Backcountry Trauma and Improvisation

[Music] this is my favorite talk and not just because I give it I give the other ones - in the past I've given all these lectures but but just because I feel like this is it's one of the most practical of the of the six or seven lectures we have in the series because it will what I'm going to try to teach you over the course of the next you know hour or so is what to do when things really go bad in the wilderness when your resources are limited when your equipment is limited and how some fairly basic things that you do or things that you take with you in order to be able to do these things can really save someone's life and I title this backcountry trauma in a proposition but it can be also be titled sort of macgyvering in the backcountry when things go bad and this is our case this is actually a real case that happened to be slightly amplified just for the purposes of illustrating some other things that we can do in the wilderness so this is a thirty-year-old helmeted mountain biker who catapults off the front of his bike down an embankment he is on his side lying unconscious bleeding from his mouth and nose he has noisy respirations and crepitus in his right chest I'll explain what that is in just a moment he has a branch in his right leg with lots of bleeding and he has a briskly bleeding wound from his scalp so this I mean I don't think it takes anything more than a small child to say this is a sick person right this is someone who's desperately in need of some aid and we are in the middle of nowhere so what do we do and this is one of the most important things to remember here because the first thing you're gonna do is take a deep breath you are not effective when your adrenaline is going when you're anxious you are effective when you are calm people say well what if that person is going to die in that time that I take to you know go through my meditation protocol I'm not talking about a meditation protocol I'm talking but take a deep breath because what will happen if that person is going to die in the time it takes you to take a few deep breaths and calm down that person is gonna die anyway okay so take a deep breath stay calm and survey the situation was this an avalanche that took this person down did they fall off a cliff are they in briskly moving water where they taken away by a Riptide what circumstances surrounded this person's accident because the last thing you want to do is create more victims okay either yourself the rescuer or other people let's say you're leading a group other people in your group okay you don't need more than one victim so survey the situation and make sure that it's actually a safe one for you to go into okay and then the next thing that I always encourage you to do is you think you know even if you're you're out with your friends you think you know your friends you don't know your friends as well as you think people have all sorts of diseases HIV hepatitis C all kinds of things which you can't undo so if that person has blood or body secretions take a moment and this is one thing I always carry with me okay I've carry this in my first aid kit I carry a pair of gloves okay I do not want to get I want to help somebody but I don't want to get sick myself okay there's a lot of blood in this scene so I'm gonna put on my gloves I happen to have glasses on if you have sunglasses everybody everything anything like that works you don't have to have anything special generally speaking off you know if you're in the outdoors you're gonna have some sunglasses leave them on okay then when you go up to someone always identify yourself okay because that's gonna give you a lot of information about what's going on with the person right away and we'll talk about some of that information but you know you can tell if someone can talk to you they can breathe okay they have a patent airway and they can breathe and sometimes let's say you come across someone who's kind of in at the bottom of an embankment and you're like oh my gosh they just fell off well what if they're just taking a nap okay you really want to go up to someone hi there my name is Judy Klein and they're like oh hey yeah this is gorgeous block I was just taking a nap you don't want to start you know freaking someone out and doing things on someone who has just taken a nap okay so so identify yourself plus it's just really nice to do that you know I would say hi there my name is Judy client I'm here to help you I get nothing okay okay what I do get is what kind of sounds am I getting here these are bad sounds coming from someone that snoring and as we go through this we'll see this the fact that this person is really sick and this last thing is super important okay activate your resources early pretty much after you've done your initial assessment and the key things that you need to try to save this person's life in the field what you can do you want to activate your resources whether that's calling on a cell phone which may or may not work activating a spot device sending people down for help because I can tell you right now this is someone I'm gonna need help with this is not something that I can just manage in the wilderness and say and he's gonna pop up off the you know the ground and walk out of here okay so it takes a lot longer to get a cert of rescue to happen than you can possibly imagine alright so activate your resources early okay so in emergency medicine we are simple people particularly when it comes to bad situations we want what to do in a bad situation to be like just just roll right off our tongue so we come up with very simple mnemonics or you know memory devices in order to tell us what to do in what order and these are the things that this person needs in this order in order to live okay and this is really important because the order of these things is the order they need to do things in order to they don't need to have these things be okay in order to live sometimes spectacular things like this are the things that occupy our attention that's not going to kill them that's not the thing that's gonna kill them first it's what's going on up here that's gonna kill them first and it's really important to do these things in order and check that these things are okay in order okay so ABCDE pretty easy to remember right so we're gonna start at the top a is airway and how many of you have taken a basic life support course BLS course a lot of you great okay so BLS teaches you that one of the first things you do when you come across someone is is you know may whatever in this case is injured mystic is that you open up you open up their airway okay in this case this person catapulted off the front of their bike and had a mouth full of what kind of things might have been in this person's mouth dirt saliva blood teeth all kinds of things these are not things that are good in someone's airway they block up someone's airway particularly someone who's unlike kind of unconscious or semi-conscious and may not be able to spit these things out so BOS teaches you that you look inside you take two fingers and you you sweep away what you see you don't do blind sweeps okay I'm just gonna dig right in there and and see what I get don't do that because you could end up knocking things further in okay so I put my fingers inside and I grabbed out a ton of dirt saliva blood and frankly part of a tongue before I realized that it was actually it was just this bloody mess okay and these were all things that that could potentially be the cause of this noisy breathing this noisy breathing is because it's airway is blocked okay so I swept aside everything but his breathing is still noisy so BLS teaches you two things you can do in order to try to open up that person's airway and these two things both help pull the tongue off the back of the throat because in a person who's conscious unconscious or semi-conscious that big muscular tongue gets all loosey-goosey and it can fall into the back of the throat and essentially make it so someone can't breathe because they're their airway is blocked so anybody remember that two techniques that that BLS teaches you in order to get that tongue off the back of the throat so when somebody's demonstrating the chin lift right what's the other one the jaw thrust I'm gonna demonstrate both of them and you tell me which one you think is better to do in someone who's fallen over the front of their bike the chin lift or the jaw thrust jaw thrust right what does the chin lift do that we don't want it just totally hyper extends the neck so no chin lifts when it comes to trauma we do jaw thrust and what the jaw now this is you can try to do this on yourself it's actually really hard in a conscious person because we have lots of really strong muscles in here that keep us keep us from being able to like there's something in the lower jaw and loosen it okay in a unconscious person there that muscle that muscle has no tension in it okay so I can pull that jaw forward and pull that tongue off the back of the throat and voila no more noisy breathing that big muscular tongue was just hanging out the back of the throat blocking off his hair way and that's the thing that this job can save someone's life because it pulls that tongue off the back of their airway and all of a sudden they have a nice patent like nice you know the conduit for air to be able to go through but I'm sitting here trying to there's all kinds of other things going on with them can I just stand here and do this no this is not a very good use of my time so how can I keep that tongue off the back of his throat without standing there well in the ER we use something like this anybody the medical students know what this is or anybody who's an EMT so this is a nasopharyngeal airway okay we put this inside someone's nose like this in order to this essentially keeps the tongue off the back of the throat it's a hollow tube okay we put it through the nose it goes down the back of the throat and it keeps the person's tongue off the back of the throat and leaves a nice kind of hollow way for air to get in and out okay I don't have one of these when I'm you know in the backcountry but I often have one of these okay this kind of looks like that doesn't it right okay so you can cut down a camel back too and it will serve the same purpose okay and the way you want to cut from nose to kind of like right the edge of the ear here that's the length that you want make it a little bit longer so a little bit sticking out of the nose so you can pull it out you don't want it to get stuck in there that'd be a bummer right okay and this will mimic the same thing it will keep the tongue off the back of the throat what if I don't have this okay if I don't have this I'll tell you one thing I always have now there's a couple things I keep in my first-aid kit and I never like I always have to have this because this thing is so useful and it's used for so many different things that it's one of those like it's anise central for survival and that's the safety pin okay safety pins are like you know the survivalists like you know dream because there's so many things you can do with it and here's the first thing you can save someone's life with it so that's what you can do if you're trying to get someone's tongue out of the out of the back of the throat you hold on to their tongue put a safety pin through each side of the tongue you have to put two alright because one will rip right through so imagine I have two safety pins in his tongue all right I take a shoelace most of us will have a shoelace when we're hiking right and I thread it through the two safety pins now these are pulling on his tongue I can tie this I can tie this like to his belt I can tie this to a shirt button if he's got a shirt on and this is pulling his tongue out of the back of his throat this is saving his life now people have asked me what if they wake up while you're doing this well glai you've solved your problem right you're not conscious they're gonna be able to a conscious person can control their tongue musculature okay so first way in which a safety pin can save someone's life you heard it here yes okay so the last thing I want to talk about is and by no means am i advocating you go out and do this if you don't feel comfortable doing it okay let's say you come across someone you've done all these things you sweat their airway you've done a jaw throw jars they're still not bleeding and you have a strong reason to believe that this person has choked on something that there is something lodged deeper down then you can see either because you witnessed it or somebody else witnessed it and there is something blocking that airway that's keeping you from being able to open it up okay this is sort of like that this is the the heroic thing you see on you know in movies that people do where they put a knife in someone's throat in order to save their life as I said I'm not advocating you go out and do this I'm just going to show you about sort of what's involved and why it works okay so if someone has something stuck here okay they can't breathe so what you're gonna do is I want you to you take a feel of your own neck Anatomy to figure this out okay so if you wanted to make let's see if something stuck here you want to make a conduit to the world to the air lower down okay because you this person is dying of lack of air lack of oxygen alright so what we do is and this is easier in men you feel your Adam's apple okay but in women feel that there's like a big right in the middle there's a big cartilage kind of like the harder it's not bone its cartilage all right and below that if you go in the midline there are fleshy spots okay they're kind of soft and fleshy all right if you if you extend your neck you can feel it even better okay extend your neck you'll feel it even better and it's in those fleshy portions where you can actually put something into that airway to provide a conduit to the outside world so what I would do is I would take a knife alright I'm not gonna hurt him don't worry okay I would take a knife I would slit the skin I'd actually do this from the other side frankly because I'm right-handed but I'm gonna show you just for the sake of illustration I would slit the skin I would find that membrane his Adam's apple is very prominent here I feel the membrane right here and I'd stick my knife in there I turned my knife a little bit once I felt that rush of air okay so you're gonna when you finally get into that trachea there's going to be a rush of air because ton of air now backed up in those lungs because the air hasn't been able to go out now I've got to put something in there alright in order to be able to provide a conduit to the outside world depending upon where you are there's all sorts of things that can serve that purpose a straw sorry all I had was bamboo straws at home this is like Marin County right all I have is a bamboo straw zone okay but you can put a straw in there people have used you know ballpoint pens nobody has ballpoint pens anymore but you know you can use the hollow portion of a ballpoint pen you can use a Camelback tube okay you know this is sort of like this is something that I kind of figured out you know in in the air we have these this is the the part of a you spike an IV bag to give someone IV fluid okay you can cut this off right here and this is super sharp you can do the whole thing just with this okay and then provide some air now you can blow then blow through that tube give them air give them oxygen and that's the way you do this okay not add don't do this at home okay you have to feel comfortable doing this but there are many ways in which to improvise these procedures and remember that this is something you're doing to a dead person if you don't do it they're dead you can't might as I tell my resonance you can't kill a dead person person's dead okay so we're gonna know and and that's that we're not gonna like talk more about that right now okay so what comes after a yeah B becomes up so the next thing that BLS teaches you is to is this sort of look listen and feel okay I'm gonna put my I have done this he's got the safety pins on his tongue of it you know and what I'm gonna do is I'm gonna put my ear right here to his to his mouth and what I'm listening for are his breaths I'm feeling for his breaths on my cheek and the other thing I'm doing by getting down to this level is I'm looking for the rise in his chest okay do I see both sides of his chest rising together okay or is one moving and the other ones not moving alright that would be an important thing notice that means something's wrong with one side of the chest and that's exactly what's going on here this side of the chest is not moving and then I put my hands on his chest okay and I'm feeling his breaths and what I feel on this side are what I call of what I refer to in that sort of little little case narrative as crepitus okay there's two different kinds of crepitus there's that crepitus when you break a bone have it anybody who's broken a bone that feeling of bones moving broken bone like bone ends moving on bone ends it's really poor it's gross actually the feel but you can feel that with broken ribs okay you can feel the ribs a broken rib pieces moving on against each other but then there's another kind of crepitus which is um really unique it's a unique feeling and once you feel like you'll never forget it but it kind of feels like rice krispies imagine who's even sees rice krispies anymore I don't know but when I was growing up we had rice krispies and we have rice krispie treats so people probably know how to work with rice krispies but it's that feeling when you run your hand over right Krispies of like little crunchies and what it is is it's air that has dissected from the chest walk from inside the lung cavity into the skin okay and if someone has crepitus that feeling of rice krispies under their skin in their chest that means they they have a hole they have they have a hole in their lung they have a hole and air is leaking out from the lung around and out probably into the area around the leg and it's creeping into the tissues of the skin okay and that it's really helpful because it tells me a lot about what may be going on with this person because it tells me that this person has something called a pneumothorax all right so the other thing that I can kind of look at is what's his respiratory rate a normal respiratory rate for us is what who's ever counted their breathing right well yeah twelve to twenty twelve you know but if someone's breathing at a rate like let's say they're reading thirty or thirty-five something's wrong something's wrong with their respiratory dynamics okay the other thing that you can look at is are they using extra muscles to breathe when we use extra muscles to breathe we use our belly we use the neck neck muscles sometimes we use our nose muscles so you can get a lot of information about whether or not someone's having a difficult time breathing okay um let's say I look listen and feel I put my hand on the chest and there is no chest movement at all okay I've opened up the airway there's no chest movement maybe even I even feel for a pulse we'll talk about in just a moment and there's nothing and this is what happened to this person okay do I start CPR most of us are going to start CPR because it seems like the right thing to do okay BLS teaches us we do compression-only CPR okay we no longer give rescue breaths except in children we no longer give rest of us we only do compressions on the chest because that's the thing that saves people's lives okay but the problem here is this is not someone having a heart attack on the street this is someone who's tumbled down an embankment and has had such a massive injury either to the head or they bled to they're bleeding so massively in their chest or their abdomen that they have stopped breathing and they have no pulse what are your chances of resuscitating that person by doing CPR throw out a number go lower pretty much you're pretty much close to zero and the reality is this is the same if their accident happens five blocks from us at San Francisco General okay someone who has this kind of accident and stops breathing and they're lose their pulse as a consequence of the accident they've had such a massive injury either their head or they're paralyzed or an internal bleeding that it's almost you know it's virtually never that they get Braque and certainly if you're in the wilderness in the middle of nowhere the chances are pretty much never and I tell you this not because I want to stop your humanitarian instinct to go and try to resuscitate this person but I just want to give you license to stop if if you're exhausting yourself you're exhausting your resources you're putting yourself in danger because you're in an avalanche path when this happens or whatever you know that your chances of success are low when someone has a full arrest in the wilderness okay there are a couple exceptions as always there's exceptions dr. Kowal mentioned one of them and and that is drowning and hypothermia so cold water drowning or someone who gets stuck out in the cold all right and you come across them and they seem dead all right those people aren't always dead and and he I'm not gonna go more into detail but but that would be a situation or I would start CPR I would keep doing CPR as long as my resources allowed for it because that person has a chance of success and the only other situation which we'll learn a little bit more about next week is lightning strikes so what lightning does is it causes a part of your brain called your medulla - which is responsible for making you breathe unconsciously it kind of resets it and sometimes it doesn't start up again for a couple of minutes so if you see someone struck by lightning you went over to them they're not breathing doing CPR on that person for a couple minutes can save their life because their own breathing mechanism will kick back in again okay most people don't won't actually die of lightning strikes if there is someone there that's seen it if because they will start breathing again on their own if you support them for that couple of minutes and that would be a circumstance in which I would probably give them rescue breaths as well not just compression only but I'd also give them rescue breaths because that's the problem they stopped the breathing because their brain has been reset by that massive charge of electricity okay so let's say I want it the reason why the BLS changed from doing rescue breaths to compression only CPR is because of the up factor okay most people don't want to kiss people they don't know they don't want to swap spit with people they don't know and yet here I am asking you to do that but I'm gonna give you a sanitary way of doing it okay I always carry three gloves not to actually carry more than two gloves but but you can use a glove to provide a barrier to do rescue breathing for someone okay take a take a glove you know tear or cut off the middle finger all right that's enough of a hole okay I can put this over his mouth okay and I can do breaths right through that and that provides a barrier so that you're not having to put lip to lip and you know if you're concerned about transmission of diseases and yet you couldn't provide rescue breathing all right so that's the poor man's poor man's protection from for rescue breaths okay but in this guy that's not the case he's actually breathing but his right chest is not moving he's got crepitus in his right chest he's breathing it like 40 times a minute I check his pulse and it's really thready he's dying of something that I met I used the term pneumothorax he is actually dying of something called that tension pneumothorax and I put a picture of this right here and this is the lung right there there's air escaping from the lung and this is the air and it's compressing that lung all right so that lungs not working but the problem is there's so much air in that pushing pressing that lung it's actually pushing everything in the chest cavity over all right and when it does that what happens is that it can compress the heart it compresses all the blood vessels that bring blood back to the heart and as eventually the person will die because no blood can return to the heart so this is one of these things you can't really wait for someone to solve this problem too you know for rescue personnel to solve this problem this is the reason why I carry and if you you know if you have access to medical equipment this would be the one piece of medical equipment it'd be great for you could to get okay if you're a medical student you definitely have access to medical or nursing student or whatever okay and this is a this is an IV catheter all right and you want a big one because what you can do is what you want to do is you want to vent that air you've got to get that air out of there so that that that there isn't so much pressure on everything in the chest all right and the way to do this is you go right below the collarbone you pick a rib high up all right pick a rib and you go over the rib and you stick that needle straight on in and you're gonna get a big rush of air all right and that is all that air that's putting pressure on the rest of the chest I push the catheter in okay we're gonna kind of pretend we're doing this here I push the catheter in and I hold on to that catheter because there's so much back pressure hit there that it's gonna explode out of the chest if I don't hold it there for a little bit okay now there's if someone is super obese this catheter may not go through I'll go to the side here all right away from the breast but always over a rib all right there's all kinds of blood vessels nerves you don't want to hit that are under the ribs should always go over the ribs all right I would do this only in the circumstances where you suspect a tension pneumothorax the person is having a lot of trouble breathing they're breathing really fast that side of their chest is not moving maybe you even feel that that crepitus that rice krispies underneath the chest on that side okay that's when I would do it to try to save somebody's life yes / so feel the ribs and if you feel it on yourself okay you can feel the top of your ribs and then underneath your ribs so the top part of the rib kind of the one clip the side closest to your head and the bottom part of the rib you can kind of roll your finger over it you want to go on the top part of the rib the top closest to your head because underneath there's all kinds of things you don't want to hit like blood vessels nerves and such yes no there's a separation between your ribs so your ribcage the ribs are go go lower down you'll easily see the separation okay do you see that there's there's tissue there's like soft spots between your ribs go on the side those are the it's in those soft spots that you're going so that the ribs are separated from one another that's a good question yeah those of us who've seen bodies like yeah yes but that's sometimes hard to pick up yeah so the I'm sorry the question is would your trachea your windpipe get pushed to the side when someone has this and yes it can it would get pushed to the side because everything's being pushed it would get pushed away from the side where all the air is accumulating but that's a tough one sometimes to pick up so you know but if you see that all the more reason why you want to intervene okay okay sometimes the problem is not air leaking out from the lung sometimes and this has particularly been true in our wartime is someone get something that makes a hole in their actual chest wall in the case of you know soldiers it's it's IEDs that have been throwing shrapnel creating holes and chests it could be a stick and you know something could have impaled the chest and created a hole in the chest this is something a little bit different this is something called an open pneumothorax it's or a sucking chest wound you might have heard where there's a hole in the chest that communicates with the lung cavity alright and that's the source of air you're getting air that's that every time the person takes a deep breath air is getting sucked in to that chest cavity all right also creating a situation where the person's gonna have a tough time breathing alright so in that setting we actually want to cover that up we want to keep air from where's my duct tape it's the other thing that I can't do without okay we want to cover this up because we want to keep air from sucking into that chest cavity so let's assume that there is actually there isn't in this case but let's say there's a hole in that person's chest cavity right here okay I want to cover that up you can use a baggy part of a garbage bag people use silver foil I find that plastics are a little bit more adhesive when you're taking a deep breath but you want to put that right over the chest cavity and this is another thing that's invaluable okay as in as add something to have with you because you can improvise so many things with it and that is duct tape you can fix your car with duct tape okay you can let do so many things with duct tape alright and one of the things you can do is cover up and open a sucking chest wound now we want to cover it up but we also want to make sure that when the person breathes out there's a way that air can get out so imagine if I have it and hence the taping on three sides if I tape it on three sides when the person takes a deep breath what's going to happen to that that baggy it's gonna adhere to the chest but when they breathe out there's a way for air to escape okay because you don't want it to get you don't want to create a situation with the air that's in there it's trapped in there alright you want to create a way for it there's egress of air so I tape it on three sides okay any questions on that so the question is if you suspect a tension pneumothorax and you're wrong and you put a needle in there what are the consequences almost nothing pretty much nothing because it's so small you won't hear you'll put it in and you won't feel hear that rush of air there will be no rush of air pick it out the lung if it's the lone heals itself quite easily frankly what can happen is you get the wrong side so if I really suspect that the person has a tension pneumothorax and I put it in on one side and it's not working put it in on the other honestly there's you know once again we go back to it's very hard to kill a person who's trying to die alright any other really good questions yes Hobbit so how deep do you put the needle in have it okay most of the problems that people that people come up with is it doesn't go far enough in because people have tissue between their skin and the chest cavity so all the way to the hub to the two end of the kneel yeah yes okay excellent question what if there is you want to put on this plastic bag but there's still an impaled object we are skipping ahead but we're gonna answer this question do you pull the impaled object out show of hands who pulls out the impaled object who leaves it in okay why yes why do we leave it in anybody it's a plug in a hole what did you put what what does it have a hole in what is it sticking through okay we're gonna talk a little bit more about this but actually I'll just talk about it now you don't know whatever that thing is plugging up if you pull it out you have to be prepared to deal with what is going to bleed when you pull it out this is actually believed to be the reason that Steve Irwin we talked about this last week Steve Irwin who was the victim of multiple stingray Barb's Matt large stingray Barb's into his chest it is believed that hit the one of those Barb's went into his right ventricle and he pulled it out he pulled out all the ball herbs and that might have been who knows but don't ever pull out impaled objects are those things though even in the emergency department we don't do it we have them go to the operating room where there's a surgeon ready to repair whatever it is that hole is through so the way I would do it is I would I would put a hole through this leave the stick sticking out and put some duct tape around and try to seal around the stick okay that's what I would do okay so this is a really good question the pervert this victim was on our side generally speaking do we leave people on their side do we leave them on their back generally speaking it is much easier to do things to people on their back all right so unless there is a reason not to put them on their back I will talk a little bit more about this but I carefully hopefully with another person around roll them on to there on very rare occasions including this one actually but for the sake of demonstration I haven't left him on his side you have to leave someone on their side because they're bleeding so much for example out of their mouth that they would constantly be choking on their blood all right does that make sense of why you might leave that person on their side the problem is and at that point you have to be protecting their spinal cord on their side and that's a little bit more of a labor-intensive thing all right so I hope that answers your question is situation we actually did leave this this patient on her side his side was a hurt but now it's a him because um because of so much bleeding from the airway okay I'm gonna go on hold your question keep we'll keep going I think some of the questions that you have I will definitely continue to answer okay so after a and B comes Wow C go figure okay as I said we're simple people in emergency medicine we don't we don't want to have to remember too much this stuff needs to kind of just roll right off okay so what can we do about CCU stands for circulation number one if the person is not laying down you want to lay them down it's a lot easier for your blood for your heart to pump blood to your head if they're laying down then if they're sitting up okay so laying down is a really good position we can tell a lot about someone's circulation how much blood flow they have going you know how much blood volume they have it they bled a lot by looking at them most of the time people are nice and pink their lips are pink you know their skin should be nice and pink it should be relatively dry if we try to do something called the capillary refill time test and you guys can do this on yourself take your arm generally speaking you do this on your torso but I don't want anybody everybody lifting their shirts up in here we don't need that right so take your arm push down and when you release notice you get a little bit of it gets white when you push down because you stop the blood flow to that area you release and it should really within unless you're really cold within you know two seconds it really should get the color back someone who's losing blood will not who's lost a lot of blood will not have good blood flow to their skin and they will not have that brisk what we call capillary refill time it'll be a lot more than two seconds so those are all things what would worry me is if someone was pale okay if they're cool if they're sweaty sweaty means that your adrenaline is going because your body's trying to save its life and then if they have this delayed cap refill time those are all bad things we can also get some information about someone's blood pressure by measuring and feeling for pulses okay most of us can are pretty good at feeling for the pulse in our wrist okay so go to your thumb side you feel the pulse in your wrist everybody who's sitting in this room should have a nice strong what we call radial pulse okay you shouldn't measure the rate typically a normal heart rate for us is what yeah 60 to 100 more than that you're worried that the person has lost simple there's a reason why their heart rate is high but what if you can't feel a radial pulse because a radial pulse tells you that your systolic blood pressure is at least 80 what's a normal systolic blood pressure I keep turning to you because you keep giving me the answers yeah so a normal systolic blood pressure we say is over 100 some people have a little low so let's say over 100 okay if you have a good radial pulse it's at least over 80 all right that systolic is at least over 80 what if I can't feel my radio pulse what do where do I go next okay the next place I go is to the groin all right you don't have to feel your groins right here but go ahead when you're at home go home and feel it there's actually a pulse in your ain't what's called your femoral pulse all right and if you can feel if you can't feel a pulse in the radial area but you can feel one in the femoral area that means your systolic blood pressure is at least 70 what if you can't feel one there then you go to the neck this one's harder to feel it's on each side of your windpipe of your trachea okay high up high up at the kind of right below your jaw you have to stop talking and you should feel a pulse there it's actually hard to feel it's very close to the side of your trachea all right if you feel none of these pulses but you feel a carotid pulse that means your systolic blood pressure is at least 60 is that a good systolic blood pressure no that's very bad and now what that tells you is it's giving you information about maybe blood loss you don't see okay this person does have some blood loss which we'll talk about places where these bleeding from but there's all kinds of places he could be bleeding from that you won't know all right because it's inside and getting a sense of what someone's pulse is like what their blood pressure is like what's the quality of the blood flow their skin what does their skin look like we'll give you a sense of how much potentially internal bleeding is happening okay so the way I remember these numbers by the way is if you look at my body my radial pulse is the one that's farthest from my heart the next the femoral pulse is a little closer to my heart and the carotid pulse is this look one that's the closest okay so as the body's blood pressure is going lower and lower it's only able to produce a palpable a pulse that you can feel closer and closer to the heart okay that makes sense okay very good so this person has a ton of bleeding and one of the place he has bleeding is his scalp see all that lovely red blood coming from his scalp what I often see people doing when they're trying to hold pressure is doing stuff like this okay does that do you think that that is providing as many pounds per square inch as this is a soccer that two fingers on a very thin whatever okay do you what do you think is providing more pounds per square inch of pressure that one okay yeah this is what you often see lots of gauze all that is doing is diluting the pressure so the way you stop bleeding two fingers direct not above not below but directly over the source of bleeding okay if you want to put something between your fingers in it just to absorb a little bit of blood great okay but nothing bulky two fingers direct pressure 10 or 15 minutes no peeking all right people are always it's the same when they have a nosebleed they're like oh simply and what that does is it just disrupts that cycle it allows a little bit of bleeding to happen whatever little scab might have formed you know from from your platelets which are the you know really what forms scab will be dislodged and you're starting all over again okay ten or fifteen minutes two points up two fingers not too bulky of dressing okay we're gonna talk specifically about what you can do with the scalp if it's still bleeding but let's take a look let's say the source of the bleeding is that it's got a lot of lean is an arm or a leg and in this case it's his leg I have done abundant I don't want to take this out okay right I'm not taking this out but it's still bleeding a lot I have put as much pressure on it as I can for 20 you know for 10 to 15 minutes no peeking and still bleeding a lot okay what can I do now back you know ten years ago before 10 years or 15 years of wartime showed us otherwise we were really the generally speaking the wilderness medicine community was against tourniquets because we always thought that what your tourniquet on someone your your your all but sacrificing that limb what we learned is that tourniquets in these you know 10 or 15 years of war time is that tourniquets save people's lives all right so this would absolutely be a reason why I would put a tourniquet on this person now there are all these fancy-schmancy tourniquet things okay that you can get this is a paramedic kind of device here okay and the what you do with it is you put it above just above the level of the thank you you know and and what this without without giving to us what this does is you your it provides this sort of like ratchet this would go all the way around by the way ratchet for you to turn and provide more and more and more pressure how do you know how much to do when the bleeding stops okay cuz then you know you've stopped all the arterial blood flow but I don't have this right well I have this but you don't have to have this okay because there's other things that you can do how do we improvise a tourniquet all right anything long a sock I mean you know the arm of a sweatshirt I didn't want to cut apart someone's jacket but that's what you would do okay you put it around you tie obviously that's not enough pressure right because I can't possibly tie this tight enough to because I'm trying to block off arterial flow I want no blood to go to that right now because all that's going to bleed sticks ample in the wilderness right I want to take that one out got to go get another one alright and I'm gonna make it shorter because it's going to intersect that stick alright and what I do is I tighten okay and this is this is the way you can provide pressure sort of provided a look you know a little diagram of that and you keep twisting this keep twisting it until no blood is coming out of there anymore and then now you would use duct tape to tie this down I'm not gonna leave him with a tourniquet because that would make him very uncomfortable and would be sort of medically medical and ethically not tenable okay so I'm not gonna yeah but that's what you would do and you would duct tape this down as best you can all right now one thing I would always caution you though is when you put a tourniquet on someone somewhere somehow put a marker that a tourniquet has been placed on this on that particular extremity because you can leave a tourniquet up for probably for about six hours with no consequence really what not not much consequence but it's that person is being evacuated and transported in a vacuum transported sometimes that process actually takes longer than six hours you don't want someone to forget the fact that there's a tourniquet up because that needs to be let down okay any questions oh man at all sorry the question was how six hours is about the time limit you leave a tourniquet up before you're concerned that that the arm or leg is going to die and the answer is yes after that you'd want to let it down give the the arm or leg a little chance to get some blood flow and put it back up unless the person is still bleeding like crazy and they're gonna die from the blood loss because ultimately it's better to use the leg than to lose your life that's what I think so the question is do you use tourniquets outside of a remote situation Ocean Beach is a remote situation okay Ocean Beach to San Francisco general during traffic is 45 minutes okay so we define wilderness medicine honestly as more than 31 minutes away from traditional medical care from regular you know and there are places in this city that are that there's places in Marin County where I live that are that you know that are not like your what you would think is wilderness so yes you would use a tourniquet to save someone's life if it's you know you've done 10 or 15 minutes of pressure and it's not working you know then that would be the time to put up a tourniquet honestly the bleeding is stopped you can then take it down so I once I put it on and I'm dealing with the person I would leave it on like I'm not gonna keep checking every hour honestly because chances are there's a lot of other things happening like someone this sick I don't want to you know if you want to take it down take a look for a moment and put it back up if you have to but definitely within six hours you have to address it yeah what should you do if the tourniquet doesn't stop the bleeding I don't know what to tell you do it tighter you have to do it we'll stop the bleeding eventually unless there's no bleed blood left to bleed you know like it will stop a bleeding you just have to keep doing it tighter and that sometimes is a problem with materials this is a sock you're gonna really have to do it tight maybe you need to do something that's less elastic try other things you know but you tourniquet stop bleeding now if the problem can arise if the bleeding is coming from a place you can't turn a kid like his scalp Hey I mean you know that's not a good turn again okay so we're gonna talk about a technique with the scalp in a little I'll talk about that in just a little bit because I'm to demonstrate on someone other than a short-haired person of how you can stop bleeding in the scalp because the scalp bleeds like stink okay it can bleed so much it has such a good blood supply that often times we'll see some with a teeny little cut on their scalp and they've just got blood all over their face their clothes whatever and it looks like a horror show and it's this teeny little cut on the scalp okay all right I mentioned all these other ways in which we can close ones were going to talk about wound closure in just a moment but if you have someone who's just got blood oozing out of someplace even losing blood can ultimately become a lot of blood duct tape is a great thing to use just to close up like if you have someone with a big leg gaping leg won't just duct tape it up okay while you says you don't want a person to be losing blood through that okay staples work Krazy Glue that's gonna be and we're gonna talk about that a little bit also works could be hard if it's bleeding a lot though crazy glue doesn't work so well through lots of bleeding yes sewing kit so the question is can you sew a wound to try to stop the bleeding yes you can but it's not that easy it's for emergency it's not like a definitive wound closure it's not like okay now we're done we need to go to the hospital at all because now I've sewn up your wound it's not easy in a briskly bleeding person and I would say some of these other techniques might be a little bit easier okay one thing I'm going to do right now which is a little bit off-topic but only because it's like a public health service I'm going to do there are so many people now who carry these let me know what this is okay because of various allergies and these have shown that over 50% of doctors have no idea how to use an EpiPen 5th over 50% of doctors have no idea how to use it so in the general public I can only imagine how large that number is so this is an interlude sorry I'm like using you as a table it's terrible that's what happens in your doctor too long right these are trainers don't worry there's no medicine in them this in contrast does have medicine it but it's out of date I just want to show you this is what you have to take it out of the container okay this is a this is a real EpiPen but it looks exactly the same right these are trainers there's no medicine in them so don't worry all right key thing this is like two steps key thing when you hold an EpiPen hold it like this don't put your thumb like this okay because what if I get it the wrong direction and I hold it not with the blue end up but with the orange end up and I put my thumb like this and I go back you know where's that epi gonna go yeah which you know what you're probably not gonna lose your thumb but more importantly you've lost the epi it's not supposed to be in you it's supposed to be in the page in the person who needs it okay so hold it like this no thumb all right in order to activate it you got to take the blue part off all right and then no need to take off clothes not at all you go straight into the person's the largest muscle that you can think of which is the thigh and you hold it there for 10 seconds 1,001 1,002 1,003 up to 10 seconds because this is an auto-injector it takes that long to get all that epinephrine in them it goes through jeans clothes anything and it's that simple okay so you can re set these like this put the cap back on okay not to distract you while I'm doing this but I want you guys to practice okay these are do it on yourself do it on your friends here you know pass it back all right this is my public service message here all right okay all right we're gonna keep going on now you're going to know more than 50% of doctors right here yes the question is if an EpiPen is discolored is it better to use it than not discolored like this one is discolored if someone's I'm gonna go back to the old adage that you can't kill a dead person or person who's dying yes I would use a discolored one if that's all you have but ideally they're not just going they just color after a year that's why they need to replace it every year okay okay so ABC next is D D is a little bit not as intuitive but it stands for disability and it and it's in this is the point at which we think about the person's neurological status okay how is their brain doing how are their spinal cord doing and there's a couple of things I want to know in this the first thing I want to know is what suppressions level of consciousness can they talk to me Edward Edward Edwards not even talking to me okay so first thing I'm just some sometimes person was just talking to you normally that's like the top of the top of the scale of level of consciousness sometimes they're talking to you but they're like my grandmother died seven years ago you know I'm like they're confused they're they think there is someplace or not okay that's not not as good as being totally being conversed but at least they're talking to you okay that would be confused the next levels you have to yell at someone to have them even open their eyes I'm yelling at Edward he's not opening his eyes okay the bottom of the scale okay it was actually not quite the bottom the quite on the scales when you don't do anything is I try to inflict a little bit of pain and see whether or not that makes the person respond okay and so I'm gonna I'm gonna pinch Edward here okay so I got him to do something so he's not alert and conversant he's not confused he's not you know responding to my yelling at him to open his eyes but he does respond to pain and that's important so I know his brain is really injured okay cuz the only thing he's respected requires that level of stimulus in order to to respond at all and in fact I'm gonna it tells me that then one of the other tests that I have to do I'm gonna actually have to pinch him for the other test because I want to know if he moves his arms and legs is he paralyzed okay so I pinch him and I see him he's moving he's moving everything okay so that tells me right there that at least for now his spinal cord is intact he's able to move his arms and legs okay so I've assessed his level of consciousness I have assessed that he knows he can't he's able to move his arms and legs the other thing that I need to do is sure my phone will work with this oh please take a look at his pupils that's why phone is great I don't even carry a flashlight anymore like in at work okay because I can look at his pupils with my light here and see and all I'm looking for is honestly is symmetry okay do his pupils look the same are they the same size and when I put a light on it do they react okay if they one of them reacts and the other one doesn't or one of them's a lot bigger than the other there's a problem okay there's a problem on one side of the brain all right and that's just telling me that it's even more urgent that this person get to medical attention so for example if someone asking me should we do a land transport or a helicopter transport and I know someone has one pupil bigger than the other helicopter okay because time is brain all right this person has got something going on something pushing on his brain that needs to not be there all right whether it's blood or whatever it needs to not be there okay all right so the other thing that we think about in disability in addition to you know do getting a sense of can they move their arms and legs what's the level of consciousness in pupils is protecting their neck we're not going to get in today to the art of moving someone and in whom you're concerned about a neck injury we're gonna do that in a couple of weeks all right but we are gonna talk about how to protect someone from moving their neck because pretty much anybody who has a serious head injury after an accident or who has you know you're seeing evidence of lots of chest injury or maybe injuries to their belly clear lots of broken bones or they're intoxicated assume they might have an injury to their neck even if they tell you their neck doesn't hurt I can't tell you the number of times I've had patients who have had lots of other injuries or they're intoxicated you know they've got a big bad broken leg that's totally distracting them and they don't have any neck pain at all and they have a terrible fracture in their neck okay so protect someone's neck how can we protect someone's neck there's essentially three parts to protecting someone's neck a collar a collar keeps them from moving their neck in flexion and extension side rolls which keep them from moving their head from side to side and then a backboard we're not going to talk about the backboard because that's only important for transport all right and and sport we're gonna talk about in a couple of weeks all right so collar and side rolls I don't have one of those I'm in the backcountry how do i improvise those things okay this is another thing that I find to be super useful you don't have to have it with you but if you do it's really helpful you can buy these on Amazon for six bucks okay these are called these are aluminum splints they're flexible aluminum splints originally they were called Sam splints but if you buy the trademarked one they're more expensive okay but there can be used for all sorts of things they're newly intended for splitting fractures all right but they can also be used to protect someone's back check it out you're gonna have to help me now he's gonna help me you obviously wouldn't want someone to help you but I'm just trying not to you know cost too much injury to him here or pain to him here is you would just slip this under someone's neck okay you can cut this thing down but it provides a great collar for someone not to be able to flex or extend their neck all right what if I don't have this you don't need to have this you can use all sorts of things all right you can use a really bulky sweater okay you could do that because it could essentially keep someone from being able to flex or extend their neck all right you really want to bulk it up that's kind of what someone did like right here you can see they use the blankets there anything that keeps someone from flexing or extending their neck we're gonna leave that there and say that how do you keep someone from turning their head to side to side okay you need some side rolls water bottles are really good okay you can use those just like this right here to the side and tape it all together with some duct tape all right another great use for duct tape I would tape all this together all right onto the onto the ground all around the paint around the sleeping bag they may be sitting on laying on okay tie it all together other options for side hoe side this this will work to check it out you know you might have to cut these down I'm not going to do that right here but this will also keep the person from being able to move their head from side to side this also has a lot of other uses splint all sorts of things ski poles what else can you imagine you might be able to to use to keep someone from moving their neck from side to side sticks yeah it could put a bunch of sticks together what if huh yeah boots awesome put the boots on the side duct-tape it all together okay you want to create a system that stays with the patient though so it can't be rolling off the sides if you have stuff sacks or a backpack you can stop it full of stuff you know what kind of stuff can you stuff it full of rocks Wow Rock medicine huh clothes I don't have clothes to spare dirt sand how about snow why no snow it melts don't use snow okay but things need to be so dirt sand clothes all these things can be put same thing on both sides duct tape together okay to keep it all together if you come up with other ideas please send them to me I love love bringing in other ideas yes yeah pebbles maybe rocks yeah if you want to cushion it you could you could put rocks in there you use what you have right oh the rocks themselves mm yes to put a boulder on each side with a little there's a little bit of cushion there remember you don't want to give people pressure sores and such because they may be in that situation for a while be creative I mean so all you're trying to do is you try to prevent this and this okay so the better you and then duct-tape it all together all right have I said that too many times duct tape it all together okay all right so we've taken care of D as best we've camera tected a snack we've determined that he's actually got something really bad going on with his brain because the only response to pain okay but he's moving his arms or legs at least he's not paralyzed right now what comes after D is e E is sort of exposure okay this is where I was intended to talk to you about impaled objects but I've already and that horrible it's just horrible okay don't remove impaled objects ever unless you you know I mean we've had patients come in brought into the emergency 207 Cisco general with rebar sticking out of them and they're on their side they got Reebok because nobody wants to take out impaled objects because you have to be then prepared to take out to to deal with whatever that thing is stopping up okay the one thing that you'll often see happen is you'll see people you know with all these fantastic things that have been done to save their lives to you know a pneumothorax relieved tourniquet up and they'll be lying there with essentially inadequate protection against the cold because people who are bleeding people who are in shock get cold faster than you can imagine so this case was happened in an environment where the temperature was 85 degrees okay our patient was shivering our the person who flew off the front of her bike was shivering because people in shock they think they constrict their blood flow away from their skin they feel incredibly cold all right you want to keep these folks warm what if you don't have a whole lot of clothing to spare if you do have a sleeping bag that's awesome okay cuz you can put part above the person and part underneath them don't forget the underneath the ground is cold dirt is cold snow is really cold okay I've seen lots of people where they're covered up from the top and they're lying on the ground all right you want to protect people from that from the conduction of cold on the ground but what's that I don't have clothing to spare you have a question sir okay so there is a technique the question was about you worried about moving them too much because of the concern about their spine and you're right because when you want to move someone who you are concerned they're his spinal cord works right now but if he has broken bones in his fine you could potentially cause injury to a spinal cord if you don't move him as I referred to in the last slide like a log okay there is a technique to rolling people who you're concerned about spinal injury that to protect their spine but it is very important to do these things now if I want to minimize moving him frankly I would be reaching underneath him four things okay I would be reaching underneath him here okay I'm just trying to spare my back here rather than you know doing a lot you know okay but you're absolutely right you want to be concerned about this fine this is another one of our like the MacGyver friends all right and that is a garbage bag we've talked about safety pins we've talked about duct tape and that is the garbage bag the garbage bag is one of the most useful things not only for you know back you know macgyvering things in the back country for trauma but for survival as well a garbage bag can be made into a shirt okay imagine I put a hole for the head and the arms here and I've slipped in and somehow underneath him okay I put one on top you can put one same on the bottom and it provides a vapor barrier you can also stuff it with leaves dry leaves okay and that will provide insulation if you don't have clothing to spare anymore because you're in a cold environment you need the clothing and you don't want to create more victims right so you can do all sorts of things with the garbage bag you know it'll it'll keep in his own radiant heat and you can insulate it alright so I seem to have misplaced my other guards but imagine now he has a garbage bag at his legs and over his top and that's keeping in a lot of his heat alright and that's a really important thing now if someone has broken bones we'll talk more about this as I said in a couple of weeks when we do our workshop on its blending in litters it's a really nice thing to splint bones because broken bones are painful when the ends are moving against one another and they also can bleed a lot depending upon the bone those bones can bleed a lot to clearly the big bones the ones like in the leg you know even ones in the upper arm but particularly ones in the leg can bleed a lot so splint them it's also really comfortable for people let's say you know he had broken his his right arm here you can use their own you can use all sorts of improvisation techniques in order to immobilize that bone just to remember them you want to immobilize the joint above and below and make sure that however you're moving the the bones or joints that you are actually check to make sure that that motion didn't cut off a pulse for example so always be checking for pulses we're gonna talk a lot more about that in a couple of weeks but I just wanted to allude to it because it is in exposure when you see big bag broken bones you want to immobilize them okay and then the last thing I want to talk about is kind of also under exposure but it's about wound care all right he has a really bad scalp laceration I have put pressure on it and it has slowed down but it's still oozing a lot what can I do all right well in him we'll talk about in the moment his hair might be a little bit well actually maybe not his hair is probably not if you have about an inch of hair you can actually use this technique but this is an excellent technique for closing wounds on the scalp to try to stop bleeding this is not like the what I call the definitive wound closure meaning like oh we've closed it up now we can keep going on the rest of our backpacking trip okay because all this is doing is its stopping leading at this point all right because wounds need to be well cleaned out for you to close them definitively but I'm going to show you actually on well I guess I could show you on my hair imagine that my part of my hair is a wound is a laceration okay what I want to do is I'm going to take hair on both sides of that laceration I'm using you as a table and what I'm going to do is I'm going to twist that hair one side to the other one side to the other I'm doing a spiral and then I'm going to rest it on each side of the cut and now I have like a little little spiral on top what I'm going to do is I'm going to take superglue from the hardware store it's the same stuff that we use in the hospital it just off gasses a little bit more okay it's a little stinky err it's the same stuff all right I always this is another thing I always have with me I put a drop of that crazy right on top of that little spiral that I've made over the cut I hold it there for a minute and then it's dry and then I keep going I do it again a little further down on the cut I take hair on both sides spin it around rest it down and I put another drop okay and so on and so forth and what that can do in the scalp is by closing it up I kind of it's like putting pressure on it constantly there's only so much space between the skin and the skull and the idea is if you close it up it might stop bleeding just from you know it'll bleed until there's so much pressure on that blood vessel that it can't bleed anymore and sometimes you'll stop the bleeding just from that there's only so much space in there so I'm not you know it's not like bleeding in your chest or your belly where you can believe your whole blood volume are you're not gonna bleed your whole blood volume out inside your scalp only outside and people can bleed an enormous amount of blood from their scalp you really have to stop scalp bleeding okay any questions on that that's called the hair tie technique this is me doing it on my son who didn't have a cut but that was my moulage cut right there my poor son has the time to do all sorts of things do you have a question my son right so when they have short hair then you can't use the hair tight it's almost like I planted him there to ask that question you can't use it you could probably do it on Edwards here here this is about as short as you can go and do the hair tie technique but other things that you can do you can try applying the skin glue directly it's difficult because if there's a lot of blood it doesn't it doesn't work all that well some of people if you have access to like one of these little mini Snape a little mini stapler frankly will do it too okay we use staples in the hair and duct tape doesn't work so well so I would say one of these three techniques is what you would do in the scalp to close that up all right I've seen people take these little mini staplers from literally from the stationery store with them because that'll do the same thing you on yeah you literally you know how it has a top and a bottom you just open it up so that the the bottom part or you put the paper in and you would put the staple in you take the bottom part out and you're just using the top part straight on to their skin and when it compresses it'll right into the into the skin not into the skull yeah the question was about how to use it go home and figure it out don't do it on your skin but you'll see you can actually no know what the question will have punch holes in the skull no no no skull is is way too hard for that yeah now there's a lotta there used to be a lot of controversy around what we should do with wounds in the wilderness the problem and there's lots of people who are really gung-ho and like to close wounds in the wilderness the problem with closing wounds in the wilderness is that you that you can try to clean them and there's lots of ways we can clean things out and we talked about in a moment but the problem is we're usually not good enough about cleaning things out in the wilderness and the risk of closing something that you haven't cleaned out well is one of infection if something gets infected you've closed it something gets infected it has to be opened up never to be closed back again with stitches meaning that person they will heal wounds will always heal but they we heal pretty ugly if you leave something open even if you don't get to medical care in time to close that wound initially most wounds in if they don't get infected in five days a plastic surgeon can close them okay so if you if it doesn't get infected you have the opportunity to have it closed delayed late but if it gets infected it's over all right it's gonna be left open for closers so what I recommend is if you have a wound in the wilderness clean it out as best you can all right and there's a lot of different ways of doing that okay um a good old baggie works okay put it fill it with water close it up if you haven't I like to carry a needle for this reason because I punch a bunch of holes in the bottom of it okay and this provides forceful water okay you what you're trying to provide is forceful irrigation of wounds you want it as close to the wound as possible and get a lot of forceful water in there we have a saying in emergency medicine but the solution to pollution is dilution okay so as much water as you can through it high force water and if the water if you have a question about whether the water is clean use some chlorine tabs which I always carry with me and my along with my duct tape safety pins garbage bag comes chlorine tablets okay because they can use you know obviously to purify water for drinking as well but you should use clean water okay yes sir so the question is could you soak it with rubbing alcohol if you really want your patient to scream you can do that rubbing alcohol it's just so it's so painful and it is no better frankly than good old clean water and lots of it okay even things like bactine bactine is iodine and iodine actually kills tissues so we don't recommend any iodine products at all alcohol is burning frankly water you know if it's just a superficial and some soap and water is just as good it's just about using a lot of it really clean it out well and we're not I don't close wounds up in the will dirty myself but that's my own choice about me and I'm an you know and it was on my face which doesn't get infected very often and I didn't want to leave the trip that I was on because it was a great trip so but but that's not for I would be very hesitant about making that choice unless I said if it's for yourself it's for yourself but making it for somebody else okay when do you evacuate people we're not gonna talk about mechanisms of evacuation but some of these things are very intuitive if you feel uncomfortable with how sick someone is they need to be evacuated if they're having trouble breathing then have a good pulse they're you know they're not unable to walk they can't talk to you well you know they have visible bone an open fracture or a clear dislocation you know or as I said if you're unsure about the severity of their injury they should probably be evacuated how that evacuation happens is just the the scope of that is way too big to talk here but it is very only will say that it is very difficult to evacuate people sometimes this is actually how this patient was evacuated on one of these litters on a wheel here it took a ton of people and it was it was really very difficult it's very very difficult to evacuate people and depends on on where you are what the terrain is like how remote it is how many people are there can a helicopter land nearby she had to be evacuated she sorry I keep saying she cuz it was a she but he for this purpose had to be evacuated like this on a trail to a fire road to a car the car then drove her or the ambulance then drove her to a helicopter landing pad where she was life flighted to hospital and reading you know so it can be very difficult to evacuate people just to give you the outcome for this patient she ended up almost completely severing her tongue it was hanging on by very little that's why she was bleeding so much out of her mouth she broke a couple bones in her neck a couple bones in her back she had a traumatic brain injury she actually had a seizure when she went oh I didn't want to make things that complicated but she had a seizure when she went and hit her head even though she was helmeted but she did well and now has three children and living in Lake Tahoe and has a lisp forever after her she was in the intensive care unit for several days with a lot of tongue swelling after her tongue was repaired in the operating room that she's done well two last things I want to leave you with this is my absolutely essential first-aid kit this is not like one that has all the things you would need on an expedition this is this stuff that I've mentioned here that you can use to save someone's life okay these are things that many of these things have multiple uses duct tape safety pins garbage bags the other thing that I mentioned in here are where an invention for buck condoms condoms are like super useful for more than just the obvious okay because they have enormous elasticity I didn't bring last time I made a mess when I did this because I couldn't pour but they can be used to carry water they can be used for irrigation they're really strong okay just don't get the lubricated kind cuz your waters gonna taste really weird but then look how look how calm you know if you need to carry water look how compact that is okay so another great thing to carry with notice a lot not a lot on the wound care there frankly you can improvise a lot of things if you're not carrying any prescription medications at the very least you're gonna you can need something for pain and always benadryl okay cuz remember that EpiPen is only buying you time until the benadryl kicks in for someone who has an allergic reaction this is what saves the person's life right there it's the benadryl that's what's working to stop the allergic reaction the epinephrine that you guys are handing around just buys you buys time until that benadryl kicks in so you want to have that in your first-aid kit okay and then some of the things that I've mentioned here and then I encourage people to add to this list okay our to any of the other things that I mentioned that have multiple uses okay this is just some of the things that I and others have thought of that you can do with safety pins okay tongue extension that's kind of an interesting that's what we demonstrated here but all these things so Kerry you know you don't have to have a large first-aid kit you just have to have a first you know in fact I try to pride myself on on having mine as small as possible when I'm when I'm backpacking it's very different if I'm traveling internationally but but backpacking you know I carry these things that have multiple lots of different uses okay I don't have a lot of specialized things alright and that's that any questions oh gosh lots of questions great yes sir you can get up Oh big hand forever yes so the question is is it safe to use essentially stream water river water in order to clean the wound and the answer is yes because the thing that you're going to get safe from a river or stream in the Sierra is Giardia and Giardia doesn't affect looms okay so if the water looks if it's that kind of I'm talking about if you're in like another country and you're looking at water that maybe have a bacteria and it just not good water then you want to purify it good question yes so that's a good question the way the question is how do we stop the bleeding from that patient from the actual patients tongue we had her on her side she kept using the whole time and we put pressure on her tongue with my arm warmer that's all I had we we didn't I didn't I don't carry gauze and my bike first-aid kit which is all we had and so I had my arm warmer essentially putting direct pressure on her tongue which slowed the bleeding of her tongue but it was constant the whole time okay so this is a good question when someone crashes with a helmet do you recommend taking the helmet off it depends if the person is having a problem with airway breathing anything around the head or scalp and I need to manage that yes I pull it off if that person is talking to me I don't see blood there's no noisy breathing I don't see blood coming out from underneath the scalp you know you because if the scalp is bleeding you're gonna see blood streaming down then no I actually might leave that on because that's gonna help actually provide some stabilization for that next certainly if there's a visor I pull it up I want to be able to see the person's lips their eyes and all that but if there's anywhere a question about a B or C issues around the head take it off okay so the question is have I heard of a product called quick there are all these products now that are it's essentially gauze or there's powders that are God's that's embedded with material more powders that do the same thing that they promote the clotting of blood they have saved the lives of soldiers in wartime because they make cuts stop bleeding faster okay they can be stuffed into wounds that can be held over wounds and generally speaking I don't have you seen if you can buy those and can you buy them like on on websites yes yes then you absolutely it would be a thing to have in your in your first-aid kit I try not to put specialty things in there man I have access to that stuff and I put what I put a couple in my first-aid kit but they have saved people's lives no no they actually have well you don't want to leave gauze in people but there are products that actually just dissolve they're all organic products they'll just dissolve in there I wouldn't worry about that don't worry about things like infection when you're when you're dealing remember remember the order of things that ABCDE is in that order because those are the order of things you need to survive don't worry about things like infection that's it that's like f/4g you know that's like way you know you're trying to save someone's life so the question is about keeping someone warm and when is something so saturated that it's actually not keeping them warm anymore because it's so wet there are some things that keep you warm even when they're wet synthetics wool down is not one of them okay but that's the reason why the garbage bag which disappeared can be a great because in addition to being a vapor barrier it protects against moisture on the outside right but it is a really important point that wetness keeps people will cool people down five to 25 times faster than being dry so if the person is wet you want to get those wet that wet clothing off alright and honestly I'd rather have wet clothing off and the person naked in a garbage bag then then to be than to have wet clothing on you know if they have if they synthetic garments on like wool or synthetic then they're probably fine and those work I'm just need to monitor that person those are tend to pull that moisture away from their skin and tend to keep people warm even when they're wet down is not that cotton is not that though bear that in mind all right if you have any other questions I'll be here for a few minutes thank you so much I hope you learned something [Music] you

Channel: University of California Television (UCTV)

Views: 468,554

Keywords: trauma, emergency medicine, first aid

Id: xkBhNEU3RfQ

Length: 79min 59sec (4799 seconds)

Published: Wed Aug 23 2017