December 20, 2007
Note: Copyright ă 2003 by Jeff Randall and Mike Perrin. This document may only be reproduced in whole or part with the following credit line:
“Copyright ă 2003 by Jeff Randall and Mike Perrin from the book ADVENTURE TRAVEL IN THE THIRD WORLD ISBN: 1581603819”
During our survival training classes and expeditions around the world we always have someone trained in emergency care just in case the worst happens many miles from a hospital. If you don't have the luxury of being accompanied by a trained professional, at least get a minimal amount of training in emergency first-aid before your departure. Even the most basic understanding of emergency care can save you or others a lot of misery and possibly even save a life. As with every other aspect of adventure travel, preparation is the key to success. Always prepare for the worst and hope for the best.
Issues Surrounding Wilderness First Aid
Before we delve into treatment, let's look at a few simple ways to prevent serious wilderness medical problems from arising. One of the best preventives is to always travel with a companion and let others know where you're going and how long you intend to be gone. Always have a prearranged evacuation route and meeting points. Avoid using drugs or alcohol while you're in the back country. Always carry adequate food and water or at least have safe ways to purify local water. Anticipate weather changes and carry extra dry clothing. Learn basic navigation and have good maps of the area. Always ask if your partner or teammates have special medical conditions such as allergies to specific medications, food or insects, and if anyone has ever been a heat casualty. Finally, never approach or provoke wild animals of the region, since 'playing' with the animals can cost you your life.
A good example of this final rule occurred during one of our overseas expeditions. An indig, who had hand caught hundreds of alligators in the past, made a simple mistake and received a nasty bite. Swelling and pain due to infection ensued and without proper first-aid treatment and antibiotics he could have lost his hand or even his life, if evacuation had not been possible.
The variations of medical problems that can occur in the wilderness are many. Due to length restriction in this book we are directing our attention to the most probable occurrences for back-country travelers. These treatments will be a general overview and should not be used as final instruction in first-aid. Anyone wishing to learn proper first-aid should do so through a reputable instructor.
Lacerations and Bleeding
Cuts and lacerations are common in the wilderness. The small bleeders are usually easy to control by direct pressure and protected against dirt and debris by using dressings such as sterile gauze pads, Band-Aids, steri-strips, or by taping the wound closed. Rarely should you attempt to sew a wound closed, especially when it cannot be properly irrigated, since debris can be trapped inside the wound with decreased drainage causing severe infections.
Serious bleeding should be controlled via direct pressure and pressure dressings. If bleeding is from an extremity, elevate the injured area above heart level while continuing to apply direct pressure. Two situations when you would not use elevation are in the case of a fracture or envenomation. Another method for decreasing hemorrhage is by applying pressure to pressure points on the joint above the injury where arteries run over bones close to the skin.
Tourniquets should be used only when arterial or severe venous bleeding cannot be controlled by any other means and the choice is life over limb. Proper procedures for using a tourniquet should be learned before attempting to save a life with this method. If a tourniquet is applied to an accident victim ALWAYS mark the letter 'T' and the time and date the tourniquet was applied on the victim's forehead. This is done so primary care personnel will readily know a tourniquet is on the patient and can evaluate whether or not the limb may be saved.
Broken bones are common back-country accidents, especially when hiking tough terrain or navigating deadfall. Treating fractures can be as simple as applying splints, or as complicated as applying necessary traction to femur breaks and attempting to control internal bleeding.
When analyzing a patient for broken bones look for visual misalignment along the bone and pain or loss of motor skills in the affected limb. Compound fractures that protrude from the skin should not be reset in a wilderness environment, since possible internal laceration to the arteries is a risk from sharp bone fragments, as well as foreign debris entering the area. A properly splinted extremity must have the joint above and below the fracture site immobilized. Any breakage in the skin should be covered with sterile gauze and tape, or pressure bandages if required.
Simple splints can be
made from sticks and rags with the idea of keeping the injured part from moving
and creating further damage. All jewelry and clothing should be removed
surrounding the fracture site due to swelling and for inspection of further
damage and bleeding. All associated bleeding must also be controlled.
Due to the large muscle mass of the thighs, femur fractures are generally the only ones that usually require traction. Since internal hemorrhaging and severe muscle spasms are frequently associated with femur fractures, traction should be applied when possible. Direct pressure and pressure points (indirect pressure) should be used in an attempt to control bleeding. Once traction is applied it should never be released until the victim is in the hands of a primary care facility.
Heat Related Illness
One of the most frequent medical situations experienced in the wilderness is heat-related illness, which includes heat cramps, heat exhaustion and heat stroke, which is a medical emergency. These illnesses are caused from dehydration and loss of electrolytes through sweating and inadequate intake of calories from food. The symptoms for heat exhaustion are cool, pale and clammy skin, weakness, headache, nausea, dizziness, thirst, rapid pulse, chills, slightly raised body temperature and low blood pressure.
Treatment should be immediate rest in a cool area, removal of excess clothing, drinking fluids and wetting the body with cool water. However, if there is not an abundance of water available, remember that water is better "in you than on you." For severe cases use 1/4 teaspoon of salt and 6 teaspoons of sugar to a quart of water and drink in regular intervals. This is the bush equivalent to pre-packaged oral rehydration salts. This technique of electrolyte replacement should only be done sparingly. The best way to replace sodium is through food.
Heat stroke is a
serious medical emergency that can kill in a matter of minutes. The symptoms are
basically the same as heat exhaustion except the body's core temperature can
exceed 106 degrees. The victim frequently shows severe personality changes and a
lowered level of consciousness. The skin will be hot and can either be sweaty or
dry. The mental status of the victim will decline usually with slurred speech
and loss of motor skills leading to possible coma. Immediately suspect heat
stroke in any person who suddenly collapses when in a hot environment.
Treatment must be rendered immediately since this is an absolute medical emergency. Remove all the victim's clothing, spray the entire body with water and fan him vigorously, which will release heat through convection and evaporation. If possible, immerse the victim in ice water, or place ice packs under the back of the neck, armpits, lower back and groin. The secret to treating heat stroke is cooling the body immediately and evacuating the patient as soon as possible. When using this process be sure to monitor the patient's core temperature. Stop the cooling process once the temperature reaches 100 degrees, or else the body can have a reverse reaction and become severely hypothermic.
Diarrhea is another common medical condition for wilderness travelers. Simple diarrhea can be caused from diet changes, stress, or nervous anticipation associated with new adventures. The more severe forms can be the result of intestinal infections (bacterial, viral, or parasitic,) food poisoning and allergies. Usually, simple diarrhea will take care of itself; however, prolonged diarrhea can be serious and cause dehydration due to loss of fluids and electrolytes. Accompanying the serious cases may be lower abdominal cramping, fever, lack of bowel control, signs of dehydration, and others in your group with the same condition.
Treatment consists of drinking copious amounts of clear fluids and a gradual return to a normal diet. Steer clear of milk products and meats for at least 48 hours after the diarrhea has stopped and avoid caffeine and nicotine since it stimulates the intestine and increases dehydration. Pepto-Bismol and Imodium AD should be included in every aidbag and used as treatment. One of the best treatments is Oral Rehydration salts which are usually found in good travel first-aid kits or you can make the bush equivalent detailed above.
Insect Bites and
One of the largest adversities in serious bush is insect stings and bites. Mosquitoes, chiggers, flies and a whole host of other creatures love to feast on human flesh. For the most part, they're relatively harmless except for those that carry disease. The biggest medical problem usually associated with bites is infection due to scratching with dirty fingernails.
Treatment for minor bites and stings is application of Sting-Eze or other product designed to neutralize the venom removing the discomfort. More serious bites such as wasps and spiders can be treated immediately with a Sawyers Extractor followed by close patient monitoring for further signs of envenomation and/or allergic reactions which can produce anaphylactic shock in those who are hypersensitive to the venom. Oral Benadryl will help to keep down mild allergic reactions, but will make the person drowsy, and heavy doses can increase the risk of heat-related illness through raising the body's heat output and by decreasing sweating.
Some serious bites like those from Brown Recluse and Black Widow spiders may not produce pain during the initial bite, however, in most all cases pain becomes evident shortly thereafter. Treatment should consist of washing the bite with soap and water, relieving pain with ice packs on the bite, keeping a check on the ABCs (Airway, Breathing, Circulation) and evacuating the victim to a primary care facility. Don't worry, most insect bites are not fatal if allergic reactions are not present.
The best treatment for insect bites is prevention. DEET is a good insect repellant, but care should be taken when applying high concentrations directly to the skin, especially in children. Another good preventive measure is applying Permethrin to clothing, however it too has shown signs of allergic reaction in some people. When traveling in tropical and other mosquito-infested areas, always use mosquito netting when camping, and apply DEET around the pant legs and boots to keep down chiggers when walking through grassy areas.
Anaphylactic shock is a severe allergic reaction in people who are hypersensitive to insect stings, drugs, or even some types of food. It is a serious medical emergency and can cause death rapidly. The majority of deaths caused are by swollen air passages literally smothering the victim.
Some of the symptoms may include severe itching, shortness of breath, coughing, sneezing, swelling of the throat, chest tightness, convulsions, and vomiting. These usually occur shortly after being exposed to the agent causing the allergic reaction (drugs, bee stings, certain foods.)
The seriousness of this problem cannot be stressed enough. If anaphylactic shock occurs, every second counts. Monitor the ABCs (Airway, Breathing, and Circulation) with special attention to the airway. The only life-saving treatment is an epinephrine injection as provided in bee sting kits. If this is not available use an asthma inhaler or decongestant spray, and administer antihistamine or decongestant medication. First aid for seizures may be necessary. Keeping the conscious victim sitting in an upright position may also help breathing. Evacuate rapidly.
Every remote adventure should include a 'bee sting kit' which includes epinephrine pre-dosed in a syringe with needle. The injection is usually given as an intramuscular shot in the upper arm or thigh. Always inquire about your teammate's allergies before traveling and be sure you have proper first-aid supplies to deal with them.
The biggest fear among wilderness travelers is snake bite. Much myth and incorrect information surrounds the dangers of venomous snakes and the treatment of bites. The snake is the perfect evil entity with myths and legends perpetuated from biblical times all the way to present day Hollywood. As a victim of a copperhead snake bite, I can say that it's painful, but nowhere near the medical emergency as anaphylactic shock, heat stroke, heart attacks and other medical situations that exist among wilderness travelers.
First of all, a high percentage of bites from venomous specie are not 'hot' (bites which inject maximum amounts of venom.) However, any bite from such snakes should be treated as potential envenomations with the victim being evacuated to a proper health care facility. Even with hot bites you are not going to die in 5 minutes - calm, steady first-aid treatment and evacuation will serve the victim much better than running or panicking, which increases heart rate and blood flow and creates more stress in the patient.
Under no circumstances should you apply a tourniquet or make incisions into a bite in attempts to extract venom. Electric shock treatment only hurts the patient and increases heart rate and blood flow. Cold packs or ice should not be used since they do not inactivate the venom. Do not give aspirin because it can cause greater intestinal bleeding and thins the blood. Alcohol should be avoided, because it also thins the blood, and dilates vessels causing pooling of blood. Do not attempt to catch or kill the snake due to the possibility of creating another victim. In many snake bite cases antivenin may not be given at the hospital, so snake identification is not top priority.
Effective treatment can be found in the Sawyers Extractors if applied within 2 or 3 minutes of the bite. Within this time frame up to 30% of the injected venom can be removed and at 30 minutes up to 3% can be extracted. If the Extractor is not available within this period of time, don't waste time looking for it and begin your first-aid procedures. Keep the victim calm and quiet since activity and increased heart rate increases venom absorption. Monitor ABCs and treat accordingly. Use a sling to immobilize the bitten limb loosely and keep at or below heart level. Most important, reassure the victim and make all attempts to keep him calm since his worst fears of the wilderness have come true. Although the victim may be in serious pain with swelling, in most cases there are several hours before 'hot bite' victims become critical. Death from snake bite in the United States is extremely rare.
I have personally treated snake bite on myself and on a family dog. In most cases, it is not the medical emergency that Hollywood and many others will have you believe. The body (in both animals and humans) has an amazing resilience to venom and will absorb large amounts before shutting down. This is one of the main reasons not to apply a tourniquet. If you localize the venom with a tourniquet it keeps the body from absorbing it and produces massive damage at the wound site, sometime requiring amputation if the bite is on a limb. On both cases that I personally treated (myself and the dog), the patient was kept calm and well hydrated with a mixture of half Gatorade and half water. It should be noted here that Gatorade should never be given full strength for any medical emergency. The large amount of sugars and electrolytes contained in pure Gatorade will actually use up existing body water while processing the Gatorade. The remainder of my treatment consisted of administering Benadryl to reduce swelling and a regiment of anti-inflammatory steroids such as Prednisone. Of all the first aid procedures for snake bite, keeping the victim calm is the one absolute “must” in the survival process. I can’t stress this point enough. If you can’t remember any other procedure, remember two words: “Hydrate” and “Calm.”
Of course wilderness first-aid can be much more complex than the issues noted above. Evacuation and rescue techniques can be just as crucial, if not more, than the first-aid given on the scene. If your trip includes very remote back-country travel, we highly suggest acquiring at a minimum Wilderness First Aid (WFA) certification. A WFA course covers all the basics from initial assessment to delivering the victim into the hands of qualified medical personnel. Throughout the course an instructor answers students' questions, has them practice techniques, drills them on critical areas, and teaches them how and what to pack in their aid bags. Students are also provided a comprehensive Wilderness First Aid manual by the National Safety Council and the Wilderness Medical Society. This manual is an easy read and takes the care-giver step-by-step through proper assessment and treatment of a casualty.
Although the majority of this first-aid section comes from direct field time and a WFA course, I also consulted an acquaintance of mine, Myke Hawkeye, for his expert opinion on the subject. Myke is an SF medic and Chief of Field Operations for Global Univision's Special Operations Medical Services. He has acquired much experience and field time in many less-than-desirable places around the world. His following words illustrates the focus of this chapter rather well.
"Having been in the bush with many different types of people, I have consistently noted that those who do not factor any accidents, injuries or illnesses into their mission planning most often sustain some such malady, while those who do consider the ever-present possibility of them, and make ready accordingly, almost never incur them and rarely are required to implement their course of action. Hence, to not plan for failure, is to plan for failure."
Myke adds, "In the course of pursuing any study, one should attempt to seek the highest level of authority for the subject matter at hand. Then they should get all the knowledge and training as is available to them. Then, if feasible, review that which is one or two levels above their means. In this way, they will have an idea of how best to proceed with their own implementation by knowing how the next courses of action will follow. Hence, know the basics, study the advanced, understand the rest."
Travel First-Aid Kits
Massive medical kits are not required to perform basic first-aid. The size of your kit will be dependent on the size of your travel group. Naturally if you are traveling solo your kit has to be able to handle most problems that can arise, however if you are traveling with a group the kit can be divided into sub-sections among the members to make traveling easier. Even with group travel, all persons should have on their person basic kit supplies and all personal medications. What we suggest is buying a commercial travel kit from a reputable company then modifying the kit to take care of your trip. A good store-bought kit will have the basic items and a quick reference first-aid guide already built in.
Our expedition kit is housed inside a bright orange Pelican waterproof case and includes basic first-aid items with the following upgrades. All of these items and procedures have been used in one form or another throughout our travels into the Third World:
Emergency dental kit. Dental pain is one of the worst things that can happen to a remote traveler. It can absolutely ruin an otherwise good time. If your trip is going to be an extended stay, we highly recommend visiting a dentist before you leave to make sure no surprise tooth pain comes your way. An emergency dental kit is available from reputable first-aid supply houses and will take care of most dental emergencies in the field, including replacing lost fillings and crowns and supplying temporary pain relief for tooth aches. We also carry prescription Lidocaine along with small needle/syringes just in case we are forced to deaden a tooth in a remote location. The process is fairly simple to do and since we rate dental pain as one of the worst "normal" things that can happen we have detailed the procedure in this book. If you have to deaden an upper tooth, the injection should go at the base of the tooth's root. A rough scale for determining this is one and a half times the tooth's length above the gum line is the injection spot. The injection should go into the gum starting from the outside of the mouth. Using a small needle slowly insert approximately 1 cc of 1% Lidocaine. For lower-jaw teeth, the deadening has to be done via a nerve block. This is a little more tricky than upper-jaw teeth but not impossible. Using your off hand grasp the victim's mouth by placing your thumb in the corner of the mouth and the rest of your hand around the jaw bone under the ear. Pinch together and insert the needle in a path that crosses over the opposite side bicuspid to the near side wisdom tooth (the side you have pinched that needs numbing.) This will line your needle up. The injection is then made just above the wisdom tooth in the fleshy part of the jaw. Insert your needle about 1 inch deep and slowly inject 1.5 cc of Lidocaine. Be sure your injection stays to the inside of the jaw bone because if it goes to the outside it will cause temporary facial paralysis. These procedures are for information purposes only and should be performed only by qualified personnel. If you attempt any of these procedures be sure you have access to epinephrine just in case there is an allergic reaction to the Lidocaine.
3M disposable skin stapler and staple remover. These staplers are handy tools for closing a wound. They are simpler than sewing and most folks can handle the pain associated with the quick action of a stapler more so than a sewing procedure. Although most wounds can and should be closed with pressure and dressings, there area few exception where sewing or stapling is an asset. If a wound needs to be closed in this fashion we suggest deadening the area with 1% Lidocaine and thoroughly cleaning the interior of the wound before closing. Numbing can be achieved by subcutaneous injections of Lidocaine at intervals around the wound area. After the area is sufficiently numb pinch the wound closed with hemostats while rasing it slightly, then staple or sew as needed. Be careful of closing wounds that have not been properly cleaned. Depending on the would severity and location a drain may need to be inserted before tight closure.
Povidone Iodine solution concentrate 10%. This is our preferred wound-cleaning solution. The 3/4-ounce concentrate packages are easy to carry and readily mix with one liter of water to provide the right solution to clean and disinfect dirty wounds before closure. This concentrated packaging takes up less room in your aid kit than the common mixed solution found in most drug stores.
EpiPen. This is an Epinephrine auto-injector. It delivers a 0.3 mg intramuscular dose of epinephrine by simply uncapping and using a stabbing motion into a muscular part of the body. This is the only cure for serious anaphylactic shock which can be brought on by allergic reactions to drugs, some foods, bee stings, and several other initiators. It is acquired through a doctor's prescription only but considered a high-priority kit item when traveling in remote areas with a group of people.
SAM Splint. A
unique device made from a piece of padded aluminum sheet metal. It can be formed
to fit the broken limb and held in place with ACE bandages, Vet wrap, or rags.
It is the preferred splinting device of the wilderness and occupies very little
room in an aid bag.
Vet wrap. Also known as Co-Flex and Co-Ban, it is similar to an ACE bandage but it is much easier to use since it sticks to itself. It can also be cut to form small bandages.
Oral Rehydration Salts. These are the best treatment for dehydration and diarrhea in the wilderness. Simply mix with a liter of water and have the patient slowly drink. During a filming venture in South America, oral rehydration salts saved me from severe dehydration after a two-day bout with food poisoning. Just like the EpiPen this is one item that no travel first-aid kit should be without.
Oral Glucose gel and tablets. These items are great for travelers with diabetes who suffer from an insulin reaction, as well as travelers suffering from sugar deficiencies brought on by dehydration. These can be safely used anytime a chemical imbalance is suspected in the patient.
Other items included in our kit are: EMT shears, hemostats, cold wrap, prescription pain killers (both codeine and non-codeine based), prescription antibiotics including Cipro, prescription Metronidazole for intestinal parasites such as Giardia, various syringe and needle sizes, Benadryl, prescription Lariam, prescription Lidocaine local anesthetic, suture kits, prescription Lamisil anti-fungal cream, Purell gelled alcohol, oral thermometer, Sawyers Extractor, and a comprehensive wound-care package.
Although our kit is
fairly extensive, we listed the items here to give the adventurer an idea on the
possible scenarios that could be handled in a remote travel emergency. It is
best to separate your kit into components, such as wound care, eye care, meds,
etc. For those dependent on eye glasses or contact lenses, it is very important
to enclose an extra pair of glasses in your kit.
Disease Free Travel
Before you begin your travels always check with the Centers for Disease Control to get the latest updates. Some countries may require certain vaccinations before entrance is granted. Proof of vaccination is obtained through the medical facility performing the vaccinations in the form of an International Certificate of Vaccination as approved by the World Heath Organization. This yellow card should stay with your passport at all times since it contains medical information about you. Your local health department will usually be the final say on what diseases you need to protect against before your travels, but in any tropical Third World country it's always safe to have the following vaccinations: Hepatitis (various strains), Tetanus booster, Typhoid, Yellow Fever, and an M-M-R booster (Mumps, Measles, Rubella). You may also need prescriptions to guard against malaria which is usually in the form of a once-a-week oral tablet called Lariam, or a once-a-day capsule of Doxycycline.
As discussed earlier, if you should get sick and need to visit a hospital for an injection, request them to use your personal needles and syringes found your first aid kit. During one training trip we witnessed doctors using the same syringe to medicate two separate patients. The syringe was aspirated on the first patient during injection which caused a back flow of the patient's blood into the syringe, then a new needle was placed on the same syringe and used on the next patient. Third World mentality is to make use of everything as much as possible before throwing it away. This is a deadly gamble, especially in developing countries where diseases such as AIDS and hepatitis are running rampant.
Possibly the biggest threat to travelers is waterborne diseases. Throughout our numerous trips into the Third World we have had team members contract a myriad of waterborne problems. Giardia seems to be the most recurring and can be very difficult to diagnose. As a precaution, always purify any water you drink overseas. This can be done with iodine-based purifiers (liquid and tablet form), chlorine, or common pump-type water filters. Also remember that brushing your teeth with tap water or ice in your drinks can be just as bad as drinking.
Another common problem is food-based sicknesses. Although most of these are mild reactions due to change in diet, sometimes they can develop into severe cases of diarrhea, or be the onset of food poisoning. Many foods are under-cooked in developing countries and can carry parasites and other nasty bugs that may make you sick. Refrigeration is typically non-existent in remote villages and meat preservation is usually done by a process of salting and smoking. We have eaten many piece of meat that were covered with flies and larvae just before being cooked. The rule of thumb is always be sure wild foods are throughly cooked and fruit is always peeled before sticking it in your mouth. If you do develop a case of food poisoning, do your best to stay hydrated. Drinking clear liquids, taking oral rehydration salts, and slowly reverting back to a solid diet will usually get you through the ordeal. We always carry prescription Ciprofloxacin hydrochloride which seems to knock out just about any nasty bug that comes along.
Wound infections can be very serious. Your body's immune system is basically undergoing a certain amount of trauma once it's introduced into a new world, with new bugs, new climate, and a new diet. Treat all minor wounds with immediate care. Even tiny bug and mosquito bites if continually scratched can develop into raging infections. Back home most of us hardly pay any attention to minor cuts and scrapes. If we do anything at all it's usually just a Band-Aid to stop any annoying bleeding. Once you're overseas this practice has to change. As soon as an injury occurs, treat it. A good triple antibiotic ointment coupled with proper wound cleansing and dressing is the best insurance policy a traveler can have. In tropical areas it is especially wise to pay attention to wounds and keep them clean.
When traveling also remember that disease goes in both directions. We have been to areas that few white men have ever seen. The indigenous populations could easily be susceptible to things which do not fatally affect us. A common cold or a flu bug taken into a "pristine" environment such as this has the potential of wiping out many people. One of our “acquaintances" even bragged about going among a very remote tribe of people while suffering from the flu. The proper thing would have been to wait until the bug had passed before going in. We never found out if this affected the tribe but it does demonstrate the contempt that the money hungry civilized world has for a group of people trying to survive the best way they know how. In short, idiots like this need to find other adventures to brag about. Just be sure to keep this in mind and notify your guide or traveling partners of any condition you have that may affect the area you're going into. Also keep your visits as short as possible and avoid as much personal contact as you can. If in doubt, do your best to avoid contact altogether with those who may be susceptible. It's just not worth the photo or video you might get.
Note: Copyright ă 2003 by Jeff Randall and Mike Perrin. This document may only be reproduced in whole or part with the following credit line:
“Copyright ă 2003 by Jeff Randall and Mike Perrin from the book ADVENTURE TRAVEL IN THE THIRD WORLD ISBN: 1581603819”
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