Backpacking First-Aid Philosophies

[Arthur]

Rex. This is right on advise. Epi is one of about 7 drugs that the Dept of Defense did a study on 30 years ago that truly does loose its potency quickly, hence the short shelf life. The Epipen is the classic study in generic drug companies gouging consumers with inflating prices for no reason. Glad to see it is down to $108 with GoodRx from over $1000 a while back. Still, we used to buy a 1 mg vial for about 75 cents back in the 90’s. But you needed a 10 cent syringe and need to administer it. And we had to buy it every year!

[Bonzo]

This is timely info: my partner looks to be developing an allergy to capsaicin, and it’s worsening as time progresses.  Even being in the same room with certain spices and hot peppers is starting to cause throat tightening, so we’re really watching what we have in the house, and what we encounter.  I’m also rebuilding the first aid kits to make room for EpiPens, now, because we may well have to start carrying them.  We may also not be able to utilize bear spray; that’s right at the top of the “don’t be anywhere near it” list.

[AK Granola]

Interesting advice about Benadryl. When my son has an anaphylactic reaction to nuts, he has to use the epipen, and then go to the hospital, where they put him on a Benadryl drip for a while, plus steroids. On one occasion the ambulance used several epipens on him before arriving at the hospital. He doesn’t go into the backcountry at all. It would be a nightmare for anyone with such a severe allergy to try to manage this without quick emergency services.

The PPE – wondering about the gloves. Are they primarily to protect the caregiver from exposure, or the patient’s wound from infection? I have never seen these for sale nor would I know what to carry.  The irrigation kit – my husband once got bitten badly by a dog on a hike (not our dog). A nurse in our group irrigated the wound thoroughly with a water bottle, all we had. It apparently worked, since he’s still around.

[Rex Sanders]

Gloves
I use blue nitrile gloves from Costco to put me into a “first aid” mind set, to comfort patients, and to protect each other. Don’t underestimate the value of symbols in stressful situations.

Wound irrigation
I’ve gone back and forth on carrying an irrigation syringe, since that’s how I was trained. Both volume and pressure are important for cleaning wounds, especially for grungy abrasions with lots of small, embedded dirt.

So of course I started searching, and found this:

Pressures of Wilderness Improvised Wound Irrigation Techniques: How Do They Compare?
Wilderness & Environmental Medicine, 2016
https://doi.org/10.1016/j.wem.2016.09.002

In brief, these common backpacking items had “good enough” pressure. From best to worst:

– 10 ml syringe often included in first aid kits
– Smartwater bottle with regular cap punctured by a dozen 1 mm (14-gauge) holes
– 50 ml Sawyer water filter cleaning syringe
– Smartwater bottle with flip-top squirt cap

Probably not good enough:
– Ziploc with 1 mm holes
– Osprey 3-liter hydration bladder through drinking tube

And you should plan on 3 to 10 liters of wound irrigation, using progressively more at lower pressures. That would take a long, long time at 10 ml or 50 ml per squirt.

For me, the clear winners are the Smartwater bottle with holy cap (make cap at home, 2 grams extra to carry), and Smartwater with flip-top cap. Both could be used as backcountry bidets for multi-use.

But here are the author’s conclusions:

Both the water bottle improvised systems and all syringe-based systems provided pressures at or exceeding those measured with a commercial wound irrigation device used in an emergency department at a level 1 trauma center. A 14-ga punctured Ziploc plastic bag and bladder-style hydration pack failed to generate similar irrigation pressures; however, recent evidence suggests even very low pressures may be effective in reducing bacterial contamination. With that in mind, the authors recommend carrying any of the equipment tested in this article for the use of emergency irrigation, with a preference for devices that would be a normal part of gear supply. In terms of ease of use, the water bottle with the sport top is ideal, being lightweight, already filled with clean water, and taken by most hikers routinely for water storage purposes.

HYOH.

— Rex

[Bonzo]

What about using a travel bidet for irrigation?  I still don’t have one so I can’t compare pressures, but that might be an option.

Gloves: Gloves protect everyone, both physically and mentally.  Of course, if you put your gloves on and then go rooting around in the first aid kit that you’ve casually dropped in a mud puddle, you aren’t doing much physical protecting of the patient…but that kind of cock-up aside, they work pretty well.  And they make you look prepared and professional, and the better the patient feels about your abilities, the better chances they have.  A good demeanor and a bit of confidence help, too.

[Rex Sanders]

Correction: A 14-gauge catheter needle, as used in the Wilderness & Environmental Medicine paper I cited above to put holes in Smartwater bottle caps and Ziploc bags, is 2.1 mm (.083 inches) diameter.

I used the wrong gauge system (there are too many!), and should have used this:
https://en.wikipedia.org/wiki/Birmingham_gauge#Sizes_of_catheters

— Rex

[Rex Sanders]

Made and tested holy Smartwater bottle caps. I poked holes in the caps using a 12-gauge finishing nail (different gauge system, right size) heated up with a Soto butane pocket torch. A natural gas, propane, or butane stove would probably work fine. Heat the nail for much longer than you might think.

Here’s a 12-hole cap, as described in the JW&EM paper. Not pretty, but it worked:

I emptied a 1-liter bottle in about 15-20 seconds. But the water sprayed over a much larger area than I liked, with too little control.

So I made another cap with just one hole that I rounded out slightly.

It took about 70 seconds to empty a 1-liter bottle, with MUCH better control over spray location and pressure. Speed is not that important when cleaning wounds, but this system is much less tedious than hundreds of 10 ml syringe squirts plus refills needed to reach 3+ liters.

I like the one hole cap much better. All 2 grams of it is going into my first aid kits. Labeled, of course:

You could adapt this scheme to any water bottle with a similar cap, like my favorite Platypus Platy 2-liter bags, which might work a lot easier for squeezing.

And if you need to make a holy water cap in the backcountry, just get out your pointy knife and start drilling. Won’t take that long, and precision isn’t critical. Just don’t make the hole too big.

— Rex

[Cameron M]

This is a great discussion, I intend to research everything that has been mentioned and look forward to personally stepping up from WFA to WFR training soon. On the simplest level, for those not inclined to get into the details, I advocate proactively questioning and helping people who may not be aware of dangers they are putting themselves into BEFORE something bad happens, knowing CPR, carrying a two-way communicator, and avoiding infection.

[Bonzo]

holy Smartwater bottle caps

Batman!

Sorry, couldn’t resist. ;)

All comedy aside, I’m going to check the diameter of the hole in a flip-top Smartwater squeeze cap.  I think it’s probably around 5mm or so.  Maybe something that could reduce that diameter would work just as well the holy perforated cap.  Hmm.

[Rex Sanders]

Karen,

I wouldn’t dare to second-guess your son’s doctors. But I could easily imagine that Benadryl and steroids after several EpiPens could be important to your son’s recovery. First keep him alive; then deal with other problems.

Hope he stays healthy.

— Rex

[David Thomas]

“Cialis (for HAPE, not what you think)”
If your breathing remains hard for over 4 hours, you should seek medical care?

[David Thomas]

I love the water-bottle cap with a single hole for irrigating wounds (or as a bidet).  I advocate for an extra, intact bottle cap (plus one with multiple holes for a shower) since it’s only 3 grams and you’re kind of screwed if your only one falls in a stream.

If you forgot to drill one at home you can put a tent stake or nail or safety pin over a Bic lighter flame and melt holes through a bottle cap.

[Rex Sanders]

I usually carry a spare-but-intact Smartwater bottle cap.

But recently realized I might be able to use a holy bottle cap as a “good enough” spare, after adding a small chunk of Ziploc bag or similar to block the outlet so water doesn’t escape under most conditions with careful handling.

Needs testing.

— Rex

[Roger Caffin]

The first rule of BPL is to eliminate all those ‘what if’ things. Extra bottle caps, even with adjustable holes, are very much ‘what if’.
Just take the ordinary cap off and stick your thumb over the hole. Like with a garden hose.

Cheers

[Bonzo]

The first rule of BPL is to eliminate all those ‘what if’ things.

Roger, that advice can backfire:

Q: What if I run out of scotch?

A: Bring more than enough scotch.  In fact, bring ALL of the scotch.

Actually, this isn’t such a bad idea after all… 🤔

[Herman]

All: good information and ideas posted.

Feel free to PM me with any questions regarding practice or gear that you may have. I have 20 years of emergency medicine experience, was a WFA instructor, have taken WFR, and did SAR for 14 years in Alaska. Sometimes easier to just shoot a simple or not so simple question over by PM than create a long thread about it. Definitely benefits to doing both. Always open to helping people learn more medical skills. Once you have those, you can MacGyver a lot.

 

 

 

[Roger Caffin]

Always good to share knowledge.
Cheers

[Josh J]

I spent 5 years on ski patrol.  Saw plenty of concussions, a few good lacerations and what I presumed broken bones but I’m not superman so I can’t definitely say…..

I’ve got several 1st aid kits, one in the car, one for family and friends hiking and one for solo trips.

I’m also well versed in wound irrigation with plenty of stitches in my court……

The hardest part of medicine is I’ve got small kids…. thier doses are way different than adults.  So keep that in mind if you’re traveling with kids.

So basically my kits are geared towards what im comfortable treating and who I might be helping.

The biggest thing to remember in any situation is your ABCs,  get those and maintain them and that’s a big part of the battle.

[Josh J]

i like the single hole approach of the bottle cap rather than the 10ml syringe due to the refill factor. since wound irrigation is more about pressure to flush the wound i would think as long as you can reproduce the same size hole as a 10ml syringe in the bottle cap then you should get around the same pressure or more. the biggest difference is a syringe is a fixed diameter vs a water bottle is going to give you different pressures depending on how hard you squeeze. but it’s better than nothing and there have been plenty of times i’ve gone in for stitches and they have literally put my wound under running water from a faucet…

[Josh J]

a great read

https://www.wemjournal.org/article/S1080-6032(14)00278-6/pdf

[Roger Caffin]

they have literally put my wound under running water from a faucet
Get the muck out of the wound and let the body do the healing. It can.

Cheers

[Arthur]

As a young resident on Plastic Surgery rotation, we had a young, good looking girl come in who went thru the windshield. (fewer seat belt days)  She had deep, ugly lacerations all over her face.  The neurosurgeons would not let us take her to the OR to sew her up due to her head injuries. So, the old attending doc says “ok you youngsters, you are going to learn a lesson here.”  He had us basically keep the wounds clean and moist after washing and debriding as much glass as we could. We had to change the dressings twice per day for 4 weeks.  No stitches, no steristrips, no nothing. Just keep them clean.   In about a month, she looked amazing.  In many places, better than if the wounds were closed with sutures.  We were all stunned by the old doc’s wisdom and learned a lifetime lesson.

[Ben H.]

Someone up-thread mentioned a cheat sheet on the uses of non-prescription medicines as being NOLS proprietary. Does the current WFA course contain information on when to and not to use non-prescription medicines in situations? When putting together my FAK I always think about what non-prescription medications could be really useful in the backcountry. I think about aspirin for heart attacks and Benedryl for anaphylactic shock. I also think about pain medicine for injuries that might make it easier to get back to the car by taking the edge off. I don’t normally take pain meds or antihistamines so I always feel a bit lost trying to supply my FAK. When I took the NOLS WFA class a number of years ago I gave the feedback that some cursory information on the use of non-prescription medicines would be useful. Are they doing that now?

[Bob Kerner]

I’d suspect that there’s not a lot of formal guidance about medication use since giving meds to someone else in a prehospital setting is really the domain of a state certified EMT or Paramedic. What I’d take myself doesn’t necessarily give me permission to give to someone else. I carry the basics: Motrin, antihistamine, and decongestant (I’m prone to sinus congestion). All in pill form. Benadryl in pill form is not going to help you with someone who has anaphylactic shock particularly if they have angioedema of the tongue or mouth; you’re creating an airway management issue by asking them to take pills. If you’re concerned about anaphylaxis, an Epi Pen is what you need. Itchy bug bit, pills are fine.

[Rex Sanders]

My copy of the NOLS Wilderness Medicine Handbook has two pages of legal considerations, and four pages on OTC and prescription medicine considerations. Not going to summarize that here, because IANAL.

In real life, do you let a patient suffer or die, or risk getting sued if you act and something bad happens? Lots of judgement calls in stressful situations.

Get trained, then try not to do anything stupid. That’s partly why I carry pocket guides and cheat sheets.

Be kind & thoughtful, and communicate more than you think necessary. After getting out of imminent danger, then stabilizing airway, breathing, and circulation (e.g. bleeding), you can take your time in most situations.

— Rex

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