Leaving Costa Rica

It's 5 a.m. here; the first airport shuttle has left Rafiki.  The second will leave in two hours.  Everyone is healthy and happy, ready for a short hiatus and then the snow!

We are once again so fortunate to have such an amazing group of motivated and intelligent students.  Swiftwater rescue training ended with everyone working until the last moment, determined to learn as much as they could and enjoy their time in the tropics.  We look forward to getting together in Montana and continuing the experience.

River Rescue

We have moved from Mastatal and are now based at Rafiki Safari Lodge, a wonderful inland location midway between Quepos and Dominical. Cody Harris, of the Whitewater Rescue Institute, has taken over instruction in swiftwater rescue, with drowning lectures provided by Dr. Greg Moore.  Our students have continued their outstanding track record of commitment, hard work and physical prowess.  We'll let the photos do most of the talking; but briefly, we're practicing on the Savegre River with throw bags, swimming through whitewater to river eddies, hauling victims out of the river, and continuing medical care on shore.  Today the students are practicing righting flipped rafts, setting up tension diagonals and z-drags to haul boats and people across the river, and - time permitting - sliding down the "world's fastest waterslide." Thanks again to Greg Moore and his wife Lori for being good sports about getting thrown repeatedly into the river for rescue practice.

Clinic and Leaving Mastatal

Over the past two days, Aerie students assessed, triaged and handed-off care of over 40 people from Mastatal and the nearby indigenous community of Zapaton.  This is always an amazing experience.  The clinic is made possible by the arrival of Aerie instructors Dr. Greg Moore and Fred Westering, PA.  Students watch as these experienced care providers assess and treat their patients, and then have the unique opportunity to receive individual feedback on their assessments and patient reports (see second photo).   

Tomorrow, we leave Mastatal after a month of living in this incredible community.  We are heading to the Rafiki Lodge on the Rio Savegre.  Over  five days we will complete our Swiftwater Rescue Technician training with Cody Harris from the Whitewater Rescue Institute.  Cody is a world-class instructor; we are very fortunate to have him with us.  

About Last Night

Given GPS coordinates, students gathered their hasty-packs for their epic, late-night jungle scenario.  Their four patients received outstanding care: one abdominal injury complete with impaled knife; one compound femur fracture; one pelvic fracture and head injury; and one sucking chest wound.  As the scenario wore on, it became clear that the group would not be able to get all these critical patients out of the depths of the river bottom before dark.  The students performed two outstanding patient carries on improvised litters through the river, in the dark, using the light of their headlamps and excellent leadership and communication.  We called a halt to the scenario after all patients were stabilized and readied for a night out.  Kudos to this fine group of hardworking students!!

Today, students spent the morning preparing for an afternoon of teaching the local high school students a series of first aid skills.  Thanks to excellent planning on the part of our students, the efforts of our translators and some excellent Spanish speaking skills within our own student group, the local estudiantes learned how to control serious bleeding and clean & dress wounds; how to splint forearm and ankle fractures; how to construct an improvised litter and safely move an injured person on a litter; and how to clear an obstructed airway and perform cpr on both infants and adults.  

Practice

In preparation for a long night exercise, we are practicing moving people through the forest.  It's muddy and thick!  Moving is slow and arduous.

Last Week in Costa Rica

Apart from general rest and rehab this past weekend, we rallied on Sunday night and made dinner for ourselves and the crew at the ranch.  We made homemade pasta and raviolis stuffed with squash for 40+ people.  It was an event.

Every day this week is packed.  Today, we are completing instruction in improvised litter construction.  Then, unbeknownst to the students, they are heading out this afternoon with GPS coordinates and gear for a long scenario.   They will be dispatched to a large wild area on the border of the local national park - a site they've never visited before with a maze of trails depicted only on hand-drawn maps.  They will encounter at least 4 victims with multiple injuries from tumbling off a 20m high waterfall, slipping on slick rock in the stream, sliding down an unstable slope headfirst, and some other horrendous malady we haven't decided on yet.  The students will, of course, have less gear than they'd like, less outside help than they'd like, and fewer radios than they'd like, but they will show off their true talents in improvising care in a wilderness setting. The scenario is planned to last well into the evening, so utter darkness will also factor into their challenges.  Hence the potential need for celestial navigation (picture below).

Tomorrow, students will be involved in teaching wilderness first aid skills to the 20 students at the local high school. Some of our students will be busting out their rusty Spanish language talents and we'll also use the translation skills of our own Fernando Giaccaglia, as well as several Ranch interns.  Our students will spend the morning prepping to teach wound cleaning and management, pressure wraps for significant bleeds (caused here by things like machetes), burn care, foreign-body airway obstruction & clearing airways, and improvised litters: all things likely to come in handy for families here, things which can rely heavily on demonstration and less on verbal communication, and which might spark an interest in first aid or medicine amongst the local kids.  We might also teach hands-only cpr, just so we can crank up the volume on Stayin' Alive.

Students will be washing and ironing their nicest clothes later today (??)  in preparation to clean themselves up so they can participate in the health clinics in Zapaton on Thursday and here in Mastatal on Friday.  We welcome Dr. Greg Moore, his wife Lori, Fred Westering (a Physician Assistant) for their contributions to the clinic.

End of Third Week

 Yesterday was Lex's birthday!

This group is highly prone to tragic events.  Today, out for an innocent bird-watching exercise, three unsuspecting tourists were horribly injured when an earthquake struck.  Serendipitously, 14 wilderness EMTs were prepared.  Using GPS coordinates given to them from witnesses, they found the patients about a mile from basecamp.  From there, they had to correct injuries that you might expect from a rock slide generated by an earthquake: head injuries, fractured femurs with significant bleeds, and holes in chests from falling debris.  Unfortunately, all of the patients ended up in the river, so our students had to move them over slippery, uneven terrain before serious care could begin.  Once on shore, groups began the difficult work of long-term care.  As nothing happens easily here, the quake struck later in the afternoon, precluding an easy or early evacuation.  This required setting up shelters and preparing for the night out.

We are now in our final official weekend in Costa Rica. From here out, things change rapidly.  Four more Aerie staff arrive this week.  Dr. Moore, our Medical Director, and Fred Westering, a PA in Missoula, will be here to lead the medical clinic that occurs at the end of the week.  Cody Harris, owner of the Whitewater Rescue Institute, arrives to help with the clinic and then run the Swiftwater Rescue Technician course that begins on Saturday.  Jillian Wheeler will arrive to help run the clinic, scenarios and the swiftwater course.

This weekend, some students are heading up la Cangrega, the tallest mountain in the area, for some sightseeing.  Some are getting involved in Ranch activities like gardening.  All are catching up on reading and finishing a large take-home exam.

Thursday

The day started with a bleeding and screaming student.  The basic idea was to give us, the instructors, a bit of the medicine we have been dishing out for the past two and a half weeks and to watch and see how we would handle the emergencies we are asking them to manage.  It's fair and fun and Bren survived, albeit with some lingering tenderness on his leg where he had a tourniquet applied.

The day proceeded with instruction in bleeding management, including use of said tourniquets, hemostatic (clotting) agents, and pressure wraps.  In no other field of prehospital emergency care has so much changed so recently.  Gone are the days of elevating bleeds.  Gone also are the use of pressure points and raising a patient's feet above their head.  All have been shown to be either useless or harmful.

The day ended with a full afternoon of practical examinations, including navigation, knots, and medical scenarios.  With four full-time instructors on site, we are able to give a lot of personal instruction and feedback.  

OTHER THOUGHTS:  IMPROV, 101

We always learn from our students.  Every now and then, their ideas really stun us.  The photo below is  an idea that we have not seen before in any manual but that we believe would work incredibly well.  Best of all, it was thought up by a Semester student, Sam Dougherty.  It's a chest seal with a one-way valve created by taping a CPR face-shield over a sucking chest wound. The face mask would allow air to escape out of a chest wound but not permit air to rush back into the chest during inhalation.  Brilliant! It looks very, very much like models that we carry on the ambulance (Asherman model), but meets the standard for being carried in a backpacking first aid kit: it has more than one function and it's lightweight.  

A photo of Jeanie's, the students' dorm.  

Tomorrow we head back into the forest for more extended scenarios that combine skills taught to date.  Students will need to locate patients with GPS coordinates, access them in difficult terrain, stabilize their injuries and prepare for an extended evacuation.  We will all sleep well tomorrow night!

Valentine's Day, Head Injuries and GPS Receiver Use

Interrupted only briefly by Valentine's gift-exchanges, the morning was filled with discussions about head trauma in an urban and wilderness setting.  Andrea took over in the afternoon to review navigation concepts from yesterday, then oversee students putting together their own orienteering courses for fellow group members to follow.  As we write, students are trekking through the forest using their new GPS skills and burgeoning situational awareness to develop a map of the local trail system down to the Rio Chires.  For anyone accustomed to using UTMs, it's eye opening to work off of Costa Rican maps that use their own kilometer grid system which is wholly separate from ours.   It takes time and practice to work between these maps and GPS receivers and be able to come up with a system that is useful and practical in an emergency.

Tomorrow, after sharing their hand-drawn maps, students will have a written exam and more instruction in spinal cord injury and bleeding and shock.

Weekend Update

There are strong rumors circulating of an Ultimate Frisbee game, Aerie vs. the Ranch.  But, game time is about a minute away and we don't see anyone on the field, so this may have been a bluff.

Instructor Andrea Stephens arrives today from Montana.  Andrea coordinates the Semester and here is responsible for instruction in route finding, including GPS, map and compass, and basic celestial navigation.   She will be with us for the rest of the Costa Rica section and continue the instruction in Montana.  Not surprisingly, navigating in the Costa Rican rainforest is different from finding your way in MT.  First of all, there is almost 0 declination here; magnetic and true North line up fairly well, particularly for gross-navigation.  Missoula's declination is about 17E.  Another significant difference is the angle of the sun off of the horizon.  Right now in Montana, the sun is LOW is the Southern skies throughout much of the day.  Here, at 9 degrees off the equator, the sun is straight up throughout the late morning and early afternoon.  It takes some adjusting to get your bearings.  Finally, bushwhacking takes on an entirely different meaning in the rainforest.  The undergrowth is thick, many of the shrubs and trees are thorned, and quite a few of the forest denizens are venomous.  In Montana, we think of megafauna, concern ourselves more with the significant distances to care, and generally can find open vistas and routes to follow.

Andrea will prepare our students for these variables within the context of caring for injured and sick people.  It's going to be fun!

End of Second Week

It's hard to believe that our Costa Rica time approaching its mid-point; that is, until we look at what the students have worked through to date.  Over the last few days, we have reviewed neurologic emergencies, diabetes and anaphylaxis.  Today began with a tour through things that bite, sting and otherwise cause skin irritations, at the end of which everyone was scratching and generally feeling like hiding.  To improve spirits, we headed back down to the waterfall for an afternoon of extended scenarios. Students found patients floating in the water and had to safely extricate them to shore, set up emergency shelters and plan for the night out.   Moving an unresponsive adult out of a deep river and carrying them over slippery rocks is incredibly challenging on its own.  Add to this the need to protect the patient's spine from movement  and your own feet from the environment, and this becomes an ever-more challenging exercise.  The keys to success are clear communication and leadership.  We practice this every day, adding and refining skills, preparing our students to provide care in any environment.

The Rio Negro sits about a mile from our classroom and is one of our favorite spots for running extended scenarios. After lunch today, students packed up oxygen tanks, oxygen-delivery supplies, survival packs and jump kits (filled with materials needed to initially manage airway, breathing and circulation emergencies) and hiked down to the river.  As promised, they needed to assess and treat patients while setting up for an overnight in the forest.  The underlying assumption for most extended scenarios is that outside help is at least a day away, and that, if it arrives, it may not provide the type of assistance you might expect in a front country emergency in the US.  We stress self-sufficiency and train our students to expect an unexpected night out with a very sick patient.  It is one thing to assess a patient in a sterile classroom and quite another to do so on a rocky streamside shared with biting ants, tree frogs, river debris and the potential for more venomous creatures under anything you move.   There is no substitute for these learning experiences.   

Of course, between scenarios, swimming, wildlife watching and general levity are highly encouraged!

First Day of Week Two

Another beautiful sunrise this morning.  Today was our hottest to date.

Class today included a full morning of anatomy, physiology and pathophysiology, followed by a review of pharmacology.  We increased our knot repertoire, reviewed last Friday's exam, and practiced clearing airways when no formal suction equipment is available.  

As a reward for an intense day, we head down to the river tomorrow (after discussing cardiac and respiratory emergencies) for extended medical and survival scenarios that will combine most, if not all, of the skills learned to date.   Although the students don't know it yet (they wont be reading this blog until tomorrow night!), they will have to assess multiple patients with chest pain and difficulty breathing, make shelters, build fires and set up for a night out with very sick patients in the rain forest.  There is nothing easy about these scenarios; neither are there any quick fixes.  Sick patients require ongoing, accurate assessments, stabilization and evacuation.  However, evacuations are complicated and strenuous, putting rescuers and patients alike at risk.  It should be a great day for learning!