These protocols are written in text form. We do not expect rescue personnel to carry them in the field, but to read, understand and remember the general principles. An abbreviated pocket reference is available, containing specifics that may be difficult to remember.
Safety of rescuers is paramount; no specifics will be covered here, as this is a major part of cave and wilderness rescue. Team leaders should depend on the team medic to provide advice about the medical condition of team members.
Personnel providing medical care should follow their first aid or emergency medical training except in those specific situations covered in these protocols. In situations not covered by these protocols or by previous training, personnel must use their best judgment.
Personnel caring for a patient or team member with any significant injury or illness should always attempt to contact a WildernessCommand Physician as provided for in the WEMSI medical policies.
Care of any patient should be coordinated by a single person: the medic. The term medic is a generic one and does not say anything about the person's level of medical training: the medic could be a physician, nurse, paramedic, EMT-Basic, First Responder, or simply a first aider. All communication with the patient should be by the medic.
In general, the person with the best medical qualifications should be chosen as the medic. However, there may be occasions where the person with the best medical training needs to perform other vital functions; in such a case, the best alternate should serve as medic.
It is appropriate for a medic to hand over care to a more experienced medical person when one becomes available. It is also appropriate for a medic to be replaced by another person so as to be able to rest. It even may be appropriate for a medic to be replaced by a less-capable medic, to avoid exhaustion or hypothermia of the original medic.
When a medic turns over care of a patient during a rescue, the medic must make turn over a written report to the new medic, with:
results of the initial examination of the patient, including all injury or illness detected,
any care rendered so far,
vital signs, and
medical plans for the remainder of the rescue.
The only exception would be if the original medic were exhausted, hypothermic, or seriously injured.
Applying a tourniquet on the street is deciding to sacrifice a limb to save a life. EMTs rarely, if ever, need to use a tourniquet, because direct pressure and elevation almost always stop bleeding. Continued slow bleeding is not a major problem for most EMTs. The patient will be in the Emergency Department before the continued blood loss will be a problem. With long evacuation and transport times, though, even slow external bleeding can cause shock. Usually, if you can slow the bleeding down, the body's own clotting mechanisms will stop the bleeding. However, these clotting mechanisms may not work properly under certain conditions, e.g., hypothermia, extensive crush injury, or snakebite.
The key to control bleeding to use firm localized pressure directly over the bleeding vessels. Your gloved finger, covered with a single gauze pad to make it less slippery, is ideal. You should apply pressure for a full ten minutes, then release pressure and see if it bleeds again. (Use your watch to time yourself) If it starts bleeding again, apply pressure, this time for fifteen minutes. If you release pressure or slip off the blood vessel and it starts again, start holding again for another full count by the clock. (When the bleeding starts again, the clot that had been building is pushed off by the bleeding.) Once the bleeding is controlled, you can apply a pressure dressing with a wad of small gauze pads under it to replace your finger's pressure to prevent it from bleeding again.
The standard rule on the street is not to remove blood soaked dressings, but to place new dressings on top. This is not appropriate for the wilderness. In the wilderness, you should remove blood-soaked dressings, identify the bleeding vessels, and apply pressure to them as described above.
On occasion, you may find it difficult to adequately stop bleeding, because you can't precisely identify the bleeding vessels. In such a situation, you may be able to use a temporary tourniquet as a tool to identify the bleeding sites. Surgeons and emergency physicians routinely use tourniquets for up to thirty minutes to allow "bloodless field" surgical repairs. Having details not obscured by bleeding makes the surgical repair much easier. Similarly, you can use a tourniquet to locate the bleeding vessels; you then apply direct pressure, and release the tourniquet. If you put a tourniquet on someone's limb, the limb won't become severely painful for about half an hour, and you won't start having irreversible damage to the limb for another fifteen minutes. However, you shouldn't need a tourniquet for more than a few minutes. (You should only apply a tourniquet with on-line medical command or standing orders from your medical director.) Whenever you apply a tourniquet, it must be wide, to prevent damage to soft tissues, and tight, to prevent any leakage. A blood pressure cuff makes an ideal tourniquet, provided you can ensure that it doesn't deflate. A clamp on the BP cuff tubes will work, provided you watch the cuff to make sure it doesn't leak.
Various materials can be placed into or onto wounds to help staunch bleeding. Thrombin powder works well. However, only one particular brand and type is stable for more than thirty days at room temperature. (Thrombin 5,000, 10,000, and 20,000 units (topical powder), Johnson & Johnson, is stable for three years at room temperature.) Other common materials include GelFoam and oxidized regenerated cellulose (Surgicel), both of which are stable at room temperature. These are light and may be carried and used, but are so seldom useful that their inclusion in a personal wilderness medical kit is questionable.
For minor injury or illness of a search and rescue team member, the medic may need only to examine the affected part. For instance, a complete primary and secondary survey is not needed for someone with a splinter in the little finger. For a rescue situation, however, the medic should perform as complete a survey as possible.
If a previous provider has performed a survey and started treating the patient (e.g. splinting injuries), the WEMSI medic has two choices: to accept the reported survey and start transporting the patient, or to take off splints, undress the patient, and re-examine the patient. In almost all rescue situations the medic should take off previously applied splints and examine the patient completely prior to evacuation.
The only exceptions are:
if the environment is so dangerous that the patient must be moved immediately for safety of life or limb, or
if the medic finds the reported survey to be as complete as needed, and it is consistent with the patient's observed condition.
The interval for taking vital signs, and the vital signs to take, are a medical decision to be made by the medic, in consultation with medical command if desired by the medic. Factors that enter into the decision include any danger to the patient from taking vital signs (e.g., exposure to cold), delay in evacuation from taking vital signs, and the stability of the patient. Frequent vital signs are not needed for stable patients; a set of vital signs every few hours might suffice. For a critically ill patient, vital signs every few minutes might be appropriate.
Medics should take and report a temperature on every patient. Even if no thermometer is available, feel the patient's skin and make an assessment of whether the patient's core temperature is normal, cold, or hot. The ideal way to measure temperature in the field is with a specific brand of ear thermometer (Exergen Ototemp 3000SD; available from Exergen Corporation; One Bridge Street; Newton, MA 02158; 1-800-422-3006; (617) 527-6660.) Other eardrum thermometers are not acceptable; cold or warmth of the external ear canal may lead to false readings.
An acceptable alternative is a continuous-reading Radio Shack indoor-outdoor thermometer, available for under $20; this can be used for continuous monitoring of axillary or rectal temperature, and all ER-NCRC/ASRC medical personnel should include one in their medical kits.
If in a cold environment, it is possible to use an oral or axillary temperature to rule out hypothermia: an oral or axillary temperature of about 98 degrees F (or about 36 degrees C) is sufficient to rule out hypothermia. If a patient has an oral or axillary temperature less than this, or if the oral or axillary temperature drops below this during evacuation, obtaining an Ototemp 3000SD eardrum, or rectal temperature, is vitally important. In such a situation the medic should overcome any revulsion and be very firm in insisting the patient cooperate. A Radio Shack or other rectal temperature probe may be placed by any rescuer and requires no special training; place the probe gently a finger's length into the rectum; place it up against the wall of the rectum, not in the middle of a piece of stool.
If treating a patient for possible heat illness, oral or axillary temperatures are not acceptable. An Ototemp 3000SD ear temperature is idea; a rectal temperature is an acceptable alternate.
To check orthostatic signs, check pulse (and blood pressure if BP cuff available) lying, sitting with legs dangling, and standing. Wait a minute after sitting or standing before rechecking blood pressure and pulse. A sustained drop of more than 10 in systolic blood pressure or a sustained rise of more than 20 in pulse with sitting or standing is a positive test for orthostasis and indicates dehydration or mild shock. If the patient tries to sit or stand and faints, that's also an adequate indication of orthostasis.
The medic should make reports to medical command, if established, or at least to the operation base. The content and timing must be adapted to the situation, but the following outline is ideal. This applies to written notes (often used in the initial phases of cave rescue) and radio/field phone communications:
Status Codes are in fairly wide use in wilderness search and rescue, and almost universally understood in the Mid-Appalachian Region:
Status II may be subdivided for medical reporting. As of 1993, this is a new extension of the standard status codes. These codes were chosen to reflect the important differences in patients' clinical status. A table of these codes should be carried by every every medically-trained ER-NCRC/ASRC person, and should be posted at all Base Camp communications or Operations Centers, and used for reporting. Extended Status Codes are as follows:
Note that actual evacuation plans include not only the patient's condition, but also other factors such as the time of day, weather, terrain, and available resources.
When available, rescuers of all levels will be expected to use the standard WEMSI patient record forms.
There are three critical areas of medical documentation, listed with the most important first:
Patients who may have been without food or water for a period of days should be given fluids and food unless there are reasons not to (see below). However, there are dangers in giving fluids or food to a starving or dehydrated patient:
In general, all patients who are more than a few hours from the hospital should be given food and fluids. The following are reasons not to give food or fluids:
Do not give patients caffeine. Chocolate is acceptable, as are decaffeinated coffee or tea.
Even if very hungry, give patients only small bits of food to begin with. Easily
digestible foods such as trail mix or gorp are ideal to start with.
Oral Rehydration
Patients, in addition to needing food and fluids for routine nutritional needs, may also need fluid replacement for various reasons: dehydration from excessive sweating, dehydration from vomiting or diarrhea, or shock from burns or blood loss or crush injury. Unless there is a good reason to avoid oral fluids (described, above), the medic should start oral rehydration for any of these situations.
Oral rehydration fluids must contain salt. Do not attempt oral rehydration without some salt in the fluid.
Two main kinds of oral rehydration fluid are available: Oral Rehydration Salts (ORS) and "athletic" drinks such as Gatorade®. Both contain salt, sugar, and potassium, but ORS is much more salty.
For diarrhea and vomiting, or for shock from blood loss or burns or crush injury, the ideal fluid is the World Health Organization (WHO) Oral Rehydration Salts. Packets of this salt mixture, each to make a liter, are available from: Travel Medicine, Inc., 351 Pleasant St., Suite 312, Northampton, MA 01060, (800) 872-8633.
For dehydration from sweating, less salt is needed; athletic drinks (e.g., Gatorade®) are best. Dilute them half-and-half with water, or alternate a liter of athletic drinks with a liter of plain water.
If only ORS is available, it may be used for dehydration from sweating; if only "athletic" drinks available, they may be used for dehydration from vomiting and diarrhea or shock.
If neither ORS nor "athletic" drinks are available, but some salt is available, add between half a teaspoon and a teaspoon of salt per liter of fluid. (A full teaspoon of salt will result in an average "athletic" drink's salt concentration.) Salt can be added to any type of fluid.
Every medic's personal kit should contain ORS packets, Gatorade® or similar
packets, or at least some salt packets from a fast-food restaurant.
Hypothermia prevention for rescuers is a standard part of search and rescue training and for the purposes of these protocols is not considered a medical procedure.
Hypothermia prevention for patients, however, is a critical medical procedure. Even aboveground in the summer, patients with illness or injury who are immobilized or not moving are subject to hypothermia.
During or after the primary survey, rescuers of all levels shall move the patient and place available insulation under the patient, then over the patient. If there are reasons to suspect a spine injury, the rescuer shall employ a log roll or similar technique to move the patient while protecting the spine.
In certain situations (cold water immersion, severe winter storms), rescuers may legitimately consider hypothermia a life-threatening hazard and do whatever is needed to protect the patient from hypothermia even before completing a primary survey.
Rescuers should generously insulate patients unless (1) the patient complains of being too hot, (2) an unconscious or uncommunicative patient's core temperature has climbed to normal levels, as judged by a thermometer, or as judged by the rescuer by skin temperature, or (3) the patient is being treated for heat ilness.
In cold environments, rescuer should not hesitate to use hot packs,
charcoal vests, or warm inspired O2 or air as "active insulation" for patients
who are not yet hypothermic.
Water Disinfection
Medics who are asked to make recommendations for backcountry water purification for drinking by patients or team members should recommend iodine tablets or other acceptable iodine methods, using adequate contact time given the temperature and turbidity of the water, or iodine-resin filtration systems.
Medics should take care to point out the limitations of most filter systems: except for iodine-resin systems, they will permit diarrhea, Hepatitis, and other viruses through. And, Giardia filters will not filter out either bacteria or viruses.
For disaster situations, medics may use the following for drinking water:
For irrigating contaminated wounds, medics should not hesitate to use clean
but not sterile water. The preference, however, is for water from a filter system
system that removes bacteria (simple Giardia filters not useful for this purpose).
There is no need to eliminate viruses from irrigation water, so most backcountry
filters will be adequate for this.
In certain wilderness or disaster situations, the risks of waiting for or using spinal immobilization are significant. In such situations, medics who have completed a Wilderness EMT class, and only those who have completed a Wilderness EMT class, may use the following protocol to exclude the need for spinal immobilization.
A person who has sustained a significant injury with the potential for cervical spine injury may be managed without cervical spine immobilization in the wilderness if and only if:
Rescuers may find patients in situations so hazardous that the patient must be
immediately evacuated without even trying to clear the cervical spine. (Example:
a patient hanging unsecured on a cliff.) This must be a decision of the rescuers
at the scene, and the decision-making process must be documented in
the rescue's medical records.
The selection and use of monitoring devices is up to the medic. Rescuers of any level of training may place a Texas (condom) drain on male patients and attach to a urine bag either for monitoring or to keep patient dry.
Return to Wilderness EMS Protocols.
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