Winter First Aid

Submitted by Thorsten on 29th December 2018

Disclaimer: I am not a medical professional so I will write about this topic from the point of view of a layperson. It is entirely possible that I will simplify things or have explanations that sound wrong to a trained medical professional. I am also not a native English speaker, and I had my course in German, so I might get some medical terms wrong. If you catch any mistakes please feel free to correct me in the comments.

When going on an adventure, we always put ourselves at risk. There are a thousand ways things can go south when you’re outside and you can only do your best to be prepared for them, never completely eliminate all risks. A good preparation also needs to take into account where you are going and what you are doing. There are different challenges for the human body in hot deserts, in high altitudes or in jungles. Of course, for us aspiring Polar explorers, knowing about the challenges of cold weather and snow is most important.

It’s cold

I think that is not a huge surprise to anyone reading this blog. That means we first aiders must always consider the effects of cold on the patient, and they can pose quite a challenge. Usually, if someone has an accident outdoors, they will lie on the ground or at least sit. Almost no seriously injured person will stand around. In the snow, the ground is always very cold, and it takes only a couple of minutes until the patient will start to freeze. Wet clothes – an inconvenience in summer – can become life-threatening in sub-zero temperatures. One of our top priorities must always be to keep the patient warm and dry.

This can lead to some difficult decisions for you since you are the one having to assess the situation and decide if immediate care is required for the actual injury, or if protection from the cold is more important. Of course, that depends entirely on the situation, e.g. how long the patient has already been lying on the ground, but as a very basic rule you’d want to treat any non-life-threatening injury – say a fractured leg –  only after having made sure the patient is warm and out of the cold. Otherwise, they will quickly become hypothermic, which is life-threatening in itself. It may also require you to decide to move an injured person without knowing for sure that it is safe. A tough decision, but not moving a person because of a suspected spinal injury won’t do them any good if they freeze to death before help arrives.

To actually keep somebody warm, use your common sense. Put them onto some insulated ground sheet: a sleeping mat, a bivy bag or a layer of empty backpacks are just some ideas. Use whatever you have available. Be careful to keep the surface free of snow, or otherwise, they will become wet again. Cover them and protect them from the elements. That’s the gist of it.

Hypothermia

The human body usually has a core temperature of around 37°C. If it is higher, we become sick with a fever. If it is lower, it is called hypothermia. Hypothermia happens in several stages, each having distinct symptoms, and each requiring different treatment. Since we usually don’t have the equipment to get an accurate temperature reading in the field, we must rely on the symptoms to determine the stage and treatment.

The first stage is something almost everyone has encountered already: we are very cold. Our skin turns pale, we have blue lips, and our body starts shivering in order to produce heat. The person will usually tell you that they are freezing. In this state, they can get out of wet clothes with our help, and put on dry ones. They can eat something to warm up, preferably something with a lot of sugar – calories are a unit of heat after all. They can drink something on their own. They can move around to warm up. You can warm them up with heat packs.

With a hypothermic patient, the arms and legs, and especially the fingers and toes, will be the coldest body parts. However, do not make the mistake of focusing on heating them up and neglecting the core. Always apply heat packs and similar measures directly to the chest. When body temperature drops, the body automatically reduces blood flow to the extremities to keep the core working as long as possible. If you raise the core temperature, warmer blood will automatically find its way to the extremities again.

The second stage of hypothermia has totally different symptoms. Here the body has reduced blood flow to the arms and legs considerably, and the patient is drowsy, confused, and apathetic. They will likely no longer tell you they’re feeling cold, but don’t take that as a sign that they’re feeling better. In this stage, it is crucial to not move the patient any longer. They are too weak to change their own clothes, and can no longer generate heat by moving. It is best to lie them down flat. At this stage, their arms and legs will contain a lot of cold blood, and raising an arm or leg above the core will result in a rush of cold blood towards the core, which can be fatal. Never raise their arms or legs. If you have to get them out of wet clothes, cut them out with scissors and move them as little as possible while putting on the dry clothes. They can no longer eat on their own since they are likely too drowsy to swallow. Never try to give a prone patient something to drink, especially if it is a hot drink. You might add first degree burns to their hypothermia. Of course, you can still apply heat packs to the chest. It is crucial that you keep them awake in this stage, although they will likely be sleepy and doze off. Talk to them, shake their shoulders, do whatever it takes to prevent them from falling asleep.

The third stage of hypothermia is unconsciousness and ultimately cardiac arrest. In these stages we can’t really do a lot any more as first aiders, except to bring the patient into a recovery position, and should a cardiac arrest happen, start CPR immediately, all while trying to warm up the core as well as possible.

Resuscitation

Speaking of CPR, here’s the good news: not everything is more difficult in the cold. For resuscitation, it actually helps! In the cold, the brain requires less oxygen, so it becomes more likely that a patient will survive a resuscitation attempt without permanent brain damage. People have spent 45 minutes in a lake under the ice and have been successfully brought back to life. Keep in mind to move them to a hard ground, soft snow will reduce the pressure you can put on the heart muscle. As always, CPR is performed on the bare chest. Once you are at this point, they are already dead, you don’t need to worry about them freezing any longer. If you are successful, remember to keep the patient cool for a while to maintain the state of reduced oxygen requirement. Warm them up slowly.

Frostbite

Frostbite is caused by a lack of warm blood reaching a body part and freezing from the outside. Logically the most likely places for frostbite are the outermost extremities, the fingers and the toes. But frostbite can also occur on the nose, the cheeks, or the ears.

Just like burns, frostbite has multiple degrees. First-degree frostbite – or frostnip – irritates the skin and will turn it pale and then red. The person will lose sensation in the respective body parts. Second-degree frostbite will form blisters and the fingers or toes will swell. It will start to hurt again and turn blue. Third-degree frostbite will look almost black. At this stage, the tissue is irreversibly damaged. To treat frostbite, warm up the affected area with body heat, e.g. putting the fingers under your armpits. Be careful to avoid heat-sources like fires or stoves, since the injured person won’t feel when they are actually burning their fingers or toes. If you have the possibility, submerge them in warm water. If you are not squeamish, urine is an excellent source of a liquid with body-temperature that is readily available most of the time.

Remember: Frostbite is a wound, just like a cut or open fracture. After heating it up, you need to bandage the injured limbs to protect them from more harm.

What else?

There are a few other things you need to watch out for as a first aider in a cold and snowy environment. It is easy to forget that not only the patient is likely cold, but so is everyone else. Especially when you are leading a group, this can become a challenge. Find something to do for everyone. Ask them to go through their gear and make a stockpile of useful items: bivy bags, sleeping mats, first aid kits, food and drinks. If you have a stove, ask someone to heat water. If you have shovels, start building a provisional shelter. The more people just stand around, the more likely you’ll have a second hypothermic patient. Don’t forget to keep yourself warm, too! Protect the patient and everyone else from snow and wind, and keep in mind that days in winter are short in most places, and helicopters usually don’t fly in the dark.

This article hopefully gives you an idea about some of the unusual circumstances and challenges for first aiders outdoors in winter. It does not replace a full course. Please consider educating yourself about the environments you plan to go, especially if you are doing guided tours. My course was provided by the ÖAV academy in Austria. It was a 3-day winter specialisation that requires a 4-day basic outdoor first aid course to attend.

Winter First Aid

Thorsten

Keen hiker and ÖAV trekking and hiking guide, in love with Nansen. Owner of the most walk-averse rescue dog ever. Ice cream lover, kit junkie, runner and mad software genius.