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Tuesday Jun 05, 2018

Into the Woods: Top Tips for Wilderness Medicine

There is a tendency in wilderness medicine to fill a lecture with 50 percent teaching and 50 percent stories of things going horribly wrong. I am going to stick to teaching in this post, but feel free to add your wilderness med stories in the comments section. I think we can get to 80/20, which would be a huge win in my book.

I got into family medicine because of wilderness medicine. As an undergrad, I took a "wilderness first responder" course so I could lead backpacking trips, and it remains the single best CME experience I've had. To this day, I remember the final scenario -- a cruise ship crash in the Caribbean. We had to swim to rescue our fellow students, who pretended to be victims. It was January in Tacoma, Wash., our "Caribbean beach" was covered in snow, and ice was floating at the edges of Puget Sound. We made excellent hypothermia packs.

In wilderness medicine training, we try to make things as realistic as possible because you need to be able to control your body's fight-or-flight response so that in crazy situations you can think calmly and clearly. By training with fake blood, screaming actors and gnashing teeth, you prepare to deal with real blood and real scenarios without being overwhelmed by adrenaline.

It's hard to learn this stuff in a book or online, but I’ll do my best. I am going to try to impart the coolest clinical pearls from my training thus far, but I encourage you to seek out wilderness medicine training for actual practice in how to use them. Again, I welcome your own pearls and stories in the comments.

"Get them stable to go home/Go home to get them stable." It is astonishing how much of wilderness medicine boils down to that. If someone has altitude sickness, descend. If they have frostbite, get them somewhere warm and stay warm. If someone gets bitten by a snake, calm them down and quickly get to a hospital for antivenom. If you have the bends, get to a decompression chamber. The art of wilderness medicine is basically knowing how to safely and rapidly get people somewhere else -- when to call for evacuation, when and how to get them out yourself, or how to help them walk themselves out.

Most of wilderness medicine is just regular medicine in austere environments. You still must know how to diagnose and deal with heart attacks, ectopic pregnancies, headaches, constipation and diabetes.

A snow cave can increase ambient temperature by 50 degrees (from -10 to 40 degrees Fahrenheit, but it counts). To build one, make a huge pile of snow, wait until its own weight compresses it, then dig out a tunnel and cave. Remember to make a CO2 hole.

Feminine hygiene products make excellent additions to a first aid kit -- tampons for nosebleeds, pads for larger wounds or lacerations. Plus, it's helpful to have them in a first aid kit for their original purposes.

MARCH. In a rescue scenario, certain things will kill victims fast, so you address these issues first:

  • Massive hemorrhage. Bleeding from the femoral artery, carotid artery, temporal artery, or brachial artery can all kill within minutes. Put some pressure on that. Use a pad and an ACE wrap to approximate a pressure bandage so you can keep your hands free.
  • Airway. Make sure their airway is patent.
  • Respiration. Make sure they are breathing.
  • Circulation. Make sure their heart is beating.
  • Hypo/hyperthermia. Make sure the situation is not going to kill them, given the weather. "H" also stands for hike/helicopter -- you have to decide how the patient is getting back home.

If someone is hypothermic, take off any wet clothing and wrap them in a "hypopack," or thermal burrito. Start with a tarp, add one or more sleeping pads, then three sleeping bags. Put the person in the middle sleeping bag, then wrap them up. If possible, also give them some easily digested, sugary food.

You can close a scalp wound by tying the person's hair from each side across the wound.

Always. Carry. A headlamp. It is a nightmare to get caught out at night without a headlamp.

Carry a pregnancy test in your first aid kit. It is one of the few things you can use to help diagnose abdominal pain in the backcountry.

To remove a fish hook, you have several options:

  • Push it through, cut off the barb and retract.
  • Cut off the tail and push the rest all the way through.
  • If it's fairly shallow push down on the shaft and yank it back out.

A hydration pack hose can make a great enema delivery system for severe constipation.

If you do get bitten by a snake, kill it and bring it with you. Or maybe just take a picture of it. Do not try to suck out the venom. Just wash, bandage loosely, keep the appendage below the heart, and keep heart rate low while you get them rapidly to a hospital.

Mosquito bites, bee stings, poison ivy and sunburn all suck. However, there is a natural soothing remedy -- plantago (plantain) poultice. Look up a picture -- you absolutely know this plant. Just find some, mash it up and put it on a sunburn. Or a bug bite. Also, try not to get bitten. Use mesh, insect repellant and covering clothing.

Carry honey. It's great for the periodic traveler with diabetes who took the usual dose of insulin but forgot to eat all day while hiking. Also, it can be used as an antibiotic. No joke.

Dehydration can look a lot like hyponatremia. Unless you get a clear story and/or see that the urine is concentrated, try to both feed and water someone who looks dehydrated. There are people every year who die in the Grand Canyon because they know dehydration is bad, so they drink gallons and gallons of water, leading to hyponatremia.

If you diagnose a pneumothorax, go ahead and make a one-way valve. Poke an 18-gauge, 1.5-inch needle with a catheter through the fingertip of a non-latex glove. Second intercostal space, midclavicular line.

Tell people where you are going and when you expect to be out.

For a makeshift shoulder sling, fold the bottom of a shirt over the injured arm held across the chest and tie it tight in the back.

Immobilize the joint above and below an injured bone, or the bones above and below and injured joint. Use tent poles, backpacks, hiking poles, paddles or just sticks for rigidity. Use clothing, sleeping pads or sleeping bags for the padding.

Learn how to splint an ankle, brace a leg and build a litter or carrying device.

When purifying water, the safest thing to do is use two methods. Boil and filter, UV and iodine -- any combo will make up for the deficiencies in one method alone. Boiling is the most comprehensive, and just reaching the boiling point will kill any living thing that could make you sick. And remember that boiling point changes with altitude, so at higher altitudes letting it boil for a minute or two is prudent.

Wilderness medicine is a fabulous way to feel prepared when you journey into the woods, but it also can come into play in just about any situation where you are called to improvise. This could be on an airplane, during an earthquake or in a remote location when help is far away. If you like playing outside, do yourself a favor and seek out a wilderness medicine course. Just make sure "moulage gear" and "clothing you are OK getting dirty and ripped up" is included in the things-to-bring list. You want an experience that uses at least a gallon of fake blood per participant. Trust me.

And please. Do not forget to bring a headlamp.

Stewart Decker, M.D., is a family physician practicing in southern Oregon. He focuses on the intersection of public health and primary care. You can follow him on Twitter at @drstewartdecker.(twitter.com)

Posted at 03:39PM Jun 05, 2018 by Stewart Decker, M.D.

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