First Aid Issues and the Appalachian Trail
Hikers encounter a wide variety of terrain and climatic conditions along the Appalachian Trail. Prepare for the possibility of injuries. Some of the more common Trail-related medical problems are briefly discussed below.
Preparation is key to a safe trip. If possible, every hiker should take the free courses in advanced first aid and cardiopulmonary-resuscitation (CPR) techniques offered in most communities by the American Red Cross.
Even without this training, you can be prepared for accidents. Emergency situations can develop. Analyses of serious accidents have shown that a substantial number originate at home, in the planning stage of the trip. Think about communications. Have you informed your relatives and friends about your expedition: locations, schedule, and time of return? Has all of your equipment been carefully checked? Considering the season and altitude, have you provided for water, food, and shelter?
While hiking, set your own comfortable pace. If you are injured or lost or a storm strikes, stop. Remember, your brain is your most important survival tool. Inattention can start a chain of events leading to disaster.
If an accident occurs, treat the injury first. If outside help is needed, at least one person should stay with the injured hiker. Two people should go for help and carry with them notes on the exact location of the accident, what has been done to aid the injured hiker, and what help is needed.
The injured will need encouragement, assurances of help, and confidence in your competence. Treat him gently. Keep him supine, warm, and quiet. Protect him from the weather with insulation below and above him. Examine him carefully, noting all possible injuries.
Back or neck injuries: Immobilize the victim’s entire body, where he lies. Protect head and neck from movement if the neck is injured, and treat as a fracture. Transportation must be on a rigid frame, such as a litter or a door. The spinal cord could be severed by inexpert handling. This type of injury must be handled by a large group of experienced personnel. Obtain outside help.
Bleeding: Stop the flow of blood by using a method appropriate to the amount and type of bleeding. Exerting pressure over the wound with the fingers, with or without a dressing, may be sufficient. Minor arterial bleeding can be controlled with local pressure and bandaging. Major arterial bleeding might require compressing an artery against a bone to stop the flow of blood. Elevate the arm or legs above the heart. To stop bleeding from an artery in the leg, place a hand in the groin, and press toward the inside of the leg. Stop arterial bleeding from an arm by placing a hand between the armpit and elbow and pressing toward the inside of the arm.
Apply a tourniquet only if you are unable to control severe bleeding by pressure and elevation. Warning: This method should be used only when the limb will be lost anyway. Once applied, a tourniquet should only be removed by medical personnel equipped to stop the bleeding by other means and to restore lost blood. The tourniquet should be located between the wound and the heart. If there is a traumatic amputation (loss of hand, leg, or foot), place the tourniquet two inches above the amputation.
Blisters: Good boot fit, without points of irritation or pressure, should be proven before a hike. Always keep feet dry while hiking. Prevent blisters by responding early to any discomfort. Place adhesive tape or moleskin over areas of developing redness or soreness. If irritation can be relieved, allow blister fluid to be reabsorbed. If a blister forms and continued irritation makes draining it necessary, wash the area with soap and water, and prick the edge of the blister with a needle that has been sterilized by the flame of a match. Bandage with a sterile gauze pad and moleskin.
Dislocation of a leg or arm joint is extremely painful. Do not try to put it back in place. Immobilize the entire limb with splints in the position it is found.
Exhaustion is caused by inadequate food consumption, dehydration and salt deficiency, overexertion, or all three. The victim may lose motivation, slow down, gasp for air, complain of weakness, dizziness, nausea, or headache. Treat by feeding, especially carbohydrates. Slowly replace lost water (normal fluid intake should be two to four quarts per day). Give salt dissolved in water (one teaspoon per cup). In the case of overexertion, rest is essential.
Fractures of legs, ankles, or arms must be splinted before moving the victim. After treating wounds, use any available material that will offer firm support, such as tree branches or boards. Pad each side of the arm or leg with soft material, supporting and immobilizing the joints above and below the injury. Bind the splints together with strips of cloth.
Shock should be expected after all injuries. It is a potentially fatal depression of bodily functions that is made more critical with improper handling, cold, fatigue, and anxiety. Relieve the pain as quickly as possible. Do not administer aspirin if severe bleeding is present; Ibuprofen or other nonaspirin pain relievers are safe to give.
Look for nausea, paleness, trembling, sweating, or thirst. Lay the hiker flat on his back, and raise his feet slightly, or position him, if he can be safely moved, so his head is down the slope. Protect him from the wind, and keep him as warm as possible. A campfire will help.
Sprains: Look or feel for soreness or swelling. Bandage, and treat as a fracture. Cool and raise the joint.
Wounds (except eye wounds) should be cleaned with soap and water. If possible, apply a clean dressing to protect the wound from further contamination.
Exposure to extremely high temperatures, high humidity, and direct sunlight can cause health problems.
Heat cramps are usually caused by strenuous activity in high heat and humidity, when sweating depletes salt levels in blood and tissues. Symptoms are intermittent cramps in legs and the abdominal wall and painful spasms of muscles. Pupils of eyes may dilate with each spasm. The skin becomes cold and clammy. Treat with rest and salt dissolved in water (one teaspoon of salt per glass).
Heat exhaustion, caused by physical exercise during prolonged exposure to heat, is a breakdown of the body’s heat-regulating system. The circulatory system is disrupted, reducing the supply of blood to vital organs such as the brain, heart, and lungs. The victim can have heat cramps and sweat heavily. His skin is moist and cold; his face flushed, then pale. His pulse can be unsteady and blood pressure low. He may vomit and be delirious. Place the victim in shade, flat on his back, with feet 8 to 12 inches higher than his head. Give him sips of salt water—half a glass every 15 minutes—for about an hour. Loosen his clothes. Apply cold cloths.
Heat stroke and sun stroke are caused by the failure of the heat-regulating system to cool the body by sweating. They are emergency, life-threatening conditions. Body temperature can rise to 106 degrees or higher. Symptoms include weakness, nausea, headache, heat cramps, exhaustion, body temperature rising rapidly, pounding pulse, and high blood pressure. The victim may be delirious or comatose. Sweating will stop before heat stroke becomes apparent. Armpits may be dry and skin flushed and pink, then turning ashen or purple in later stages. Move victim to a cool place immediately. Cool the body in any way possible (e.g., sponging). Body temperature must be regulated artificially from outside the body until the heat-regulating system can be rebalanced. Be careful not to overchill once temperature goes below 102 degrees.
Heat weakness causes fatigue, headache, mental and physical inefficiency, heavy sweating, high pulse rate, and general weakness. Drink plenty of water, find as cool a spot as possible, keep quiet, and replenish salt loss.
Sunburn causes redness of the skin, discoloration, swelling, and pain. It occurs rapidly and can be severe at higher elevations. It can be prevented by applying a commercial sun screen; zinc oxide is the most effective. Protect from further exposure and cover the area with ointment and a dressing. Give the victim large amounts of fluids.
Every hiker should be familiar with the symptoms, treatment, and methods of preventing the common and sometimes fatal condition of hypothermia. Wind chill and/or body wetness, particularly aggravated by fatigue and hunger, can rapidly drain body heat to dangerously low levels. This often occurs at temperatures well above freezing. Shivering, lethargy, mental slowing, and confusion are early symptoms of hypothermia, which can begin without the victim’s realizing it and, if untreated, can lead to death.
Always keep dry, spare clothing and a water-repellent windbreaker in your pack, and wear a hat in chilling weather. Wet clothing loses much of its insulating value, although wet wool is warmer than other wet fabrics. Always, when in chilling conditions, suspect the onset of hypothermia.
To treat this potentially fatal condition, immediately seek shelter, and warm the entire body, preferably by placing it in a sleeping bag and administering warm liquids to the victim. The close proximity of another person’s body heat may aid in warming.
A sign of frostbite is grayish or waxy, yellow-white spots on the skin. The frozen area will be numb. To thaw, warm the frozen part by direct contact with bare flesh. When first frozen, a cheek, nose, or chin often can be thawed by covering it with a hand taken from a warm glove. Superficially frostbitten hands sometimes can be thawed by placing them under armpits, on the stomach, or between the thighs. With a partner, feet can be treated similarly. Do not rub frozen flesh.
Frozen layers of deeper tissue beneath the skin are characterized by a solid, "woody" feeling and an inability to move the flesh over bony prominences. Tissue loss is minimized by rapid rewarming of the area in water slightly below 105 degrees Fahrenheit (measure accurately with a thermometer).
Thawing of a frozen foot should not be attempted until the patient has been evacuated to a place where rapid, controlled thawing can take place. Walking on a frozen foot is entirely possible and does not cause increased damage. Walking after thawing is impossible.
Never rewarm over a stove or fire. This "cooks" flesh and results in extensive loss of tissue.
Treatment of a deep freezing injury after rewarming must be done in a hospital.
Artificial respiration might be required when an obstruction constricts the air passages or after respiratory failure caused by air being depleted of oxygen, such as after electrocution, by drowning, or because of toxic gases in the air. Quick action is necessary if the victim
’s lips, fingernail beds, or tongue have become blue, if he is unconscious, or if the pupils of his eyes become enlarged.
If food or a foreign body is lodged in the air passage and coughing is ineffective, try to remove it with the fingers. If the foreign body is inaccessible, grasp the victim from behind, and with one hand hold the opposite wrist just below the breastbone. Squeeze rapidly and firmly, expelling air forcibly from the lungs to expel the foreign body. Repeat this maneuver two to three times, if necessary.
If breathing stops, administer artificial respiration, since air can be forced around the obstruction into the lungs. The mouth-to-mouth, or mouth-to-nose, method of forcing air into the victim’s lungs should be used. The preferred method, protecting yourself with a mask or other cloth barrier, is:
1. Clear the victim’s mouth of any obstructions.
2. Place one hand under the victim’s neck, and lift.
3. Place heel of the other hand on the forehead, and tilt head backwards. (Maintain this position during procedure.) Use thumb and index finger to pinch nostrils.
4. Open your mouth, and make a seal with it over the victim’s mouth. If the victim is a small child, cover both the nose and the mouth.
5. Breathe deeply, and blow out about every five seconds, or 12 breaths a minute.
6. Watch the victim’s chest for expansion.
7. Listen for exhalation.
Poison ivy is the most common plant found along the Trail that irritates the skin. It is most often found as a vine trailing near the ground or climbing on fences or trees, sometimes up to 20 feet from the ground. A less common variety that is often unrecognized is an erect shrub, standing alone and unsupported, up to 10 feet tall.
The leaves are in clusters of three, the end leaf with a longer stalk and pointed tip, light green in spring but darkening as the weeks pass. The inconspicuous flowers are greenish; the berries, white or cream. The irritating oil is in all parts of the plant, even in dead plants, and is carried in the smoke of burning plants. Those who believe themselves immune may find that they are seriously susceptible if the concentration is great enough or the toxins are ingested.
If you have touched poison ivy, wash immediately with strong soap (but not with one containing added oil). If a rash develops in the next day or so, treat it with calamine lotion or Solarcaine. Do not scratch. If blisters become serious or the rash spreads to the eyes, see a doctor.
Lyme disease is contracted from bites of certain infected ticks. Hikers should be aware of the symptoms and monitor themselves and their partners for signs of the disease. When treated early, Lyme disease can usually be cured with antibiotics. (Its occurrence is greater along the northern mid-Atlantic areas of the Trail than in the sections covered by this guide.)
Inspect yourself for ticks and tick bites at the end of each day. The four types of ticks known to spread Lyme disease are smaller than the dog tick, about the size of a pin head, and not easily seen. They are often called "deer ticks" because they feed during one stage of their life cycle on deer, a host for the disease.
The early signs of a tick bite infected with Lyme disease are a red spot with a white center that enlarges and spreads, severe fatigue, chills, headaches, muscle aches, fever, malaise, and a stiff neck. However, one-quarter of all people with an infected tick-bite show none of the early symptoms.
Later effects of the disease, which may not appear for months or years, are severe fatigue, dizziness, shortness of breath, cardiac irregularities, memory and concentration problems, facial paralysis, meningitis, shooting pains in the arms and legs, and other symptoms resembling multiple sclerosis, brain tumors, stroke, alcoholism, depression, Alzheimer’s disease, and anorexia nervosa.
It is not believed people can build a lasting immunity to Lyme disease, but vaccines are being worked on. A hiker who has contracted and been treated for the disease should still take precautions.
The Trail community learned in the fall of 1994 that—18 months earlier—an A.T. thru-hiker had contracted a form of the deadly hantavirus about the same time the infection was in the news because of outbreaks in the Four Corners area of the Southwest. After a month-long hospitalization, he recovered fully and came back to the A.T. in 1995 to finish his hike.
Federal and state health authorities are still not certain but surmise that the hiker picked up the airborne virus somewhere in Virginia. (The virus travels from an infected deer mouse, characterized by its white belly, through its evaporating urine, nesting materials, droppings, and saliva into the air.)
Hantavirus is extremely rare and difficult to "catch." Prevention measures are relatively simple: Air out a closed, mice-infested structure for an hour before occupying it; don’t pitch tents or place sleeping bags in areas in proximity to rodent droppings or burrows or near areas that may shelter rodents or provide food for them. Don’t sleep on the bare ground, use a mat or tent with a floor or ground cloth; in shelters, ensure that the sleeping surface is at least 12 inches above the ground. Don’t handle or play with any mice that show up at the campsite, even if they appear friendly; treat your water; wash your hands if you think you have handled droppings.
Although the odds of being struck by lightning are low, 200 to 400 people a year are killed by lightning in the United States. Respect the force of lightning, and seek appropriate shelter during a storm.
Do not start a hike if thunderstorms are likely. If caught in a storm, immediately find shelter. Large buildings are best; tents offer no protection. When indoors, stay away from windows, open doors, fireplaces, and large metal objects. Do not hold a potential lightning rod, such as a fishing pole. Avoid tall structures, such as flagpoles, fire towers, powerline towers, and the tallest trees or hilltops. If you cannot enter a building, take shelter in a stand of smaller trees. Avoid clearings. If caught in the open, crouch down, or roll into a ball. If you are in water, get out. Spread out groups, so that everyone is not struck by a single bolt.
If a person is struck by lightning or splashed by a charge hitting a nearby object, the victim will probably be thrown, perhaps a great distance. Clothes can be burned or torn. Metal objects (such as belt buckles) may be hot, and shoes blown off. The victim often has severe muscle contractions (which can cause breathing difficulties), confusion, and temporary blindness or deafness. In more severe cases, the victim may have feathered or sunburst patterns of burns over the skin or ruptured eardrums. He may lose consciousness or breathe irregularly. Occasionally, victims stop breathing and suffer cardiac arrest.
If someone is struck by lightning, perform artificial respiration (see pages 15 and 16 ) and CPR until emergency technicians arrive or you can transport the injured to a hospital. Lightning victims may be unable to breathe independently for 15 to 30 minutes but can recover quickly once they can breathe on their own. Do not give up early; a seemingly lifeless individual can be saved if you breathe for him promptly after the strike.
Assume that the victim was thrown a great distance; protect the spine, treat other injuries, then transport him to the hospital.
Reports of bites are extremely rare, but hikers on the Appalachian Trail may encounter copperheads and rattlesnakes on their journeys. These are pit vipers, characterized by triangular heads, vertical elliptical pupils, two or fewer hinged fangs on the front part of the jaw (fangs are replaced every six to 10 weeks), heat-sensory facial pits on the sides of the head, and a single row of scales on the underbelly by the tail. Rattlesnakes have rattles on the tail.
The best way to avoid being bitten by snakes is to avoid their known habitats and reaching into dark areas (use a walking stick to move suspicious objects). Wear protective clothing, especially on feet and lower legs. Do not hike alone or at night in snake territory; always have a flashlight and walking stick. If you see a snake, walk away; you can outdistance it in three steps. Do not handle snakes. A dead snake can bite and envenomate you with a reflex action for 20 to 60 minutes after its death.
Not all snakebites result in envenomation, even if the snake is poisonous. The signs of envenomation are one or more fang marks (in addition to rows of teeth marks), burning pain, and swelling at the bite (swelling usually begins within five to 10 minutes of envenomation and can become very severe). Lips, face, and scalp may tingle and become numb 30 to 60 minutes after the bite. (If those symptoms are immediate and the victim is frightened and excited, then they are most likely due to hyperventilation or shock.) Thirty to 90 minutes after the bite, the victim’s eyes and mouth may twitch, and he may have a rubbery or metallic taste in his mouth. He may sweat, experience weakness, nausea, and vomiting, or faint one to two hours after the bite. Bruising at the bite usually begins within two to three hours, and large blood blisters may develop within six to 10 hours. The victim may have difficulty breathing, have bloody urine, vomit blood, and collapse six to 12 hours after the bite.
If someone you are with has been bitten by a snake, act quickly. The definitive treatment for snake-venom poisoning is the proper administration of antivenom.
Keep the victim calm. Increased activity can spread the venom and the illness. Retreat out of snake’s striking range, but try to identify it. Check for signs of envenomation. Immediately transport the victim to the nearest hospital. If possible, splint the body part that was bitten, to avoid unnecessary motion. If a limb was bitten, keep it at a level below the heart. Do not apply ice directly to the wound. If it will take longer than two hours to reach medical help, and the bite is on an arm or leg, place a 2 x 21Ú4"-thick cloth pad over the bite and firmly wrap the limb (ideally, with an elastic wrap) directly over the bite and six inches on either side, taking care to check for adequate circulation to the fingers and toes. This wrap may slow the spread of venom.
Do not use a snakebite kit or attempt to remove the poison. This is the advice of Maynard H. Cox, founder and director of the Worldwide Poison Bite Information Center. He advises medical personnel on the treatment of snakebites. If you hike in fear of snakebites, carry his number, (904) 264-6512, and if you’re bitten, give the number to the proper medical personnel. Your chances of being bitten by a poisonous snake are very, very slim. Do not kill the snake; in most Trail areas, it is a legally protected species.
The following kit is suggested for those who have had no first-aid or other medical training. It weighs about a pound and occupies about a 3" x 6" x 9" space.
Eight 4" x 4" gauze pads
Four 3" x 4" gauze pads
Five 2" bandages
Ten 1" bandages
Six alcohol prep pads
Ten large butterfly closures
One triangular bandage (40")
Two 3" rolls of gauze
Twenty tablets of aspirin-free pain killer
One 15’ roll of 2" adhesive tape
One 3" Ace bandage
Twenty salt tablets
One 3" x 4" moleskin
Three safety pins
One small scissors
One tweezers
Personal medications
References
American Red Cross First Aid Manuals, American National Red Cross.
Emergency Survival Handbook, by the American Safety League, 1985. A pocket-sized book and survival kit with easy instructions.
Medicine For Mountaineering, edited by James A. Wilkerson, M.D., published by The Mountaineers, Seattle, WA.
Medicine for the Outdoors: A Guide to Emergency Medical Procedures and First Aid, by Paul S. Auerbach, M.D., Little Brown & Co., Boston, 1986.
Mountaineering First Aid: A Guide to Accident Response and First Aid, The Mountaineers, Seattle, 1985.
Mountaineering Medicine, by Fred T. Darvill, Jr., M.D., Wilderness Press, Berkeley, 1985.
The Outward Bound Wilderness First Aid Book, by Jeff Isaac & Peter Goth, M.D., Lyons and Burford, New York, 1991.
Appalachian Trail guidebooks are copyrighted property of the Appalachian Trail Conference (ATC) or its member clubs