Saturday, June 2, 2012

Lost Brook Dispatches: The Essential First Aid Kit

When last we met I devoted a column to essential equipment and in the process invited a plethora of opposing views.  Now let me get into even deeper trouble with the one essential item for which I left the details to this week’s column: the first aid kit.

Let me first preface my list by saying that safety in the back country to me implies an indefinite period of time.  My first aid kit reflects the possibility of being stuck for days facing a serious illness or injury.  As always, discomfort or inconvenience don’t matter much to me.  This is about potentially saving a life.

Here is the crucial disclaimer.  I am not a medical doctor.  I am not a nurse.  I am not an EMT (I’m seriously thinking about going for that, though).  My qualifications are first aid training (a fairly extensive version of that), a lot of experience and a primary care physician who advises, treats and prescribes for me and is himself a hard core back country adventurer. If you want expert advice you should not rely upon me; you should seek the same thing I have at my disposal: a medical professional who also knows life in the woods.

With that said, off we go.  Let the arguments and scathing criticism commence!

Here’s a typical recommended first aid kit, pulled from a backpacking site on the web:

Essential First Aid Items: first aid manual, antiseptic cream, adhesive bandages, butterfly bandages, sterile gauze pads (several sizes), medical tape, alcohol or iodine wipes, pain killers, latex gloves, flashlight, scissors/knife and medications – any prescription or non-prescription medications that anyone in your group needs

Non-Essential Items: elastic (ACE) bandage, moleskin, safety pins, miscellaneous lotions – Burn lotion, anti-itch cream, anti-fungal cream, aloe-vera gel, etc., duct tape,  Second Skin , petroleum Jelly, bandana, tweezers

Here’s my list:

Essential First Aid Items: training, ACE bandages (2 or 3), duct tape, sterile gauze pads, moleskin, small scissors, ibuprofen, aspirin, epinephrine, ciprofloxacin, any prescription medications others in the party may need

Generally I don’t carry non-essential Items.  If I go solo I forego the moleskin and scissors too, since I last had a blister many years ago.

Here’s my argument for my kit, item by item.

Training – Experience and attitude once again matter more than anything else.  Get training.  It’s cheap, easy and at most a moderate time commitment to get basic training.  It will have a great effect upon your attitude in dealing with a situation.  Having a manual to leaf through in panic time is not really all that terrific.  Training and a cool head is far more important than a manual or even the kit itself.  I am not going to give an abbreviated course in the first aid process here (there is a process).  You need to know it.  It is common sense, rational and effective.

ACE bandages or equivalent – It boggles my mind that this item fails to make the cut on so many essential lists.  If I bring only one item this is it.  You are not all that likely to encounter a potentially fatal injury or illness.  You are much more likely to injure a limb or get a bad cut.  An ACE bandage can preserve enough mobility to get you out of the woods.  In combination with sticks it can splint a broken bone.  It can stabilize a sprain.  It can help with contusions and wounds.   I carry a minimum of two.  Absolutely essential.

Duct tape – You need tape.  It might as well be duct tape.  It is more versatile than medical tape.  It comes in bigger widths (very helpful) but can be stripped to any needed width.  No tape on Earth will adhere to skin in wilderness conditions, with dampness, sweat, greasy residues, dirt, etc.  What you need is tape that adheres well to itself, even under sub-prime conditions.  Duct tape is that (except if it is too cold – be careful if you are a winter camper, most tapes become ineffective in extreme cold).  Duct tape can do all that medical tape is called upon to do and more, plus repair most of your other camping gear to boot.  Caution: it is not as strong as medical tape, you may need to layer it.

Sterile gauze pads – Okay ladies and gentlemen, here comes the fun.  We are a culture obsessed with germs.  We buy antiseptics.  We buy Lysol and spray it all over the place.  We buy anti-bacterial soaps.  In the past five years we have had a veritable explosion of hand sanitizer.   Much of this is silly, even counter-productive (compromised immune system, anyone?).  In the back country, where preventing the spread of germs is generally not the issue, it becomes relatively pointless.

There is an anti-bacterial agent far more effective than rubbing alcohol, antiseptics creams, ointments, iodine and the like (notice that the canonical first aid kit I listed at the beginning of this article had some version of all of these things): it’s called your immune system.  You should trust it.  Your immune system needs you to support it and not get in its way.  Enter the woods healthy, eat nutritious food, drink water, rest… do those things and it will be happy.  Then when you get a wound it will need only a mild assist from you.

What is this assist? Simple: you need to keep the wound clean and dry.  Your immune system will handle the rest.

What do so many people when they get a cut?  They slather some ointment on it and slap on a band aid.  This is first aid?  Let’s see: we smear goop on the wound, dirt and blood and all.  The antiseptic properties of the ointment notwithstanding, this is not a clean wound.  We then put a band-aid on it, which has not one chance in a hundred of staying on during the rigors of even a moderate backpacking trip.  Not only that, it doesn’t really keep dirt out.  Worse, a wet band aid does not feel all that different than a dry one, and a wet, dirty wound is the worst possible thing you can allow.

My essential first aid kit does not have ointments and band aids.  What is does have is sterile gauze pads and duct tape.  And clean water.  If you followed the last dispatch my essential back country gear includes the ability to create a supply of filtered water, clean water.  So here’s what you do.  You clean the wound with filtered water.  It’s not sterile water, of course, but if filtered with a typical filtering product it is quite clean.  Get all the dirt and oil out of the wound, flushing it as much as needed.   Apply direct pressure as necessary with a gauze pad to stop the bleeding.  Let the wound dry.  Secure a gauze pad or two over the wound picking a pad that is much larger than the wound, for excellent coverage.    The pad is secured with tape-to-tape, not tape-to- skin.  Done well it will not fall off.  For a larger deal or if it is in a tough spot you can assist with an ACE bandage.

What does this get you over the ointment scenario?  It gets you a clean, dry wound, ready for your immune system to protect.  A large, well-taped gauze pad will be far more effective at keeping out dirt than a band aid.  Gauze padding is tolerant of some moisture and will still keep the wound relatively dry.  If the pad gets wet for whatever reason you will know it- the feel will be obvious.  You then immediately put on a dry one.

Antiseptics are overrated in the back country.  If you want some, fine.  But prepare and clean the wound right first, then get it dry and keep it dry!  Gauze pads are an essential part of that equation.

Moleskin and small scissors: other than minor cuts and bruises the most likely injury that will need treatment in the back country is a blister.  First of all, per my previous Dispatch, the top priority is to have a perfect-fitting pair of boots.  Second, know how to tie them (not as obvious as you might think).  Third, have good socks and make sure they enter the boot without wrinkles or bits of trail junk.  Fourth, wear gators if the trail is going to be wet or if you are going to go off trail.  All of these things affect the odds of getting a blister, with boot fit being number one.  If you get one there is no effective treatment, so really the only good blister treatment is prevention.

Blisters affect mobility, so having one can be a safety issue.  Moleskin is therefore in my kit as an essential.  Anyone who has ever tried to cut moleskin with a knife will understand the scissors, plus scissors can cut tape and even dig out splinters.

Medications: here is where you need to pay attention to your qualified medical professional of choice.  For your basic go-to drug, ibuprofin is a great choice unless you are sensitive to it.  It is a good general pain reliever and particularly effective with the common back country retinue of muscle and joint aches.  These benefits aside it is in my kit because it does the essential work of reducing inflammation and/or fever.

Aspirin is in the kit not as a pain reliever but as a medicine to give to someone exhibiting heart conditions or even a heart attack.   The onset of a heart problem in the back country is not uncommon and it is best to be ready for it – news stories or reports of people stricken or even dying from heart attacks in the Adirondacks come along on a regular basis.  Knowing CPR and how to treat for shock comes first, but aspirin can make a real difference and is low-risk.

(aside – some might reach for the epinephrine I listed if a member of the party has a heart attack: this is liable to be either ineffective (dose too low) or exceedingly dangerous… giving epinephrine to a heart attack victim is for a doctor in a hospital who has diagnosed the type of heart attack, as adrenaline can make things much worse.  I would try epinephrine only as an absolute last resort if CPR failed)

Of course you need to bring whatever prescription medications you need and bring extra just in case.

The next two items are serious.  You have absolutely no business choosing them or using them without a doctor’s advice, prescription and training in their use so you know what you are doing.  I carry neither on short trips.  I carry both on longer trips or with more people along whose medical conditions may not be known to me.   Both can save lives.  Enjoy my comments, then throw them away and go talk to a doctor.

First, the epinephrine.  I carry it in the form of an Epipen. I have never used it yet.  Good thing – it is an extremely powerful drug that provokes a tremendous reaction in the body.  Its use is for a life or death choice.  If you are miles from help and someone is undergoing a violent allergic reaction, even anaphylaxis, administration of epinephrine can save their life.  After its use the victim is going to need ongoing life-saving first aid care, but without it you may not get to that point.

Finally, I carry ciprofloxacin, or cipro for short.  Never – I mean never – carry an antibiotic that you have selected unless you yourself are a medical professional.  Only carry the antibiotic your doctor has selected for you and legally prescribed.  Antibiotics vary both in their effectiveness and in your tolerance for them, so you need a doctor to make the choice for you.  If you have rarely or never used antibiotics you must proceed with great care.  For example, plenty of people are allergic to the penicillin family.  If you are but don’t know it and take it in the middle of nowhere you will be in grave danger.

With that said, there are times when an antibiotic is going to save a life. Cipro is a very strong drug and it is effective against a broad spectrum of maladies.  I tolerate it well (some do not) and I myself am allergic to penicillin.  So it’s an excellent choice for me.

When do you use it?  If you have a fever?  No.  If you are in severe pain?  No.  If you have an infected wound?  No.   With all of those, take ibuprofen, clean the wound, drink liquids, rest, just like at home.  However… you’ll likely know if you are dealing with something more serious.  I have two examples, both involving my son Zach.

Three years ago I took an extended trip with Zach.  We were going to do the Western High Peaks including Seymour and the Seward Range. I started to feel poorly as though I had a bad case of the flu.  For a while I ignored it.  We did Seymour and I felt okay until most of the way down.  Then I hit the wall.  It was a long hike back to our lean-to at Duck Hole.  I knew something more serious was up.

I went for fluids and rest.  We hung out at the lean-to and left the Seward Range in peace.  I waited it out two days but I got progressively worse.  My throat started to hurt like the devil.  My fever was high, I was flush, weak and dizzy.  This was no virus; it felt like strep.  Whatever it was I could not have hiked out.  It was time to pull the trigger so I took the cipro and two days later we walked the NP trail out to Lake Placid.

Many years before that when Zach was a young lad of eight or so, the whole family was on yet another extended trip, this time in the Central Adirondacks.  Zach cut the side of his foot on a rock, a small cut, nothing that was concerning.  I treated it but it went back in the boot and we had a mucky, humid day.  That night Zach complained about his cut hurting.  I examined it and found it to be inflamed, pinkish red and raw.  It was infected.  Zach kept it dry and clean that night and in the morning we resumed our trip.

Sometime in late morning Zach came to me.  “Dad my foot hurts,” he said.  I removed his boot and peeled off his sock.  His entire foot was bright red to just below the ankle.  I knew what this was.  I scooped him up and we headed out as fast as we could move.  We got to the car in a couple of hours.  The redness was now past the ankle and I was good and scared.  We drove at high speed to the emergency clinic.  The doctor took a quick look at his foot and got out a magic marker.  He drew a black line about a ¼ inch above the red line of the infection, which was now a good inch above his ankle.  “If it crosses that line we’re transporting him to a hospital,” he said.

Zach was put on an antibiotic IV.  We watched as the infection moved up his leg, spreading so fast you could see it with the naked eye.  The drugs began their battle with the infection and the spread began to slow.  It was arrested about 1/16 of an inch below the line.

Zach had gotten a virulent type of cellulitis, an infection of the subcutaneous layers of the skin that spreads incredibly fast and can lead to sepsis, a life-threatening reaction from the immune system, as well as other complications such as blood clots.  I had no cipro that day, but I might have needed it to save his life had we been further in the back country.  Now I have it.

That’s my kit, minimalist as is my general style.  Comment away!  Remember, make your own choices for medications in consultation with your doctor, not from my column nor any other column on the Internet.

There’s still a lot of room in the pack.  Now, at long last, I can get to the subject of cooking and fill the rest of it with food.  See you next time.

Photo courtesy North Dakota Parks.


Pete Nelson

Pete Nelson is a teacher, writer, essayist and activist whose work has appeared in a variety of Adirondack publications, and regularly in the Adirondack Almanack since 2005. Pete is also a founder and current Coordinator of the Adirondack Diversity Advisory Council, which is working to make the Park more welcoming and inclusive.

When not writing or teaching mathematics at North Country Community College, Pete can be found in the back country, making music or even walking on stilts, which he and his wife Amy have done professionally throughout the United States for nearly two decades.

Pete is a proud resident of Keene, and along with Amy and his dog Henderson owns Lost Brook Tract, a forty-acre inholding deep in the High Peaks Wilderness.




6 Responses

  1. Laurie Dirkx says:

    I felt this to be a phenomenal resource. Thank you. Though, I can only imagine how many doctors would not prescribe cipro as a precautionary item. I would hope they’d understand the need to have this on hand as a back country emergency med, but wonder how many doctors would not prescribe it when it wasn’t right then evidently needed.

  2. Pete Nelson Pete Nelson says:

    Laurie:

    Indeed you are right. I get both cipro and epinephrine only because my doctor trusts me. The trust is based not upon how sincere I am but on demonstrated back country journeys of scope and length that call for such emergency medications, plus demonstrated first aid training and demonstrated experience administering medications to sick people.

    You can’t just walk into a clinic and get a prescription for cipro. However if you have some training and a back country plan requisite to the potential need, than you should be in good shape.

  3. Mark Genier says:

    An excellent article. I am impressed that you stressed attitude as a key part of first aid. That is how I start all my first aid presentations to classes. (I’m a DEC Hunter Ed Instructor). I found your entire article to be informative and well thought out. There is no substitute for experience and you obviously have that. In my opinion, your first aid kit is on the spot!

  4. Pete Nelson Pete Nelson says:

    Thanks Mark, your endorsement is very gratifying. In the mean time readers, a good friend with a wealth of experience just got himself a severe sprain in the back country. That’s the kind of risk we all take, a welcome risk indeed, but best to be ready for the consequences.

  5. another says:

    Benedryl is another drug worth having in any kit. No script needed, and very cheap. It can help with numerous maladies, and may be of some use if you don’t have epi.

    Great article.

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