In the summer of 2008, I took a Wilderness First Aid course and part of the course covered what to do when help is delayed.

Below is my summary of the booklet offered by the American Red Cross: First Aid - When Help is Delayed. While I have taken training classes in first aid, I am not a certified EMT or medical person. So, use your best judgement and common sense. If you don't understand something or have additional question, ask a qualified person.

These notes are for general discussion purposes.


Types of Delayed-Help Situations

Delayed-Help definition: Emergency help is more than 30 minutes away.
a. No easy way to call for help
b. No easy way for emergency personnel to reach the victim
c. No easy way to transport the victim to medical care

Three Types of Delayed-Help Situations

Rural areas - usually involve equipment, animals, electricity, falls, fires, overturned vehicles, chemicals or pesticides and agricultural machinery.

This is my personal situation, 12 miles from the nearest medical facility. Our local volunteer fire department is the first responder unit.

Wilderness - need to consider how to get help and what care to give. This will be discussed more in-depth since this is what this site is all about.

Other Delayed-help Environments
Natural and man-made disasters - hurricanes, earthquakes, tornados, terrorist acts and some boating activities.

Applying the Emergency Action Steps: Check-Call-Care

Check: scene, victim, resources

Check the scene - check the whole scene to get an idea of what happened and look for potential dangers that threaten your safety or that of the victim (e.g. falling rocks, tree limbs, unsafe equipment). If you see any dangers, do not approach the victim until you have carefully planned how to avoid or eliminate the danger. Also note any impending dangers such as bad weather.

Check the victim - approach carefully and continue by checking for life-threatening conditions (airway, breathing, circulation). If the victim has fallen or if you don't know how the injury occurred, assume they have a head injury. BE VERY CAREFUL. If you are not trained in how to move someone, then don't. STABILIZE the victim and get help.
Check for any other problems that are not immediately life threatening but may become so over time. Make sure you have all the information about the victim's condition in order to make a plan for getting help. Whenever possible, perform a head-to-toe check. Write down the information. If you have nothing to write with, try to remember the most important or unusual observations.

Check for available resources - gather information needed for planning how and when to get help. Check the surrounding environment for conditions or developing conditions that could endanger your or the victim during the time it will take to get help (e.g. weather, insects, etc.) Note any conditions that will make it difficult to get help. Consider whether you may have to move the victim and how.
Resources include: people available to help, communication equipment or signaling devices, food and water, shelter, first aid supplies and means of transportation.

Call: making a plan, executing the plan

Making a Plan - four choices
Stay where you are and call, radio or signal for help (do you have a means to do so?)
Send someone to get help or leave the victim alone to get help
Transport the victim to help (is it even possible?)
Care for the victim where you are until the victim has recovered enough to travel on their own (what type of care needed and how long?)

You may discover there is no "best" plan. You may have to compromise.

Executing the Plan
Calling - If you have some means of two-way communication (e.g. radio or telephone), make sure you have gathered all necessary information about the victim's condition and your location. This reduces potential confusion and improves the likelihood that the correct help will be sent to the right location. Make the first contact count. Later attempts may fail. Know your landmarks (or if you have a gps - know your coordinates). Some may be visible in the daylight but not at night. Don't use flares in a heavily wooded or dry area that might ignite a forest fire. You may need to send someone to meet the SAR personnel at a main road or easy-to-identify location.
Signals in Threes - a series or set of three is the universal signal for help - three shots, three flashes of light, three blasts on a whistle.
Ground-to-Air signals - mark a large X on the ground in a large, open area. Make sure the X stands out against its background and is at least 20 feet across.

Sending for help - make sure the person doesn't leave without certain information: victim's condition, a map indicating the location of the victim, a list of other members in the group and available resources, weather, terrain and access routes. Needs to be in writing in case something happens to the person or they get lost.

The safety of the messenger is extremely important. Send enough people to ensure the safety of the messenger. Do not send people who are not prepared to overcome hazards or challenges.
Make sure the person going for help can lead the SAR team back, if necessary.

Care
Remain calm, provide support and reassurance to the victim.
Monitor the victim - continously monitor the breathing victim who is unconscious or has an altered level of consciousness (e.g. hyper/hypo thermia). Check them every 15 minutes.
Watch for changes in skin appearance, temperature and level of consciousness. Keep a written record and note any changes, the time they occured and the care provided.

Obtain training for serious injuries such as:
Fractures and Dislocations
Severe Bleeding
Burns
Sudden Illness (e.g. diabetic emergency, allergic reactions, etc.)
Shock
Head,Neck and Back injuries
CPR
Rescue Breathing
Heimlich manuever

Protection from the Weather
Protect the victim from heat and/or cold
Construct shelter if needed, keep it simple, use resources on hand

Remember - CHECK, CALL, CARE

All of this assumes you are not hiking solo. If you do, that opens up a whole different discussion. But, you may come upon someone that has been injured and needs assistance.

So, let's discuss!

Tango61

Tango
this seems like such a complete article, and its beyond my first aid knowledge, that its easy to see why people simply read it without replying. I certainly have nothing to add. Also I tend to skim things, so I should slow down and read it again. I'm replying to move it back up the ladder.
Jim

To echo Jim, it is going to take me a while to digest. I am not a first-aid expert, so thanks for more info.

Tango
I guess I have to ask you the same question I asked Steadman. I tend to hike solo. I don't carry anything but band-aids. I am not trained. I know not to move someone who may have a spinal injury. I am concerned that If I do anything that they may die. If they're gonna die before I can get back I'd probably cry and hold their hand and reassure them as they die rather than leaving them. At some point I have to decide that they have more than maybe two hours to live to make it worth while to go for help. I'm neither young nor fleet of foot. If I try to help them and they die am I liable? Can their family sue me? What do I do? Help might be a day or two away. I guess I'd take GPS coordinates and try to cover them with a sleeping bag, but not if I can't get out in a day unless, probably, they have a pack with them.
Jim

To the questions that jimshaw raised:

The questions of liability, etc. tend to boil down to a question of a duty to act vs. the Good Samaritan law. If you're "on the job" as a guide, outdoor professional, or healthcare provider you fall under the duty to act principle. Good Samaritan laws vary slightly from state to state, but the general principles are that in order to be protected you should;
1) act in the best interests of the patient
2) act within the scope of your training (as a paramedic, I shouldn't do surgery, insert chest tubes, etc.)
3) receive no compensation or renumeration for your efforts. This one can be tricky; if you're brought along as a trip "doc" and not paid, but are allowed to keep whatever gear they buy you at the end of the trip....you get the idea.

Worst case scenario, can the family sue you? Sure...but you can sue anybody for anything. The most common charge to seek would be negligence, and that's a pain to prove. There are four components;
1) duty to act (in other words, not being eligible for Good Sam.);
2) breach of duty (you either do something you shouldn't, or don't do something you should);
3) damages, and
4) causation. Your breach of duty must directly contribute to the damages. My understanding is that this is where the majority of cases break down.

Your best defense is to get some training and a certification of your skills and knowledge, keep it current, and stay within the scope of tha training. Most courts and regulatory agencies will grant you some leeway if you're acting in the best interests of the patient, within reason (using an AED on someone is appropriate, trying to defibrillate them with a car battery and some jumper cables will definitely land you in court).

Now for the disclaimer...what I just posted is based on my professional training as a paramedic and EMS educator; I'm not a lawyer, nor should you take my post as Holy Writ, just the legal practices as I understand them.

Gorge_medic
well reading your post, I have no duty to act, and I could do harm if I tried. I have no training and I wouldn't have any jumper wires, so where does that leave me? I guess I say "I'll be back", look them over, take GPS reading and look for someone with a cell phone that gets a connection. Maybe ask if they want me to put their pack by them or get something out of it for them.

Now what if someone says "I need my pills, they're in the top of the pack." Or even weirder, they reach in their pack, pull out a gun and say save me or I'll kill you and so you try to walk them out and they die of a spinal injury. I had to throw that in just to make your brain hurt...
Jim

I've seen a lot of emergencies in the wilds and none of them resemble what you are imagining here. Most of them are chaotic. If you have even basic first aid training, your knowledge will be a priceless asset.

The most common error is moving the victim prematurely, before a proper evaluation has been performed. Most of my situations have involved trauma, usually a slip or fall of some sort. I don't recall how many involved an obvious injury (say a broken arm), as well as a hidden, potentially more serious injury (compression fracture of the spine).

Keep them breathing, keep the blood circulating, and don't move the victim unnecessarily.

Too true.

I had a woman fall off a 2 metre cliff on a walk I was leading. Luckily there were two of us on the walk with First Aid training. We made the lady stay where she was (face down in the scrub) for a few minutes to let her relax and make sure all was right before anything else. After she relaxed we got her to check that she could move everything and then we checked for other injuries like cuts and bruising. Thankfully she was able to get up and continue, the only real injury was a big split down the rear of her trousers that got larger as we continued along.

Dear Mr. Devil's Advocate,

That was some funny crap! On a more serious note I have some firsthand experience in criminal courts and civil courts (cop). The bad thing about being sued is that it goes into civil court and this only requires the burden of proof to be by a preponderance of the evidence. Basically 51% = guilty. I have been involved in some bogus lawsuits that died a quick death as a result of their "bogusness". Typical ambulance chasing lawyer crapola!

And if someone pulls a gun on you and up and dies on you consider the old abandonment of property theory. Look at all that cool backpacking gear that you just found abandoned on the trail! Looks like someone was littering and you were just LNT'ing the trail and sprucing the place up.

Of course I am not a lawyer so don't take my advice. Jim you could have them sign this release of liability that I "made" for you before you help them:

In consideration for Jim Shaw helping: Mr./Mrs/It:__________ and other valuable consideration, I hereby RELEASE, WAIVE, DISCHARGE AND CONVENANT NOT TO SUE Jim Shaw, Jimmie Shawshank Redemption, James Shaw, Jimmy Shaw, and his officers, servants, agents, and employees (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise, while participating in such rescue, or while in, on or upon the premises where the rescue is being conducted or in transportation to and from said premises.

2. To the best of my knowledge, I can fully participate in this rescue. I am fully aware of risks and hazards connected with the rescue, including but not limited to the risks as noted herein, and I hereby elect to voluntarily participate in said rescue, and to engage in such rescue knowing that the activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or any loss or damage to backpacking property owned by me, as a result of being engaged in such a rescue, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES or otherwise.

3. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS THE RELEASEES from any loss, liability, damage or costs, including court costs and attorney's fees, that may incur due to my participation in said rescue, WHETHER CAUSED BY NEGLIGENCE OF RELEASEES or otherwise.

4. It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and spouses (if any), if I am alive (and Jim hasn't Shawshanked me), and my heirs, assigns and personal representative, if I am not alive, shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of ______.

5. I UNDERSTAND THAT MR. SHAWSHANK WILL NOT BE RESPONSIBLE FOR ANY MEDICAL COSTS ASSOCIATED WITH AN INJURY I MAY SUSTAIN.

6. I further agree to become familiar with the rules and regulations of the LNT environmental conduct principles and not to violate said rules of any directive or instruction made by the person or persons in charge of said activity and that I will not contaminate the environment by bleeding on the ground and further assume the complete risk of any activity done in violation of any rule or directive or instruction.

7. I also understand that I should and am urged by Mr. Shawshank to obtain adequate health and accident insurance to cover any personal injury to myself which may be sustained during the rescue or the transportation to and from said rescue.

IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by same.

IN WITNESS WHEREOF, I have hereunto set my hand on this ________ day of ________________________, 200__.



_______________________________________
Participant



_______________________________________
Parent must sign if under 18 years old



EVERYONE PLEASE NOTE THAT THIS FORM OF RELEASE IS A JOKE AND NOT TO BE USED. CONSULT AN ATTORNEY FOR A REAL ONE!

Skippy
I met a doctor who backpacks a lot wile camped in Ventana wilderness, and he found a man laying unconscious on a trail with a broken leg. Since he was a doctor and he carried a surgical kit, he operated on the guy and the when the guy came to, helped him out. The guy sued him for $150,000 (for operating on him without his consent) and won by default because the doctor didn't show up in court. The Doc said to me "If I ever run into him again, I'll break his leg and leave him there."

So thank you for bringing up a very valuable point I think I'll carry a medical release in my first aid kit, right next to the band-aids. I believe you have given me permission to use the one above, but maybe I'll rewrite it a bit with your permission, and Thanks Skippy. You're a real pal...
Jim
P.S. I have rewritten the release with only minor changes, I took out the LNT part and the attorney my wife works for is reviewing it for me.

Something doesn't compute. According to my training,(which is not current) when the victim is unconscious, consent is implied, and you are good to go.

Well old rangerhe story is from 40 years ago and I think in Arizona. The point is you can be sued for anything and if you don't show up in court with an attorney, you lose.

Jim

My training and experience also dates from 40 years ago and is also from Arizona. Granted that is you don't show up, the judgment will be against you. Is there a citation for the case?

Default judgements do not make case law. The cite is worthless.

Its still a good practice to perhaps carry a consent form with you on long trips, as well as any allergies or wishes such as DNR you may have.

Jim, I would not use that form as a release as it was a joke. Also just because you have a release doesn't mean you won't be sued. I've been involved in 3 different lawsuits one involved a settlement, (I was deemed to have no role but someone else was) one has been filed as an intent to sue the city I work for (I caught a guy stealing and he fought with me) and one was as a defendant witness in a very pathetic attempt at trying to get money from a crippled old woman in a car accident.

Our society is encouraged to be sue happy and nearly every cop I know has been sued or will be sued more than once in their career. I've actually considered quitting my job as I get tired of being threatened with lawsuits.

-Skippy

Alright, let's take a step back and look at a non-extreme scenario. I understand the point everyone is making about liability and I don't want to discuss/argue that point. There is a good thread titled Liability in the Backcountry Health & Safety forum.

This scenario involves two solo hikers, one east bound (Joe) and one west bound (Tom).
(No, this isn't your junior high math problem)
Remember the points of check, call, care and see what we can learn.

It is about 3pm on day 2 of a 5 day hike for Tom and he comes upon Joe sitting on the side of the trail and appears to be in pain.

Tom - Howdy, how ya doing?
Joe - Not so good. I tripped and think I sprained my ankle pretty good.
Tom - oh man, that's a bummer. I've had some basic first aid training. You want me to take a look at it?
Joe - sure, should I take my boot off?
Tom - no, leave it on. It will help control the swelling. Do you have a sit pad or a sleeping pad to sit on? It might make you a little more comfortable. We can prop your foot up on your pack to help elevate it and slow the swelling. You got any water?
Joe - yeah, I got about half a liter.
Tom - when was the last time you drank anything?
Joe - about 10 minutes ago.
Tom - how far back was the last water source.
Joe - about 2 hours.
Tom - hmm, mine was about an hour ago. I've got a half liter and a full 1 liter platy.
Joe - I've got an empty platy in my pack.
Tom - you got any first aid supplies.
Joe - yeah, I got a few things in my pack.
Tom - are you taking any medication or have a history of heart disease or diabetes?
Joe - no heart disease or diabetes but I do take blood pressure medicine.
Tom - you look like your about 35, am I close?
Joe - no, more like 45.
Tom - well, let me feel your ankle and see if we can see how far up the swelling goes.
Joe - dang, that hurts.
Tom - yeah, the swelling goes about half-way up your calf and it's about one and half times bigger than your other ankle. Looks pretty serious. How long ago did this happen?
Joe - about 20 minutes.
Tom - well Joe, you got a few choices here. It's two days to the nearest trail head. Did you leave a hike plan with someone? When are you expected out?
Joe - I left a plan with my wife and I'm supposed to be at the trail head in two days and call no later than three.
Tom - There's about two hours of good daylight left. I can find a campsite near-by and set up camp and help you get into your tent. We can also figure out a way to wrap your ankle to give it some support. We can see how you're doing in the morning and if you want to try and walk out. Or, you can stay here and I can go back to the trail head and get some professional help. It'll take me two days and then drive to town or at least some place I can get a cell phone signal. Do you have enough food for 3 days?
Joe - yep.
Tom - you got any ibuprofen?
Joe - yeah, I'll take a couple of those.

So, using the Check, Call, Care protocol - what do we know.
Joe's got a pretty bad sprain. He's 45 years old and takes blood pressure meds (it would be good to know what kind and dosage). He's running low on water but appears to be hydrated. He's not in shock and is coherent. We're two days from the trail head and he has enough food. Water is a concern.

If Joe decides to hike out in the morning, I'll go for water and make sure he has both containers full. I'd show him how to wrap his ankle using a couple of bandanas or perhaps some straps from his pack. I'll use his gear rather than mine.
If he can't wak out, I'll decide if I'll hike back to the trail head and call/go for help. Or, if I'll continue on and try to find a signal or a road and flag someone down. Someone may be coming up the trail behind Joe and they could continue on to the trail head and call/go for help. We need to get his contact information of who to call.

What we learn from Wilderness First Aid training is how to improvise and use the gear you have (or better yet, what the victim has).

You can also "suggest" ways they can treat themselves.

Without getting into the discussion about liability, what else could/should we determine?

Tango61

Whats the weather like? Will it storm. Does Joe have enough fuel to cook for 2-3 days. Does Joe have a cell phone. Does Joe have food? Whats the chances of bears? Do you have a gps to get good coordinates or can you locate him on a map. You said you would get his contact information. Does Joe have insurance? Did he maybe fall and injure something else.
Like that? Is that what you mean?
I think this is a more likely scenario than finding him laying in the trail leaking fluids from his head.
Jim

These are exactly the kinds of questions to ask, Jim.

In fact, I think I have a list that they gave us in class.
I'll see if I can find it and post it.

Tango61

If the scenario is in my stomping grounds, the chances are the answer is "yes" because it's frequently "you can't tell".
again based on my usual haunts - "doesn't matter - won't work anyway"


mostly irrelvant on a 2-3 day timeline - he'll be uncomfortable without, but won't die.




In my case again, "pretty good" but in this case *why does it matter* I guarantee you, a grizzly will outrun me on my best if the victim is in a camp and stable, this does *not* matter. (any more than it did when he was healthy.) Once in a decent camp with some help in setting up a proper bear hang, it's not an issue.



Dear god. that's a sad commentry on the state of society down south that this would be even a consideration..



I agree completely with this.


I think there's another little modification with me. I hike now with a PLB. An ankle is not life threatening, so I'd probably be doing much like what is described, making he same decisions here.

I'll give you the "other" likely scenario I think, aside from the ankle - and that's the 55 year old "joe" - stopped and with chest pain. In this case, it comes out of my pack, and I press the button, and sit with joe and keep him calm waiting for SAR.

I think phat about has it nailed!

At age 74, I've only encountered auto accidents, never anything on the trail.

I will admit, the recent Oregon court case which basically overturned Oregon's "Good Samaritan" law gives one something to think about. I don't think I'd hesitate, though, if someone needed my help! I'll worry about the consequences later. On the other hand, I won't act beyond the parameters of my training. The case in question involved those with no first aid training at all moving an auto accident victim without first stabilizing his neck/spine.

Of course, according to the Oregon Motor Vehicle code, if we don't stop and "render aid," we're guilty of a felony. 'Tis a puzzlement!

Mouse
I guess I missed the clause where its a felony to not stop and render aid. The court case and the fact that you can't go beyond your training are in clear conflict, with this law. Hmm I'll have to look into the vehicle code. I would think if rendering aid is legally mandated even if you aren't qualified, that should be a defense for over stepping your ability. hmmm...

phat
see our discussion of liability, there are good reasons to not render aid, especially to a minor.
Jim

Mouse
Here is the Oregon law:
Render to any person injured in the accident reasonable assistance including the conveying or making arrangements for the conveying such person to a physician surgeon or hospital for medical or surgical treatment if it is apparent that such treatment in necessary or if such conveying is requested by any injured person. The next part say you have to remain at the scene unless you have to go to get help.

I cannot find anywhere in the code that requires someone coming along and seeing an accident to do anything unless they are a witness.

Interestingly the laws for hitting a domestic animal are very similar to those of hitting another car.

There is nowhere a requirement to render medical aid. You simply must try to get them aid, but only if you are the responsible driver.

A minor point, but in the patient Q&A, get his contact info and the name of his MD.

The sprain is the obvious injury. It would be worth while to do a head to toe survey to be sure he didn't crack a rib, ding his head, etc. in the course of the trip and fall. Multiple injuries are more common with longer falls than the usual sprained ankle, but you want to be sure. Poeple who catch a fall on their outstretched hands often ding their wrists.

The one serious accident that I did encounter while out on a pleasure hike did involve a very obvious head injury. I can't remember if we observed any leakage from the ear or nose, but I know we checked.