On the Trail Triage: What to Do When the Trail Takes Its Toll

Runners are a group not unfamiliar with the concept of “injury.” In fact, we may have been labeled as injury-prone on an occasion or two. Many of our many injuries are of the repetitive or sport-induced nature: sprains, strains, and errant pains. However, for those of us who wander out into nature in search of many miles and a good dose of solitude, we need to be aware of the more traumatic kind of injuries that are available to us. This article seeks to serve as a quick primer on the injuries you can face on the trail and how to treat them trail-side and after get home. By way of full disclosure, I am trained as a Wilderness EMT and not a doctor. Follow any medical advice contained herein as such and, above all, use your best judgment!

Before you run, it is always a good idea to review your preparations. How many layers do you have? How many can you use if you need to improvise a sling or bandage? Are you carrying a cellphone? Do someone know where you are going and when you will return? Are you carrying an ID? These steps should be second nature, only take a few seconds, and can truly make the difference between a good war-wound and tragedy.

So, you have taken a fall or a branch or a rock or.. or… what’s next?

[Editor’s Note: You might be interested in our companion piece to this article outlining the long-term treatment of trail trauma to prevent compensatory running injuries.]

Bleeds – When You’re Leaking

You’re bleeding. What next? Before you slap a sweaty shirt on top of it, take a moment to figure out the type of bleed of your bleed:

Just a flesh wound

Just a flesh wound… specifically, a capillary bleed.

Capillary BleedsSlow-moving, dark (de-oxygenated) blood – These constitute the majority of the bleeds we will likely see on a trail run. As a general rule, letting capillary bleeds bleed a bit is a good thing. It allows the wound to flush out some of the dirt, rocks, and whatnot. And, it means you can finish your run! However, when you get home, you need to scrub that scab away and get the rest of the junk out.

Venous BleedsFast-moving, dark (de-oxygenated) blood – Venous bleeds put out a good amount of blood and will likely have a hard time clotting if you continue moving. Apply direct pressure to the wound with your hand and/or clean (as possible) absorbent fabric. Continue to apply pressure until the bleed clots or stops. Venous bleeds are a reason to turn-around.

Arterial BleedsFast-moving, spurting, bright-red (oxygenated) blood – If you have a bleed that is spurting, apply direct pressure immediately and consider sacrificing a layer to wrap around the site to help restrict the bleeding. While tourniquets have come back into fashion in emergency medicine, you should be able to control an arterial bleed with a good firm wrap. Do not remove pressure or bandage until you have definitive help. Turn around immediately and get help from anyone else on the trail that you may encounter.

Bumps – When You Thump

Generally, bruises (contusions) are only an irritating byproduct of a fall. Most can be treated with ice and rest after the run. However, there are a few cases where you should pay close attention to that bruise:

Bruising with significant and increasing swelling – This could be a sign of internal bleeding. This means increasing tissue damage and loss of blood.

Bruising with significant and increasing swelling – This could be a sign of internal bleeding. This means increasing tissue damage and loss of blood. If a bruised area continues to swell and do so rapidly, take note. There isn’t much you can do on the trail except to  turn-around and take that trip to the ER.

Bruising to the chest-cavity (front and/or back) – The majority of us run with a minimal amount of fat padding our cores. Bruising to internal organs, damage to the lungs, and internal bleeding are all distinct possibilities if you have a significant bump to the chest-cavity. If you have bruising to the chest coupled with abdominal pain, difficulty breathing, and/or firmness at the site of the bruise, you need to get it checked out by the professionals.  Keep yourself as comfortable as possible (sometimes applying pressure to the area with a balled up layer can help) and avoid any exertion on the lungs or core on your way back out.

Impalement – When You Get Stuck

Nobody wants to think about a stick stuck into a leg or, (deep breath), an eye. But, this happens easier than most of us would assume. Do not remove the impaled object. If the impalement is preventing moving towards home/help, try to break it off closer to the body. Pad around the impaled object with clothing to help stabilize it and keep it from moving and causing more damage. If you take something to one eye, pad it and remember that our eyes are meant to move in tandem. Minimize eye movement to prevent further damage to the eye. If ever there was a case for sunglasses and other protective eyewear…

Breaks/Dislocations – When You Bend the Wrong Way

At the hospital, treatment of a dislocation or a break go two very different ways. But, on the trail, it makes very little difference. Your priority is immobilization. If it is a bone, immobilize the joints above and below. If it is a joint, immobilize the bones above and below. The vast majority of the time it is not advisable to try and straighten the break/dislocation trail-side. Doing so can cause more nerve and vessel damage. Pad to fill gaps and put the limb in a comfortable position and make your way out anyway possible. If you have a compound break (bone through the skin), treat the bleed accordingly.

Conclusion and Call for Comments

Clearly, this is not a complete or definitive guide on trail-side injuries. If anything, hopefully it has whet your appetite to becoming better prepared. Prevention and education are the two best things you can bring to a trail run if you want to avoid and survive a traumatic injury. Wilderness first aid classes are available in most areas, only take up two days (three with CPR certification), and usually cost less than a couple of pairs of shoes.

So, who has a good war-wound picture or cautionary tale to share? We emergency medicine types love the gore.

[Editor’s Note: Check back in tomorrow when Joe Uhan explains what to do for longer-term treatment and rehabilitation for your trail trauma.]

[The contents of this column as well as the author’s comments are provided for general informational purposes only and are not intended as a substitute for professional medical advice. Do not use the information on this website for diagnosing or treating any medical or health condition.]

Adam Barnhart

discovered from an early age that he loved running , but didn't like starting guns. As a result, he is frequently found wandering the area trails around Anchorage, AK, but only at races after considerable peer-pressure is applied. When not trail running, Adam keeps pace with his wife and kids, works as a pastor and, with the Alaska Mountain Rescue Group.

There are 29 comments

  1. Jess

    The biggest hazard on my local trails is thorns. Getting your legs covered with tiny lacerations on a run stings, but it's not too dangerous… and then there was the time that the thorn scratches swelled into welts after about twenty minutes. By the time I had gotten back to a road, over an hour later, the welts had mostly gone away. Scary but harmless, I'm hoping. Any advice for what to carry for skin reactions to plants on the trail? I suspect what got me was stinging nettles, whereas normally it's blackberries and gorse that are scraping at me.

    1. Adam Barnhart

      Hey Jess – Sounds like, at worst, a mild allergic reaction to whatever scrapped you. However, lots of folks have mild reactions to nettles and some of their cousins. You can toss a tube of diphenhydramine (benadryl) in your pack. It'll calm the reaction. Your best bet is avoidance. Figure out which plants do that to you and do some fancy footwork.

      Also, be sure to clean out those scrapes at home!

  2. StumpWater

    Not an issue in sunny, 70-degree central NC right now, but you might want to add frostbite to this article. Any individual living in … I dunno … Park City, Utah … might want to brush up on the whys and whatfors of frostbite.

    1. Adam Barnhart

      StumpWater – Great suggestion. I actually didn't include any environmental concerns in this article, hot or cold. Was trying to keep it to a reasonable length. If there is sufficient interest, I'll gladly put together an article that addresses those… and a few of the other things left out of this one!

      1. Clint

        I would love to see that discussion about environmental concerns like heat stroke (I live in Australia) and also animal interactions gone bad.

  3. art

    most recent trail injury … cracked rib.

    I fall a lot, so much that some running partners joke about it.

    because of that I have falling down to a science and am usually ok.

    but a recent fall took me totally by surprise and happened fast and hard.

    bottom of water bottle slams onto hard rocky ground, upper chest slams onto top of water bottle, many other scrapes and bruises, but the rib pain convinced me to get an x-ray, cracked rib, nothing to do but take it easy for 4-6 weeks or so.

    1. Bryon Powell

      I, too, have crushed a rib (no idea as to actual injury, as there's not much treatment so long as you've not punctured anything else) during a trail run. Interestingly, is that, like you, what made it so much worse than your standard superman was that I had an object on my chest. Specifically, a small (1 ounce) plastic vial (like you'd find at an outdoor store) for salt tabs. Dang that hurt like a mofo for quite a while!

      1. Mike Hinterberg

        Yes, guys! Did that earlier this year just hiking in winter with a water bottle in the front of my jacket, thought I was being clever in keeping it warm…until I tripped.

        Took about 3 weeks for breathing to get back to normal. Lesson learned.

        This has to be a common "one-time" injury, a couple of local Nick's (who should know better!) had mentioned doing the same thing. One of them has taken to the softer Platypi for longer races.

        1. Brian T

          Common, indeed. My broken rib was from a cell phone in a chest pocket. I was snowboarding, not running, but I remember that shallow breathing out of fear of stabbing pain.

          Wrecked the phone, too….

  4. Ric Moxley

    Man, did I wince reading this — likely because I've had my share of bleeds and contusions and near-breaks on trail mishaps. But great article, with helpful info. One thing though — please do an edit pass — some of the info got jumbled and, i suspect, is thus inaccurate (like for instance "If it is a bone, immobilize the joints above and below. If it is a joint, immobilize the bones above and below." — funny how the advice is identically worded for both … typo?). Thanks! :)

    1. Adam Barnhart

      Hey Ric! Thanks reading and the good words. Odd as it sounds, that's actually the correct mantra.

      For example, let's say you break your right radius (right lower arm). Ouch! You want to stop the wrist joint and the elbow joint from moving to stabilize that bone.

      Likewise, you think you have dislocated your elbow… stop the upper arm and lower arm from moving to stabilize the compromised joint.

  5. KenZ

    One slight correction to your impalement section: Based on experience, I suggest it should read: "Do not remove the impaled object, unless said object is a 3/4" wide x 1/8" thick metal gate latch driven roughly 1.5" into your hand and almost poking out the other side. In this case, slide hand off gate latch and immediately apply pressure. Then, as you wrap duct tape from your first aid kit in your pack around your hand while running to the next aid station, think about your stubborn choice of American style treads on slippery UK mud and grass (Inov8 treads don't look like soccer cleats for nothing), and that you now also understand why the Euros insist on every racer carrying a small first aid kit."

    It's times like these that I wish irunfar allowed for picture uploads. I have an awesome shot of the doctor opening up this gaping gash in my hand while cleaning it out. He was mumbling about how it would have been easier if it had popped out the other side.

    1. KenZ

      By the way, on that note how about modding the article to have a (small) list of items that one might consider carrying on a long, solo, unsupported run. In addition to toilet paper (aka "mountain money"), I ALWAYS carry some duct tape, enough to wrap around a thigh. Doesn't weigh much. On longer runs in remote areas, a lighter and a space blanket: basically enough to survive a night. Not enjoy it, but survive it.

      1. Jen Young

        KenZ— Ouch! I'd love to see a picture of that :) I agree with you on duct tape is always worth its weight in gold, even on a supported run.

        I recently ran an aid station for an ultra, and the first thing out of my personal stash to help a runner was the duct tape. (Followed shortly by the toilet paper, of course!)


        1. Mike D.

          The duct tape can be wrapped around a shortened pencil as to not take up much room, and you also have a writting utensil in case you need to leave a note (or need to write down a great idea) on that "mountain money."

  6. cdb

    hi! good to know i'm not the only ultimate clumsy out there. i trail run in tahoe – distance – and i get out where no one else is. now that the snow and ice are here, i've taken to my elliptical and rowing machine WHICH I HATE. Any suggestions for running in snow and ice? because i WILL fall. having already broken my face falling on ice once previously, i do not intend to do it again.

    1. Kristin Z

      1 option: screw your shoes (literally)… find how-to's by jeff browning (bronco billy), adam feerst of Denver Trail runners, etc.

      2nd option: yaktrax, microspikes, etc.

      Tried and tested.

    2. Adam Barnhart

      Screw shoes are the best! I always keep a pair of trail shoes screwed. They are surprisingly effective.

      Also – Microspikes by Kathoola – I've shredded too many pairs of Yaks and their clones. Microspikes get the work done and are easily thrice as durable (and twice the price).

  7. Rob Furness

    Another good point to mention is the possibility of Hypothermia. For example, a fairly innocuous wound could lead to a fatality if the climate is harsh and the casualty is left immobilised. Golden rule if you're on your own in the cold and aren't 100% that help is on its way is to get yourself off the hill to a safe location, even if this means struggling along on a broken leg. A damaged leg is better than dying.

  8. Dan H

    Running in a brand new pair of cleated Inov8s on a wet day, I felt like I had invincible traction despite the mud. And then I found out the hard way that rubbery cleats don't mean jack on a scummy, wet wooden bridge.

    I strode onto the bridge at a slight angle coming down off a hill fast, and one flailing step later I was airborne. I was extremely lucky to land on the very edge of the bridge on my back rather than falling the 8 feet down onto jagged rocks.

    I was not so lucky to also land on my can of pepper spray which broke, and started spraying everywhere. So with the wind knocked out of me, I had to crawl away from a cloud of pepper spray, and then limp 2 miles back to the car half-blind and coughing.

    Lessons learned: Be very careful on wet bridges. Don't carry pepper spray on your hip.

    1. Ric

      omg, I laughed so hard reading ur story, Dan. I should feel bad but the image of you scrambling out of a haze of pepper spray … lol – sorry. :)

    1. Jen Young

      Good question! I run into (literally) snakes more often than anything on the trails in my area. This would be great to include in the article on environmental hazards, Adam! :-)

    2. Adam Barnhart

      Thanks Craig and Jen! I'll send Bryon an email and see if we can't get an environment hazards (or just a part two) article in the works soon.

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