#cycs

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CYCS... Hypothermia?

Let's set the scene. It's cold. Outside the cabin, the wind howls. Character A has had a crush on Character B for as long as A can remember and what's this? B spent too long outside and has caught quite a chill? The only solution, surely, is to get in a sleeping bag and cuddle until B has warmed up. Hopefully, the treatment won't awaken anything in anyone... and hopefully, it will treat the hypothermia.

What is Hypothermia?

Hypothermia is when your body gets too cold. If you want to get all technical about it, it's when body temperature falls below 95 degrees F, but in the wilderness, we don't usually need a thermometer to reckon something is hypothermia and treat for it.

Types of Hypothermia

Acute hypothermia

Character A and B wanted to enjoy a nice (romantic?) skate on a frozen pond before retreating back to the cabin. Suddenly, the ice cracks (this is why we don't skate on frozen ponds). A leaps forward but it's too late—B has fallen through the ice into the freezing cold water below.

A conducts an excellent rescue, hauling B back onto ice and then onto dry land, but even being in the water for a few minutes has caused B's body temperature to plunge. She is now suffering from acute hypothermia, which is hypothermia caused by a sudden, large decrease in body temperature

Long-onset hypothermia

A and B opt for a cross-country skiing trip over the taiga. They're bundled up against the cold: hats, gloves, long underwear, snow pants, the whole nine yards, ten yards even. As time passes, B catches a bit of a chill, but it's nothing too bad. The team decides not to stop for lunch so they can get farther and by the time they return to the cabin, B is a shivering, babbling mess. She is suffering from long-onset hypothermia, which is hypothermia that occurs when someone is a little too cold for a little too long.

Unlike in acute hypothermia, by the time A starts to treat B, B's body has used up most of the resources it has to regulate temperature.

Symptoms of Hypothermia

Hypothermia can be roughly separated into three stages: mild, moderate, and severe. Everyone, I'm sure, will be surprised to hear that severe hypothermia is the worst. However, mild hypothermia isn't just "really cold." To count as mildly hypothermic, B needs to have an altered mental status.

Symptoms of mild hypothermia

A few obvious symptoms:

Shivering

Feeling cold

Reduced coordination

A few less obvious symptoms:

Nausea

Hunger

Confusion (gotta get that altered mental status)

Faster breathing

Symtoms of moderate hypothermia

Moderate hypothermia is my favorite stage because we break out the uncontrollable shivering. We've all shivered, I'm sure, but if you expend some effort, even if you are "really cold," you can stop shivering.

Not so in moderate hypothermia. B is literally incapable of not shivering anymore.

B is also suffering from all of the symptoms in mild hypothermia but worse now.

Severe hypothermia

Uh oh. Uh oh. B has... stopped shivering.

This is bad. The body is so cold, it can no longer compensate by vibrating really fast. This is when you get patients who remove all their clothes (called, to my delight, paradoxical undressing) even though they are dying of being too cold.

B is now extremely confused, probably not making much sense when she speaks, if she can speak at all. Her heart rate is weak—if A checks her pulse, she may not even have one anymore (but don't initiate CPR!). She's panting more than breathing.

If the hypothermia progresses untreated, she will slip into a coma and die.

Complicating factors

What can make hypothermia worse? All the usual stuff: being young, being old, being sick, having a head wound that exposes the brain to the elements (you know, just normal stuff).

Less intuitive, perhaps, is that burn patients are at a high risk of hypothermia. (Imagine how annoyed you'd be if you burned yourself [got too hot] and then simultaneously had hypothermia [got too cold]). But, burns are basically big open wounds on your skin. Skin helps regulate body temperature and keeps your warm (sort of like blanket?) and if it is injured, it struggles at the job.

In all but the most balmy environments, as soon as someone gets an extensive burn, the wilderness first responder is thinking about the increasd risk of hypothermia.

But enough about that. Let's get A and B into the same sleeping bag.

Treating Hypothermia: when do my characters get to cuddle??

Severe hypothermia cannot be treated in the field. When people who get super cold are rewarmed in hospitals, they suffer from myriad heart problems, including heart attacks and strokes. Unless you need a lot of angst in your story, refrain from giving your character severe hypothermia.

So, how to treat mild or moderate hypothermia? Two things are key: 1) human burrito, and 2) food, food, food.

Human burrito

B is too cold. What's warm? Blankets! One legit wilderness treatment for hypothermia is to essentially wrap B up in a ton of blankets.

A places B on a blanket or in a sleeping bag. She carefully puts hot water bottles on her neck, armpits, thighs, and ankles (or other places—if A doesn't remember where to put them, a hot water bottle basically anywhere won't hurt). A zips up the sleeping bag, then burritos B in the blanket until she is all snuggly and warm.

Source

No water bottles available? Uh oh. Guess A will just have to slide into the sleeping bag next to B to keep B cozy and warm. (Note: water bottle method is preferred becase 1) water bottles are warmer than people, and 2) it frees A up to move on to the next stage of treatment).

Food food food

A has just dragged B in out of the cold and diagnosed her with hypothermia. The only food they have in the cabin is ice cream in the freezer and a pot of water that she could boil to make tea. What should she feed B?

If you guessed hot tea, congrats on being incorrect. The best food to give to a hypothermic patient is whatever food you can give them immediately, in this case, ice cream.

Fun fact: in stage two of hypothermia, you burn 600 calories an hour from shivering (or an entire Snickers bar each hour). Replacing these calories is vital.

But, I hear you cry, ice cream is cold! Won't ingesting cold food make B colder? To which I reply, yeah, maybe, but it's all sugar and fat and you know what sugar and fat are good for? Shivering. B cannot ingest enough hot tea to warm herself up from hypothermia—she needs to shiver her way through this. This also means tea without sugar is essentially useless to treating hypothermia. If someone is really cold, all we care about are calories.

Conclusion

Hypothermia occurs when you are so cold, your brain stops working right.

During hypothermia, first patients shiver a lot and then they stop shivering and this is actually worse.

Treat hypothermia by wrapping the patient up in blankets and feeding them a lot of any type of food.

Yes, if you must, your characters can cuddle for warmth to treat hypothermia. Just make sure there's a lot of food within reach from the sleeping bag.

[icasttourniquet]

Common Misconceptions: Raising the Dead (CPR)

Let's start with the bad news: basically all the CPR you've seen in movies and TV shows is performed terribly.

Here's the good news: most CPR is performed on dead patients, which means even bad CPR is better than nothing.

What is CPR?

CPR stands for (googles hurriedly) Cardio-Pumonary Resuscitation. It has two parts: 1) chest compressions and 2) rescue breaths. Here's a video in case you're still confused, but most people have seen CPR performed a ton of times during the climaxes of medical shows. It comes right before either a) the nurse yells "Clear!" and the patient comes back to life or b) the EMT says "I'm not losing you" and injects the patient with adrenaline right to the heart, and then they come back to life.

Raising the Dead

CPR is generally performed on dead patients. That is, patients without a pulse. In the first responder business, the situation doesn't really get worse than dead, so it provides a unique opportunity for authors because you can't really get it wrong.

Here are some questions I've heard people ask while learning CPR:

Should I perform CPR on pulse-less patients who have chest wounds?

Can I continue performing CPR if I break a rib?

Should I perform CPR on pregnant people?

What if I can't give rescue breaths? Should I still give CPR?

My patient has a lot of broken limbs. Should I fix those before performing CPR?

My patient was electrocuted. Should I give CPR?

Here's the trick to answering all your CPR questions. Is my character dead (no pulse)? Does performing CPR put a) the first responder, b) another patient, or c) a bystander in danger?

If you can answer (yes) (no, no, no), congratulations! Your first responder can perform CPR, even really crappy CPR, even CPR that is ineffective, for as long as the plot requires (ModN's WFR instructor tells the story of a 6-hour CPR session on a dead patient during a journey to care that included a toboggan ride).

(NOTE: there's actually one solid contraindication: if the patient is severely hypothermic, their heart rate may be so slow and weak as to be undetectable. In this case (and pretty much only this case) chest compressions may actually do more harm than good. Other than that, obvious signs of death like decapitation or rigor mortis indicate you don't need to start resuscitation, but there are still plenty of compelling interpersonal reasons to do it – at that point you're doing CPR for the responder and survivors rather than the patient.)

Otherwise, your character should go for it!

The bad news about CPR

Time for the bad news (other than you having a dead character on your hands). In general,* CPR is not enough to bring someone back. Its role is to continue circulating oxygenated blood while you wait for a defibrillator like an AED to arrive. The AED or manual defibrillator is what actually convinces the heart to stop fluttering/beating erratically, and allows it to resume something like a normal rhythm. That means that in the wilderness, CPR is almost never going to work. That said, ModN's WFR instructors had a couple tales of AEDs falling from the sky (via helicopter, not under their own power), so it's worth trying regardless.

* The exception: lightning-struck patients can at times restart regular rhythms with just chest compressions. This leads to interesting triage considerations when dealing with the aftermath of lightning, but that's a subject for another post.

How to perform non-crappy CPR

There are a million videos on YouTube that can talk you through every sort of CPR. Keeping in mind, of course, that some CPR is better than nothing on a pulseless patient, here are some quick tips that could indicate your character has some training:

Your character distinguishes between adult and pediatric CPR. Because children don't tend to get heart attacks, pulse-less children almost always have a trauma or respiratory cause. This means responders give children more rescue breaths.

Your character keeps their elbows locked. Here's a playlist of some examples of bad CPR (and some are really quite bad). Actors generally can't lock their elbows because they'd risk injuring or even killing their scene partner (so, okay, fine, that's a decent excuse), but people with real training will know better.

They do not always give rescue breaths. Any CPR is better than no CPR. Rescue breaths can put the first responder at risk because they can involve lip-to-lip contact, assuming no PPE is available. I once had a paramedic say bluntly that he really only gives breaths to children—it's just not worth the risk to him for anyone else. If this sounds callous, remember, CPR is (almost) only performed on dead patients, and the number one priority in any disaster is yourself.

(ModN edit: in a professional setting your character will always have some sort of PPE for rescue breaths: a face shield at the minimum, or in the front country a full-blown bag valve mask (BVM) that allows them to use their hands to get air into the patient.)

Your character does a blood sweep before staring CPR in a trauma injury. You may have heard the rule no pulse = chest compressions immediately. This is almost always true, especially in the frontcountry, when most pulse-less patients you encounter will have had a heart attack. However, in the wilderness, we can run into a bad situation: chest compressions that pump all my patient's blood out the gushing wound in their side.

Maybe you're thinking, hey! I thought you said my character could always do CPR on a dead patient and they'd be fine! And yes, I did say that—thank you for listening. If your character performs CPR on a patient with no pulse and arterial wound, they have not killed their patient. This is because the patient was already dead. They have not "sped up" the bleeding out process because this patient has basically already bled out. So, I'm not blaming your character for anything.

That said, the pro-est of pros will do a blood sweep after finding no pulse and stuff/apply direct pressure/tourniquet as necessary. As an added note, your character with no pulse and the arterial bleed? Probably not going to survive.

This leads me to...

Writing more realistic necromancy

If your character's CPR is successful, your character has just raised the dead. Thinking about it this way can help you write more realistic resuscitation scenes. Here's the number one thing that will make all your CPR more realistic:

Your dead patient does not go from dead to walking and talking in a few seconds.

When the body has no pulse for a while, it gets unhappy. This is because all its internal organs are dying and also because it is dead. CPR replicates the pumping of a heart, but not particularly well. Most people whose organs are all dying don't get that shot of adrenaline to the heart (this is not part of any WFR or EMT protocol but whatever) and then go back to swashbuckling adventure after a quick sip of water.

In fact, in real life, checking the pulse of your patient is an important part of performing CPR because sometimes they come back to life and you don't notice.

So how might you accurately describe someone who's just come back from the dead via CPR (possibly plus defibrillation)? May I recommend some of the following words (no need to cite me—just plop 'em in your writing):

Unconscious

Unmoving

Pale

Clammy

Weak pulse

Non-responsive to pain

Not dead!!!

An added point: absolutely no one whose heart stopped is now "okay" because their heart restarted. They are "not dead" because their heart restarted. Admitedly, not dead is pretty good in the first response business, but they need to see a doctor. As soon as possible. This is because something caused the heart to stop and CPR did not treat that underlying cause. Many people who come back from the dead die again soon after, and could come back and die multiple times before picking a state more permanantly.

Wilderness-Specific CPR

In the wilderness, we have get one (1) special CPR-related ability and that is the ability to stop.

In the US, there's a thing called patient abandonment that can get folks in trouble. Basically, if you start treating a patient, you need to keep treating them until 1) they are dead, 2) they are conscious enough to refuse further treatment and do so, or 3) someone else with an equivalent or higher level of training is treating them (ModN: as a W-EMT this is tricky – it's hard to find people more qualified in the wilderness to hand a patient off to!).

Because WFRs and EMTs cannot declare patients dead, and a dead or unconscious patient cannot refuse treatment, that means you are treating them until someone else is treating them. (As a side note, my first first-aid instructor told the story of performing CPR for 30 minutes in an ambulance on a patient missing part of his brain [this is bad] because the police officer at the scene didn't want to declare him dead on the highway, which would mean shutting down the road for a few hours).

CPR is unique, however, because it's performed on dead patients. The law doesn't want a poor WFR to be stuck in an endless CPR loop because they can't abandon their patient, so in the wilderness only, your character can stop CPR:

After 30 minutes of sustained pulselessness.

If another patient needs more help.

If continuing is dangerous to self or others.

Otherwise, backcountry and frontcountry CPR are pretty similar.

Summary

CPR is generally performed on dead people.

It is difficult to get worse than dead.

Garbage CPR is better than no CPR.

Recovering from being dead takes time and always warrants more care.

WFRs have a superpower and it is called stopping CPR.

Good luck raising your characters from the dead!

[icasttourniquet]

Can Your Character Survive... Avalanches?

Alternative title: why your character who lives in the mountains should be more scared of avalanches than they currently are.

What's an avalanche?

Avalanches are large masses of snow that speed down mountainsides, carrying humans with them. There are a number of different types of avalanches, depending on who you ask. Let's look at a few:

Wet Snow Avalanche

These avalanches are relatively safe, as far as avalanches go. They travel slower than their dry counterparts (10 to 20 miles per hour) and are harder to trigger. However, wet snow is often a good deal heavier than dry snow, so getting buried in it is still inadvisable. 

Sluffs

Sluffs are dry avalanches composed of the top layer of powder moving downwards. They occur when the weak layer of snow is on top as opposed to underneath, and they are far less dangerous than the opposite, a slab avalanche.

Slab Avalanche

(Or, as I cannot help but say in my head every time I read about them: Slabalanches.)

A slab avalanche occurs when the weak layer of snow is on the bottom. When an avalanche is triggered, the weak layer separates from the slope and carries with it the stronger, more cohesive snow on top of it in a slab. 

Slabs are typically about the size of a football field and more than a foot deep. They can reach speeds of 20 miles per hour within three seconds, 80 miles per hour within six seconds, and max speeds in excess of 150 miles per hour. 

Hidden by more compact snow, the weak layer can lie in wait for days or months until something heavy (say, a human) triggers it loose. To make them even deadlier, the break often occurs above whatever triggers it, meaning the victim is already on the slab when it starts to speed down the slope.

How do avalanches kill you?

In the words of Shakespeare, let me count the ways. (spoiler: there are two).

Asphyxiation

In a study in Utah, 85% of avalanche fatalities died of asphyxiation alone. This is likely because humans cannot breathe snow [citation needed].

Once an avalanche gets going, the snow behaves sort of like water, and any humans trapped in it sink. However, unlike water, when the avalanche stops moving, it hardens, leaving the sunken human entombed in concrete-hard snow—this snow sometimes also hardens in the victim's lungs, with predictable consequences. It is essentially impossible for a fully buried human to dig themselves out of an avalanche—most victims won't even be able to move their limbs. It is now a race against time: can rescuers dig them out before they run out of air?

To make matters worse, human breath is hotter than snow. As the trapped human exhales, they melt a small pocket of snow around their face, which then refreezes as far-less-permeable ice. Any chance of breathing through the snow pack has now disappeared.

Source: A concept for optimizing avalanche rescue strategies using a Monte Carlo simulation. (And you know a paper is good when they're whipping out the Monte Carlo simulations).

After only about 20 minutes, a buried victim has less than a 50% chance of survival. Avalanche rescues are all about time time time. But I'm getting ahead of myself.

Blunt force trauma

In the remaining 15% of cases, that same Utah study found that blunt force trauma was involved in the death. This hopefully makes sense, given how fast, heavy, and large avalanches are.

In some terrains, avalanches can take helpless victims through a "sieve." Let's say you had to be dragged down a slope at 150 miles per hour. In the picture below, which slope would you prefer: A? Or B?

Hopefully, you said B. While being dragged anywhere at high speeds is undesirable, at least B is empty. A is a sieve, and anyone swept through those trees would be lucky not to hit at least a couple of them.

Avalanche Likelihood

According to Bruce Temper's Staying Alive in Avalanche Terrain, 9 out of 10 avalanche victims trigger the avalanche that kills them. That means your character has a lot to do with whether or not they die.

Since we are are all authors here, let's design the scenario most likely to kill a character.

Avalanche-friendly conditions

There has been a recent, dramatic change in weather (storm to no storm, hot to cold, cold to hot, etc.).

The slope is between 30 and 45 degrees steep (contrary to popular belief, steeper does not automatically make an avalanche more likely). Side note: humans are rubbish at judging slope, so a modern-day experienced backcountry explorer will likely have her clinometer on her.

The slope faces north. These slopes get less sunlight in the winter (in the Northern Hemisphere), which makes the slow less 'sticky' and more unstable.

The slope is wind-loaded or beneath a cornice. If a cornice falls, it can trigger an avalanche above you, which is the worst place for an avalanche to be.

It has recently snowed (or is currently snowing!).

It's been windy recently.

Risky character traits

Your character doesn't know the area well.

Your character is a man (assuming the story takes place on Earth, where 92% of avalanche fatalities are men).

Your character is in a group that wants to press forwards.

Your character is overcommitted—they need to get to their destination, fast.

They are convinced they are an expert, or that someone in their group is.

Other people have gone down that slope already, which makes your character sloppy. Unfortunately, avalanches don't always trigger when the first person touches them.

Ironically, a slope that no one has gone down is also dangerous due to "powder fever," or the delight some skiers feel when they see an untouched slope and stop doing risk assessments.

High consequence locales

In the sections above, I discussed risk, or the likelihood that a bad thing (avalanche) occurs. Potential consequences also matter—it is safer to engage in high risk activities in places where the consequences are low, like rock climbing without ropes one foot off the ground.

How to make your avalanche as high consequence as possible?

Your character is alone. Recall that at 2 hours, the likelihood of surviving an avalanche has fallen to 20%. If your character is alone, what is the chance anyone notices they're missing within 2 hours, let alone they get to the exact slope where they're buried in that time?

The landscape has a lot of rocks or trees, making blunt force trauma likely.

The bottom of the slope is a crevasse or river bed or narrows as it goes down. This is because it takes time to dig someone out of an avalanche, even after you find them, so the deeper your character is buried, the more likely they are to die.

Avalanche Rescue

The worst has happened: one of your characters has been swept away in an avalanche and buried. Now what?

If we want a 50% chance of survival we have 20 minutes to 1) find the victim and 2) dig them out.

Immediately, your character's friends, who are, of course, avalanche rescue experts, leap into action. Having determined the slope is safe, they get to wherever the avalanche ended as fast as possible and commence a search.

Before launching into a search pattern, bystanders probe areas there friend has a high likelihood of being in. This means probing around any equipment they see sticking out of the snow (ski, glove, hat, etc.) and especially around any limbs (if the buried person is sticking a hand above ground and waving, start there). They also check around protruding objects like rocks, where their friend may have gotten stuck.

Source.

Probing means sticking a ski pole or some other long object into the ground at a 90 degree angle in the hopes that you poke the buried person. 

Source. *poke* "Ouch!"

A note on pole length: six feet should be adequate. It is both rare to be buried deeper than six feet and essentially impossible to rescue someone six feet under before they die.

Let's say your characters probe all the likely areas and find nothing. Now what?

Beacon search

What is an avalanche beacon? Basically, beacons are small devices you can carry into avalanche country that help you find your friend, or your friends find you, if one of you gets caught.

Example of an avalanche beacon. Source.

Avalanche beacons have two modes: "send," which sends out a signal, and "search," which looks for a signal. The idea is, everyone on your team has what is essentially a GPS tracker on them. If one gets buried, the others can use their beacons to triangulate the position fast enough to, hopefully, do a fine search in the correct area before the buried person is dead.

If the bystanders in your plot have beacons, they switch them to "search" mode. (It is tragically common for people who carry beacons, but don't practice with them often, to commence an excellent search pattern while their beacons are still projecting their location instead of searching for the location of their friend.)

The video above shows an example of a search pattern with one rescuer. The more rescuers, the faster the search, and the more likely the buried victim is to survive. The picture below shows some multi-rescuer search patterns.

Search patterns based on the number of searchers. Source.

Beacon-less search

What if your characters don't have beacons? First of all, they had better be in a world without beacons, because there isn't really a good excuse to be caught in an avalanche without one. Even if you are skiing alone, because beacons are interoperable, you might as well carry one to help out any potential rescuers.

But let's say your character lives in pre-industrial avalanche country so we can't judge their decisions too hard. Now what?

Assuming the victim's hand isn't sticking out of the ground and waving for help, your rescuers are stuck doing a probe search everywhere. This involves sticking a long pole in the ground every 1.5 feet or so in a spiral or grid pattern and hoping you poke your friend before they die.

Source

A spiral search may be easier with only one rescuer.

Source

If there are a ton of bystanders ready to rescue the buried victim, they can get regimented about it, setting up lines and moving in interlocking grid patterns to search the largest area possible in the shortest amount of time.

DIG

The rescuers have successfully poked the buried victim. The next step is simple: DIG.

https://www.youtube.com/watch?v=hJbnc4MjylI (no more embedded videos allowed :sad face:)

https://www.youtube.com/watch?v=dGQg9o3vAkM

Medical Care

Ideally, your bystanders dig the head out first, since this is the body part with all the important bits in it. My WFR instructor recommended starting Positive Pressure Ventilation (PPV—the thing you see in movies with the plastic mask and bag that EMTs squeeze to help someone breathe) immediately after rescue unless the victim protests loudly. This can clear snow out of the lungs and in general help them maintain oxygenation.

As other body parts get uncovered, treat what you see.

How to Show Your Character is a Pro

They dig a trench before going out too far. This allows you to see the layers of snow and judge how likely an avalanche is.

https://www.youtube.com/watch?v=vcXogVHecFQ

They test snow density by trying to poke through it with a knee, hand, finger, and knife.

They might also intentionally knock a cornice over to see if it triggers an avalanche (this is done from a safe distance).

And finally, they consider walking above someone on a dangerous slope attempted murder.

Conclusion

The best way to survive an avalanche is to avoid being caught in one. Barring that...

We at ICT recommend your character carry a beacon, be in relatively safe territory, and have a flock of friends available for rescue purposes.

[icasttourniquet]

Can Your Character Survive... Altered Mental Status

Character E is confused. She thinks she's talking to someone besides Character F and accidentally admits that she has a crush on F while F is treating her injury. Oops.

Or, F is trying to get E out of the enemy base and E keeps laughing when F shushes her, attracting the attention of the guards

Whether for comedy or tension, altered mental status can add a fun wrinkle to your plot. But, what causes altered mental status and how do you make sure E survives?

STOPEATS

The big kahuna of the altered mental status world is the acronym STOPEATS. If it makes your brain go a bit wonky, it's probably included in STOPEATS.

Sugar

If E is a diabetic and lost track of her sugar intake, she could suffer from altered mental status as a part of hyperglycemia. If F knows E has diabetes, he can hopefully guess at the cause of her confusion and help her take her medication, or get her to a hospital.

Temperature

When the body gets really cold or really hot, the brain can stop working right. In fact, altered mental status is a key sign of being hypothermic vs. just cold. Ditto with heat stroke. Hopefully, the environment makes if obvious to F what is causing E's weird behavior. He can treat her by bringing her out of the cold or heat.

Oxygen

Hypoxia occurs when the brain is starved of oxygen, such as at a high altitude. It is most common in mountain climbers and pilots, such as the one in this video who reports having "no control" of his aircraft but otherwise, is not concerned at all about the situation. Astronomers may also suffer from hypoxia on occasion.

XKCD 1463: Altitude

Hypoxic people behave as if drunk. They are often euphoric, may speak slowly, and will act confused. The key treatment for high-altitude hypoxia is reducing altitude ASAP. In the video, you can hear the air traffic controller trying to coax the pilot lower. He knows he doesn't need the pilot to land—as soon as he can breathe a little better, he'll remember how to fly be able to land himself.

Pressure

If a brain injury causes bleeding in the skull, that blood has nowhere to go and can build up pressure. This causes the brain to lose functioning and is called intracranial pressure (ICP). It's the worst type of traumatic brain injury (TBI) besides one that just kills E outright.

If E is suffering from ICP, she'll probably be confused and behaving erratically. She may have gaps in her memory as well. Most likely, she'll also report "the worst headache of my life"—literally. In training, we were told to look out for that exact phrase when diagnosing head taumas. In later stages of ICP, E may also vomit, a lot.

Treatment involves getting to surgery ASAP so a doctor can cut open her skull and relieve some of the pressure. For obvious reasons, that is not something we attempt in the field.

Electricity

I'll be honest: I think they just wanted the acronym to work when they made this one E. What they actually mean in most cases is seizures. The classic seizure is a grand mal seizure, which involves the muscles tensing, twitching, etc. But seizures come in all shapes and sizes. For some, a seizure might mean smelling something that isn't there, or hearing music, or a single twitching muscle. Because seizures are unauthorized electrical activity in the brain, they can cause disorientation and erratic behavior.

Often, coming out of a seizure can be quite disorienting too. If F is helping E through a seizure, he should first try to prevent her from harming herself. If she's banging her head against the wall, that means putting a hand or pillow there. If she's near a table, that means moving the table. (NO sitting on / restraining people with seizures and NO putting stuff in their mouth! No! Why? You want them to choke? No!). As she recovers, F can remain calm, help her understand what happened if she needs it, and get her further care if requested.

Altitude

As with temperature, both very high and very low altitudes can cause brain problems (if you are beginning to suspect the brain is just a picky organ, you'd be correct). Scuba divers who ascend too quickly can suffer from nitrogen narcosis, which can lead to euphoria, confusion, memory loss, difficulty concentration, etc. (all classic signs of altered mental status).

If E goes too high, say, on a mountain, she could suffer from High-Altitude Cerebral Edema (HACE—controversial opinion but high-altitude stuff has all the good acronyms and names, HACE being but one example). It occurs when the brain swells at a high altitude and leads to confusion, lethargy, and a headache.

Luckily, as with most high-altitude problems, it can be solved quickly by going lower. When in doubt, on a mountain, taking the patient to a lower altitude is probably a good idea.

Toxins

Alcohol, LSD, marijuana, morphine—drugs cause altered mental status, as can bites or stings from venemous animals.

There are as many ways to treat toxins as there are toxins, maybe more, so I leave you with a fun fact the majority of snake bites in the US are people who tried to pick up the snakes.

In the words of Mod N's WFR instructor: "Red near black? Who cares. It's a snake. Why are you messing with snakes?"

Salt

Salt concentrations across cell membranes is one way nutrients travel into and out of cells. If E's blood suddenly has way less salt (electrolytes) than normal, this causes all the nutrients to flow out of her cells and into her blood, starving her organs. Brains run on salt and not having enough salt makes... neurons fire different? Stop firing? Something scientific and complicated. For our purposes: not enough salt = brain go weird.

This is called hyponatremia and is my favorite of all the STOPEATS ailments. Hyponatremic people behave as if drunk. The treatment is to 1) stop chugging water, 2) stop competing in your high-endurance sport (and therefore stop sweating), and 3) drink / eat something salty.

Conclusion

Give your characters altered mental statuses. It will be fun. I promise.

The most easily treatable problems that make brain go weird are: hypoxia and high-altitude cerebral edema.

Please write more characters with hyponatremia.