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+SENIOR EDITOR
+Richard J. Ingebretsen, MD, PhD University of Utah School of Medicine Salt Lake City, Utah
+
+EDITORS
+Paul Schmutz, DDS Salt Lake City, Utah
+CONTRIBUTORS University of Utah School of Medicine Jonny Woolstenhulme, MD Justin Coles, DO
+
+Copy/Format Editor
+Lisa Plante M.Ed.
+Edition 2.0 Copyright © 2025 by
+Richard J Ingebretsen MD PhD and The University of Utah School of Medicine All Rights Reserved. No part of this book may be reproduced in any manner without the express written consent of the author or the School of Medicine.
+ISBN: 978-1-7359710-3-2
+
+Table of Contents
+Click on a chapter to advance
+J
+Basic First Aid Chapter Patient Assessment Vital Signs Wound Management Bleeding and Shock Airway and Breathing Musculoskeletal Injuries Medical Problems
+Chapter 1: Chapter 2: Chapter 3: Chapter 4: Chapter 5: Chapter 6: Chapter 7:
+
+Chapter 1: Patient Assessments
+The management of someone injured or sick in the wilderness is probably the most important topic in all of wilderness medicine. Imagine that you are enjoying a back-country jog and you see another runner fall hard. When you get to her, she is clearly confused and incoherent. You note a bruise on her forehead and her lower leg is bleeding profusely from a deep gash. There is already quite a bit of blood. In this situation, what should you do first? What medical issues are the most important? There are four effective survey techniques that are strongly recommended to use in your initial assessment of a sick or injured person in the wilderness. These four survey techniques are: scene survey, primary survey, secondary survey, and ongoing survey.
+
+Scene Survey
+The first survey technique is the scene survey. When you first approach a scene, the tendency is to approach the patient immediately and start rendering aid. Don’t. You must first make sure that the scene is safe before you enter to assess the victim. Don’t put yourself in harm’s way and potentially become a victim yourself. Look around and consider physical dangers such as snow, ice, rocks, fire, and animals. Other potential hazards include bikers on single track, climbers above, or hunters shooting guns. The adage, “Don’t just do something, stand there!”, is true. Making sure that the scene is safe is critical before entering to assess a victim.
+Once you’ve determined the scene is safe to enter, you need to determine how many people have been injured and how they were injured. This survey should take only a few moments. This can effectively be performed by discovering the mechanism of injury (MOI) and the nature of the illness (NOI). If victims are conscious, ask them if there were others involved, as other victims may have fallen behind a bush or been swept downstream.
+
+Primary Survey
+The second survey technique is the primary survey. The purpose of the primary survey is to keep the victim alive. To help prioritize the treatment of injuries during the primary survey, refer to the table below which uses the MARCH acronym. It’s important to note that preventing major hemorrhage is the top priority, even coming before Airway.
+If the patient is awake and alert, you should ask the patient if she/he would like your help. It is good practice that before you start treating a responsive patient you should identify yourself and ask if they want help. This helps protect you legally and gives the patient the opportunity to refuse care. If the patient is not able to clearly communicate their consent for treatment, then the consent is implied.
+Primary Survey prioritization using MARCH
+M Massive hemorrhage A Airway (with C-spine precautions) R Respiration C Circulation H Hypothermia/Hyperthermia or Hike vs. Helicopter
+In the Intro scenario above, the fallen runner was bleeding profusely. Anytime there is major bleeding you should always take steps to stop the bleeding first. Typically, direct pressure is done to stop heavy bleeding. In the wilderness, however, don’t hesitate to use a tourniquet. It is a fast and simple method to stop a major bleed.
+If a victim is unresponsive, assume there is a C-spine injury even if there is no clear mechanism. Therefore, for Airway, you should hold the C-spine as a precaution during your primary assessment. If the patient becomes responsive later, you can re-evaluate the need to hold C-spine.
+Next, you can quickly check for a victim’s Respiration before evaluating their pulse. Checking the pulse falls under Circulation when using MARCH. Hypothermia/Hyperthermia refers to making sure that the patient is warm and dry and whether or not the patient will need to be evacuated or not (thus the alternative of Hike vs. Helicopter). Using the MARCH prioritization as you quickly go through the primary survey ensures your patient is alive and as stable as possible. Learn it well.
+
+Secondary Survey
+The third survey technique is the secondary survey. This survey is done after the Primary survey and can be remembered using the SAMPLE acronym.
+Secondary Survey using SAMPLE
+S Symptoms/Subjective A Allergies M Medicine P Prior medical history L Last oral intake E Events leading up to illness/injury
+Address these items to the victim as questions and pay close attention to what they say. It they cannot answer, ask if family, friends, or people at the scene might be able to help with some or all of the questions. As well, you can look for medical alert tags and bracelets on the victim. Check backpacks, purses and wallets for medical information too.
+
+Ongoing Survey
+The fourth survey technique is the ongoing survey. You should repeat this survey as often as needed. If the patient is unstable, go through the survey more frequently. Until the patient is in the hands of medical help you should keep assessing them with the Ongoing survey.
+If at any time there is a change in the patient’s status you should always go back and repeat the primary assessment. This is essential to determine what caused the change in the patient’s medical status.
+
+Ongoing Survey using AVPU
+A Alert V Verbal P Pain U Unresponsive
+
+Summary of Surveys
+These are the four effective survey techniques recommended to use in your initial assessment of a sick or injured person in the wilderness. However, there are often other issues that present themselves and may need to be addressed during these four survey techniques. The victim may have an altered mental state, or be in a significant amount of pain. They may be unconsciousness and remain that way. They may have nearly drowned or have fallen from a cliff. Let’s explore these types of issues and how you would assess a victim in these situations.
+
+Altered Mental Status
+There are many reasons that can lead to an altered mental status, and often there can be multiple causes for one patient. A well-known pneumonic to use is AEIOU Tips. There are some minor, but important additions for its use in wilderness medicine.
+Start at the top of this list and work your way down to come up with a differential of potential causes for a victim’s mental status. Victims with an altered mental status, or who are unresponsive, can be some of the most challenging patients to care for. Remember, you should check for medical alert tags which may be around the neck, wrist, ankle or even tattooed on the skin. They also might have information in a pocket, in their gear, or wallet/cell phone
+Altered Mental Status Checklist using AEIOUTIPS
+A Allergies/Altitude E Environment/Epilepsy I Infection O Overdoes U Underdose T Trauma, toxins I Insulin (diabetes) P Psychological disorders S Stroke
+
+Pain
+Pain is often a common presenting sign in a victim. Understanding the caliber of someone’s pain may well be the key to a diagnosis of what is causing it. The acronym, COLDERR, is used to characterize a victim’s pain.
+Pain checklist using COLDERR
+C Character O Onset L Location D Duration E Exacerbation R Relief R Radiation
+
+Recovery Position
+Another situation you may encounter is that of an injured and unconscious victim. If you are alone, you may realize that your only option is to leave the victim and go get help. Before you go, put the victim on their side in the recovery position. This helps keep the airway open and prevents them from aspirating if they vomit.
+Airway is assessed with C-spine in the MARCH acronym. The victim is on their side with the top arm forward and the top leg forward. This position will help keep the patient from rolling onto their back. You don't want the patient on their back as they are at risk of aspirating if they vomit and their airway may not stay open.
+
+Drowning
+After performing a scene survey, if you pull someone from the water and suspect drowning, what should you do? Your thought might be to conduct the Primary survey, using the acronym MARCH. However, in the case of a potential drowning victim, they need air in their lungs quickly. Therefore, you should perform rescue breaths if the patient has a pulse. Since there is no massive hemorrhage, airway and respirations are the next steps for the primary assessment.
+A submersion injury is a special case where oxygen becomes an important part of giving CPR, as drowning victims will often have a depletion of oxygen. Therefore, start with two-rescue breaths. Once the patient is breathing on their own, you would finish the primary assessment. If they don’t have a pulse, then you should start chest compressions. Chest compressions only, or “hands-only CPR,” is an option for lay rescuers in urban settings. However, in a submersion injury, patients usually need oxygen, and CPR with breaths becomes very important. Maneuvers to remove water from the airway is unnecessary and is potentially dangerous.
+
+Scene Safety
+In a case where the scene is not safe for the victim, you may need to move them to a safe location. For example, consider a situation where a person falls a short distance off of a rock-climbing cliff. This fallen person is now below the cliff, and other people are still climbing with the potential to
+dislodge loose rocks. These falling rocks could be a danger to the victim lying below. Should you move the patient to a safer location and risk causing a potential spinal injury? Clearly, the scene is not safe. You need to move the injured person away from the base of the cliff. If you started treating the victim here, you would be subjecting the victim, yourself and other rescuers to additional injury.
+When considering scene safety, it is important to keep in mind the risk-to-benefit ratio. Moving the victim(s) may result in spinal injury but keeping them at the base of the cliff could result in more injury or even death if there is more rockfall. In this case, the risk of rockfall outweighs the risk of spinal injury in moving the patient. Be careful of the spine!
+
+Blood Sweep
+In the example above where someone has fallen from a cliff, they could easily have cuts on their skin. A quick look will determine if they are bleeding. This is known as the blood sweep and allows you to identify any major bleeding. It’s important to look under layers of clothing when doing your sweep, as blood can collect between these layers, especially if the clothing is waterproof. It’s recommended to perform the sweep in small segments to determine where the blood is coming from.
+The blood sweep also allows you to find deformities in the musculoskeletal system. An injured patient might not have cuts on their skin, but may have internal injuries. The body can bleed out in several internal cavities within the human body. The chest, abdomen, the space behind the kidney, and the thigh are all big enough areas where a person can bleed to death. To help you remember these internal areas, use the CARTS pneumonic.
+
+Blood sweep checklist using CARTS
+C Chest A Abdomen R Renal T Thigh S Skin/street
+There is often little you can do if someone is bleeding to death inside their body, other than evacuate them very quickly. At least you will know to do this. Remember also, that people will often bleed on the ‘street’ or they will bleed in one place and then stumble to another place. Be sure to look on the ground or the street for blood.
+
+Wound Irrigation
+If the patient’s wound need to be treated, irrigation can be very messy, even when done correctly. Even if you are irrigating away from yourself, the liquid can still splash backward. Protect yourself with proper Body Substance Isolation (BSI) any time you are treating a patient. You might need to improvise BSI in the wilderness. You should cover yourself with waterproof clothing, even if you borrow the patient’s gear. Using the waterproof clothing ensures that your gear does not become contaminated. If you are in a situation where the patient will be at risk of hypothermia without their waterproof layer, you can use your own jacket. It is better to use the patient’s gear, so your
+own clothing does not become contaminated with blood. You can also use a different piece of the patient’s gear (such as their backpack) to create a shield.
+
+Exposure
+You should always look under the patient’s clothes for additional injuries. However, proper exposure is a double-edged sword in the wilderness. It’s important to check the whole body for any hidden injuries, but it’s also important to ensure that the patient stays protected from the environment. Avoid damaging the patient’s clothes, which are a valuable resource when it’s cold outside. In fact, cutting off the patient’s clothes for better exposure could be a waste of resources. If the patient recovers after rewarming, they would be unable to walk out because they would have no clothes. While it’s important to start the rewarming process, it is vital to first examine the patient for any injuries.
+The first step to any wound management after the primary survey is to have exposure to the injured area. Direct visualization is needed to create a treatment plan. You may have to first remove equipment from the patient, such as a backpack, helmet, or gloves. You may need to cut or tear open the patient’s clothing near the affected area(s). Be mindful of exposing only what is necessary, as hypothermia can occur even in mild climates.
+
+Medical documentation
+Medical documentation is an essential part in caring for a patient. The most common method for creating a document is to use the acronym SOAP. A SOAP note is considered a standard in medical documentation.
+Medical documentation using SOAP
+S Subjective O Objective A Assessment P Plan
+Be prepared to give a verbal presentation when the patient is handed off to medical personnel. The verbal presentation should be structured the same way as a SOAP note. The SOAP note and verbal presentation should start with demographic information on the patient. This would be followed with the patient’s chief complaint or chief injury (subjective). You would then briefly state what you found on your exam (objective) including patient vitals, followed by a list of injuries or medical problems you found, and the treatments performed (assessment and plan).
+
+What are vital signs?
+The word “vital” refers to items that are essential for life. The vital signs are the measurements. Some vital signs are easy to measure like the pulse. Some require instruments like a blood pressure cuff to measure the blood pressure. Most people don’t carry a blood pressure device with them. So, most often we must rely on other measurement. Some are subjective such as the level of consciousness. The main vital signs are:
+• Level of consciousness / level of responsiveness (LOC / LOR)
+• Heart rate (HR) or pulse
+• Respiration rate (RR)
+• Skin color, temperature, and moisture (SCTM)
+• Body temperature (T)
+Taking a patient’s vital signs is part of the physical exam. Consecutive sets of vital signs will help to tell you how the patient is doing. When you do this, it is important that the same person do it for consistency. The second set of vitals is often more important than the first, the third set is more important than the second, etc. This is a good way to follow how a patient is progressing. Make sure you document the time each set of vital signs was taken.
+
+Level of Consciousness / Responsiveness
+This is a measure of the brain’s ability to relate to the outside world. It is important for many reasons. It is the first vital sign to change. It is usually subjective. The acronym that is most often used is:
+• A - Alert
+• V - Verbal
+• P - Pain
+• U - Unresponsive
+Alert
+This looks a whether the patient is awake and able to answer questions appropriately. You should ask tif he patient is “oriented” to who they are and some basic situational information
+Each question they answer correctly = oriented by X / 4
+⚫ What’s your name?
+⚫ Where are you?
+⚫ What day is it?
+⚫ What happened?
+If they answer all 4 correctly, they are oriented by 4 / 4 but if they only know their name, then they are oriented by 1 / 4
+
+Verbal
+The looks at whether the patient can talk or not. You might comment if they follow simple commands.
+Pain
+This assesses that if the patient does not react to talking but does react to painful stimuli.
+
+Unresponsive
+This look at if the patient does not respond to any stimuli, to include verbal and painful stimulation.
+
+Heart Rate / Pulse
+Normal pulse is 60-100 bpm in adults. The heart rate can be taken anywhere you can feel a pulse. The radial pulse at the wrist is usually the easiest to check. Children typically have a higher heart rate with newborns ranging from 100-150 bpm. Count the pulse for 15 seconds and then multiply by four.
+
+Respiratory Rate
+Normal between 12-20 breaths per minutes. Breathing in and out counts as one breath. Count the number of breaths for 30 seconds and multiply by two. You should make a comment about the quality of the breathing, such as labored or shallow breathing.
+
+Skin Color, Temperature, Moisture
+The color of the skin in non-pigmented areas hold a key to that patient’s status. Red skin could mean fever or hyperthermia. Blue skin could mean hypothermia or a lack of oxygen in the blood. You can feel the skin to check temperature. And you can feel for moisture. If your patient is sweating it could mean fever or hypothermia.
+
+Body Temperature
+Most people don’t take thermometers with them. But is you do, a thermometer that does not break and one that goes lower is the best. You might have to estimate the temperature.
+
+Recording Vital Signs
+Here is an example of what you might record if you took vitals on a young, healthy person with
+normal vitals.
+⚫ LOC = Awake and oriented to person, place, time and events (A+O×4)
+⚫ HR = 70 bpm, regular, strong
+⚫ RR = 15 breaths per minute, regular, unlabored
+⚫ SCTM = pink, warm, dry
+
+Chapter 3: Wound Management
+Wound management in the wilderness backcountry is different than wound management in an urban setting. One significant difference is that backcountry wounds are often dirty or may become dirty. There’s often a lack of first aid material too. A single abrasion wound may use up all the gauze pads in your entire kit, leaving nothing for other injuries. You may not have the appropriate first aid material for closing a wound, such as sutures or steri-strips. And, if the injury happens at night, seeing the wound could be difficult without proper lighting. The following addresses these types of issues in managing wounds in the wilderness.
+
+Hemostasis
+The next step is to stop the bleeding. This is called hemostasis. If the wound is such that a person is going to bleed out, this becomes emergent and is first in the primary survey using the MARCH protocol, where ‘M’ stands for massive hemorrhage. Direct pressure is the first step in stopping any blood loss. The application of direct pressure controls bleeding from most wounds. Use the cleanest materials available and apply direct pressure to the source of bleeding. This may take several minutes. Larger wounds may require direct pressure for a longer period.
+Scalp wounds may require continuous, direct pressure for 30 to 60 minutes in order to achieve
+hemostasis.
+If direct pressure does not stop the bleeding, use a tourniquet. Rapid arterial bleed can cause a patient to go into shock very quickly. It is vital to recognize a severe arterial bleed that requires a tourniquet which will quickly and efficiently control the bleeding. If a tourniquet is used for more than several hours, it places the patient at risk for limb loss. Elevation of the limb above the heart alone is rarely sufficient enough to stop bleeding. You should always check for distal neurological function to ensure adequate blood flow to the extremity.
+
+How to Place a Tourniquet
+• Place the tourniquet over clothing if possible, about two to four inches above the wound.
+• Do not place the tourniquet on a joint or directly over a wound or a fracture.
+• Once the tourniquet is in place, it should be tightened so that all bleeding stops. Secure the windlass so that it does not unwind.
+• Mark the time that you placed the tourniquet on the patient’s forehead, so it is rapidly visible to other personnel when the care for the victim.
+• There is no need to intermittently loosen a tourniquet for “perfusion” of an extremity.
+
+Cleaning/Debridement
+All wounds need to be cleaned. “High-pressure” irrigation is the most important intervention to prevent infection and decrease bacteria content for most wounds. A wound should not be closed by any means prior to proper irrigation and decontamination. Leaving the wound to dry and scab over has the potential to form a larger scar and become infected over time.
+Irrigate the wound with a solid stream of the cleanest water available. Tap water has been shown to be as effective as sterile saline. You can use a syringe with a catheter tip to create a high-pressure stream of water, or you can fill a plastic bag filled with water. Poke a small hole in the corner of the bag, and then close the top of the bag to create a seal in order to force a stream of high-pressure water from the bag. An alternative would be to use your plastic water bottle that has an adjustable top. Rinse the wound forcefully with the water, protecting your skin and eyes from fluid splashes. If a splash shield is not available, a 4x4 gauze pad can be taped at the opening of the irrigation system.
+It is important to remove visible foreign matter from the wound to minimize infection, inflammation, discomfort, and skin tattooing. If possible, remove any clearly devitalized tissue, which may serve as a culture medium for any remaining bacteria. Debridement should be followed with another round of high-pressure irrigation and reexamination.
+
+Dressing a Wound
+Dressing a wound is difficult in the wilderness but very important. It protects wounds from the dirty wilderness environment, helps with the prevention of infection, and can be accomplished in a number of ways. If a commercial pad or dressing is not available, improvise using a 4 x 4 pad covered in an antibiotic ointment. Cover this dressing with an absorbent gauze dressing, then secure with tape. If the injury is on a flexible part of the body you might want to immobilize the joint using a splint to prevent the wound from reopening.
+Topical antibiotics are appropriate for all skin wounds in the wilderness. Bacitracin is a good choice. Neomycin is less ideal because it is associated with allergic reactions. A great topical ointment is honey. The osmolarity and bacteriostatic compounds in unprocessed honey make it an extremely effective, inexpensive and readily available alternative for topical application. Oral antibiotics is still a debated subject. Adequate cleansing and protection from the environment are much more important factors in prevention of infection. If it is a complex or mutilating wound or grossly contaminated with a lot of debris, oral antibiotics would be given. Some animal bites require antibiotics as well. Any wounds with signs of infection should receive antibiotics. These signs include pain, redness, swelling, or purulent discharge. If you suspect a wound is infected, you should always apply a new dressing and consider evacuation.
+
+When to Evacuate a Wound
+The injuries that require considerations for evacuations are:
+• Complex or mutilating wounds
+• Grossly contaminated with penetrating debris
+• Laceration of eye lid, ear or cartilage
+• Penetration of bone, joint or tendon
+• Bites of hands, legs or feet
+• Amputations
+Scabs
+Contrary to popular belief on letting a wound scab over, recent studies have shown that keeping the wound environment moist promotes wound healing and reduces scar formation. This can be done
+with daily application of Vaseline, honey, or a clean moist dressing. When wounds are kept exposed to the air, they will dry and form a scab.
+Scabs slow the wound healing process. The purpose of the scab is to protect the wound from environmental contamination. A scab forms a barrier to the generation of new tissue. Studies have shown that, under the influence of scabbing, the regenerative wound healing processes take more time and thus increases the risk of scarring and infection.
+Wounds should be kept moist for the entire duration of healing. Grass doesn’t grow well under a rock, and skin cells do not grow well under a scab. Keeping the wound open and dry slows wound healing and promotes scar formation. The wound should be rinsed daily to keep scab formation to a minimum. Dressing inspection and dressing changes should happen daily, if possible.
+
+Closing a Laceration
+Closing a laceration in the wilderness is difficult. The decision to close a wound is broken down to two courses of action:
+1. Primary closure: You can close it with sutures, staples, tape, or skin glue.
+2. Delayed primary closure: You can pack it with gauze, wrap it and clean it often until you can get to definitive care.
+Closing the wound with sutures, staples, tape, or tissue adhesive has the advantage of immediate treatment with better mobility and less pain. However, the risk of infection is higher. If you decide to pack the wound, the infection rate will be less, but it is more painful, and the patient will have less function of the area. There’s also the consideration that only one of the two action plans may be suitable or even available given the situation. Interestingly, there is no improved outcome of primary closure versus delayed primary closure.
+Steri-strips or tape: Closure may be simply achieved by placing steri-strips or tape of some kind over the wound and pulling the wound together. If necessary, trim the hair around the edges of the wound so the tape will adhere better. Duct tape with perforations made with a safety pin may suffice. The holes should be made from the sticky side pushed out towards the non-sticky side so that it will allow better drainage of fluid from the wound.
+Sutures and staples: These can both be used effectively if continued cleanliness of the wound can be assured and are more appropriate for large wounds and those in high-tension areas. Staples can be used anywhere except the face.
+Tissue adhesives: Skin glue can be used for closing small and uncomplicated lacerations. The glue is applied on top of the wound and serves as a bandage to close the wound. They are used in low tension areas. They are good because they produce an impenetrable barrier that requires a thoroughly cleansed wound.
+If an injury is on a flexible part of the body, such as an elbow or a finger, immobilize the joint with a splint to prevent reopening of the wound. Do not take aspirin. Taking aspirin with an open wound may worsen bleeding. One should not close a wound in the wilderness to aid in hemorrhage control. It can lead to an increased infection rate. The one exception is scalp injury. The increased vascularity of the scalp can make bleeding control more difficult. At the same time, the increased vascularity makes the scalp and face one of the body areas least prone to infection. Animal bites to hands, leg, and feet require medical attention in a clinic or hospital. There is an elevated risk of infection, and antibiotic prescription is often needed. The patient might also need a tetanus booster and a rabies vaccination.
+Burns
+Burn injuries are common in the wilderness, where many sources of heat are used. Before initiating treatment, a burn must first be classified, as its classification determines how it is treated. Burns are classified three ways:
+• by depth
+Depth of Burns Spears rerees Mecanees: es Sennees
+• by area
+location on the body
+In superficial burns, the skin can become red and painful. Mild sunburns are a type of superficial burn. Partial-thickness burns are generally very painful as the burn depth is at the level of the nerve endings. They blister and can have skin discoloration. Full-thickness burns are deep and are classically painless. They burn through the dermis.
+
+Treatment of Superficial Burns
+Treat superficial burns with aloe-vera gel and for comfort, cool the area with damp, wet cloths. Aloe vera has no antimicrobial properties, however. Leaving the wound to dry increases scar formation and slows wound healing, so keep the burn moist. It is essential to avoid further exposure to heat and sunlight. Patients with these types of burns might be able to stay in the backcountry if the pain is controlled.
+
+Treatment of Partial and Full Thickness Burns
+Partial and full-thickness burns are more serious and will be painful. Gently clean the burn with cool water to remove loose skin and debris and trim away all loose skin. Apply a thin layer of antibacterial Ointment (i.e. Silvadene) to the burn and cover it with a non-adhesive, sterile dressing. Inspect the wound and change the dressing at least once a day. These might be too painful to keep in the backcountry. Do not apply ice directly to burns for more than 15 minutes, as this may cause more tissue damage due to a decreased blood supply to the area.
+Know the TBSA (Total Body Surface Area) for burns to aid in decision making for evacuation.
+The Rule of Nines Each arm 9% Each leg 18% Front of trunk 18% Back of trunk 18% Head and neck 18% Groin 1%
+
+When to evacuate a burn
+Burn injuries that require evacuation consideration are:
+• Partial-thickness burns greater than 10% body surface area
+• Full-thickness burns greater than 1% body surface area
+• Partial- or full-thickness burns involving the face, hands, feet or genitals
+• Electrical burns
+If the burn victim is medically ill
+•
+• Uncontrolled pain
+• Burns complicated by smoke or heat inhalation (evidence of smoke inhalation include difficulty breathing, hoarse voice, singed nasal hairs, or carbon in patient’s sputum)
+Blisters
+A blister is a pocket of fluid between the upper layers of skin and are common to develop in the wilderness. The most common causes of blisters are friction (i.e. from poor fitting shoes), freezing of the skin (frostbite), and burns.
+The blister bubble is formed from the epidermis, the uppermost layer of skin. Its purpose is to protect and cushion the layers underneath. Blisters can be filled with serum, plasma, blood, or pus, depending on how and where they are formed. Friction blisters usually form a ‘hot spot’ (sore spot) first.
+6
+} ’
+If a small blister or hot spot forms, place a dual-layer pad over that area. Blist-o-ban is one such material. These pads address the two causes of friction blisters, the friction and shear forces on the skin. The dual-layer will allow the bandage to glide smoothly in all directions, deflecting friction and shear forces away from the skin. The key to preventing blisters is to reduce ‘hot spots’ by properly breaking in boots and reducing moisture by wearing wool socks.
+You can treat a blister that has already formed, by cutting a hole in the moleskin and placing the ring of moleskin around the blister. This reduces the pressure placed on the blister. This should help reduce the pain. It is not recommended to pop or drain blisters that are small (<2cm or <0.75 in).
+When should a blister be opened? The answer is not clear. In general, if the blister is 2 cm in diameter or larger, then it is likely to rupture spontaneously and may be amenable to initial treatment by intentionally rupturing it. However, there is no best answer to this issue. In those cases where it is large enough or it has already ruptured, wash the area and puncture the base of the blister with a sterile needle or sterilized safety pin. Debride the external flap of skin from the blister, apply an antibiotic ointment, and cover the blister with a sterile dressing. This can be protected with moleskin or mole foam. Hydrocolloid dressings have increased in popularity, also providing protection and comfort.
+
+Amputated digits
+An amputated digit should be transported promptly. It should never be placed directly on ice, nor should an attempt be made to reattach the finger in the wilderness. Placing an amputated finger in milk has no benefit. (Placing tooth in milk is good to preserve it.)
+
+Penetrating objects
+Never try to pull a penetrating object out of the patient in the field. Use gauze or similar material, alone or with a bulky dressing, to stabilize the object as best you can and evacuate as soon as possible. Removal of the object in the field may cause additional damage and/or cause bleeding and result in serious harm to the patient. Although the surface of a puncture wound should be cleaned to facilitate examination, puncture wounds themselves should generally not be irrigated, as this may further push in contamination. The than simple lacerations, as they are associated with a high risk of infection.
+—
+wound should be dressed without closure. Puncture wounds should be evaluated more frequently
+
+What Ointment should be used on a wound?
+Honey has been used in wound care for thousands of years to prevent infection and speed the healing process. Medihoney works by keeping the wound bed moist and slow-releasing an antibacterial agent into the wound site. Most normal honey has varying levels of hydrogen peroxide, but Medihoney specifically uses Manuka honey, which also contains methylglyoxal. This helps it to fight a broader range of bacteria strains.
+Lodosorb is an advanced wound care gel used to treat open wounds, stalled wounds, and infected wounds. The gel design provides an excellent wound healing environment while slowly releasing antibacterial iodine into the wound bed. Iodine concentrations at the wound site suppress bacterial populations, including antibiotic-resistant strains like MRSA, while leaving the body’s cells unaffected.
+Topical First Aid Antibiotics are available over the counter. These include bacitracin, neomycin, and polymyxin B sulfate. Some also contain the anesthetic lidocaine for pain relief. These products are well tested. There is a large allergic reaction rate to neomycin, so clinics are moving away from this. Make sure someone is not allergic to sulfa, and bacitracin is sulfa-based.
+Silvadene Cream 1% (silver sulfadiazine) is a topical antimicrobial drug indicated as an adjunct for the prevention and treatment of wounds and in patients with second- and third-degree burns. It contains both silver as antimicrobials, but it also contains emollients that help ease the pain.
+
+Chapter 4: Bleeding and Shock
+Everyone reading this chapter has cut or scraped themselves and has bled. Bleeding is also called hemorrhage. It can happen inside the body where it is called internal bleeding, or outside of the body, where it is called external bleeding. When you look at someone bleeding you can usually tell which type of vessel has been ruptured.
+• Capillary bleeding – slow oozing and bright red in color
+• Venous bleeding – steady flow and dark maroon (due to lower oxygen in the veins)
+• Arterial bleeding – under high pressure, often spurting and brighter red in color Most capillary and small venous hemorrhaging will stop bleeding without your assistance. However, larger wounds and arterial damage will usually require your assistance to stop the bleeding.
+
+First Step: Direct Pressure
+The first method is to apply direct pressure on the wound. When applying direct pressure, remember to follow these rules:
+⚫ Use gloves and sterile dressing if available to reduce infection
+⚫ Apply pressure with the heel of hand directly onto wound
+WY y = \\
+Certain wounds are more difficult to control the bleeding, Such as large wounds because of the large number of blood vessels involved. And it is harder to put pressure on the entire wound. Scalp wounds bleed a lot and are thus more difficult to control the bleeding.
+
+Second Step: Pressure Dressing
+A pressure bandage should be applied if there is continued bleeding or if you need your hands to provide other care to the patient. Wrap and hold the dressing in place with an elastic bandage (Ace® wrap) or tape that you wrap around the extremity. If the patient continues to bleed through the pressure dressing, then you should remove the elastic bandage and place additional dressing on top of the dressing that is already on the wound. After applying a pressure bandage, be sure to check to see if they have blood flow at the fingertips.
+
+Third Step: Using a Tourniquet
+While widely viewed as a last resort, in the wilderness a tourniquet can be used initially to stop bleeding. It will hurt where you apply it, but it might save a life. After it is on, you can assess the wound and determine the best approach of treatment and evacuation. If you have tried the other methods to stop the bleeding and the wound continues to bleed a lot through the dressing, then you should consider a tourniquet as well. Always note the time the tourniquet was applied. Writing the time on the victim’s forehead is very effective because it is obvious to other rescuers and to the providers who receive the victim as they are brought into a hospital setting.
+
+Internal bleeding
+Bleeding into a body cavity is life-threatening, so getting the patient to surgical help is essential. Patients can bleed internally anywhere, but there are specific areas of the body (CARTS) that more easily allow for life threatening bleeding
+• Chest (from a broken rib)
+• Abdomen / Pelvis (usually due to a spleen and/or liver injury or pelvis fracture)
+• Renal/Retroperitoneal (kidney area in the back)
+• Thigh (From a broken thigh bone)
+• Skin / Street (Blood is seen on the skin or the ground)
+Patient may lose a lot of blood before you are aware of any bleeding because it is not obvious to
+you.
+You should look for external bruising, guarding, and an increasingly abdominal pain. There is little treatment that can be done while in the field for internal bleeding. You need to get them to help quickly.
+
+Shock
+Shock has many meanings in the real world. But in medicine, it is defined as the lack of blood flow to vital organs, particularly the brain. This is why people going into shock will be confused and lightheaded.
+
+Causes of Shock
+If you suspect someone is going into shock or is already in shock, you should determine the cause so you can best treat them. Here are the most common causes of shock. Remember that all shock results from failure of one or more of the components of the cardiovascular system.
+Cardiogenic Shock. This is failure of the heart to pump normally. A heart attack is the most common cause. This is where there is muscle damage due to lack of blood supply to the heart muscle.
+Hypovolemic Shock. This is caused by excessive bleeding where a person loses blood and the volume of blood is critically low (hypovolemic). This can happen from severe bleeding, dehydration of from burns.
+Vasogenic Shock. This means that the vessels enlarge and so the heart cannot maintain blood flow and blood pressure. It is usually cause by spinal injuries or severe by severe allergies (anaphylaxis), or by severe infection
+Symptoms of Shock
+The signs of shock or a progression of signs and symptoms. It begins with anxiety, confusion and pale and cool skin, which then progress to becoming unconscious and then to death. Here are the progressive stages of shock.
+⚫ Stage 1: Compensatory Shock
+Anxiety, confusion, restlessness, pale and cool skin
+Increased pulse and respiration rate
+Patients showing these declines in vital signs should be evacuated.
+⚫ Stage 2: Decompensated Shock
+Altered level of consciousness, cold and clammy skin
+Rapid weak pulse and respirations
+It may be hard to find a pulse
+⚫ Stage 3: Irreversible Shock
+Drowsy, unresponsive, cold skin
+Slow heart rate and slow, labored respirations
+No pulses palpable, death
+
+Special Risk Factors of Shock
+It can be difficult to tell if children and teenagers are in shock as their bodies tend to be more resilient and compensate for a longer period. But the elderly are the opposite of children and young adolescents, as their bodies do not compensate as well and have an earlier onset of shock.
+
+Management of Shock
+Anticipate and treat for shock until you have ruled it out. Early intervention is very important. Y9ou should treat the underlying cause if possible. Stop the bleeding, and splint fractures. Insulate from cold or protect from heat and monitor vital signs frequently. Patients with a good level of consciousness should drink to keep hydrated. But most importantly evacuate as soon as possible.
+
+The Airway
+You will hear the expression “open airway.’ This term means that air can flow freely from the mouth or nose to the lungs. A lot of things can block the airway, including debris, blood, teeth, and dentures. A very common problem is that the tongue often blocks the airway in cases where the patient is unconscious and laying on their back. The unconscious victim does not “swallow their tongue”. Instead, the tongue is attached to the mouth but will relax backwards and may block full flow of air down into the lungs.
+\ oS —<Urrr
+There are two maneuvers that can be used to open the airway in this situation.
+• Head-Tilt/Chin-Lift Maneuver
+• Jaw-Thrust Maneuver
+
+Head-Tilt/Chin-Lift Maneuver
+1. Tilt the head back by placing pressure on the forehead and lift the chin as shown.
+2. When lifting the chin, apply upward pressure on the bone (avoid pressing on the soft tissue below as this may further block the airway).
+3. Continue until chin points to sky. In children, place head in neutral position.
+
+Jaw-Thrust Maneuver
+1. Kneel at the victim’s head facing the victim’s feet.
+2. Put arms in such a position that creates a continuous line with the patient’s spine.
+3. Place thumbs on cheekbones and two or three fingers at the corner of the patient’s jaw (at the angle between chin and ear).
+4. Use counter pressure from your thumbs on the patient’s cheekbones to pull the jaw forward with your fingers.
+• Assess the patient’s breathing.
+• A breathless patient requires foreign-body removal and/or rescue breathing.
+
+Foreign-Body Airway Obstruction: Conscious Adult and Child (Heimlich Maneuver)
+1. Wrap arms around the person’s waist from behind (keep elbows out from ribs).
+2. Make a fist and place thumb in on midline abdomen above navel and well below the bottom of the sternum (breastbone).
+3. Grab your fist with your second hand and pull quickly in and up in a powerful motion.
+4. Repeat until airway clears or until the patient goes unconscious.
+
+Foreign-Body Airway Obstruction: Unconscious Adult
+1. The victim should be lowered to the ground and CPR should be initiated.
+
+Foreign-Body Airway Obstruction: Conscious Infant Less than One Year Old
+1. Determine why there is a lack of breath
+2. Hold infant as shown in the image above, supporting the head with the head positioned lower than the trunk.
+3. Give five forceful blows between shoulder blades with the heel of your hand.
+4. Using the hand that was used to give the blows, support the neck and back of the baby’s head while turning the baby on its back, then give five chest thrusts with the finger of your free hand on the lower half of the baby’s sternum.
+5. Repeat until the breathing is clear or until the baby is unconscious.
+¢ *
+
+Foreign-Body Airway Obstruction: Unconscious Infant Less than One Year Old
+1. Open the airway using tongue-jaw lift maneuver. Look for obstruction—DO NOT blind finger sweep.
+2. Open the airway and ventilate by sealing your mouth over the patient’s mouth and nose and breathe out slowly so the baby’s chest rises.
+3. If the first attempt fails, reposition the airway and try a second time.
+4. If the airway is still blocked, give five back blows then five chest thrusts.
+5. Repeat steps 1-3 until the airway is opened.
+6. If the baby is still not breathing once the airway is open, start CPR.
+
+Rescue Breathing Review
+In most situations, hands only CPR should be performed without any rescue breathing. Those unique wilderness situations that may require rescue breathing as part of CPR include drowning, lightning strike, and avalanche burial. If you are going to perform rescue breathing on a victim, you should use barrier protection to keep yourself safe. This is especially true because rescue breathing is only really indicated in drowning, lightning, and avalanche burial.
+1. Pinch the patient’s nostrils and hold the mouth open.
+2. Take a deep breath away from the patient’s mouth. Seal your mouth over the patient’s mouth.
+3. Give two breaths over one second each making sure to see the chest rise for each one.
+4. If you cannot see the chest rising, reposition the airway and try again.
+5. Check for pulse: If it is present, continue breathing. If there is no pulse, start CPR.
+Naw
+6. Use one breath per five seconds.
+7. Rescue breathing can be done mouth to mouth or mouth to nose if necessary.
+
+Rescue Breathing Exceptions in Children and Infants
+When performing rescue breaths on children, do not tilt the child’s head too far back as this may block the airway in young patients. If you are going to perform rescue breathing on a victim, you should use barrier protection to keep yourself safe.
+1. Seal off mouth and nose with your mouth.
+2. Use small puffs instead of full breaths.
+3. Watch the patient’s chest and abdomen.
+4. Use one breath per three seconds.
+
+Chapter 6: Musculoskeletal Injuries
+Sprains
+A sprain involves the ligaments (tissue that connects bone to bone) of a joint and means that the ligaments have been stretched or even torn. A sprain usually occurs when a joint is twisted or wrenched beyond the normal range of motion which causes the ligaments to stretch or tear. While sprains can occur in any joint in the body they happen most often in the knees and the ankles. Symptoms include pain, swelling, and discoloration of the injured joint Sprains can be difficult to differentiate from fractures, due to the fact that they share many of the same signs and symptoms.
+
+Strains
+Strains, unlike a sprain, involve tendons which are the fibrous bands that connect muscles to bones and facilitate the movement of our limbs. A strain, simply put is fatigue due to overuse or strenuous movements. While strains are usually considered to be minor injuries, they can cause pain and discomfort.
+While strains are not as severe as the other injuries that have been mentioned there is treatment for them. The best way to deal with strains is to try and minimize the use of the limb or area that is causing pain. Anti-inflammatories as well as analgesics can help to combat both the inflammation and pain that accompany strains.
+The image to the right is an ‘open’ fracture of the tibia. Note the open sore on his foot where the bone is partially exposed.
+
+Dislocations
+A dislocation occurs when a sufficient force (a push or a pull) is placed on a joint which causes a bone to come out of its socket. Dislocations are most common in the shoulder, elbow, finger, and kneecap. While dislocations themselves can create quite an ordeal the real damage is usually caused to blood vessels, nerves, muscle, and ligaments.
+
+Fractures
+A fracture is any break or crack in a bone. There are two general types of fractures:
+1. Closed fracture: In this case the bone is broken but has not punctured the skin exposing the bone. If a closed fracture is left untreated or handled improperly, it can quickly progress into an open fracture.
+2. Open (compound) fracture: Just like a closed fracture the bone is broken except in this case the fractured bone has punctured the skin creating an open wound. Be aware that the bone does not need to be protruding out to be considered an open fracture. This may happen when the broken bone cuts through the skin. Bbacteria and debris can ultimately lead to serious bone or other tissue infection that can impede bone and wound healing.
+Since fractures can be difficult to diagnose without x-rays the following signs may help to indicate where there is a fracture. Note that even with these guidelines it will not be possible to identify all bone fractures.
+⚫ Point tenderness - pain and tenderness at a very specific point of the body.
+⚫ Deformity – as mentioned before our bodies are symmetrical so if there is an abnormal shape position, or motion of a bone/joint then a fracture could be present.
+⚫ Inability to use the extremity – a bone fracture can most likely render the limb unusable. If a victim cannot move the limb or joint, or cannot bear weight on it, a fracture should be
+suspected.
+⚫ Swelling and bruising – at or around the fracture site.
+⚫ False joint – the ability to move a limb at a point where no joint formally exists.
+⚫ Bone snap – sometimes the victim will hear or feel a bone snap which can help to diagnose a bone fracture.
+⚫ Crepitation - the grinding of bones that can sometimes be heard moving a fractured bone.
+The image to the right is a fracture of the radius and ulna bones in a 17-year-old biker who fell in a competition. Note the ‘false joint’ that is typical for this injury. It is swollen and tender.
+
+Pelvic Fractures
+Fractures sustained to the pelvis or pelvic area is serious because they are usually accompanied by significant internal bleeding. This bleeding can result in shock or even death. Along with internal bleeding, pelvic fractures can also cause damage to other internal organs such as the intestines or bladder. Symptoms of a pelvic fracture include pain in the pelvis, hip, or lower back. with the inability to bear weight or significant pain around the hip or waistline. And there will be pain when you push (gently) on the pelvis from the front.
+⚫ Pelvic fractures call for immediate helicopter evacuation. Arrange for helicopter transport.
+⚫ Place a sweatshirt or jacket around the pelvis and create a knot that gently secures the fractured pelvis
+⚫ In the most comfortable position for the victim create a splint by placing padding between the legs and then by strapping the legs together.
+⚫ Do not elevate the legs.
+⚫ Refrain from pressing on the pelvis more than as absolutely necessary.
+
+Femur (Thigh Bone) Fractures
+Due to the presence of very large thigh muscles and arteries that surround the femur, a broken femur can be life threatening due to bleeding. They are very painful. When the bone breaks, the thigh muscles strongly contract and force the broken bone ends into the muscle, which causes extreme pain and increased blood loss.
+
+Treatment
+General
+If the mechanism of injury is unknown or such that a neck or back injury is suspected, immobilize the neck immediately upon reaching the victim. Completely uncover the injured area to look for deformity, swelling, discoloration, breaks in the skin consistent with an open fracture, and other associated injuries. Gently feel the injured area for tenderness, abnormal movement, and crepitation. Check for numbness or altered sensation beyond the injury. Check circulation beyond the injury by pinching the fingernail or toenail bed (if the injury is to an arm or leg) and see how long it takes for the color to return to normal (from white to pink). It should be less than 3 seconds.
+
+Splinting Basics
+The main reason for splinting an injury is to immobilize a limb to not exacerbate an injury. Splints can also help to reduce pain that accompanies various musculoskeletal injuries. Please note that while splinting is not only good practice but is also necessary to reduce pain and protect the injury from worsening. It is also only a preliminary treatment used in the event to evacuate a victim to seek further medical care. General principles regarding splinting include:
+A splint should be long enough to immobilize the joints both above and below the fracture, sprain or site of dislocation. The splint should immobilize the fractured limb in its functional position.
+The leg should be splinted with a slight bend at the knee.
+The ankle and elbow should be splinted with the joints flexed at a 90-degree angle.
+The wrist should be splinted straight or slightly bent backwards (extended).
+The fingers should be bent in a position like that of holding a can of soda and should have loose swath or cloth in between each finger to ensure proper blood as well as lymph flow.
+
+General guidelines for splinting
+⚫ Remove ALL (including sentimental) jewelry and accessories, such as watches, bracelets, and rings, before applying a splint. Swelling due to injury will make these objects very hard to remove if left in place.
+⚫ Use padding within the splint to make it as comfortable as possible for evacuation. Use plenty of padding at bony protrusions, such as elbows, knees, and ankles.
+⚫ Splints should be made from rigid, sturdy material. Examples are sticks, boards, skis, paddles, heavy cardboard, and rolled up magazines or newspapers. Be creative when creating trying to conjure materials for a splint.
+⚫ Secure the splint in place with pack or lifejacket straps, tape, belts, strips of cloth, webbing, or rope. Tie securely, but not tightly enough to inhibit distal function or blood flow to the limb. Secure the splint in several places, both above and below the fracture, sprain or dislocation.
+⚫ Mold the splint on the uninjured limb or body part first and then transfer it to the correct site.
+⚫ After splinting, elevate the injured body part to minimize swelling.
+⚫ Always recheck sensation and circulation beyond the site of injury after placing a splint. If distal sensation and circulation is inhibited due to splinting redo the splint.
+
+Sprains
+RICES was the acronym that is used to treat sprains: Rest, Ice, Compression, Elevation, and Stabilization. The problem is that prolonged ice application may prevent blood flow to the area and retard healing, So, ice should be applied initially only Compression also, prevents blood flow into the area so this is discouraged. Stabilizing the injury is important and elevation will help with the swelling. Rather then rest, a patient can start to use the injured area as the pain decreases.
+This treatment helps to prevent/reduce swelling. Follow the RICES treatment for the first 72 hours following the injury.
+
+Realignment of a Closed Fracture
+It is not necessary to realign a fractured limb unless distal function and circulation is restricted or in the case that deformity makes it impossible to splint and transport. However, if it can be easily realigned here are some things to consider:
+⚫ Numbness, tingling, and/or blue discoloration of the skin beyond the injury, all of which indicate poor blood flow (circulation) indicate the need to realigned the fractured limb.
+⚫ Realignment is easier if it is done soon after the injury as pain will make it more difficult.
+
+Realignment of a closed fracture
+⚫ Straighten the limb by pulling on it below the fracture in a direction that will straighten it. This
+should be done while someone else holds the limb above the fracture.
+⚫ While continuing to hold the limb straight, apply a splint to prevent further motion.
+⚫ Check distal function and sensation after realignment often and track the limb’s progress.
+
+Realignment of an Open Fracture
+Reasons for realigning an open fracture are fundamentally the same as for realigning a closed fracture. The procedure for aligning a closed fracture is like an open fracture but also includes the following:
+⚫ The wound and extruding parts of the bone should be thoroughly irrigated and removed of all foreign matter. Although risk of infection is present, it may be necessary to replace the exposed bone end back into the wound during traction for proper realignment.
+⚫ While continuing to hold the limb straight, apply a splint to prevent further motion.
+⚫ Cover the wound with a sterile dressing, then bandage.
+⚫ Check and recheck distal function, sensation and function often after realigning an open fracture.
+Dislocations
+After a dislocation occurs the muscles that surround the joint will begin to spasm making it harder to reduce the dislocated limb. If you know how to reduce a dislocated limb the sooner after the injury it is attempted the higher the chance that you will be able to reduce it as it becomes more difficult with time. Reducing a limb will also be helpful to the victim as dislocations are very painful and reducing them can provide relief.
+⚫ Splint the joint with plenty of padding.
+Ice the joint to minimize swelling.
+⚫ Check for sensation and circulation distally of the injury.
+⚫ Seek professional medical help as further damage beyond the visible can be sustained.
+
+Femur Fractures
+⚫ Use a traction splint if available. The traction splint will pull the overlapped bone ends into alignment and help to relieve pain.
+⚫ If a traction splint is not available, then splint the injured leg to the good leg by tying them together and recheck sensation and circulation in the foot often.
+
+Evacuation Guidelines
+Reasons for evacuating victims with musculoskeletal injuries from the wilderness include:
+⚫ Sprains that are significant enough to prevent further activities in the wilderness.
+⚫ All suspected fractures, whether open or closed.
+⚫ Any victim who has loss of sensation or impaired circulation beyond the site of the injury.
+⚫ Any suspected fracture that is in an area that would be considered life threatening.
+
+Chapter 7: Medical Problems
+Think of the differences in having a serious medical problem while you are home, knowing there is medical help nearby, to having a serious medical issue when you are in a remote section of the backcountry, and have no clue how to get help. Some medical problems occur with higher frequency in the backcountry, while others occur about the same rate while at home. By being able to recognize the signs and symptoms of serious medical conditions, you can provide a proper treatment plan for someone in the wilderness and potentially saving their life.
+
+CARDIAC EMERGENCIES
+Not long ago in the mountains surrounding Chamonix, France, a 56-year-old man began having chest pain while hiking on the famed Tour du Mt. Blanc. Friends and family were the only people nearby. The man survived and was ultimately brought out by a rescued team, but it was only after many hours. Evaluating and treating cardiac problems can be difficult in a hospital setting where the full spectrum of diagnostic equipment and treatments are available. It is even much more difficult in the wilderness. Let’s go over the basics of backcountry care of cardiac problems.
+
+Angina
+Angina is the term given to chest pain that is associated with diminished blood flow to a portion of the heart that does not cause actual damage. It is cardiac ischemia (low blood flow) but not infarction (death of heart muscle). Angina results from an imbalance between cardiac muscle oxygen demand and oxygen supply. This supply may be restricted due to atherosclerotic disease. But there are many reasons for an imbalance in oxygen supply and demand to occur in the wilderness. For example, there is an increased exertion that causes increased cardiac work. People are in cold temperatures, which creates peripheral vasoconstriction and increases cardiac work. Fear, mental stress, and/or pain, all of which increase the release of catecholamines, which in turn increase both heart rate and blood pressure. There can be decreased pressure of oxygen as a person gains altitude, which results in less oxygen being delivered to the heart.
+
+There are two types of angina:
+1. Stable angina is chest pain due to cardiac ischemia that is well known to the patient for a period of several weeks, months, or even years. It is commonly due to stable atherosclerosis in the coronary arteries. The patient knows the symptoms and usually knows what level of activity causes these symptoms.
+2. Unstable angina is new chest pain that is concerning for cardiac ischemia or a changing pattern in formerly stable angina. This is commonly attributed to a worsening of atherosclerosis in the coronary arteries or a sudden rupture of an atherosclerotic plaque with the formation of a partial clot in a coronary artery.
+Symptoms of both stable and unstable are chest pain and/or pressure. This is often described as a squeezing or tightness. The pain is usually in the center of the chest, but it may occur unilaterally or even across the entire chest. The pain may radiate to the arms, jaw, neck, or back, typically more towards the left. Victims may have shortness of breath, nausea or vomiting, lightheadedness, or actual fainting. They can sweat.
+Treatment for angina includes any steps to reduce the oxygen demand of the heart muscle. Also, rest is the key to the recovery of anginal pain. You should minimize exposure to the cold and decrease the elevation when possible, if possible, provide oxygen to the patient.
+Medications can be used, as well. The patient might have been prescribed a drug called Nitroglycerin (NTG). It is given as 0.4 mg sublingual. This may be repeated every 5 to 10 minutes until the pain is relieved or until three tablets have been given. After three tablets have been given, you may continue to give the NTG if it is working, and it is all that you have, which is usually the situation. However, when going beyond the initial 3 NTG tablets, it should be given with a greater time interval between the tablets. If symptoms do not resolve after 3 NTG tablets, you should assume the patient is having a myocardial infarction and begin immediate evacuation plans. The biggest side effect of NTG is a drop in the blood pressure. If the patient has a strong radial pulse, then it is probably safe to give them at least one tablet. You should have the patient lying supine when you give them the NTG. If there is any concern of dropping the blood pressure too much or if the patient is ill-appearing, then it may be prudent to not treat with NTG. This is because the NTG can help the pain, but it will not stop or treat a myocardial infarction.
+Aspirin 325 mg chewed is also possible. It is chewed to ensure that it is rapidly absorbed. Aspirin is an anti-platelet agent that may decrease the formation of thrombus in the coronary arteries. It is proven to decrease mortality in myocardial infarction (heart attack). It does not help with angina, but in the backcountry, it is never clear if the patient is having angina or a heart attack. All patients with unstable angina must be evacuated from the wilderness as soon as possible.
+
+Acute Myocardial Infarction (MI)
+Acute Myocardial Infarction (MI) is the term given to chest pain that is associated with absent or diminished blood flow to a portion of the heart that causes myocardial tissue death (infarction).
+The most common etiology for an MI is an atherosclerotic plaque in one of the coronary arteries that rupture, causing the formation of a clot within the artery.
+This clot obstructs the flow of blood distal to that obstruction. If that clot is not relieved as soon as possible, myocardial cell death will occur within 15 to 60 minutes with larger areas of infarction as time progresses.
+Symptoms of MI are similar to angina. However, the symptoms are usually more severe in nature and last much longer than angina. Typical angina should be relieved within 15 minutes. If symptoms last longer than 15 minutes, the patient should be considered to be having an MI. Patients without a prior history of angina should be assumed to be having an MI and treated as such.
+Chest pain or pressure is one defining difference between MI and angina. This is often described as a squeezing or tightness. The pain may be in the center of the chest, unilateral, or even cover the entire chest. The pain may radiate to the arms, jaw, neck, or back, frequently towards the left side.
+Other symptoms are shortness of breath, nausea or vomiting, lightheadedness or actual syncope, diaphoresis, and a feeling of impending doom.
+Treatment of an MI is immediate evacuation. This is the most critical priority for the patient with a suspected MI. The fastest way to the hospital is the best way to the hospital. This means that you may be required to put a patient through some exertion-such as walking out-in order to get him/her evacuated instead of waiting for evacuation. All of the following treatments are temporizing measures only until the patient can get definitive treatment. Steps to reduce oxygen demand of the heart muscle are important and similar to angina treatment. They should rest, reduce exposure to the cold, minimize anxiety, and go to a lower elevation.
+Medications such as Nitroglycerin 0.4 mg are given under the tongue. This may be repeated every 5 to 10 minutes until the pain is relieved or until three tablets have been given. After three tablets have been given, one may continue to give the NTG. However, it should be given over a longer period of time, checking the patient’s radial pulse each time prior to giving an additional dose. The biggest side effect of NTG is a drop in blood pressure. If the patient has a steady radial pulse, then it is safe to give them at least one tablet. There is one type of MI, right ventricular infarction, which is very sensitive to preload (venous return) reduction. This means the patient may have a significant drop in blood pressure with even one NTG tablet. Understand that this is a potential complication and ensure that you evaluate the patient’s vital signs before each NTG tablet by checking for a steady radial pulse each time.
+Aspirin 325 mg chewed is chewed to ensure that it is rapidly absorbed. Aspirin is an anti-platelet agent that may decrease the formation of thrombus in the coronary arteries if that is the primary problem. It is proven to reduce mortality in myocardial infarction. All patients with acute MI must be evacuated from the wilderness as soon as possible.
+
+RESPIRATORY EMERGENCIES
+The inability to breathe normally is a scary feeling and causes anxiety for many. Respiratory issues are common in the wilderness for a variety of reasons, including increased allergens, smoke from
+campfires, lower oxygen and drier air associated with higher altitudes, increased exertion, and increased physical and emotional stress.
+
+Asthma
+Asthma is a chronic, non-progressive lung disorder characterized by increased airway reactivity to irritants, airway inflammation, and reversible airway obstruction. In the wilderness, asthma can be triggered by a multitude of potential etiologies such as increased strenuous activity, exposure to cold, changes in humidity, exposure to
+mance muscle tightens muscle swelling mucus Normal Airway Asthmatic Airway
+environmental allergens, exposure to camp smoke, and medication noncompliance due to running out of medications.
+Patients who have asthma usually know that they have it and are taking medication. They will have shortness of breath on exertion, wheezing, or a dry cough. Most patients will know when they are having an asthma exacerbation based on their previous episodes. They should also be able to tell you whether their current symptoms are mild, moderate, or severe in comparison to previous episodes. This is useful in terms of judging their response to treatment and the need for evacuation.
+If the patient can speak in full sentences, then this is a mild exacerbation. If the patient can only speak a few words at a time, they are having a severe exacerbation. An epi-pen is a significant consideration if the patient is not responding to the inhaled medications.
+Patients with severe exacerbations of asthma must be evacuated from the wilderness. Those patients with mild to moderate exacerbations must be monitored closely and should have their activities limited. They do not require evacuation unless their symptoms do not resolve with field treatment.
+
+Pneumonia
+Pneumonia in the wilderness is a clinical diagnosis based on the patient’s history and exam findings. The patient will have chest pain that may be dull or sharp, may have a pleuritic component, and a cough that may be dry or productive of sputum. They will have shortness of breath, and also on exertion. They will have a fever and chills and an increased respiratory rate.
+If you suspect that someone has pneumonia, you should start antibiotics, even if unsure. Azithromycin or doxycycline are good choices. Remember to keep the patient well hydrated. If you suspect pneumonia, then the patient should be evacuated.
+
+Pulmonary Embolism (PE) & Deep Venous Thrombosis (DVT)
+Pulmonary Embolism (PE), or a blood clot to the lung, can be seen in wilderness activities. Traveling a long distance with relative immobilization places someone at risk of developing a deep venous thrombosis (DVT) and/or a PE. This is an essential consideration for those who traveled great distances to begin their wilderness adventure. High-altitude climbers are more susceptible to PE, particularly if they are dehydrated. Risk factors for DVT/PE include a previous history of a blood clot/DVT/PE, a long travel time to get to the destination, leg trauma while hiking or doing other outdoor activities, being tent bound or sitting on a raft for a long period of time, oral
+contraceptives, especially in women over age 35 who smoke, a family history of blood clot/DVT, and a history of cancer or recent surgery.
+Symptoms may look similar to pneumonia. They may have a sudden onset of chest pain that may be dull or sharp and may have a cough that may be dry or productive of bloody sputum. There could be shortness of breath and/or dyspnea on exertion, an increased respiratory rate, and unilateral leg swelling.
+There is no specific treatment that can be given in the wilderness that will help these patients. Recognition of this potential diagnosis is the most important part of the management of these patients. Aspirin could theoretically help. Descent, if at altitude, may help those with more significant symptoms. All patients with suspected PE or DVT should be evacuated as soon as possible.
+
+Cerebral Vascular Accident (Stroke)
+Cerebral Vascular Accident (CVA), or stroke, can occur anywhere but are seen in the wilderness for a variety of reasons. There are two types of stroke:
+
+Ischemic
+This is the most common type of stroke. Obstruction of blood flow to a portion of the brain leads to one-sided weakness, paralysis, trouble talking, or facial droop. This obstruction is most commonly due to a small intra-arterial blood clot.
+
+Hemorrhagic
+This stroke is due to intra-cerebral bleeding, most often from high blood pressure or a ruptured brain aneurysm. Patients usually have a significant headache and a denser neurologic deficit, or complete loss of consciousness.
+The signs and symptoms of each are not consistent enough to allow one to discern an ischemic stroke from a hemorrhagic stroke in the wilderness. The only accurate way to tell the difference between ischemic and hemorrhagic strokes is by brain imaging (CT or MRI). Always consider hypoglycemia of a migraine headache, as they have stroke-like symptoms.
+The signs and symptoms of a CVA vary depending on which part of the brain is affected. It can be a single sign or a combination of any of the following depending on the area and extent of the involvement.
+• Alteration of mental status. Common symptoms include confusion, stupor, and unconsciousness.
+Two Types of Stroke techeenle Stroke Hemorrhagic Stroke
+• Difficulty speaking or an inability to speak and ataxia. Symptoms include weakness to complete paralysis with the involvement of a single leg, arm, hand, or a facial droop.
+• Unilateral facial involvement. Symptoms include numbness or a total loss of sensation. If symptoms resolve quickly, then it is more likely a transient ischemic attack (TIA),
+sometimes called a “mini-stroke.” However, a TIA is a harbinger of a stroke, so even if the symptoms resolve, the patient must be evacuated as soon as possible.
+Treatment for presumed ischemic CVA or TIA is the same; evacuate the patient as soon as possible. Aspirin is to be given in an ischemic CVA, but not a hemorrhagic CVA. Since an Ischemic CVA is more likely than a hemorrhagic CVA, a single aspirin is unlikely to affect a hemorrhagic stroke adversely (if you’re not sure of the difference). However, it is not recommended to give aspirin to a patient with a known hemorrhagic stroke. All patients with CVA or TIA should be evacuated from the wilderness as soon as possible.
+
+Seizures
+Seizures are an uncommon medical problem in the wilderness because most people with this disorder tend to avoid wilderness activities. Either that or they are well controlled. In general, patients should be seizure-free for approximately six months before attempting to trek into the wilderness for any significant amount of time. There are numerous reasons for a patient with a known seizure disorder to seize in the wilderness, including:
+• Fatigue and lack of adequate sleep.
+• The risk of diminished absorption of their medications due to dietary changes.
+• A higher risk of missed medication doses due to the rigors of the trek and a different schedule than at home.
+Increased stress, which could exacerbate someone’s condition.
+Treating a seizure in the backcountry can be a real problem if everyone in the group is in a remote setting. The seizure may occur in someone while the group is doing a more technical activity, such as climbing or rafting. When treating a seizure, look for trauma, and consider hypoglycemia as an etiology. Allow the seizure to run its course. Most seizures will resolve spontaneously within 1 – 5 minutes. While the patient is seizing, you can do things to protect them from harm, such as:
+• Remove the patient from any hazards, such as pulling them out of water or away from a cliff edge.
+• Lay the patient on the ground so that they do not fall and hurt themselves further. Do not restrain them or hold them down. If possible, positioning them on their side may help avoid aspiration. Once they have stopped seizing, consider the recovery position.
+• Move objects that are a potential danger away from the patient.
+• Do NOT try to prevent them from biting their tongue by placing objects in their mouth. They will NOT swallow their tongue. You will do more harm by placing objects in their mouth.
+The group trip must be halted until the patient is out of the postictal phase. This timeframe may last hours, up to a day, and can be characterized by drowsiness, confusion, nausea, and headache.
+Evacuate anyone who has had a new seizure. If the patient has a known seizure disorder, it might be possible to increase the patient’s anti-seizure medicine in order to keep them in the wilderness (as long as there are no other risks such as falling from a significant height or drowning). This should only be done in conjunction after a thorough discussion with the patient, and the group, regarding the risks.
+
+DIABETIC EMERGENCIES
+Diabetic patients who travel in the wilderness have very few limitations. Most diabetics know their diabetes well and are usually able to manage it appropriately on their own. Diabetics should carry a method to measure their serum glucose level on their trips. The diabetic should educate other people on how to use their glucose monitoring equipment in case they are unable to measure it themselves. This is especially important for you to know if you are going to be the medical provider on a wilderness trek.
+If you are leading a group, or providing medical care, on a wilderness trek here are some proactive precautions you should take if you know you will have a diabetic patient in your group:
+• Check that their diabetes has been stable for one year before going to altitude.
+• They need to stay well hydrated.
+• Their insulin needs to be kept at an appropriate temperature; otherwise, it may become ineffective.
+• There should be enough medicine to last for a period of time past the scheduled end of the trip in case the trip is extended due to unforeseen circumstances.
+• Diabetics must monitor their serum glucose more closely in the backcountry as food and activities will be different.
+• Always keep a sugar source nearby to treat low blood glucose if necessary.
+Hypoglycemia is common in the backcountry. It occurs when a person’s blood sugar becomes too low. It could be the result if the patient:
+took too much insulin or too much of an oral agent;
+• ate too little in comparison to the diet they are on at home;
+• exertion level is much higher than usual, resulting in higher glucose metabolism than expected.
+Symptoms may look precisely like a stroke, so hypoglycemia should be considered as a diagnosis. Rapid onset of confusion, irritability, combativeness or agitation, or the loss of coordination, or inability to walk. They can have a headache, slurred speech, weakness or numbness, tremors, and sweating.
+Treatment for hypoglycemia is sugar (glucose). Administer it immediately as hypoglycemia is a true emergency where minutes do count. There are several methods to give glucose. The most common is oral glucose paste; however, carrying a small tube of cake frosting will work. If the patient is unable to eat, you may rub the glucose solution on the gums of the patient. Once you have gotten them out of the initial stage and the patient’s mentation has cleared, feed them. Give them a meal that has complex carbohydrates and protein that will last for a longer period. These patients must be monitored closely for the next 6 hours to ensure that their hypoglycemia does not recur.
+Patients with hypoglycemia do not require immediate evacuation. Evacuate those if their hypoglycemia returns despite treatment with glucose and a meal. Evacuate those who do not have a rapid clearing of their neurological deficits.
+High altitude is associated with severe diabetic ketoacidosis, though the reason is unclear. Above 2,500 meters, freezing temperatures, hypoxia-induced lack of appetite, medication side effects, and
+the higher incidence of mountain sickness can make diabetes difficult to control. Diabetics CAN travel safely to high altitudes, but they should be warned of these potential issues.
+
+ALLERGIC REACTIONS AND ANAPHYLAXIS
+Allergic reactions are common in the backcountry. On a spectrum, there are three types of allergic reactions that exist: local, generalized, and anaphylaxis. Any of these reactions can occur within seconds of exposure to an allergen.
+Local reactions are very common in the wilderness setting. They are characterized by red and swollen areas of the skin that are usually pruritic. Topical corticosteroids provide relief and should be carried in a first aid kit. Benadryl (Diphenhydramine) may be useful for the itching. Cold packs may alleviate some of the pain or discomfort.
+A generalized reaction can come from any source. Symptoms include itching, hives, redness, and possibly difficulty breathing. Any of these may begin immediately or hours after the exposure occurs. Treatment is to remove the patient from the allergen and to treat them with antihistamines and possibly prednisone.
+Anaphylaxis is a real life-threatening emergency. It begins as a generalized reaction but rapidly results in respiratory and/or circulatory collapse. These reactions are not subtle and include pruritus, hives, flushing, and swelling of the tongue and lips. The patient will have shortness of breath, wheezing, and tightness in their chest. Nausea, vomiting, diarrhea, and abdominal cramping sometimes occur. A drop in blood pressure may also occur.
+Treatment for anaphylaxis must be immediate, as shock and respiratory arrest can occur in a matter of minutes. A delay of even several minutes can be life-threatening. An EpiPen® (epinephrine auto-injector) is the primary treatment. This auto-injector also comes in both adult and junior forms. Every wilderness medicine kit should carry one of these. Give the IM injection directly into the thigh muscle, through pants if necessary. Familiarize yourself with the pen prior to your trip to avoid confusion in an emergency. A second dose of epinephrine may be required within 5 - 20 minutes after the first dose, depending on the severity of symptoms and the initial response to the epinephrine.
+Antihistamines need to be given. There is no best antihistamine, although non-specific antihistamines such as diphenhydramine (Benadryl) or chlorpheniramine (Chlor-Trimeton) are most commonly used.
+An H2 blocker such as cimetidine (Tagamet), ranitidine (Zantac), or famotidine (Pepcid) should be administered in addition to the other antihistamines. Steroids should also be given, such as prednisone. And inhaled albuterol can be used for wheezing.
+All patients with anaphylaxis require immediate evacuation from the wilderness. Although the patient may rapidly improve with epinephrine, and all of the other medications, they are at risk of rebound anaphylaxis that could be worse than the initial reaction. Those with local and generalized reactions do not usually require evacuation unless their symptoms do not resolve with treatment, or they have worsening symptoms.
+
+ABDOMINAL EMERGENCIES
+Any cause of abdominal pain in a city can also be a cause of pain in the backcountry. However, there are some causes that are more common in the backcountry. It can be a challenge to know what is causing the pain, and if a person should be evacuated out of the backcountry.
+
+Severe Constipation / Fecal Impaction
+This is more common in the wilderness than most people realize. A person can become dehydrated easily, which leads to hard stools. They may feel awkward defecating outdoors, the delay of which can lead to impaction.
+Symptoms are no stooling for several days, gradually increasing the pain. The treatment is high levels of hydration plus increased fiber. Bowel stimulants are indicated. Caffeinated drinks can stimulate bowel motility. Fecal impaction is not an indication for immediate evacuation, but it can lead to severe problems if not resolved.
+
+Gastritis / Gastroenteritis
+This is a very common cause of backcountry abdominal pain. It is often caused by a virus or a bacterium that is ingested with food.
+Symptoms include nausea, vomiting, and abdominal pain or discomfort. The patient often has, or will have, diarrhea that may be watery and contain mucus and blood. They may have a fever. Patients may have significant malaise and fever. Dehydration may occur from an inability to take liquids and considerable fluid loss from diarrhea. While in an urban setting, Diarrhea is uncomfortable, in the wilderness setting, it can pose a serious problem.
+Treatment is large amounts of fluids that contain sugar and electrolytes. This should be given frequently in smaller than usual amounts due to nausea/vomiting. Imodium may be used in those with frequent stooling. However, this is an area of controversy due to the concern of worsening illness in those with symptoms due to a bacterial infection.
+Most patients with gastroenteritis will resolve their symptoms in 24 to 48 hours with symptomatic treatment. Those with intractable nausea, vomiting, and diarrhea who have significant dehydration, abdominal pain, or fever should be evacuated.
+
+Ectopic pregnancy
+Ectopic pregnancy is probably the most urgent cause of abdominal pain due to its potential to take a life. The symptoms are not subtle. There is lower abdominal pain or abnormal vaginal bleeding in a sexually active fertile female. The pain may be in the midline or unilateral in location, depending on where the ectopic pregnancy is located. Initially, the pain may be mild in nature. Not all patients will have vaginal bleeding or specific vaginal symptoms. An over-the-counter urine pregnancy test
+is very reliable and accurate in determining pregnancy. The best urine sample is the first-morning void as it is the most concentrated. Always consider bringing several pregnancy tests along if you are the responsible health care provider on a wilderness adventure. An important differential diagnosis is a ruptured ovarian cyst, which presents similarly with unilateral pain but with a negative pregnancy test. A cyst that ruptures adjacent to a vessel may continue to hemorrhage and requires emergent surgical intervention.
+Treatment is immediate evacuation for any patient you think might have an ectopic pregnancy. This is a true medical emergency, and immediate evacuation is required.
+
+Appendicitis
+Appendicitis does occur in the backcountry, and it is difficult to diagnose. It’s difficult to diagnose appendicitis in the hospital setting, even with diagnostic testing, so you can imagine the difficulty with making a diagnosis in a wilderness setting.
+Symptoms often start as epigastric discomfort that may be associated with anorexia, nausea, and possibly vomiting. The abdominal pain progressively worsens over the next 6 to 24 hours as it localizes to the right lower quadrant. The patient will develop initial tenderness in the right lower quadrant, which then progresses to peritoneal signs. Patients may develop a fever much later in the disease process.
+Ensure that the patient has not already had their appendix removed. Appendicitis is a disease that requires surgical removal. All patients whom you suspect of having appendicitis should be evacuated.
+
+Gallstones
+Gallstones have occurred in people on a wilderness trip, but no more frequently than if one is at home. Most people know if they have gallstones, or have had gallstones, and will recognize the pain. This will help in making decisions. Gallstones present with abdominal pain that is typically located in the middle of the abdomen. The pain may radiate to the back or into the right shoulder. Nausea and vomiting are common and may be the initial symptoms before the pain.
+Treatment is to first ask the patient if they have gallstones or if they have had their gallbladder removed. Pain relief can be provided with ibuprofen or possibly opiate analgesics depending on the amount of pain. A “gallbladder attack” alone is not necessarily an indication for evacuation unless the symptoms do not resolve over 6 to 12 hours. Evacuate those patients who have continuous or worsening pain, or intractable nausea and vomiting.
+
+Kidney stones
+Kidney stones can occur in the backcountry, and possibly with more frequency in people who are prone to them. The reason is dehydration. People will who have had kidney stones should make sure they stay hydrated. Symptoms are the sudden onset of severe pain in the flank or back or unilateral abdominal pain. The pain is colicky and may radiate to the groin. The patient has difficulty finding a comfortable position and will be writhing in pain. Treat them with pain relief. Ibuprofen may help, but a narcotic might be needed. The primary reason to evacuate someone is due to the amount of pain they are in. Most patients will require evacuation, but those achieving adequate pain control with NSAIDs may be able to stay out in the wilderness.
+General evacuation guidelines for abdominal pain are to evacuate a patient if abdominal pain has any of the following:
+• The pain is associated with any signs or symptoms of shock.
+• The pain persists for longer than 24 hours or gets progressively worse over a period of time.
+• The pain localizes, and there are signs of guarding, rigidity, and tenderness.
+• Blood appears in the vomit, feces, or urine.
+• The pain is associated with a fever higher than 102 degrees F.
+• The patient has a positive pregnancy test.
+• The patient is unable to drink or eat.

data/ijfae-2688-gholeh.extracted.txt

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+Untitled Section
+Gholeh, I. (2024). First Aid in Conflict: A view from the occupied Palestinian Territories. International Journal of First Aid Education, 7(1), 1–3. https://doi.org/10.25894/ijfae.7.1.2688
+
+Ibrahim Gholeh
+Introduction from the Editor:
+The horrific and devastating conflict in many parts of the world poses significant challenges to first aid, humanitarian, and medical responders as they struggle to provide care with limited resources and often while under attack. The IJFAE seeks a systematic understanding of the gaps, and how emerging norms are developed in these conflicts in order to reduce suffering and promote healing at all levels. Our View from the Field articles offer individual perspectives; we also seek other perspectives that describe the situation and first aid elements that align with the Chain of Survival Behaviors.
+Keywords: Conflict; EMS; first responder
+CONTEXT
+The occupied Palestinian Territory, encompassing the West Bank and Gaza Strip, faces significant humanitarian challenges due to its complex geopolitical situation. With a population of approximately 5.5 million as of mid-2024, the region experiences frequent tensions and
+severely restricted access to essential services, impacting healthcare delivery and the provision of first aid.
+In this context, the Palestine Red Crescent Society (PRCS) plays a crucial role in addressing humanitarian, social and health needs. As a recognized member of the International Red Cross and Red Crescent Movement,
+Submitted: 03 October 2024 Accepted: 03 October 2024 Published: 23 October 2024
+Submitted: 03 October 2024
+Accepted: 03 October 2024
+Published: 23 October 2024
+International Journal of First Aid Education is a peer-reviewed open access journal published by the Aperio. © 2024 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.
+OPEN ACCESS
+Gholeh International Journal of First Aid Education DOI: 10.25894/ijfae.7.1.2688
+the PRCS operates under the Geneva Conventions and the Movement’s Fundamental Principles.
+PEACE-TIME ACTIVITY
+The PRCS’s Emergency Medical Service (EMS), established in 1996, is a cornerstone of its operations. The organization manages a network of emergency centers across the territory, as well as in Lebanon, Syria, Iraq and Egypt. It is equipped with modern ambulances and staffed by highly trained medics. Its 24/7 emergency services, accessible via a dedicated hotline, are vital in a region where access to healthcare is often compromised. The PRCS has developed a thorough and extensive volunteer recruitment and training process which operates in peace-time. This consists of a 160- hour first responder training course of which half the time is spent in class learning theory and the other half is practical. The practical part consists of 10 ambulance shifts during which the volunteers join the ambulance team in real calls working as team assistants.
+training on how to manage bullet injuries and the how to assess for inlet and outlet damage to the injured body is included. Volunteers are retrained on how best to assist qualified medical personnel to deliver fluid resuscitation, bone injury management and splinting; and are updated on basic communication, documentation processes, and fundamentals of emergency teamwork and chain of command.
+Emergency Medical Services, Palestinian Red Crescent Society, PS, [email protected]
+Mperio
+3
+
+EXAMPLES OF ACTIVITY AT MEDICAL
+POSTS
+The PRCS worked to set up a triage center at the Episcopal Al-Ahli Arab Hospital as it was the only functioning hospital in the Gaza Strip at the end of 2023. Since then, damage by an air strike and subsequent shelling has forced the hospital to close. Despite this, the PRCS uses this medical point to continue to help patients with light to medium wounds providing a minimum level of care to those in need.
+
+CONFLICT ESCALATION ACTIVITY
+Under continued Israeli occupation, EMS providers face significant risks. Between 2000 and 2022, 22 PRCS medics and volunteers lost their lives while on duty in the Palestinian Territories. The current war on Gaza (since 7th October 2023) has significantly intensified tensions, complexity and danger in what was already a protracted crisis situation with a further 21 PRCS medics losing their lives. Tens of thousands of civilians have been killed and wounded, and thousands more have been trapped under rubble. Hospitals and other medical facilities have been targeted and destroyed.
+In response, the PRCS declared a maximum state-of- emergency at all its facilities and operational capacities were increased by mobilizing additional volunteers from amongst those previously trained as first responders. Special procedures were then put in place to prepare those volunteers and to make them ready to serve at medical posts. Volunteers must attend an intensive two day refresher training focusing on personal safety and trauma management including: airway management, oxygenation and ventilation, CPR, and bleeding control including tourniquet application. In particular, focused
+An Advanced Medical Post was established at the Jabalia EMS Center to provide medical services to local populations after all hospitals in the northern Gaza Strip had ceased to function. The post continues to offer basic medical services despite aggressive behavior, raids and bombardments from the Israeli military.
+Five Emergency Medical Posts in the West Bank are fixed points equipped with first aid tools and other resources that can be used in the field during emergencies. They are managed by community-led committees of volunteers who collaborate to support the EMS. The PRCS has additionally provided medically trained volunteers including first aid providers, first responders, nurses and doctors to provide immediate emergency care as needed to the thousands of refugees forced to live in camps. As of August 2024, 104 staff have cared for 3950 casualties at these five posts.
+
+WHAT NEXT?
+This View from the Field highlights the extreme challenges of providing first aid and emergency medical services in conflict-affected areas, offering important lessons for first aid educators and practitioners worldwide. These experiences highlight the critical need for specialized first aid training and protocols tailored to extreme conflict
+2
+Gholeh International Journal of First Aid Education DOI: 10.25894/ijfae.7.1.2688
+situations (working under fire, working under threat, low or no medical resources, non-existent chain of care etc), presenting important areas for further research and development in the field of first aid education.
+3. How can first aid education be adapted to prepare responders for the unique challenges of providing care under siege conditions (e.g., know what and where casualty collection points exist)?
+
+RESEARCH QUESTIONS FOR FIRST AID
+EDUCATION
+4. What strategies, policies, or enforcement of law can be developed to protect first aiders and facilities in conflict areas while maintaining operational capacity?
+1. How can the sustainability and efficiency of emergency medical posts be improved in conflict zones by first
+aiders?
+
+COMPETING INTERESTS
+The author has no competing interests to declare.
+2. What training makes sense during a conflict? What specific training, equipment, logistics, and standard operating procedures are needed for first aiders in these high-risk environments? What alternatives are there if these don’t exist?

data/slidesaver.app_mzmoid.extracted.txt

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+Untitled Section
+BY: ROGENE BAJE & RICA ARADO
+
+AREAS COVERED:
+> What is First Aid? > Aims of First Aid > Chain of Survival »EMS >CPR >» AED » Scene safety assessment
+
+What is First Aid?
+The treatment given for any injury, or sudden illness before the arrival of an ambulance, doctor or any other qualified person.
+
+Aims of First Aid
+* To Preserve life
+* To Prevent the condition getting worse
+* To Promote recovery
+
+First Aid Provider
+* Recognize, assess, and prioritize the need for first
+aid
+* Provide appropriate first aid care
+* Recognize limitations, and seek professional medical assistance when necessary
+Early Activation of : Recognition & Emergency High-Quality : Post-Cardiac : Prevention Response CPR Defibrillation Arrest Care Recovery
+
+CHAIN OF SURVIVAL
+Sepuring the scwue
+Before performing any First Aid,
+Check for:
+paca
+* 41. Electrical hazards hoo * 2. Chemical hazards * 3. Noxious & Toxic gases rae 4. ole hazards > - 5. Fire * 6. Unstable equipment sam
+
+ACTIVATE EMS FOR:
+1. Immediate threats to life.
+si Significant mechanisms of injury.
+Warning signs of serious illness.
+Bw Unsure of the severity of a person’s condition.
+
+EMERGENCY SERVICES - 911
+1. Name and telephone 2. Give exact location 3. Type of incident 4. Seriousness of incident 5. Number of casualties 6. Condition of casualties 7. Any hazards
+number
+NOTE: DON'T HANG UP THE PHONE UNTIL YOU ARE TOLD TO DO
+SO!
+
+USE COMMON SENSE
+®@ Activate EMS (Emergency Medical @ Ifscene is unsafe, do not enter! ® Ask for permission ®@ Never exceed your training ® Once started, don’t stop until relieved
+System or emergency action plan
+
+PPE — Personal Protective Equipment
+=>
+is protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection.
+
+How to remove contaminated gloves?
+«tee “St
+1. Grasp First Glove - avoid bare skin, pinch the glove at either palm with the gloved fingers of the opposite hand .
+2. Remove Inside Out - gently pull the glove away from the palm and towards the fingers, turning the glove inside out without snapping. Gather the glove you just removed with your gloved hand,
+3. Slide Finger Under Second Glove - carefully slide your bare index finger inside the wrist band of the gloved hand.
+4. Remove Inside Out - gently pull outwards and down, inverting the glove and trapping the first glove inside,
+Hand under chen to keep mouth open ‘ Leg bert to Arn pent to Suppor postion prevent rating over
+
+PREPARE:
+|. Place arm nearest you up alongside head.
+2. Bring far arms across chest and place back of hand against cheek.
+3. Grasp far leg just above knee and pull it up so the foot is flat on the ground,
+
+Roll
+Grasping shoulder and hip, roll person toward you in a single motion, keeping head, shoulders, and body from twisting.
+*
+* Roll far enough for face to be angled toward ground.
+Stabilize
+* Position elbow and legs to stabilize head and body. Ensure there us no pressure on chest that restricts breathing.
+
+ASSESMENT
+* Keep person close to your * Avoid twisting * Consider person’s weight * Respect your limitations * Extremity drag * Clothing drag * Blanket drag
+* Avoid twisting
+body
+
+CONTROL OF BLEEDING
+¢ Apply Direct Pressure
+Using a clean pad, apply pressure directly on point of bleeding. Use just gloved hand if pad is not available,
+If the bleeding doesn't stop. Apply second pad, leave in place until the bleeding stops.
+* If Bleeding ts Controlled
+Consider a pressure bandage, Wrap a conforming bandage around limb and over dressings to provide continuous pressure.
+Avoid wrapping so tight that skin beyond bandage become cool to touch or blue in color.
+CPR
+
+PULMONARY
+RESUCITATION
+
+What is Cardiopulmonary Resuscitation?
+(CPR) is a lifesaving technique that's useful in many emergencies, such as a heart attack or near drowning, in which someone's breathing or heartbeat has stopped.
+NV. Ss
+
+SCENE SAFETY ASSESSMENT
+CATEGORY ADULT CHILD INFANT RATE 100 to 120 beats per minute DEPTH 2 to 2.4 inch 1.5 inch Sto6cm 4cem 1 rescuer: 30:2 COMPRESSION S cycles/2 minutes VENTILATION RATIO % 5 2 rescuer: 2 rescuer: 30:2 15:2 5 cycles/2 minutes 10 cycles/2minutes
+ve YS Se Scene safety - The scene is safe. . Check for Response - Hey, hey are you okay? (tap shoulder) Get Help - Help someone help. Check for Breathing - 1 1000, 2 1000, 3 1000, 4 1000, 5 1000 .... Activation - Activate EMS and get the AED. Start High Quality CPR - Perform CPR. ( 30 Compression, 2 breaths,
+5 cycles)
+
+Cardiopulmonary Resuscitation
+Parameters of High Performance CPR
+BLS ASSESSMENT Scene Safety & Assessment
+1. Push hard at a correct depth 2. Push fast at a rate of 100-120 compressions per minute. 3. Allow full chest recoil. 4. Minimize interruptions to less than 10secs.
+5. Avoid excessive ventilation.
+Check scene safety “Scene is safe”
+Check for responsiveness
+“Hey are you okay?”
+“Activate emergency response protocol and get an AED.”
+Check for breathing for 5 to 10 sec,
+Start High Performance CPR,
+
+HOW TO PERFORM CPR FOR INFANTS (NEWBORN TO 1 YEAR)
+A s elias
+
+What is an Automated External Defibrillator?
+(AED)is used to help those experiencing sudden cardiac arrest. It's a sophisticated, yet easy-to-use, medical device that can analyze the heart's rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm.
+
+Usage of AED — Automated External Defibrillator
+Turn on the AED Follow the prompts Apply the pads to the patient’s bare chest. Plug in the connector. Analyzing heart rhythm. “Clear” Shock is advised. Charging. (Resume HPCPR) Stay clear of the pt. Deliver shock now. “ Clear! Shocking on 3.1,2,3.” Resume HPCPR
+
+TAKE NOTES!
+Recognizing an Emergency — priority is personal safety Deciding to Help — if safe, take action Implied Consent — unresponsivement, need additional help “When in doubt, don’t drink medication.”
+
+SYMPTOMS OF SUDDEN CARDIAC ARREST
+a
+
+CARDIAC ARREST
+Y No warning ¥ Abnormal gasping Y Heart stops beating “No pulse ¥ Unconscious
+
+7 aeeeais
+* Early Defibrillator
+- electric shock
+- Itrestores blood flow
+
+Primary Assessment for Cardiac Arrest
+If breathing is not normal, perform CPR Recovery position 1. Ask—Are you alright? 2. Alert—-AED/EMS 3. Assess normal breathing 4. 2
+CPR Narre cn Leg bent lo Aem bert to
+support postion
+prevent rolling over
+
+Choking
+Mild blockage - cough Y Can take action on his own
+Severe ¥ Cannot take enough air Y Locate navel until he/she spills
+
+For infant:
+* Baby facing down * Support head * Rest in your lap * 5 back tap * Turn 5 press (chest)
+
+Control bleeding
+1. Pressure injured part with clean absorbent pads and wrap roller gauze 1. First Aid kit 2. Call EMS
+Note:
+¥ If pressure cannot control use TORNIQUETS ¥ TORNIQUETS — help control bleeding
+Once a tourniquet is applied, it is not to be removed , only by a doctor
+
+Absolute last resort in controlling bleeding. Remember
+Life over limb
+
+HOW TO TREAT SEVERE BLEEDING
+St John Arberoee
+Arberoee
+
+Shock
+* Internal bleeding (sweating) * Call EMS * Adequate clear breathing * Maintain body temperature * Keep calm
+
+Treatments:
+Treatments: * Halt the burning process * Relieve the swelling * Relieve the pain ¢ Wash with water * Minimize risk of infection * Seek medical advice
+¢ Wash with water
+* Minimize risk of infection
+* Seek medical advice
+
+Treatment:
+eFlood the area with slowly running water for at least ten minutes.
+eGently remove contaminated clothing while flooding injured area, taking care not to contaminate yourself.
+eContinue treatment for SEVERE BURNS
+eSeek medical advice
+
+Don't straighten break Treat the way you found it
+Must treat for bleeding first
+way you
+Do not push bones back into place
+
+DISLOCATIONS
+The most common dislocations occur in the shoulder, elbow, finger, or thumb.
+
+LOOK FOR THESE SIGNS:
+1. swelling
+2. deformed look
+3. pain and tenderness
+4. possible discoloration of the affected area
+IF A DISLOCATION IS SUSPECTED...
+1. Apply a splint to the joint to keep it from moving.
+2. Try to keep joint elevated to slow bloodflow to the area
+3. Adoctor should be contacted to have the bone set back into its socket.
+
+Two person carry
+sel
+——
+-_
+.¢ )
+
+REMINDERS!
+The goal of your training is to help you gain knowledge necessary to effectively manage a medical emergency until more advanced help is available.
+BY: ROGENE BAJE & RICA ARADO