Mountain biking carries with it inherent risk.. The recipe for awesomeness shares many of the same ingredients with injury, disability and death. Gravity, speed, rocks/trees/fixed objects, limited protective gear and the constant desire to test it mean that it’s all fun and games until somebody gets hurt.
I have been riding for 23 years and have been a career Paramedic for the latter fifteen. I’ve worked in a variety of systems and in a number of roles including SWAT Medic, Ski Patrol Medic, Rescue Diver, Firefighter Paramedic, and even one terrible day as a Bike Medic.
There are million finer points to Paramedicine, and a million complex assessments that we are trained to perform. Most of that stuff is all bonus points however when you’re stuck in the backcountry with limited supplies and zero resources other than what you hold in your pack and have in your head. It’s always a good idea to ride armed with some sort of provision for disaster. The bigger the ride, and the further from help, the more involved these provisions will be. An appropriately stocked kit is an important part of the equation but is a distant second to the ability to devise a clear plan to get the injured to help, or to bring help to them. As mountain bikers we put ourselves at greater risk than most people because of the nature of our sport and its relative remoteness. Anyone traveling beyond readily available access to help/medicine/rescue is, whether they are aware of it or not, assuming responsibility for those functions themselves. There is plenty of excellent training publicly available. Wilderness First Responder is an example, and covers a variety of topics at a detailed level, but is an 80-hour classroom commitment. Basic First Aid and CPR are, in my opinion the minimal prerequisites for mountain biking even at the most mundane of local trails and are simple, short, and widely available.
In my backpack a carry a first-aid kit made of a few simple items available at a local drugstore or outdoor supplier like REI. I try to Keep It Simple Stupid as much as possible and although this list is short most of these items can be used in a multitude of ways.
4” Kerlix (Roller gauze)
5×9 “abdominal pad” dressing (maxi-pads are probably just as good or better, and have an adhesive strip which can help secure them).
Pressure bandage (bulky dressing with a cloth wrap)
While there are a multitude of medical and traumatic issues worthy of discussion in regard to mountain biking it is useful to focus on those found at the intersection of severity, likelihood, and ability to stabilize. The Red Badge of Courage is one such affliction. Blood loss is the endgame of all trauma, and so it marks a logical place to begin the discussion.
Bleeding: The world is full of sharp objects just waiting to slice and dice you as you whiz past them. Most of the lacerations we in incur aren’t too serious. As scary as they look, as bad as they hurt, our bodies are pretty good at handling the minor ones. Generally speaking, an adult can lose around a liter of blood before they are in real trouble. Shock occurs from inadequate tissue “perfusion” or inadequate delivery of oxygen and sugar to cells.There are lots of scales and types of shock which are great to discuss in classrooms and books. Compensated and uncompensated, Stages 1-5, none of which is going to help your buddy who is bleeding out. I like simplicity. I think of things in terms of OK, WORSE, and BAD. We can measure this in a clinical setting in a number of fancy metrics including the old standby, blood pressure. BP is good to know because it is directly related to tissue perfusion. When BP drops beyond a certain threshold so does perfusion. Blood pressure is a function of three basic elements: Blood Volume, Container Size, and Pump Output. When we are sliced open on a chunk of razor-sharp scree and start leaking our body compensates for the lost blood volume by vasoconstricting (squeezing down the diameter of our blood vessels, effectively making the container smaller) and by increasing heart rate and strength of contraction. The body will begin to shunt blood from areas that are able to withstand shock, to those that are not, shutting down blood flow to the extremities and preserving the heart and brain at all costs. The good news is that this provides us with three ways to assess the severity of blood loss with about 10 seconds and our bare hands. We can put this information into terms of OK, WORSE, BAD and use that to guide our decisions.
1. Check a radial pulse (the one below the lowest thumb knuckle, between the midline tendons and the thumb-side arm bone (radius)). At the outset of blood loss one of the first ways we compensate is to increase heart rate. Most healthy people can maintain normal blood pressures in even moderate blood loss this way. A high heart rate (greater than 100ish) can indicate that we have a problem, but for the time being, the body is compensating.
2. In most people, it takes a blood pressure of at least 90/x to produce a radial pulse. So if they have a radial pulse their BP is probably at least 90-over-something. This is good. As BP drops we start to lose pulses from the places furthest from the heart. It takes around 90mmHg to make pulses at the wrists, 70mmHg to make them at the brachial artery in the middle of the upper arm, 50mmHg in the femoral (groin) and carotid (neck). Likewise, by comparing the skin temp of those distant body parts with that of parts closer to the heart we can get an idea of how far the body is going to keep blood going to the heart and brain. The further up the arms and legs the cold creeps, the worse the blood loss.
3. End-Organ Perfusion: Shock being a problem of perfusion, or delivery of blood to tissues, the most sensitive and oxygen-demanding tissues are the first affected. Unlike our skeletal muscles which can cope quite well with low oxygen levels for extended periods, our brains will begin to die within about 4 minutes. This makes it among the first affected and easiest assessed. Mental status changes such as confusion, loss of coordination, irritability, are signs that the brain is losing perfusion pressure and that shock is imminent. Skin is the other End-Organ readily available for assessment. People are generally pink, warm, and dry. Even people whose skin isn’t pink, like anybody who isn’t Caucasian, have pink parts like fingernail beds. When people’s skin changes from their normal condition, becoming pale, gray, blue, cold, and/or super-sweaty (diaphoretic) that can also indicate a shock state and progression along that OK/WORSE/BAD spectrum.
How to deal with it:
Dress it up. Clean, dry, sterile dressings are ideal. 4”x4” gauze and 4” rolled gauze (roller gauze, Kling, Kerlix) are my go-to’s here. Slap some 4x4s against the surface of the wound and wrap it up with the Kerlix. If there’s a whole bunch of “schmutz” (technical term for dirt, debris, etc) in there consider washing it out. However, you’re going to also wash out all the fibrin and platelets which are already in there making things better. Infection is a concern here, but you can worry about that later. If proper bandages can’t be found then use whatever is at hand: clothing, napkins, etc. Feminine hygiene products are actually pretty good at this, and most good girl scouts travel with some provision to greet Aunt Flo. If you’re a female, or have one in your group, your backpack probably already has a pretty decent bandage in it. Don’t forget it’s there.
Direct pressure: When the bandage alone fails to stop bleeding, apply some direct pressure. It’s OK to press real hard. The idea is to squish the leaky vessels flat. Arteries are generally deeper than veins and require more pressure to close. If your original bandage gets soaked through, just add something on top of it. Don’t remove the bandage contacting the wound as you may dislodge whatever clot has managed to form.
Elevation: Bring the affected body part above the level of the heart, or recline the patient to bring their heart lower. The extreme of this is the Trendelenberg Position, which is simply an elevation of the feet to a position above the level of the head. This reduces the workload on the heart using gravity and leaves more blood pressure in reserve to power the heart and brain.
Tourniquets: Use of these is somewhat controversial in the pre-hospital setting. They were in, they were out, now they are back in. EMS is like that. *sigh*. It can be difficult for the layperson to determine when these are indicated. Typically arms and legs can survive with limited blood flow for extended periods (hours) but other factors like lactic acid buildup and rhabdomyolysis (muscle tissue destruction) can cause even bigger problems. Bleeding this severe usually involves industrial accidents or plate-glass windows. I have never, in the mtb setting, seen anything that came close to needing a tourniquet. Not that it can’t happen, but in 20+ years I’ve never had instance to use one on a mountain bike ride. I would caution their use.
Bleeding, hemorrhage, theraputic blood-letting. While we often wear our scabs and scars as badges of honor, the reality of our physiology demands that we respect the mortal danger that blood loss can present. This is by no means a comprehensive study of hemorrhage, nor is it intended as a replacement for formal training or substitute for medical advice in an emergent situation. This information is but the first step in preparedness for dealing with injuries of these types.