Understand how to obtain more advanced medical and rescue care at the teaching site, and recognize challenges associated with medical care in remote / aquatic environments
Part of site selection is researching the nearest hospital or critical care facility. You should also take note of nearby trails, fire roads, etc. that could be used for an evacuation should that be necessary. As rescuers, we always ask ourselves the question - what if? Suppose someone with a preexisting back problem slips, falls, and wrenches their back. Let's face it, we are not properly equipped to transport someone with a C-Spine injury any significant distance. This is especially the case in more wilderness settings like canyons or riversides with thick underbrush. This is why we should pack a cell phone in a waterproof container - to call for help should that be necessary. I also like to pack two copies of a patient assessment form with a pencil in my first aid kit - one stays onsite and the other goes with the runners.
Another major challenge is getting the help and equipment you need (like a backboard and trained personnel). This is where the SOAP form and practice play a vital role. Practice your pitch before running for help. You need to convince that 911 operator you know what you are talking about, else they will need to send an inexperienced scout with a radio.
We boat in some pretty remote areas. Although it is easy for us to head downstream with our boats, picture how difficult it can be traversing up a stream bank with heavy equipment. Helicopter landing sites are not typically close by either. Let's face it, getting the professionals to your accident site can be quite challenging and time consuming. You will also need to provide some sort of weather protection in the meantime to prevent hypothermia.
First Aid considerations - boating
Introduction & Need for Training
Instructors, trip leaders, and participants need to mitigate risks for any outdoor activities. The best risk reduction measures are trip planning and training. I suspect that none of us with expensive paddling experience hasn't seen some sort of medical issue take place over the years. This is a major reason the ACA requires proof of suitable first aid training when requesting liability insurance. All first aid certification courses these days require CPR/AED training. After that, they specialize a bit. At the entry level we have basic (urban) first aid. This level of training may make sense if you can guarantee professional care can reach you within an hour without much difficulty. A reasonable example would be a roadside park & play near most cities. Truth be told, it's hard to imagine a 5 hour class would be suitable for most of our paddling trips. The next level of training is Wilderness First Aid (WFA). This class takes one weekend and covers the basic first aid needs for weekend outdoor trips. For most of us, this is the minimum level of training we should take. Advanced Wilderness First Aid (AWFA) takes about one week and provides more training on stabilization and evacuation. Planning overnight trips, AWFA is more suitable. Wilderness First Responder (WFR) takes two full weeks and is far more comprehensive. Anyone leading extended trips in the wilderness need this level of training. Many professional outfitters require WFR certification for their staff. Training/certifications also have an expiration date - usually two years. Each Winter (off season), check your certification card and recertify as necessary.
Training and planning are essential but sometimes you need tools to work with. This is where a First Aid Kit comes into play. Commercial first aid kits have a wide variety bandages, implements, and medicines. Some are very minimalistic and hardly cover situations we have seen on river trips. Others are very expensive and seem to mimic a medical clinic. You can make your own kit and this is perhaps the best route as many pre-made kits are more targeted to land based activities. Here is a list of issues I have seen or heard of on river trips:
- Cuts, abrasions, splinters
- Headaches (even hang-over's)
- Hypothermia & Hyperthermia
- Dehydration & cramping
- Eye injuries
- Sprains & fractures
- Spinal injury
- Bee, snake, tick, etc. bites
- Burns & Blisters
- Digestion track issues
- Diabetes issues
Before we think about what tools and supplies we may need for the above issues, let's think about how we are going to carry this stuff. First and foremost, most first supplies must be kept dry. It is nice if we can easily access the contents without spilling all over the ground as well. Pelican containers are rectangular, crush proof, and water tight. It's easy to open the lid and inspect most of the contents. Two downsides are the price and you need to be careful when closing to make certain none of those plastic baggies get between the rubber seal. A one quart Nalgene wide mouth bottle is very inexpensive, crush proof, and water tight. The major downsides are limited size and having to dump everything to get at what you need. Dry bags (most call these damp bags) don't provide crush protection but are very spacious. When using these, everything needs to be secured in high quality zip lock bags. Some first aid kit contents like a Sam Splint cab be stored separately. One variety of zip lock bags that are very useful are made by AlokSak. These are very inexpensive and approved for diving down to 200'.
When administering first aid, you need some basic protection. Common items are Nitrile gloves, CPR mask, and eye protection. Few first aid kits carry eye protection. I stow common swim goggles in one of my dry bags, sometimes I wear them. These are great for practicing rolls if you wear contact lenses. They also come in handy when someone drops gear in the water and you need to try and retrieve that gear. Another great use is eye protection with gauze. A bio-hazard bag (small sturdy plastic bag) and a bottle of hand sanitizer.
Let's take a closer look at the above list and determine our needs:
- Cuts, abrasions, splinters: Band-aids assortment, sterile gauze pads & rolls - 4", triangular bandage, ace wrap, vet wrap (sticks to itself even when wet), 2" silk tape (hypo-allergenic tape which sticks to wet skin), safety pins, Tincture of Benzoin (Makes dressings adhere well)
- Hypothermia & Hyperthermia: Water! Carry at least a quart., Honey packets or Glucose
- Dehydration & cramping: Water
- Eye injuries: See cuts & abrasions, Saline contact solution
- Blisters: Second skin blister pads
These are items we may use more than once or are used for special purposes:
- Cuts, abrasions, splinters: Trauma shears, tweezers, irrigation syringe and splash shield (crucial), 1.5" hypodermic needle, combat gauze (somewhat expensive but could be a real life saver)
- Headaches (even hang-over's)
- Hypothermia & Hyperthermia: Space blanket bivvy, insulation, tarp or large plastic sheet, neoprene dive hood or insulated skull cap, water proof matches
- Eye injuries - Swim goggles
- Sprains & fractures: Duct tape & cord for splints, Sam Splint, instant ice compress (optional)
- Spinal injury & other serious injuries: Pen/pencil & multiple SOAP notes, digital thermometer
- Bee, snake, tick, etc. bites: Tick twister
- Miscellaneous: Small non-climbing carabineers, small first aid guide, small light
As always, pay close attention to your special needs. If you have an underlying medical condition such as severe allergies, make certain you bring your personal medicine/s and inform someone else in the group. Medicines have certain shelf lives before their effectiveness degrades. Every Winter (off season), empty out all of your medicines, inspect expiration dates, and order replacements. A first aid kit inventory sheet is quite valuable and strongly recommended.
Whenever anyone uses the kit, they should ad their name and date and decrement the count of any used supplies/medicines. Medicines should be purchased in individually marked packets which are easy to identify and have clear expiration dates. These packets typically provide dosage guidance as well. There are many online sites that sell medicines for restocking your kit at reasonable prices. For most, the one item in your kit that will get the heaviest usage is Ibuprofen (AKA: Vitamin I). I carry an additional small bottle and place in the easiest to access part of my kit. We seldom need to access these medicines so place all of them in one bomb proof zip lock bag like AlokSak. Brand names in parenthesis are simply provided as examples, nearly all have generic equivalents which are less expensive.
- Cuts, abrasions, splinters: Triple Antibiotic
- Headaches (even hang-over's): See pain management
- Hypothermia & Hyperthermia: Honey Packets
- Dehydration & cramping: Electrolytes (Pedialyte)
- Bee, snake, tick, etc. bites: Diphenhydramine (Benadryl), Hydrocortisone (Cortisone)
- Burns & Blisters: Burn Gel
- Digestion track issues: Aluminum-Magnesium Hydroxide (Alamag, Maalox), Bismuth (Pepto-Bismol, Diotame), Loperamide (Imodium, Kaopectate, Diamode)
- Pain management, inflammation: Aspirin, Acetaminophen (Tylenol), Ibuprofen (Advil, Motrin), Naproxen (Aleve)
- Diabetes issues: Oral Glucose (Cake Icing, Honey Packets)
- Miscellaneous: Decongestant - Pseudoephedrine (Sudafed)
These are only suggestions for items to consider in first aid kits, many will have different requirements (and levels of training). A good practice is having two persons bring first aid kits on your trips - each will pack different items and that diversity can be quite valuable. Using a risk management approach as above is a good way ensure your kit has what is needed should an incident take place. Your contents will vary over the years as you encounter new situations, this is why I plan to add a small bottle of saline solution to my kit based on several participants scratching their eyes - water worked but saline solution and cool shades are even better. First Aid techniques and special gear evolve over time, thus the need for retraining. If time and budgeting are available, consider pursuing the next higher certification level.
Hypothermia - I'm Cold
Hypothermia is not that uncommon in whitewater boating. Milder forms of hypothermia can even occur on a hot summer day (as many whom have paddled the Savage River and swam have discovered). Hypothermia in simple terms is when the body's core temperature drops and it doesn't take too much of a drop to cause significant problems.
Here are the various stages of hypothermia:
- Stage 1: Body temperature drops just a degree of two. You will notice that the person is shivering and may have blue lips. Take these warning signals seriously. Check the persons clothing for suitability. Provide extra insulating layers and wind protection. I really like a skull cap or storm hood to add warmth really fast. If you have warm liquids like soup, tea, or coffee - offer it to the victim. If you have been sitting eating lunch, get back to paddling to get the blood flowing again. If these steps are not feasible, consider walking out with the person. Whatever you do, don't ignore these symptoms.
- Stage 2: Body temperature drops 2 - 4 degrees. This is starting to get very serious. The body in an effort to save itself shuts down blood flow to the extremities to concentrate on core protection. The muscles stop working in this stage and that means they can't even hold their paddle properly. Many start acting rather silly in this stage of hypothermia and are often totally unaware on where they are at. If someone is in this condition, they don't belong on the river - period! You need to get them dry and warm pronto. You also need to evacuate them and get them to a hospital for further evaluation. In the mean time, wrap in anything that provides significant insulation like a sleeping bag, blankets, space blanket, spare clothing, etc.
- Stage 3: Body temperature drops roughly 10 degrees. This takes some time to occur and the body basically shuts down as much as possible. Heart rate and breathing slow considerably in this stage. You must get the victim to a hospital or ambulance ASAP!
Prevention is rather simple:
- Check the weather and water temperatures prior and during the trip.
- Dress appropriately
- Dress in layers, bring spare clothing
- Look for hypothermia signals on your paddling buddies
- When paddling in cold weather, paddle at least one grade lower than your normal runs
- Remember the 50-50 rule: if either the water temperature or the wind chill factor is 50° or lower - be prepared for hypothermia
Hyperthermia - I'm Hot
Hyperthermia is the exact opposite of hypothermia,, the body gets too hot. Other terms for hyperthermia is heat exhaustion (beginning stage) or heat stroke (advanced stage). This isn't as common as hypothermia in paddling but does occur (I know from firsthand experience). Initially, you begin to sweat profusely which is the bodies cooling system. Dehydration then takes place. Muscles cramps are really common and they really smart! You may get a splitting head ache, tire easily, vomit, and find your heart racing. Believe it or not, you may shiver periodically. The body is doing everything it can to drop your core temperature. You need to take care of this now! In mild forms, try rolling or use your helmet to pour water on your head. Consider taking a break and completely immerse your body in the water. Water does a great job at transferring heat from the body. Take off excess clothing. By all means, start drinking - you need to replace lost fluids. Water is best but sometimes you also need to replace the salts as well. Dilute Gatorade is great at quickly replacing your vital salts. I always take a bottle with me and drink throughout the day. If the situation is serious, take the person to a hospital immediately.
- Dress suitably, clothing that aids in rapid evaporation is ideal
- Drink early and often
- Monitor your urine. Ideally, it should be clear. If it is a dark yellow, you are dehydrated.
- Consider dilute Gatorade to replace salts
- Get wet. This is a great time to practice your rolls.
- Eat lunch in the shade
Rescuers need to be able to handle common medical problems including hypothermia, drowning, cuts and scrapes, and dislocations/broken bones
Besides training, several people in each paddling party should carry a First Aid Kit of some sort. Hypothermia, at least the initial stages isn't all that uncommon on Spring, Fall, and Winter trips. Dress in layers and dress for full immersion, even if you never swim. When paddling with less experienced boaters, take a close look at their gear for suitability. Keep an eye out for them during the trip as well and be prepared to offer one of your outer layers if you can do so safely. Here is a decent article on Hypothermia. Drowning is another issue you may need to deal with. Don't take ANY chances. Even if the victim appears to recover 100%, insist they visit a hospital for a 24-hour evaluation period to avoid any chance of a Near Drowning death. Cuts and scrapes are pretty easy to deal with if you have a decent First Aid Kit, these typically are not life threatening. Dislocations are more difficult and definitely fall into the "Do No Harm" category. If you don't know how to properly reduce a dislocation - don't try! A better course of action is to immobilize and get them to a hospital ASAP. Broken bones need immobilization and proper evacuation. A good first aid course covers all of these common issues and a great deal more. Here is a comprehensive article on this subject: First Aid considerations - boating.
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