follow up q&a to my wemt/emt+w post

A friend of mine asked me some questions about my last post (finished my WEMT) and I thought the answers might be helpful for others out there.

What was your favourite part of the course?

Having people in it who had some serious experience. Two guys were heli-ski operators, one guy was a mine rescue technician, several were guides, one guy got shot in the chest point blank, and the instructor is a paramedic who has patients she can’t transport for up to 48 hours because of weather and general Alaskan-remoteness.

In a normal world I’m the most outdoorsy-medical guy around, so it was really humbling and level setting to be around others who experience near daily horror stories and handle them with grace.

What was your least favourite?

I think from an annoyance prospective it was dealing with state and local protocols which are basically always a little out of date with current research. You learn and get tested on some things that aren’t in the best interest of your patients because it takes years for medicine to change (great example: back boards and traction splints, medieval torture devices that are still on most rescue inventories).

At a personal level it was going through scenarios that I had never considered. Like a pediatric with multiple gunshot wounds or a woman who just had a miscarriage, sitting on a toilet, and you being the person who’s going to manage that scene and bring calm. I think everyone has situations that hit them hard in the emotional department, and you never really know what they’ll be until you’re in it or perhaps after the fact.

What surprised you the most?

How quickly a talented person can burn through a primary assessment, establish an airway, stop major bleeds, and prep for transport. It’s like less than a minute (tops) if you’re good, complete with all the gore/mayhem/ppe/bsi/safety.

Going back to the last one, it was also the scenarios that I hadn’t considered. Using a plastic model to practice sticking your hands into a vagina to push a baby’s face off a prolapsed cord and keep the airway patent. Or how to deal with excited/agitated delirium. They’re not scenarios I really signed up to handle, but if you’re functioning as an EMT in an urban setting you can’t pick and choose your patients.

Also, how easy it is to get a bp via a pedal pulse and a cuff on the thigh on a neonate now that I know what I’m doing.

Have you done the NREMT yet, and was it different than what you learned in class?

I’m an Alaskan EMT-1, and have applied for my NREMT course but haven’t taken the test yet. If you’re taking a state’s written and practicals I would really focus on that (which is different than wilderness protocols, which is different than NREMT) because you need to pass it to move on and remembering multiple protocols is rough. It’s a bit dumb because I had to memorize Alaskan procedures I’ll never do in California, but conflicting and head-scratching protocols seem to be the name of the game with medicine in general. Most things are right, but some protocols are bad and just haven’t been fixed yet.

But in general Alaskan and NREMT protocols overlap probably 90%. Dyspnea is dyspnea, a biphasic AED is a biphasic AED, and COPD is COPD. The differences are more subtle like: emphysema patient with a 2LPM nasal cannula complaining of difficulty breathing. Do you crank up the flow a bit or swap her out for a NRM at 15LPM? Either way you’re increasing their O2 but  what’s the specific blow-by-blow protocol? Did you need to use pulse oximetry and if so how? Stuff like that.

My sample tests I’ve taken for NREMT are going well; there’s a few items that are new but nothing mindblowing.

Are you planning on working as an EMT, or did you just do the class for the knowledge?

I think like sailing you suck unless you do it so I’m going to try to work at the local hospital maybe 20 hours a month covering other people’s shifts. My neighbors are trauma surgeons at the local hospital so if I’m lucky I can work with them, or try to hang in the ER in general.

I studied vital sign ranges before the class but from taking literally over 100 blood pressures from various people I actually learned way more about the ranges and concreted in the numbers. Ages and sex matters it seems but I learned that a skinny 14 year old girl probably just has a really low BP and that for little pediatrics I’m high as a kite if I think I can get them to sit still. So the practical application seems to be part of the knowledge to me, if that makes sense.

Do you plan to register in California by county?

So after I get through NREMT I’m going to hit up the hospital in town and just say “Hey, I’m a NREMT EMT-B, what else should I do and what other training would be helpful?” I think there’s ancillary stuff they’ll want too like phlebotomy, probably some blood borne pathogen training, etc. It’s a super rural county so I’m expecting some hoops but probably not a million.

What extra study materials would you recommend?

I was based out of the “Brady Book”, it was the major text we used in conjunction with our wilderness stuff. I bought the workbook along with it and burned through those chapters doing the work before the class. It was probably 100 hours of my life I’ll never get back but the pathophysiology really helped and I liked learning why a pulse oximeter sucks for CO poisoning, as an example.

My learning style is that I need to understand the whole circle and then I can branch out so I felt like (for me) I really need to go ham on the textbook and know underlying health-nerd stuff that there just isn’t enough time in a lecture to cover.

Also, really knowing a lot of the abbreviations and medical terms help. Writing tx is way faster than treatment, ditto pt for patient, hx for history, etc. Sometimes people toss out things like npo and it sucks to have to stop and say, “Huh?”. Yeah, they should speak in normal English but around hospitals they don’t and it’s pretty available info.

In class I made flashcards of things I didn’t understand.

Are there any extra non-study materials you’d recommend?

I made good use of 3×5 flashcards (in addition to pre-made NREMT ones), highlighters, a notebook, and rite-in-the-rain for outdoor stuff. For field scenarios and on actual sar callouts I have WMA’s field guide. It’s 4″x6″ (same size as my rite-in-the-rain book), and both fit in my radio chest harness pocket. On real ops I thumb through it for whatever the suspected injury is to remind myself what the hell I’m doing. There’s also some dope stuff in the back on litter tie-ins, chopper stuff, and medical terms. For whatever field team I’m in I’ll read it out loud (before we get to the patient) and we can discuss what to look for, who’s doing what, what gear we’ll need, what complications we might see, etc.

I just have the boring rite-in-the-rain 4″x6″ because I end up jotting down notes from witnesses, cops, other teams, etc. I’ll write a SOAP and try to format it well enough. In sar land I hand it off to the chopper/ambulance and ask them to give it to the receiving facility as well.

Anything else?

Just because I took so many damn blood pressures I’ll add that quickly being able to ballpark the systolic on a patient, rapidly getting there, then rapidly getting down to the diastolic then rapidly deflating completely is the difference between pro bp readings and torturing a patient by keeping what is essentially a tourniquet on their arm whilst futzing around trying to find their brachial artery for a minute solid.

 

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three weeks later, i’m an emt

I’ve previously written up my views on WFR vs WEMT (aka EMT+W), and now I’ve got both of those cards tucked in my wallet.

For two weeks I lived, ate, and breathed emergency medicine up in Skagway, Alaska. I met some amazing people and as an aside I definitely want to write up an entire in-depth post/book/article about not so much the course but the trajectories of those involved. Think about it for a minute: who exactly are the cast of characters already armed with their WFR who are going to spend weeks of their lives up in Skagway learning a super persnickety version of medicine? But first, here are some pictures (some others on my Instagram account too).

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My class. Bent down in the middle is a former CHP trooper, and current paramedic in a fairly remote part of Alaska. When she spoke, everyone shut up and listened.
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On my one day off I hiked with a classmate up to some lakes near the far end of the Juneau Icefield
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The incredibly new and awesome fire department building, where I spent most of my waking hours for two weeks.
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Being in the “south east”, as Skagway is referred to we were actually in a temperate rain forest. As such it rained *constantly*. With the exception of pavement and well worn trails everything else was covered by copious amounts of plant life. The roofs of buildings had green moss, and I dare you to find a single square foot of raw dirt in the area.
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Skagway’s main business is the constant stream of cruise ships dropping off passengers. These folks buy ice cream cones, jewelry, t-shirts, and have a few beers. As such the majority of the town residents cater to these people. This shot was taken the day after “Last Ship Day”, and shows the ghost town that Skagway becomes after the final cruise ship of fall.
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Wilderness EMTs pass all the regular “in town” EMT training, but then we also have to perform the skills with less gear in jacked up environments and handle longer transport times plus coordinate our transport decisions. This photo was from a campfire after one of our nighttime simulation trainings, somewhere in the Alaskan woods.
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When not in the woods, we trained in the firehouse using the gear from Skagway’s ambulance, sar, and fire teams.
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My bunk and living space for a few weeks.
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The kitchen that myself and four others shared. Thanks to the dog sled gang from Alaskan Icefield Expeditions who let us use their bunkhouse while they were off somewhere else. I left you guys some fishsticks and 3/4 of a bottle of vodka.
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When not in the field or the engine bays, it was classroom land. I of course sat in the back because that’s where the cool kids go.

It was an awesome course: no way around it. Being up in Alaska, especially in such a small town, really focused the laser beam on what I needed to do. In the evenings we did assessments and simulations at the bunkhouse, otherwise we’d be out in town taking vitals on random strangers. I’ve probably taken the blood pressure of every child and barstool drunk in Skagway. I’ve auscultated the lungs of infants, found pedal pulses for systolic/palpation readings on neonates, and observed COPD sufferers. Protip: stay healthy, don’t get obese, and don’t smoke cigarettes.

We made jokes about putting a grim reaper sticker on your ambulance every time you screw up and someone suffers, and I watched one of the toughest people I know cry when he discussed a friend who slid in an avalanche and was attacked by a grizzly. The snowstorm cut their visibility down to near zero and as they moved his blood soaked trauma-ridden body out of the avalanche burial. He could still hear the grizzly somewhere close, howling in the hidden whiteout as he provided treatment.

The day after we finished our state practicals we found out about the Las Vegas mass shooting. As the eternal optimist, a silver lining to me was on a day of such madness and mayhem 18 more people walked back into society with the sole intention to help others in their hours of greatest need. It doesn’t cancel out horror or balance the ledger, but it buttressed me a bit to personally know such dedicated professionals that would have been those headed towards the danger.

If any of my classmates ever stumble across this blog entry, I can’t wait to work with you again in the future. Dangling from a chopper or a cliff, pushing the skinny pedal code 3 to a sick child, or just making someone feel better who’s having a bad day: I’d be proud to be there with you.

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Yes, as soon as I got home I popped that shit on my sar chest harness. I know I’m on the lowest end of medical professional but here’s me being proud.

my super cool coat rack

We’re living up the lazy days of summer right now in Mammoth Lakes. Temperatures hit 80 during mid day: a regular Mammoth heat wave. But #WinterIsComing so it’s time to button up all the outdoor and winter-esque projects. Even taking a whizz outside becomes a challenge, what with the gloves and snow pants. Imagine trying to do some finish carpentry.

A big thing I wanted to do was put in a new coat rack. Something stout, woodsy, and with tons of hooks. Something I would see every time I walked in or out of my house, and something I would use multiple times a day. Something like this:

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My finished product.

To start with, we had a piece of crap that came with the house. It had four pegs (one that broke), a mirror, and a sort-of shelf. It was also small. A family of four could make it work, but when friends came over it was a zoo.

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The old coat rack. Hat and shades to show scale.

I started my project nearly a year ago over at Drake Wood Milling. In the “forest products” area of Mammoth’s industrial area, I left a couple of unanswered voicemails and eventually just hung around like a poltergeist in the typical uncomfortable and socially awkward setting that is industrial work areas.

Any sailors know what it’s like to walk around in a boat yard. Sure, it might be your boat on the straps and your money paying the invoice but basically you’re a nuisance and everyone wants you to leave.

Once I met Bob Drake though he couldn’t have been any more helpful or fair. We picked out a slab of wood with “living edges” and chopped it to size.

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Bob Drake doing his thing on my future coat rack.

The slab I got was roughly 70″ long and 30″ wide, although the width fluctuates due to the natural variability of the trunk. I wanted the bark edges because they look dope as hell but had to figure out a way to treat them.

I opted for Ace’s spray-on clear polyurethane to hit the bark on the sides and Minwax’s Polycrylic for the exposed wood. It doesn’t really have to deal with UV, but it does have to deal with abrasion. I wanted something physically durable, shows the natural wood, that can be easily touched up, cleaned with water, and if I re-apply in the house won’t gas off xylene.

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My template (and drill) on the wall.

The damn thing weighed over 100 pounds and could easily have another 50 with stuff hanging off so it needed to be ridiculously secure. I took a cardboard box, split it down the middle, and used it for my template. Pilot holes went into the studs which were the conventional 16″ spacing.

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Moving a piece of cardboard around is much easier than moving a 100lb slab of wood.

The real pro-tip I’d have for anyone doing this is to consider the fasteners. I opted for bolt-head 3/8″ lag screws with 1″ OD washers, counter-sunk using a 1″ spade paddle bit. Reverse the paddle bit for the first centimeter or so to keep chunking to a minimum, then advance slowly with minimal pressure, doing maybe a single revolution in forward then back to reverse.

But start those holes with a small (~1/4″) bit (the same one you used on the studs). The spade bits need that small hole to act as a pilot. Until the countersunk 1″ holes are in, the pilot holes exit the back of the wood, and the small pilot holes are in the studs, don’t reach for your big bit that will actually accommodate the real screws.

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1″ OD washers not pictured. These bad boys aren’t going anywhere, and while pulling it off to repaint the wall won’t be fun it’s certainly designed to do so. 3/8″ x 5″ 

Once on the wall, I had massive 1″ holes staring at me where the bolts and washers were exposed. I grabbed the fasteners and finish products from the local Ace, but the Do-It-Center had the 1″ plugs that I was lucky enough to be able to pound in. A few coats of finish on them, start them in the holes, a piece of sacrificial wood over them flat, and then pound. To remove and re-access the fasteners rock a < 1″ spade bit after you put a small pilot hole, then break them apart.

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On the bottom left there, sort of in the middle of the shot you can see one of the eight 1″ holes countersunk in.

For hooks and exposed hardware I wanted to stick with the rustic thing and fell in love with bent railroad ties. They’re recycled from old railroad lines and hand-bent by small craftsmen. We eventually settled on some local-ish hand forged iron deer figures for our shades and keys.

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It’s amazing how much work can go into making something look like no work was put into it at all.

Our shoe organizers are mounted underneath the coat rack (not pictured), so my next project might be to mount some small fans in the top which will circulate air up to the coats and hats hanging around. Something dripping with caked snow still belongs over by the heater but some air circulation blowing on the coat rack should help things considerably. The same low noise muffin fan I used for my boot-glove-stuff dryer will probably get enlisted.

So hopefully that gives you some ideas if you’re looking to build a coat rack of your own, especially if a massive assortment of winter gear is par for the course.

summer vs winter

Summer finally got started a couple of weeks ago in early August. The insane 16/17 snowpack left much of the High Sierras covered in snow all the way through July and the melting snow created happy breeding grounds for mosquitoes. When not sliding on hardpack snow you were getting eaten alive by bugs: party time.

But no matter: I could still go for a run, ride my bike, climb a rock, and drive off road. These things and many like them are laughable pursuits mid-winter. There’s a lot to be said for just hopping in your car and driving away, without thinking about warming it up, scraping ice, timing the snow plows, and digging. The digging never stops.

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Super cool part of living in Mammoth: “going out for a walk” looks like this.

But just like that, the thermostat space heater in my office clicked on the other morning. Instead of having our bedroom window wide open at nights it’s been slowly closing more and more until last night when (with three blankets) I woke up cold and shut it completely. Pellet prices go up in a month. There’s less than 90 days until Mammoth opens for skiing/boarding. In short: #WinterIsComing.

And winter is a pain in the ass, don’t get me wrong. Everything is harder. Your hands are in gloves nearly all the time so doing any kind of detailed work outside (automotive, construction, etc) is brought to a halt. Travel schedules get blown out, and portions of your home (like a deck or yard) become effectively off limits.

But with that comes simplicity as well. Armed with a season pass, a board, and some insulated clothes I can spend copious amounts of free time shredding. With my new splitboard this year and snowmobiles (cool kids call them sleds) for sar I need to qualify on, there is a lot to do. The days are shorter and the activity options reduced so “lazy summer days” are a thing of the past. It’s time to hustle either to stay alive (pellets, shoveling, driving and not dying) or time to hustle to enjoy life.

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Winter. One night did this.

When you walk out and see your truck sitting there looking like the above, and you have a list of a few things that need to get done that day, things get very straight forward.

I had a friend who told me that people who live in far northern (and far southern) climates tend to be harder working and more industrious than our more equatorial and horse-latitude dwelling brethren. The idea being that in areas with harsher seasons you have to figure out your winter plans and equip yourself during the summer or you simply won’t live to see spring. Conversely in a more mild climate you can get still go out mid winter and find some food, plus you won’t freeze to death.

Obviously modern society has negated this a bit and not a lot of folks are dropping dead in our mountain town of malnourishment. The Donner Party excluded, the rest of us can find something to eat at Vons.

I’ve been reluctant to write about the 16/17 winter because of how powerful it was and like a victim of abuse every cloud still makes me jumpy imagining three feet of snow is about to drop. Not knowing what’s in store for next winter is part of the fun: will it be another snowpocalypse, fueled by some new twist of climate change? Or will we get barely any snow and my cool snowgear will just collect dust as I lament the snow-less terrain.

Stay tuned.

i don’t like heights, just to be honest with you

There’s an inherent problem with fear-of-heights (acrophobia) and mountain rescue. Like a lifeguard who’s afraid of water, there exists a constant and underlying carrier signal that ranges from slight anxiety to full fledged terror. Interestingly enough I’ve met a lot of climbers who only got into vertical pursuits because they were afraid of heights.

Exposure therapy can be done in a clinical setting under the guidance of a skilled practitioner or you can just DIY the goddamn thing. Like home surgery it may not work out well all the time but you can’t knock the sense of accomplishment when you pull it off successfully. Chalk it up to the many cases of things that work out well for you but that you may not advise others to do themselves.

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A view from my harness as I dangle on the edge of a cliff.

So when I got tapped in rescue training the other day for “edge”, I had the dueling voices in my head:

  • Voice A, my helpful voice, the angel on my shoulder: “This is great, you’re around expert climbers and riggers, you know all your system components yourself, and you’re going to get exposure and show yourself that you know how to do it.”
  • Voice B, my other-than-helpful-voice, the coward on my shoulder: “HOLY SHIT NO YOU’RE GOING TO DIE WTF ARE YOU THINKING!?!?!?!?!”

I nodded at my instructor, “Got it, edge.” For those not in the know, “edge” basically means you hang out near, on, and sort-of-but-not-really-over the cliff edge. Rarely are “edges” a clear delineating 90 degrees, hence the vagueness. People up higher who aren’t in the “hot” or “death” zone as it’s affectionately called can be unroped, but “edge” needs to be properly able to move around, securely, while ensuring a nice, happy, and safe environment in the aforementioned “death” or “hot” zone. Terms clearly used to remind you that a single careless act will, not could, result in your untimely expiration.

These days, I’ve found it best to not think about the scary stuff. The old expression of “don’t look down” is well intentioned but unrealistic. Better for me is “look at the task at hand and things you need to pay attention to.” That gives me a focal point and objectives so I keep my mind occupied in a constructive capacity.

Like telling someone to think of anything other than an elephant, instantly they think of an elephant. I’ve needed to scrape the whole concept of “down” out of my mind and fill it with anchors, edge protection, patient comfort and safety, and kilonewtons. Randomly tapping on my carabiner gates to ensure that yes, just like thirty seconds ago, they’re still locked.

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Yeah, I really didn’t like doing this either. Solo skydiving is no longer an activity I voluntarily participate in.

I’m still a scaredy cat around heights and have very little desire to intentionally place myself in harm’s way. Gravity never sleeps and the minute you screw up Newtonian physics is there to turn you into a mushy pile of goo at the bottom of whatever you’re on top of. Ladders, roofs, mountains, ski lifts: we should all do these wide eyed, knowing that better people have died doing the same.

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Shoveling the roof, thirty feet in the air, on top of snow and ice. Mid winter, 2016/2017.

But I’ve tried to replace that fear with more helpful things. The other day I tied some bowlines in an old 8mm rope and had some fun. Secure one end to a big rock and the other to my truck’s 8,000lb winch, I had a go at it. Then I did the same with a dynamic load by having it tied off to my truck’s rear bumper as I drove away. Faster and faster until eventually it broke. It might sound dumb, but now I know my properly-tied-tail-inside-double-bowline on 8mm from GM climbing will hold me. There’s more parts to the system to verify (anchors, harness, etc), but piece by piece we can build confidence.

In rescue world, we have dedicated safety officers who are inspecting all the equipment that you can’t see yourself, monitoring for loosening, chafe, and the such. Once you get to know the system, you can start drilling into the component parts a bit more. Coupling all that knowledge with the mental discipline to never even think of the “down” word, one can at least occupy their mind with other things. Things that are productive, helpful, and genuinely reduce the risk of you turning into a human pancake hundreds of feet below.

And then when on flat and wonderful ground again you can shake your head at all these stupid vertical objects on our world and go sit on the couch, where god intended us to be all along.

 

time is the enemy: ischemia and infarction

In many wilderness medicine curriculums a core area of focus is distal CSM. Distal being “away” (in this context from the heart) and CSM being circulation, sensation, and movement. Blood and nerves tend to be wires hanging out in the same conduit throughout your body, collectively known as neurovascular bundles. Slice one and the results are clear: blood pours out and everything south of the severed nerves now has no feeling and muscles don’t work. Pretty terrible. Definitely something to avoid.

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The yellow and red stuff makes it so you get blood, can move muscles, and feel things. You generally don’t want to have that get trashed.

In wilderness medicine you additionally have to deal with those neurovascular bundles getting pinched or squeezed. Even something as common as a dislocation, definitely something with lots of trauma (like a fall) that jammed a bone into some weird position, can now be putting sufficient force on blood and nerves that it went from a nuisance problem potentially life threatening.

In search and rescue, time is always against you. Consider a typical situation:

  1. Someone slips on a rock when backpacking and plants their next foot into a hole, bending their ankle in a way that baby jesus never intended it to move. It’s now 0800 just after breakfast.
  2. The patient tries to move around a bit and see how bad it is. Yep, it hurts like hell. They confer with their friends and decide there’s no way they can walk out. They need help. It’s now 0815.
  3. The friends get to a mountaintop where they can get a cell signal out and call 911, explaining the situation. It’s now 1130.
  4. Search and rescue gets mobilized and a helicopter is put on alert status. 1140.
  5. SAR is staging at the trailhead a few miles from the patient, packing the right gear. The helicopter has been re-assigned to a case of massive head trauma. No chopper today. 1200.

I’ll stop there as even before the first boot step moves in the patient’s direction four hours has already elapsed. You can chop that time down by having a $250 satellite communicator (and $15/month service plan), but it’s still going to take a while for folks to get to that patient and really this article is written towards the folks providing that medical care.

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My preferred satellite communication device these days. GPS, bad-but-useable text messaging, tracking with a map folks at home can see, an SOS feature, and a good amount of battery life.

My training has taught me that infarction (tissue death) happens within about two hours. It’s not the same for all tissues, but for the arms/legs/hands/feet I go with 120 minutes. Pinch that blood supply off for that length of time and the tissue distal from it is deader than Firefly.

Fortunately ischemia (restriction of blood flow) is typically not an all-or-nothing thing. A bone jammed up against a tube of moving blood might block it a little, a bit, a bunch, or entirely. Think of having a plastic bag over your head versus one with a small hole in it. With the sealed plastic bag, you’re pretty dead pretty fast. With the small hole in, you can eek out a few more moments of life. The more restriction, the bigger the problem. So maybe you’ve got more than two hours since the ischemia might not be so complete. That’s hardly wonderful news since rescue response times can be all over the map with “a few hours” being optimal if the patient’s position is known, authorities were alerted immediately, and the terrain is not too difficult. If a patient’s location is unknown, response times to the tune of days is not uncommon.

And then you have transport time, which of course is wildly dependent upon terrain, the patient’s injuries, available air assets, and the size and ability of the ground crew.

Time is the enemy in other ways as well. Hypothermia in some climates, hyperthermia in others. Increasing intracranial pressure, HAPE, HACE, and a host of other problems get worse the longer they are left untreated. And generally by the nature of the operation you can assume they already have gone untreated for a prolonged period of time. With some exceptions, a properly trained wilderness medical provider can slow or even reverse many of these life threatening conditions.

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There’s nothing easy about transport.

By constantly remembering the impact of time on our patients, both before we got there and after they are in our care, we can do several things:

  • Shorten the list of serious problems that higher levels of medical care need to focus on. Instead of clinical moderate hypothermia, a patient now might simply want a second blanket on arrival to the hospital due to your interventions.
  • Save a limb. The next time you hug a loved one or stand on two feet, imagine not being able to do that quite so easily. By ensuring proper perfusion our patients can fully live out their lives.
  • Provide more insight to higher levels of care. If our attempts at providing perfusion are inadequate (perhaps through manual alignment in accordance with your training and agency protocols), it’s a clear signal that other issues such as acute compartment syndrome might be at play.
  • Slice and dice between the the original chief complaint (an unstable and painful ankle) and new issues such as dehydration and heat illness from laying in an unshaded spot because of the ankle.

One way that time can be somewhat of your accomplice if not outright friendly:  keep track of things you may want to do during transport and execute them when appropriate. If a belay needs to be rigged, take some vitals. If the litter team is scouting a route, toss in some more heat packs.

And although an entirely separate conversation, haste can also be your enemy. Rigging a belay takes time, but is obviously better for the patient than chucking him or her down a cliff. We want to move fast, but only as fast as safety and the patient’s interests will allow.

Going back to the example of the injured ankle, if the ground team gets there at nightfall and a storm sets in, if perfusion isn’t an issue and there’s no immediate need of extraction would be it safer to set up camp for the night, wait out the weather, and then proceed with daylight and dry footing 12 hours later when potentially more rescuers are available as well? That’s a very big question and can’t be answered in a hypothetical: much more information is needed that only a real scenario would be able to address. I only bring it up to to balance against rapid transport as a rule, rather than a probable option.

My writing is commentary on my training and personal experience. I try as often as I can to discuss patient care with medical teams I interact with in order to learn where I can improve and provide better outcomes. Please don’t substitute my writing for comprehensive and recognized medical training.

 

 

hartley springs campground

With five sar missions in the last week, I left town (and cell service) for the weekend. Destination: Hartley Springs Campground. Located about 20 minutes north of Mammoth Lakes the decided (as best I’ve been able to tell) lack of a “spring” is the reason I wanted to go there. The intense 16/17 winter has left snow everywhere, even in July. Much of it will stick around until next summer. With that snow is melt, and with that melt is water. Combine warm summer air and you get mosquitoes: lots and lots of mosquitoes.

I can handle mosquitoes but purposefully putting myself into the midsts of clouds of them is insane. Yes, I know about permethrin and DEET. I use a tent. I have coils. But “managing” mosquitoes for a weekend is tolerable but best avoided altogether.

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Our little slice of paradise, at Hartley Springs Campground.

Not only is there no natural water in Hartley Springs Campground, but there’s also no plumbed water: you need to bring all your own. There’s also no trash cans, no bear boxes, and no real anything. Some porta-potties, picnic tables, and a fire ring is about as fancy as it gets. The upshot is that it’s free to stay there and maybe 10 minutes from June Lake (20 from Mammoth Lakes) if you forget anything or just want to buzz into town for a bit.

It was also packed: we got the last spot when we showed up on a Friday around 4pm. It’s a haven for dirt bikers and 4x4s as well, so expect lots of poorly muffled exhausts blaring around you. Not in a horribly obnoxious way, but definitely in a you’ll-know-you’re-around-dirt-bikes sort of way.

rigging
In my sar pack I need to carry webbing, carabiners, and 50 of 8mm. Apparently that and a milk crate allowed me to set up swings and with my winch a zip line.

Verizon has a bit of coverage there, but no dice for AT&T. We had come through here a couple of months ago and there were little snow patches around so I safely bet that by now it should be bone dry and indeed not a single mosquito was found.

So especially in the non zany busy season if you’re looking for a free campground and can handle your own water and trash, give Hartley Springs a once-over. There’s a bit of dirt roading to do on the way in, perhaps a passenger car might have a tough go of it, but any AWD should be fine. I think I saw a couple 2wd passenger cars; I’d certainly give it a shot. If you do go up in a 2wd perhaps stick to a busier time period so that if you get stuck there’s a high likelihood that someone can help you out.

WFR vs WEMT (Wilderness First Responder vs Wilderness EMT) for search and rescue

As I study my WEMT material, I’m pondering the differences between the two courses thus far. Currently a WFR, I’m headed up to Alaska in the fall for a multi-week WEMT course. Sleeping in a bunkhouse with my other classmates, on a somewhat remote Alaskan island (population 741), I’ll have 8am-8pm class 6 days a week, in addition to the months of material I’ve had to go over in advance (doing it now) and the WFR I needed just to register.

 

I started writing a whole primer on the various levels of wilderness medicine but I deleted it all as the topic is huge. Instead, I’ll try something new and focus on the title: WFR vs WEMT, specifically for search and rescue folks.

study
WFR is the books on the right. WEMT is the books on the left *and* the books on the right.

WildernessFirstResponder

Coming in with roughly ~100 hours of training is the Wilderness First Responder, or WFR, pronounced “woof-er”. This swiss army knife of wilderness medical response is the expected level of quality sar team members and outdoor guides need.

  • Laser beam focused on the task and environment. You’ll learn nothing about ambulance gear because hey: there’s no ambulances in the wilderness.
  • While still a multi-week time commitment it’s possible for most normal people to figure out a way to pay for it and take the time off.
  • Available in a lot of parts of the world.
  • Fairly uncomplicated focus on critical system stability. Identify and treat the things that are field manageable, identify and prioritize transport for the things that need higher levels of care.
  • By being able to dismiss the urban setting and ambulance (or better) equipment, things get simple pretty fast.
  • You are not operating under an agency’s medical direction so your protocols (reducing dislocations, clearing spines, administering epinephrine, stopping CPR, and declaring dead people dead) is actually much more than an EMT would be able to do provided you’re in a wilderness context (typically defined as two or more hours from definitive care).

wemtpatch

Coming in with roughly ~200 hours of training (tack on another 100 for the WFR you generally need to take the course) is the funky WEMT or EMT+W. It’s basically an EMT+B with special focus given to non-ambulance gear and prolonged care and life support in an austere environment.

  • You can have way more patient exposure if you want it. As an EMT-B you can be treated like shit and underpaid riding around in ambulances with horrible working hours. But hey, it’s work and more importantly it’s experience.
  • On a SAR team you’ll probably be the, or at least one of, the primary medical providers as WEMT is a rare designator that few people trot around with. Again, experience.
  • You can expand your reach by riding ambulances, joining (typically smaller) fire agencies, and even working in hospitals or at a local physician’s office.
  • With all that experience, you can move towards being a paramedic (EMT-P) if that suits you and you have the time/money.
  • You’ll understand more of what’s going on with your patients at a physiological level and have a broader understanding of chronic and acute disease.

The real benefits for WEMT comes down to experience and advancement. Working as an EMT-B sucks for most people. You’ll make roughly $12/hour, which is what I currently pay my babysitter and she sits around watching Netflix not dealing with death around the clock. Even paramedics make roughly $17/hour, and that’s after spending $10,000 – $20,000 to go to paramedic school and after having worked as an EMT making peanuts long enough to get the experience to even apply to paramedic school.

All that being said, your ability to gain experience and advancement as a WFR is basically zero, strictly from a medical perspective. You’ll be limited to the patient contact you have in SAR which can be pretty thin. Also, you’re hogging it and not letting others on your team drink from the firehose that is the primary medical provider role.

It was explained to me when I got my USCG Captain’s License: this means you can do the job, you don’t get good at it until you’ve done it a lot. When you first get your driver’s license you’re a terrible driver. It’s the years of driving experience on top of the license that make you decent. The same goes with all skills including medicine.

Captains with a license but not a lot of time running commercial ships are referred to as “paper captains” on the waterfront: it’s not a term of endearment. Whether it’s driving a car, flying a kite, or diagnosing hypovolemia you are better at it the more you do it.

wemt
Typical SAR work. You’re a long way from an ambulance.

Search and rescue is basically an all volunteer system, as it always has been. Going back to 1000AD, search and rescue is a side gig. And in a big way, that’s what makes it so great. Everyone is taking time away from their families, taking time off work, and prioritizing helping others. I heard a joke the other day that to get into sar you need to take the psychological test, and fail it. Getting a chance to work with these outstanding people is a privilege. And of course it is a privilege and not a right to treat a patient when they are in one of the scariest moments of their life.

Everyone in sar needs to make the decisions for themselves as to how far “good enough” is. Perhaps because I’m a bad climber, middle of the road tracker, and crummy mountaineer I think my medical skills are where I can do the most good. It’s not lost on me that my own daughter’s life was saved by a sar team’s medical chops.

If you’re a WFR and keep your skills sharp, I’ll work with you anytime. I’ve seen firsthand a WFR keep someone alive for hours in a jacked up situation before evacuation could occur. If you’re a WFR and want to get more time with patients and perhaps go onto other aspects of medicine short of nursing or doctoring, consider the WEMT route.

 

the evolution of my sar packing

Mono Search and Rescue got called a few days in the early afternoon and we finished up around 0500 the next day: roughly 14 hours of humping and pumping through ice and snow, waiting around, treating patients, and rigging rescue lines/anchors/stuff. After some sleep I checked the back of my truck:

sarmess
Rat’s nest of line, wet gloves, dirty socks, dirty gaiters, consumed medical gear.

SAR packing seems to be based around three key concepts: mandatory, optional, and spare capacity.

Mandatory Gear

Bivy sack, head lamp, dry socks, and things of that nature: stuff that you’re going to carry no matter what. Most of those items are specified by my team but I toss a couple of my own in there too. I’m sort of a dork so I wear my helmet to almost anything except blazing sun mid-day and my own medical go-bag.

All of this stuff is in my pack, ready to go.

Optional Gear

Next to my pack is a milk crate full of optional items. My tent (as opposed to my tiny bivy), my backpacking cooking gear, crampons, snow shovel, helicopter goggles, etc.

The reality is that I can’t bring everything you’d ever want so on a operation-by-operation basis an educated guess is made. Headed to the desert? Extra water. Headed up a snowy mountain? Snow anchors.

Spare Capacity

Another reason you can’t load up on everything you want from your own gear is that team gear has to be lugged out as well. The litter, oxygen tanks, vacuum splints, long ropes, and all nature of climbing and medical equipment beyond your personal gear needs to head out as well.

And remember that you need to balance all of that with the fact that the more you’re lugging the slower you go and the less nimble you are. With more gear you get to your patient(s) slower and your agility at transporting them out is reduced.

sarclean
Cleaned up, ready to go. Mandatory in the bag, optional and clothes in the crate. Down bag de-compressed and puffy.

I’m still relatively new in my SAR career so I imagine I’ll be learning and refining as I go. And then there’s winter, which in a place like Mammoth really goes haywire. My own personal gear is much bigger, overnight gear is bigger, and between skis/boots/crampons/splitboard/snowshoes it’s tricky as hell to walk around.