Kid meets tree in the middle of nowhere. Now what?
June 18, 2010 5:22 AM   Subscribe

WildernessFirstAidFilter: 11 yr old kid knocked out after hitting tree on mountainbike... what should we have done? Naturally, there's a catch.

Last night we encountered a situation which I think we handled as well as we could, but I would like to know if we could have handled it better.

Apologies for the length of this but it was a tricky situation.

We (three of us, all adult males) were riding mountainbikes on a local trail system, about halfway through a 3 hour ride. It was just before dusk (we had lights and were going to be night riding). Up ahead we saw that the trail was blocked.

When we got there, we saw it was a group of kids with two adults, a man and a woman. One of the kids had hit a foot-thick tree at speed (hard enough to leave a mark on the tree) and was lying on his back, just regaining consciousness. The kids told us he'd been out cold for fifteen seconds or so.

It was immediately apparent that the adult male didn't really know what he was doing. He immediately started trying to get the kid to sit up and asked him if he could stand. I immediately told him not to try to move the kid and that they needed to get help. The man seemed a bit put off by this. The woman was passively watching.

By now the kid was talking. His ABCs were fine. He was bleeding from his ear, although it wasn't clear if it was a flesh wound or what it was. He told me he was dizzy and shaky, and had a huge headache. He kept asking what had happened, and asked three times if his bike was OK, even though we had already told him it was fine.

Neither of the adults appeared to be his parent.

The woman left with the other kids to get help, but it was not clear she knew the fastest way to the trailhead and it was obvious the kids were going to slow her down.

By now the kid was sitting up, still feeling shaky, dizzy and clearly confused, and the man was talking about walking out to the dirt road. I kept telling him to keep the kid where he was, and we would get help, but he replied that he'd 'seen lot of mountain bike injuries', implying that the kid was fine to walk.

Eventually we got him to agree that he wouldn't move the kid, and set off ourselves. We immediately bailed to the trailhead where we found the rest of the group. Apparently his mom had already left in a vehicle to find the accident site.

However, nobody had called 911, so I told them the kid needed to get the ER ASAP. So an ambulance was called, and we waited until it arrived (about 10 minutes), and then led it on our bikes to near where the kid was.

However, as we were on our way, another cyclist intercepted us, and told us that they'd already got the kid out and he was in the parking lot. The ambulance headed off with him.

That was our last interaction with the group.

I have two related questions.

1. What was the correct immediate medical response at the accident site? The kid was conscious and breathing and in no immediate danger apart from getting bitten to death by bugs.

2. What could we have done better in terms of our non-medical response?

It was a tricky situation because we were not in loco parentis but we did not feel confident about the decisions the other adults were making. I just kept thinking what I would have wanted someone to do if it was my kid sitting there on the trail.

This definitely made me wish I had some proper wilderness first aid training.
posted by unSane to Health & Fitness (16 answers total) 4 users marked this as a favorite
Get your WFR man! It's good times!

I'm a twee out of practice on my WFR, and cranial trauma is a tough one. IMO, if there is enough trauma to knock you out, you need to stay down.

Next step, call emergency medical services.

Determine mechanism of injury. Did he hit the tree w/ his head? His arm? Is there a snake? Did he possibly pass out before he hit the tree because of another medical issue?

Forget ABC's, you need to know your AxO's (Awake and Oriented), 5 questions. Name, Day of the Week, etc. Anything less than an AxO of 4, and you need to take immediate triage action.

Past and present meds, medical conditions, etc. All of it goes on your paper.

From here, victim is chunk-checked for readily available external injuries, then palpated for immediate internal injuries.
Regardless, individual lays on the ground, is logrolled onto something providing a thermal break from the ground, and treated for shock. ((ASSUMING NO THOUGHT OF SPINAL INJURY!!) Vitals are checked at 2-5 minute intervals and recorded. BP can be determined by checking for alternate pulses. Victim should be constantly talked to, asked questions, etc, to help determine if they are losing any brain function.

For direct cranial trauma, you can continue to check behind the ears on on the neck for pooling blood causing discoloration, etc. Assuming there are no immediate threats to life, you now treat injuries from most to least serious---bandaging wounds, splinting if necessary, etc. The whole time you're monitoring vitals and checking the AxO's. You continue palpating the femur, stomach, and chest areas to feel for swelling and pain. (Either/or can be an indication of severe internal injury.)

There's a lot to long-term wilderness life support, and I've alreayd pretty well butchered this answer. However, ideally the crew shows up about now, and you give them your note and you let them take him away.

Your real concerns here, pretty much, are increasing cranial pressure, internal bleeding, and spinal trauma, although not necessarily in that order depending on circumstances.
posted by TomMelee at 5:41 AM on June 18, 2010 [14 favorites]

Okay, so from earlier comments, maybe there's some ideal response you could have had, with first-aid training. But in the end, you got the nominally responsible adults from "rub some dirt on it" to "meet an ambulance in the parking lot."

Head injury, knocked out, bleeding from the ear, short-term memory problems (asking the same question 5 times) -- those are worrying signs. I'm sorry you couldn't convince them not to make the kid get up and walk around immediately after, but at least you ensured that he wasn't just taken home and put to bed.

Good for you; a lot of people would just figure "it's their lookout" and keep going.
posted by palliser at 6:13 AM on June 18, 2010 [1 favorite]

Pretty much what TomMelee said. A head-on collision with a tree followed by a tumble to the ground is a significant enough mechanism of injury to demand cervical spine precautions. Not only should you not be moving the patient, you should be actively preventing head movement using manual in-line stabilization (for illustration purposes only, take a first responder course to really learn how to do it). I've heard more than a couple stories of people who walk away from car accidents, only to drop to the ground once they turn their heads the wrong way. Beyond your A&Ox4 (person/place/time/condition), other things to check for include raccoon eyes, battle's sign, cerebrospinal fluid (CSF) leakage from the ear,* and unequal or nonreactive pupils.

*Fun CSF-leakage test: if the patient's bleeding from the ear, dab the corner of some gauze or a napkin in the blood, if after a minute or so there's a halo, then you've got CSF.
posted by The White Hat at 6:15 AM on June 18, 2010 [4 favorites]

I'm forgetting my technical language from WAFA, but people can have distracting secondary injuries that obscure even more serious ones. In other words, someone could have a spinal injury but not be aware of it just because or due to a nasty cut on their side, etc. It happens all the time that people have accidents, damage their spine, don't realize it, and then due even further damage trying to get up and "walk it off."

In this case it sounds like there was definitely a mechanism of injury for the kid's spine, so under no circumstances should he have moved around. There are wilderness tests you can learn to definitively check for spinal injury, but only if the patient is otherwise ok. If someone has a concussion the only way to check them for spinal injury is to do xrays in a hospital.

It sounds like you already know all that. My point is that the kid suffered a pretty serious concussion, which is itself no small thing. The fact that there was a mechanism for a variety of other injuries means that he should not have been moved at all until the ambulance came. There's not a lot you can and should do here other than that.

Non-medically, it sounds like the dad was one of those idiotically gung-ho people who think you walk off anything but a decapitation. ("Be a man.") It seems he agreed not to move the kid just to get rid of you. There might not have been any way to tell that at the time, but perhaps to be safe you could have sent the rest of your group back to get an ambulance and yourself stayed to make sure the kid wasn't moved at all.
posted by resiny at 6:27 AM on June 18, 2010

Don't take any chances on any sort of head injury.
posted by corpse at 6:54 AM on June 18, 2010

Thanks White Hat. You filled in some of my too-quickly-typed gaps. Appreciated.

I also wanted to say that when you get advanced lifesaver techniques (WFR, WEMT, etc.), you learn very quickly that much of what is taught in a Red Cross First Aid class is for people who breathe through their mouths. Ok, that's not true. But---a regular First Aid class assumes that you're w/i 5 minutes of emergency medical care. In the wilderness, you are not, and so a lot of the "zomg never do this!" advice in a regular Red Cross First Aid class goes right out the window.

WFA does a little better (Wilderness First Aid) than just FA, but WFR and WEMT just go so much futher. WEMT isn't really necessary unless you find yourself spending weeks and weeks a year far away from civilization and it requires a hefty investment of time. WFR is great, you learn how to pull traction and drop airways, how to reduce dislocations and how, when necessary, to clear a spine.
posted by TomMelee at 7:22 AM on June 18, 2010


Nthing this. If there is any suspicion of a head or neck injury, and the person will not be placed in any additional danger by remaining in place then, for the love of god, do not move that person an inch.

It sounds like this was the case here, and you can treat for shock and check for other injuries without moving the person.. I don't usually recommend being confrontational, but you definitely should have put the "incompetent adult male" in his place. If the kid had an actual spinal injury, it's also likely that he'd have some degree of legal liability.

And on that note, I really should get an actual WFR one of these days.
posted by schmod at 7:59 AM on June 18, 2010

Nthing the "do not move them". Call 911. Wait for qualified personnel.

Also this is a good time to point out that 911 from a cell phone does not always call a local call center. Here in NorCal it calls CHP dispatch in LA. Know your local emergency/non-emergency numbers and put them in your cell phone. Or use a landline.

Question to the OP - Was the kid wearing a helmet? I'm assuming not based on it not being mentioned.
posted by Big_B at 8:40 AM on June 18, 2010

What you did was fine, because you have no formal training. The actions of well-meaning but untrained people are often as dangerous as the initial trauma itself. Echoing the above, get training if you intend to spend any time on the trail. Then, the best approach to this situation would be to inform the adult that you are specifically trained for this situation and calmly, but with authority, offer to "look him over to make sure everything is O.K." Then and only then use your skills. Don't ever become confrontational. The kid wouldn't benefit from a loud argument or fistfight while he is wandering around in circles. An old trick we used in the field is to find the loudest mouth, give him an important task (like holding a roll of Kerlex) and get him involved in reassuring everyone else that the situation is under control. When he is "helping" he is less likely to be screwing things up.

Also, use your assets wisely. Send one of your own companions, with one of the bystanders for help. Keep as many allies as possible with you in case you need someone whom you can trust to either follow up on outside help or to render onsite assistance.

Lastly, let go. Some things are beyond your control. When everything is done, spend no more time dwelling on what should have been done than you spent actually doing. Your next adventure is right around the next bend.

Next week's lesson: Triage.
posted by Old Geezer at 8:48 AM on June 18, 2010 [2 favorites]

Response by poster: Thank you everyone. Couple of points --

1. Yes, kid was wearing a helmet. Was a very professional looking group in team colors. It looks like he lost grip with his front wheel and went into the tree sideways, which bike helmets are not optimally designed to protect against.

2. Man with him wasn't his dad. That was what was bothering me most, actually, since I felt like the parent but didn't really have any leverage.

In retrospect, we should definitely have left someone with him and, yes, he was trying to get rid of us. I don't really know why we didn't. I guess it didn't become clear until somewhat later that we were the only people who were taking it as seriously as it needed to be taken.

(Hitting a tree is one of the nastiest things that can happen to you when you fall off a bike. If you hit the ground, you tend to roll. When you hit a tree, you stop dead. It's staggeringly painful).
posted by unSane at 12:24 PM on June 18, 2010

"In retrospect, we should definitely have left someone with him and, yes, he was trying to get rid of us. I don't really know why we didn't." This mostly because you aren't experienced in these things. I don't know what you do for a living, but I'm gonna guess that I wouldn't be able to jump into your shoes and do an optimal job. This is where both training and experience help.

"When you hit a tree, you stop dead. It's staggeringly painful" It is also extremely dangerous because the brain doesn't stop when the skull does. It crashes into the inside surface of the skull and rebounds to crash into the opposite side of the skull, what is known as Coup/Countercoup Injury (pronounced coo/countercoo). Imagine what that is doing to the brain. Any injury that includes loss of consciousness is, by definition, a concussion no matter how brief the event and should always be taken seriously.
posted by Old Geezer at 8:10 PM on June 18, 2010

Expired WFR, Expired EMT here, past Search and Rescue volunteer. I think TomMelee nailed it as far as best case scenario goes.

I think in reality, if kids seems better (aware of where he is, is communicative, even if dazed) or pretty much fine (less confused and adamant she/he can walk out) the adults are going to walk the kid out.
posted by fieldtrip at 10:31 PM on June 18, 2010

Oh, and if you enjoy thinking about this sort of thing -- and I do think it is a good mental exercise if you spend time on trails -- you might enjoy Accidents in North American Mountaineering which comes out annually from the American Alpine Club. It is climbing and mountaineering, obviously, but it has case studies of accidents analyzing down to the minutia.

And, do get your WFR! NOLS/WMI is good.
posted by fieldtrip at 10:38 PM on June 18, 2010 [1 favorite]

A couple of thoughts:

Your mention of team colors raises a red flag. In EMS, sporting team staff (and often parents) are notorious for not taking serious concussions seriously. That's one reason it would have been better to leave at least one sensible person on scene. Or remove one of the child's shoes and retain it to discourage further walking.

Nothing you describe was a sure sign of serious brain injury, but some hinted at the real possibility. They also suggest that any thought of "clearing" him of spinal injuries is out of the question. He should have been immobilized and carried out.

The likelihood of aggravating a spinal injury in this case is very, very small, as is the chance of life threatening problems from his head injury. But either could have such catastrophic results that it is not worth taking the risk.

Even stubborn people in denial will yield to reason a surprising amount of the time if given accurate information on the possible consequences. So, as others have suggested, arming yourself with some training and good information will help if there's a next time.
posted by wjm at 4:52 AM on June 19, 2010

You did pretty good for someone with no training, no authority, and no notice; I wouldn't beat yourself up too hard. That guy sounds like a dangerous dickhead.
posted by smoke at 7:20 AM on June 19, 2010

Just for the record, I agree with smoke, and I think it's awesome that you stepped in and did your best to help. Yeay for being an active bystander!
posted by radioamy at 11:57 PM on June 19, 2010

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