Recently I read an article in the Denver Post about a woman who "became separated" from her hiking group and spent 9 days in the Sierra Nevada mountains before she was rescued.  The article didn't say how she became separated, but I am guessing she stepped off the trail to answer the call of nature, and when she returned everyone was gone.  I am also guessing she either didn't have survival gear in her pack, or couldn't find it when she went back to the trail. 
There are two lessons here.  Number one:  always tell someone when you leave the group to answer the call of nature, especially a large group where your absence might not be noted for awhile.  This is particularly true for groups with hikers of varied ability who don't stay together.  Number two:  NEVER, NEVER, NEVER leave your pack!  Always take your pack with you wherever you go.  That way, you will never be without your survival gear.  
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Repeat:  NEVER, NEVER NEVER LEAVE YOUR PACK!

This isn't exactly a wilderness or remote first aid story, but it makes a good point, so here goes...

I drove a friend to an appointment at his cardiologist's office a few weeks ago  While we were waiting I noticed an elderly gentleman sitting across from me.  He didn't look well, and he was talking on his cellphone.  "I don't know what's going on," he said. "I'm sweating all over."  After he hung up and I approached him and asked if he needed some help.  He replied that he thought he needed some sugar.  He didn't have a glucometer, but the woman next to him did, so I did a quick blood test for sugar.  He had a reading of 50, well below the normal range of 80 to 120.  I notified the front desk and they brought two glucose wafers.  "I already tried that," the man said, "and it didn't help."  He ate the wafers anyway.   At that point the medical staff the arrived.  I told them he was very diaphoretic (sweaty), and they put him in a wheel chair and took him to an inner room.

At first glance, the man's statement that he needed sugar plus a reading of 50 would lead one to a conclusion that he was simply having a hypoglycemic emergency, i.e. low blood sugar.  I'm sure this was true, but that was just the beginning.  Look at all the facts:  we were in a cardiologist's office, he was an elderly male, he didn't look good, and especially, he was intensely sweaty all over, a classic symptom of what?  A heart attack!  Remember that older people, and also women don't necessarily present with a lot of chest pain.

The point of this story is, don't get cocky or even overconfident when you find something wrong with the victim.  You always have to do a complete assessment, including a SAMPLE history, to find everything that is wrong with her or him.

When you think of it, the first aid spectr always begins with prevention and avoidance.  Here is an interesting story that might help you avoid a medical emergency some day.

In his book, The Mind of the Raven, Bernd Heinrich relates on page 193 an incident involving a woman who lived with her husband in a cabin near the head of Boulder Canyon.  The woman was outside when she noticed a raven flying nearby.  "I never paid much attention to ravens," she said, "but this one was so noisy that it was downright irritating."  The raven came closer, made a pass near her and then flew up to some rocks where she saw a crouching mountain lion.  Just then her 300 pound husband came out of the cabin and the lion slipped away.

The woman, who was very religious, thought it was a miracle.  "That raven saved my life," she said.  Maybe so, but Professor Heinrich thought it might also be because the raven was luring the cougar to make a kill, alerting it to a suitable target.

Whichever you choose to believe, the point is, be alert to unusual signs and sounds in the environment around you.  It could help you avoid a medical emergency some day!

     My obsession with carrying enough lights when I leave the trailhead began on the Grand Teton in Wyoming.  My climbing partner and I had started late so it got dark as we were coming down.  And then we got lost!  Being experienced mountaineers we both had flashlights.  Then came the big surprise:  mine didn't work at all, and hers made it for about 30 seconds.  All we had at that point was a little techtonic flashlight powered by a AAA battery.  We stumbled around, trying  to find the trail and get down, but it soon became apparent that we were in a real life-threatening situation and needed to put down and wait for dawn.  Fortunately it wasn't too cold and didn't snow.

     The funny part of the story is that we were only about 50 feet from the trail and probably could have made it back if we had only known!

     Now I always carry lights.  Lots of lights.  In my pack are a headlamp and a cap lamp which clips on to the brim of your cap or hat.  I also carry a couple of those little keychain lights that realtors hand out.  But wait!  There's more.  In my pocket I carry at all times a penlight powered by two AA batteries.  It gives off usable light for about 24 hours.  Then there is the flashlight on my cell phone, and also a little keychain light/tool kit I got at SWISS+TECH.COM which, believe it or not, actually got me down the steep side of Mt. Sanitas in Boulder one summer evening.

  Lights are another one of those "effectiveness multipliers" that I mentioned in a previous post.  Without a light you are just fumbling around in the dark.  With a light you can see what you are doing in a medical emergency as well as give the victim, and yourself, a psychological lift.  

     One last thought:  CHECK THE FREAKING BATTERIES before you leave the trailhead!

     When done properly, CPR is a rigorous physical activity.   In a 911 area we can probably keep up chest compressions until the ambulance arrives, that is for about eight to twelve minutes.  After that we get tired or our hands and back begin to hurt.  At some point we can go on no longer. 

     In the wilderness there will be no ambulance arriving, so we have to take extreme measures to keep going.  At Far Out First Aid we suggest that you use your knee to continue compressions on the victim's chest when everything else fails.  You won't find this in any of the conventional texts on CPR, but using your knees might provide just enough additional time to make a difference, particularly when the victim goes into and out of cardiac arrest. 

      Even more effective is using your legs.  Place the ball of your foot in the same spot you placed your hands, mid-sternum, and continue compressions.  Your legs are much stronger than your arms and back, and you can actually do CPR for quite a while using this technique.  

     These are extreme measures, but when there is nothing else available and you are exhausted from doing conventional CPR, why not add a few more minutes using your knee or foot?  It could make a difference. 

Recently a highly experienced hiker in Oregon died of hypothermia in forty degree weather.  She had left the day before on a day hike over familiar terrain, but something happened and she had to spend the night in the outback without adequate equipment. 

Most of us are familiar with the Boy Scout motto, "Be Prepared," but how many actually follow this good advice in all circumstances?  The answer is not many. And how many of us carry the so-called "Ten Essentials" every time we go out?  Again, the answer is, not many.   Just ask yourself this question:  "If I go for a day hike and I'm not able to get back to the trailhead by dark, would I be able to survive the night?"  Even in temperate climates the answer may be "no." In Colorado where I live , temperatures usually drop dramatically at night, sometimes even below freezing, especially in the mountains.  And we all know that rain, even on a hot summer day, can strip the body of its normal warmth and lead to hypothermia. 

My advice to you is to be prepared for what is POSSIBLE, not what is PROBABLE.  in other words, the forecast may be for clear weather, but you should still carry rain gear because it COULD rain.   Obviously there are limits.  You don't want to carry a huge pack every time you you go for a jog on the greenbelt.  But there are some lightweight things you can carry in a fanny pack without getting bogged down.  I would start with the Ten Essentials: food, water, knife, first aid kit, map, extra clothing, fire starters, compass, space blanket, and flashlight. 

 I also carry at least one 55-gallon plastic bag which folds up pretty small.  It makes a dandy bivvy sack if you have to spend the night out.  In addition I carry a lightweight plastic poncho which you can buy for less than a dollar to keep my top half and my pack dry.  And while we're on the subject of plastic, I always carry two plastic bread bags.  I slip them over my socks in wet weather to keep my feet dry.  Amazingly, I have hiked many miles on bread bags with no problem!  

I also carry a pair of trauma shears which you can buy at Walgreens for cutting up clothing and packs to use as field expedients for bandages or for making a stretcher, and a small hand saw or wire saw to use for cutting down saplings for making a stretcher.   These two items are what I call "effectiveness multipliers."  They will greatly improve your effectiveness in a wilderness first aid situation. 

Lastly, I always carry lights.  If you have ever been be-nighted on the trail, you know the psychological value of having even a small light, not to mention the fact that it might keep you from walking off a cliff.

If you are still dubious about my "Be Prepared" advice, go hang out on your favorite hiking trail after dark some evening and see if you think you could survive the night. 

Anaphylaxis is a form of shock which arises from a severe reaction to an allergen.  The allergen can literally be anything. Insect stings, peanuts, and shellfish are common examples.  Most people know what they are allergic to and take steps to avoid exposure.  But sometimes they, and we, are fooled.  For instance a person may have a severe reaction to a bee sting even though a previous sting did not affect them.  For some reason the first sting sets them up, and the second sting brings on a severe allergic reaction, resulting in dilation of the blood vessels, or anaphylatic shock.

Peanuts, or more specifically, peanut oil, can also be a problem because it is found, or shall we say hidden, in many prepared foods, particularly snack foods such as cookies and potato chips.  

The symptoms of anaphylaxis often begin with urticaria, or severe itching and welts all over the body.  Swelling around the face may follow, followed by elevated and heart and respiration rates rate as the victim struggles to breathe.  Eventually, if left untreated, the swelling may occlude the trachea and the person dies.  Therefore it is important to monitor the victim's airway at all times.

Individuals who know they have a severe allergy will usually carry an EpiPen, which is simply a spring-loaded syringe loaded with epinephrin, which is another word for adrenalin.  Lay persons are not permitted to administer EpiPens, except in certain specified situations, such as trained school staff, but we can help the individual find her EpiPen and prepare it for injection by her.  Injection is accomplished by removing the cap and jamming the business end of the EpiPen against the outside of the thigh and counting slowly to ten while the epinephrine is automatically injected into the patient.  The pen will go through some clothing, but it will not go through car keys or coins, so slow down and make sure the area of injection is clear of objects, or better yet, actually pull up the shorts or pull down the pants to visualize the person's thigh.

If you are in the wilderness, an EpiPen may not be available.  For this reason I carry liquid benadryl capsules.  Benadryl is a strong anti-histamine, and will help contract the blood vessels to a more normal state.   I will make a slight slit in  three or four capsules and ask the victim to hold the liquid under her tongue as long as possible before swallowing it.  There is huge vascularization under the tongue, and medications are immediately absorbed into the body there.  The victim may also bite the capsule to open it.

I also carry two or three instant coffee servings.   There is some evidence in the medical literature that coffee helps to contract the blood vessels, so I will make a couple of cups of strong, black coffee and ask the victim to drink them.  Note that this is a violation of the usual rule of not giving victims anything to drink, and you would never do this in a 911 response area.  But in the wilderness, things are different, and you will want to do anything that might help.

And of course don't forget to treat for shock, maintain the victim's airway and continually monitor the victim's condition.

    911 AREA
    When you are confronted with a medical emergency in a 911 area, your response, after you determine that the scene is safe for you to enter, is basically to check the victim for breathing and bleeding and call for help.  If the victim is not breathing,  CPR must be started.  If the victim is severely bleeding, a pressure bandage must be applied.  If the victim is breathing and not bleeding severely, you will apply a pressure bandage,  treat the victim for shock and monitor her condition until emergency medical services personnel arrive.

    WILDERNESS OR REMOTE AREA
    In a wilderness or remote situation things will be different:
    a.    You will have fewer resources, including less equipment, supplies and fewer (if any) trained personnel
    b.    You will have to do a more extensive assessment of the victim to find out everything that is wrong with him
    c.     You may have to treat the victim much longer, hours at least, and maybe days
    d.    You may have to move the victim out of immediate danger, e.g. a rising creek, or approaching fire
    e.    You may have to evacuate the victim
    f.     You may have to deal with severe environmental factors, e.g. adverse weather conditions and difficult terrain
    g.    You might be sick or hurt too
    h.    You will have to deal with the effects of the emergency on yourself and others, e.g. fatigue and emotional strain
    i.     You will need to keep a written record of the status of the victim to hand off to rescuers

    Obviously, in a medical emergency in a wilderness and remote situation, you and those around you are more important than when an ambulance is on the way.  Therefore it is important to carry sufficient supplies and equipment and complete appropriate training to be prepared for whatever may arise.


   

Okay, so you have recognized that there is an emergency, and you have  made a decision to act.  You go
over to the victim and say, “Hi, I’ve had first aid training, can I help?” And they say “No!”   Now what do you do?  Force
the victim to accept your help?  Go about your business?

 No.  If you think that  there is a medical emergency and the victim needs help, just hang around and keep talking.  Sometimes it takes a  little persuading to get a sick or injured person to accept your help.  And remember, it is always your choice  whether to call for help or not, no matter what the victim says. 
 
If you think about it, refusing help when we are sick or hurt isn’t so  unusual.  None of us really wants  five fire/rescue responders, an EMT and a medic, and a couple police officers, plus all the neighbors hanging around, and we’re in our underwear or pajamas!  What we really want to do is to go home and get in bed with the dog or the cat and make it go away.  
 
So be patient.  Keep talking calmly and explain what you would like to do to help.  Tell the victim  what your
training is and try to engage him conversation.  Ask if there is someone he would like you to call.  Eventually he will
accept your help.  

     "Shock" is the failure of the cells of the body to be adequately profused with oxygen.  This can be a result of"

     1.  Substantial loss of blood volume, as in a severe laceration 
     2.  Decreased heart function from Injury or illness, such as a heart attack or trauma to the chest, leaving the heart unable to pump sufficient blood to the tissues
     3.  Dilation of the blood vessels, making the "container" larger than normal, as in anaphylactic shock

    Recognizing the onset of shock isn't always easy, but it doesn't make any difference, because you always treat for shock from the very beginning of your rescue!  If you wait until you think the victim is going into shock, it is probably too late.   

    So how do you treat for shock? 

    1.  First, treat the underlying pathology.  For example, stop the bleeding
    2.  Second, place the person in a "position of comfort."  Lying down is often best, but not always.  Heart attack        victims often can't breath when they are lying down, and some people will feel claustrophobic or panicky in a prone position.  Ask them how they feel most comfortable.  
    3.  Maintain body temperature.  We used to say, keep the patient warm, but this is clearly inappropriate on a high humidity, 100 degree day.
    4.  Reassure the person.  This is extremely important.  As discussed in a previous post, your voice and calmness can go a long way toward keeping a person from panicking.  Talk to the individual, but slowly and calmly and with good eye contact.  Don't be afraid to interject a little humor if it seems appropriate.  Surprisingly, sick or hurt people often joke about their condition.  Play along with them.  

    As always, be careful not to discuss the patient's condition within his or her hearing.  

    Shock can be deadly, so remember:  Always treat for shock from the very beginning!