Deaths in the backcountry are rare, exactly how rare is up for debate. Much depends on how you define backcountry and where you get your numbers (outside of the National Park Service, accurate statistics are hard to find). That said, a few hundred people appear to die each year while recreating in the outdoors. Given the number of people who play outside annually, statistically, death is pretty rare. While the order often changes annually, the top ten causes of death in the backcountry appear to be:

1. Falls
2. Drowning
3. Avalanche
4. Heart Attack
5. Hypothermia
6. Heat Illnesses: heat stroke, exertional rhabdomyolysis, exertional hyponatremia (low sodium)
7. Lightning
8. Infectious disease (typically transmitted by biting insects)
9. Anaphylaxis
10. Wild animal attacks

So what should I do if I'm with a person who is dying?
There is no single answer that applies to all people other than support their process to the best of your ability. For many, this means holding their hand and simply being present. For some, it may include praying with or for them. If the person is awake, it may mean taking notes to share with relatives and friends. The specifics vary from individual to individual.

How do I know when a person is dead?
They will not have any signs of life: no pulse at their carotid artery, no chest rise, and no air coming from their mouth or nose. Over time their body will cool until it reaches the ambient air temperature and rigor mortis and liver mortis will set in.
Rigor Mortis: When energy is no longer being produced, muscles contract and stiffen beginning with the small muscles of the face, neck, arms, and shoulders and gradually encompassing larger muscles until the person's body is completely stiff. Rigor is typically fully set within eight hours and remains in place for roughly eighteen hours before reversing itself to pre-rigor status, starting with the large muscles.
Liver Mortis: When a person's blood stops circulating after death, gravity causes the red blood cells to settle leaving dark "bruising" in areas of the patient's body that are in contact with the ground. The process begins roughly thirty minutes after death and is fixed after approximately six hours.

What should I do after a person is dead?
Keep in mind that your first priority is yourself and the living members of your party. Make sure everyone is safe. Then, if possible, note the GPS coordinates of the body's location and notify the local authorities via radio, cell phone, satellite phone, or other communication device and follow their instructions. If the dead person was your patient, complete a SOAP note. If they were a client or student, also complete your program's accident/incident report form. Take pictures of the site and body, especially if the mechanism was trauma, and do your best to preserve the scene for the authorities; most states prohibit moving a dead body from the scene of the accident without the authority of the coroner. Of course, some scenes cannot be preserved due to weather or terrain. If you can't contact and receive direction from local authorities and find you must leave the scene, your photos become evidence and part of any subsequent investigation. If you decide to leave the scene and the body, do your best to protect the body from scavengers and clearly mark its location both visually and on a map. Although rare, some expeditions have decided to transport the body of the deceased out of the backcountry. Treat the body with respect and be sensitive to the cultural mores of the deceased and those around you.

You are en route to a backcountry lean-to managed by the forest service in the summer. Although the current temperature is in the low single digits after a cold front moved in early this afternoon, the weather yesterday was warm, above freezing, with bouts of hard rain. The snow is crusty and heavy on the forest road leading to the hut. You are two days from your car and it will take another day to reach the lean-to. You are carrying two weeks of supplies and hoping for new snow and fresh tracks after you reach the lean-to.
When you arrive at the forest service campground two of the shelters are occupied by a high school group who have been touring in the park the past week leaving an older, half-buried one for you and your friend. After setting up camp and eating dinner, you wander over to the high school group to say "Hi." They are starting to eat dinner when you arrive. The leader, one of the school's teachers, tells you much of their gear is frozen from yesterday's rain. You notice that a student is huddled in their sleeping bag in one of the shelters, everyone else is eating dinner. The group leader tells you the student, a 15-year-old female, was very cold when they arrived, immediately went to bed, and said she wasn't interested in dinner. While your gear is dry, you can see that many of the students' sleeping bags are frozen. The group leader is concerned about the drop in temperature and unsure how to keep the students warm at night.

What can you do to help? Click here to find out.

Deaths due to opioid overdoses continue to rise. Opioid abuse knows no age, race, or economic barriers; and, abuse is often hidden, making it difficult to know who is at risk for an overdose. In April 2018 U.S. Surgeon General, Dr. Jerome Adams, issued a public health advisory urging more Americans to learn to use and carry naloxone. Most states have approved Narcan® Nasal Spray for over the counter sales and publicly encourage addicts, family, and friends to carry it. Communities provide training and naloxone to police and place naloxone in public places with AEDs; some public health agencies provide it for free. Colleges and universities provide training and naloxone to staff and students. While still uncommon, opioid overdoses have occurred in wilderness settings. This begs the following questions:

1. Should I carry naloxone in my wilderness first aid kit? Answer: Maybe. It makes sense to carry naloxone if you use high dose opioids, or if you are a friend, family member, or person who comes into contact with people at risk for an opioid overdose. Theoretically, the list could include almost everyone; that said, the risk of encountering an opioid overdose is likely higher for ski patrollers, outdoor therapy/substance abuse staff, park rangers, campground hosts, etc. and anyone who attends a party where alcohol and drugs are likely to be present.
2. If so, how should I administer it? Answer: Narcan® Nasal Spray. While one ml vials and ampoules of naloxone are slightly less expensive than  Narcan® Nasal Spray, they require a prescription and take more training to use.
   

What are Opioids?
Heroin, morphine, codeine, and thebaine are naturally occurring opioids made from the resin of poppy plants; hydromorphone, hydrocodone, and oxycodone are derived from resin in a lab setting. Fentanyl, pethidine, levorphanol, methadone, tramadol, and dextropropoxyphene are synthetic. All opioids depress the central nervous system (CNS) and cause feelings of euphoria; when used correctly, for short periods of time, they are effective pain medicines. All are physiologically addictive. Chronic opioid users develop a tolerance for the drug and require increasingly higher doses to achieve the same level of pain control or well-being. (Note: Opioids are often mixed with other drugs for recreational purposes.) Withdrawal signs and symptoms are the result of excessive stimulus of the sympathetic nervous system and include: increased pulse rate and blood pressure, restlessness, tremors, sleeplessness, muscle and bone pain, abdominal pain, diarrhea, vomiting, sweating, and shivering; patients in acute withdrawal may become combative. As opioid tolerance increases so does dependence…and the severity of withdrawal S/Sx.

An opioid overdose typically occurs when someone takes a large amount of an opioid or a drug containing an opioid, mixes opioids with alcohol, or had a recent change in their level of tolerance. Life-threatening signs and symptoms of an opioid overdose include:

• decreased level of consciousness from drowsiness to unresponsiveness
• decreased pulse rate
• slow, irregular, or no respirations
• low blood pressure
• the person’s skin is often pale or cyanotic (blue-tinged) from the lack of oxygen in their blood

Death due to an opioid overdose is usually due to respiratory arrest and the subsequent lack of oxygen to vital organs as the central nervous system shuts down.

What is Naloxone?
Naloxone is an opioid antagonist; it binds with and blocks opioid receptor sites in the brain, reversing the signs and symptoms of an overdose. In order to be effective, naloxone must be given before the patient goes into cardiac arrest. Except in extremely rare cases when someone is allergic to naloxone, administering naloxone to a patient who is not suffering from an oipoid overdoese does no harm. Naloxone will not prevent deaths caused by other drugs: alcohol, speed, cocaine, or sedatives (e.g.: benzodiazepines like Xananx®, Valium®, etc.).

While there are numerous delivery methods only two are conducive to using in a remote setting: intranasal spray and intramuscular (IM) or subcutaneous (SQ) injection. Of the two, only Narcon® nasal spray is available over the counter in most states, making the choice easy for lay people, outdoor educators, and guides.

Naloxone delivered as a nasal spray or injection takes roughly 3-5 minutes to act. If there is no response after five minutes, give another dose. Naloxone is metabolized in the liver within 30-90 minutes and its metabolites excreted in the urine over the next 3-4 days. Because naloxone is metabolized faster than most opioids—especially long-acting opioids like methadone or sustained-release pain compounds—it’s vital to carry more than one dose. Patients should be monitored for 2-3 hours as further doses may be necessary to treat a relapse. Acute withdrawal symptoms are possible but rare with intranasal administration of naloxone but cause for concern should they occur as the the patient may become combative and a danger to themselves and others.  
Naloxone slowly loses its potency over time or if it is exposed to too much heat, cold, or sunlight. That said, using expired naloxone will not cause harm but you may need more doses to reverse the S/Sx of an opioid overdose. Ideally you should replace expired all expired drugs, and store naloxone in a dark and dry place between 80°F (25°C) and 40°F (5°C)...you want to make sure that it is easily accessible should you need it.

When should I administer naloxone?

• Give naloxone at as early as possible when an opioid overdose is suspected.
• If no response after five minutes, give another dose.
• If the patient’s breathing is slow, and they are cyanotic and obtunded (VPU), assist their breathing and give naloxone.
• If the patient is in respiratory arrest, begin rescue breathing and give naloxone.
• If the patient has no pulse and appears to be in cardiac arrest, begin CPR. Detecting a pulse in opioid overdose patients can be difficult and it may be reasonable to give naloxone based on the possibility that the patient is not in cardiac arrest (2015 AHA guidelines); note that naloxone alone will not reverse cardiac arrest.

You are a trip leader for a week-long snowshoe trip over winter break. You are responsible for a coed group of high school juniors and seniors; your assistant, Steve Hall, is a 38-year-old math teacher from the school with some outdoor experience. As you are setting up camp on the third day of the trip, you notice that Steve stops what he is doing to stretch and rub the left side of his lower back. When you ask him what's wrong, he says he thinks he strained it earlier in the day when helping one of the students put their pack on after a break. 

Forty-five minutes later as you are beginning to assist the students with dinner preparation, Steve says his back is hurting more and he needs to lie down. Roughly an hour later, dinner is ready and you send one of the students to get Steve. After a few minutes, the student comes running back saying Steve is curled on his side in his sleeping bag moaning in pain. You tell the students to start eating while you go and check on Steve.

You find Steve in curled his sleeping bag as reported by the student. He can barely talk through the pain. Gradually you come to understand that the pain started slowly on the left side of his lower back and, over time, began to move down into his groin and scrotal area. He has never experienced pain like this before; changing his position does nothing to relieve it. His history is unremarkable. At 5:48 p.m. Steve's vital signs are: pulse rate: 92 and regular, respiratory rate: not taken due to pain, blood pressure: not taken, skin: pale, cool, & slightly moist, core temperature, 98.4º F, AVPU: awake, alert, and in extreme pain.

What is wrong with Steve and what should you do? Click here to find out.

The progression from a local infection to septic shock typically requires weeks, and once diagnosed, the mortality rate is 25-50% during the following month. While the immune system in healthy adults is typically capable of dealing with the index infection, the immune system of infants, immunocompromised persons, and persons 65 years old and older, may not be.

In a wilderness environment where minor wounds are, unfortunately, all to common, thorough wound cleaning and subsequent monitoring are important. Local inflammation—mild pain and tenderness, redness, and warmth—are normal but should not extend more than a millimeter or two beyond the site. Increased inflammation and pus at the site after 24 hours indicate a local infection; red streaks and fever indicate a systemic infection.

MRSA thrives in crowded, unsanitary conditions and outbreaks have occurred in children’s camps and on expeditions where poor personal and group hygiene was the norm. Be aware that MRSA infections—Methicillin-Resistant Staphylococcus aureus—are highly contagious and can be acquired through contact with the contaminated clothing or the skin of an infected person. MRSA bacteria may enter the body at the site of a minor wound or present as swollen, painful bumps that resemble pimples or a spider bite. This may quickly turn into a painful abscess that requires surgical draining. A few cases will continue to progress to a systemic infection, and fewer still to sepsis.
Lower respiratory infections are also relatively common in the outdoors, especially on longer expeditions; fortunately most resolve with simple rest and fluids. That said, some, particularly those associated with a flu virus, may progress to a pneumonia. Symptoms of a pneumonia vary from mild to severe but typically include a dry or productive cough, fever, chills, fatigue, and respiratory distress. Some people experience a sharp or stabbing pain that gets worse with a deep breath or cough.
Urinary tract infections (UTI) are relatively common among females in the outdoors and are often linked to poor hygiene and/or chronic dehydration. Treatment with antibiotics is recommended to prevent the infection spreading to the kidneys and blood. Once active in the blood, sepsis is possible.
Travelers diarrhea caused by some strains of E. coli may lead to a systemic infection and sepsis, as can any intestinal infection that results in a perforated bowel: diverticulitis, appendicitis, ulcerative colitis, Crohn’s disease, strangulated hernia (which can result in poor blood flow to the intestines), peptic ulcers, etc. All require an urgent evacuation to a hospital for physician assessment and follow-up treatment; refer to the “Red Flag” signs and symptoms for an urgent—level 1 or 2—evacuation listed in our Wilderness Medicine Handbook.
Sepsis is rare on wilderness expeditions for a number of reasons:

• Sepsis rarely occurs in healthy adults with good personal and group hygiene. (Focusing on personal and group hygiene goes a long way to preventing the index infection.) That said, remember that the risk of sepsis from a local infection increases in immunocompromised individuals and patient’s greater than 65 years old, especially those in poor health.
• Patients with a local infection are typically evacuated early in the continuum in order to prevent a systemic infection; or if one already exists, starting a course of broad-spectrum antibiotics during the evacuation helps prevent the infection from worsening.

Sepsis S/Sx

• A probable or confirmed local skin, lung, GI or GU infection plus two of the following:
• Core temperature greater than 102º F (38.9º C) or below 96.8º F (36º C)
• A pulse rate greater than 90/min; a patient’s pulse rate increases roughly 10 beats/min for every degree increase in core temperature.
• A respiratory rater higher than 20/min; a patient’s respiratory rate increases roughly 2 beats/min for every degree increase in core temperature. (Breathing fast “blows off” carbon dioxide; lab results in a patient with sepsis will show low levels of blood CO2 (PaCO2 < 32; normal = 38-42).

White blood cell production increases in an effort to combat the infection by releasing nitrous oxide and cytokines and engaging in phagocytosis (cell eating). Nitrous oxide causes the blood vessels to dilate and increase the permeability of their walls leading to plasma leaks. And, as plasma leaks into tissue spaces, it takes oxygen longer to diffuse into individual cells. Cytokines are proteins that activate the patient’s cellular defenses and immune system. Pulse and respiratory rates increase in patients with a fever to increase oxygen delivery to tissues. The increased pulse rate also helps maintain the patient's blood pressure.

Severe Sepsis S/Sx
The S/Sx of Sepsis plus one of the following—which may indicate initial organ failure:

• Significantly decreased urine output indicates kidney failure. As kidneys fail, urine output drops and the kidneys are no longer able to clear toxins from the blood or balance blood pH. (In the hospital decreased urine output with fluid bolus via large-bore IVs indicate sepsis.)
• Abrupt change in mental status
• Respiratory distress indicates damage to the blood vessels in the patient's lungs.
• Irregular pulse or heart sounds indicate heart damage.
• Severe abdominal pain often indicates a perforation.

Septic Shock S/Sx

• S/Sx of Severe Sepsis plus a drop in blood pressure. (Initially, the patient’s pulse rate increases in an effort to maintain BP; however, if septic shock progresses and the heart is damaged, the pulse rate and blood pressure will drop. Death will ensue.)

You are leading the eighth pitch of a 12-pitch climb on chossy rock when your rope dislodges a small pillar of loose rock. Your belayer is hit on her helmet by a chunk of the falling rock the size of a baseball; the remaining fragments shatter into small shards. Janey is initially unresponsive but awakens quickly. Despite the generally poor quality of the rock on this pitch, you are able to construct a solid anchor and within a few minutes Janey is able to give you enough rope to rappel down to her belay stance. Careful not to dislodge any more rock, you head down. When you reach the belay station she is awake and alert with a cracked helmet; she cannot remember the rockfall or being hit. During the focused spine assessment she reports both pain (4/10) and tenderness in her neck around C-3, says her entire neck is stiff, and she doesn't want to move it; she passes all the motor and sensory exams. Aside from a few superficial scratches from small rock shards and a headache (3/10), she has no additional injuries. From the base of the climb it is an hour hike over third and fourth class terrain to your vehicle and another three hours to the hospital. There is no cell coverage and there is roughly four hours of light left. It's cool on the route, and you need a thin insulated shell to stay warm while climbing. Nighttime temperatures are expected to drop below freezing and a front is expected to arrive sometime tomorrow morning bringing wind, rain, and perhaps some snow.

What's wrong with Janey and what do you do? Click here to find out.