You and six other friends are on a 5-day high water trip on the Middle Fork of the Salmon River in Idaho. You have one paddle raft with five paddlers and some gear, a kayak, and a gear boat. It's the afternoon of day two when the paddle raft slams into a large hole and flips. Everyone is recovered safely with the next half mile. One of your friends managed to punch himself in the left eye with the T-grip of his paddle when the raft folded in the hole just before it flipped. He says his eye doesn't hurt (see photo).

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tired. One of your friends enters the hole for what she says is "the final time". Unfortunately she's a bit too tired and is unable to exit the hole before a raft lands on top of her; however, she did have the presence of mind to turn upside down before the raft landed on her. The raft exits the hole with her upside down kayak pinned under its floor. The bow of the kayak is sticking out the from under the side of the raft and members of the raft crew together with a couple of the kayakers attempt to free it. As they are working on the kayak your friend pops up slightly upstream of the raft coughing and gasping for air. She is quickly pulled into the raft by an attentive paddler.

It takes her about five minutes to stop coughing and speak normally. Although she is wearing a full drysuit she is actively shivering even after sitting in the sun for five minutes. As she is catching her breath she is cradling and supporting her right arm. After she regains her breath she is able to relate details of the entire event. She tells you that she turned over just the raft hit the bottom of her boat. She felt something in her shoulder tear and she couldn't use her right arm. With the raft on top of her kayak and her right shoulder not working properly, it took her a while to get out of her boat. She remembers breathing in some water as she surfaced. She says her shoulder hurts a lot (8); she is supporting the arm on her injured side with her elbow held about eight inches from that side and she unable to touch her opposite shoulder with the hand on her injured side.

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   “Go” and “standby” requests are usually made via a radio, cell phone, or satellite phone. Most aeromedical helicopters are dispatched directly from their base, by Search and Rescue (SAR) teams on the scene, or through local law enforcement (sheriff’s office). Rescuers should immediately request a helicopter to standby if they suspect a critical need; in most cases there is no charge for a standby request. Map or GPS coordinates insure that the pilot will find you. Each trip should have an Emergency Evacuation Plan (EAP) that describes what to do in the event of an emergency including phone numbers and locations of hospitals, SAR teams, etc. Many life-flight helicopter operations offer expedition or annual insurance plans that can save you thousands of $$$ should you require a heli-evacuation.
   Helicopters have limitations. Most fly under “Visual Flight Rules” (VFR) and require a minimum of 1/2 mile of visibility and a 500 foot ceiling during the day; the visibility minimum increases to 3 miles at night. Larger helicopters often have greater VFR minimums. Some helicopters, usually military, are equipped with specialized instruments that permit them to fly in more difficult conditions. Even with a helicopter en route to your scene, weather and air turbulence at the landing site could pose a significant problem and prevent landing. Never assume that a helicopter dispatched for you will arrive; always have a backup plan.
   While helicopters require less space than fixed wing aircraft to land, they have their limitations here too. A safe landing zone is flat and approximately 100 feet x 100 feet depending on the size of the helicopter. It should permit the chopper to land and take off into the wind; a light breeze is preferable to no wind, heavy wind, or gusts. At night use head lamps to illuminate the landing spot and any hazards. Rotors generate extremely high wind; hold down or anchor any loose gear. In below freezing conditions beware of windchill; exposed skin can freeze in moments. Direct everyone near the landing site to cover their eyes or look away. Most pilots circle the landing zone before landing. Avoid waving your hands above your head to attract attention; this is the universal “wave-off” signal that tells a pilot NOT to land. While it is helpful to know the hand signals used to guide a helicopter to a safe landing you do not need to know them; if possible contact and follow the pilot’s instructions via radio or phone. Once the helicopter has landed wait for the rotors to come to a FULL STOP. Continue to wait until you receive a clear signal from the pilot (or crew member) before approaching any helicopter. Stay within the pilot’s (or crew member’s) line of site and follow their directions. Do not smoke within 200 feet of any helicopter.

You and a small group of friends are on a late May rafting trip on the Main Salmon River in Idaho. The day time temperatures have been in the 40s and 50s with less sun than expected, lots of clouds, and occasional rain. The past few nights have been below freezing with a heavy layer of frost covering everything upon awakening. The water temperature is in the low 40s. Upon arrival at camp on day three of the five day trip one member, a 26 y/o male complains of cold, numbness, and achy pain in his feet. On examination you see (refer to photo). He says the pain started yesterday and has

 gotten worse throughout the day today. Your friend is the only person wearing sneakers and wool socks while on the water; the others are wearing thick wet suit booties.

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related to the type, location, and size of the compromised tissue. If the blocked artery services the specialized conduction cells that coordinate the pumping action of the heart, arrest occurs within seconds or minutes. If the blocked artery services the heart’s contractile fibers rather than its specialized conduction cells, the pumping action of the heart may be compromised. A reduction in the heart’s ability to pump blood efficiently may cause a back pressure in the pulmonary vessels and force fluid into the alveoli causing respiratory distress, fatigue, swelling in the hands and feet, indigestion and loss of appetite. Complete pump failure and arrest may develop if a significant amount of heart muscle has been injured and the heart cannot continue to meet the body’s demands for nutrients. Aspirin therapy increases the chance of survival, minimizes permanent damage, and improves recovery. The longer arrest is delayed the more likely the patient will survive without immediate hospital treatment. The following YouTube video shows the development of atherosclerosis and clot that cause a heart attack.

The classic signs and symptoms of a heart attack are non-traumatic chest pain or pressure often accompanied by respiratory distress, sweating, and pale skin. The pain may mimic indigestion and is typically described as pressure or squeezing. The pain may radiate to the patient’s neck or arms (classically the left arm but can be either arm or both); in women the pain often radiates to between or under the shoulder blades. The patient is weak and tired, often denying the possibility of a heart attack.

Aspirin is one of the best drugs available for treating heart disease due to atherosclrosis. The dose is 162-325 mg (2-4 baby aspirin) per day and can be administered by lay people in the field when a heart attack is suspected. Aspirin is an anti-platelet agent; it interferes with the clotting process and may be safely given with other blood thinning agents (clopidogrel, warfarin). While aspirin is a relatively "safe" drug there are a few instances when you absolutely don't want to use it:

1. When active bleeding is suspected. Epigastric pain due to a stomach ulcer can be difficult to differentiate from the substernal pain of a heart attack.
   
2. When the patient is allergic to aspirin.
3. When a stroke is suspected (it will increase bleeding).

Given the high incidence of atherosclrosis in today's world it makes good sense to carry a small bottle of chewable baby aspirin in your first aid kit when traveling with adults, especially those with a cardiac history. If you suspect a client, student, or friend is having a heart attack, limit their exercise — carry them if possible — and begin an urgent evacuation to the nearest hospital. If respiratory distress is present allow the patient to sit or support them in a sitting position during the evacuation. High flow oxygen is helpful during transport.

feet, into a fallen tree, and trapped under water against its branches. The rescue, although poorly conceived and extremely risky, was ultimately successful; however, the victim was recovered unresponsive with no pulse or respirations; and, her gear was lost. CPR was initiated and also successful; the patient recovered consciousness after 15 minutes with no memory of the event. One hour after the event she was warm, awake and alert with normal pulse and respirations, no spine pain or tenderness, and normal motor and sensor exams.

What were the administrative and site management errors, if any, that contributed to this incident? What are the patient's current and anticipated problems and what level of evacuation, if any, should be initiated? Click here to find out.

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As you approach, you ask him to stop struggling and then free him from his board, and stabilize his spine. After asking him to hold a trauma dressing to his forehead to stop the bleeding, you improvise a cervical collar using a SAM splint from your first aid kit and do your best to work with him to align his spine so you can move forward gathering his SAMPLE history. Joe tells you he feels sick and might vomit, can't move his right arm, and that both his right shoulder and wrist hurt. He estimates the pain in his shoulder is a three and his forearm a six. He confirms that he has no allergies, is not taking any medications, has indeed been drinking water and is not dehydrated (his urine was light yellow at the top of the run). He admits to having been hospitalized for a concussion a few years ago when he totaled his car. He tells you he didn't "black out" when he hit the tree and proceeds to describe his fall in detail.

Upon exam, his right forearm is tender and while he can move the fingers of his right hand, it hurts quite a lot and he is unable to hold onto a one liter water bottle due to the pain in his forearm. The laceration on his forehead has stopped bleeding and upon close inspection is more a scratch than a serious wound. His right shoulder is sore but he can move it without pain.

By now, twenty minutes have passed and his arm, although throbbing, doesn't hurt quite a much (3 on the 10 scale) as long as he supports it against his chest. He also says his nausea is gone and he feels better. His pulse is 68 and regular, his respirations 16 and easy, the skin on his face and hands is a bit pale and cool (it is cold out after all), and he is able to easily carry on a discussion with you regarding his injuries. He says his back doesn't hurt. While he is able to resist pressure applied to his ring and index finger equally on both hands, the fingers of his right hand are significantly weaker than those on his left even with his hand supported. His feet show no weakness when asked to push down or pull up. He has a no spine tenderness and no shooting or electric-like pain.

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history. No one else in the group is feeling poorly. His pulse is 72 & regular, his respirations are 18 and easy, his skin is pink, and warm, & dry, his oral temperature is 99.4º F.  A "heel drop" test is negative. You prudently decide to remain at the hut for the day to see if he gets better and to examine your evacuation options.

Three hours later he reports that he is nauseous and the pain is still getting worse and is now six on the ten pain scale. The pain has also localized to his lower right quadrant. Another abdominal exam reveals slight tenderness in his lower right quadrant. He reports a sharp pain when asked to stand on his toes and drop suddenly to his heels. His pulse is 80 & regular, his respirations are 20 and easy, his skin is pink, warm, & dry, and his oral temperature is 100.6º F.

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