Making the call after a fall |

Hunting and Wildlife Magazine - Issue 226 - Spring 2024

Words By: Simon Carkeek, PracMed NZ

During my time in service (New Zealand Defence Force) and subsequently as a private security contractor, there were many times when, due to injuries or simply because of medical events and conditions, I had to make a plan, an alternative plan, a contingency plan, and an emergency plan to either wait for quick reaction forces to arrive (if and when available) or decide to go. In some of these events, the added complexity of enemy actions in a contested environment added to the challenges that I faced.

As hunters, the challenge of a contested environment shouldn’t be an issue. However, let's not let that detract from the fact that most of us are not trained to navigate the challenges of our outdoor environment, nor do we have the medical knowledge or experience to make accurate decisions or understand casualty-survival expectations from the most common injury to claims lives in the outdoor recreational space - Falls from height. This is a situation that I've had to deal with on a number of occasions and I would like to pass on what I know.

Due to the nature of many hunts, falls from height are an inherent risk; razor-back ridge lines, step escarpments, or simply putting a foot wrong can result in life-threatening injuries and, as per the Mountain Safety Council's data, death. 

When looking at the potentially survivable injury profiles caused by falls, we must understand more about the situation. Any fall from standing or greater must be assessed and managed for the best possible outcomes.

The most common injuries that I have experienced and suffered myself are generally fairly manageable in a field setting. Long-bone fractures (arms and legs) are typically not life-threatening, with the exception of the femur, which, even when resulting in a closed fracture (bone still inside the skin), results in up to a 17% mortality rate as a stand-alone injury. This is due to internal bleeding when the fractured bone causes damage to the blood vessels of the upper leg, and the creation of a compartment that these blood vessels could bleed as much as 2 litres or more into.

Aside from the obvious deformation of the patient's limb and the pain response, the casualty will display the same signs and symptoms of blood loss (Hypovolemic shock) as someone who is bleeding externally. These are a decreased level of consciousness, pale skin, nausea/vomiting, cyanosis or blueing of the lips, skin or nail beds and extreme thirst.

The solution is to identify the problem - which is ultimately a blood loss issue - and address it. At this level, our only real option is to apply a tourniquet (we recommend the Tacmed Solution Special Operation Forces Tourniquet Gen. 5) above the injury site as you would for an external massive haemorrhage.

For all other long bone fractures, it is best to stabilise the casualty and, if you are competent and able to do so, weigh up the risks of extraction, splinting, and self-evacuation.

To simplify this further, for the upper limbs, if the casualty is still foot mobile and walking out is a safe option, then do so. This should be considered as the actual injury isn’t life-threatening. For the lower limbs, stabilisation and activating a Personal Locator Beacon (PLB) or sending for higher medical assistance/Search and Rescue is completely acceptable. 

But let’s take a deeper dive, particularly around the real danger of falls from height and head injury resulting in brain injury. There are four main general causes of brain injury: explosive force, blunt or penetrating trauma, rapid acceleration/deceleration and falls from height. With falls claiming more than 50% of the deaths in the wilderness, we must learn how this occurs so that quick and accurate decisions can be made, not only with the initial and ongoing care of the casualty, but also regarding when to make the call and activate the PLB.

The brain is a large and very vascular organ. In an average adult, approximately 750ml of blood flows through it every minute, which equates to about 15% of our total cardiac output. As with any other part of our anatomy, there are large vessels that branch and become smaller. Even these smaller vessels can become problematic if ruptured, due to the limited space inside the skull and the extreme sensitivity of the brain to changes in pressure within the skull.

The process of bleeding on the brain can be as mild as a so-called concussion, more accurately referred to as a mild traumatic brain injury (mTBI), or can lead to a haemorrhagic stroke or, in the worst case, the haemorrhage can cause swelling within the skull to the point that death can occur. The time associated with this is subjective and depends on the size of the affected vessel/s. However, it will also be significantly affected if the casualty is taking blood-thinning medications or has taken aspirin, which both reduce the chances of the affected blood vessel forming a clot and increases the chances of a life-threatening hematoma developing. This is why when someone presents at an emergency department for a head injury from a fall from height, they are kept for a minimum of 24 hours for observation so they are on hand for the fastest possible response if needed, which can be chemical or surgical intervention.

So, how do we know when an injury is serious enough to make that call to activate the PLB? For me, it’s KISS (keep it simple stupid) - for any head injury that involves a fall and subsequently immediately presents with one or more of the following it is a no-brainer (pun intended) to activate that PLB:

loss of consciousness

seizure

seeing stars

altered mental state

Or after the initial examination, progressively presents with:

dizziness

slurred speech

loss of motor function, paralysis or unilateral (one side) paralysis

headache that increases over time

vomiting

Sleepiness, or

presentation of pupils that are unequal in shape

So, what can we do?

In plain English, urgent evacuation to the nearest properly equipped medical facility that is capable of emergency procedures always gives the casualty the best chance of survival. However, on the ground, we can still have a positive impact on the outcome. As always, we must address massive bleeding. Without tank volume, you will not have a TBI to manage down the line. Care must be given here with managing fall injuries appropriately, depending on what kind of dressing we are using to control the bleeding. For example, if there is a skull fracture associated with the fall and we apply pressure, this will most likely increase the pressure inside the skull, exacerbating the situation. 

Training to dress head injuries with the equipment you carry should be an absolute before embarking on your hunt. Also, selecting the right style of bandage that is suitable for this task is important. This is why we favour the OLAES modular bandage, as it can be modified to provide a flat external dressing that minimises the risk of direct pressure into the skull itself. 

Now that the bleeding is managed, it’s time to prioritise the airway. Positioning is the key, and the stable side position, also known as the recovery position, is a great option as it keeps the casualty at ground level and protects the airway. In my experience, however, this can be easier said than done as head-injured patients can be aggressive and noncompliant - expect this and manage them with rationality and patience, as you would an intoxicated person. On the topic of alcohol, sometimes this can be incorrectly used as a pain reliever; please don’t do this as it will only increase the development of any hematoma and decrease the chances of a good outcome. The same can be said for the use of aspirin. 

At this point, our next step is to protect the casualty from hypothermia. This can be done concurrently with sleeping mats under them and hypothermia wraps or sleeping bags used to passively maintain and rewarm a patient after removing them from their wet clothing. Then the wait begins - time is never on your side. As mentioned earlier, the faster you make the decision to activate the PLB based on your knowledge of the situation, the clinical indicators and observations listed, the better the outcome will be.

To manage expectations, as time goes by, you may see a decrease in the level of consciousness, seizures/posturing (stiffening up), increased irritability/aggression and, unfortunately, death. If posturing occurs in the first 10-15 minutes, the probable outcome is death and there is absolutely nothing that could have been done to avoid this outcome. Again, I stress that this is subjective, and we do not write people off. We continue working for both their sake and ours in the aftermath, whether the result is positive or negative.

Hopefully, this article raises awareness of the seriousness of head injuries and elevates your confidence in responding appropriately if you encounter one. As always, prevention is significantly better than cure. Plan your mission, know your limits and don’t take risks; the price is too high. Good training in the management of cranial bleeding is very important. Our terrain is unforgiving, and our injury numbers obtained via the Mountain Safety Council (MSC) show that. Have fun in nature's playground/supermarket, but let's ensure that it stays fun and that we don’t contribute to those statistics.

Ad Salutem - To Save Lives. 

References

https://issuu.com/nzmountainsafetycouncil/docs/180529.msc.com.insights-awalkinthep

https://emedicine.medscape.com/article/824856-overview?form=fpf#a2

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5406181/