The ABCs: Medical Emergencies on the Trail
BY LAURA ZARUBA

It is a gorgeous day in October—honestly, drop-dead gorgeous. The kind of day that makes you feel lucky to be alive. I am out on a solo run up Longs Peak, joined by dozens of smiling hikers. The early morning’s breezes have picked up to 50-60mph winds (I can tell by the angle I need to lean to stay upright), and by afternoon the gusts have notched up even higher.

Unbelievably, in a section called the Narrows, a young guy in front of me gets literally lifted by a gust, and dropped 40 feet off the cliffy, narrow trail. I watch in horror. The first thing that hits is his head.

The first thing he says to me when I get to him is, “Let me die.” Oh, shit! The ol’ fight or flight adrenaline kicks in, followed shortly by a heightened awareness in my body and a focusing of my mind.

The assessments begin. Is the scene safe? Was anyone else hurt? How serious is the injury? (Very. This is a rapid assessment and transport, ideally.) What are the immediate threats to this poor guy’s life? (I tell myself I am not going to let him die! At the same time, I do not tell him, “Everything will be okay.”) What am I carrying for first aid? And what do I need to plan for as this progresses?

I tell him my name and I quickly get his— it’s Scott—as well as his permission to help, as I stabilize his spine by putting my hand on his head. There is obviously a mechanism of injury (MOI) for a spinal cord injury. Luckily, he did not lose consciousness.

I then start the checklist of life threats with the mnemonic (memory aids are great) ABCDE. A-Airway: his screaming only assures he has an airway now. I also check for anything in his mouth. B-Breathing: “Is it painful to take a deep breath?” I ask, while my hands feel for broken ribs. C-Circulation (as in, is his heart beating, but also, is he bleeding so heavily that he is going to die from blood volume loss?): Sure looks like it; that landing on his head fractured his skull. There is massive bleeding and matter pushing out from a hole in the skull.

Stop and fix, if you find anything in this initial assessment. I use a fleece shirt that was tied around my waist to make a bulky dressing and apply diffuse pressure to his head.

D-Disability: Others have arrived to help me stabilize his spine. He is frightened, combative, and wants to move. We are in position to roll him, with his spine stabilized, in case he vomits. Aspirating vomit has a high mortality rate. E-Environment/Expose: Look at all life-threatening wounds, at skin level, and protect from the environment. We carefully get this guy on an insulated pad someone in the group was carrying and put more clothing on him.

I am thankful for my Wilderness First Responder (WFR) training—a little understanding to help me remember what to do and what not to do. I am also considering critical questions I need to ask Scott, if and before he loses consciousness. Any pertinent medical conditions—seizures, diabetes, asthma? Any medications? Severe allergies? What really happened—do I know the wind knocked him or did something cause him to black out?

At ten days, a WFR course is a huge time commitment, and worth every hour. A lighter alternative is a WFA (Wilderness First Aid) course, which is usually three days.

Anytime you are more than an hour away from definitive medical care, you are in a wilderness medicine situation. You now have to deal with the management of the patient over time in an environment that can create further problems. The time element plays into decisions such as whether to reduce a dislocation, how long to attempt CPR, and who gets the call for the helicopter. (Note: When you are working as a backcountry trip leader, medical protocols given by a medical advisor also play a part in your decisions.)

So how much medical training should people have, if they are runners, climbers, hikers, and other outdoorsy folks who could become lay rescuers at any time? Whether you run the alleys by your local hospital or hike hours into the backcountry, get as much as you can. You never know what can go wrong. (Not to sound like Mom, but it is true.) Some situations I have helped with, as an employed outdoor instructor or guide or as a good Samaritan, include: reducing a shoulder dislocation; coaching an asthmatic with the inhaler; treating for shock (you cannot stop shock until the root cause has been addressed); rubbing sugar into the gums of an unconscious diabetic; and giving salty snacks, but no additional water, to a runner who had hyponatremia, not heat exhaustion.

Currently I am required to be a WFR, but I took my first Wilderness EMT course in the ’80s, just for my knowledge. My ideal comfort zone is being trained within an inch of my life. I’m just more comfortable being somewhat prepared. And to me being prepared includes taking courses and practicing scenarios, frequently.

I also think of my WFR training as part of my first aid kit. After all, your first aid kit is not only the tangible stuff you carry, but also your decision-making mind. As for what to actually carry, the first suggestion is: only what you know how to use. The second deciding factor is: how much fun do you want to have? Or the flip: how uncomfortable do you want to be? It is similar to the question you ask about the gear you carry, balancing going light for efficiency with personal choices of risk and comfort. Start with a commercially prepared kit and make adjustments. Keep track of additional things you wish you had and things you wish you had more of. Don’t forget to pack a little creativity. And know your ABCDEs by heart. By heart—maybe a bad pun, but here’s your motivation for at least learning CPR.

You can effectively learn CPR, including practice time on manikins, in only three hours. The American Heart Association simplified CPR instruction in 2005. This also improved retention and competency. I teach CPR classes to all kinds of lay rescuers—volunteers working at aid stations, pacers/crew for trail runners, grandparents babysitting when parents are out training, personal trainers, coaches—all of whom are amazed at the simplifications.

The emphasis is now on chest compressions and the ratio of compressions to breaths is 30:2 for all victims. (A recent news flash of a study recommending compressions only applies strictly to people who suddenly collapse from a heart attack. Victims of drowning, drug overdose, anaphylaxis, lung injury, to name just a few still require conventional CPR.)

There are some special considerations for CPR in the backcountry. For example, you should not do compressions on severely hypothermic patients, because you could trigger an abnormal heart rhythm, and you need to do prolonged rescue breathing, without compressions, on lightning-strike victims. I did rescue breathing for Scott occasionally during the overnight wait for the helicopter (and yes, he survived this head injury).

Amazingly, this same research study  also reported that three-quarters of bystanders who observed a heart attack in a stranger declined to perform CPR because they feared infectious diseases. I carry a face shield on my key ring. If you are willing to carry even more, a facemask with a one-way valve will provide a better barrier.

I have heard people play devil’s advocate by mentioning the grim chances of surviving cardiac arrest in the backcountry (or front country for that matter). I let fighting against the odds be part of my motivation. And we have all heard about situations where CPR did save a life.

The devil is being truthful about some cardiac victims needing an automatic external defibrillator (AED). You will learn to use an AED in a CPR course.

Do you need motivation for stepping in to help? I tend to be one of those people who rush in, and my challenge is to stop and think about scene safety first. Here are some other possible motivations: You won’t be bored. There is drama in trauma. As Howard Donner, a volunteer MD at the Denali medical tent, says, “It’s kind of fun, but different” (as told by Jon Krakauer in Eiger Dreams). It’s really uncomfortable to feel helpless. Trust me, this is real physical and emotional pain.