Columns, Commentary, Operations

Improvisation: A Valuable Skill in EMS

Issue 3 and Volume 43.

It might be all you have

An eight-foot wave at an Acapulco beach proved too much for a middle-aged body-surfing American tourist. After the pummeling, he lay in the shallows, his distal tib-fib a mushy mess of crepitus. Hearing the cries for help and seeing none on the nearly deserted beach, I went into action, an earnest advanced first aider with little direct experience with an actual injury.

This being the mid-70s, there was no 9-1-1, no Mexican emergency response. I headed over to him, introduced myself and offered to help. The physical exam proved the leg fracture to be an isolated injury.

Time to splint. The beach was all sand and seashells. Scanning for possibilities, I saw a small wooden sign pounded into the beach nearby. A couple of willing assistants separated the crosspiece from the stake, and I borrowed some towels for padding, then used a couple of belts to hold it all in place.

Someone brought a lounge chair over and a group of volunteers helped haul the man to a waiting cab. Off he went with his friends to the hospital.

It wasn’t textbook, but it worked (and worked well, he reported, when we saw him at the airport in a cast a few days later).

Beyond the Usual

What I love about wilderness medicine is the need for improvisation. And as the example from Acapulco shows, “wilderness” might be as close as your next tornado, hurricane, or other disaster.

A knack for improvisation relies on two things: 1) attention to the principles of care while employing flexibility; and 2) creativity in their application. There might not always be a well-stocked ambulance at hand or an ED 20 minutes away. Improvisation means taking the knowledge in your head and using whatever you can scrounge up from your backpack or from other nearby sources.

At the time of the Acapulco rescue, my only EMS experience consisted of a year with a volunteer mountain rescue team in Colorado, a couple of years as an assistant instructor for a wilderness-oriented first aid course in New England, and a winter mountaineering course at the National Outdoor Leadership School (NOLS). Unconventional, true, but these experiences left me adept in the art of improvisation.

It’s a worthy skill. Knowing various alternative ways to provide emergency care using limited tools will help anyone cope with abrupt changes to the EMS landscape, even right at home.

Improvisation demands that you be emotionally & logistically prepared to think beyond the usual.

Improvisation demands that you be emotionally and logistically prepared to think beyond the usual. It’s one reason I always wear a webbed belt in the backcountry and carry a cotton bandana, usually tied around my neck. Each has multiple possible uses, such as a rapid dressing, bandage wrap, splint tie and even a tourniquet. Everything I carry–extra clothing, a ground pad, walking sticks—can serve in various ways. What’s in your pack?

Natural materials can also be handy. Many a stick has been padded and pressed into service as a splint. Soft grasses make excellent padding. Streams are great for cold soaks on sprains, and for cooling burns. Snow packed into a bandana works well as a cool compress. In less remote settings, use a magazine to cup a forearm fracture. At a crash demanding rapid extrication, I quickly devised a pillow splint for a nasty lower leg injury, and we got the job done fluidly while preserving the principles of fracture management.

You can even use your own body. A (gloved) hand against a bad bleed is better than nothing while others scramble for a proper bandage. Your arms can serve as temporary splints: envision a motorcycle crash victim face down, his mid-shaft femur fracture draped over the top of a small berm. It worked well to stabilize both sides of the femur with my arms when he was turned (another person rotating the lower leg in synch) and moved fluidly to the backboard. Then I slid my arms into proper position to pull traction and was greeted with that classic “ahhh!” of relief as his muscle spasms relaxed.

Conclusion

Improvising doesn’t give you permission to be slack with standards of care. Joints above and below fractures need to be immobile. Cardiac patients shouldn’t be walking. Distal pulses and sensation need to be accessible for rechecking. But as long as you are flexible and creative, it can be a great skill to add to your toolbox. After all, you never know when you’ll need to think on your feet and find an improvised solution.