to purify water, a small compass, batteries for the headlamp. Duct tape in there or wrapped around the water bottle. A length of paracord, And a pair of latex/nitrle gloves.


Some wilderness medicine rules that I like:

1: Don't cut down jackets, the feathers go everywhere.

2: Take care of the rest of the group first, make sure they are safe, get them busy making shelter, setting up camp etc.

3: Slow down. Most wilderness situations are more than an hour from the hospital. So 5 minutes isn't going to make a difference of life or death in terms of getting the patient out. Have a plan, know where you are before someone runs off for help. Better to figure out what is going on if it's going to be an hour hike out to get help.

4: Take care of yourself and your gear first. You can't help anyone if you are dehydrated, hypothermic or injured. Have enough gear to survive 24 hours on your own, good if you get lost or have to stay with a patient.

5: Get the patient onto a sleeping pad (ie log roll with help). They lose a lot of heat into the cold ground.


And speaking of the OPs case, remind people you climb with to tie a figure 8 knot at the end of their rappel ropes. Better to be stuck at the end of your rope then fall off the end.

Man this is making me miss search and rescue/ski patrol

I'm assuming there's a subtle difference here that I'm missing, but...can has clarification?

 

[The White Coat Investor]

Benadryl, the wonder drug. For itching, insomnia, headaches, motion sickness, you name it.

Space blankets are funny though. It's not bad as a lean to, or windbreak, or to gather water, or to signal rescuers. But it is pretty terrible as a blanket.

I agree, having spent a night out with one. The lighter turned out to be far more useful that night. You know what would have been more useful? Remembering that the camera had the same size batteries as the dead ones in the headlamp.

 

[Pose]

I'm a long distance (and ultralight) hiker, so I am pretty selective with what goes in my pack. I always take some sort of narcotic pain killer, ibuprofen, Zofran ODT, Benadryl, antibiotic, duct tape, safety pins, needle, non-adherent gauze, bandaids, Leukotape, and an emergency bivy (better than blanket -- can be used as vapor barrier). Meds go in one bottle, and the other stuff is with my other gear (compass, knife, headlamp, etc). Ah, and sometimes I take Flagyl if multiple reports of Giardia.

When I hiked the Appalachian Trail, the number one thing used from my kit was Benadryl. I gave this **** away like candy. I also gave away a load of Zofran because if people didn't have Giardia, they had Norovirus. I met a lot of people that were days away from roads, ****ting and puking their brains out, and almost entirely unable to keep down fluid. Popping a Zofran under their tongue made it easier to manage their symptoms and help them to safety the next day.

I'm not a doctor, and don't think being an EMT has helped me in any way while hiking. I think the priority for most people needs to be making people feel good enough to move them to a safer location. Or calling for help.

 

[jbar]

I'm assuming there's a subtle difference here that I'm missing, but...can has clarification?

Assume you are hiking with a group of people. You see someone else fall off a cliff. Take care of the group means make sure your group doesn't freak out, doesn't rush over and get hurt themselves. Often this is in a situation where you are a leader (say of kids or leading a kayaking trip). If you have two leaders one can go check the patient while the other gets the group ready for the rescue or making camp to take care of the patient. So making a shelter, rehydrating, getting food cooking if you are going to be there for awhile, having 3 people get ready for the hike out to get help. It all depends on how many people you have, how many leaders there are, how far out you are, how injuried the patient is etc.

The point of that is mainly that you can't just focus on the patient but you have to keep an eye on the rest of the group/ rescue party.


Taking care of yourself means just that. Like don't immediately give the injured person your jacket, you aren't going to be helpful if you are getting hypothermic. (Find out if someone else has an extra jacket, check the patient's backpack) Same goes for splinting material. You should be cutting up the patient's extra shirt for things to make a splint before you start cutting your own shirt. Stay hydrated. Don't fall off the cliff.

The main point being taking care of your self the way in the previous point you take care of the group.

 

[jbar]

. I think the priority for most people needs to be making people feel good enough to move them to a safer location. Or calling for help.

This is one of the big things in wilderness medicine. The decision of "is this someone I can evacuate out with what I have by carrying them or splinting a shoulder, or do I have to hunker down and keep this person warm and alive until a rescue party can be brought in."

My rule of thumb was the it was going to take about 1 hour per 3 miles to go get help, about 1 hour per 2 miles of decently steep slope to get help in, and about 1 mile per hour to carry someone out. Slower if you are setting up anchors in a low or high angle system, faster if it's a nice trail and you have a wheel for the litter.

But that means that if you are 5 miles in, it's going to take 2 hours to notifty search and rescue, 3 hours for them to mobilize and get to you, and 5 hours to carry the person out. So you might be looking at 10 hours with the patient.


Those rules of "don't feed your patient" sorta go out the window if you are trying to keep them warm and hydrated for 10 hours.

 

[The White Coat Investor]

This is one of the big things in wilderness medicine. The decision of "is this someone I can evacuate out with what I have by carrying them or splinting a shoulder, or do I have to hunker down and keep this person warm and alive until a rescue party can be brought in."

My rule of thumb was the it was going to take about 1 hour per 3 miles to go get help, about 1 hour per 2 miles of decently steep slope to get help in, and about 1 mile per hour to carry someone out. Slower if you are setting up anchors in a low or high angle system, faster if it's a nice trail and you have a wheel for the litter.

But that means that if you are 5 miles in, it's going to take 2 hours to notifty search and rescue, 3 hours for them to mobilize and get to you, and 5 hours to carry the person out. So you might be looking at 10 hours with the patient.


Those rules of "don't feed your patient" sorta go out the window if you are trying to keep them warm and hydrated for 10 hours.

I like the guidelines. I think they're pretty accurate for flat trails. Too bad I don't do any of those!

Another useful thing to learn if you're in a decent sized group is how to make a litter out of a climbing rope, sleeping pad, sleeping bag, and tarp (ground cloth or tent fly works). Actually, you could do it with just the pad and rope if you had to, but it's definitely better with the other stuff. If there's 5-6+ of you carrying the person out is very realistic. It isn't a spine board (slumps in the middle) but it isn't bad.