Primal Quest Utah 2006

The first few teams at Transition Area 5 arrived within minutes of each other, 32 hours after starting Primal Quest (PQ) Utah, the world's toughest expedition adventure race. The four-person teams had completed 29 miles of horseback riding, 21 miles of desert trekking, 65 miles of mountain biking, 8 miles of whitewater swimming and 35 miles of tandem kayaking on the Green River. Daytime temperatures had soared above 100ºF, and the racers were hot, tired, hungry and thirsty. In a flurry of action, they unpacked from kayaking, repacked for the next leg-26 miles of canyoneering-and pillaged their food boxes for the 5,000+ calories they would need for the next 24 hours.

     I was a medic stationed at Transition Area 5 and 6 at the Ruby Ranch on the Green River for the first three days of PQ. Teams arrived at the transition area to check in with race directors, exchange gear for a new discipline, replace food and fluids, and receive medical care.

     Just after midnight on Day 3, Chris shuffled up to the medical tent and asked for help with a "few blisters." He grimaced in pain as he gingerly removed his shoes from his swollen and blistered feet. On his right foot was a quarter-size, fluid-filled blister at the base of his big toe, popped blisters between most of his toes, and the skin was circumferentially degloving around his left pinky toe. Eventually, he would lose the skin and nail from that toe. He asked, "Can you help me tape these blisters before I start the canyoneering section?"

     Twenty-two hours later, Chris shuffled back to the medical tent after completing the 26-mile canyoneering section, during which he and his teammates walked on hot sand and rocks, swam across rivers, rappelled from cliffs and ran out of water six hours earlier. Chris asked, "Can you look at my feet again? I have some new blisters. Also, can you listen to my lungs? I have been coughing up blood for the last six hours." Chris was just one of the many patients I saw as a medical team volunteer at PQ.

Primal Quest 2006
     Eighty-nine four-person teams from 20 countries registered for a 7-10-day test of physical endurance, mental strength, teamwork and logistical cunning. The 2006 race was contested in the blast furnace heat, sandy desert, red rock cliffs, slick rock trails, mountain slopes and cool rivers in and around Moab, UT. Transition Area 5 and 6 is a 1½-hour drive from Moab (location of nearest hospital).

     PQ is an unsupported adventure race. At transition areas, support teams could not be used to help with food or equipment. In addition to completing the physical challenge of the race, teams had to wrestle with the complexities of bike assembly, equipment packing and medical selfcare in a sleep-deprived haze.

     Most PQ teams had spent a year or more preparing. Teams earned required certifications in climbing, kayaking, horseback riding and first aid, and participated in local 24-48-hour "sprint" adventure races to fine-tune their gear and technique and test their endurance. In the days before the race, each team had to demonstrate skill proficiency for race staff and volunteers. Each team member completed a medical history and was interviewed by a medical team member. Finally, each team completed a check of mandatory safety, bicycling, swimming, climbing and first aid equipment.

Primal Quest Disciplines
     29-mile horseback ride
     (1 horse per team)
     21-mile desert trek
     65-mile mountain bike ride
     8-mile whitewater swim on Green River
     35-mile tandem kayaking on Green River
     26-mile canyoneering trek
     45-mile tandem kayaking on Green River
     29-mile canyoneering trek
     68-mile mountain bike ride
     38-mile mountain trek with orienteering course
     41-mile mountain bike ride
     14-mile desert trek, including two 400' rope ascents, two 400' rappels, and Tyrolean traverse
     2-mile tandem kayak on Colorado River to finish line
* See an interactive race map at www.ecoprimalquest.com.

Primal Quest by the Numbers
     89 teams
     356 racers from 20 countries
     160 volunteers from 14 countries
     417.3-mile race course
     42 checkpoints
     11 transition areas
     38,000 lbs. of racer gear
     18,000 lbs. of bikes
     8 miles of fixed rope for climbing and rappelling
     15,000 gallons of water on course
     2,000 cases of Gatorade (46,800 bottles) on course
     28 teams finished the full course with all four members
     143 hours winning time for Team Nike PowerBlast (13 total hours of sleep)

Medical Team
     The 30-person medical team was directed by AdventureMed, LLC. Our international team consisted of physicians, nurse practitioners, registered nurses, paramedics, EMT-Bs and wilderness first responders (WFRs). Each of the 11 transition areas was staffed with a physician, nurse and paramedic. EMT-Bs and WFRs were assigned to high-risk checkpoints. Medical volunteers were selected for their experience in adventure and endurance racing, wilderness expeditions, emergency and wilderness medicine, and providing medical care in unique environments.

     The purposes of the medical team were to respond to urgent medical emergencies, consult with racers about treatment for injury and illness, and instruct racers on how to treat injuries and illness. For example, nearly every racer experienced foot blisters. Racers with minor blisters received advice on how to care for the blisters. Racers with large fluid-filled blisters or open blister wounds into the dermis were treated by the medical team-including draining, cleaning and dressing. Generally, most of the patients were walking wounded, and the medical team only responded to one significant medical emergency.

     Before the race, a comprehensive medical plan was prepared. The plan outlined PQ medical capabilities, directions for interfacing with local EMS, locations of the nearest hospitals, available air medical resources and locations of Level 1 and 2 trauma centers.

     The medical volunteer team expected to treat a wide range of injuries and illnesses. We most anticipated heat emergencies-heat challenge, heat exhaustion and heat stroke. During pre-race meetings, medical volunteers reviewed heat-emergency signs and symptoms, treatments and triggers for evacuating a racer from the course to the hospital.

Wilderness Medicine
     Wilderness medicine is often defined by three conditions: severe environment, prolonged patient care, and improvised or limited equipment.

     The Utah desert is a severe environment. Daytime temps were regularly over 100ºF and nighttime lows were rarely less than 80ºF. A hot, dry breeze grew in strength during the day. One afternoon, a blinding sandstorm nearly blew away the medical tent. Occasional light rain and thunderstorms fell on parts of the course. Elevations on the course ranged from 4,000-10,000 feet above sea level.

     An injured or ill racer might have to rely on his teammates for care before a medical volunteer or local EMS could arrive on scene. Transport time just to a vehicle could take hours. When patient care is prolonged, problems can worsen. A wilderness medical provider needs to assess the current and anticipated problems if the underlying condition is not corrected. For example, an open blister could lead to local infection and possibly sepsis.

     A transition area medical tent was similar to an ALS ambulance without the air conditioning, bug protection, lighting, cardiac monitor and mechanical suction. Each transition area was stocked with a limited amount of assessment and treatment supplies, including:

• BLS and ALS airway management tools
• Supplemental oxygen
• Bandages, dressings and tape
• Extremity and spine immobilization
• Medications for treating pain, allergic reactions, respiratory distress, GI upset
• IV fluids

As a medical team, our treatment priorities were:

1. Encourage teams to prevent injury and illness, and practice self-care for minor problems using a simple strategy of rest, food, fluids, sun protection, monitoring and blister care.
2. In-race training on self-care and prevention techniques, especially for blisters.
3. Provide treatment to continue the race, such as compression bandages and pain medication for patellar tendonitis.
4. Discuss risks and benefits of continuing the race with an injury.
5. Evacuation to hospital care by PQ vehicle, PQ helicopter, air and ground EMS for injuries and illnesses that need definitive hospital treatment.

Casting a Big Net for the Fearsome Five
     A 30-year-old female presented to the medical staff 40 hours into the race complaining of being tired, nauseous and overheated. She was awake and lethargic; her skin was warm to the touch and flushed; and her vital signs were stable. This was a common complaint with many potential causes.

     As a wildnerness medicine instructor, I teach my students to cast a "big net" when considering all the reasons a patient could be ill or injured. For example, a racer is observed lying in the direct sun next to his food box, shirtless and not moving. What are the possible causes? Sleep, hypoglycemia, hyperthermia, anaphylaxis, stroke, cardiac arrest, head trauma and airway obstruction are a few. As I collect data about the patient, I can throw problems out of the net that are not supported by assessment findings. In this case, I considered the worst, threw problems out of the net as I collected data and learned that the racer was sleeping.

     During PQ, the big net was important, because many of the racers presented with a generic set of signs and symptoms, like altered mental status, mild respiratory distress, and elevated pulse and respiratory rate. The Fearsome Five-food, fluids, fatigue, feet and Fahrenheit-is a memory tool for five common causes of illness in the backcountry.

Food
     Energy demands for nonstop adventure racing are high. A typical racer might use 6,000-8,000 calories per day. Replacing this many calories while racing is no easy task.

Fluids
     Humidity is very low in the Utah desert, and sweat evaporated so quickly from racers' skin that they were not aware of its presence. The body can use up to two liters of fluid per hour, but can only absorb about one liter per hour through the digestive tract. Without enough rest and with continued fluid consumption, racers become fluid-depleted.

Fatigue
     The winning team slept only 13 hours during 143 hours of racing. Even low-ranked teams that were just trying to finish the race never slept more than four hours per day. Due to the heat, many PQ teams chose to sleep during the day, taking short naps when they found shade.

Feet
     Race headquarters was at 4,000 feet above sea level; the highest point on the course was over 10,000 feet above sea level. As elevation is gained, the percentage of oxygen in air remains the same, but the total amount of oxygen inhaled with each breath is less. The relative hypoxia and resulting hyperventilation can initiate a cascade of altitude-related illnesses.

Fahrenheit
     The risks for hyper- and hypothermia were exacerbated by thermoregulatory compromise from inadequate food and fluids.

     General complaints that are common to the Fearsome Five include: weakness, nausea, vomiting, dizziness, malaise, rapid pulse and breathing, shortness of breath, altered mental status and peripheral vasodilation or vasoconstriction.

Case Study: Heat Stroke Patient
     Late morning on Day 5, headquarters received a satellite phone call from a team on the mountain biking leg in Pritchard Canyon, just outside of Moab. They reported a male team member had collapsed. He was unresponsive, and had irregular snoring respirations and a rapid pulse. Their coordinates in the canyon placed them at about 3km from the nearest road. The canyon terrain was steep and rocky with a sand ATV and bike trail in the canyon basin. PQ medical director Bill Webster, MD, and I boarded the PQ helicopter to view the scene and determine access to the canyon. We anticipated landing on the canyon rim and hiking to the patient.

     At 12:45 p.m., about 45 minutes after dispatch, the helicopter was able to land within 50 yards of the patient's location. It was a short scramble through a boulder field to access him.

     We found an unresponsive 31-year-old male propped up in a sitting position, with his head being held up by another racer. The patient's respirations were irregular, snoring and rapid. Other racers had used a tarp to shade him and were wetting him with water and fanning him. The patient's clothes had not been removed. There were no other obvious injuries.

     According to his teammates, the patient had eaten a large meal at 10 a.m. and drunk a lot of water and Gatorade. They had been hiking and biking uphill for approximately one hour when the patient said he was "having difficulty keeping up." A few minutes later, he inexplicably veered off the main trail onto a small side trail. When they yelled to him to return to the main trail, he refused and then suddenly collapsed. He was found lying on his side, unresponsive and not moving.

     We directed rescuers to continue wetting and fanning the patient. A #16 IV was started in the patient's left AC for a rapid fluid bolus. He was moved onto a stretcher and carried to the helicopter.

     It was determined that any other on-scene interventions would delay rapid transport to the Moab hospital, just five minutes flight time. Upon arrival, the patient's rectal temperature was 104.7ºF after approximately one hour of field cooling. The patient was sedated, intubated and cooled. Within 30 minutes, his temperature was below 100ºF, and he was flown to a Level 2 trauma center for further evaluation and treatment.

     Unlike many heat stroke patients, this racer made a quick recovery. He was extubated within 24 hours and discharged from the hospital five days later. He had no evidence of brain swelling, and vital organ function was normal. He continues to do well and is preparing to resume adventure race training.

Injuries and Illness
     The No. 1 problem that racers self-treated and sought assistance for was blisters. Racers' feet suffered from a disastrous combination of fine sand, hot surface temperatures, swelling and constant use.

     In addition to blisters, the medical team treated patients with heat exhaustion, heat stroke, mild hypothermia, upper extremity fractures, lower extremity tendonitis, strains and sprains, rashes, respiratory infections, nausea, vomiting, diarrhea, nose bleeds, corneal abrasions and sunburn.

     Most racers wanted to understand the risks of their problem, receive "make-do" treatment and continue the race.

     Based on my experience at PQ, following are several case examples. As you read each example, answer these questions:

• What is the patient's problem?
• What are the patient's anticipated problems?
• How would you treat this patient?

Chest Pain
     A 48-year-old male complained of intermittent chest pain for 12 hours during a daytime canyoneering trek. Pain was worse with exercise and felt like a "heavy pressure." The patient was pain-free upon presentation and denied radiation of pain, shortness of breath or diaphoresis. He had no pertinent or family cardiac history, no medical problems and took no medications. Food and fluid intake during the last 12 hours was inadequate. He had a pulse rate of 60, respirations 20, BP 140/palp. His oral temperature was normal, and he had normal breath sounds.

     After 30 minutes of pain-free rest and food and fluid consumption, the patient said he wanted to sleep for a few hours and continue the race. He was advised of the risks of continuing, and the doctor told him, "There are lots of causes of chest pain, but only a few matter, such as angina." The patient considered the risks, continued the race with no return of symptoms, and his team finished the short course.

Dry Cough and Nose Bleeds
     A 38-year-old male complained of dry cough and frequent nose bleeds and told us, "I am coughing up blood." He had just finished a 26-mile canyoneering trek and had spent the last 48 hours in a high-heat, low-humidity desert. Exam findings: lung sounds clear, vital signs normal, intermittent dry and unproductive cough. Pertinent history findings: ran out of water during the canyoneering trek.

     Treatment recommendations for this patient included: rest, fluids, moisten anterior nasal passages, control nose bleeds with well-aimed direct pressure. He continued the race without relief of cough or nose bleeds.

Nausea and Vomiting
     A 30-year-old female complained to medical staff of nausea and vomiting for the last 12 hours. She was pale, weak and lethargic and had had only a few hours of sleep in the last 96 hours. Vital signs: pulse 80, BP 110/palp., respirations 20, oral temperature 98.8ºF. The patient reported being unable to eat or drink enough due to nausea. Pertinent history: Patient was seven months postpartum and attempting to pump breast milk during the race.

     Treatment recommended: Rest one hour in medical tent, take sips of diluted Gatorade and water and IM promethazine for nausea. After one hour and one liter of oral fluids and snacks, the patient felt better and continued the race with advice to rest more and drink more fluids.

Flank Pain
     A male in his early 30s complained through an interpreter of right flank pain. He had been kicked in the right anterior pelvis by a horse 30 hours earlier and had a dinner plate-size hematoma at the location of the kick. Pain, which he described as dull, throbbing and a 7 out of 10, was now radiating to his flank. He was able to bear weight, had full range of motion, no deformity, no point tenderness, and distal CSM was intact. Pertinent history: Just finished first kayak leg (35 miles) on Green River. Patient ran, swam and biked since being kicked. He denied blood in his urine and was urinating normally. Vital signs were within normal limits.

     Treatment: Continue rest, stretching and pain medication for stable musculoskeletal injury. Monitor for changes in vital signs, decreased range of motion or CSM, decreased urine output or blood in urine. Return to medical team if symptoms worsen. He completed the race seven days later.

Heel Blister
     A female in her late 20s presented to the medical tent requesting assistance with fluid-filled blisters on her right heel and left big toe. The blisters were drained, cleaned and dressed. The patient then said, "I have another problem-a really painful rash in my butt crack." Exam revealed a red and swollen "diaper-like" rash. The patient was advised to keep the skin dry and treat with Desitin or zinc oxide cream.

     Twenty hours later the same patient returned with an open wound on her right heel. The skin around the wound was throbbing and visibly pulsating, extremely tender to touch, and a lot of sand was embedded in the wound. The wound was cleaned, dried and dressed. The rash on her buttocks plagued the patient for the remainder of the race, but she was able to finish seven days later.

Lower Leg Pain
     Teammates summoned medical staff to the room of a patient who had finished the race the day before and was complaining of progressively worse right leg pain. On examination, the leg was red, swollen and warm to the touch. The patient was unable to bear any weight, his toes were numb and tingling, and he was not able to move them. There were numerous blisters on his right foot in various stages of healing and some signs of local infection.

     This patient was transported nonemergently to a local hospital, where he received IV and oral antibiotics to treat cellulitis, a bacterial skin infection.

Conclusion
     There are many opportunities for EMS providers to apply their skills in unique settings. I encourage you to seek out opportunities in your region to volunteer at adventure races, running races and other community events.

For more information visit:

• Primal Quest Dispatches at www.emsresponder.com/interactive/category/primal-quest-dispatch/
• AdventureMed, LLC: www.adventuremed.com
• Primal Quest: www.ecoprimalquest.com.

Greg Friese, MS, NREMT-P, WEMT, is president of Emergency Preparedness Systems LLC. EPS helps clients rapidly deploy emergency education. Greg and EPS associates have authored and edited dozens of online education programs for first responders, EMTs and paramedics. Friese is a paramedic, Wilderness Medical Associates lead instructor and EMS author. Contact him at gfriese@eps411.com.