AAA,BB,CCC

It should be understood that these techniques are designed to give the reader a background of what the standards of emergency medicine and the rationale to these techniques.  Sierra Sasquatch® takes no responsibilty if this information is inferred/practiced incorrectly resulting in harm to anyone. The main purpose of this information is to stimulate thinking and creativity in times of an medical emergency when professional services are unavailable. 

 

     Hiking in the Sierra Nevada back country can be a very beautiful and spiritual time. It can also be a time when you can get hurt far away from help or communication. What is one to do?  Let's start with our perception of how you view the wilderness.  The old saying of  "One man's trash is another man's treasure" can be applied here with the perception of how you view the wilderness.  To some it can feel like a very hostile,   inhospitable  and unforgiving place and to others an area of opportunity. It all comes down to your ability to adapt to your environment, so what I say here is not the only the materials that can be used. What I would like for you to take from this are ideas on how you can create splints, clean, close, dress and manage wounds with the materials you have around you whether you brought it in ie.. backpack, Horse, snowmobile, 4x4, quad, plane or whatever brought you into those circumstances. 

 

     Let's start with the first step with the first step when you come upon someone in need of medical assistance. It can be broken down into the ABC's, actually is is more like AAA,BB,CCC.

 

A-Assess the situation

A-Airway

A-Alert

B-Barriers

B-Breathing

C-Circulation

C-Cervical Spine

C-Cover and Protect

 

A1. Assess the situation-

     Before going into any area and rendering aid make sure it is safe for you to proceed. Ensure that any further danger is not present such as rockfalls, avalanches, dangerous animals, waterways, or percarious positions like a tree hanging over a cliff.  Do not allow yourself to become part of the problem by not assessing the situation first.  By first assessing the situation prior to any action can prevent further injury to the victim or exacerbating the problem by creating more problems like rockfalls from approaching from above or removing an impaling object thus removing the finger from the dam, so to speak. Jumping into raging rapids would also not be helpful for the survival of you or the victim. So assessing the best possible way of helping someone in need without sacrificing yourself is the first and most crucial step of the ABC's. Once upon the victim a quick assessment must be made to determine what is the most critical injuries. An airway is important to establish breathing to circulate oxygenated blood however it is useless it the pt is bleeding out rapidly. I have been taught for decades the order of resuscitation is the ABC's.  Studies and data gathered from previous practices are now showing the order is now CAB's. I will get  into that a little bit later. 

 

A2.- Airway-

     A non-spontaneous airway on an unconscious person could be stimulated to being spontaneous just by positioning the head to open the airway (certain circumstances require a specific technique of opening an airway which I will get into later).  By speaking out loudly or providing tacitile stimulation to the hands or feet with simple taps can also be helpful. If this does not work a pinch while speaking their name loudly might just be enough to spark a response.  Be aware of just how hard you are pinching since adrenaline could be surging through your veins at this time.  It should be understood that given the circumstances of being in the wild and for the ability for someone to be fit/young enough to be out there, most cardiac events are created by lack of oxygen (hypoxia).  If there is no response then immediate action should be taken to determine if the victim is breathing which cannot be possible without an open airway.  If the victim is face down then they should be rolled over as one unit, head shoulders, torso, legs (log roll) to prevent any further damage should they have any preexisting spinal injuries unknown to you at this time.   By turning your head in the direction of their feet and placing your ear by their mouth you can look, listen, and feel for the movement of air exchange by feeling and hearing breath sounds as well as watching the chest rise and fall during inspiration and expiration. If the victim is laying on their back their toungue might be closing their airway then one way of opening up the airway is by titling the head back in a position to align their airway (you will hear the exchange of air when done correctly). If there is suspicion of a neck injury (fall) then a jaw thrust should be used. This is done by pulling the Ramus (back of the jaw) forward until you hear the exchange of air. This can be done very easily since they should be in a more relaxed state.  Care must be used not to move the neck with this manuever. A collar can be placed once an airway is established to protect the neck from any further injury. You can also create a collar with clothing, blankets or anything that will keep the head from moving by bracing both sides of the head and either taping or roping into place.  Once an airway is established circulation should be checked.  This is very important since oxygentated air is useless if it does not get to areas where it is needed mainly the brain. The brain can only tolerate about 6 minutes of absence of oxygen. Getting the victim to medical facilities should be your ultimate goal with the management of injuries your immediate goal. 

     If the victim is unconscious when transporting it might become necessary to create a way to keep the tongue from falling back into the throat closing the airway. Most of todays backpack have a hydration system. You can cut a measured peice of the tubing (measure from the pt tip of nose to earlobe, give yourself enough tube so you can anchor it with tape to the outside of their face), and inserting it into one side of the notril. Make sure you lubricate the tube prior to insertion with a jelly or other nontoxic lubricating substance (chapstick could even work in a pinch even your own saliva). If you find resistance try twisting the tube as you slowly reinsert, if there is still resistance or blood is visible then try the other nostril if you still have problems then discontinue.  There are other ways of maintaining an airway during transport of an unconscious person, so let's try another idea.                

     Another way of maintaining an airway is to anchor the toungue forward to prevent further blockage using safety pins on both sides of the tongue and attaching a string through the pins  to anchor on a shirt button/zipper or some other point to prevent the tongue from closing off  the airway. If safety pins are not availble then fishing hooks or any type of wire to anchor the tounge out of the airway is useful. This may sound barbaric or even cruel but it is far better than death through asphyxiation. Some people say "Well what if they wake up while your doing this?" If they awake in the process then that means that their relflexes have returned to keep an open protected airway.......problem solved. 

 

A3.- Alert

     Onceyou have determined that there is a medical emergency try to alert anyone around you to contact emergency services. In the back country that might not be possible however there are companies that use GPS services to notify Search and Rescue if the need ever arises while too distant for help. There are many different types GPS emergency locators and I recomment that you look into them. It's cheap compared to your life. If there is no one around then look around to see what you could burn to create a large plume of smoke. The rubber on tires works well as well as any sort of petroleum based parts. Be creative do an inventory of what you have around you. Sometimes that is what you need to spark an idea. 

 

B1.- Barriers-

     They say that you really don't know your friends until you know your friends and contracting an infectious disease from helping them out is not the time to find out. People will not reveal very personal problems to just anyone for fear of judgement so please keep this in mind.  In the Operating Room we practice standard precautions treating everyone as if they have an infectious disease because it is not the ones you know about, but the ones you don't know about. Gloves should be part of your outdoor gear. It is estimated that 2 billion people are infected with Hepatitis B and 350 milllion of them will never rid themselves of this disease. Cutting  the middle and ring fingertips on a glove and placing them in the mouth of the victim while using the cuff to blow in can be a barrier just as a hole cut in the bottom of a sandwich bag can also be used as a barrier. Just about any flexible impervious material can be modified as a barrier so be creative.

 

B2- Breathing-

     Once you have established a patent airway and the victim does not breathe spontaneously then rescue breathing should be considered. The reason I say "consider" is that statistics has shown that the chances of bringing a person back from an event so traumatic in the back country with rescue breathing is very remote. With that said the first responder must make a decision how long to attempt rescue breathing and also if there are other victims  they can help. If the rescuer decides to begin rescue breathing then there should be a time limit of around 30 minutes. It is not only a very remote chance of restoring breathing but it can  also be very emotionally and physically taxing. The exception to this is cold water injuries (hypothermia). Victims whose body temperature has been drastically lowered quickly (the lowest recorded temperature on a human was 56.7F).

 

Story

     The lowest temperature recorded was Dr. Anna Bangenholm, a Radiologist studying to be an orthopedic surgeon, was out skiing in May of 1999 in the Kjolen Mountain Range. While skiing with some friends she fell forward and broke through the ice covering of a  stream.  She fought to free herself with the help of her companions for 40 minutes unti her body went limp, it was at this point that her heart stopped and it would be another 40 minutes before rescuers could bring her out,  she was flown to Tromoso University Hospital.  Two hours had passed since Anna's heart had beaten. Her temperature had reached a record low of 57.6 F.   Anna was taken to the Operating Theatre where she was hooked up to a bypass machine that warmed her up slowly.  After 9 hours and more than 100 Dr's and Nurses working on her she was brought back to life, but how much damage did the lack of oxygen due to her brain?  Once she was brought back she would spend another 35 days on life support and spend another two months in ICU to recuperate from temporary paralysis as well as kidney and digestive problems. Although she had not suffered any brain damage she does suffer from severe nerve damage to her hands making daily activities difficult as well as continuing the Orthopedic Program.  Open heart surgeons have cooled pts down with slush on the heart to buy them time when bypassing damaged vessels with very little if any ill effects. It was common practice when I did Open Heart in the mid 90's. Today Anna works part time in the medical field and although she cannot ride her bike because of nerve damage she has returned to skiing.  In Norway there is a saying "Your not dead until you are cold and dead".

 

Circulation-

     Circulation is a very important part  of saving a life. You must determine if a victim will succumb to bleeding to death over hypoxia. Determining bleeding site and type of vessel and quality of bleeding  should help in prioritizing which should be attended to first. The head is very vascular and bleeds much but a partially severed femoral artey would take precedence because of th greater volume. The vascularity of the scalp would make it appear to be more important but assessing the quality of the bleed ( estimate how much blood loss per 30 sec) as well as location ( example.. finger vs neck).  An artery that is partially severed will keep the vessel open allowing it to bleed unimpeded as opposed to a completely cut vessel which can contract into the muscle providing pressure. In recent years the ABC's of CPR has been turned over on its head.  It has only been through studies and data that the American Heart Association (AHA) has changed their thinking from ABC's (Airway, Breathing,Circulation) to CAB's (Circulation, Airway, Breathing), putting circulation as the first responders main priority. Oxygenated blood is useles if it does not get to the parts of the body where it is needed mainly the brain. The new data has shown that quality compressions have decreased the mortality rates. Translation- If providing chest compressions, hard and fast is best for good perfusion. You might crack a rib but that won't kill them as fast as lack of perfusion. 

 

Treatment-

     Direct pressure has always been the gold standard and will work on the majority of bleeding injuries with about 10-15 minutes of continuous pressure. You can apply a pressure dressing by using any sort of cloth, at this point it does not really matter if it is dirty or not, infection will kill them as fast as loss of blood. If the bandage becomes soaked with blood then just add more bandages, do not remove soaked bandage since it could dislodge the blood clot. There are very few situations where a tourniquet would be indicated and requires advanced skills to apply and manage so I will not cover it.

 

Impalement-

     If the victim is impaled by an object like a stick the object shoud be anchored into place. By pulling the object out could release any pressure could of been applying to the bleeding vessel.  It is best to trim as much of the object off and anchor in place with clothing and/or tape. 

 

Feel the Skin-

     Is the skin warm and pink or cold and clammy? When the body diverts circulation to the more important organs it will sacrifice the skin's perfusion to maintain more vital organs like the brain. Drinking alcohol and hand warmers actually robs heat from the body's core through dilation of the vessels on the surface of the skin. The skin is the body's thermostat so if your skin feels warm you feel warm however, it is a false sense of warmth brining core body heat to the surface of the skin to be dissapated into the surrounding environment.  Intoxicated people are actually harder to warm up because they are constantly ridding themselves of heat through the dilation of their blood vessels even though they may state that they are warm. 

 

Pulses-

      Pulses are vital to assessing the body's perfusion.  Blood pressure helps determine how well the body is being perfused. The farther away from the heart you feel a pulse the better your perfusion the greater the blood pressure. Determining the systolic (heart beats/top number) will help you undertand how much circulation is reaching the parts of the body farthest from the heart which tells you how well the body is being perfused.  In order for a pulse to be felt the blood pressure has to be at a certain level. Where it is felt tells you what the minimum pressure has to be to feel that pulse, this  can be correlated to perfusion. The following are three landmark areas to check for a pulse and what the minimum diastolic blood pressure would be needed to feel that pulse in that spot. 

 

Carotid-

     From the side closest to you palpate the trachea and slide your fingers towards you going down the trachea as far as you can between the muscle and trachea.  A pulse should be felt here and can be felt on either side but it is not recommended you palpate both sides of a conscious person simultaneously which might cause of fainting episode. If a pulse can be felt here you diastolic blood pressure is at least 70mmHg.

 

Femoral-

     This pulse can be felt within the fold between the groin and thigh. You might have to open their legs a little or even do some digging to be able to feel the pulse. You will find greater difficulty  in the more of the heavier population. If you feel a pulse here your diastolic pressure is at least 80mmHg.

 

Radial-

     Starting from the thumb side (radial) underside of the wrist start palpating from the outside and work your way inward until you reach the first groove. Within the groove you should feel a pulse. Make sure that the hand is in a non-flexed (neutral) position to be able to reach the radial artery.  If you feel a pulse here than your diastolic pressure is at least 90 mmHg.

 

Chest Compressions-

     Stastistics have sadly shown that the likelihood of restoring cardiac rythmn to a victim who has suffered enough trauma that their heart has stopped has a poor chance of recovery in the wild. A rescuer must keep this in mind prior to starting CPR.  It was once thought that when you start CPR you should never stop until physically unable to do so. Studies have shown that if a rythmn is not established within 10-15 minutes the chances are almost nil of returning to a normal sinus rythmn. It is safe to assume that if there is no response after 30 minutes of CPR the recuer should stop. The only exception to this is when the victim is extremely hypothermic.  As in the case of Anna people can return from a sustained abscence of a heartbeat or breathing if they are in a hypothermic state. Chest compressions should be 2 inches deep and around 100 per minute (it is around the same pace as the song Staying Alive by the Bee Gees). Continue to give compressions with very little interruptions. Don't worry about the compression to breath ratio but do try to give rescue breaths at some interval. There is actually some passive breathing created by compressing the chest. Your goal is to perfuse the brain and vital organs and that can only be done with continuous compressions. It takes several compressions for an effective perfusion level, every interruptions drops that level so it is vital to maintain compressions.  

 

Cervical Spine

     If there is a suspected injury to the spinal cord then precautions should be taken to ensure no further damage is done. Further damage could cause permanent damage or even death. The neck should be immobilized to prevent further damage when moving. The head, neck, torso, pelvis and legs should move as one unit when moving (log roll). If the vicitm was involved in a fall it should be assumed that there is a neck injury. Imobilizing the head with blankets or clothing and taping or roping in place is recommended.  Here is a list of possible signs and symptoms that should be considered when assessing for a spinal cord injury. 

 

*Unconsciousness

*Altered level of consciousness

*Head injury or had fallen on head

*Any sort of fall

*Complains of loss of feeling or unable to move extremities. 

*Altered sensation to extremities

*Numbness, weakness or tingling to extremities

*Pain or tenderness anywhere along the spine. 

*Any symptoms to extremities without direct trauma to them.

*Shock

*Another injury that is so painful that it distracts them from the pain in         their neck, examples are:  Femur or Pelvis fractures, broken ribs or               dislocations of the shoulder and hips. 

 

Cover and Protect-

     Keep them warm and protect them from exposure. The ground will rob them of heat so ensure there are barriers of warmth below and above them and in loose layers. Remove wet clothing, it is better to be naked than in wet clothing. Give warm fluids if possible. Use your own body heat if there is no other source of warmth. If in a hot environment shade them and loosen clothing.  Hydrate and keep cool by wetting areas where vessels are close to the skin such as the neck, armpits, and groin.  These sites can also be used to help warm up the body by applying warmth to these area since blood  vessels are closer to the surface at these sites. If in a dangerous area move them to a safer location keeping in mind spine immobilization when applicable. Immobilize joints above and below break with a splint. Cover open fractures.

 

Treat for Shock-

The main signs of shock is cold and clammy as well as pale. There are many different types of shock and all can be treated differently. A common symptom between all of them is a drop in blood pressure threatening the survival of vital organs. It is because of this threat that their feet and legs should be elevated just above head level for perfusion of the brain. Warm the pt with blankets ensuring that there is a barrier between them and the ground. If no blanket then body heat will work.  Loosen clothing provide comfort, reassure and do not give fluids for risk of aspiration if they go unconscious. 

 

 

     Once the more obvious injuries are tended to take the time to do a complete head to toe assessment. It does not matter whether you start from the head or toe as long as you do not miss any area of the body looking for foreign objects, pain,swelling, bleeding, cuts or anything out of the ordinary. We will start from the head. Feel the head for any foreign objects cuts or bleeding as well as bumps or irregular areas. Move to the ears neck then the throat and chest. The throat should be centered (if to one side is an indication of a serious problem). Check the collar bone and feel the chest for crunching, this could be an indicator of broken ribs. The stomach should be soft and non tender to the touch. Check the shoulders and move down both arms, comparing limbs  is a good way to check for irregularities as well as comparing one side from the other. Check the pelvis and go down both legs to both feet.  Shoes can be put back on after assessment of the feet. The back of the body should be assessed in the same manner. Care should be taken if there is suspected spinal injury by log rolling them.  If possible stay in place and wait for help if not move in the most stable way possible. If a cold injury be very careful with transporting since jostling a pt around could cause and arrythmia. 

  

Bringing it all together

 

    -When you come upon an injured victim make sure the environment is         safe for yourself and the victim to give aid, don't become part of the           problem. 

    -Assess what is the most life threatening problem. Breathing is                     important but severe blood loss takes precendence.

    -Establish and airway. A supsected neck injury would require a jaw               thrust manuever over a head tilt chin lift. Remove any debris that might       be blocking the airway ie teeth, dirt, blood.

    -Sound the alarm. Yelling for help a whistle having another get help.            The sooner you can get them to a hospital the better the outcome.

    -Attempt rescue breathing but remember the odds of returning to                 spontaneous breathing. Consider ceasing rescue breaths after 30               minutes.

    -If giving chest compressions give them deep (2inches) and fast 100 per       min. Remember the song "Staying Alive" Perfusion is Paramount. 

    -Direct pressure 10-15 minutes works on most bleeding. If bandages             become soaked just add to them do not remove existing bandages, you       will remove the clot. 

    -Do not attempt to remove impaled objects. Trim object as best as                 possible and anchor to body with tape or cord. If object appears to               pulse, you are near an artery. 

    -The farther away from the heart you feel a pulse the greater the                   perfusion.

    -Compress chest at least 2 inches at around 100 compressions per               minute (Staying Alive) tempo. Keep compression interruptions to less         than 10 seconds. Perfusion is Paramount. 

    -Cover and protect wounds and breaks. Splint should immobilize                   joints above and below break.

    -If you suspect a neck or spine injury immobilize head and if needed to         be moved (dangerous area, it should be done as an entire unit (log             roll). 

    -Treat for shock by providing warmth, elevating legs and keeping                   comfortable. 

      

 

Be informed be alive.