Core Concepts (HB)

There are four main areas that this course is focused on, and these are the lessons learned from the Andy Palmer incident on the Dutch Creek Fire.

Medical

This course is designed to reinforce and improve your overall medical knowledge and skills to a level where you can effectively manage a medical incident within an overall wildland fire incident.

Communication

Because you are working with an organized team during a scaled event, you must provide effective communications. Effective communications will help your leadership understand what is going on within the overall context of the incident. And it will help you get the right resources for your patient.

Leadership

Medicine in a wilderness environment requires leadership. Most people around you are not trained to your level, but can readily be utilized as a force multiplier. This course helps you to develop the knowledge, skills, and demeanor required to manage a medical incident regardless of the size or complexity.

Decision Making

Managing a sick or injured patient requires critical thinking and timely decision making. There are real-world consequences for not making decisions–patients can die. The important thing is to make a decision and to be able to back up that decision. Ultimately it might be a less optimal decision (or not the right one). Being able to explain why you did what you did helps with the after-action.

There are a number of other concepts that are referred to throughout this course and are the main things you should consider frequently.

Probability versus Consequence

Injuries in an urban environment are inherently easier to manage. When we think about risk and how to mitigate risk, we cannot only consider how often injuries occur. We also need to consider the consequence of that injury.

Think about slipping off of a small retaining wall (let’s call it two-feet high) in a park in the middle of a city and rolling your ankle badly enough you cannot bear weight. You can call someone for help, maybe a friend or emergency services. You can sit in place and wait for the services to get to you in likely a few minutes. Your risk of dying of exposure to the elements before help arrives is pretty low.

Now apply that same situation to the backcountry. Instead of being in a park in the middle of the city, you slip off a two-foot-high rock, five miles from the trailhead. There is no cell service. The probability of the fall is about the same as in the park in the city. But the consequences of that injury are much higher in the backcountry.

Ideal to Real

When you encounter a patient in distress, ideally, you would like access to a room full of specialists and the resources of a fully stocked and staffed hospital. Unfortunately, no one has figured out how to fit one of those in a portable medical kit.

In the context of austere medicine, we have to be flexible enough to adapt to the current reality of the situation. You might know a dozen different ways to splint an unstable ankle, but you don’t have an air splint or an aluminum splint and cravats. You will need to compromise and figure out how to stabilize that ankle using what you do have–which might be some branches and some excess straps from a pack.

Maybe your patient took a fall and had pain on palpating the spine and some numbness in one of their arms. You are at the base of a chute with some unstable snowpack at the top. Do you wait for a litter team with a way to stabilize the spine, or do you get them moving to a safer location?

The better trained you are, the more tools you have at your disposal–be that knowledge, techniques, or familiarity with equipment and concepts. Identify the problem and solve it to the best of your abilities with the tools you have available at that moment. Don’t get trapped in the mindset of “If I only had a…”

General to Specific

Your job as a medical provider is to figure out what is going on with the patient. Figuring out the problem takes information, and one of the main components of this course is to teach you to gather facts to make this determination. When you first encounter your patient, your information is limited, and so you may only have a general impression of the problems.

As you continue to gather information, you start narrowing down the possibilities of what is wrong by ruling things out. Your general impression will eventually become a specific set of problems that you can treat or manage.

Oxygenation and Perfusion

All of the cells in your body require some basic things to survive. One of the primary components is oxygen. Oxygen gets transported to the cells suspended in blood–oxygenated blood. Oxygen is brought into the body via the lungs, where it is exchanged with carbon dioxide (one of the waste products produced).

The transportation of sugar, oxygen, and water under pressure to the cells is “perfusion.” That same pressure also carries the waste materials from the cells to the organs that exchange or eliminate them. All of this is precisely regulated by the brain, and any disruption to this flow causes a problem.

Ischemia leads to Infarction

We have talked about perfusion and its importance to all of the tissues in the body. Perfusion requires pressure to work, and inadequate perfusion pressure is what we call “ischemia.” Ischemia can affect a small local area or an entire limb. The problem is that the cells cannot exchange the waste materials for the fresh materials they need to survive. This problem is similar to letting the trash pile up in your kitchen and never bring in fresh groceries–eventually, the place would be uninhabitable, and you would starve.

If that ischemia continues long enough, the tissue will eventually die. This tissue death is called “infarction.”

Different types of tissues are affected by ischemia differently, and thus “infarct” at different rates. For example, immobile patients in hospitals must be rotated frequently to prevent pressure sores from forming. Pressure sores are small areas of the skin (generally over a bony prominence) pressing against a surface. The perfusion force cannot overcome this pressure, and the tissue becomes ischemic. Eventually, that tissue will break down and die, forming open sores, but this takes a couple of hours. Brain tissue is especially sensitive to inadequate perfusion and can die in a matter of minutes.

A common form of infarction is a “heart attack” whose clinical name is “myocardial infarction.” “Myo” is muscle, “cardial” refers to the heart. So a myocardial infarction is literally “death of the heart muscle.”

Swelling

Damaged tissue swells. This swelling occurs as fluids are moved into damaged tissues from ruptured blood vessels or leakage from damaged cells. Swelling generally peaks over the course of twenty-four hours.

Swelling is generally the cause of diffuse pain after an injury. The pain happens because the pressure created from the leaking fluids affects nerves in the area. If the swelling occurs in a constricted area, it can impact perfusion.

Injury to the head can cause swelling in the brain. Damage to a muscle can cause swelling in the limb, and if it is severe enough, it can create a condition called “compartment syndrome.” Swelling in the neck can impact the airway. Swelling in any confined area is dangerous and should be anticipated.

Obstruction leads to Infection

Many hollow organs and tubes in the human body manage liquids (transporting, storing, or excreting). These could be anything from sweat glands to the bladder or the tubules in the kidneys. If these hollow spaces get blocked or obstructed, the pressure from build-up can cause inflammation. Like stagnant water, these trapped fluids can grow bacteria, eventually forming an infection. If left untreated, these infections can become serious, even progressing to sepsis. A couple of common causes are kidney stones and the average pimple.

Serious or Not Serious

You should not expect to be an expert medical provider after a week-long course. Even after eight to twelve years of medical school, doctors are still considered to be “practicing medicine.” For the level of this course, and at a bare minimum, you should have no problem identifying the severity of problems with a patient. What we need to know about all patients is:
Right now, my patient is “NOT SICK,” “KIND OF SICK,” “REALLY SICK.”
Over time the patient is “GETTING BETTER,” “NO CHANGES,” “GETTING WORSE.”

If you can identify status and trends and enact a treatment and transport plan, patients that can survive will survive.