Thoughts on the painful subject of first aid
I got an email this week from my friend James, who lives in Switzerland:
“Last week my wife tripped over in the mountains.... as she was about to get up, she looked down and noticed she was staring at her open kneecap. Game over for her first 50km ultramarathon event. (three stitches, no other damage thankfully, so on track for a quick recovery).
The event organisers got her off the mountain... the guy who picked her up later explained he was mortified to not have a single bit of first aid gear on him... shockingly silly for a trained 'sapier pompier' who you may know are like the special forces of firemen - as well as fighting fires, in the mountainous parts of France and Switzerland they're also trained in mountain rescue and paramedicine. He figured as a 'helper' that day, he wouldn't need anything with him! He was extremely sheepish as he explained this to my wife, in a tiny cablecar service cage, hundreds of meters above the valley floor as he helped her down. What a pillock... he was hugely lucky she was calmly holding the wound closed and had stopped bleeding quickly (I guess there really is something to this 'be fit and healthy' stuff!).
Fast forward a few days... my daughter fell off her bike and broke her wrist. A few minutes later thanks to my rudimentary emergency first aid knowledge and kit she was SAM-splinted up, my guessed diagnosis would turn out to be spot on, and we had her arm in a sling on the way to hospital.
The hospital were surprised I had any first aid gear with me. Astonishing stuff... I'm continually surprised at how few folks who play in the mountains have any first aid knowledge or gear.... it seems to be the exception and not the rule.
As one mountain rescue chap I once heard say; "People forget... mountains can kill you. They're not like a football pitch."
Reading the email made me think about my own opinions, thoughts, observations and actions around the issue of first aid kits, and also the people who use them.
My friend Paul Ramsden once told me that it really wasn’t worth bringing much of a first aid kit on a mountain, and that all you needed was enough strong drugs (generally the kind you need from a doctor, not over the counter), to stave off the pain of a broken leg long enough for rescue to arrive (and I suppose if they don’t arrive soon, you’ll probably be a goner anyway), and that '70% of all victims with untreated compound fractures die after ten days’.
Paul famously carried a single magic red pill (we’re taking pre-Matrix) that he’d been told would overcome any sort of pain, no matter how great. He carried it around for years until one day he took a hard fall while taking part in a fell race. He laid there in agony, his knee cap feeling as if it had broken in two until a runner came along, and Paul sent him on to call out the mountain rescue. Then he remembered his single red pill, dug it out of his micro first aid kit (it was his first aid kit), and swallowed the pill.
Twenty minutes later he overtook the guy who was sent to call out the rescue team, telling him he had a miraculous recovery (note, the many years of pain caused by running on a knackered knee demonstrate that red pills should not be used for performance purposes).
An alternative view can be gleaned from Lindsay Griffin, who received a double compound fracture - alone - when a boulder rolled over his leg in the remotest part of Mongolia. Luckily for Lindsay, he had a ‘red pill’ close at hand, and having stemmed to pain somewhat, managed to set up a 6:1 haul system that took a small amount of crushing weight off his leg, saving it (he would eventually be helped down to a tent by his two climbing partners, using a makeshift splint with ice axes, and wait for four days until a helicopter picked him up).
On the subject of wilderness first aid, the one thing that always troubles me is how people so qualified, always seem to have a gleam in their eyes, as if they cannot wait to start sewing someone up, or administering saline solution (even though it’s generally a frozen lump).
I tend to think that in terms of emergency wilderness first aid, instinct way well is just as valuable as training, and how just like how partners with degrees in geology never seem to know anything about rock, the truth might be the same with a doctor (especially if they turn out to have a doctorate in education).
Serious accidents are serious
It’s easy to be flippant about this subject, but I will always remember a conversation with a Norwegian friend who saw someone fall over a bergshrund in the alps, breaking his leg. Apart from the broken leg, he seemed OK, but while waiting for the swift Chamonix rescue helicopter to arrive, he simply died of shock (like you now, my first thought was “how does that happen?”, and next came how little I knew about the subject).
I find the idea of having an accident, and thinking you’d dodged death, only to die anyway seems worse than just dying, but it seems all to common. I remember when Paul Williams died after a fall while soloing, and that although he seemed OK, died of internal bleeding. A neighbour once told me a story of a friend taking a big ground fall, but who said he was OK, and would walk it off back to the car, only to drop dead just before he got there. Now I come to think about it, there are quite a few stories like this rattling around in my head.
I suppose the two take aways is that when you have a serious accident – and you’ll know it when it’s serious – you should let what happened set for a while, and not do what most people do, which is just feel embarrassed and foolish and try and laugh it off as just a close call (that’s something that decided long after).
The second take away, connected to the first, is that this same reaction will often see a climber rebound from a near-death incident - or near ground fall - and rush to get back on the lead, as if to show nothing happened here, kind of getting back on the horse. What is going on here is the embarrassment as shown above, but also a big dose of adrenaline, that fight or flight (or just lay down dead) juice. In climbing terms, jumping back on a climb that spat you off, without a break to reconsider or regroup your thoughts, is a BAD idea. Most times, a few moves up, or at least where you can do a better job at killing yourself, that juice will run out, leaving you even more exposed and vulnerable than before.
As in most things, it’s best to leave your ego on the ground, doubly so if you’re in a crater.
In my long life as a climber, I’ve met far too many climbers in wheelchairs, some paraplegic, another quadriplegic, all with life-changing injures, changing both their lives and the lives of those around them. None of them got that way by “accident”, but each by a tragic error, lack of judgement, or failure to see their risk awareness was faulty, or not even care. But for some, being semi paralysed for life may have come about due to ego, the desire to ‘walk it off’, or else the desire for others to save them, to move them, to rescue them.
Generally, in any fall, or head injury, you should treat it as a potential spinal injury until you’ll be told it’s not. What this means (and I know most of you know this), is that you need to immobilise the casualty until it’s deemed safe for them to move. In most cases, this happens sometime after they arrive at the hospital via helicopter, while in others, it’s about checking the warning signs. These include:
Pain in the neck or back at the site of injury
Irregular shape or twist in the normal curve of the spine
Tenderness and/or bruising in the skin over the spine
Movement of limbs may be weak or absent
Loss of sensation, or abnormal sensations, e.g. burning or tingling
Loss of bladder and/or bowel control
I’ve seen many climbing falls in which someone somehow got away with JUST a broken back, a broken coccyx, a broken neck, but not everyone is so lucky.
If you suspect a spine injury then you need to totally immobilise the person, especially their head and neck (just as in motorcycling accidents, don’t remove their helmet).
On the subject of helmets, you’ll often hear anecdotal evidence from people who “know” a surgeon or some medical expert, who will tell you that helmets are dangerous and that X, who is now quadriplegic, and who was not wearing a helmet, might be dead now if they had. Personally, I don’t take much evidence seriously, as would the motorbiking, horse riding, or hard hat-wearing builder community. Helmets not only save lives, they also profoundly alter the consequences in long term outcomes from both your head hitting the planet, or the planet hitting your head.
So, what about first aid kits?
When it comes to first aid supplies, I expect - and being honest - it’s often been so far down on my list that it’s generally not there at all, and beyond cutting toenails, in all my years I’ve never used one. Yes, on big trips I’ll carry a medium-sized first aid kit, but generally not for day trips, which is bad, as I should know better.
The issue of not bringing along even a basic kit, with some tape, a bandage, over the counter pain killers etc, is not about you, or when YOU need it (because nine times out of ten, you’ll be depending on the foresight of others), but when someone else has an accident close by.
When something bad happens at the crag, hill or campsite, such as rock striking someone‘s head, a tooth breaking, boiling water being spilt on a leg, what are you going to do? Call 999 or 911? But what happens while you wait? What will you do? Probably just stand there with your metaphysical dick in your hand.
On most climbs, as climbers, we tend to have a culture of making do and tend to have more of a body maintenance kit instead, some finger and duck tape, a knife, maybe some stuff for sewing, and so depend on making do, using clothing and slings to make up for what we didn’t bring, as well as a large serving of “it won’t happen to me” (“or them”).
Yes, I know people who always have a first-aid kit handy, but I don’t think they’re in the majority.
I’m not saying that alpine climbing, or hillwalking or multi-pitch climbing is like warfare, but what if soldiers took the same approach to first aid kits (again, they don’t carry it for themselves), how many would survive?
Here’s what a soldier would carry in their IFAK (individual First Aid Kit) pouch:
2 x Large Non-Sterile Nitrile Powder-Free Examination Gloves (Pair)
1 x Waterproof Plasters Assorted Wallet.
1 x Mini Trauma Shears.
1 x Sharpie Marker Pen.
1 x Micropore Tape (2.5cm x 9.1m).
1 x Trauma Dressing (10cm x 18cm).
1 x CAT – Combat Application Tourniquet.
1 x Sterile Non-Woven Triangular Bandage.
1 x Rebreath CPR Face Shield.
1 x WoundClot ABC Haemostatic Gauze (10cm x 10cm).
1 x Space Rescue Blanket.
How does that compare to what you’re carrying on the hill, or take along to the crag? Or do you have a first aid kit, but have yet to even open it?
Personally, I’d add a few more items to an outdoor IFAK, which would include:
1x Pair of tick-removal tweezers.
1x Small tin of Vaseline, good for dealing with rubbing, chafing and chapped lips (will get someone home at least).
2x Safety Pins (use with lighter for blisters).
1x Tampon (comes in handy).
1x Packet of Puritabs.
You will also often be carrying a mini repair kit (or include it in your IFAK), which will include a sewing kit, cord, trimmer line etc, more duck tape, which can be used if needed (like sewing someone up with dental floss).
Ideally, all this needs to be stowed in some way it’ll say dry and can be stored where it can be grabbed quickly (like the lid of your pack), either by you, or someone else (not just another black stuff sack, but something that could only be a first aid kit).
Of course for longer trips, you’d carry a much bigger kit which would include more drugs, as well as body repair stuff, like dental stuff (tooth problems seem to be a very common problem on big trips). Lastly, no expedition first aid kit is complete without a copy of Jim Duff’s Pocket First Aid book.
It’s interesting where your thoughts lead, but reading Jame’s email made me see I’m a little too complacent, and just because I’ve got away with it in all my yesterday’s doesn’t necessarily hold true for tomorrow. At the same time, writing this, I’m aware of how limited we are in what we can do – something you feel acutely aware of when you witness an accident – both as amateur EMS practitioners, but also how little that can be done outside of a fully stocked ambulance or accident and emergency unit. It’s always best to avoid this messy stuff by applying better judgement (not bandages). Nevertheless, each of us in some way is connected to the other, in the outdoors doubly so, and so it’s important that we can come to one another's aid when needed, even if it’s with nothing more than a waterproof sticking plaster.