Abstract
I had been a doctor for all of 7 days when I unexpectedly had to step into the role. I had planned a vacation. What I got was a vacation plus blood, bone, remote rescue, coagulopathy, and personal danger.
I graduated June 5, 2015. Within days I had shipped my new diploma and my life’s possessions in boxes to my new home halfway across Canada—residency didn’t start until July. For now I was on holiday. The only things I had were what I could carry 100 km across rugged, root-filled, ladder-strewn coastal trail. My pockets were stuffed with guidebooks, dehydrated food, and a ton of ibuprofen.
The funny thing is that I had spent the wrong part of the trip being neurotic. Transitioning from medical student to resident is odd—I would call it “the change” if that term were not already given to another hot-flashing, mood-swinging, insomnia-ridden transition. I boarded the plane from Edmonton to Vancouver Island in a dead sweat, looking worriedly around at the plane full of older folk headed to a city renowned for retiree living. Many of these passengers looked like prime potentials for a myocardial infarction, pulmonary embolism, or stroke. And in that case, as a newly minted MD, how would I react? The scenarios played out in my head endlessly. They all ended poorly. Needless to say I was immensely relieved to see the general surgery chief resident board after me, also on vacation. Thank goodness—a senior to defer to! All of you are safe, for now.
My (also newly minted) lawyer friend and I hit the trail, discussing life updates, philosophical points, and plans for future hikes. We had a lot of time to talk, while bumping up and down logging roads to our remote destination. When we lost all cell phone service, I breathed a deep sigh of relief. Finally off the grid! An hour later our bus rolled up beside the sign for Pacific Rim National Park. Welcome to the West Coast Trail, a backpacking mecca. It was originally called the Dominion Lifesaving Trail and was used as a path for rescuers to cut through Ditidaht First Nation land to rescue shipwrecked people off the violent shore. When we learned this, my friend and I were puzzled at how they evacuated anyone at all in the days before electricity and gas-powered land and sea vessels. There are only 3 ways to access the trail, really: from the northern tip, the southern tip, or smack in the middle. The rest is a demanding, root-laden, narrow trail, interspersed with tiringly sandy or rocky tide-pooled beach hikes. There are a few arm-powered cable cars across creeks. There are more ladders than I can count, some with 70-plus rungs to them. It is pristinely beautiful, but physically rigorous. Gray whales, seals, sea lions, otters, bald eagles, and deer say hello to you several times a day.
On day 5 of this trip, my friend and I were grateful the trail had not broken our toes, our relationship, or our spirits. The weather had been too good to ask for—not a drop of rain on terrain that can turn instantly slippery and treacherous the minute water lubes up the rooty path or the seaweed-slimed rock. Day 5 took us through one of the most scenic parts: Owen Point. Traversing Owen Point must be timed with the tide tables if one is taking the beach route, or you do not make it around the point and get swept out to the Pacific.
We were hiking behind some wonderful German sisters we had befriended and were alarmed to see them wave a bright red flag (a rain jacket on the end of a hiking pole) about 100 m ahead. When we caught up with them, the problem was clear.
A large, 50-something-year-old man was lying in great pain on his side, with a pool of fresh blood around his ankle. We were on the slab rock beach, with waves crashing against the shore 60 m away. He had been solo hiking, had fallen 4 m off a slippery beach access point, cracked his ankle, and impressively dragged his body closer to the shore where he hoped a passing fishing boat might spot him. He had lain in the hot sun for a full hour before the Germans found him. I swallowed a bolus of anxiety and identified myself as “Um, a physician,” then began to direct the surrounding hikers, asking one of the sisters to continue her excellent signaling with the flag and her whistle, then asking my friend to amass the first aid supplies. What had they taught me in medical school? Oh yeah, ABCs, and take a history! That I could do. The man was from an Eastern European country, visiting his son in Canada, and had decided to do the West Coast Trail alone. He had no “SPOT” device or satellite phone. He urged us to go on, saying he could manage, and I told him I had to assess what turned out to be an open lateral ankle fracture, just above the top of his hiking boot. Bone and flesh peeked out from his broken skin. We were definitely not leaving him alone.
This was a month before I took Advanced Trauma Life Support, so I used very basic logic to assess him and his limb. No head trauma and no airway or breathing issues. No medical history except what he described as “hypercoaguability.” As for medications, he was on what sounded like a low molecular weight heparin, but not one that I had heard of. Oh, dear. Pain? 10/10. He looked sunburnt, and extremely uncomfortable. He was probably about 86 kg and in average physical shape. His hiking equipment looked about a decade old.
He had good capillary refill in the foot, good pulses, but was numb in his first digit. In retrospect I wish I had irrigated the wound, but I did not think to at the time. I also wish I had torn up a shirt or used clean socks to achieve better hemostasis. Our pathetic amounts of gauze were soaked red in seconds. I also wish I could have better reduced the ankle, but I honestly was not sure how I would immobilize it once I did. There was no driftwood around me to use. The girls saved the day by signaling boats (who in turn radioed the park rangers). Because of their whistle, a hiker came by who had Tylenol 3 to contribute. They were infinitely more helpful than my meager ibuprofen. I merely directed the scene, and splinted the fracture as best I could. Duct tape, an emergency blanket, and broken up hiking poles are miracle tools on a barren rocky shore, but how I wished I had a flexible splint!
We looked at the ominous waves climbing higher along the shore. This was not a safe place. Luckily the rangers came within an hour. One stayed on the rescue boat while another swam in, helmet and waterproof supplies and all, and radioed for the helicopter. This man was getting airlifted to Victoria.
We hikers said our goodbyes and wished the unfortunate solo hiker good luck, silently hoping he had travel insurance. After a few minutes of deliberation, we decided to continue rounding the point. Now our adrenaline ran as high as the encroaching tides, and all we could think of was open ankle fractures and how little time we had remaining to make it to camp. We were forced to climb higher onto shoulder-height boulders to avoid water. As we looked back we could see and hear the helicopter flying away with our injured hiker friend, and we wondered if we would be next.
What followed was the most beautiful landscape of the trail. We took brief photos, calmed momentarily by the realization that we were alive and healthy enough to witness this scenery, then we hustled along as the sun began to set.
To our dismay we saw the rescue boat approaching us, and the same rangers waved us down. We stopped, and the swimming rescuer braved 20 m of large swells and climbed ashore to us again. We were in so much trouble, was all I could think. To have hiked 5 of 6 days on the trail, only to jeopardize ourselves and require yet more evacuation courtesy of Parks Canada. How irresponsible of us! Yet the ranger was smiling and gallant as could be: “Thanks for your help back there, ladies,” he said, doffing his helmet. “One of you left your knife back there. Sorry I got it a bit salty!” he said with absurd politeness, as he produced my friend’s Swiss Army blade from his wetsuit pocket. Now we were overcome with waves of relief. We were going to make it to camp (barely)! The authorities were not angry; they were grateful and chivalrous.
I have learned a few things from this escapade: Be better prepared. I understand now the limitations of my first aid kit. I was frustrated at not being able to treat his wound, on a barren rock beach. A flexible splint would have worked wonders. My next backpacking trip will include a fuller kit. I insist on flexible splints, which are godsends when treating any fracture. With respect to mental preparedness, I took Advanced Trauma Life Support a month later, which is a nice framework to have in trauma situations. Be creative. We used hiking poles and duct tape to good effect, but still the immobilization was poor. If only we had thought to use the extra clothes in our bags as padding. We also could have irrigated his wound with our filtered drinking water. Now I look at everything in my pack in a different light, imagining secondary uses for every object I have to carry into the bush. You have time. I was rushed, as I did not know how soon he would be evacuated. In reality he was not airlifted until an hour later, so I could have been much more thorough and deliberate. When stressed, the temptation is to act fast, even if it is not necessary to do so. If solo hiking in a remote location, definitely use a SPOT device or carry a satellite phone. If we had not found that hiker, he would have been a victim of the Pacific Ocean as the tides came in. My friend now carries a SPOT on her backcountry hikes because of our experience on the West Coast Trail. Parks Canada has the nicest, most capable rangers. We chanced upon them at the end of our trek a day later, and we discussed the rescue. This was one of the more extreme evacuations they do. They showed us the medical equipment on the boat, and I was keenly interested in how I could work with them formally in a physician role in the future. Parks Canada left a lasting impact on me as a result of its efficiency and infrastructure. They make hiking safer for everyone on these remote, demanding trails. In an emergency, your role as an impromptu trauma team leader is chiefly and simply to lead. The rangers said they were looking at us through binoculars off shore trying to assess the severity of the situation, and that we all seemed calmer than they had expected—taking out first aid supplies, putting on gloves. It was not until he homed in on the pool of blood from the hiker’s ankle that he realized how serious it was. I do not think I provided the best possible medical care out there on that beach, but what I did do was step into the leader role and direct my team. That led to an impression of control, and the injured man was appropriately reassured. This is part of “the change” all medical students must experience—the assumption of responsibility and the trust you put in yourself as a doctor. Even 7 days after you walk across that stage and the ink is still fresh on your diploma.
I look forward to further wilderness medicine training, as this episode has fueled my burning interest. We all hope the injured hiker is doing well, and I count myself lucky to have had the supportive, quick-thinking team I did that day.