Wilderness medicine

Mishaps

Mishaps are rarely life and death situations in which the outcome depends solely on what the rescuers do: most accidents result in nothing more than cuts and bruises, sprains and sometimes broken bones; the victim’s outcome is usually determined by factors outside of the rescuers’ control. Second to ensuring the safety of the rest of the party, your most important decision is whether to seek help, or to carry on.

ABC

Ensure that any rescuer will be safe before dealing with an accident victim. If they are not responding normally then check that the victim:

• has an open Airway,
• is Breathing,
• has a pulse (Circulation).

RICE

Treatment for most soft tissue injuries is RICE:

• Rest the patient until they are able to use the limb with the majority of function restored and pain essentially gone.
• Ice (actually just cold water) to reduce the inflammatory response: immerse hands, or feet in cold, flowing water for up to 20 minutes; otherwise wrap cold, wet cloths on the injured part.
• Compression with an elastic bandages, to reduce swelling that results from the inflammatory process (take care not to bind the injury too tightly, which is counterproductive).
• Elevation, to reduce swelling by helping return blood from the injury.

Shock

Shock may result from blood loss arising from either internal, or external injuries.

Symptoms: rapid and/or weak pulse; rapid and/or shallow breathing; pale cool, clammy skin; anxiety, or restlessness; nausea and/or thirst. Later, decreasing level of responsiveness, which ultimately may lead to death.

Treatment: Open and maintain airway; stop bleeding and stabilize fractures; keep warm; elevate legs. Arrange urgent evacuation and if conscious, give plain warm water to drink if you are more than six hours from a hospital.

Brain injuries

Symptoms of mild brain injury: brief loss of responsiveness; short term memory loss; temporarily blurred vision, or “seeing stars”; nausea and/or isolated vomiting; headache, dizziness; and/or lethargy.

Symptoms of serious brain injury: disorientated; confused; irritable; aggressive; unconscious; worsening headache; vision disturbances; protracted vomiting; excessive sleepiness; seizures. These symptoms may not be immediately apparent, but may come on some time after the injury, in which case they are still very serious.

Treatment: Roll patient on to their side, keeping head neutral. Watch airway and breathing; keep patient warm. Urgent evacuation is required for any of these symptoms, unless the patient has had only very momentary loss of consciousness and exhibits no other signs.

Spinal injuries

Symptoms: pain, or tenderness on the spine; weakness in extremities; loss of strength, or ability to move extremities; numbing and tingling of hands and feet; incontinence; signs and symptoms of shock; shortness of breath.

Treatment: Do not move patient unless absolutely necessary. If the patient must be moved, move all body parts as one, as if they were rigid, especially the spine and head. Seek urgent evacuation.

Burns and scalds

“Stop, Drop and Roll” is the rule in the case of a person’s clothes catch fire. Hot water spilled onto clothing, or into boots can cause serious scalds as the heat is retained.

Treatment: remove clothing and for minor to moderate burns apply and reapply wet cloths, or immerse the affected area in cold, preferably running water for at least ten minutes. For extensive major burns, there is a risk of making the patient hypothermic so prolonged cooling is not recommended. Protect the burnt skin with a dry gauze dressing. Superficial burns are red and painful, but the surface layer of the skin is intact. More serious burns are extensive, or deep. This is as indicated by large areas of blistering, or even worse where the surface of the skin looks burnt through, and can often appear pale. Burns around the face, or neck can be serious because they can involve the airway. Urgent evacuation is required for serious burns.

Broken ribs

Symptoms: point tenderness over the fracture; pain on breathing in; shallow breathing and coughing; shortness of breath during exertion.

Treatment: administer ibuprofen. For multiple ribs, tape the fractured side from sternum to spine with 4, or 5 lengths of tape to improve patient comfort. Patients with shortness of breath after a blow to the chest; open chest wounds; or other obvious signs of chest injury need to be rapidly evacuated.

Sprains and strains

Symptoms: swelling and discolouration; pain, or tenderness; instability and/or loss of range of movement; inability to bear weight.

Treatment: RICE. Tape the limb for support. The need for evacuation depends on circumstances and the terrain to be covered. Stable sprained ankles can be walked on: to prevent re-spraining, make an ankle collar around the top of the boot, just below the ankle, with a sleeping pad strap. Take another strap and make a stirrup by passing it through the ankle collar on both sides of the foot; pass the straps under the heel and secure them on the outside of the foot. This will provide rigid webbing that will prevent sideways flex, but allow flex front and back. Ensure that the straps are not so tight as to inhibit circulation.

Fractures and dislocations

Symptoms: pain that is severe on movement and point tenderness; the patient may have felt the bone break; the area may be swollen and deformed; loss of function.

Treatment: immobilise the injury with a splint; clean and dress any wounds; remove rings, watches and tight clothing; check for a pulse, temperature and sensation before and after splinting; assess for other injuries. Treat for shock. Rapidly evacuate a patient with an open fracture.

Do not attempt to relocate the arm for a dislocated shoulder. Splint the arm and seek urgent evacuation.

Wounds

Control any bleeding by applying pressure directly to the wound and/or elevating the wound. If the wound is dirty then clean it by generously irrigating with clean water. A water bottle may be used to jet water into the wound. Let the area air-dry and then dress and bandage the wound. The dirtier the wound was, the higher the risk of infection. Expansion of redness and increasing swelling, warmth and local pain over 18 to 24 hours suggests infection, which should be monitored. In severe cases, red streaks radiating from the wound, fever and chills may develop, which requires urgent evacuation.

Bruises

Treatment: RICE

Snowblindness

Symptoms: the eyes feel as if they are full of sand; the eyes are red; any eye movement is painful. Symptoms may develop up to 8 hours after the eyes have been burnt.

Treatment: snowblindness heals by itself in several days. Do not rub the eyes; apply cold compresses and take pain medication.

Foreign objects in eye

If tears do not wash out the foreign body from the eye, fold the eyelid back on itself, using a matchstick as a hinge and flick the material out with a tip of a clean cotton tip applicator. The cornea will likely be scratched, so administer pain relief and refrain from rubbing. If material is stuck in the eye itself, seek evacuation.

Drowning, or near drowning.

Treatment: Check airways, breathing and circulation and perform CPR if needed. Treat for hypothermia. Be alert to spinal injuries.

Cold injuries

Frostbite

Take great precautions to avoid cold injuries as even minor injuries, such as frostnip, can cause discomfort for many years afterwards. Generally, frostbite is only incurred on cold winter days in powder snow, at altitude, or if caught out overnight in sub-zero conditions above the snowline. Constricted, wet boots compounded by cold air temperatures are the most common cause. Prevention is easier than cure: if your boots are wet, wearing dry socks inside plastic bags is a good start. Don’t over-tighten your crampon straps (but keep them sufficiently tight to keep them attached).

Symptoms: skin is cold, waxy and pale; tingles, numbness, or pain. The tissue may be soft if partially frozen, or hard if frozen.

Treatment: frostnip and small areas of partial thickness frostbite can be treated by putting fingers and toes into armpits. Otherwise, keep the injury frozen until it can be thawed out without risk of refreezing. To thaw out the injury in a hut, or shelter keep the patient comfortably warm and immerse the affected area in hot water between 38°C and 40°C made up from mixing 4 parts boiling water (100°C) with 6 parts ice cold water (0°C). Continually replace the hot water to keep the temperature constant. Administer ibuprofen to try and minimise the pain. A flush of pink will indicate blood returning to the site, after which air-dry the extremity. Keep the ensuing blisters intact. Prevent refreezing. Arrange for urgent evacuation.

Hypothermia

Risk of hypothermia when tramping is highest when the victim is wet, and it is cold and windy. Risk increases without adequate food and fluid intake. These miserable conditions prevail when travelling above the bushline in driving rain, or sleet, where air temperatures will be below 10 °C, or so. Stopping to rest, or eat in such conditions leaves the party colder than they started, while changing into dry clothes without shelter is near impossible and trip planning should take this into account. Cold water immersion and wet clothes both considerably increase the risk of hypothermia.

Stages of hypothermia

Stages of hypothermia	Treatment
Patient feels chilled; goose bumps; numb skin.	Seek shelter; dress patient in dry clothing and give the patient a warm drink and simple food.
Shivering begins; clumsiness; slurred speech; stiff clumsy fingers; responses are slow and improper (e.g. not putting on jacket, or hat).	As above, but put patient in a sleeping bag to warm up; give a hot meal and several litres of hot drink.
Stumbling, falling and irrational behaviour.	Place the patient in a sleeping bag with a second bag and a foam pad underneath and a third bag on top. This is known as a “hypothermia wrap”. Warm the patient with two water bottles filled with hot water (test the water temperature on someone’s skin first to ensure they are not too hot). The first bottle is held by the patient on their chest. A second bottle should be at their feet. The patient should come right overnight; monitor the patient for the rest of the trip.
Obvious mental deterioration; incoherence.	As above. If the patient’s mental state does not improve, seek urgent evacuation.
Unconsciousness.	Put the patient in recovery position in a “hypothermia wrap”. Place hot water bottles close to the body. Seek urgent evacuation.

In mild cases of hypothermia, the patient may not admit to their symptoms. Have the person walk an imaginary five metre long tight rope, heel to toe, which will show up any loss of coordination.

Medical emergencies

Heart attacks

Symptoms: chest pain, which can be crushing, tight, pressing, or constricting, which may radiate to arm or jaw; shortness of breath; pale, cool sweaty skin; light-headedness; anxiety; rapid, slow, weak, or irregular heartbeat; history of heart conditions.

Treatment: administer one aspirin; immediate rest in a comfortable position; arrange urgent evacuation.

Abdominal pain

There are many causes of abdominal pain, which makes diagnosis impossible in the field. Evacuation is recommended for any patient suffering from abdominal pain with:

• Signs and symptoms of shock,
• Duration longer than 24 hours,
• Localised pain, especially if the pain involves marked tenderness when pressed on, or there is abdominal rigidity,
• Pain made worse by movement,
• Blood in vomit, faeces, or urine,
• Nausea, vomiting, or diarrhoea persisting for more than 24 to 72 hours,
• High fever,
• Unable to eat, or drink and thus unable to stay hydrated.

Asthma

Symptoms for severe asthma: laboured breathing; only able to speak one or two words at time; sleepiness; lips turning blue; history of asthma.

Treatment: use the patient’s inhaler and organise prompt evacuation.

Diabetes

Patients will have a known history of diabetes. Patients requiring insulin treatment are prone to hypo- or hyperglycaemia.

Symptoms for hypo-glycaemia can occur quite quickly: change in mental state, which could progress to coma; rapid heart rate; pale, cool, clammy skin.

Treatment: administer sugar. If the patient is unresponsive, establish an airway and place sugar between patient’s cheek and gum. The patient should recover within minutes.

If the patient does not recover with sugar, the patient may have hyperglycaemia, which requires evacuation. Patients with hyperglycaemia have normally been unwell for hours, or days. They look quite unwell, often with rapid breathing.

Seizures

Treatment: protect from harm, but do not restrain; pad, or cradle the head; do not place any object in the mouth. Afterwards place patient on side to maintain an open airway. Check for other injuries. Evacuate all patients with first time seizures, or with multiple seizures in a short time period.

Unconscious state

Place in recovery position. Search for clues. Consider administering sugar. Seek urgent evacuation.

Cardio-pulmonary Resuscitation, CPR

Unless you can get advanced care to the patient within 30 minutes from when the patient stopped breathing, you have no realistic chance of saving the patient, even if you use CPR. This is one of the risks of entering the outdoors. One exception to this may be the patient who is hypothermic.

Tramping aliments

Blisters

Blisters are debilitating and can lead to stressed joints in an attempt to alleviate discomfort. Prevention is much better than cure: stop at the first signs of rubbing, or development of a ‘hot spot’ and apply waterproof zinc oxide tape (e.g. Blue Leukoplast), or duct tape to reduce skin friction and protect the skin. Round the corners of the tape so that your socks won’t catch and pull the tape off. For better adhesion, first swab the area with tincture of benzoin and let it dry before applying the tape. Walking through a creek and letting the water soak your boots and socks may be sufficient to alleviate hot spots.

To treat small blisters: apply a proprietary blister dressing (e.g. Spenko Second Skin, Moleskin, Compeed Blister). Do not burst the blister.

To treat large blisters that would prevent the patient walking: disinfect the area surrounding it with antiseptic gel (e.g. Dettol Wound Wash Spray, Purell Hand Sanitizer), then sterilise a needle with a match flame and pop the blister. Apply proprietary blister dressing.

Chaffing

Chaffed thighs are caused by wet shorts and/or sweaty knickers.

Treatment: apply a proprietary baby nappy rash cream at the first signs. Consider dressing immodestly and/or putting on fresh garments.

Dehydration

Dehydration usually only occurs on energetic, hot days, leaving the patient lethargic and perhaps with a headache. After such a day, drink copious tea, coffee, water and/or fruit juice until you relieve yourself with clear urine several times.

In severe cases, caused by diarrhoea and/or vomiting, the patient may get very lethargic, stop passing urine and look quite unwell. Give the patient 1 to 2 litres of rehydration salts to drink, made from mixing 6 level teaspoons of sugar and 1/2 level teaspoon of salt dissolved in 1 litre of clean water. Do not make the drink more concentrated than this.

Sandfly bites

Stoicism goes a long way when dealing with sandflies.

Skin conditions

Some people are prone to acne and pimples forming on their shoulders where pack straps sit. Prevention is the best remedy: wash the susceptible skin each morning and night with either a disinfectant soap, or a gel disinfectant hand-wash. This can be applied with a small piece of a disposable kitchen cloth. Supplement with a proprietary acne cream.

Sunburn

High SPF, waterproof sunscreens and makeup provide best protection. Reapply frequently in sunny locations, or at altitude.

A patient with extensive sunburn may complain of chills, fever or headache. Treat the burnt skin with cold, wet dressings to relieve pain, and take aspirin, or ibuprofen.

Tendonitis

Tendonitis of the Achilles tendon (which runs up the back of the ankle) is caused by stiff, or tight high-topped boots that constrict the tendon and cause swelling and inflammation. Its onset is usually gradual. Moist heat, massage and ibuprofen will help. Try stretching the boots, inserting a 10 mm or so thick foam pad under the heel, and/or don’t use the top few eyelets when lacing the boots.

Toenails

Cut your toenails short and straight across before going tramping. Make sure that there are no sharp edges remaining that can dig into adjacent toes when you toes scrunch up.

Wasp stings

Relieve pain by applying a cold compress. Take an over-the-counter antihistamine, such as Telfast, for the itching and swelling unless you have to avoid this medicine for medical reasons, or apply an antihistamine cream. Monitor the patient’s symptoms. Serious symptoms (anaphylaxis) include the patient starting to generally feel “strange”, or “off”, is flushed, has a rapid pulse (>100 per minute), fullness in throat, tightness in chest and coughs. Keep the sting below the heart and seek urgent medical assistance.

Wrinkled feet (Warm water immersion foot)

This condition occurs when feet are wet and hot for long periods of time, especially in summer and/or wearing synthetic, non-breathable boots. Dry out the feet in the sun and liberally apply moisturiser afterwards and when going to bed. At a pinch, sunscreen lotion can be used.