Wilderness First Aid

Whether new to the forum, or completely new to the community, herein you will find the best information to-date to help you get started on the right foot with that dangerous business of going out your door.

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SierraStrider
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Wilderness First Aid

Post by SierraStrider »

EDIT: When I first wrote this, the top post treated on hypothermia. With the decision to increase the scope of this post, I’ve decided to replace that with a general overview of wilderness first aid as a practice, bumping hypothermia down to a separate section. This may make the first few comments seem a little out of order.

Disclaimer:

Where I can, I draw my knowledge from published, empirical data, with personal experience filling in the gaps. This personal experience comes mostly from training, with (thankfully) very little opportunity to put that training into practice. This is meant as a jumping-off point, and I welcome the expertise of others and heartily encourage anyone who thinks they might need advice on this subject to review other data available on the web and in books. I'm not an expert; just an amateur who's studied enough to get through some tight situations and recognize how easy it is to get into them.

Principles of Wilderness First Aid

Wilderness first aid differs from what’s taught in most first aid courses in a very important respect: you’re usually much further from help. If you find someone lying unresponsive in town or even on a rural road, your first priorities are: 1) alert emergency services and 2) keep the patient’s condition from deteriorating until emergency services arrive.

Both of these goals are much more difficult if you’re, say, a mile and a half from the trailhead with no cell reception—and that’s not even a very long hike! You can’t drive an ambulance up a twisting mountain footpath. Therefore, the principles that govern first aid in an everyday situation change when we’re talking about the backcountry. While alerting emergency services should still be very high on your priority list if possible, you may find yourself in situations where you need to be more proactive, taking risks you would normally eschew in the usual course of administering first aid. This makes the decisions you have to make harder, and increases the risk that they’ll end poorly. For this, as well as many other reasons, I encourage anyone who might need this information (which is to say, anyone on this forum) to take a course in wilderness first aid. Standard first aid courses can often be had for free and are also very useful.

First Contact with the patient: What do do and when

Much of the knowledge in this section is drawn from the NOLS Wilderness first aid course. You can find a lot of this on their website, though I’m supplementing somewhat with my own memory of the course and outside reading I’ve done.

I’ll talk about what to do regarding specific maladies in subsequent posts, but let’s first talk about what to do if you’re not sure what’s wrong. Let’s say you come across someone in distress or unresponsive in the backcountry. What is your first move? Remember the mnemonic, 12345.

The 12345 of situation assessment

1: Look out for number one.

If you are injured endeavoring to help someone else, you are not making a noble sacrifice. You are making a bigger job for the next poor schmuck who comes along. To quote Lois McMaster Bujold, Suicidal glory is the luxury of the irresponsible. Take a moment to remind yourself of this.

2. What’s the matter with you?

Look around for any obvious hazards that may have caused the patient’s current distress. Ask the patient for their status—What happened? Do you need help? Are you injured? If they can respond, this will help you start formulating your next move to A) avoid falling prey to the same hazard and/or B) help them.

3. Don’t get any on me!

Remember that people themselves are hazardous, and that even if the initial cause of the injury is something easily avoided, communicable pathogens are no joke! If you have rubber gloves or other personal protective equipment in your first aid kit (which you should!) put them on now. Glasses (inc. sunglasses) are a good idea, as is a bandanna over your nose and mouth. The Rangers of Ithillien knew what was up.

Likewise, be prepared to dispose of any contaminated materials safely afterward, such as gloves or bandages. Seal them up if you can, or burn them.

4. Are there any more?

Assess, through discussion with the patient or your own reconnaisance, whether there are any more patients. Start thinking about triage.

5. Dead or alive?

Start prioritizing which patients to help first, based on the severity of their injuries, your ability to treat them, the number of rescuers vs. patients, etc.
Once you have a plan on what to do, we’ll move on to the next mnemonic.

The ABCDE of vital threats.

These are “vital” threats. As we go down the list, if any one of these has a problem, we address that first before moving on to the next item. Note: The most current medical literature advises promoting "C" to the front of the list. This breaks the acronym, but makes a fair bit of sense, since trying to get someone breathing when they don't have a pulse is unlikely to be successful. Moreover, recovery rates were shown to be higher when cardiac needs were attended to first. If you can remember "CABDE", that's probably better...but if "ABCDE sticks in your head, it's a lot better than nothing, and frankly, a major cardiac event that would necessitate the rearrangement occurring out in the wilderness has a pretty bad prognosis either way.

Airway. Make sure that the patient’s airway is clear. If they’re talking to you, that’s a good bet, but if they’re unresponsive, check their nose and mouth for obstruction. Previous first-aid courses I’ve taken have promoted the use of a “sweep” of the mouth, hooking a finger and passing it through the patient’s mouth in an effort to extract any unseen obstructions, but the most recent literature on trauma and life support at the time of this writing advise only attempting to extract obstructions you can see, to aovid the risk of pushing potential obstructions deeper into the airway. If the airway is clear, move on to:

Breathing. Look, listen, and feel for breathing. If they are breathing, note the nature of their respiration. Are they hyperventilating? Gasping? Wheezing? Or breathing normally? Either way, move on to:

Circulation. Check for a pulse and look for signs of bleeding. If the patient is breathing, they will obviously have a pulse, but you should assess its strength. If they are NOT breathing, then check the pulse before trying to eliminate other reasons for respiratory arrest.
If no pulse is present, or if the pulse is very weak, then beginning CPR is likely the only thing you can do.
You can often see a pulse at the neck, and can check the pulse at their wrist without alarming them by holding their hand. Checking for a pulse at the throat or wrist are very good skills to learn and practice. When you check the pulse, note its speed. Check the pulse in both wrists to ensure that they’re of equal strength. Squeeze a nail on any exposed hand or foot and see if color returns to the nailbed afterward. Check if the extremities are as warm as you’d expect them to be. If their pulse is acceptable and are not bleeding heavily, move on to:

Disability, or Dorsal injury. Do we need to immobilize the patient’s spine? If they’ve had a bad head injury, report numbness or paralysis, or report back or neck pain, it’s a good idea to immobilize the patient’s spine to the greatest extent possible. This means taking great care in positioning and/or moving them such that they’re unlikely to exacerbate a possible spine injury. Even an injury which results in immediate paralysis can sometimes be recovered from if it isn’t made worse, and injuries which could later result in paralysis are not always immediately obvious. If there’s evidence of a neck injury, play it safe. To check for loss of sensation, pinch the patient’s thumb or pinky on each hand, and the corresponding toes on each foot. Ask them to identify the digit you’re pinching. As them to wiggle their fingers and toes, and test their strength by asking them to squeeze your hands. If dorsal injuries seem unlikely, move on to:

Exposure. Consider the patient’s exposure to continued threats to their wellbeing. This could mean external threats such as exposure to heat or cold or falling branches, or it could mean more subtle injuries than the vital threats we’ve discussed so far. Now is the time to move the patient out of harm’s way (making an effort not to injure them further while doing so), and to staunch any minor bleeding if present.

Once we’ve gone through the 12345 and ABCDE of assessing the patient, we can move on to addressing any specific ailments they might have that are of lesser importance, which I’ll cover in later posts. There are, however a few good things to check regardless of the injury.

LORe

The patient’s Level Of Responsiveness can give you valuable clues about their condition. You’ve probably been gauging this to one extent or another throughout your 12345 and ABCDE assessments, but it’s worth paying particular attention to after those are completed. Are they conscious? Do they seem confused? Are they responding to your prompts? Ask them about what happened, what time it is, current events, etc. and judge whether they seem to be ‘all there’. Easy stuff, like “Who’s the current president/head of state?” and “are Istari incarnations of Maiar or Valar?” You know, stuff any normal person should immediately know the answer to.

SAMPLE

If you can, ask the patient about their medical history. SAMPLE helps you remember which things to ask:

Symptoms: What symptoms is the patient showing? Remember, when talking about “signs and symptoms” signs are what we can observe (e.g. bruising) while symptoms are things they tell us about.

Allergies: To things like environmental factors, insects, medications, or food.

Medications: Ask about any medications, including prescription and over the counter medicines.

Previous/Pertinent: Ask about their medical history to discover any pertinent, prior events related to the current injury or illness.

Last intake/output: When was the last time the patient ate, drank, urinated, and defecated?

Events: What has led up to the incident in the last few days? Gathering this information is crucial to your assessment and plan for handling the situation.

With all that out of the way, We'll move on to various common wilderness maladies and how to treat them!
Last edited by SierraStrider on Sun Feb 16, 2020 4:30 am, edited 8 times in total.
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Greg
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Re: Hypothermia and how to not die from it

Post by Greg »

That's a nice guide, Sierra. Thanks for writing this up!

Would you mind if I moved it to 'getting started'? There'd be less of a chance of it getting buried, so it'll stay available to the right people.
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Re: Hypothermia and how to not die from it

Post by SierraStrider »

Greg wrote:That's a nice guide, Sierra.
Would you mind if I moved it to 'getting started'? There'd be less of a chance of it getting buried, so it'll stay available to the right people.
Sure. I'm thinking about doing a few more, so would it be possible to change the title to something like "wilderness first aid"? Then I could add things like heat exhaustion, altitude sickness, and dehydration to this single thread.
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Re: Hypothermia and how to not die from it

Post by Peter Remling »

Excellent guide and looking forward to reading future writeups.

Thanks
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Re: Hypothermia and how to not die from it

Post by Iodo »

Amazing guide :P thanks for taking the time to write it and quite honestly I thought I knew about hypothermia but at least half of that I didn't know
SierraStrider wrote: Cool rain or wind alone can be as dangerous as driven snow, if you have the wrong equipment for that type of weather.[/b][/i] I've spent nights where I was much closer to hypothermia in the jungles of Hawaii in midsummer than I was in a snow cave in midwinter in the Sierra.

â—‹ Often, your extremities will start to show signs first. Stiffness or clumsiness in the hands is a warning sign; when I'm feeling cold, I'll make a point of pinching my thumb and pinky together every minute or so--if it becomes difficult or impossible to do so, I know my extremities are getting colder than I'd like, and I'm probably losing a lot of heat through them.
â—‹ Slurring of speech indicates dropping temperatures in the face, an even bigger red-flag, since your body will fight to keep your head warm far more than your hands. When I do the pinch trick, I say, "Momentum" aloud, because I've found M sounds to be the hardest when I'm getting too cold. If saying "Momentum" becomes difficult, you very likely need to change your strategy for keeping warm as soon as possible.
â—‹ Shivering is an obvious sign, but all the more important not to ignore for that. If you are shivering, you need to attend to warming up.
This is the most useful thing I've read for a long time, not only does it show me how to recognize the symptoms but that I've had mild hypothermia with out even knowing it a number of times, although not since before I joined this forum and never in kit. On a lot of my first hiking trips I fell for the same trap, wearing modern hiking clothing I would start low down, where the air is warm, wearing a thin cotton shirt and pants, then I would climb past the snow line and into wind/snow/rain and take plenty of warm/waterproof layers for the upper half of my body, completely forgetting that my legs would get cold and wet and it wasn't until I started wearing ranger kit that I made myself some wool leg coverings and realized how much difference it makes to the point where I find I don't need to wear as much on my upper body if I'm equally warm all over, sometimes this can even mean carrying less weight altogether

About five years ago I attempted to climb Ben Nevis in this manner, just past half way up the wind chill was easily down to 5 degrees C and the rain had set in, by two thirds of the way the fog came down, at the time I turned back because once the path reached the scree slope it cant be navigated in thick fog without a compass (that I didn't have on account of knowing the path well) at the time I didn't think I was to cold to carry on and was cursing the fog and hoping it would lift, after all, I was so close, but now, after reading this I'm so glad the fog didn't lift, if it had the best case scenario would have been being air-lifted off that mountain
SierraStrider wrote:if you have a camp stove, make some tea, or better yet, cocoa--simple calories are your friend.
and I knew hot chocolate was a good choice :mrgreen:
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Re: Hypothermia and how to not die from it

Post by Manveruon »

Iodo wrote:
SierraStrider wrote:if you have a camp stove, make some tea, or better yet, cocoa--simple calories are your friend.
and I knew hot chocolate was a good choice :mrgreen:
Indeed, as usual, it seems Professor Lupin was on to something :D :lol:

Thank you for sharing this, SierraStrider! Being a considerably less experienced bushcrafter than most who are active on here, this is exactly the kind of clear, concise explanation of important information I’m always so happy to see pop up! I’ve got a winter hike coming up here later this month in the Colorado foothills, and while we will likely only b going a short distance, and certainly not camping for the night, this sort of thing is still very important for us to be mindful of! I’ll share it around to my local group :)
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Re: Hypothermia and how to not die from it

Post by Iodo »

Manveruon wrote: Indeed, as usual, it seems Professor Lupin was on to something :D :lol:
an excellent point indeed :mrgreen:
Gimli: It's true you don't see many Dwarf-women. And in fact, they are so alike in voice and appearance, that they are often mistaken for Dwarf-men.
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Re: Hypothermia

Post by SierraStrider »

EDIT: This was originally the top-level comment in this thread, but in deciding to turn this into a continuing series, I replaced the top comment with a general overview. Take a look, if you haven’t seen it!

By request, this is my attempt at a guide to recognizing and avoiding hypothermia in the wild. These methods are not specific to period reenactment, but apply to it as well.

First, what is hypothermia, and why is it important?

Hypothermia is when your body fails to maintain the 37°C/98.6°F average that it keeps when everything's as it should be. This usually happens because your body can't generate heat fast enough to counterbalance the heat it's losing to the environment. It's not the same as feeling cold; you often feel cold when you don't have hypothermia, and one of the most dangerous things about hypothermia is that it sometimes messes with your body's ability to tell how cold it is.
That insidious nature is one of the reasons hypothermia is so important to be aware of and know how to watch for. If you sprain an ankle in the backcountry, you know about it. If you become sick, you can tell. Hypothermia sneaks up on you--and it CAN kill you, even in situations that don't seem 'dangerously' cold.

34°C/83°F is a pretty warm day, verging on hot for most people, yet that's the core body temperature at which your heart is in imminent danger of stopping. You freeze to death at 34°C/83°F.
Of course, you usually don't freeze to death when the environment around you is that warm, because your body can make plenty of heat to keep up. The point is that it does not need to be freezing out to get hypothermia.
Cool rain or wind alone can be as dangerous as driven snow, if you have the wrong equipment for that type of weather.
I've spent nights where I was much closer to hypothermia in the jungles of Hawaii in midsummer than I was in a snow cave in midwinter in the Sierra.

So, if the symptoms of hypothermia aren't always obvious to the person experiencing them, and you can get it in weather you wouldn't expect, how do you recognize it?

Knowing that it's possible is a good first step. If you feel cold, don't just ignore it and soldier on, and don't assume it's "not that cold out"--start thinking about what your body is telling you, and looking for the telltale signs of hypothermia's onset.

â—‹ Often, your extremities will start to show signs first. Stiffness or clumsiness in the hands is a warning sign; when I'm feeling cold, I'll make a point of pinching my thumb and pinky together every minute or so--if it becomes difficult or impossible to do so, I know my extremities are getting colder than I'd like, and I'm probably losing a lot of heat through them.
â—‹ Slurring of speech indicates dropping temperatures in the face, an even bigger red-flag, since your body will fight to keep your head warm far more than your hands. When I do the pinch trick, I say, "Momentum" aloud, because I've found M sounds to be the hardest when I'm getting too cold. If saying "Momentum" becomes difficult, you very likely need to change your strategy for keeping warm as soon as possible.
â—‹ Shivering is an obvious sign, but all the more important not to ignore for that. If you are shivering, you need to attend to warming up.

These are self-tests to recognize problems, but be watchful for them in companions as well. Slurred speech, shivering, disorientation and clumsiness are all signs that you should attend to your companion's warmth, especially since they may not realize how cold they are themselves.

Now that we know what hypothermia is, when to look for it and how to recognize it, what do we do about it?

Remember, the goal at all times is to keep your body producing as much or more heat than it's losing. As such, the strategy to combat hypothermia is twofold:
â—‹ Make more heat.
â—‹ Keep more heat.
Making more heat is usually accomplished by exercising, but this strategy is most useful to prevent hypothermia, not necessarily to treat it. If you are sitting still and cold, a bit of exercise--some push-ups, squats, sit-ups, or jumping-jacks--can do you good. I often go for an evening ski when camping in the snow, to keep warm after sunset but before bed. However, if you are exerting when you notice yourself getting cold, exerting harder is likely not the best strategy. You need to focus on keeping your heat at that point. DO NOT PRESS ON!

I have heard that a distressing proportion of those who die of hypothermia do so with warm, dry clothes in their pack. Don't let this be you! If you are hiking and start to notice the aforementioned symptoms, STOP. It doesn't matter if you're pretty sure the lake is just around the next bend, or if you really want to make a few more miles before lunch--STOP. Attend to your warmth. If the weather is bad, find or set up shelter. If your clothes are wet and you have dry ones, change into them. Better to briefly expose yourself to the elements than to remain in wet clothing. If you have a way to make heat, do it--if you have a camp stove, make some tea, or better yet, cocoa--simple calories are your friend. If, as may be more likely in our case, you have no stove but need to start a fire, consider whether you can do so without exposing yourself to the elements in a counterproductive manner. If you DO start a fire, think about ways to get that heat into your body as effectively as possible--heat water to drink. Warm water bottles or rocks to tuck under your armpits and between your legs. One particularly good trick that I've found (though less applicable in our situation) is to set up a reflective 'space blanket' behind you, to reflect the radiant heat of the fire back onto yourself from behind.

Making heat also plays a role in this type of rest; your body cannot make heat without fuel. As I alluded to above, taking in calories--especially simple, easy-to-digest ones, can be very helpful in warming up. Dried fruit or other sources of carbs, the simpler the better, are your friend. This is also highly applicable when enduring a cold night; I always try to take a little something to bed with me.

This type of rest can go faster than you think and mean the difference between life and death. Often, you're back on the trail before you know it, feeling warmer and happier. Even if you have to stop there for the day, though, it's worth it.

Let's talk about clothing.

A lot is made about the type of fiber you wear. "Cotton is death!" is the common refrain. Luckily for us, it's also not canon--but linen is likely materially similar enough that we can think of it in the same way. Either way, this study shows that, while plant-based textiles like cotton and linen may not be as good as wool, they're not as awful as they're often portrayed. The important thing, if you use them, is to use them as part of a layered system and to wear garments that are appropriate to the weather. You will certainly be happier if your garments are dry, whether plant-or animal-based, and that means not water-logging them with sweat. If you're expecting to be cold later, try not to get too hot now--even if that means removing warmer clothing. Just keep an eye out for those signs that your exertion isn't keeping up with your heat loss.

Oh--and the idea that you should sleep naked is a myth. If you have warm, dry clothes, wearing them inside your bedding will keep you warmer through the night.

Finally, let's talk about what to do if you or a companion are fully hypothermic.

Much of the above is as much a treatment for mild hypothermia as a preventative against it:

â—‹ Seek or set up shelter as soon as possible.
â—‹ Remove wet clothing and don any warm, insulative clothing you have. Bedding should also be used, if possible.
â—‹ Get heat into you, whether directly (hot water) or chemically (food calories).
â—‹ Avoid alcohol, as it can raise your surface body temperature and make you feel warmer at the expense of your core temperature.
â—‹ The use of external heat sources, like warm stones or water bottles recommended above for prevention, is controversial when it comes to treatment. Some feel it runs the risk of disrupting your body's autonomic responses to cold. Either way, great care should be taken when handling hot objects with hypothermia patients, since numbness can make it hard to perceive when something is TOO hot.

Extreme hypothermia is denoted by a worsening of confusion or other mental symptoms (refer to the LORe section in the first post of this thread), as well as a weakening pulse and respiration. Cessation of shivering is a VERY bad sign. Treatment is the same as above, but the patient must be taken to a hospital as soon as possible, and with as great a care as possible; jarring movements can disrupt their vital functions. Great care should be taken if food or drink are administered, since choking becomes a risk with deteriorating mental state.

Some of the most rewarding nights I've spent outdoors have been the coldest. With care and attention, we can enjoy nature safely. Learn to listen to your body and know what it's saying, and be prepared to give it what it asks for. Remember: discretion is the better part of valor. Know when to stop and get warm, and know when to head home. I can't count the number of times, often after having already set up camp, that I've headed back to the car and driven home. I probably didn't need to, in most cases, but even with all of that I count every single one of those as a successful trip. I learned something every time, and I'm still here to apply that newfound knowledge.
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Re: Heat-related illness

Post by SierraStrider »

In 2005 I attended the National Boy Scout Jamboree in Virginia. A traditional part of this event is a speech by the president of the United States. All 40,000 scouts in attendance marched to the big amphitheater for the speech, but looming thunderstorms made it too risky, so we all marched back to our campsites. In the intervening hour or two, hundreds upon hundreds of scouts contracted heat-related illnesses and had to be carried to the massive, air-conditioned tour busses parked at the top of the amphitheater for this purpose. This was at a well-organized event with plenty of water and featuring, by and large, healthy young men enduring only light exertion. Like hypothermia, heat-related illness doesn't care how good of shape you're in--it's simple thermodynamics.

First, what is heat-related illness, and why is it important?

Heat-related illness is a catch-all term for what are colloquially known as heat exhaustion and heat stroke, both of which are really just different levels of hyperthermia. Hyperthermia is the opposite of hypothermia--instead of your body temperature becoming too low, it becomes too high. To avoid confusion between the two similar looking and sounding words, we call it heat-related illness.

Heat-related illness occurs when the body can't get rid of heat fast enough. Your body generates quite a bit of heat in the course of its normal function, and has limited ways of getting rid of it. Even a sedentary human produces about 100-120 watts of heat, and that can be radically higher when exerting. The best way for us to get rid of that heat is through evaporation of sweat, but this requires 2 things:1) enough water to produce sweat, and 2) air which has a low enough relative humidity that evaporation can occur.
This is why on humid days, sweating doesn't seem to cool you off as well. Your body doesn't account for this, and just sweats even more to compensate. You can lose quite a bit of water this way. When exerting hard on days that are hot or humid, be on the look out for the symptoms of heat-related illness in yourself and your companions:

If your body temperature does start to creep up, you may start to experience symptoms of heat exhaustion. These are often counterintuitive, just like the symptoms of hypothermia. Clammy skin, goosebumps or even shivering may occur despite the hot weather. Additionally, muscle cramps, headache, dizziness, nausea, fast pulse and low blood pressure are signs to look out for. Since these are also signs of a heart attack, they can be quite alarming. Treatment for heart attack, such as chewing aspirin, or administration of nitroglycerin, is fine if you aren't sure which malady you're treating. Heat exhastion can be treated fairly easily and safely in the field, but should be treated quickly and taken seriously, lest it progress to heat stroke.

Heat stroke is really just an advanced level of hyperthermia, when the body's temperature rises above 40°C/104°F. The symptoms are quite distinct; instead of pale, clammy skin, the patient's skin will be red and dry. Sweating will cease as the body's attempts to cool itself are overloaded. Vomiting commences or increases, and confusion sets in--check out the LORe section of the first post in this thread. The patient may even lose consciousness. THIS IS A MEDICAL EMERGENCY.

Now that we know what heat-related illness is, when to look for it and how to recognize it, what do we do about it?

Well, unsurprisingly, we need to cool the body. Reduce exertion. Find shade, and remove anything that might be insulating the body like heavy clothes, shoes or pack. Water is good at absorbing heat even when it doesn't evaporate, so cool, wet compresses are beneficial. If a body of water is close at hand, immersion is very useful. Hydration is also very important, since your body is likely losing water to sweat at an alarming rate. Just like in the case of hypothermia, alcohol is not advised. Caffeine is also better avoided, though beverages with electrolytes are a good idea.

Once symptoms advance to the level of heat stroke, extra care must be taken. Reduced consciousness makes administration of fluids or bathing risky. Wet compresses and relaxation in a cool area are mandatory. At this point the patient is in a positive feedback loop, where higher temperatures cause higher temperatures, which can rapidly spiral out of control. Don't let that happen, and if possible, seek emergency medical care as soon as possible.
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