Less than a minute after the mountain biker blew by me on the trail I heard the wail. It was scary. I raced forward with my hiking partner and very quickly came upon the accident scene. Thomas was laying in a crumpled mess, his $1500 mountain bike further down the trail with one more bend in the frame than the manufacturer had created it with. This didn’t look good.
The hillside was steep and Thomas was on his side. I dropped my pack and went to backside of Thomas. Quickly my training kicked in. I introduced myself and asked him his name. His response re-assured me. He was breathing and had a pulse. And in medical terms, he appeared to be alert and oriented times three.
I put on my gloves (yes, I do carry nitrile or latex or material gloves pretty much anyplace I go, you should too!) I then moved to his backside and palpated his head. So far, so good. No blood or cerebral-spinal fluid. Since he was on his side, it was an ideal (if one could call his situation that) position for me to check his spine. Working down, so far so good until I got to the top of his lumbar portion. There I felt something very wrong. Ok, shit just got real. Upper torso, so far so good. Lower torso, right side, a reaction to pain. Barely noticeable, but definitely some mass internally. Again, not good. I continued down his legs. I got to his feet and normally I’d have saved this for the secondary survey, but since I already had a bad feeling and this wouldn’t take very long, I asked him to press his toes against my hands like he was pressing the gas. Nothing. I asked him to pull up his toes, again nothing. This was not good. Same lack of reaction on the other side. I could hear the panic in his voice, “why I can’t I move my legs?”
In all my past training they always taught us, “never lie to the patient. But also remember you’re not a doctor.” So I was honest. “Look, it could be a lot of things. I’m not a doctor so I don’t want to speculate. We’ll leave that to the professionals.” But deep down I knew. Bad tumble off a bike, bad position of a lumbar vertebra, and lack of sensation distal to that all added up to some sort of spinal injury. Would it be permanent, I had no idea.
I also checked his right arm since it was immediately available and this time came up with blood and point pain over the radius/ulna. This matched what the accident most likely was. He had hit a rock or something and wrapped his right side around a tree, breaking his arm, damaging his spine and most likely causing internal bleeding.
But I still had the left side to check.
With my partner’s help, we got a ground pad behind him and then rolled him very gently onto it. It’s always a risk moving a patient with apparent trauma like this but we needed to get him isolated from the could ground which was stealing his body heat and I needed to check for injuries on the left side.
Fortunately, this was the only bright news. A thorough check of his left side showed no apparent trauma. But, his shivering was getting worse and his mental state was decomposing. Whereas he was had previously been alert and oriented to who he was, where he was and approximately the time, now he kept asking the time. Taking a set of vitals, things were not what one would like to get.
My partner was writing down all this information and giving me gear as needed. We had gotten the groundpad under him and clothing on top, but we needed to do more. At this point, since we confirmed he wasn’t about to bleed out, we worked on splinting his arm. Providing traction in-line proved to be a bit painful at first, but ultimately gave him some pain relief and temporarily solved that particular issue. We did as much as we could in the back-country.
I took another set of vitals, and the numbers were a wee bit worse. In addition, Thomas was now wondering where he was. I repalpated his lower right abdomen and got an increased pain response and the firm area was larger. This was a very worrying sign.
While doing this, my partner ran down the trail with a copy of his notes until he got cell service and called 911. He gave them the details and then came back. At this point, with his help we decided to get Thomas into a bivy sack to help keep him warm. This took some effort since Thomas was bigger than either of us, fairly muscular and we were doing out best to protect his spine. But eventually we got it around him. Between this and some liquid “squirt” we were able to give him, his pending hypothermia appeared to stabilize and eventually improve.
But his vitals continued to degrade and the pain and mass in lower right his abdomen continued to get worse. He was dying and there was nothing I could do about it.
Well there was one thing I could do. I looked at Thomas and said, “well I think that’s it. Did I miss anything or do you think we got this exercise covered?”
He looked up and smiled, “Nope, I think you got it. By the way, the biv sack really did help a lot. I was actually starting to get cold for real.” We removed the biv sack and he remarked, “Wow, you really did have a lot of warm stuff on me.”
Now, fortunately, all this had been an exercise, part of a SOLO Wilderness First Aid class I was taking over the weekend in order to renew my certificate. The scenario was completely made up. But, I have to say, the feeling of helplessness was real.
Strangely though I’d say that was a good thing. For any skill we want to maintain competency in, we need to practice. Fortunately, I haven’t come across a crumpled mountain biker and most if not all back-country medical emergencies I’ve encountered have basically been fairly simple (an abrasion here, a blister there, or most commonly, mild hypothermia). But, continual practice does help. When arriving at the staged scene, I knew what I wanted to do and I knew how I wanted to do it and how to do it. The years of training and practice came back very easily. I knew how to do a primary survey and what I wanted to look for. I knew what vitals I needed and what trends I wanted. There wasn’t much searching for knowledge, it bubbled up as needed. Practice really does in a sense “make perfect.”
And, even knowing that my mock patient most likely had internal bleeding that was leading to hypovolemic shock was good to know. Knowing that there was very little I could do if this was a for-real in the back-country was scary, but also strangely reassuring. I was confident that I had done all that I could reasonably do. And sometimes that may have to be enough.
I’ve talked previously about training as one fights. This should be true in any situation you may find yourself in: caving, the back-country, or even something as mundane as being a DBA. When’s the last time you practiced restoring a backup or doing a failover test?
Practice may or may not make perfect, but it does provide confidence.
P.S. if you’re in the Hampton Roads area tomorrow night (October 16th) come check me out speaking on System Databases at the Hampton Roads SQL Server User Group. Rumor has it, they’re serving wings!