Concussion Recognition and Treatment in the Backcountry

Concussion recognition and treatment has gotten a lot of attention over the last decade, mostly in the context of youth and professional sports such as tackle football and soccer. It’s even a topic for those who serve in our armed forces. However, confusion over its prevention, diagnosis, and treatment remains widespread. 

In an interview with a reporter from the Chicago Sun Times, former National Football League quarterback Brett Favre, who was knocked out cold only once in his 20-year career, claimed that “probably 90 percent” of the tackles he endured left him with a concussion.

He’s most likely correct in that estimation. After all, the definition of “concussion” is broad: “A concussion is a brain injury, a disturbance in brain function induced by traumatic forces, either from a direct blow to the head or a transmitted force from a blow to the body.” It disrupts brain function at the cellular metabolic level but does not result in major structural damage. Conventional MRI or CT scanning will not show evidence of a concussion.

So, how do you know if you or someone else has suffered a concussion while in the backcountry? And, after having made that determination, what should be done? Having clear answers to these two questions is essential for successful recovery and to prevent long-term cognitive and psychological complications. This is true no matter where the concussion takes place, but especially in the backcountry where medical treatment from a full-time team is unavailable.

Knowing When to Suspect Concussion

Most concussions result from direct injuries to the head. Head injuries are common in nearly all sports, especially contact sports such as football, soccer, hockey, and boxing. But they can also occur when hiking, surfing, rock climbing, or whitewater rafting. Even a simple trip and fall while backpacking can result in a concussion. In fact, concussion can occur anytime someone hits their head hard enough for it to hurt, and even when the incident doesn’t result in a loss of consciousness. 

The defining feature of a concussion is altered brain function. Confusion, balance/coordination problems, memory problems and slowed response times are common signs. Patients frequently complain of a headache. With more severe concussions, symptoms may include nausea/vomiting and light/noise sensitivity.

Performing Concussion Field Tests

In the event of an injury, always treat life-threatening injuries first. Stop any bleeding and ensure the person is breathing adequately. If the person has lost consciousness, assume critical injuries have been sustained and respond appropriately.

If the person is conscious and, after an assessment, appears to have only minor injuries, perform the following tests to determine whether the person has suffered a concussion:

1. Ask detailed questions to evaluate memory function. Simple questions like, “What’s your name?” or “What year is it?” are not adequate. Try asking something about events earlier in that day or events planned for later. For example, if you were mountain biking and a friend took a bad fall, ask questions such as, “What trail are we riding?” “What trail did we ride yesterday?” “Who was in the lead when you fell?” “What were we talking about at the last water break?” If the individual is slow or unable to answer, assume they have a concussion.
2. Test balance using a heel-to-toe walk (as long as there are no other injuries). If they stumble or have gaps between the heel of one foot and the toe of the other, this indicates poor coordination — likely the result of a concussion. (Note: When you administer this test, make sure someone is prepared to assist the individual in case they stumble and fall.)
3. Check cognitive function. Ask them to recite the alphabet or days of the week backwards. Ask them to spell a word backwards or recite a numeral “Three hundred eighty-seven” backwards (783). Or ask them to count by 7’s or 9’s. If they have trouble with these tasks, assume concussion.

Remember: All of these tests assume that you (the tester) have some knowledge of what would be considered “normal” performance for that individual. Use your best judgment.

Identifying Signs of Severe Injury

Severe concussion, traumatic brain injury (TBI), or internal bleeding (in the skull) may be present if the injured party is experiencing any of the following symptoms:

• Loss of consciousness (especially lasting a minute or longer)
• Severe headache
• Repetitive vomiting
• Seizure activity
• Unequal pupils
• Any localized neurologic problems (for example, slurred speech, vision problems, numbness or weakness on one side of the body)

Treatment and Evacuation Considerations

For all concussions, the treatment is rest (mental and physical), proper nutrition, and monitoring. The individual should not be allowed to return to physical or mental activity until 24 hours of being symptom free and then the return should be gradual. Concussion symptoms should improve gradually over hours to days. If symptoms do not improve or if they worsen, consider the possibility of a more severe problem.

Deciding whether to evacuate depends on the situation:

• If evacuation would be quick and require minimal exertion, consider assisting the patient to hike out, being sure to take frequent breaks. This allows recovery to occur in a more controlled setting. In the backcountry, full rest can be impractical or impossible.
• If self-evacuation would take multiple days, the patient should rest and recover in place. This can take two to three days. The goal is to rest until symptoms improve, then gradually increase activity. For example: Day 1, rest. Day 2, short, light hike. Day 3, hike without a pack. Day 4, hike with a pack. If symptoms worsen, go back to the previous stage for 24 hours. 
• With a severe concussion or if the individual does not seem to be improving (or is getting worse), consider calling for search and rescue to assist with the evacuation. 

Recognizing the Consequences of Improper Treatment

With proper rest and recovery, most people will return to 100 percent within five to 10 days. If the brain is not allowed to fully heal, the individual is at risk for long-term cognitive and psychological complications.

It is imperative not to let someone jump back on their bike or start back up the mountain just because they insist they are “fine.” Persuading someone that they need to slow down can be a challenge, especially when dealing with friends or peers. Before going out in the backcountry, have frank discussions with your group about how you plan to respond to medical emergencies, including concussions. That way everyone knows what to expect and will be more receptive to responding appropriately in the event an accident occurs. Wear appropriate safety gear including the most up-to-date helmets.

Head injuries — regardless of how minor they may seem at first — should always be taken seriously. Early intervention can lead to a better recovery and reduce the risk of severe complications. After returning from the backcountry, be sure to get plenty of rest and drink enough water in the days and weeks following the injury. If symptoms don’t improve or they get worse, seek professional medical treatment.

If the treatment of medical emergencies in the backcountry is something you’d like to know about or train for, visit the wilderness medicine training section of the NCOAE website. There you’ll find information on courses that not only teach you how to prevent, identify, and treat medical emergencies in the backcountry, but how to lead and think critically during one as well.

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About the Author: Kate Javes is a North Carolina Level 1 Paramedic and EMT Instructor at The National Center for Outdoor & Adventure Education. A former two-sport NCAA Division I athlete at Rutgers University, Kate received her Bachelor of Science degree in math, and a second bachelor’s degree in History from the United States Naval Academy in Annapolis, Md.