Student Voice by Daniel Coleman (M’17)
The guy was not in a good way: two miles from the closest road, a steep 1500-foot trek separating him from the valley floor. Before I even got close, I could see the laceration—a six-inch oblong cut that looked like it was splitting his right forearm in half. Caitlin called out to let him know we were coming. We downclimbed a short stretch of gently graded cliffs, then tread carefully, because there was another 20-foot drop to the left. Up close, he was remarkably calm.
“Sir, my name is Dan Coleman.”
“Hi,” he answered.
“I’m a first year medical student working with the mountain rescue group,” I explained.
But the way I said it, I think it sounded more like an excuse, absolving myself from any soon-to-be-made mistakes. The guy raised his eyebrows, maybe wondering if he should roll off the edge and save himself several hours of pain and amateurish fumbling. I checked his pulses and made sure he wasn’t thirsty. He hadn’t hit his head or blacked out, and he was adamant that he had “just slipped.”
His name was Jed Knight, but his friends called him Jedi. I asked if I could be his padawan, but he didn’t laugh and I could sense my stock plummet even further.
Jedi also had 10-out-of-10 pain under his left knee. He couldn’t bend it and there was a decent amount of dried blood, enough so his pants were sticking to the skin. Caitlin went to work, cutting away the pant leg as I irrigated the forearm and firmly dressed the wound. We removed the pant leg, and looking down at that mess, I thought a bad word. There was a jumble of bones erupting through the skin, like when continents collide to form mountains. A compound tibia-fibula fracture. Help was on its way, but I didn’t think they would make it in time.
Wild places have always intrigued me. Places where you can smell eucalyptus, sweet and oily, and feel a carpet of dried pine needles beneath your feet. Places that are far enough away to make things like email and texting obsolete. I look for the high points, promising vistas of rock and snow, with an incomparable sunset if you can wait just long enough. And I’m not the only one.
The outdoor recreation industry is booming. The latest report on outdoor participation from the Outdoor Foundation shows Americans engaging in an estimated total of 11.7 billion outings in 2015. But as more people go outside, more accidents will happen outside, whether due to poor preparation, ignorance, or just bad luck. That may mean more twisted ankles and skinned knees, a few more hapless hikers walking into camp delirious and dehydrated, or lost in the middle of nowhere with a compound tibia-fibula fracture.
Jedi had been hiking along a ridgeline in the Massanutten Mountains of Virginia, across the valley from Shenandoah National Park. He enjoyed wildlife photography and had seen a deer, a young buck, off in the woods. He told his two friends that he would catch up further down the trail. They separated and Jedi wandered through some thick underbrush to get into position, but took one step too far, slipped, and fell. That was almost 18 hours ago.
Looking down at it, I wondered what to do. I had recently finished gross anatomy, so I knew about the bones and their connections. I knew which nerves and arteries might be injured. I even knew about compartment syndrome and its symptoms.
“My foot feels kind of tingly.” I felt his foot. It still felt warm with good pulses, but he had a lot of pain whenever I moved it. For all of that preclinical knowledge I had, none of it was going to help. Even if I knew then what I know now, I think there is little precedent for a fourth year medical student attempting a backcountry fasciotomy. We had to get him down the mountain.
Caitlin and I thought about supporting him between us, using a bit of tubular webbing I had in my pack, but discarded the idea because we were still going to have to scramble up a few gentle cliffs to the trail. We would have to wait for the litter to arrive from base, load Jedi in, and haul him up using a system of ropes and pulleys. In the meantime, we splinted the injured leg to the good one and waited.
During that time, my job was to make sure he was still alive, which is a tall order for some kid who had spent the last year memorizing the Krebs cycle and figuring what Brodmann area 4 really was. So I just kept talking to him, taking what vitals I could every so often, and wishing that I really knew what to do.
When people get injured in a city, they are a short ride from a well-equipped emergency room and a team of specialists, ready to tackle whatever comes their way. Wilderness medicine, however, is about using the accoutrement you can fit in a backpack to keep someone stable for hours, pending slow transport to a proper healthcare facility.
It’s this improvisational aspect of wilderness medicine that I find fascinating. Flipping through Auerbach’s compendium on the subject, there are pages upon pages of unique solutions for when that first, best option isn’t available. In place of a knee immobilizer, use a tightly wrapped sleeping pad. No sling? Just pin up the bottom of the shirt to create a cradle. And for a compound tibiafibula fracture…splint the leg and get to definitive care. Great. Finally, the litter arrived, along with dozens of other rescue denizens. I checked in with Jedi and then we loaded him in and strapped him tight.
“Hey, I can’t really feel my foot anymore.”
We were making slow headway. The semi-technical team had rigged their pulleys and the rest of us were helping to pass the litter up the rocks. I tried feeling the pulses in Jedi’s foot, but it was difficult because the litter kept moving around. It took over an hour to move Jedi up the rock. After that, the rescuers had to pass the litter hand-tohand over uneven terrain, but once we got to the trail, they attached a single large wheel and we started down at a (slightly) faster clip.
“Man, I don’t know, my leg feels, like, dead now. It’s like it’s not attached.”
There was no point in stopping. We were only about halfway down. There was an ambulance in the parking lot, but the closest medical center was almost an hour away. By that time, it had been nearly 24 hours since the accident. Jedi was going to lose his leg. And then our team leader went to the front of the line, blew a whistle, and announced that he was ending the mission. We unstrapped Jedi, and he hopped down on both feet, full strength, no pain. A miracle? The Force?
In fact it was a training exercise, not a real search and rescue. The injuries were painstaking moulage. Jedi was (thankfully) not his real name. But my nerves were real. I had been unsure of myself the entire time, unsure if what I had done was correct. There wasn’t an attending to consult, no one was double-checking my work, and I barely knew anything about managing a patient, let alone a patient in the middle of nowhere when I only had a few bandages to my name. I had been in the backcountry plenty of times, but this was my first real experience with wilderness medicine.
When we go outside, the chances are slim that something bad will happen. Most likely, the hike will go according to plan, and we’ll walk across that snowfield without incident, snapping a picture of an incomparable sunset before tucking into camp for the night. But what if some kid nicknamed Jedi slips off a ledge two miles from anything and ends up with a compound tibiafibula fracture? For future medical professionals who enjoy venturing outdoors, it would be prudent to be ready for anything.
Daniel Coleman (M'17)
Daniel is a member of the class of 2017 going into Emergency Medicine, with a particular interest in Wilderness Medicine. He founded the GUSOM Writers Group, and is a student editor and writer for In-Training.org. We are grateful for his current and future contributions to Georgetown Medicine magazine. He can be reached at Daniel.Coleman@georgetown.edu.