As
we move through the various paddling seasons, we find ourselves
periodically evaluating issues about our boating. We change boats,
river destinations, the clothing we wear, the food we bring, but what
about our first aid kits? Do they need to change? Are they adequate?
Are they too complex? Too minimal? When was the last time you really
dug deep into your kit to refresh your memory of what you really have
vs. what you really need? We all have our opinions of what we need to
bring. We have past experiences and endless river stories to stoke
our thought process and help shape our packing list.

Some paddlers
may find themselves packing to fit their boat. Their train of thought
may be that, since they have a tiny play boat they don’t want to
overload, they don’t bring anything. Others may believe that since
they have a huge river runner or open boat, they should bring the
kitchen sink. I suggest paddlers first evaluate the type of water
they want to boat in. There is not one comprehensive list that will
cover every contingency for every type of paddling, from swamping to
white water to sea kayaking. So in the beginning, don’t focus on the
comprehensive list, focus on a strong foundation of basics to build
upon. When considering the issue of paddling and first aid,think
first of the basics. Approach the adventure by asking yourself, “What
items do I need to treat life threatening issues?” Once that
question is answered, anything else you bring is just gravy.

Education
& Training

The
first thing to bring on a trip is education. Knowledge is power; go
get some. The Wilderness First Aid courses offered today are
outstanding. Several organizations teach Wilderness Medicine at all
levels. The drawbacks are that they are not widespread throughout the
country, they tend to be a little pricey and are sometimes offered at
times that it is inconvenient to attend. However, if these courses
are unavailable to you, the American Red Cross and the American Heart
Association offer first aid and CPR on a regular basis. The course
they teach covers the basics, giving you a solid foundation of skills
to build upon. This foundation will help gear your way of thinking to
consider the “what ifs” during paddling trips.

These
courses can be found at your local hospital or community college,
given typically on weekends and evenings, and are fairly inexpensive.
Look into your local paddling club. Through these clubs you can find
classes covering everything from basic and advanced paddling to
safety and rescue courses — what to do when something bad happens
while paddling. Once armed with some knowledge, gather your gear.
When you get your kit together, keep in mind that everything you
bring should have at least two uses. This may require some creative
thinking at times, but in the end, it will save you space, weight and
time sifting through all the non-essential items in your bag.

Clothing

Dress
for the occasion. You don’t go to a black tie affair in a T-shirt and

flip flops, so why boat in frigid temps wearing just a dry top and
shorts? Using the excuse that “I never swim” is complete
nonsense. Be prepared. If you try to wade into 40-degree water when
you don’t have insulation on your legs, you will not be an asset. If
you try to handle wet throw ropes with bare hands when things are 50
degrees and blowing wind in the early spring, you won’t hang on long.
Hypothermia is a not an equalizer, it is a killer. If it doesn’t get
you, it will prevent you from helping your buddy. If you find
yourself too warm, it’s easy enough to remove a layer or two and
stuff them in the back of the boat. Perhaps another member in your
paddling team gets cold easier and would love to borrow your extra
stuff. If nothing else, your extra clothes make a fine pillow for a
catnap during the lunch stop.

Taking
Charge

If
things do go bad on a trip and the team winds up with a patient,
things get complex. There will be a lot of chaos going on, from no
one taking charge, to everyone wanting to take charge, to people
chasing gear, to people not wanting to be involved, to everyone
wanting to get involved. These are real issues and they need to be
dealt with. It can be frustrating, confusing and intimidating. But
first and foremost, before everything else gets wild and crazy, is
your patient.

Hypothermia

People
are tough animals; they can take a lot of abuse. People have
survived, soldiers have fought, mountaineers have continued to climb
for days with broken limbs, open cuts, gastrointestinal problems —
but one of the few things a body cannot take is being cold. A
hypothermic patient is a dead patient. You must keep focused on the
task at hand and the first task is to do no further harm. Do not
allow them to become chilled. Ensure they are dressed in wicking
layers. Keep a close eye on them for signs of hypothermia. A person
in distress from injury, near drowning, allergic reaction to a bee
sting/food, lightening strike or other traumatic event will not be
able to compensate their loss of heat. If hypothermia begins to set
in, active re-warming needs to happen. Skin to skin contact between
the victim and a buddy is one of the most efficient ways to re warm a
person in the field. But if you can’t keep the breeze off the
backside, then you are fighting a two front war. Get up against a
wind barrier of some sort. Use a downed tree, a boat turned on it’s
side, a rock pile. Something that will push your body heat back
towards you. A space blanket or large plastic bag, such as a garbage
sack, is an ideal emergency shelter. There are also emergency bivy
sacks on the market. Resembling the space blanket, these emergency
bivies offer a good bit more protection.

Fire

Carry
fire-starting material in a waterproof container. There are
commercial preparations on the market such as magnesium or fire
paste, or you can make your own. A couple of cheap concoctions
include rubbing cotton balls or #0000 steel wool soaked heavily in
Vaseline, storing them in an empty film container. Another option is
to take the shavings from a pencil sharpener, mix them with melted
paraffin. Pour the mixed preparation into cardboard egg cartons,
filling each one about 3/4 full. Let them cool. Paraffin is water
resistant and stable, but burns nicely. Higher quality pencils are
made from cedar wood. The cardboard of the egg carton acts like a
wick. You can also dip your matches in melted paraffin to waterproof
them. When it comes time to use the match, use your thumbnail to
scratch off the wax, strike as normal. Don’t build your fire under
trees with snow on the branches. Do build your fires with reflectors
to push the heat back towards you. That can be anything from a rock
pile to a downed tree. Make your fires small to huddle up against.

Food

Stress
and cold will burn sugar stores. No glucose equals no brain power. If
(IF IF IF) there is no head trauma and your patient has the ability
to swallow, administer some easy to digest simple carbohydrates or
sugars. Charms candy is popular with the armed forces for battlefield
pick me ups. There are gels on the market that also offer
carbohydrates, protein, and energy. These gel packs are small,
lightweight and effective. If a patient is only semi-lucid, appears
to have difficulty in maintaining their own airway, or runs the risk
of choking on anything given by mouth, I strongly caution against
feeding them. To do so puts them at risk of choking on the item
placed in their mouth. If they choke and/or gag on it, they may
vomit. When they vomit and lack the control of their own airway, they
run a high risk of sucking their emesis back into their lungs. This
will invariably lead to something called aspiration pneumonia
Aspiration pneumonia has an extremely high death rate but takes a few
days to really show its affects.

Shelter

Day-tripping
white water boaters may consider their chances of having to spend an
unplanned night in the woods practically nil. However, extrication of
a non-walking patient over moderately rough terrain moves typically
at less than 1 mile an hour. It is hard work, physically and mentally
draining, and painstakingly slow. Add an elevation factor and your
speed has dropped dramatically. Sometimes the best choice is to send
for help and sit tight while waiting for it to arrive. Making that
choice, you may need to settle in for the night. A strong knife with
a at least a three inch blade and a bit of lashing material can go a
very long way in making things less miserable. A throw bag can be
used to lash materials, but 50 feet of 2 mm cord tucks up smaller
than your average candy bar and is perfect for building your bunk.

ABCs

If
the patient requires a bit of medical treatment, be creative, but
remember your ABC’s: Airway, Breathing, and Circulation. Doing CPR in
a remote setting for an undefined period of time is moral, ethical,
and logistical nightmare. Reading an article it not nearly enough
discussion to cover this complex topic. I suggest you interact in
face-to-face discussion with your CPR instructor to help you define
your own decisions. The choice to carry a face mask for CPR can be
covered during that face-to-face discussion. Maintaining an airway,
however, is not just for CPR. An unconscious person, such as one
struck in the head by a rock, will not be able to keep their tongue
from falling to the back of the throat. To keep that tongue forward,
there are a couple of techniques, however, they require constant
interaction by a rescuer. A device to assist you is called an oral
pharyngeal. This is placed in an unconscious victim who does not gag
on it. If they still have a gag reflex, but cannot keep their tongue
forward, there are nasal pharyngeal. I caution against placing these
without proper medical training however. These devices are fairly
small, very inexpensive, and a real lifesaver. If you are not trained
in such placements, or don’t have one, there is another choice to
help maintain their airway. Take a safety pin from your triangular
bandage package, pierce the patient’s tongue, then pin their tongue
to their lip. Yes it is extreme. Yes it is barbaric looking. But
would you not be upset if someone let your friend choke on his or her
own tongue? The holes will heal over; a dead patient won’t get
better. To breathe for a patient see discussion of CPR above. Get
some training. Circulation refers to blood flow. People bleed. It’s a
fact of life. It’s messy, it’s scary looking, it can be hard to deal
with. However, over 90% of the time, it’s not life threatening. Even
a little blood will look like a lot. Head wounds tend to bleed more
since they are more vascular. To see a face covered in blood hits the
anxious button in most of us. The treatment is the same, no matter
where the bleeding is. Direct pressure first, then elevation of the
injury. If that is unsuccessful, then use pressure points. In over 13
years of emergency medical experience, I have never used a
tourniquet, but if you feel compelled to do so, do it only after you
have exhausted all other possibilities. When you apply the
tourniquet, you are making a conscious decision to destroy all the
tissue distal of the belt. I have always found that direct pressure,
elevation, and pressure points have been enough, even in traumatic
amputations.

Dressing
Wounds

Do
not remove the dressing to add clean ones nor to inspect. Place
whatever form of material you have against the opening, and just keep
stacking it up. Even in the case of compound fractures, where the
bone is sticking out, pad it, preferably with something from a
sterile or at least clean package. If you remove the original
dressing, then you disturb any part of a clot that was beginning to
form, allowing it to bleed longer. For dressings, there are seemingly
a million on the market and we all have our favorites. I caution
against redundancy. A 4×4 will do the job of a 2×2, but not vice
versa. Most medical tapes will not stick in wet conditions. Even if
you are taping a dry dressing, more times than not, your hands
handling the tape are wet from boating. Cotton cloths such as a
T-shirt and duct tape are great dressing materials. Duct tape belongs
everywhere, and it’s so easy to wrap your water bottle in a half a
roll of duct tape, taking it with you everywhere.

If you prefer not
to be so basic, invest in Ace Ban-dages. They don’t need tape to hold
to itself; they make great pressure bandages, splint a million
things, and are so easy to use. Roller gauze, AKA Kling wrap, is
another great investment. Wound closure in the field is a risky
undertaking. I have seen people out there with bottles of super glue
and or suture kits ready to close that leaking pesky wound. If you
close a wound in the field, you are more than likely sealing in
bacteria that does not belong there. Even with aggressive irrigation
from your drinking water supply, you are asking for infection. You
can temporarily close a wound with butterfly closures made from duct
tape, but don’t seal it. Leave that job for the thoroughly trained.
Primary closure of a laceration can be delayed safely for up to 8
hours. After than point, doctors have to shift their technique just a
little. After 12-14 hours, still closure can be done, but typically
after some debridment. My point is that you don’t have to close
wounds on the banks of a river when home is just a short jaunt away.

Splints

Splinting
is a hobby lover’s dream. You can be creative. Your only limit is
your imagination. In a perfect world you want to immobilize the joint
above and below the fracture site after first ensuring they have good
nerve and vascular function below the site of injury. After
splinting, check the nerve and vascular function again. If changed
for the worse, undo your splint and re adjust. If a patient does not
have a pulse or good nerve function below the injury site, CAREFULLY
return the limb to the position of natural function, consistently
monitoring for a pulse and nerve function return. Once it has
returned, immobilize in that position.

Arms can be slung in your own
shirt tail, with the bottom hem being safety pinned to your collar,
fingers can be buddy taped to the finger beside them, as can legs.
Collarbones can be splinted with a short piece of webbing; ribs can
essentially be left alone in the short-term setting. Be creative but
keep in mind that you will not make these people pain free. That is
not your goal. Your goal is to minimize further movement, thus
minimizing further damage.

Dislocations

Dislocations
can be tricky. Rapid reduction in the field can be done faster with
better long-term recovery results. It eases the patient’s pain, and
in some cases, allows them to extricate themselves from the situation
rather than depending on others. However, field reductions by
unskilled people can also pinch off the neurovascular bundle that
feeds that limb, causing permanent damage and/or bone chips.
Misdiagnosing a fracture for a dislocation, or vice versa, can be
devastating to long-term recovery. If you want to perform reductions,
seek training to the highest level and be prepared to accept
responsibility for your actions. If there is no distal pulse in the
affected limb, or medical treatment is greater than 8 hours away,
then there is argument for re-setting a joint in the field by someone
who perhaps has not been trained thoroughly.

Drugs

The
world of medications is another sticky subject. Discuss medications
that you want to carry with your doctor. Mountaineers carry a
pharmacy with them, expedition boaters carry pharmaceuticals with
them, they can make a difference. However, they can also cause
allergic reactions, untoward side affects, create drug resistant
strains of bacteria, and even lead to death. If you want to take
medicine prescribed for yourself by a trained health care provider,
that is fine. But if you want to give medication to a person who you
think has a situation that your pills may fix, be prepared to accept
all the responsibility and consequences of possibly adverse
reactions. So when you dig into that first aid kit buried way in the
back of your boat where you hope you never have to reach, take a look
at it. Do you have what you really need? Do you really need what you
have?

Steve
Revier is a career firefighter/paramedic in Maryland. He has worked
as a Navy corpsman, Tidewater Search and Rescue member and white
water raft guide. He is an ACA certified Swift Water Rescue
Instructor and a nationally registered paramedic. Barring regional
drought, you can usually find him running the steeps on the Mid
Atlantic watershed around 150 days/year.


by
Steve Revier
From The Eddy Line, October 2002