Backcountry First Aid

[splat]

Someone told me there's a new gunshot wound kit that's being touted and recommended for everyone, given the gun violence out there.

Anyone heard about it? Wondering if there's any crossover advantages in it to add to a ski kit.

But yes, blunt force trauma is the suck.

[summit]

Someone told me there's a new gunshot wound kit that's being touted and recommended for everyone, given the gun violence out there.

Anyone heard about it? Wondering if there's any crossover advantages in it to add to a ski kit.

But yes, blunt force trauma is the suck.

The trauma items I mentioned in the other post ($22 and $77 options) would absolutely supplement your ski first aid kit to fulfill this need for external hemmorhage from gunshots... although gunshot specific ifaks usually have a chest seal which is something I would improvise from bandaging packaging and tape for penetrating chest trauma in a skier/biker since nobody is shooting at me and it shouldn't be a mass casualty.

But I think the biggest thing someone can do who doesn't have WFR/WFA training is take a Stop The Bleed class (1-2 hours, free, see previous long post.

[AKPogue]

Splat, is this what you're talking about?
https://www.revmedx.com/xstat/

I wouldn't see much of need for the above in a backcountry ski kit.

[snapt]

It is hard to reliably asses for the experienced provider in the prehospital setting. It is doubly so in the cold and snow.

The reliable signs and symptoms are late and indicate that is likely severe (meaning you should already have taken action and definitive treatment is bright lights (hospital) and often cold steel (OR)).

Really what you are asking about is what are the earliest signs/symptoms of hemorrhagic shock due to internal bleeding in blunt trauma to the chest/abdomen/pelvis without obvious findings like fracture. While I can tell you classic things like increased heartrate and breathing rate, pale, sweating, rapid appearance of bruising/hematoma/swelling, rigidity over impact site, slow cap refil (check the gums in winter because hands are often cold) etc, these aren't reliable as EARLY indicators... many could also be due to pain... bruising doesn't mean severe internal bleeding (and absence of bruising does not offer any reassurance that internal bleeding is absent)... etc

My Advice:
In a major impact, keep a high index of suspicion combined with a good physical assessment, consideration for the impact forces, and close attention and questioning of how the injured person feels: if they feel anxious, distracted, dizzy, tired, or simply don't feel right, that is enough to suspect significant internal hemorrhage, which is an emergency in an environment where one can do nothing definitive, the injured person can become incapacitated very quickly, and assisted extrication can take hours. Keep reassessing as the adrenaline wears off. If you don't feel right about the injured person, go with your gut!

How someone feels is often the earliest indicator of internal hemorrhage.
It's always better to self-extricate while you still can.
When in doubt, get them out.

I would disagree and argue its pretty easy to asses and even a non provider could be trained:
1: Do they have a strong radial (wrist) pulse, if so they're systolic BP is at least 90 and they have some time, if no we're in trouble.
2: Skin color: if turning ashen we're hypotensive.
3: Check for diophoresis (sweaty/clammy), another sure sign of shock.

In the BC I can potentially treat one corner of the trauma triad so I'm going to focus on keeping somebody warm and getting them out of dodge.

I carry less now the more training I have. I carry pressure dressings and some bandages I can pack with. I make sure I wear a belt I can use as a tourniquet and carry some webbing. Hemostatics aren't proven to really be worth it IMHO. The only airway control I really plan on is recovery positioning.

[summit]

I would disagree and argue its pretty easy to asses and even a non provider could be trained:
1: Do they have a strong radial (wrist) pulse, if so they're systolic BP is at least 90 and they have some time, if no we're in trouble.

1. That radial=90SBP is a load of crap. Twas taught by ATLS years ago and filtered down in the wilderness world, but its wrong. There's plenty of studies showing the 100/80/70/60 2+radial/1+radial/fem/carotid is BS and I've seen it be wrong many times with my own eyes on patients. I've been able to palp radial pulses on a patient with a SBP in the 60s.

2. Difficulty in palping a radial could just mean the patient is pretty cold.

3. Even if it were right "the patient has SBP>90" does not mean that we shouldn't be extricating emergently from the BC if we otherwise have a suspicion of internal hemorrhage... all SBP>90 means is that they aren't yet in PROGRESSIVE hemorrhagic shock, which I could probably tell without a BP because the patient isn't yet laying down, dizzy, and telling me they have an impending feeling of doom. >90 just means you haven't yet reached the "you're fucked if the helo is not en route" stage of hypoperfusion.

2: Skin color: if turning ashen we're hypotensive.

That doesn't fall under early signs. That falls under "you are fucked without a helo" signs.

3: Check for diophoresis (sweaty/clammy), another sure sign of shock.

Diaphoresis can be hard to pick up in the winter BC when people are well covered, maybe its snowing too.
Its presence, initially, can be from adrenaline... and then it wearing off... after that, suspicion that they are in shock...
Its absence does not rule out shock or impending shock.

In the BC I can potentially treat one corner of the trauma triad so I'm going to focus on keeping somebody warm and getting them out of dodge.

Well said!

I carry less now the more training I have. I carry pressure dressings and some bandages I can pack with. I make sure I wear a belt I can use as a tourniquet and carry some webbing. Hemostatics aren't proven to really be worth it IMHO. The only airway control I really plan on is recovery positioning.

I too have carried less and less over the years. That said...

Improvised tourniquets are often ineffective and more likely to cause complications (and plenty of data to show both, I've seen anecdotal examples of a failed belt tourniquet first hand... patient exsanguinated).

Hemostatics lit is mixed with a few studies showing them nonsuperior, but there are plenty showing them superior. What I think is key for the BC is prevention of rebleed during extrication (there is evidence for this) and doubly so if you get the coagulopathy/hypothermia going as the hemostatic agents are able to work despite cold and some coagulopathy (obviously if you are in DIC you are dicked). If you want I'll go dig up the links.

[Dromond]

I’m a total goon when it comes to anything medical and have been meaning to take at least WFA for years. I finally signed up recently and the class is in two weeks. Long overdue!

I also suffered a blunt trauma to the abdomen from a protruding rock while skiing 12 years ago. It split my pancreas in half and caused massive internal bleeding. If I had been far from rescue I likely would have died within a day. Luckily I was in VT, on a blue run, within earshot of a chairlift...

Needless to say, there are so many injuries that could be fixed in a hospital but quickly become lethal in the backcountry. The cold and mobility limitations of winter and snow can really exacerbate this. Realistically, I think it pays to be increasingly cautious the further one gets from civilization. That said, I’m looking forward to starting with some basic first aid training.

[summit]

Just remember that epi doesn't fix the problem, it merely treats/slows down the symptoms until Benadryl can treat the reaction.

Carry Benadryl with your epi.

That is only half right.
Epi is the lifesaver that counters the deadly effects of an anaphylactic reaction, such as airway swelling and low blood pressure.
Benadryl is NOT life saving. It just treats some of the annoying symptoms such as itching. We'll also use an H2 like Pepcid AC.
A corticosteroid like methlyprednisone is an important drug to help shut down the immune overreaction and deal with swelling.

In the BC, anaphylaxis = epipen + 911.

Seriously, SAR will be bringing you more epi (and the other above drugs in IV form) by helicopter, ATV, snowmobile, we'll call USFS for motorized wilderness access because this is a life or limb thing, and we'll use trail runners or crosscountry skiers to go fast if there is no way to fly or motor to you. Will they get there it time? True anaphylaxis is ultra time sensitive and needs to be in the ICU right now.

Epipens should be cheaper now that the patent expired as well.
When I worked as a "guide" we used bottles of epi with a syringe. Packs down smaller and gives you more doses.

That works great! Just remember your dosages and inject it in the thigh muscle like you were trained. Epipen users should know this emergency trick to get an extra dose out of the epipen:

[snapt]

1. That radial=90SBP is a load of crap. Twas taught by ATLS years ago and filtered down in the wilderness world, but its wrong. There's plenty of studies showing the 100/80/70/60 2+radial/1+radial/fem/carotid is BS and I've seen it be wrong many times with my own eyes on patients. I've been able to palp radial pulses on a patient with a SBP in the 60s.

Agree to disagree. The majority of my patient assessments come from initial pulses check, and skin condition. It's pretty damn effective at establishing sick/not sick and determining my transport decisions.

[summit]

Agree to disagree. The majority of my patient assessments come from initial pulses check, and skin condition. It's pretty damn effective at establishing sick/not sick and determining my transport decisions.

I agree with you that if I go up a trail and find a trauma patient without peripheral pulses, ashen, and diaphoretic, I'm thinking "SICK - emergent extrication!" Again, that combination is a late indicator of severe hemorrhage and their absence doesn't rule it out.

I understood the question asked to be how should a partner evaluate someone who crashed in the BC to determine EARLY signs of internal hemorrhage? We don't want the BC skier to wait until someone loses radial pulses, turns ashen, and gets cold cool and clammy before going, "uh-oh, no more toughing it out, time to call 911." They've probably already had other early signs.

On the peripheral pulses vs BP thing, their absence generally concerns me, but their presence doesn't reassure me that BP is acceptable based on my own experience and studies like this.

[Bronco]

[/QUOTE]

Thanks for posting that!

[Abol98]

Just completed a Stop the Bleed class through the hospital I'm affiliated with. They're very general, but on the upside, you can probably develop employer-buy in for having this kind of training, regardless of your job, and take a class during the day. Mine had lots of nurses FTW. Come armed with scenario specific questions - my experience was that the curriculum was built to get civilians through the thing without them fainting, but the facilitators were super excited to work through potential real world scenarios. In my case, I purchased a Cat 7 tourniquet because that's what we train with and stock here, but we also made a list of all the things I carry that could be used in a pinch - Voile straps, arcade stretchy-belt, boot straps, neck buff, etc.

[adrenalated]

This is a great thread, much thanks to all the knowledgable people for their expertise.

I finally took WFA last year and plan on re-upping it every two years from here on out. It's a great value in both time and money for the knowledge you receive in the class.

I am also making it a point to emphasize the importance of first aid and CPR training much more heavily in my avalanche awareness presentations.

Can any of you med folks recommend a good, preassembled first aid kit for backpacking/touring?

From what I can tell most pre-assembled kits are pretty worthless. They include a ton of shit you don't need (tiny bandaids, little packages of OTC medications, etc) and are light on the things you actually do (z-gauze, triangular bandage, tourniquet, etc.) The preassembled kits are OK for people with no medical training to treat minor things, but someone with WFA or above is probably better off ordering stuff ala carte and building the kit up from scratch. Maybe Summit knows of a good preassembled kit though.

[SumJongGuy]

Our scout troop's requiring WFA for all adults going on high adventure hikes. They're also paying half the cost for adults who want to/need to take it.

[WestCoast]

This is a great thread, much thanks to all the knowledgable people for their expertise.

I finally took WFA last year and plan on re-upping it every two years from here on out. It's a great value in both time and money for the knowledge you receive in the class.

I am also making it a point to emphasize the importance of first aid and CPR training much more heavily in my avalanche awareness presentations.



From what I can tell most pre-assembled kits are pretty worthless. They include a ton of shit you don't need (tiny bandaids, little packages of OTC medications, etc) and are light on the things you actually do (z-gauze, triangular bandage, tourniquet, etc.) The preassembled kits are OK for people with no medical training to treat minor things, but someone with WFA or above is probably better off ordering stuff ala carte and building the kit up from scratch. Maybe Summit knows of a good preassembled kit though.

As an advanced medical provider I bring very little into the BC with me. The most important thing is to educate yourself, develop solid assessment skills and learn how to stabilize and arrange an evacuation or self extraction.

That being said, I do bring a tourniquet, Sam splint pelvic sling (on my sled), a needle decompression kit for hemo/pneumo, I do find Celox sponges useful for large lacerations (light anyhow), a few narcotics, athletic tape, I can rig up traction for a broken leg with ski poles and webbing and tourniquet.
Understand what will kill a person and what you can actually do about it is the most important part of your kit. Keep them warm, minimize blood loss, protect the airway, stabilize any long bone fractures and GTFO.

Ps. Just for those reading this thread Epi has almost no role in trauma resuscitations especially by non trained people. A bit of hypotension is ok in trauma. (Push dose pressors aside)


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[PNWbrit]

Maybe Summit knows of a good preassembled kit though.

I'd love to know this too.

Alternatively a concise what to put in your day pack first aid kit.

[Bronco]

Here's my multi day BC first aid kit for 4 people (and what's usually in my pack):

• five 1/4-ounce Nalgene bottles (Oxycodone, Benadryl, baby aspirin, advil, petroleum jelly)
• one 1/2-ounce Tincture of Benzoin
• one 1-ounce Povidoone-iodine Solution (10%)
• one 50 ml Snap top vial with 2-inch roller gauze
• one 12 cc irrigation syringe
• one large safety pin
• one 28 ml Snap top vial with cotton applicators
• four blanket pins
• one 2-inch sterile roller gauze
• one WMTC weatherproof patient SOAP note
• two 2.3- by 2.75 micro-thin film dressings
• two feet of 2-inch flexible medical tape
• two feet of 4-inch flexible medical tape
• two packets of 1/4- by 3-inch Steri-strips
• two packets of 1/4- by 1.5-inch Steri-strips
• two large oval ENGO blister patches (place on footwear)
• two 2nd Skin blister pads (place on skin over blister)
• two scalpal blades (no handle)
• one small trauma shears
• one 3.5-inch forceps
• one sam splint
• one extended range thermometer
• one gripper tweezers
• two pair trauma gloves
• Wilderness Medicine Handbook

Here's my day trip kit when weight is at a premium:
5 oxy pills
10 immodium tabs
10 Advil PM sleeping aid
20 Advil Pain
10 Aspirin headache/chest pain
3 Medium Bandaids
3 Knuckle Bandaids
2 packets of Neosporin
1 packet of 6 steristrips
2 antiseptic towlettes
2 butterfly bandages
3 feet of kinseo tape
1 scalpel blade
tweezers and scissors on small leatherman

Being able to decide what medical situations are most likely to occur on a trip and being prepared for that scenario is a really important skill.

[old goat]

Be sure and include this in your backcountry kit



To dial it back when you're far from help

[mattig]

first of all, thanks for the big knowledge drop. Thinking about this kind of stuff more and more in my old age.

2nd, re: preassembled kits. From what I gather, an ideal pre-assembled kit doesn't exist. Use posts like this and lists comprised by people who know what's up to build your own. Don't forget the multi-tincture pack of betadine! Can't have too much betadine--especially if you've seen the effects of blood poisoning firsthand. Some people are allergic, fwiw.

Some critical pieces of kit that most people don't want to pay for or carry, but that can be of far more value than any first aid item: PLB and AED. Not really practical for everyone to carry an AED every time they go more than a few hours off grid, but it would be ideal. I always carry my ACR PLB now that I have one, but I realize it does me no good if I need the AED, or something to stop persistent bleeding.

My list is similar to the above, but I definitely add xanax. Also be careful with aspirin if it could be a brain bleed and not a heart attack.
If you're going to be multiple days off-grid, and if you've had a serious blood infection from a wound before, talk to your doc about getting some emergency oral antibiotics. Could save your life if you get the red line creeping toward a lymph node.

[PNWbrit]

I definitely add xanax.

Huh?

[cat in january]

I added this to my bc kit last year and thought it was wicked smart so will share.

1 liter titanium pot with smallest snowpeak canister and ultralight stove. Hypothermia is a serious worry in winter bc from a health risk viewpoint imo, especially if you are not moving and night is coming in. Besides the canister and small stove, the pot holds my repair, essentials stuff not likely to be needed including a reflective blanket. Need to preheat stove and canister near body for a few minutes. Often this meets the weight to safety trade off into my pack. Gorilla tape and voile straps in repair kit pull double duty.

Extra heavy small ziplock from amazon holds first aid kit: IB, Benedryl, aspirin, medical tape, couple large bandages, some steristrips, nitrile gloves, chocolate bar. Carry different kit for hut trips, canoe trips, back packing, but one always goes along.

[PNWbrit]

reflective blanket..

Get one of the mylar bivy bags.

[cat in january]

Good point, just have the small reflective lying around

[summit]

old goat's volume knob is the best advice the whole thread

I have yet to see a preassembled FAK that had most of things I wanted and not a bunch of stuff I didn't. This is probably the best preassembled BC FAK I've seen as far as having useful things and not being ridiculously priced (but it has way too much shit, just take half the stuff out of it and add SAM splint you need splinting material). Better yet, build your own kit. I'll paste over my 8oz fa kit from the bike thread in a little. There's a LOT of personal preference in FAKs so preassembled sucks by definition.

MYLAR EMERGENCY BLANKETS/BIVY

It's really easy to cross over your survival gear into your medical gear... that's ok, just think it through. old goat gave some good advice on this already.

On the emergency blanket vs mylar bag thing, here is the deal: those super light silver blankets/bags are fairly useless: fragile as surface hoar, and make an ungodly amount of noise with the slightest breeze. Don't believe me? You paid what, $4? $6? Go try it out in your backyard with some gear and ski boots on and report back.

So at the risk of turning this into a survival gear thread, what you want is a fabric backing with the reflective stuff so it is durable, waterproof, hivis, heat reflective, and useful for packaging a patient.
Here is an 8oz blanket
Here is a 1lb blanket that also can serve as a tarp and has grommets.

The nice thing about blankets is that they are more multipurpose and easier to pack/unpack someone in, like if you need to assess them or they need to pee when you are extricating (or in a snow cave). But it's harder to get them fully sealed up h if just using as a survival bivy.

I've carried this 9oz bivy for years and used it 2-3 times. It's dead now and I need to replace it. You can take it out, use it, and put it back in its bag! it has velcro closures 1/3 of the length and even a velcro foot vent. But try to imagine getting a person inside that with an injured leg?
Here is a 6oz breathable version at the cost of some durability (I haven't tried this one, might try it out though).

Ortovox also makes some very nice survival bivys which I checked out at SIA/OR. These have the same problem as the SOLs if you are trying to stuff a casualty inside.

[old goat]

If you're going to be multiple days off-grid, and if you've had a serious blood infection from a wound before, talk to your doc about getting some emergency oral antibiotics. Could save your life if you get the red line creeping toward a lymph node.

The brit who was trying to solo traverse antarctica a couple of years ago died of peritonitis--maybe a ruptured appendix. Antibiotics might have helped, or maybe a scalpel and a mirror.

[cat in january]

Thanks Summit, yeah I know about the silver blankets are not much good. Have had a tnf bivy for a long time, but I don't carry that on a ski. Blanket is a good suggestion. I also don't carry a SAM in my ski pack as I feel this is something that can be improvised. Agree simple is best.