Hypothermia on Eisenhower

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John,

I think there is a changing opinion in backcountry medicine. Putting a second person in the bag has been the traditional recommendation but observations have shown it to be ineffective. Many leading edge organizations (SOLO, NOLS) no longer recommend this, and I suspect others will follow over time. Just like cutting the wound to suck out snake bite poison, some methods that were widely recommended may lose favor.

From here :
The traditional recommendation is to place the patient in one or more bags with at least one other person as a heat source. In our experience the hypothermia wrap with hot water bottles is a more effective practice. The insulation of the sleeping bags suffers as people get in and out and the warmers are not available for other tasks such as setting up camp and preparing food. If one person in the group has become hypothermic others are at risk. The warmers can quickly become cold and fatigued. Experts disagree on the amount of heat transferred body to body - some think its low. The value of the warm person in the sleeping bag may be to heat the insulation, not to transfer heat directly to the patient. We recommend, if this method is used, that the warmers wear at least a thin layer of clothing. Feed the warmers to keep their energy level up. Clothing placed over the opening of zipped-together sleeping bags helps reduce heat loss. Several sleeping bags placed over the patient and the warmers will also help. A humid environment inside the sleeping bag reduces respiratory heat loss as does loosely wrapping a scarf or other article of clothing across the patient's mouth and nose.

It's not likely to harm someone, but there are better ways to expend your energy in this situation.

-dave-
 
Well, with all due respect to Dave and others - if I were ever in a situation and there was no other way to warm someone with life-threatening hypothermia, then I could care less what some journal said - a heat source (another human body), no matter how feeble, has got to be better than nothing. And, knowing that you're actively trying to do something rather than sitting around watching the person freeze to death has got to produce better memories in your old age than the alternative.
 
Re: warming by 2 in a sleeping bag:

I believe my info is from Dr. Murray Hamlett and is consistent with Dave's comments--the technique is obsolete.

On the other hand, if there were absolutely no other option, it might be worth trying. But I have also heard reports that 2-in-a-bag is not as warm as two separate bags (something about a nasty cold air channel down the center...).

Doug
 
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Kevin Rooney said:
Well, with all due respect to Dave and others - if I were ever in a situation and there was no other way to warm someone with life-threatening hypothermia, then I could care less what some journal said - a heat source (another human body), no matter how feeble, has got to be better than nothing. And, knowing that you're actively trying to do something rather than sitting around watching the person freeze to death has got to produce better memories in your old age than the alternative.


Well if I listen to the current medical thinking on the subject it really doesn’t seem to be of any use. Maybe I didn't explain this correctly the first time. It is very simple and fully accepted by the medical community that someone in stage III hypothermia cannot be rewarmed from anything that can be reasonably done in the field. At least that is what I was taught. The usual treatment for this is abdominal lavage, warmed IVs, extracorporeal rewarming with cardiopulmonary bypass, close scrutiny of the electrolytes etc.

Body to body contact doesn't work because the persons extremities are shunted and vasoconstricted. This means that virtually no blood is moving from the extremities back to the core. If you place a body to warm this person up none of the "warmed" blood get back to the core. Their furnace has shut down and cannot be refired because they can't get water and food in. If you place hot water bottles or the such on the arms and legs you stand a good chance of giving this person pretty serious burns with relatively low temperatures. Again the reason is that the heat you are applying, while it feels fine to you, burns a hypothermia patient because none of the heat is being pulled away from him because no blood is moving.

I know the old thinking was that you crawl into a sleeping bag with a person and in stage I or II that may have some merit though you are still much better of feeding and hydrating them if their airway isn't compromised. We know a lot more about this now and I haven't had one doc who specializes in wilderness or emergency medicine tell me that there is any merit to the crawling into the sleeping bag with the person scenario.

You ask if it is better than doing nothing and it actually isn’t. Instead of doing that you should be trying to do the medically sound thing which is to get this person into a hypothermia wrap and getting them off the mountain as gently as possible. Trying to stay in a sleeping bag with them is just delaying the treatment that they need to get to so they can stay alive. And the longer they stay in that state, the more unlikely they will recover. There is a technique used to rewarm hypothermia patients called active external rewarming for mild and moderate hypothermia. It uses blankets at 105degrees F in order to actually accomplish this. You don't have enough heat, or high enough heat to accomplish this in the field.

Medical science is funny because you can almost find at least one doctor who shares a certain point of view. On this subject though I have been taught and read the same thing over and over. It doesn’t work and isn’t recommended.


Here is a chart to the signs and symptoms of hypothermia and related core temp.

F
99-96 Shivering. Poor complex tasking.
95-90 Violent shivering. Poor speech and thinking. Amnesia. Tachycardia.
90-86 Increasing muscle rigidity. Blue/ puffy skin. Jerky movement. AMS with false normal appearance.
85-82 Decreased reflexes and A fib.
<82 Coma, cardipulmonary failure, pulmonary edema, V fib and death.


Here is at least one excellent reference on the subject:
Hypothermia and localized cold injuries
By Andrew S. Ulrich, MD*, Niels K. Rathlev, MD
Department of Emergency Medicine, Boston University School of Medicine
Published in the Emergency medicine clinics of North America 22 (2004) 281–298


Hope this helps make it a little clearer.

Bear in mind I am not telling anyone what to do. I am just telling you the course of treatment I would pursue.

Regards,
Keith
 
Keith,

Your table of temps made me do a search on the wayback machine. I found an article on hypothermia that I posted on the site almost 10 years ago (back in the lexicomm days - for you long term site members :) ).

http://web.archive.org/web/19990224053428/www.lexicomm.com/views/features/hypo.html

The article is fairly lacking in hard info, but the table was a little more detailed. I'm guessing I was somewhere around 86 or 87 degrees. "Shivering stops, severe lack of coordination with stiffness and inability to walk or stand, incoherence, confusion, irrationality. Severe muscular rigidity, extreem lethargy and desire for sleep." Yah, that was me alright. :eek:

- darren
 
Timidly raising hand

Darren - A scary and well-told story. I'm glad you made it out; sounds like something I hope never to experience.

On the other hand, I wonder if you would have gone at all if you were going alone. Despite feeling less than well, you seemed to experience some social obligation not to disappoint your friend. It might also be true that, if alone, you would have turned back at an earlier sign of trouble, such as worse weather than anticipated, unable to find trial, snow too deep to break with only one person, etc.

I agree that hiking alone is dangerous, and usually more so than hiking with others. In this case, though, you might have been better off if the trip were planned as solo.
 
dclynch said:
On the other hand, I wonder if you would have gone at all if you were going alone. .... I agree that hiking alone is dangerous, and usually more so than hiking with others. In this case, though, you might have been better off if the trip were planned as solo.

At that stage in the game, I had been doing more and more solo. Including solo winter backpacks above treeline. If I had been solo on this particular trip, then yah maybe I would have turned around. However, if this event had not happened to me then I have no doubt that a similar event would have happened to me while I was solo at some point in the near future.

I had been increasingly biting off more and more with each successful solo trip. The more experience I got, the more I would do. Up to that point I had never had a backcountry mishap that I couldn't get myself out of. I can say that at that time I had no idea that hypothermia could come on and increase in severity so fast. I was always aware of hypothermia, its warning signs, and its associated dangers, however I had NO idea of how fast it could get to such a degree of severity.

I really believe that had this event not happened, I would have had a much worse event within a few years. I lucked out to have it happen while I was with Dave and not when I was solo.

Live and learn.

- darren
 
just guessing...

Thanks so much, Darren, for sharing a well-written and tremendously valuable story. My idea, based on a rudimentary knowledge of physiology, goes like this:

You have a tank. It's full of different kinds of gas: sugar, glycogen, fat, and in a real pinch, muscle (don't want to burn that stuff). When you're sick, your body burns all of its gas more quickly to help you heal, leaving you (often unknowingly) with less gas by the time you feel better.
Adrenaline really turns on the afterburners, making you be able to do a lot of things better, faster, stronger, but using a ton of gas in the process. It also blunts your body's warning signs that your tank is almost empty. When you are young and strong, it does that even more. But when your tank is empty, it's really empty.

This idea is bolstered by the fact that several times I've really maxed out on a winter hike, and it isn't till I get to the bottom (and the adrenaline stops) that I start shivering like crazy. The older I get, the less I try to do this.

Anyone with more in-depth knowledge is welcome to chime in.

Weatherman
 
Another key point...

darren said:
I had been increasingly biting off more and more with each successful solo trip. The more experience I got, the more I would do. Up to that point I had never had a backcountry mishap that I couldn't get myself out of.

- darren
... and the backbone of both the risk and safety of an envelope-based system (as mine is). I, too, continue pushing the boundary of what I can do, but I rely on mistakes and "bad luck" to fill up my bag of experience.

I am always aware, however, that I can't actually control the severity of what befalls me, except in the caution that I bring to bear.

Darren, I agree that you would probably have had an experience later, if not then, but are you now so dialed back that you don't get out there? I assume the answer is "of course not," but we do dial it in, and that's how we survive long enough to get that 'experience' bag filled up (before our 'luck' bag runs out).

I don't think hypothermia is a show-stopping risk, although it's obviously a show-stopping reality. It can be accounted for, as much as one can account for stroke, broken leg, or lightning.

Thanks for putting your story out there as an object lesson; great thread.

--M.
 
--M. said:
... and the backbone of both the risk and safety of an envelope-based system (as mine is). I, too, continue pushing the boundary of what I can do, but I rely on mistakes and "bad luck" to fill up my bag of experience.
The superb pilot is best defined as the pilot who uses
his superb decisions to avoid situations in which
he has to use his superb skills. --Dick Rutan
IMO, a nice quote that also applies to mountaineering.

The only problem is how one acquires (and survives long enough to acquire) those superb skills...

Doug
 
Dick Rutan said:
The superb pilot is best defined as the pilot who uses
his superb decisions to avoid situations in which he has to use his superb skills.

Very much like a quote that a driving instructor gave me. Basically it was "Don't consider yourself to be Mario Andretti (yeah, I'm dating myself) simply because you got yourself out of a skid that was your fault to start with"

Keith


DougPaul said:
IMO, a nice quote that also applies to mountaineering.

The only problem is how one acquires (and survives long enough to acquire) those superb skills...

Doug

See my tagline. :D
 
If nothing else this story will provide me with the motivation to carefully plan my winter hiking and possible contingencies for when things don't go according to plan. I think it will also motivate me to hike the more aggressive peaks in winter with companions rather than solo.
 
hypothermia

sorry i am tuning into this discussion late. maybe i can clear up some of the confusion/disagreement in the previous comments with what i learned while getting an AWLS certification for medical professionals (advanced wilderness life skills--a week of classwork and assessing fake victims) summer of 2005. this hardly makes me an expert but those teaching were definately so.... instructors had worked everest basecamp, insane credentials...

basically a persons thermostat is in their skin. so if your insides are warm but your skin is being cooled by wind and rain you feel cool and vice versa. shivering is the body's attempt to generate heat. if you warm someone externally without doing anything to heat their insides you risk both shutting off that shiver drive and causing the small vessels in the periphery to dilate, both leading to further hypothermia.

warm liquids are helpful but the amount any of us carries in a backpack would have only a negligible effect on core body temperature. (about 2L of warm soup is about 1 degree). sugar in any easily digestible form provides fuel for the furnace. if you have a stove, inhaling steam from hot liquid helps slightly too.

at 88 degrees a person stops shivering and has an altered mental status. under 90 degrees is considered profoundly hypothermic. it is still under this temp ( 86 and under) you worry about cardiac instability and gentle handling, for example if you have to provide cpr it should be at half the usual pace. there is nothing that can be done on the trail to rewarm someone at this point and the goal changes to preventing further heat loss. i agree with rooney that most of us would have difficulty not crawling into a sleeping bag with someone to try to prevent further heat loss regardless--moral vs scientific view, but hopefully none of us will be in this situation to have to make this decision.

obviously what goes on in an e.r. setting is a different can of beans. the profoundly hypothermic person is best not rewarmed in the field bc of risk of complications but again prevention of further heat loss is the goal in the field.
thats my two cents. hoping i wasted my money on the course and never have to put it to use.... :) :)
 
runnynose said:
basically a persons thermostat is in their skin. so if your insides are warm but your skin is being cooled by wind and rain you feel cool and vice versa.
I believe that I have tuned myself to perceive my internal temp and skin temp separately. Don't know if it is actually true, but that is my percept.

shivering is the body's attempt to generate heat. if you warm someone externally without doing anything to heat their insides you risk both shutting off that shiver drive and causing the small vessels in the periphery to dilate, both leading to further hypothermia.

at 88 degrees a person stops shivering and has an altered mental status. under 90 degrees is considered profoundly hypothermic. it is still under this temp ( 86 and under) you worry about cardiac instability and gentle handling, for example if you have to provide cpr it should be at half the usual pace. there is nothing that can be done on the trail to rewarm someone at this point and the goal changes to preventing further heat loss. i agree with rooney that most of us would have difficulty not crawling into a sleeping bag with someone to try to prevent further heat loss regardless--moral vs scientific view, but hopefully none of us will be in this situation to have to make this decision.
The temp sensor system also goes out of wack beyond a certain point and the victim can feel hot and take off insulation. IIRC, some have been found naked or nearly naked. One of the reports in one of these threads reported that the victim was found with his feet in a stream...

obviously what goes on in an e.r. setting is a different can of beans. the profoundly hypothermic person is best not rewarmed in the field bc of risk of complications but again prevention of further heat loss is the goal in the field.
There are three basic situations for dealing with an immobilized and nonfunctioning victim:
1). Professional help and a hospital are available within a few hours. Insulate the victim to slow his temp drop and get help.
2). Only a warm shelter (such as a private home) is available. You may be able to get the victim into the warm shelter, but still be unable to rewarm him successfully.
3). No help. No warm shelter. Not much chance of successful field treatment unless the victim can rewarm himself.

Obviously there are factors such as personell, available equipment, and weather conditions to be factored in.

BTW, transporting an unconcious victim can be very difficult--jostling the victim can thow him into fibrillaiton.

thats my two cents. hoping i wasted my money on the course and never have to put it to use.... :) :)
If you learned enough in the course to keep youself out of hypothermia, I'd say it was money well spent.

Doug
 
runnynose said:
basically a persons thermostat is in their skin. so if your insides are warm but your skin is being cooled by wind and rain you feel cool and vice versa. shivering is the body's attempt to generate heat. if you warm someone externally without doing anything to heat their insides you risk both shutting off that shiver drive and causing the small vessels in the periphery to dilate, both leading to further hypothermia.

Check with your instructors. Your thermostat is in you brain. It is called the hypothalmus. It doesn't care what the temperature of your skin is. It does care what the temperature of your internal organs is.

When your internal temps are ok you are vasonormal and not shunted. This means if you have cold temperatures at the skin cooling the blood that is carried into the body core and that lowers your core temperature then the hypothalmus starts the hypothermia sequence with shivering.

On the other side of the equation when you are hypothermic and vasoconstricted and shunted any heat that you apply to the skin doesn't get to the core because there is very little blood in the extremities and it is moving very slowly into the core. It is not enough to make any difference in core body temp.

FWIW,
Keith
 
hypothalamus on a hiking website??!!??

you misunderstand me....
temperature receptors are at the skin level sending a message to the anterior hypothalmic regulatory system which begins the shiver response.

also the physiology is far more complex than your summary. for example, if you were to wrap a blood pressure cuff around your forearm so no blood travelled back to the rest of the body and then dunked your hand in icy water all of your extremities would vasoconstrict not just the icy arm even tho the other extremities experienced no cold. this is the hypothalamus at work. but to a lesser degree vessels in the hand also respond directly to cold without that regulation. and so the reverse is true, applying direct heat to an extremity causes both local and generalized cutaneous (skin) vasodilation and therefore heat loss. it is true that if an extremity is vasoconsticted blood flow is poor but this is not the only mechanism at work.

also prolonged cold exposure eventually leads to vasodilation --the "paradoxical undressing" you hear about --a blast of heat at the end, why everest victims have been found dead with their jackets off, etc. this was mentioned previously.

i am happy to hear, dougpaul, that you are in tune with your gut. this sounds like a fine idea. :)
 
runnynose said:
also prolonged cold exposure eventually leads to vasodilation --the "paradoxical undressing" you hear about --a blast of heat at the end, why everest victims have been found dead with their jackets off, etc. this was mentioned previously.
I've heard it called "paradoxical heating", but it is the same beast

i am happy to hear, dougpaul, that you are in tune with your gut. this sounds like a fine idea. :)
Works for me. :)
(Or at least, it has so far...)

Doug
 
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