After having a Positive Mental Attitude to survive, and once you’ve located Shelter, the next on the list of priorities is First Aid. This will likely be in a wilderness environment. Just so we can put a label on this, lets look at some definitions.
Wilderness is defined as “An uncultivated, and inhospitable region.”
First Aid is defined as “help given to a sick or injured person until full medical treatment is available.”
I’ll go a step further with defining this by saying wilderness, medically speaking, is an hour or more from the time the incident occurred, to treatment in a definitive care facility. Wilderness First Aid is also all about Improvising. We often can’t lug around an ALS ambulance with us or pack our gear with with the contents of a paramedic’s trauma bag. We can take minimal supplies and the rest is improvising. We can splint a leg fracture or configure a c-collar with a sleeping pad. We can use a bandana as a trauma dressing.
In a wilderness medical setting as well as the urban setting, we can categorize our patient as either Medical or Trauma. A medical patient in my experience as a former Combat Medic and Wilderness EMT seems to be more subjective, which means they tell you what’s wrong with them more than you can see it objectively. With trauma, it’s the opposite. A person who crashes their mountain bike on a trail and has an open fracture to an arm is pretty self-explanatory.
S-A-B-A stands for “Self-Aid / Buddy-Aid”. Self-Aid sounds easy when we know how we feel and pretty much know we crashed a bike or twisted an ankle on the trail. Except for that, we might have to perform some functions with only one hand, reduced or no vision, and not being able to move around because of trauma to our bodies. I would emphasize to practice applying a dressing & bandage to yourself with the use of one arm or blindfolded. This can be done while sitting on the couch watching TV. Buddy Aid is being able to medically assist another person.
Scene Size-Up: Dr A-B-C-D-E
This is our first action. We assess the scene from a safe distance so not to become part of the problem. We observe the area to determine if it is safe for us to enter or not enter. I’ll share with you how I keep track in my head on how I make decisions along the way.
Remember this as DR, as in doctor. D stands for Decision and that would be whether to enter or not enter the scene. R stands for Response and how do we respond to this scene. Do we enter and start assessing the patient or patients? Do we make the scene safe and then enter? Do we try to get the patient to move to you? Or do we decide it’s bigger than you and you’re going to need help. How many patients do you have? Can you determine the mechanism of injury?
A rule you’ll want to become familiar with is: “Risk a lot to save a lot, and risk nothing to save nothing.”
In our example, we have determined that the scene is safe to enter and we have one patient. He is near a mountain bike that has a badly bent wheel. He’s holding one arm up and against his chest. As I describe this, we can safely determine he crashed his bike and has some type of injury to his arm. You have completed the DR part; the Decision and Response.
Initial Assessment DR A-B-C-D-E
We have determined we can now start assessing the patient. Prior to this, we should account for BSI or Body Substance Isolation. We will put on a pair of rubber gloves in order to keep from blood and other substances. We can put on our rain jacket and pants from our pack to help accomplish this too. We should also identify ourselves and ask if they need our assistance.
A will assess for an open Airway and clear any obstructions.
B will assess for Breathing / Bleeding. Look, Listen & Feel. Look for life-threatening bleeding.
C will assess for Circulation. Feel for a pulse and control any life-threatening bleeding.
While we are checking the ABC’s, we are looking for the patient’s LOC or Level of Consciousness (response to pain stimuli) and that can be remembered as AVPU.
- Verbal stimuli response
- Pain stimuli response
This assessment of the ABC’s and all while determining the patient’s LOC quickly checks the Circulatory, Respiratory and the Nervous Systems. The bleeding gets assessed by checking the pulse. The breathing is assessed by checking the airway, the spine by checking AVPU.
D will assess for Deformity / Disability. Look for obvious deformed limbs that might be broken. Look for a potential Disability such as a risk of spinal injury.
E will assess for Environment where they are in. Can they stay there or must they be moved? Can you place the patient on a sleeping pad or erect a tarp overhead?
Once all of this has been accomplished, take a quick break for a minute. You have now controlled all of the life threats to the patient. After a quick breather, we can now look at the patient more in depth.
The next stage in assessing the patient is a Head to Toe Exam. But before I go any further, we will discuss recording your findings through SOAP Notes. This stands for Subjective, Objective, Assessment and Plan.
Subjective is what the patient tells you such as where the pain is located.
Objective is what you can observe such as an open cut or bruise.
Assessment is what you determined as your best guess after examining the patient. An Assessment might be, “After finding swelling and pain in the wrist, the patient stating they crashed their bike and using their hand to break their fall, I determined that the patient may have a broken wrist.”
The next is Plan. That is to record what you plan to do with the broken wrist. The Plan could be, “Splint the arm by stabilizing the joint above and below the injured site and provide a sling & swath. Walk the patient out and transport to a medical facility.”
Head to Toe Exam or Secondary Assessment
When we perform this Head to Toe Exam, we will assess without any medical equipment since this is not in the back of an ambulance. We do not have a trauma bag in our packs. This is the core of Wilderness Medicine, improvise.
We will start the examination at the head. That includes checking the ears, nose, eyes, and mouth.
- Ears – Look for pinkish clear fluid coming from the ear canal which might indicate spinal fluid. Also look around the base of the ears for what appears to be bruising. This is another indicator of a skull fracture called, Battle’s Sign.
- Eyes – Look for “Raccoon Eyes” which appears to be bruising like a black eye, which is a sign of a skull fracture. Look at the eyes and look for Pearl, spelled P-E-R-R-L. Pupils are Equal, Round, and Reactive to Light. When checking for PERRL, compare to see if they are the same or different.
- Neck – Check the neck for anything out of the ordinary such as cuts, bruises, bulging veins, trachea off to one side, etc.
- Chest – Check the collar bones, then the rib cage, and check for symmetrical rise and fall while breathing. (You should have checked for bilateral rise and fall in your primary airway assessment, but if you ended up having to handle a flail chest or pneumothorax, now is when you reassess your treatment to ensure it’s still doing its job).
- Abdomen – Check for TRD (like turd) which is Tenderness, Rigidity & Distention. Divide the abdomen up into four quadrants, using the navel as the center. Check each quadrants individually.
- Pelvis – Check for its stability by putting pressure inwardly from the sides and then push down. You are looking for bone movement, pain, etc.
- Arms – Check along each arm for cuts, bruises, pain, etc. After checking both arms, Check CSM or Circulation, Sensory & Motor function at the same time. You will check both radial pulses, ask the patient if they can feel your touch and then ask them to squeeze a couple of your fingers. By checking both hands at the same time, you can determine if one side is less functioning than the other.
- Legs – Check the legs much the same as you did with the arms. When you get to the feet, check for CSM by asking the patient to push their feet down and up with your hands as resistance.
- Spine – Some of the spinal column, including the neck can be checked before moving the patient. To properly examine the spine, you roll the patient onto their side while properly maintaining the head and spine. Palpate the entire spine to feel for abnormalities, pain and numbness. Roll the patient onto a sleeping pad or some other barrier from the cold ground, if it has not already been placed.
This is an ongoing process since we have to periodically recheck after getting our baseline vital signs. Record the times you take the vitals.
- LOC – Level of Consciousness using AVPU.
- HR – Heart Rate and note the rhythm & quality. Weak? Strong?
- RR – Respiratory Rate and note the quality & rhythm. Shallow breathing? Heavy breathing?
- SCTM – Skin Color, Temperature & Moisture. Pink, Warm & Dry is the normal.
After recording the baseline vitals, make a point to recheck the vitals after about 15 minutes and continue on every 15 minutes. This will let you and the medical facility see how the patient is trending. This can also show if your treatments are effective or reassess your plan.
Patient SAMPLE History
You’ll need a history from your patient, if they’re awake and alert enough to give you one. If your patient is unable to talk to you, ask any bystanders if anyone knows something about your patient. The list of questions you need answered is called a SAMPLE history, which is an easy way to remember the questions to ask.
- S – Signs & Symptoms which is part of your SOAP Notes (Subjective & Objective)
- A – Allergies, which can be for insects or medical allergies.
- M – Medications that are using. That can be broken down even further by using PORCCH. This is an acronym I use to remember the Medication questions.
- P- Prescription drugs
- O- Over the counter drugs
- R- Recreational drugs
- C- Contraceptive drugs
- C- Compliant with the medication instructions or doctor instructions.
- H- Herbal supplements
- P – Past pertinent history that might be part of the incident.
- L – Last ins & outs which includes oral intake of food & water along with asking if they have been having their urinations and bowel movements.
- E – Events leading up to this incident. This is just a question on what was going on prior to the incident.
This information sounds like a lot but it really goes by quick as you are evaluating the patient. My suggestion is to keep a 3×5 card with this information on it. This will help make sure you haven’t overlooked anything.
Part 2 of this article will give you pointers on using improvised items to help in treating your patient. I will also discuss plants I have successfully used to treat patients.
Until Part 2 is posted, practice this Patient Assessment with someone and get used to checking someone normal. Don’t forget to check for pulses in the extremities and record your findings.
HolySerf is the nom de plume of a student of the wilderness and an amateur naturalist. He is a formally trained search & rescue tracker and wilderness survival instructor. He is a veteran of the war in Iraq where he served as a Combat Medic. He also served as a Sergeant in the 82nd Airborne Division as a Combat Engineer with a deployment to the Sinai Peninsula and a graduate of Panama’s Jungle Expert School. He has held certifications as a First Aid Instructor, Wilderness First Responder and Wilderness EMT. After retiring with more than 20 years as a law enforcement officer, he works on pairing his amateur radio skills and wilderness wandering. He holds an FCC General Radio license.