BASIC EMERGENCY CARE IN THE WILDERNESS

Adventure through the wilderness is an exhilarating feeling for an avid backpacker and most especially a mountaineer. Either to escape the metro or to be one with nature, the thrill of going into untamed territory tests a person's skill in coping up with his basic resources.

Certain medical conditions may arise on such events and knowing how to handle them can make the difference of continuing to enjoy the trek or become a full-blown emergency. This chapter deals with such conditions that maybe encountered and dealt with accordingly.

THE FIRST AID KIT

Equipping oneself with the basic medical aid kit is the first step for a less precarious trip in the backcountry. There are available emergency first aid kits that are sold locally and abroad but you can assemble a set of your own by just knowing the essentials at a lesser cost. The list rundowns the supplies and instruments that you should have on hand. PICTURE OF KIT

1. Bandage Scissors
2. Oral Thermometer (preferably with own plastic case for preventing it to be broken)
3. Tweezers (for removing splinters)
4. Safety pins
5. Snakebite kit (scalpel and suction for the venom)
6. Flashlight/penlight
7. Syringe needle gauze 21
8. Sterile gauze pads individually packed
9. Roll of gauze bandage
10. Band-aids
11. Butterfly bandage or steri-strips (small bandage for facial/gaping cuts)
12. Adhesive tape, 1 inch size recommended
13. Elastic bandage 3 inch size
14. Cotton tipped swabs
15. Roll of absorbent cotton
16. Hydrogen Peroxide
17. Calamine Lotion
18. Povidone-Iodine solution
19. Rubbing (70% Isopropyl) Alcohol or Bar of plain soap

Over the counter medicines that maybe useful. (OTC Meds)

1. Aspirin or an Analgesic (i.e. Mefenamic acid*) or an Anti-inflammatory (Ibuprofen**)
2. Paracetamol tablets

*Locally available such as Ponstan

** Sold as Alaxan

N.B. Aspirin/Mefenamic/Ibuprofen should not be given to persons with allergic reactions to these medicines. Asking before administration is a must.

Individuals who have specific medications to carry should bring it along, i.e. anti-asthmatic inhalers or anti-allergy meds, and inform their companions of their health status.

TIP:

1. Do not minimize or forego portions of the kit. Doing so will undermine the First Aid Kit's use and it will be to your disadvantage.
2. Place the kit in a water repellant pack to prevent the materials from getting soaked if such occasions arise.
3. A Swiss Army Knife or any multi-purpose device that you bring along may already have tweezers and scissors as well as a penlight. This can spare you a few grams off your pack.

VITAL SIGNS

Proper taking of the pulse, temperature and breathing is easy but must be done properly. Such vital signs monitor a person's condition along the trail that guide the one administering the first aid of what to do.

Areas that a pulse can be monitored: Should be taken for one full minute.

1. Common Carotid (Neck)
2. Radial (Wrist area)
3. Femoral (Inguinal /Crouch area)
4. Dorsalis Pedis (Top portion of foot)

NORMAL: Resting Pulse of an average Normal adult is between 60 to 100.

1. Clean the bulb of the thermometer.
2. Hold the thermometer at the stem and shake it until the mercurial reading is at least down to 35C or 95F
3. Read the baseline temperature and place the mercurial bulb under the patient's tongue. Instruct the patient to close his lips tightly.
4. Leave the thermometer for 3 minutes after which you remove it and get the temperature reading.
5. Clean the bulb and stem of the thermometer before replacing it in its container.
6. NORMAL: Average range of a resting individual is between 36 to 37.5 C (96.8 to 99.5 F)

BREATHING:

1. Monitor the breathing by looking at the chest expansion of the patient.
2. Look for any signs of labored breathing such as:
3. Gasping for air through the mouth
4. Enlarging nostrils
5. Use of neck muscles for breathing
6. Asymmetry or unequal expansion of the right and left side of the chest
7. Monitor for a full minute:

NORMAL: Average range of a resting Respiratory rate is 24/min

WHAT TO DO's:

I. Open Wounds: (Scrapes/Scratches, Cuts/Lacerations, Puncture Wounds)

Basic procedures for any of the above injuries are the following:

1. Wash your hand or rub with alcohol before treating the wound.
2. If there is bleeding, stop or control it. If it is continuous or severe, SEE Management of severe bleeding.
3. Remove as much as possible any dirt that is around and within the wound.
4. If possible, wash the injured area with soap and water. Plain clean water for washing off dirt will do.
5. Sterilize or disinfect any instrument to be used for the care of the wound.

Objectives of managing open wounds are to:

1. Stop bleeding
2. Prevent contamination and infection
3. Seeking medical attention if wound is severe.

a. SCRAPES AND SCRATCHES

After doing the basic procedures. PICT:

1. Pat the wound dry
2. Place an antiseptic like povidone iodine on the wound.

Large areas of wound or areas most likely to be reinjured or soiled should be covered with sterile gauze and bandage.

1. Minor scrapes can be left exposed to the air.
2. Watch for any signs of infection

b. CUTS (LACERATIONS)

1. Primary concern is to stop the bleeding with the basic procedures in mind. PICT:
2. When bleeding stops, wash the wound to remove the dirt or other foreign materials in and around the wound. Pat the wound dry
3. Do not remove foreign objects deeply inserted in the muscle or any deeper tissue, this may cause serious bleeding.
4. If no foreign object is imbedded, apply an antiseptic over the wound
5. Cover the cut with sterile dressing and use a bandage around it. If cuts are gaping, especially in the face area, apply steristrip or butterfly bandages to appose the wounds. PICT

c. PUNCTURE WOUND

This results from a sharp, pointed object that pierces the skin and deeper tissues. Nail, splinter, horn, or teeth/fang marks are samples of puncture wounds.

1. Assess the wound if any object had broken off and remained inside the wound (deeper than the skin).
2. Do not attempt to remove it since serious bleeding may ensue.
3. Do not manipulate, poke or put medication into the wound.
4. Cover the wound with sterile gauze and bandage it.
5. Seek the nearest medical attention.
6. For minor puncture wounds, objects lodged no deeper than the skin may be carefully removed with tweezers.
7. Press on the edge of the wound to encourage bleeding to wash out germs inside the wound.
8. Cover the wound with sterile gauze and bandage it.

MANAGEMENT OF SEVERE BLEEDING:

Continuous or profuse bleeding is a medical emergency that needs prompt management and control. Bleeding can come from the veins or arteries or both. Venous blood is characterized by a dark red color and flows steadily while arterial blood is bright red and spurts from the wound. Immediate treatment can be done by a.) Direct pressure to the wound, b) application of pressure points or c) tourniquet.

a. Direct Pressure: Picture

The first and preferred choice to control bleeders. This is usually all that is needed to prevent further lose of blood.

1. Apply a thick clean gauze or soft clean cloth, i.e. a towel or handkerchief, directly over the entire wound to act as a compress. In extreme situations, bare hands or fingers can be used to compress the bleeder, but be sure that it should be clean as possible. Keep the pressure steady over the wound.
2. Do not remove or disturb blood clots that have formed on the compress.
3. Apply another pad over the initial compress if this gets soaked with blood. Do not remove the initial compress. Apply a firmer pressure over a wide area.
4. Elevate the bleeding limb/portion above the victim's heart level. Do not do these if a fracture is suspected.
5. Once bleeding stops, apply a pressure bandage to hold the compress in place.
6. Placing the center of the gauze directly over the compress does this. Pull it while wrapping both ends around the injury. Tie the knot over the compress. PICTURE
7. The ties should not be to tight that it cuts circulation. Check the pulse distal to the wound or check the nailbeds if they become bluish in color. Any change means it is too tight.
8. Keep the limb elevated.

b. Pressure Points:

This should be used only if bleeding cannot be abated by direct pressure. This requires pressure on the artery supplying blood to the wound against an underlying bone and cuts off the arterial supply to that area affected. This should be used with direct pressure and elevation.

ARM:

1. Hold victim's arm bone midway between the elbow and armpit. The thumb should be on outside the victim's arm. The other fingers should be on the inside of the arm. This places the arm bone in between the thumb and 4 fingers.
2. Squeeze the fingers firmly toward the thumb against the arm bone. This compresses the arterial vessel. Do this until the bleeding stops.

LEG:

1. Position the patient by letting him lay on his back. Supine position.
2. Press at the front center of the thigh, at the crease of the groin, by using the heel of you hand.

N.B. Pressure point technique is used no longer than necessary. If bleeding recurs, it may be reapplied.

c. Tourniquet:

This is a measure that is used as a last resort for life-threatening situations where the two above management are non-relieving. Weighing its use is based on fact of either losing a limb or bleeding to death.

Requirements of a tourniquet:

1. 2 or more inches wide.
2. Length should be enough to wrap around the limb twice with ends for tying.

Procedure:

1. Place the tourniquet just above the wound. Wrap it around twice.
2. Do a half knot.
3. Place a stick or straight object on top of the half knot.
4. Tie then 2 full knots over the stick
5. Turn the stick to tighten the tourniquet. This is done until bleeding stops.
6. Secure the stick in order to hold its place by tying the loose ends of the tourniquet to the stick..
7. Do not remove tourniquet.
8. Attach a note to victim's clothes or body as to what time the tourniquet is place.
9. Don't cover the tourniquet.

II. Bruises

The most common type of injury that is sustained from a fall or blow to the body. Small blood vessels break beneath the skin that causes discoloration and even hematoma.

1. Assess if there are any broken bones. See Splinting:.
2. If there are no suspected fractures, apply immediately a cold compress on the affected area to minimize swelling, pain and hematoma formation.
3. Apply pressure on the affected area.
4. Elevate the part or limb affected
5. Stabilize or immobilize the joint as needed.

III. Burns:

Burns arising from camping stoves, fires or hot utensils and boiling water are the most common causes one will encounter.

1. Cool running water or cold water compress over the burned area is an ideal immediate management which is applied for about 5 to 10 minutes. This is to give pain relief over the site.
2. Protect or cover the area with sterile gauze or clean bandage. In less than ideal settings, a clean polyethylene bag wrapped around maybe used.
3. DO NOT apply any butter or grease to a burn area. Locals have the habit of placing even toothpaste or powdered antibiotics to the burn site. Just keep the area cleans and protected.
4. If blisters form, (sign of second degree burn), do not puncture or remove the skin covering. This helps keep the wound safe and free from infection.

N.B. Second degree burns that are more than 15% of the body surface for an adult needs medical care immediately. Rough estimate is by using the palm of the hand with the fingers to represent 1% of total body surface that is burned. Injuries covering the face, groin, hands and feet or has inhaled smoke that could have injured the lungs are also included for prompt medical attention.

IV. Blisters:

Usually caused by excessive rubbing of skin over clothing or equipment (i.e. boots).

1. Minor, small, unopened blisters that will have no further irritation can be managed by placing a sterile gauze pad and bandage over it. If it was accidentally opened, wash the wound with clean water and cover it with a sterile dressing.
2. Puncturing large blisters that are prone to be broken is a last option wherein just sterile dressing will likely fail. Puncture site should be at the lower edge of the blister. A sterile needle is needed to puncture the blister. Press the blister slowly until it flattens. Cover with sterile gauze
3. Watch out for signs of infection such as redness or pus. This needs prompt medical management.
4. Blisters caused by burns should not be opened. Fluid imbalance may occur if this is done especially if it covers a lot of area.

V. Splinters:

1. Wash the area and clean your hand.
2. Sterilize a sewing needle (ideal is a syringe needle) and tweezers by boiling for 5 minutes or holding it on an open flame.
3. Splinters stuck inside the skin with a portion exposed can be pulled out gently with the tweezers placed at the same angle as to which it entered.
4. Use the needle to loosen the skin around the splinter if it is not deeply imbedded and remove it with the tweezers at the same angle as which it entered.
5. Once removed, clean it and cover it with sterile dressing.
6. Watch for any signs of infection.

VI. Foreign bodies in eye/ear.

a. EYE:

Foreign particles that are floating in the eyeball or inside the eyelid can be removed with proper care. NEVER attempt to remove particles that are piercing the eyeball. Trained medical personnel should handle such cases. Protect the area and bring him/her down to the nearest medical facility.

Management for foreign bodies that are floating on the eye is as follows:

1. Do not let the patient rub the eye.
2. Wash your hands.
3. Flush the eyes with warm water until particle is removed.
4. If particle is still not washed-out and is attached to the inside of the upper lid, ask the patient to look down.
5. Hold the upper eyelid down. Place a cotton bud handle horizontally across the outside of the lid. Flip the eyelid backward over the lid causing the inner portion to be exposed with the foreign particle.
6. Remove the particle with moistened corner of a cloth or handkerchief.
7. If the particle is on the inside of the lower lid, gently pull down the lower eyelid and carefully remove it with the handkerchief tip.
8. If particle remains, cover the eye and seek medical attention.

b. EARS:

Insects may find the ear canal a tempting place to investigate and buzz over with the result of getting stock and you in anxious haste.

1. Placing several drops of oil (cooking, baby) is warranted if the insect is alive and buzzing all over. This will immobilize and kill it. N.B. Do not use oil on foreign objects that may absorb it and make it more difficult for extraction.
2. Flushing with warm water may also be a next option for removing insects.
3. Attempts to remove clearly visible foreign objects may be tried. Do not poke or proceed if the object is unyielding or goes in further. Seek medical attention.

VII. Nosebleed or Epistaxis

Epistaxis or nosebleeding occurs on certain situations such as high altitudes, hot weather or even persons with high blood pressures.

1. Make the patient sit down and lean the head forward. Keep the mouth open.
2. Pinch the nose for 15 minutes. Release it slowly, if bleeding recurs, pinch it again for 5 minutes. Check and continue this until it stops.
3. Place cold compress/cloth against the nose to help constrict the blood vessels.
4. Don't let the patient swallow the blood or blow his nose

VIII. Insect Stings

Stings from bees, wasps or hornets can cause local swelling, pain, redness, and a burning or itching reaction to the bitten site. Mostly this is non-life threatening unless the bitten patient is allergic to the venom. Shock may ensue. Backpackers’ known to be susceptible to such reactions should bring their own medications and instruct their companions on how to use it.

1. Removing the stinger is by using a knife blade and scraping it off. Tweezers should not be used since you may squeeze and push the venom into the skin.
2. Wash it with water.
3. If available, wrap it with a cold compress.
4. Calamine lotion, paste of baking soda and water may be used to relieve discomfort.

IX. Animal bites.

Bites from wild animals carry the risk of bacterial or tetanus infection. Animals infected with rabies may introduce this condition to the ailing victim. Treatment should be sought if this occurs.

1. Wash or pour water over the wound for around 5 to 10 minutes to remove as much as possible the saliva and other foreign object introduced with the bite.
2. Bleeding should be managed by applying continuous pressure until it stops and sterile dressing placed over the wound site.

X. Venomous bites/Stings

a. Scorpions

Scorpions or "Alakdan" in the local dialect just like bee stings can cause severe burning pain at the site of the sting. Signs and symptoms that develop vary from the amount of venom introduced to the victim. Adults rarely die from such stings* except that they are particularly harmful to young children* or adult individuals who show signs of shock or convulsions. Numbness or tingling sensation may be felt or even difficulty in swallowing and breathing for extreme cases.

1. Immediate treatment by maintaining an open airway and restore breathing should be done.
2. Simply clean the wound and the surrounding area with water or alcohol
3. Keeping the bitten part lower than the level of the heart will help minimize spreading the venom.
4. Place ice compress on the bitten site is also advisable.
5. Watch out for any signs of shock or allergic reactions.
6. Secure him to the nearest medical center if symptoms progress

Grade I to II scorpion envenomations such as local pain/and or numbness at the site of envenomation or remote from the site of sting are treated symptomatically with oral analgesics. They are observed for 3 to 4 hours to note for any progression of the symptoms.*

Grade III and IV such as blurring of vision, hypersalivation, trouble swallowing or breathing, slurring of speech or even jerking of extremities needs immediate medical attention to the nearest health center.*

b. Snake bites:

Bitten by a snake, entails one to immediately assess if the snake is a poisonous or non-poisonous variety.

Poisonous snakes have slitlike eyes, poison sacs or deep pits between the nostrils and the eyes and sharp long fangs leave a distinctive 2 piercing fang marks. In comparison with non-poisonous snakes that have rounded eyes and no deep pits.

Grading of envenomation by signs and symptoms is helpful in assessing the current state of the patient.

(The Clinical Practice of Emergency Medicine p614.by Harwood-Nuss,M.D., Ann; Linden M.D.,C.; et. al. 1991, J.B. Lippincott Company)

N.B. Dry bites produce no signs or symptoms other than the mechanical puncture wound. Sudden severe pain at the bite site followed by progressive swelling and/or numbness is a sign of envenomation.

Immediate care for snake bites:

1. Maintain an open airway and breathing if this is affected.
2. Position the bitten part lower than the victim's heart.
3. A light constricting band at bites on the arm or leg can be placed 2 to 4 inches above the bite toward the body. It should not be too tight that it cuts circulation to the affected limb. Feel for the pulse on the distal portion. A finger should be able to slip under the band. The wound should ooze.
4. Replace the band another 2 to 4 inches above from its previous position if swelling reaches its initial position.
5. Do not remove the band until the patient is safely brought to medical care.
6. Wash the bite area and immobilize the limb
7. For Dry bites, cleaning the wound with vigilant monitoring up to 12 hours should be done to note for any changes or progression of symptoms. Medical attention should be done as soon as possible.
8. Loose (lymphatic) tourniquet, incision and suction are probably effective if used within 30 minutes of envenomation but are not substitutes for definitive care in the nearest medical facility.* Reference
9. A Snake bite kit is helpful in this situation. A sterile knife should be used to make a one-eight to one-fourth inch deep cut through each fang marks. This should be in the direction of the length of the leg or arm, not across. The incision should not be more than one-half inch long. Do not make cross mark cuts. Incision should be done not any deeper than the skin since muscle or tendon may be damaged.
10. Suction cups are then used to draw out the venom on each fang mark. Continue suctioning for 30 minutes. Suctioning the venom by mouth can be used if free from cuts, sores or open wounds. Don't swallow the venom. It must be spitted out. Rinse the mouth after finishing the suctioning.
11. Cover the wound with sterile dressing, keeping the victim calm. Do not let the victim walk unless extremely necessary.
12. Do not give alcohol or water if victim is nauseated, vomiting or unconscious. If he/she has no difficulty in swallowing, sips of water is permitted.
13. Prompt medical care to the nearest facility is a must.
14. Take note of the time of envenomation, vital signs of the patient during the course of management.

XI. Plant Irritations:

Itching, redness of the skin or blister formation, and even headache or fever can occur if such irritating plants touch the skin of a backpacker. Plants like the poison ivy can have a very annoying effect.

1. Remove the clothing and wash the area with soap and water.
2. Apply rubbing alcohol to the affected site.
3. Application of calamine lotion will help alleviate the itchiness.
4. Wash the clothes used to remove unwanted irritants.

XII. Heat and Cold induced conditions

a. Hypothermia

Body temperature is a function of the production and loss of heat.* Hypothermia occurs if heat production fails to balance heat loss. Hypothermia is defined as a core (Rectal) temperature less than 35C (95F). It can be a.)Mild (32-35C) b.)Moderate (28-32C) or c.)Severe (<28C). It can be characterized as acute (<6 hours duration) or Chronic (> 6 hours). N.B. Oral temperature is normally 0.5C lower than the rectal temp.* Ganong p232

Mild hypothermia causes shivering, difficulty in doing complex motor functions with noted cooling or vasoconstriction of the peripheral area like the fingers and toes. Shivering can be stopped voluntarily.

Moderate hypothermia causes loss of fine motor coordination, apathy "I don't care attitude" or confusion, slurred speech, and violent involuntary shivering. Shivering increases body temperature by 0.5 to 1C per hour.* Emer. Paradoxical undressing may happen which is a person starts to take off his clothes even though he is feeling cold.

Severe hypothermia can make a person shiver in violent waves wherein the interval between shivers increases until it totally stops. This is a telltale sign of a critical condition. The person cannot walk, muscle rigidity develops, the skin is pale, pupils dilate. The pulse rate decreases too.

Cold, wet weather on high altitude with poor raingear and warming clothes is a sure way to acquire hypothermia. Water dissipates heat away for the body 25 times faster than air. Wet clothes increase the potential for conductive heat loss to 5x normal.

Mild-Moderate Hypothermia:

Rules to live by:

1. Reduce heat loss by

1. Removing wet clothing and replace with dry ones
2. Increase or add more layers of clothing; a large plastic bag covering his body and extremities can help retain heat for the victim.
3. Increase muscle/physical activity
4. Keep the victim warm and dry in a shelter

1. Adequate hydration and food intake

1. Carbohydrates are a good source for energy. i.e. bread, rice, candies
2. Hot liquids helps a lot in increasing the core temperature

1. Never take in alcohol (a fallacy), caffeine or tobacco/nicotine. All of these may aggravate heat loss.
2. Add heat by:

1. Fire or other heat source
2. Body to body contact with dry clothing on.

Severe Hypothermia

1. Reduce heat loss by placing a hypothermia wrap. The patient should be dry. A 4" insulation covering the entire neck, body and extremity should be done using blankets, sleeping bags, or clothing. A space blanket could be used.
2. Give a dilute solution of warm water with sugar every 15 minutes. Severe hypothermic victims' stomachs usually will not digest heavy, solid food.
3. A full bladder increases the loss of core heat. Let the patient urinate but make sure the insulating material will not get wet from the urine.

N.B. Afterdrop - core temperature decreases or drops during rewarming. Peripheral vessels in the arms and legs dilate causing cool blood flow to the core. This is best avoided by just rewarming the core and not the peripheral area (hands, feet)

b. Heat Illnesses:

Heat cramps are due to muscle fatigue combined with water and salt depletion.*

Heat exhaustion results from dehydration with inadequate fluid and electrolyte replacement.* This may progress to heatstroke.

Heat stroke is due to severe dehydration with failure of the body's thermoregulation causing body temperatures above 40C (105-106F).

Heat Cramps/Exhaustion:

1. Patient may complain of headache, nausea or vomiting, dizziness, weakness and fatigue and even disorientation.
2. Find a cool shady place and keep victim there.
3. Apply cool clothes. Give adequate ventilation and cool the patient using a fan. Stop if he develops shivers. Do not over cool him.
4. Instruct the victim to take in fluids if conscious. Intake of a mixture of 1 pint water with 1 teaspoon of salt every 30 minutes is advisable.
5. Don't give patient alcohol beverages and cigarettes. Do not leave him alone until he is stable.

Heat Stroke:

1. Patient may present with mental confusion or disorientation, incoherent speech or even unconsciousness. Victim develops flushed, dry or warm skin with extremely high body temperature.
2. Immediately place him on a cool shady place.
3. Remove most of his clothes. Apply cool compress if possible. Fan may increase heat dissipation.
4. Don't give fluids, alcohol to incoherent or unconscious victims. Don't overcool him by causing shivers. Monitor the patient until he is stable. Transporting to the nearest medical facility is warranted if condition does not improve. Do not give medications for lowering fever, it is not effective.

XII. SPRAIN/STRAINS

Sprain is an injury to the supporting ligaments of a joint while strains are injuries that occur on the muscle or tendon. Sprain occurs commonly on the ankle for backpackers when there is poor hold of the foot while stepping on slippery surfaces. Strains usually occur at the lower back during sudden lifting of the packs from a forward bending position at the hip area.

a. Sprains:

Assess if the area affected is just a sprain or a broken bone. If there is high suspicion of a fracture, treat it as a fracture. (See splinting)

Ankle/Knee:

1. If possible, place cold compress on the sprained area 15 to 30 minutes intermittently. Do not apply warm compress for the first 24 hours since this will aggravate the swelling or edema. Note for the amount of swelling and or any signs of hematoma formation. Sudden enlargement of the joint due to swelling and presence of a hematoma are signs of a severe ankle sprain or a possible broken bone.
2. Keep the affected part elevated to minimize further swelling.
3. Bandage or support with a blanket the site. Loosen the bandage if numbness or increased swelling is seen. The bandage is then to tight at this point.
4. If victim need to walk, minimize bearing weight on the affected foot, secure a sturdy stick or wood that can be used as a crutch or cane. General rule is placing the stick opposite the affected limb, this will serve as a support during walking. When going downhill, the bad leg first before the good one. Uphill is good leg first before the bad. Easier to remember is by the saying "Good leg to heaven, Bad leg to hell!"
5. Medical attention should be done as soon as possible.

Wrist/Elbow/Shoulder:

1. If possible, place cold compress on the sprained area 15 to 30 minutes intermittently. Do not apply warm compress for the first 24 hours since this will aggravate the swelling or edema.
2. Just like in the ankle, elevate and bandage/support the area. A supporting bandage can be used for the wrist
3. Seek medical care as soon as possible.

b. Strains:

1. Victims may have a difficult time in moving the area, especially if it occurred at the back. Rest it immediately. Apply cold compress if possible. No warm compress for 24 hours.
2. Look for medical assistance if pain or swelling is severe.

N.B. Anti-inflammatory over the counter medications like "Alaxan", which is a combination of Paracetamol/Ibuprofen, can be tried to help alleviate the pain. DO NOT give it if the victim is known to have allergic reaction to this medicine or to aspirin. Ibuprofen is usually the culprit for such allergic reactions. DO NOT also give it if victim is known to have a stomach ulcer. Oral intake of the medicine is contraindicated.

XIV. Hematoma under toenail: Subungal hematoma (Patay na Kuko)

Injuries of the toes either by tripping on a rock or root or heavy object falling over the boots can cause hematoma formation below the nailbed. Prolonged walking causing contusion of the toe over the inner portion of a poorly fitted shoe can also cause this. Options for this condition is either letting it as is and place cold compress on the nailbed affected or to evacuate the hematoma if there is severe pain.

Draining the blood.

1. Clean the nail and toe.
2. Use a sterile needle and gently press the nail doing a screw-like motion. Do this until you feel a 'give'. You have then reached the inner end of the nail. Another option: If you have a straightened paper clip, heat it up until it turns red. Apply the heated end to the nail and it will bore through the nail with minimum pressure.
3. Drain the blood by pressing on the sides of the nail.
4. Apply povidone-iodine and cover it with a dressing.

N.B. Consider delaying in doing the removal of the blood if you will still go over a lot of mud or dirt trail that may soil or infect the toe. If needed, make sure you always clean and apply a new dressing to the punctured nail.

XV. Leech management

The "Limatik" or "Linta" in the common dialect is notorious for its stealth like feature. It has a covert way of attaching to the skin and sucking blood without ever knowing it until you bleed.This is very common especially on the wet season, wet forest areas or after a rain in the woods.

1. DO NOT pull off the leech, its suckers may be left attached to the skin.
2. Apply a hot material, knife or any metal object put over a flame, on the leech. This will make it detach by itself. Application of rubbing alcohol may also do the trick.
3. Bleeding over the site of attachment will be noted. This is due to the anti-clotting factor that the leech uses for to get the blood. Some itchiness maybe noted. Wash it thoroughly.

XVI. Diarrhea:

There are many causes for diarrhea. Trying to deduce through the victim's history would help in knowing the probable culprit. This may range from food poisoning, intake of medications, emotional stress, excessive alcohol beverage, viral or bacterial infection.

Assess the victim if there are any signs of dehydration. The victim is dehydrated if the mouth and tongue is dry, restless and irritable attitude and very thirsty.

1. Replace the same amount of fluid solution (1 liter clean water, 1 teaspoon salt and 1 tablespoon sugar) with the amount of loose stools.
2. Vomiting may also be present. Let the patient sip the fluid solution gently and slowly to avoid further vomiting.
3. Loose stools that are blood tinged or bloody or even black in color warrants immediate medical attention. These may be an internal bleeding or an infectious type of diarrhea.

IV. Techniques in bandaging, splinting, basic cardio-pulmonary resuscitation. CPR:

Practice makes perfect, is the key ingredient for proper use of medical materials. With limited resources in the backcountry, you must make use of this in the most efficient way.

A. Circular Bandage: Placed over the sterile gauze covering the wound to keep it in place and avoid further contamination.

This is used on areas that have a relative uniform width, like in the forearm or leg.

1. Place the end of the gauze over the affected part. Make 2 to 3 turns around the wound at the same spot. This serves as the anchor for the bandage.
2. If the site to be bandaged is large, make additional turns by overlapping the bandage strip one from the other by around 3/4 the width of the previous turn. This is done until all of the area to be protected is covered.
3. Secure the bandage by applying tape or safety pin. If it is not available, tie a knot by rolling out the gauze for about 8 inches in length from the underside of the arm/leg. By using the thumb or any finger, place it in the middle of the rolled out gauze and pull the half section back under the wrist to the opposite side. Then tie the knot with double gauze on one side (the one with the loop), and single gauze on the other side

B. Figure of eight bandage:

Its use is for the ankle, wrist or hand that need stability and a little mobility.

1. Anchoring the bandage is first done at the distal (toe area). Make 1 to 2 circular turns around the same area.
2. The bandage is then brought diagonally across the top portion of the foot and around the ankle.
3. The bandage is continued across the top of the foot and passing under the arch.
4. Follow the #2-3 procedure with each turn overlapping the previous one by 3/4 of its width.
5. Continue this until the foot, ankle and lower leg are completely covered. Make sure the bandage is snugly in place. DO NOT cover toes in order to assess if the bandage is too tight. Bluish discoloration of the toes is indicative of a too constrictive bandage.
6. Secure the bandage with clips or tape.

C. Finger Bandaging:

Suspected fracture or injury to the finger could be immobilized by using the buddy taping.

1. Appose the affected finger with the adjacent good finger.
2. Use a tape or gauze to anchor the two together. Make sure the tape is placed at the farthest/distal end as well as the portion near the base of the fingers. This secures the fingers. Tape between this if needed.
3. A cut tongue depressor or flat wood can by used to secure the palm side of the finger for better stability.

D. Triangular bandage:

Can be used as a shoulder sling.

1. A 40-inch square cloth cut diagonally from corner to corner makes two equal triangular halves.
2. One end is placed over the non-injured shoulder. This makes the base and the other end is hanging down over the chest. The point should be under the elbow of the injured shoulder/arm.
3. Position the hand 4 inches above the level of the elbow
4. Wrap the injured forearm/arm/elbow by lifting the lower end of the bandage over the shoulder of the affected extremity. Tie the two ends over the side or back of the neck.
5. Fold the point forward and secure it with a pin on the outside portion.

N.B. Fingers should not be included in the covering to assess if there are any circulatory compromise.

E. Splinting:

Fractures of the arm and leg should be immobilized during transport. This is to protect it from further harm during the travel to the nearest medical facility.

Lower extremity:

1. If necessary, gently straighten the injured extremity. Stop if pain increases during the procedure.
2. Place paddings such as folded blankets between the victim's extremity.
3. A board placed underneath is the most ideal way of immobilizing the affected extremity. If not available. Using sturdy wood placed on both sides of the extremity may be used. Length of the board/wood should stretch from the heel to the buttock area. Secure it by tying it at the following areas.
4. Just above the ankle
5. Just above and below the knee
6. Above the thigh, near the groin.
7. DO NOT tie directly over a broken area
8. Another alternative is to tie the injured extremity to the uninjured extremity with the ties at the same positions in securing one with a splint.
9. Watch for signs of circulatory compromise, bluish toenails, poor distal pulses

Upper extremity:

This follows the same principle like in the lower extremity.

1. Use a sturdy board or stick to immobilize the injured area. A rolled blanket may be used.
2. Tie it at both ends and in between, just below and above the elbow.
3. Don't cover the fingers. Watch for any circulatory compromise.

Neck:

Suspected fractures on the neck is a possible life-threatening situation. Any wrong movement of the neck can result to paralysis or death. Seek medical assistance.

1. If the victim's life is of immediate danger in the vicinity and needs to be moved, immobilization of the neck is a MUST. Do this by placing a rolled towel or blanket around the neck and tie it in place. The tie should not interfere with the breathing. If a flat wide wood is available, place it behind the neck and back. Secure the neck by tying the board to the victim around the forehead and under the armpits.
2. Lifting the head is done together with the shoulders and upper trunk with no twisting motion (Log rolling technique). The one giving the first aid should position himself at the top of the victim's head. Place both palms of the hand at the back of the shoulder with the forearms at the side of the head. Press the head to secure it by using the forearms. Once it is secured, lift the head and neck together with the shoulders.
3. If there is difficulty in breathing, slightly tilt the head backward to maintain an open airway.
4. Place the victim in a secure location and seek for medical assistance.
5. Rigid boards or a make shift stretcher must be used for transport of the victim.

F. Cardio-Pulmonary Resuscitation (CPR)

A life-saving procedure for victims not breathing and has no pulse. The first priority in suspected arrest is that if the patient is breathing or not. Remembering the "ABC" of CPR that stands for Airway, Breathing and Circulation are the basic steps for CPR. First assess if the patient is conscious or not. Then do the following if unconscious.

Airway:

1. Lay victim on his back on a firm surface, such as the ground.
2. Check the mouth and airway if there are any foreign objects i.e. dentures, that may block the air flow.
3. Assess if there is a suspected neck injury.
4. If this is suspected, gently tilt the head with the head-tilt/chin-lift procedure. Place one palm of the rescuer on the forehead of the victim with the other hand, using two fingers, under the chin. Simultaneously, tilt the head back with the hand/finger in place. This is to clear the airway.

Breathing. If not breathing

1. Keep the head tilted
2. Feel and see if the patient is breathing. Placing an ear of the rescuer near the nose of the victim such as the rescuer is facing towards the chest will help him detect if there is breathing from the nose and lifting of the chest. If there is none then continue the procedure.
3. The hand that is placed on the victim's forehead is used to pinch the nose using the thumb and index finger.
4. The rescuer takes a deep breath in order to blow air into the victim's open mouth (mouth to mouth). Make sure it is effective by noting a rise from the chest with your mouth completely sealed during the blowing. Inflate the lungs rapidly for 3-5 times. (Take deep breathes in between)
5. Feel for the carotid pulse. If pulse is present, continue blowing air at the rate of 12 per minute.

Mouth to nose resuscitation may be warranted if the victim's mouth is blocked for free air passage.

Circulation: If pulse is absent

1. Feel for the carotid pulse. If pulse is absent begin cardiac compression. General rule:

1. One rescuer: 15 compressions then 2 quick breaths.
2. Two rescuers: 5 compressions then one breath

1. Palpate with the index finger one of the victim's lowest ribs then slide upward until the sternum or breastbone is felt meeting with the rib. Keep the index finger there.
2. Use the other hand's heel by putting it over the breastbone above the index finger. This is where compression is done.
3. Place the other hand over the other one pressed on the breastbone. Keep your elbow straight, lean over the casualty and press down vertically and release. Depress the sternum approximately 4-5 cm.
4. This is done until spontaneous pulse returns.

V. Dangerous Diseases:

The table below lists the diseases to watch out for.

*Malaria prophylaxis is advised on locals that are endemic with the disease. Locally available medications are Fansidar (Pyrimethamine/Sulfadoxine) and Chloroquine. Consult a physician on its proper use and precaution. Some individuals may have adverse reactions to these meds i.e. rashes, tinnitus, deafness.

**It is advisable to secure a tetanus shot from your physician and remembering when was the last booster shot. This would help the attending physician in knowing the recommended form of tetanus immunization once the situation arises.

VI. Emergency Signals: Signaling for help.

A. Ground Markers

Using ground markers for aircraft to spot the signal is a good way to send your message across. Make sure signaling the serious injury marker is used with utmost importance. There is no room for false information. PICT.

B. Smoke:

Creating a camp fire and signaling using its smoke may be used to attract attention. Windy or rainy situations limit the capability of this type of signal.

C. Sun:

A mirror or a heliograph (reflective surface with a hole in the center) can be effective in seeking attention from flybys. Use the sun to reflect a bright beam focused on the vehicle's cockpit. Move the reflected beam to and fro to catch attention rather than focused on one place.

D. Morse Code:

An international standard of transmitting messages that still has its use. It takes time to know it by heart, but it is worth the effort.

Picture of Morse code.

Practice it with the following phrase:

"The quick brown fox jump over the lazy dog"

E. Semaphore:

It is an alphabet signal using arm/hand positions for transmitting messages. A person deciphering the message needs binoculars if the person signaling is at a very distant location. Do it slowly. Flags (Square with red and yellow divided diagonally) are held with arms extended.

The arm patterns are fashioned like a clock but with only ten positions, Up, Down, Out, High, Low each for the left and right.

An easier way to familiarize with the flag signals is grouping it into circles:

First Circle:

Left Right

A or 1 down low

B or 2 down out

C or 3 down high

D or 4 down up

E or 5 High down

F or 6 out down

G or 7 low down

Second Circle:

H or 8 across out

Low

I or 9 across up

Low

K or 0 Up low

L high low

M out low

N low low

Third Circle:

O across out

high

P up out

Q high out

R out out

S low out

Fourth Circle:

T up high

U high high

'Annul' low high

Fifth Circle:

'numeric' high up

J out up

V low up

Sixth Circle:

W out across high

X low across high

Seventh circle:

Z out across low

TOPICS:

   Basic Equipments
   Preparation
   Organizing a Climb
   Trail Movements
   Camp Management
   Ropemanship
   Basic Emergency Care
   Other Things to Do