‘Dacks Dips – It is a beautiful, but hot and muggy July afternoon and you and five buddies are canoeing the Adirondacks in three boats, on day two of a three-day paddle.  You are in the middle of one of the larger lakes when a thunderstorm rolls through.  The thunder you barely heard five or ten minutes ago is now crashing all around you, accompanied by blinding flashes of lightning.  The clouds have unleashed buckets of water, wind has started to howl, and whitecaps are picking up.   You are suddenly very glad you have all been wearing PFDs, but soaked, you wish you had a raincoat on and something beyond cotton t-shirts and shorts.  You paddle as hard as you can for shore and just before making it there Megan and Mark’s boat flips, 100 feet from shore.

Scene Assessment #1: You have two people in the water.  You can barely keep your boat upright.  What do you do and why?

The safest, most conservative thing to do would be to think about scene safety and get yourself to shore.  Having another boat flipped is only going to make things worse.  However, if you were really worried about your friends, and you had more than beginner level canoe skills, you could consider “rafting up” the two boats still upright (bring and then hold them together and create a more stable platform) and trying to get the two in the water in your boats.  A very tough call in rough conditions.

Scene Assessment #2 and Primary Assessment: The lightning and thunder continue, as does the rain and wind, but it starts to diminish.  The temp seems to have dropped 20 degrees.  Your two friends, Megan and Mark, who were in the water and the rest of you are now all on shore.  Megan and Mark, the “swimmers,” are huddled in fetal balls at the edge of the water.  Both appear to have good primary assessments, other than a suspect E, as they are looking very cold (shaking and white to cyanotic skin).  The rest of you are wet to the bone and shivering now that the mad-dash paddling is over.  

Secondary Physical: Both friends are violently shivering.  One of them, Megan, has a large gash on her knee but minimal bleeding at this time.   You find no issues with you other friend, Mark, but he is a bit “fuzzy” and slow in his responses.  Otherwise everything thankfully normal.

SAMPLE: Both Megan and Mark complain of being really cold, though you can barely understand them through chattering teeth.  When you ask them about allergies or medications they mumble “none.”  They ate some crackers at lunch a couple hours ago and they’ve been drinking a good amount of water (you think they were a bit hung-over from last night’s partying).  When you ask about “outs” they say they don’t know, they just want to get warm.   They were fine before the storm.

Vitals: Round 1 – a) Megan, with cut knee: AVPU AOx4, HR 56, RR 14. B) Mark: AVPU AOx4 but fuzzy; HR 56, RR 12.  Round 2 –Megan: AVPU AOx4, HR 60, RR 14. B) Mark: V on AVPU scale, HR 52, RR 10.  

Setting: You are on a steep (15-20 degree slope), rocky, and heavily wooded shoreline.  No great or even good campsites (no room for even one tent) where you are on in sight.  You get out your map: Nearest road-side take out is a 4 miles away, but it is back across the widest part of the lake (a 2 mile open crossing).  Next nearest take out is 6 miles away with a quarter mile portage.  One canoe with all its gear is still in the lake and you aren’t exactly sure where (but wind is blowing towards shore so you hope it isn’t too far away).  Wind is still gusty, up to 20 or 25 mph and light rain, with a beautiful rainbow as the sun starts to emerge.  It’s much cooler now, maybe 60 degrees F.  Lightning and thunder are almost gone as the storm blows eastward.  It is 4 pm.  No cell phone coverage. 

Response: 

What are your patient assessments and anticipated problems?

Megan is a 23 year old female complaining of being cold and cut knee.  Anticipated problems: hypothermia, knee?  Mark is a 25 year old male with mild hypothermia.  Anticipated problems: worsening hypothermia, cardiac instability.  Missing canoe and gear could cause problems (but in big picture, compared to human life and suffering, it’s only “stuff”), it is apparently impossible to camp at current site, wind still strong and likely water still rough so risk of another capsize (and how stable will canoes be if you add a third person to each boat) and it’s a long way to take-out.

What are you worried about?

It might be July but the biggest concern is hypothermia.  Can you get Mark re-warmed?  Could he go into moderate hypothermia?  Is he safe to sit in a canoe?  What about his heart?  Is Megan going to continue to get colder and go into hypothermia?  Can you hunker down at present steep and rocky shoreline (where you can’t camp) or should you try to get to a nearby place where you can camp?  Or should you evacuate and go straight out to nearest take-out?  Is getting back out on the lake too dangerous?  What about Megan and Mark’s canoe and gear?

What is your plan?

Best course of action is to stay put for now; you have lots of daylight and moving immediately, even though your location and situation is not ideal, involves all kinds of risk, and you likely have very little reserves or margin for further set-backs at this point.  Get Megan and Mark insulated from the cold wet ground.   Get lots of fast acting (sugars and carbs) calories on board the two of them.  If you have dry sleeping bags or dry clothes, get Megan and Mark into them.  If you only have wet clothes, and they are synthetic or wool, ring them out and get the them both into those; they are still better than wet cotton t-shirts and shorts.  Wrap them tightly in a vapor barrier (rain suit, plastic garbage bags, tarp, tent fly, etc.).  Cover their heads.  Treat them gently and let them rest, eat, shiver, and hopefully warm-up.  Depending on how bad Megan’s knee is, consider cleaning and dressing it (or wait until you are at camp or out – unless it is really deep, there is underlying trauma, or you have trouble stopping the bleeding, this is the least of your problems).   Meantime, assuming it is safe, two of you could be looking for the missing canoe and gear.  Hopefully by the time Megan and Mark do warm up, you have recovered the missing canoe and gear and the water has calmed down enough to safely paddle over to the nearest decent camp site.  Split Megan and Mark up into different canoes and put them in the bow where they don’t have to steer and they can be watched (or, if necessary for Mark, put him in middle of a canoe with two others paddling and solo paddle the canoe he was in).  Set up a safe, secure, and cozy camp, continue to feed and keep Megan and Mark warm.  In morning decide to continue the trip or head straight for home.