I have a story where a character gets their leg caught in a bear trap, and due to other injuries aren't able to free themselves on their own. When they are rescued by a character proficient in wilderness medicine, what steps would they take to treat them, in a situation where access to emergency care is not possible for the foreseeable future?
It would kind of depend on the injury incurred. Depending on the type of trap, they may see:
Broken bone with no broken skin
Broken skin/soft tissue injury but no broken bone
Both broken bone and broken skin
With any of these scenarios, someone trained in wilderness first aid is going to start with their Primary Assessment. This means determining immediate life threats to a victim’s Airway (is their mouth/nose/throat/chest intact enough to support breathing), Breathing (are they actually breathing), Circulation (is their heart beating/is there life threatening blood loss that needs immediately addressed), Deformity/Disability (is the mechanism of injury something that may have caused a head or spinal injury), and Environment (is there something life threatening about where they are- cold, heat, physical danger).
Once that is done and life threats are addressed (tourniquet application, stabilizing a possible spinal injury, getting the patient on dry ground), the Secondary Assessment can begin. This includes vital signs (in the wilderness, vital signs are pulse rate, respiration rate, level of consciousness, and skin condition (color, temperature, and moisture), a brief medical history (usually following “SAMPLE” or Signs/Symptoms (what are you feeling/what hurts?), Allergies (if the patient has any allergies, if they came into contact with any allergens recently), Medications (do they take any medications? Did they take them today?), Past Medical History (has anything like this happened before? What did they do about it then?), Last Intake/Output (have they eaten/used the restroom recently? Was it normal for them?), and Events Leading Up To Injury/Illness (how/when did this start? What were they doing just before?). It also includes a full-body pat-down, exposing as much skin as possible without damaging clothing that might be vital to keeping the patient warm for the rest of the journey.
The full-body pat down ENDS with the obvious injury. This is because it is really easy to get caught up in treating a specific, obvious, or scary-looking injury and miss a more subtle but life threatening one until it is too late.
If you’re interested, this chapter from Michael Palmer’s Resistant is probably the best I’ve ever seen this process done in fiction.
In this case, the rescuer may choose to remove the trap during the “Environment” or “Deformity/Disability” portion of the primary assessment, but unless that causes life threatening bleeding, they’d go through the rest of their assessment before coming back to the actual injury.
Once they had completed both their primary and secondary assessments, they’d start assessing the injury itself. This is going to be a musculoskeletal assessment, meaning the rescuer is going to assess for “CSMs.” CSM stands for Circulation, Sensation, and Movement. Assessing circulation is going to help determine how much damage has been done to the vasculature (essentially, is the foot getting the blood it needs), and the sensation and movement assessments are going to help determine how much damage was done to the nerve (is the foot still getting nerve impulses).
Generally, each of these assessments are going to be compared between the injured and uninjured limb (for example, if the right ankle is injured in the bear trap, they’d assess the right ankle, and then also do the same assessment on the left ankle for comparison), and above and below the site of injury (for example, for the same ankle injury, they’d do the same assessment near the right knee and on the right foot).
The Circulation assessment is generally about finding pulses. They’d want to find a pulse “above” the site of injury first. For a right ankle injury, this would be either the femoral pulse in the groin, or the popleteal pulse behind the knee. Checking one of these pulses on both sides confirms that there isn’t an injury further up that could complicate your assessment (in which case one of the limbs wouldn’t have a pulse and the other would), or that the patient’s blood pressure isn’t so low that there isn’t a pulse at all in the legs (which needs more immediate attention).
Next, they’d find a pulse “below” the site of injury. This would be on the foot on the side of the injured ankle. There is a pulse on the top of the foot, between the tendon going to the big toe and the one going to the second toe in. They’d find that on the injured side, and compare it’s strength and timing to the one on the uninjured side. They would also touch the skin of both feet at the same time to make sure they had the same temperature.
Next, they’d move on to the assessment of Sensation. This would entail having the victim close their eyes, and the rescuer touching the bottoms of their bare feet, first on one foot, then the other, having the victim identify which foot was being touched. Then, they’d touch both feet at the same time and ask if they felt the same or different between the two. They may do this several times, in several places, to make sure the victim wasn’t just guessing.
the last assessment of the injury would be one for Movement. The rescuer would start by having the person wiggle their toes on both sides at the same time, and compare the movement. They would then have the victim roll, flex, and extend their ankles while holding or pressing on various aspects of the victim’s feet, comparing the strength of the injured and uninjured sides.
By this point in the assessment, the rescuer knows the following:
If the person is in a life-threatening situation (and if so, have managed it)
A baseline set of vital signs
A medical history for the patient
Any other injuries they have
Whether or not the ankle is broken (significantly decreased strength and movement (with a lot of pain) on the injured side)
Whether the injury has disrupted the blood flow to the foot (pulses are not equal between feet, temperature is unequal between feet)
Whether the injury has disrupted nerve signals to the foot (sensation is not intact between feet).
So now they are finally ready to treat.
Now, if there’s no way to get to surgical care, I would highly, highly recommend you go with either a bear trap that causes a minor fracture (where the bone ends are still lined up correctly, can still be very painful, though!) with no broken skin OR broken skin with no fracture. I would also advise that you go with no (or very limited) nerve or circulation damage, as the nerve damage will likely be permanent and circulation damage would cause the foot to die without surgery. Unless you’re trying for a field amputation, because that could be your other option.
They’d then clean the wound (any water will do as long as they’d feel comfortable drinking it), getting as much dirt/debris out as possible, bandage, close, or pack it. They’d splint the ankle (there are plenty of good resources for this out there- search for “improvised splint for ankle” or similar) and then assess weight-bearing by supporting the person as they put gradually more weight on the splinted limb until it was too painful, which would give a good indication of how functional the person will be in the near future. Functionality is key, as a single rescuer is generally not going to be able to carry someone out of the backcountry.
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