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First Aid Considerations

Introduction

Paddlers face risks every time they get in a boat or on a board, but fortunately there are many ways to reduce these risks. Two of the most effective ways to reduce risks are training and prior planning. Commonly faced risks during paddling trips include injuries and illnesses. Because of this, all ACA instructors are required to hold current first aid and CPR certification. Most CPR classes take about 4 hours to complete and cover roughly the same content. On the other hand, first aid classes vary widely in their length and content.

Many organizations, including American Red Cross and American Heart Association, offer basic first aid courses. These courses are generally four to five hours in length, and provide an overview of how to recognize and treat common injuries and illnesses. They spend little time on general patient assessment, injury prevention, extended treatment, or evacuation considerations. A common theme in these courses is “call 911”. Longer courses, including Advanced First Aid, First Responder and Emergency Medical Technician (EMT), spend more time on patient assessment and treatment, but maintain the focus on calling 911. When calling 911 isn’t a viable option, as is true on most paddling trips, a different type of first aid training is probably appropriate. There are a wide range of wilderness medical courses that can meet this need.

The shortest wilderness medical course commonly offered is Wilderness First Aid (WFA). WFA courses are generally 16 to 20 hours long, and are often taught over a weekend. They cover recognition, initial treatment and prevention of soft tissue and musculo-skeletal injuries, and of common medical emergencies such as allergic reactions, diabetic emergencies, and bites and stings. WFA courses also discuss patient assessment and evacuation considerations. Much of the teaching is done through scenarios. WFA courses provide an overview of many of the common medical problems paddlers face, but do not provide the in-depth instruction found in longer classes. Advanced Wilderness First Aid (AWFA) courses are 32-40 hours long, and provide more training on patient assessment, stabilization and evacuation, as well as additional scenario training. Wilderness First Responder (WFR) courses are 8 to 9 days long, and cover assessment and treatment in much greater depth. Mental health issues and expedition behavior are often addressed in WFR courses. Scenarios in WFR courses are more challenging and formal written tests more difficult than in WFA and WAFA courses. Many professional outfitters require WFR certification for their staff. Healthcare professionals can pursue training beyond WFR, including Wilderness EMT (WEMT), Advanced Wilderness Life Support (AWLS) and Fellowship in the Academy of Wilderness Medicine (FAWM). Just like ACA instructor certifications, wilderness medical certifications do expire. It is important to stay up to date, and to make sure certifications are renewed as needed.

Many organizations provide wilderness medical certifications, but most follow guidelines established by the Wilderness Medical Society (www.wms.org). The American Camping Association provides a partial list of course providers on their website (www.acacamps.org/accreditation/firstaidcpr). Because most courses have similar outlines, content from one course provider to another is generally not a deciding factor when choosing a course. Courses can be expensive, so cost, location, and timing are obvious considerations. Once a course is identified, it is important to ask about the experience and qualifications of the instructors, and the course focus. Although course content between providers is generally similar, instructor qualifications, experience, and on going education can vary widely. Any wilderness medical course is likely to be a fun and rewarding educational experience. When students can ensure the instructor is highly qualified and experienced, and has a background in the student’s areas of interest, the classes are even more fun and rewarding.

Common Incidents

When deciding what type of first aid training to pursue, it is important to consider the conditions likely to be encountered. For example, alpine climbers might expect to treat acute mountain sickness (AMS), whereas mountain bikers might expect to treat wrist and shoulder injuries. Data on the frequency of wilderness injuries and illnesses demonstrate that injuries are more common than illness in the backcountry. For example, as shown below, data collected by the National Outdoor Leadership School (NOLS) from their classes shows roughly 2/3 of medical events are injuries and 1/3 illnesses.

Injuries Illness
Injury Type Incidents PCT Illness Type Incidents PCT
Athletic: Sprain/strain/tendinitis 158 38% Nausea/vomiting 41 18%
Soft tissue: all types 138 33% Allergy 31 14%
Fracture   27   6% flu symptoms 23 10%
Cold injury (frostbite/immersion foot)   26   6% Infection 16   7%
Dislocation   25   6% Abdominal pain 14   6%
Head w/no loss of consciousness   14   3% Other 14   6%
Other     9   2% Asthma 14   6%
Dental     7   2% AMS 13   6%
Head w/loss of consciousness     6   1% Diarrhea 11   5%
Eye injury     5   1% Genitourinary 11   5%
Snow blindness     1   0% Dehydration 11   5%
Totals 416 100% Respiratory/not Flu 10   4%
Hypothermia   7   3%
Cardiac/chest pain   4   2%
Heat illness   2   1%
Fever (non specific)   2   1%
Anaphylaxis   0   0%
Totals       224  100% 

Bone and joint injuries make up half of all reported injuries. Soft tissue injuries (cuts, scrapes, bruises) make up an additional third of reported injuries. Many injuries can be treated during a trip, and do not require evacuation. Common illnesses include gastrointestinal problems and sinus and breathing problems. In many cases, these common problems also can be treated during a trip. It is, however, important to always consider the need for evacuation. Hypothermia appears to be a rare problem, but it always is a concern in wilderness medicine, and many paddlers report suffering from mild hypothermia at some point in their paddling career. Region of the country is an important consideration as well as paddling preferences.

The NOLS data addresses a wide range of wilderness activities. When only paddling is considered, the frequency of injuries appears to increase. A British study of Olympic paddlers (Canoe & Kayak) found the data below.

Type of Injury Frequency
Sprains 32%
Tendinitis 20%
Chronic muscular pain 14%
Simple bruises   9%
Infections   8%
Dislocations   3%
Lacerations   2%

The data show that, among highly skilled paddlers, injuries to bones, joints and soft tissue are common, and infectious problems are rare.

A US study of paddling club members found similar data. This study also noted that chronic injuries such as tendinitis (particularly in shoulders and wrists) are common among paddlers.

( www.wemjournal.org/article/S1080-6032(02)70607-8/fulltext#back-bib4):

Acute Chronic
Injury Type PCT Injury Type PCT
Lacceration, Contusion, Abrasion 40% Tendinitis  44%
Sprain, Strain 26% Sprain, Strain  27%
Fractures   9% Unknown Cause  25%
Dislocations   6%

In all of these studies, soft tissue injuries and injuries to bone, muscles and joints make up roughly two thirds of all reported injuries and illnesses. In particular, almost every study on whitewater injuries reports that shoulder dislocations are the most common reason for a whitewater paddler to seek emergency medical care. Roughly 15% of whitewater paddlers will dislocate their shoulder during their paddling career.

The research above, combined with paddling accident reports, suggests all paddlers should be prepared to assess and treat cuts, scraps and bruises; sprains, strains and tendinitis; fractures and dislocations (especially shoulder dislocations for whitewater paddlers); environmental emergencies such as hypothermia; upset stomachs; sinus and breathing problems. All of these topics are covered in most WFA courses. Finally, although drowning is exceedingly rare for paddlers, all paddlers should be prepared to care for drowning victims.

Tools and Equipment

It often is taught that knowledge is the most important tool for medical care. Knowing how to assess, diagnose and treat common problems is essential. Perhaps more important is knowing when problems can’t be treated with the resources at hand and when evacuation to a higher level of care is needed. Knowing what to do is critically important, but having appropriate equipment makes it much easier to provide care. WFA courses teach how to improvise medical supplies using commonly carried equipment. There are, however, first aid kits and other supplies that make providing care much easier. First aid kits of all shapes, sizes and costs are available. Many people start with commercial kits, and customize them by adding equipment. Others prefer to build their own kits. Either way, first aid kits for paddlers should consider the common problems paddlers face.

Personal Protection – Before caring for a patient, it is important to protect yourself with barrier devices. First aid kits should include CPR masks and gloves. Waterproof paddling gear provides excellent barrier for skin protection and eyeglasses or sunglasses can provide eye protection. A small plastic trash bag can hold dirty supplies after use.

Cleaning – Ideally, caregivers should clean their hands before and after providing care, and also should clean any wound suffered by the patient. Equipment for this can include a small bottle of liquid soap, a small bottle of alcohol based skin cleanser, tweezers, and a way to irrigate the wound. Irrigation syringes work well, but squirt top water bottles or Ziploc bags (with a corner cut out) also work. Topical antibiotic ointments can be applied to wounds, but they often wash off when paddling.

Cuts and Scrapes – Dressing supplies for cuts and scrapes include Band-Aids, gauze pads and tape. In some cases, tincture of benzoin can help dressings adhere to skin. Elastic wraps (Ace wraps), self adherent tape (Coban) or conforming gauze can help hold dressings in place. Trauma shears are helpful when clothing has to be cut away to see injuries, and if dressings have to be improvised. Duct tape can be used to hold dressings in place, or to protect skin where blisters are starting.

Bruises, sprains, strains, fractures and dislocations – Each of these conditions benefit from immobilization. Flexible aluminum and foam splints (SAM splints; www.sammedical.com/products/sam-splint/), elastic wraps and triangular bandages are all useful tools. Splints also can be improvised using a wide range of clothing.

Stomach problems – Although abdominal pain, nausea, vomiting and diarrhea are among the more common illnesses seen in wilderness medicine, they’re hard to treat while paddling. Prevention through good hygiene is the best treatment. Paddlers with these conditions should consider not paddling. Adequate hydration is important. On longer trips, over the counter medications such as loperamide (Immodium) and bismuth subsalicylate (Pepto-Bismol) might be included in first aid kits.

Sinus problems – Over the counter medications such as diphenhydramine (Benadryl) and pseudoephedrine (Sudafed) can help relieve the misery of seasonal allergies.

Breathing problems – About 5% of the US population suffers from asthma. Prescription medications are most appropriate asthma and related conditions. Prescription medications should only be used by the person for whom the prescription was written. Each paddler who suffers from asthma should carry a rescue inhaler on them, and a second one in their personal first aid kit.

Hypothermia – Prevention is the best treatment, so paddler should be careful to dress appropriately. Paddlers also should have extra warm clothes, food and water. Hats (that can fit under helmets for paddlers using helmets) can make a huge difference. Emergency shelters (expensive) or emergency bivies (less expensive) can help shelter hypothermic patients. Plastic drop clothes and heavy duty trash bags are inexpensive alternatives. Fires can help warm patients, so kits might include matches or other fire starters.

Pain Control – Over the counter medications such as ibuprofen (Motrin, Advil), naproxen (Aleve) and acetaminophen (Tylenol) can provide effective pain relief for many wilderness medical conditions. Ice packs can be helpful for some injuries, but they are often bulky and require well protected storage.

Medications – Individual paddlers should carry all personal prescription medications they need. Prescription medications should be used as prescribed and should not be shared with others. Use of over the counter medications is sometimes debated. Some argue that no first aid provider should give any medication to a patient. Others argue that “if you’d offer it to your friend at work, you can probably offer it to your friend in the backcountry,” and “if the patient is asking for some Motrin, you should be able to give them some.” Ultimately, this decision is up to the caregiver and the patient. Paddlers who keep medications in their first aid kits should be careful to check expiration dates for medications, and replace them as needed.

Instructions – A small first aid guide can be stored in the first aid kit. The pocket guide for the American Red Cross’ Wilderness and Remote First Aid Course is found at: www.redcross.org/images/MEDIA_CustomProductCatalog/m4240197_WildernessRemoteFirstAid_PocketGuide.pdf. Other guides are available for purchase from many wilderness first aid course providers.

Record Keeping – A written inventory of the first aid kit’s contents helps ensure supplies are replaced after use. Whenever supplies are removed, a note should be made on the inventory. A written record of patient care is helpful when care is transferred or if care is provided over a long time. A small notepad and pen or pencil should be part of every first aid kit. The ACA has accident report forms available on their website, at the address below.

( https://c.ymcdn.com/sites/www.americancanoe.org/resource/resmgr/insurance-documents/aca_incident_accident_report.pdf)

Accident report forms help ensure accurate information is collected and recorded at the time of the event. Several wilderness medicine training organizations publish their own patient care report forms, and some are available online. Two examples are below.

( www.wildernessmedicinenewsletter.com/wp-content/uploads/2012/02/soapnote-860x1024.jpg)

( http://library.constantcontact.com/download/get/file/1101635218710-296/ACC+Ottawa+SOAP+NOTE+-+Sept+2011pdf.pdf)

Use of these forms helps ensure caregivers collect accurate information with a consistent format.

Storage – The best first aid kit in the world becomes useless if everything in it is soaked. Keeping supplies dry is particularly important for paddlers. Supplies must also be accessible and their container must be re-sealable. Many options are available. Pelican containers (www.pelican.com/home.php) are crush proof, water tight, and available in different sizes. They allow easy inspection of contents. They are, however, expensive and care must be taken to avoid damaging gaskets required for a watertight seal. Wide-mouth Nalgene bottles (https://store.nalgene.com/) are inexpensive, crush proof, and water tight. However, it can be difficult to access the equipment stored in them. Dry bags do not provide crush protection, but can be found in a wide range of sizes. Zip seal dry bags (e.g., Watershed bags, www.drybags.com) are more expensive but much drier. Traditional dry bags with folding seals often allow minor leakage, but are less expensive. Some are transparent, making it easier to find supplies. Supplies inside the kit should be placed in watertight bags for additional protection. Ziploc style freezer bags work well. More durable bags are available from LokSak (www.loksak.com). LokSak bags are designed to be opened and closed multiple times, and are guaranteed waterproof to 60 meters.

Regardless of what is used to store the kit, caregivers should consider how to effectively pack the kit. Barrier devices should be readily accessible. Frequently used items should be at the top of the kit. Rarely used items can be stored at the bottom of the kit. Medications should be carefully stored, so they can be easily identified. Medication dosages, treatment guidelines, and expiration dates should be easily visible. In some cases, the kit might be distributed across two or more containers. One container might contain frequently used items, whereas the second might contain bulkier or less frequently used equipment.

Conclusion

Adequate training and appropriate supplies make it much easier to care for injured or ill paddlers. This article provides some broad guidelines, but nothing replaces hands-on training. First aid standards and techniques change over time, so it is important to keep certifications current. All paddlers should strongly consider earning WFA certification. If time and budget allow, paddlers should obtain first aid training beyond WFA.