Embarking in the Backcountry: Traumatic Injuries Sustained in the Boundary Waters Canoe Area

Introduction

The Boundary Waters Canoe Area (BWCA) is a remote backcountry recreation area spanning the US-Canadian border of Minnesota with limited access to food, clean water, and medical care. Each year, during a 5-mo period, the BWCA sees large numbers of visitors partaking in backpacking, paddling, and day-use recreation. ¹ The isolation of the BWCA is what attracts most nature goers, but this same isolation complexifies access to medical care in the setting of unexpected injury. Given this situation, individuals must prepare themselves to manage medical emergencies prior to the arrival of Emergency Medical Services (EMS).

To the best of our knowledge, currently, there is no literature describing injuries sustained in the BWCA, which contributes to a lack of guidance on medical contingency planning for individuals. At large, previous studies have evaluated injuries sustained in remote settings within the United States. A review of medical emergencies occurring in the National Park System found that ∼3000 traumatic injuries occur per year, with 4% of patients subsequently dying from their injuries. ² Furthermore, in a review of injuries occurring in Washington state parks, it was found that most injuries occurred in males, and although most injuries were mild, 19 deaths occurred, most due to falls and drowning. ³

This study aimed to characterize traumatic injuries sustained in the BWCA that were treated at the closest Level 1 trauma center (Essentia Health–St. Mary's Medical Center [EH-SMMC]) to the BWCA. We hypothesized that given common activities partaken during a trip to the BWCA, similar mechanisms of injury may occur in relation to previous studies mentioned earlier. Given the remote location of the boundary waters, potential delays in care, and risk of severe injury, this review adds significant knowledge in efforts to reduce morbidity and mortality for this patient population.

Methods

Results

A total of 1091 patients were identified as having an injury sustained in ZIP codes surrounding the BWCA. Of the 1091, 18 patients had documentation of the injury being sustained in the BWCA (Figure 1).

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Figure 1.

Patients meeting inclusion criteria.

Injury/Extrication Data

Seven patients self-extricated out of the BWCA, 6 were transported by ground Emergency Medical Services (EMS), and 5 required flight extrication. Median time of notification of injury to EMS arrival was 1 h and 4 min, with a median scene time of 28 min. Time from notification of injury to time to hospital was a median of 2 h and 11 min.

Initially, 11 patients presented to a different hospital and required transfer to EH-SMMC. Nine patients required flight transfer from the outside hospital to EH-SMMC, 6 required ground EMS, and 3 self-transported. On presentation to EH-SMMC, 78% had a Glasgow Coma Scale score of 15. Median injury severity score was 9 (IQR=5).

Falls were the main mechanism of injury (61%), followed by strike injuries (22%) and water injuries (17%) (Figure 2). Extremity injuries were the most common injured body areas (61%), followed by thorax injuries (39%) (Figure 3). Fewer than 10 patients had lower extremity injuries, and fewer than 5 had both upper and lower extremity injuries. Five patients sustained more than 1 body area injury. A few patients (<5) required EMS lifesaving interventions (eg, prehospital intubations and needle thoracostomy). A few patients required blood transfusion and/or intubation in the Emergency Department. Twelve of the 18 patients required a procedure (ie, <5 chest tubes and 10 operative procedures). Median hospital length of stay was 2.5 d (IQR=2.75). All 18 patients were alive at discharge, with most discharging home (83.3%). Fewer than 5 patients required readmission to the hospital within 30 d.

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Figure 2.

Mechanisms of injury.

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Figure 3.

Body areas injured.

Discussion

With well over 100,000 individuals visiting the BWCA each year, frequently during a 5-mo time period, ¹ there is a need to educate backcountry goers on common injuries sustained in the BWCA. This knowledge may encourage medical contingency planning and expedite medical care before EMS arrive. This study aimed to characterize injuries sustained in the BWCA in order to provide preparative information for individuals prior to embarking on their backcountry trip.

The findings of this study demonstrate similar findings to other studies conducted in other backcountry settings within the United States. ³ Most injuries occurred due to falls, which could be expected given the terrain of the BWCA and the requirement of individuals to hike to their respected destination, often while portaging a canoe. The most common sites of injury were the extremities, which may be expected because previous research has found that most injuries sustained in the prehospital setting are orthopedic injuries. ⁴

While completing the chart review for this study, we noted that many injuries required uninjured hikers to leave the injured individual behind to get help. Therefore, it may be beneficial for individuals to understand basic trauma evaluation and management to deploy prior to EMS arriving. Courses such as Stop the Bleed or Basic Life Support prior to a trip to the BWCA may be beneficial.^5,6 Additionally, basic understanding of treatment of limb injuries, such as early immobilization, may allow BWCA travelers to alleviate pain, avoid further injury, and allow for adequate circulation prior to the availability of professional medical care. ⁷

The second most common mechanism of injury in the BWCA was injury due to being struck by an object. The nature of the BWCA requires individuals to canoe islands or settings where there may be limited options for pitching a tent. Given this situation, tents may be placed in areas that are susceptible to tree falls. Unfortunately, with unpredictable weather, trees may fall on tents where backcountry goers sleep. We found that these individuals often required EMS or flight extrication from the BWCA.

Given the climate and remoteness of the BWCA in Minnesota and Canada, hypothermia is a major comorbid factor for trauma patients in the BWCA. Backpackers may consider reviewing prehospital management research, which recommends removing any wet clothing (although this may be contraindicated in patients with concern for spinal injury) and drying and covering the injured individual with an insulation barrier. Studies and the Committee on Tactical Combat Care have previously recommended the use of a hypothermia prevention kit, which has been shown to reduce the rates of hypothermia in combat trauma patients.^8,9 Other rescue blankets made of transparent polyethylene terephthalate foils also have been shown to reduce rates of hypothermia and are appealing to the backpackers given their light weight and packable properties. ¹⁰

Finally, the third most common mechanism of injury was water injury, which also may have been expected given the vast number of lakes in the BWCA. Prior to embarking in the BWCA, we recommend that individuals be competent swimmers, wear life jackets, and consider training on how to reenter into a canoe that has capsized.

The information obtained from this study will be shared with superior national forest ranger stations in the hope that informative materials may be displayed at various entrance points to the BWCA. Also, it is our hope that this information will guide training for rangers and EMS personnel surrounding the BWCA to best be prepared in the event of a medical emergency.

This study does have its limitations. The study used only trauma registry data; therefore, minor injuries sustained in the BWCA not meeting trauma criteria were not included. Because of this, these minor injuries presenting to emergency departments surrounding the BWCA were not included in this study. Additionally, deaths that occurred in the BWCA were not included, potentially limiting the severity of potential injuries in the BWCA. It is important to note that because this study was completed by manual review for inclusion, inclusion bias or misclassification errors may have occurred. Finally, inclusion criteria for this study required that the BWCA be listed as the injury location. It is possible that trauma injuries may have been sustained in the BWCA, but the BWCA was not mentioned in the individual's chart. Future studies may include prospective analysis of tertiary emergency departments to better capture all patients injured in the BWCA.

Conclusion

Most of the injuries sustained in the BWCA were in adults, commonly from falls, strikes, and water injuries. To best prepare for backcountry emergencies, we recommend that individuals consider taking part in preventative classes such as Stop the Bleed and immobilization courses and carry emergency blankets in the event of hypothermia. This research will provide significant knowledge to backpackers to aid in contingency planning as well as providing information to EMS personnel surrounding the BWCA to improve outcomes for this patient population.