The following is from the 95 proceedings of NASAR 

WILDERNESS IMPROVISATION 
STEVE E. PEHRSON MD 

THE PROLONGED CARE MIND-SET: 

It is of critical importance that EMT's functioning in the prolonged care setting develop a feel for long term medical consequences. A significant aspect of wilderness EMS care involves the planning for anticipated problems that are likely to appear with time. Problems of prolonged care basically focus on three issues. The most obvious would be problems that arise as a consequence of progressive pathology. The second requires knowledge of environmental situations that may impact the various aspects of the patient's condition and care. But the third, more obscure and often not considered, is the consequences of previously rendered care. Thus an important aspect of prolonged prehospital care involves not only anticipating patient's needs as the medical condition progresses over time and the protection from environmental threat, but implementing treatment plans that prevent consequences of short term care principles that may be implemented correctly but allowed to exist beyond the time frame of patient safety. 

In wilderness prehospital care, the patient is denied timely access to the emergency department because of logistical or geographical isolation. That isolation does not change the patient's needs. The evolving concept in wilderness prehospital care is to bring emergency department care to the patient - as far as possible - within the limitations of provider capabilities and equipment availability. This concept places a significant burden of responsibility upon those who have accepted the role of extended care providers. You simply have to know more in the way of medical principles if you are going to practice safely in this environment. 

Conventional EMS education focuses on the patient management principles appropriate for a relatively brief patent care encounter. The world changes significantly when dealing with critically ill or injured patients when you may be the only care giver for several hours. Not only must you provide appropriate 
initial care, but you may well have to deal with the complications of your care. Needs traditionally managed in an institutional setting, and all of this while trying to manage the evacuation. This wilderness EMS stuff is not simple, nor is it easy. 

There are two general rules of wilderness medicine that need be emphasized. 

1. You will usually have more time than you would like. USE IT ! 

2. You will never have everything you need except time. IMPROVISE ! 

Improvisation is an art form based upon knowledge of fundamental principles. In the wilderness setting, knowledge is your most valuable piece of equipment. If you don't understand the needs of the patient you won't know what to improvise or even that you need too. It would be impossible for us to cover the vast amount of material and practical skills necessary to provide advanced medical care in the wilderness setting in the next four hours, or for that matter in the next four days. The scope of this presentation is to give you some fundamental prolonged care principles and then allow you to exercise your ingenuity to conceive some improvisational maneuvers. Like anything else, wilderness medical improvisation is limited only by your fundamental knowledge and ingenuity, and how many episodes of "McGuiver" you are able to remember. The key concept involves the understanding of general principles, then using what is available to manufacture an implement applicable to the principle needing attention. 

Improvisation begins with what you choose to carry in your medical kit, and the non-medical equipment on your person. In the typical backcountry situation, space and weight are prime considerations. Items that have can be utilized in a variety of situations should be sought after. Large medical items such as commercial splints, and bag-valve-mask devices usually are so cumbersome as to be nearly impractical. Items that can be used over and over are also intelligent choices. It seems that we often take for granted a nearly unlimited amount of gauze allowing us to sponge and dab and soak up things with impunity. This attitude works well in situations where you have an ambulance to carry boxes of the stuff, and you are only going to be sponging, dabbing, and soaking things up for 10 to 20 minutes. In the wilderness setting you may be sponging, dabbing, soaking and bandaging for hours. If your "one time use" supplies are used up quickly because of your ingrained street savvy, you'll quickly be left with no choice but to improvise. It is much easier to plan in advance for the more common emergencies you are likely to encounter and devise in your mind contingencies for management based upon your supplies/equipment and capabilities. 

Remember that life threatening injuries are likely to become life taking injuries in a wilderness setting. With rare exception, it is impossible to carry the equipment necessary to sustain a valid ACLS effort in a true wilderness setting. Additionally, a true life threatening ACLS situation will have died long before an equipped team could arrive on scene. It is therefore probably unreasonable to take up a lot of room in your kit with ACLS type equipment. The other side of this coin is the very real scenario of typically non- life threatening injuries becoming life threatening as 

1) the pathologic progression of injury evolves unchecked, 

2) environmental insult places additional stress on an already taxed situation, or 

3) initial interventions have become ineffective, harmful, or were inappropriate in the first place. 

Once you are placed behind the power curve in a prolonged care setting, you might just be along for a very long frustrating ride. You simply must know more and be able to apply some principles of medical reasoning if you are going to be able to maneuver out of some of these situations. You will never have enough of what you need except TIME. Your knowledge and ingenuity are your most important assets. 

SPECIFIC TECHNIQUES: 

WOUND MANAGEMENT 

One of the more problematic situations in any prehospital situation is wound care and the control of bleeding. I have been the personal witness of virtual miles of gauze being used primarily in an effort to soak up bleeding that was far from under control but exhibiting a valiant effort to hide the fact. Gauze is one of those single patient use items that is difficult to resurrect for additional uses but can certainly be expended rapidly. 

Lets consider the issue of sterility. Medical gauze is sterile so long as it's container is intact. This is a valuable characteristic, however it needs to be understood that there is no such thing as a sterile open wound found outside of the operating room ( and some would debate even that). If you place a sterile dressing on a non-sterile wound you do not mystically transfer sterility to the wound, but you do effectively contaminate the dressing. If you are putting a dressing on a wound for the purpose of hemostasis, or to simply hide it from your view, and the wound has not been disinfected, a "clean" material will work nicely. 

We're talking wilderness medicine here, so some of the rules are changed. The well trained WEMT is a master of hemostasis. First of all, blood is a fairly precious commodity that is always prudent to conserve. Secondly, the less lost to ground the easier to clean up. And thirdly, it makes it much easier to properly clean/irrigate/debride/disinfect a wound if you don't have a lot of blood in the way. If you are going to treat the wound appropriately in the field, meaning to clean the wound, then save your sterile dressing material for dressing the clean wound. Until then use a clean towel/cloth. I prefer to carry a couple of surgical towels in my kit specifically for this purpose (but they are often used for a multitude of other purposes). The other advantage to the towel idea is that they can be washed in the field and reused if necessary. 

Wound irrigation is essential if good wound care is to be accomplished in the field. Ideally, this is accomplished using a syringe and angiocath. Several field expedient methods have been described, but the basic principle is being able to deliver a forceful well directed stream of water into the wound. I have heard of people poking a hole in a plastic bag, in latex gloves, in other latex things, and even using one of those sun shower devices. For that matter, probably exposing the wound to a swift moving mountain stream would probably work much in the same way as it helps when you are gutting a fish. The important thing is that you flush as much foreign matter and bacteria as possible from the wound. 

Safety pins are a very light weight item with a multiplicity of uses. If you can find them, use the heavy blanket pins. The last ones I was able to find was through Campmor mail order. These pins, in particular, are heavy enough to be really used. Like most of the other items we have talked about, these have multiple applications, both medical and utility. Use your imagination. Here are some suggestions. 

1. Two safety pins used to pin the anterior tongue to the lower lip in situations where airway obstruction from the tongue in an unconscious patient is a problem. 

2. Neurosensory skin testing 

3. Removing slivers or other small imbedded foreign material in the skin. 

4. Relieving a subungual hematoma. 

5. Finger splint ( especially for mallet finger injuries ). 

6. Removing a corneal foreign body ( must anesthetize the eye first ) 

7. Making a sling and swath for shoulder and arm injuries. 

8. Pinning a wide strap around the chest to stabilize rib fractures. 

9. Draining abscess or blister. 

10. To puncture the plastic bag you are going to use to irrigate a wound with. 

11. Making improvised sun glasses 

12. Fishhook 

13. Replacing a broken zipper or securing a tear. 

14. Replace a lost screw in a pair of glasses. 

15. Unclogging a camping stove jet. 

16. Sewing needle ( use dental floss for thread ) 

I always carry a foley catheter in my kit. Other than acting as a urinary catheter it can function in a variety of ways. If you know the technique, it is used for the control of epistaxis. If you know the technique it can be used to remove a foreign body from the esophagus. It can be used to fashion a stethoscope. It can be used as a nasal airway. It can be used as a chest tube. It can replace broken tubing on your water filter. It can be used as a tourniquet. It can be used to siphon gas. You can make a sling shot out of it. And with a bit of imagination, there is probably several other things that can be contrived. 

l MEDICATIONS) 

For wilderness applications, medications should be considered in a similar way as equipment. Find medications that might serve multiple purposes. There are some very good OTC medications out there that have significant application in wilderness medicine. 

One word of caution; if you are using a medication you had best know everything about it that you can. If you cannot deal with the potential side effects or allergic reactions then you best not be giving it to someone else. 

Intermediate level EMT's in Utah have some good medications that can be used in a wilderness EMS situation IF they are functioning under medical control. If you give medications without medical control you are practicing medicine without a license. With the implementation of the new EMT - B curriculum, you can provide "patient assisted" medication administration in a couple of crucial situations. Again, realize that you are assuming some significant risk if functioning in a prolonged care situation. In the urban scenario, medication reactions hardly have a chance to develop before the patient is in the emergency department. Not so in the prolonged care situation. Here again you may have to deal with the consequences of your earlier interventions. If you don't know what to expect 30 to 60 minutes down the road after administering a medication, even with medical control backing, you may be in for a very emotionally traumatic education. The moral of the story, know what you are doing before you do it. 

I feel it is prudent to know some important aspects of some of the more useful medications available by "over the counter" means. But, such a topic could well be a lecture in and of itself, and is beyond the scope of this discussion. Suffice it to say know what to expect later from the medications you use now. 

ALL IN ALL, THE BASIC RULE IS; IF YOU ARE GOING TO BE ABLE TO IMPROVISE EFFECTIVELY, YOU MUST FIRST BE ABLE TO RECOGNIZE AND UNDERSTAND THE PROBLEM, THEN HAVE THE UNDERSTANDING OF THE FUNDAMENTALS OF HOW TO ADDRESS THE PROBLEM. THE KEY IS KNOWLEDGE. 

IF YOU WANT TO BE A "WILDERNESS" MEDIC YOU SIMPLY HAVE TO KNOW MORE. 

Edited for readability by RR