Thursday, November 4, 2021

Wilderness First Aid, & Kits Pt. III


Part One 

Part Two

This part will conclude the series, and we'll include our suggestion for a model Wilderness First Aid Kit at the end.

We pick up where we left off with Jim Baird's article for Field and Stream.

Sprained Ankle

Ankles will roll… This is one of the most common injuries in the outdoors, because of the uneven terrain in the backcountry. The chances of spraining an ankle increase with fatigue, slippery conditions, or when you’re carrying a heavy load. The typical treatment for a sprained ankle begins with the acronym R.I.C.E.S. 

Natzsofast, Guido. It's R.I.C.E., not R.I.C.E.S. 

Stabilization comes first, not last.

So let's helpfully fix that error.


  1.  This is particularly important for more severe ALL sprained ankles, because they're all potential fractures, plus all obvious fractures or dislocations, when bones aren't where they belong, because it’s hard to tell the difference between a bad sprain and a break, due to your lack of X-ray vision. Added pressure on a break could result in serious injury or a compound fracture in extreme situations. So, if things are bad you will have to get creative: Stabilize the injury by splinting the ankle with hiking poles, a snowshoe, or a foam ground pad. Also, take ibuprofen.

A sprained ankle can be a real challenge in the backcountry because it can destroy your means of transportation to get out. Fashioning crutches to assist with mobility may help, but if you can’t put any weight on your foot at all, you will have to consider other means of evacuation, such as an emergency air lift. Consider carrying an InReach messaging device for such situations.

You should carry a PLB, SatPhone, InReach, SpotMessenger, etc. for all excursions off the beaten path. Because with them, for a measley couple/few hundred bucks (and a subscription fee for messaging or SatPhone service) you could save your life, or someone else's. In any number of instances, not just a bad sprain/broken bone. We'll come back to that at the wrap-up. For now, back to sprains, dislocations, and fractures.

You should absolutely be able to construct your own orthopedic devices. Part of the passing grade for my wilderness medicine class (when Bush the Elder was president, btw) was constructing both a full-leg traction splint, and arm splint, and a working crutch from found items one might carry or add to what you already had in your backpacking/outdoor kit. For example:

50' of paracord, and about a dozen 12" x 3/4" sticks: one forearm splint

One walking stick, plus 2 eyebolts, a couple of nuts and washers, 20' of nylon line or paracord, and a hand towel: one fully functional full-leg traction splint, with stick windlass. 

Two ski poles, a stick, and 20' of paracord: One walking crutch.

So yes, learn to improvise.

Principles of stabilization

1. Stabilization means you immobilize the joint above the injury, and the joint below it. For example, if you break one or both of the bones in your lower arm, you'd have to immobilize both the elbow, and the wrist.

2. Splint it where it lies. Do your best not to move it around. If it's a fracture, jagged bone ends might lacerate a tendon, nerve, or blood vessels. The exception(s) would be if there's no circulation before you start (and if you don't set it better, the limb is going to die anyways). Or any deformity so wildly misplaced that failure to set it better will preclude any movement or further care. If someone can tolerate the movement, you're better off gently and carefully adjusting position when rescue is delayed, and getting it to a more anatomically correct position.

3. Whenever possible, let the victim self-splint. They know what hurts, and what feels best; assist them in this.

4. Improvisation is fun. Carrying a SAM splint is both faster, and smarter.

5. Pad bony prominences. Or else, you'll create new and bigger problems later on.

6. Check CSM (Circulation, Sensation, and Movement) before and after anything you do with injured joints and bones. If you had a pulse in the foot before you splinted it, but you can't find one afterwards, or it goes numb, or they can't move something they could move before, you f**ked up. Put things back, and work out what the trouble is. Make sure you haven't made it worse. Don't make it worse. 

7. Good stabilization usually feels better to the patient when you're done.

Now, let's go back to post-injury follow-up care:

Here’s a breakdown:

  1. Rest: To prevent further pain and injury, take some time to rest on the trail. An extra day or even a few hours to take take the stress off of the injury goes a long way.
  2. Ice: This helps reduce swelling, and reduced swelling promotes healing. Keep an instant cold pack or two in your first aid kit. Don’t have these? Place your foot in a cool stream or use snow if it’s available. Ideally, you want to be icing your ankle three to four times each day for about 20 minutes each time.
  3. Compression: Here’s where your elastic bandage comes in. The tightness helps reduce swelling and it adds additional support to the ankle. Wrap the bandage starting at the end of your foot and continue up above the ankle. Be careful to not make it too tight.
  4. Elevation: Rest your ankle above the height of your heart. This will restrict the blood flow enough to reduce swelling.

That's better. If you can, it's okay to dunk a probable sprain in snow, or cold water, for 20 minutes initially, then stabilize.

What else? We'll return to Mr. Baird first.

Final Thoughts on Wilderness First-Aid

Because help can be days away, wilderness first-aid can be more like second-aid in many cases. Being prepared with the proper first-aid kit is one thing—but you also need to have the skills and knowledge if you or someone in your group gets injured in the backcountry. The best motto to go by is: Plan for the worst and hope for the best. Having an exit strategy, carrying wilderness comms, and taking some basic wilderness first-aid training will go along way. Now get out there and enjoy the outdoors, but don’t forget your first-aid kit.

And if you follow what we wrote, rather than what was erroneously suggested in the article, you can avoid a lot of situations where you're doing Last Aid! And avoid making a bad situation even worse.

Learn how to splint anything and everything: hand and arm injuries, broken collarbone, ankle, knee, and hip injuries, as well as fingers and toes. Full explanations are beyond the scope of this post, or the referenced article, but if you know how to do it right, you can improvise it anywhere with minimal assistance or additional supplies. And reading a first aid book while your buddy's (or your own) knee swells up to the size of a cantaloupe isn't wise, nor practical. Learn before you go out to play. Practice what you learn.

The same is true of wilderness first aid in general. You can likely find a two-day weekend wilderness basic first aid class near you, and it should be taken by anyone who leaves paved roads for longer than 5 minutes. Stuff happens fast, and the further you are from cell phone coverage, the greater the odds you'll need the knowledge, sooner or later. Mr. Murphy is a cold-hearted SOB about that.

So, about that Wilderness First Aid Kit...

First, take as much first aid gear as you can get away with, without going full retard.

If you're on a cabin cruiser, or in any motor vehicle, a full M17 bag and even a floating backboard wouldn't be problematic.

For a group on a weekend or multiple days' trip, the standard No. 3 CLS bag is reasonable.

FWIW, when I ventured afield with anyone more than just me, that was the minimum kit I would tote, and for days on end. Good enough for Army medics and Navy corpsmen to tend to a whole platoon; good enough for me. It was the same jump bag I used to take care of 100+ person movie crews in town and out in the boondocks, and 90% of what I needed fits inside it.

Ski patrollers and hiking groups have used an ordinary fanny pack for the same purpose.

If it's just you on a day-trip for fishing, hunting, hiking, or whatnot, the minimum I'd consider would be an IFAK-size bag. 

Just remember the opening lyrics of The Ballad Of Gilligan's Isle: "...a three hour tour, a three hour tour...". Best laid plans, and all that. And from back when they were single-sex, the Boy Scouts' Motto: Be Prepared.

So, what to put/keep in it?

The article links to another Filed and Stream article, where they provide a suggested wilderness kit. FTR, theirs is IFAK-sized.

We'll start there:

1. Tourniquets, Chest Seals, Compression Gauze

Clever readers will note a trend here. Enough said.

2. CPR mask

A big, fat "Meh" to that. How far are you from help? How long can you do CPR? Unless this is for a trip to the zoo, a CPR mask probably isn't going to do much good if you need it for more than 10-15 minutes. An hour, tops. The exceptions would be for cold-water immersion, where you could get back to shore inside half an hour. Or a near-miss lightning strike. Farther from definitive care than that hour, and you'd be better served with a priest's stole, and a small New Testament. Sorry, but that's the reality. People who died tend to stay dead. If you're 5 minutes from paramedics with cardiac drugs and a defibrillator, ROWYBS, you may save a life. If you're a two hour hike cross the desert to the trailhead and cell-phone coverage? Yeah, no. Do what your conscience dictates, but don't expect miracles. If space or weight is a concern, I probably wouldn't bother with this if we were talking far afield. This is also why any version of defibrillator is probably a waste of time, except on a cabin cruiser or RV. NOT on a wilderness trip. ER more than an hour away? Fuggedaboudit. Ruby Slippers would be more useful, if you needed it.

3. Trauma shears

Hell, YES! Use 'em every night, for 25 years. The key here: good quality ones, kept razor sharp. In a good leather or nylon holster.

4. Sterile eyewash

Hell yes! It doubles as wound wash. If you can put it in your eyes safely, you can put it in an open wound safely.

5. Mylar Emergency blanket

That should be in your pack already, but it doesn't take much space in a first aid kit, for preventing shock, blocking wind for treating frostbite, making shade for heat casualties, and signaling for help, among other uses. I'd keep one of the cheap folded ones, and get a better one mounted to a sturdy tarp with eyelets and paracord ties on the corners, to keep in my pack.

6. Bandages: Band-aids, butterfly bandages, etc.

Duh. All you can fit. Then more. Realize heat and time inactivates the sticky. Rotate and replace regularly, and more frequently if the kit lives in a hot car/car trunk.

7. Moleskin

Absolutely. Sheets and sheets of it. Spenco Second Skin too.

8. Medications

Your personal Rx ones, marked and kept separate. 

And aspirin, Tylenol, ibuprofen, Benadryl, Sudafed, Tums, Immodium, Pepcid, hydrocortisone cream, Bactine, povidone iodine, Neo- or Poly-sporin or bacitracin. Throat lozenges, cough drops, and any other snivel meds you want, because it's stupid to suffer needlessly. That's not hardcore tough, it's just dumb. 

(Sunscreen - SPF 15 or better; lip balm; bleach; and water purification tabs should already be in your pack, somewhere. Possibly zinc oxide too. And for the women, any necessary feminine hygiene supplies. If not, you're wrong. Fix that.) 

Maybe Silvadene, if you can get it.

Learn when, why, why not, how much, how often, and precautions for all of the above meds. No exceptions. No excuses. If possible, obtain unit dose (1-2 pill) packages. Watch expiration dates. Rotate out as necessary. If you won't do that, leave it all behind. Or you're going to kill someone, and I will so testify in court for the prosecution.

Times X people.

Times X days.

Plus some cushion. (IOW, if you're going out for 3 days, you should have 10 days' of your cardiac and BP meds, or diabetic supplies. For rather obvious reasons.)

E.g., if you don't have enough Immodium for everyone in the party to get through a group-wide case of the Traveller's Two-Step, you're doing it wrong.

9. Tweezers

And a headlamp. And a magnifier.

10. Cell phone. SATPhone or PLB or SARSAT Messenger or All Of The Above.

Fixed it for ya. A cell phone has a very limited range, and life. But if you're close enough to use it, sure. A PLB talks to space, FFS, and will get you rescued in the middle of the ocean or the Arctic tundra. You decide how much your @$$ is worth. With any of the above, I'd get my hands on a solar panel and hand-crank charging/recharging gizmo. Endless battery life for lifesaving comm gear? Count me in. And BTW: PLBs are designed to work by pressing one button, while floating in the ocean in a life jacket, in a storm. Cell phones aren't. Choose wisely.

BTW, there's damned few places you can't hit a passing 737 overhead on 121.5Mhz with a MAYDAY from a handheld VHF transceiver. The FAA may get pissy for a bit, but life and death emergencies (not "I'm lost and I ran out of trail mix and Twinkies") are absolute excuses to judiciously encroach on the benevolence of commercial air transport pilots to relay a message to SAR. And either way, the food is better in federal lockup waiting for bail than it is starving to death at the bottom of a canyon with a broken leg, fending off wolves or coyotes with a flaming stick. Do what you think is prudent. Judges and juries aren't completely stupid about such things. It's an option in the bag of tricks I'd leave open to consideration.

11. Bag (to keep it in).

We kind of covered that, above. Sturdy non-mil CLS bags can be had in OD green, tan, and black with minimal hassle. Also red, blue, and orange.

And of the stuff Baird added?

  • Blister Foam MEH. PROBABLY NOT.
  • Orthopedic Felt NOPE
  • Small Scissors DEFINITELY YES
  • Gel Toe Sleeves OPTIONAL
  • Scalpel, Pin, or Needle (for popping a blister) YES

We would add:

12. SAM splint

13. Stethoscope

14. BP cuff

15. Pulse oximeter

16. Dressings: 2x2s, 4x4s, ABDs, eye dressing(s)

17. Bandages: Kerlix, ACE wrap(s)

We would skip:

Chemical ice packs:

They die in your bag, unless you put it in that day, and they're only good for 10-15 minutes.

Heat packs:

Same reason, unless you're summiting in the mountains, in which case they should probably be in your pack and jacket pockets, not your FA kit

Any nonsensically-carried field suture or surgery kits, skin staplers, and other nonsense.

IVs, start kits, tubing, saline or any other bags, etc.

99% of prescription meds not my own, unless you're talking a Zombie Apocalypse Wilderness Medical Kit. If it's that, I get Darryl on my team, right off. Just saying.

Pretty much anything related to CPR for any trip more than an hour from civilization. Some things, you can't fix, and you're kidding yourself if you think otherwise. (Don't believe me though. get or borrow a CPR mannikin. See how long you, personally, can do one-person CPR, with compressions and ventilations, best case. That's your distance limit.) It's a futile effort for all but an infinitessimally small handful of cases, like cold-water drowning, nearby lightning strikes, etc. Let your conscience be your guide. CPR mask in my car? Sure. In my kit for an eight-day yomp across Yosemite at 8000'-10,000'? Nope.

Don't put anything in your kit you don't know how to use.

Things That You Should Already Have Managed To Include:

The Ten Essentials

Because you're not stupid.

And BTW, this whole first aid kit? It's #4. So you're already 10% good-to-go.

Things That A Kit Will Not Help

You, or anyone else, if you don't get properly trained in how to use everything in it, and when, and then practice doing it.

You, or anyone else, if the kit's at the back of your closet instead of on you, or with you.

BTW, you're far more likely to use it at the side of the road, after you get to the accident (or, are perhaps part of it). If you never learned how to use it, and/or it's sitting in your pack at home, it's worthless. And hey, remember what I said about practice? Being a Good Samaritan counts for that.

Get your kit. Learn your kit. Carry your kit. 

And hopefully, only use it on strangers, rather than friends, relatives, or yourself.

But being prepared for all of the above already puts you halfway there.

[And note to Field and Stream, and any 20 other outdoor publications, if you ever see this: 

FFS, find someone who can find their @$$ without needing both hands, a mirror, a map and compass, and an anatomical chart, and stop getting layman to half-@$$ this topic. There are just over 1,000,000 doctors and 2,000,000 nurses in the U.S., besides P.As and paramedics, and a goodly number of them boat, sail, hike, fish, hunt, and generally recreate in the vast outdoors. Many of them are not only subject-matter experts in wilderness medicine, they can actually write articles cogently and with professional expertise, and they'd love to help you out here. Survive for three months on Vancouver island with just my brother? Jim Baird's the guy for that story, absolutely. Treat a serious injury? Not so much. I yell because I care. - A.]


  1. Danchenko did not kill himself.

    Watch moderna...


  2. Good stuff. Yes on vitals and vital trending. Burn vics go super hot to super cold before that sterile water hits the ground. Something we added to every truck. Mega movers ones with the backboard pockets.

  3. Excellent Post. I like this first-aid mnemonic: SRIRACHA

    Sleep in. You're hurt.
    Recliner. It's downstairs.
    Ice. For a cool beverage.
    Remote. Have Pugsley find it.
    Ask again. He had it last.
    Curb Your Enthusiasm. There's a new episode.
    Have a nap. Larry David would.
    Ask The Mrs. what's for dinner.

    (seriously, though, great posts)

  4. Penny for your thoughts on the Water Jel burn treatment pre-treated bandages and such for localized burn treatment?

  5. No charge. Go read the comments on Pt I.