The ski mountaineer, when called upon for help in case of accident, must often give more than first aid, for he may be far from organized medical assist­ance. In addition to a thorough knowledge of first aid he should therefore be familiar with a few of the simpler medical procedures—so-called "second" aid. For the usual first-aid work, publications of the American Red Cross should be carefully studied. This chapter will go a bit beyond first aid, but the procedures should be within the ability of ski mountaineers well-trained in first aid.

Shock.—When any but a minor accident happens, shock develops, more severely in ski accidents than usual because of the ever-present cold. The injured man should be laid down, head lower than feet, and should be kept as warm as possible, special care being taken to see that there is abundant insulating material between him and the snow. Extra clothing will serve, supplemented by branches, pack, tent, or air mattress. As every first aider knows, the victim must be moved little, and then only with caution, so that he will not be injured further.

Fig. 12. Velpeau bandage (modified). Begin with two turns (1, 2) around waist, rolling toward affected side; bring third turn upward across chest, down behind shoulder and arm, upward over shoulder, across the back, and horizontally across forearm (3). More turns can be applied (4, 5), depending on desired stability of arm and length of bandage roll.

Heat should be applied. This may require that one member of the party build a fire or start a stove and heat water, coffee, or tea; hot-water bottles may be impro­vised from canteens or extra fuel cans. Avoid overheating the patient until he perspires. Although such a condition can hardly be attained outside in the snow, room tem­perature, blankets, and hot-water bottles may cause the patient to perspire after he has been brought indoors. He is then subject to being chilled later; moreover, the blood is brought to the skin and thereby is lost to the general circulation and to more important organs, where it is badly needed.

To minimize shock, pain must be relieved. Capsules of codeine sulfate, 1 grain, and aspirin, 5 grains (obtained on prescription), will help relieve pain, and should be carried by all ski mountaineers. Aspirin may cause perspiration and should be used with caution, not more often than once every four to six hours. It is hoped that the morphine syrettes used extensively by the armed forces, or an equivalent product, will be available on prescription. The morphine solution is injected under the skin and is used when pain is severe, as in fractures; it should not be given more often than once every four hours.

When a serious accident occurs on a trip, make camp at the spot immediately. Pitch the tent, get the victim into a sleeping bag, start the stove, and perform the necessary treatment.

Fig. 13. Adhesive traction for fractured leg or thigh. Three-inch adhesive tape is applied along side of leg, beginning just below knee. Tape is extended three inches below sole of foot and is brought back up other side of leg the same distance. A spreader is put across the stirrup. Adhesive is then anchored by a spiral reverse from ankle to knee. Traction is applied by the usual windlass between stirrup and end of leg splint.

Hot tea, coffee, or chocolate is helpful when the patient is able to take and retain it; but avoid too much fluid, for it is then sometimes necessary for the patient, soon afterward, to empty his bladder—an extremely difficult feat if he is supine, and especially if he has a traction splint on his leg.

Fractures.—Fractures of the extremities must be im­mobilized with splints. Traction splints are absolutely necessary for thigh fractures and are preferable for lower leg and ankle fractures. The Velpeau bandage (fig. 12) is considered preferable for upper arm and shoulder im­mobilization and padded board splints for forearm fractures. Such splints may be used for lower leg and arm fractures if it is more convenient to do so. It is better to use a good padded wooden splint than to use a poorly improvised traction splint. In using any splint— especially the traction type—care must be taken not to restrict the blood supply and thus increase the suscepti­bility of frostbite. When applying a traction splint, leave boot and sock on; loosen the laces and straps. If the socks are wet, however, a change to dry must be made first. The entire body of the patient—including his injured arm or leg—must be kept warm. For other details of splinting, see the Red Cross publications.

In transporting an injured man who is wearing a traction splint, continually check the injured extremity to see that it does not become cold. If it should, traction must be released gently and the extremity warmed until the danger of frostbite is over; the traction may then be reapplied.

If it becomes apparent that the time between injury and admission to a hospital will be more than eight hours, some means of obtaining traction on the leg must be resorted to other than the hitch over the ski boot, for long-continued traction will cause severe damage to the tissues and circulation of the foot. To prevent this, ad­hesive-tape traction is applied (fig. 13). After the shoe and sock are removed, the leg shaved (if possible), dried, and warmed, a strip of 3-inch tape is started just below the knee on one side and continued down the side of the leg below the sole of the foot by 3 inches, and in stirrup fashion around the foot and up the other side of the leg to the starting level. The adhesive strip is anchored by a spiral reverse bandage from ankle to knee. A spreader must be put in the stirrup below the sole to prevent con­striction of the foot.

Fig. 14. Taping an ankle (see text), (a) Two adhesive stirrups are applied, extending one-third the way up each side of the lower leg. (b) Stirrup-like strips are continued forward down the foot, crossing over ankle and instep, (c) Strips are continued down to the base of the toes on the sole, (d) Layer of strips is applied over the top of the foot, starting at the base of the toes, crossing from side to side, (e) The strips are contin­ued up the foot, ankle, and leg to the top of the first two stirrups.

Compound fractures.—If possible, carefully wash the wound with soap and water; at least two quarts of clean water, to which two level teaspoons of ordinary salt per quart have been added, should be poured onto any ex­posed bone and into the wound. Dirt from the outside must never be washed into the wound. The skin around the wound, but not the wound and bone, should be painted with a skin antiseptic (e.g., 2 per cent tincture of iodine or the commercially prepared mercurial anti­septics in alcoholic tinctures. These freeze at about —37° F). If there is going to be a delay of more than twelve hours in getting to medical care, the use of broad spectrum antibiotic is advisable. Ask your physician what you should take. The wound should finally be covered with sterile gauze, bandaged, and traction ap­plied.

Injuries to joints.—It is often not possible to dis­tinguish a sprained from a fractured joint without X-ray examination. It is only permissible to tape a joint and to allow further skiing when the injury appears so slight that the additional support of tape would allow the skier to travel without undue discomfort. If there is any question about the severity of the injury, the skier should be transported on a toboggan or ski sled. With all joint injuries, a doctor should be consulted as soon as pos­sible to avert any permanent disability which might otherwise result.

The accompanying drawing (fig. 14) illustrates the taping of the ankle. Recommended tape width is 11/2inches. Note that in taping an ankle the tape is extended on the foot to the base of the toes, both on the sole and top, to prevent swelling of the foot and cutting of the sole by the tape.

Dislocations should be considered fractures until proved otherwise; splint the same as simple fractures.

If a shoulder is dislocated by a victim who knows the injury is recurrent, the dislocation may be reduced as follows: place the injured man in a horizontal position on a ledge so that his arm can hang down and free below him. Tie a weight of about ten pounds to the arm. In 30—45 minutes the shoulder muscles should tire enough to permit the dislocation to reduce itself. If not, treat as a simple fracture and seek medical aid as soon as pos­sible. A Velpeau bandage is recommended to immobilize a dislocation of the shoulder.

Lacerations.—Lacerations that occur in skiing are rarely severe enough to need a tourniquet, and only as a last resort should one be applied, inasmuch as frostbite may develop quickly when the blood supply is shut off. All effort should be directed to stopping the flow of blood by pressure of a compress over the wound. This can almost always be done. Then sterilize the skin with the skin antiseptic; apply sterile compress and take the in­jured person to medical aid. If medical aid is not avail­able within six hours, the following procedure should be performed: Wash out the wound with clean salt solution (see p. 135). Apply skin antiseptic to the skin only; if laceration is large, antibiotic capsules are recom­mended (see Compound fractures). Press the skin edges together and fasten as adequately as possible with ad­hesive "butterflies" (see fig. 15); apply sterile gauze dress­ing and bandage firmly but not too tightly.

Fig. 15. The butterfly bandage with 11/2-inch adhesive tape.

In working on any open wound, the worker's nose and mouth should be covered, because on a ski trip more harmful bacteria enter the wound from these sources than from any other. A bandanna will serve as a cover, used as a highwayman would use it.

Treatment of lacerations and compound fractures as outlined here does not replace proper surgical care. But the ski first-aider can delay or prevent infection by proper use of procedures described above.

Frostbite (freezing).—Frostbite is usually of quick onset. The sensation of cold dies away and all sensation in the affected part is lost. At this stage the skin is white; the part becomes stiff. Three possible results of frost­bite are:

Complete recovery.

Apparent complete recovery, but with loss of sen­sation, especially to temperature, in the affected parts and the predisposition of these parts to be more readily frozen. Neuralgic pains occur, especially in affected joints of the fingers and toes. Use of these joints is very pain­ful.

Gangrene, with the gradually developing line of •demarcation of normal and gangrenous tissues; these gradually separate from the body, but may be held by bone.

Causes: The essential change that occurs in frostbite is damage to the blood vessels, causing hemorrhage and liberation of plasma from the blood into the tissue. This causes swelling and blisters.

At high altitudes less oxygen reaches the tissues, and the warming effect of oxygen is reduced, thereby predis­posing the tissue to frostbite. Undernutrition, physical exhaustion, general illness, especially heart trouble, dia­betes, and diseases of the blood vessels in the arms and legs—these are other recognized predisposing causes. Previous attacks increase the susceptibility.

The general condition of the individual as well as his protection at the time of exposure also determines the degree of tissue damage. As the circulating blood is the primary heating system in the body, any decrease in this volume which might occur at high altitude, where severe dehydration exists, would accentuate the process. It is sometimes difficult to tell how much tissue is affected. Dead tissue may merely appear slightly discolored and have a feeling of warmth imparted to it from the adjacent normal tissue. This is misleading, as one is sometimes overly optimistic about the damage only to observe later that the gangrene has extended.

Treatment: Of course the best treatment is prevention with adequate clothing, gloves, boots, oxygenation, food, fluid intake, and minimizing of fatigue and perspiration. Military experiences in the Korean War and research have resulted in the modern concept of rapid thawing of frozen tissue and abstinence from incurring further tissue injury by brisk rubbing or prolonging the thawing proc­ess. Large damaging crystals are prevented from form­ing in the tissues by rapid thawing, and a marked vaso-dilatation in the extremity is demonstrated proximal to the injury. This method is carried out by immersing the affected area in a water bath of 45 degrees Centigrade, or 115 degrees Fahrenheit. This procedure can usually be performed without difficulty at a high camp with the available equipment of cooking pots and Primus stoves. It should be done promptly.

The treatment may be painful, but pain can be con­trolled with narcotics. Following this, sterile moderate-compression dressings should be applied to control the edema before it develops. Some authorities advise no dressings. However, some form of sterile protection should be afforded while the patient is being transported. Anti­biotics are begun immediately, and the patient should not be allowed to walk if a foot is involved. Certain cir­cumstances may make it expedient for a climber to de­scend under his own power to a more appropriate camp with feet still frozen rather than to attempt to thaw them on the trail, thereby becoming totally a litter case. Less damage comes from walking on the feet or toes that are frozen than walking on them after they have thawed.

Additional methods of treatment, such as dilatation of blood vessels by oral medication of nerve (sympathetic ganglion) blocks and the use of anticoagulants, have not proved especially valuable. The gangrenous area will be­come fully demarcated after about a month, and no at­tempt at amputation should be performed earlier.

In summary, frostbite is better prevented by proper clothing and footwear and by adequate food and liquid intake. Should it occur, turn back early before extensive damage results. Treatment should be instituted in an ap­propriate camp rather than on the trail and should in­clude rapid thawing; the gentle handling and cleansing of tissues to prevent further damage and infection; the prophylactic use of antibiotics; and general supportive measures determined by the patient's condition, shock, and other injuries. Walking on thawed frostbitten feet and premature "surgery" must be avoided. If nothing can be done, at least protect the part from further cold and allow it to thaw slowly by itself.

Snow blindness.—The temporary diminution or loss of sight of varying degree, occurring when unprotected eyes are subjected to the intense light reflected from the snow, is known as snow blindness. It may occur on cloudy days as well as clear, and is particularly apt to occur on brilliant days in the spring, when the sun is high and the days are long. More harmful rays exist at high alti­tudes because there is less in the air to absorb them.

The action of reflected light from the snow is three­fold. Ultraviolet light causes "sunburn" of the conjunc­tiva and cornea. The dazzling visual rays cause squint­ing and, finally, spasm of the muscles surrounding the eye. The infrared rays may coagulate the protein of the structure of the eye. The effect of light on the eye is cumulative to the extent that many short, repeated ex­posures in one day are about as damaging as one longer continuous exposure.

The onset of snow blindness may be immediate or de­layed as much as twelve hours, and the condition may last several days. The symptoms are burning or smart­ing of the eyelids, sometimes a sensation akin to sand in the eyes, spasm in the muscles surrounding the eye, pain in the eyes or forehead, sensitivity to light, and pro­fuse watering of the eye. Sight may be unaffected or definitely increased. The affliction is usually temporary, although for some time afterward there may be pain in the eyeball, "weak eyes," or headache.

To prevent snow blindness proper dark glasses must be worn, such as Calobar, Rayban, or Fieuzal. They absorb ultraviolet rays, some infrared, and diminish the inten­sity of the reflected light so that it ceases to be dazzling. Spare glasses should be carried. Should a skier lose or break his, he may protect his eyes by improvising shields with the use of adhesive tape. A horizontal slit not wider than 1/8inch is made by stretching strips of adhesive tape across the eyeglass frames or improvised frames. A refinement of a crossed slit helps the skier to look up and down as well. He may help protect his eyes by keep­ing them nearly closed or not looking at bright surfaces.

A blue sky, trees, his own shadow or companions, will tend to alleviate the dazzling glare. Optical quality in dark glasses is needed to prevent eyestrain.

First aid consists of relieving the local irritation and spasm. This may be accomplished by cold compresses over the closed lids for 15-20 minutes at a time. Instilla­tions of bland oils, such as castor oil and mineral oil, are good first-aid measures. Irrigations of boric or salt solutions several times daily also give relief. Local anes­thetics may be used if pain is severe. Ophthalmic ponto-caine (1/2 per cent in ointment form) is recommended. Others which may be substituted are 2 per cent butyn, 4 per cent metacaine, or 2 per cent holocaine. These may be used in either solution or ointment. Too frequent use of these drugs is to be avoided; one or two applications a day should be sufficient. Patients should be cautioned against rubbing the eyes when anesthetic agents are used. Dark glasses are indispensable for relief of the sensi­tivity to light. Several pairs may be worn if one is not enough.

If pain is severe and not relieved by the use of local anesthetics, aspirin, or even the codeine compound re­ferred to under Shock, should be used.

Though the above-named methods may prove bene­ficial the most dramatic relief is obtained with the use of one of the many ophthalmic Cortisone preparations. As this steroid hormone inhibits inflammatory processes and fibrous tissue proliferation, it is a logical choice in such a condition where the main pathological reaction is inflammation of the cornea from a photochemical burn. With one or two applications of the ointment placed on the retracted lower eyelid, the symptoms are dramati­cally relieved in eight to ten hours. Though snow blind­ness is not seen frequently, when it does occur it can be totally disabling, and this method of treatment is excel­lent. Of course, adequate eye protection from the glare is of utmost importance and should be provided for all directions around the eye.

General Considerations: Though knowledge of the fore­going First and Second Aid measures have pertained par­ticularly to injuries, there are other misfortunes that may be encountered. Such may be a severe respiratory infec­tion or pneumonia or a heart failure or to a lesser degree a heart strain.

In recent years a condition called High Altitude Pul­monary Edema has been described. It is probably a form of heart failure that is brought on by rapid exposure to high altitude and oxygen lack. It is characterized by the rapid onset of extreme fatigue and shortness of breath usually occurring within a day or two after ascending to altitudes above 10,000 feet. Symptoms progress rapidly to include a dry cough and difficulty in sleeping, espe­cially in the flat position. The individual may want to sit up because his breathing becomes noisy and bubbling and his cough productive of frothy sputum. Usually the pulse is rapid, the temperature is normal, and the patient appears acutely ill. The skin color may be pale or have a bluish tinge. In this condition the patient has often been considered to have a pneumonia and the true diag­nosis has only recently been recognized.

Treatment must be prompt and the patient gotten to a lower altitude as quickly as possible. Oxygen if avail­able should be given by mask. Antibiotics are indicated as the diagnosis can not readily be distinguished from a pneumonia and secondary infection can be controlled. Other drugs and methods of treatment are best reserved for the discretion of a physician.

In general, mountaineers should be aware of this condition and adequate time should be taken in gradual ascent to allow the process of acclimatization to occur. The pos­sibility of one of these problems occurring depends bas­ically on the general condition of the individual prior to his participation on an outing. Preliminary conditioning should be taken seriously in order to prevent extreme ex­haustion which may otherwise occur. Any preliminary respiratory infection should contraindicate participation in any extended mountaineering adventure. Routine phys­ical examinations are advised and in this way serious problems may be avoided. Sufficient rest, even if the com­mon sleeping capsules are needed, and adequate fluids, amounting to at least six pints a day, are two very impor­tant measures for good health. Needless to say, for these serious problems prevention is easier than treatment, which for all practical purposes is transportation to medi­cal care.

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