September 2005

It was a great level for Gore, 1050cfs, but cold at the put-in. Not really any colder than it usually is in September, but the wind had picked up and was vicious. I’d guess sustained 15-20mph – upstream of course. It’s not that I’d never seen wind like this funneling up the canyon and making white cap waves on the flat water, but it almost never started before noon. We put on before 10am. 
I was the safety boater for two commercial rafts. As we floated on the endless flat water at the beginning of the day, I did what all good safety boaters do during this time…I tried to find the victim. While the raft guides gave through Safety Talks and instructions on exactly how they wanted the clients to paddle, I floated nearby looking for the guy who just didn’t get it. The guy who looked like he had problems paddling, following instructions, sitting on the boat, etc. The victim. This whole time there was the unrelenting upstream wind, which forced the clients to paddle the entire way in – tiring them out before the game had even begun. At the end of the flat water, all of the clients were required to jump into the water and pull themselves into the boat. This is the final attempt to find the victim. I was feeling really good because all eight of the clients on both boats looked strong and were able to at least pull themselves most of the way into the boat. 
At the end of the first class II/III we got out on the beach and instructed the clients on white water swimming technique. This had already been discussed during the Safety Talk, but we wanted to show them what was meant by “calm water”, eddies and waves. I also gave a short talk about my role as the safety kayaker. The key point I heard at the talk and emphasized personally over and over again was don’t panic. I was still feeling good and everyone looked ready. The one nagging thought I had was that the wind hadn’t stopped. Invariably, the wind stops once you get into the canyon, but it hadn’t. No big deal, we were professionals with good crews.
Alex was a guide with 10+ years experience from back East on the Gauley river. I’d spent the summer guiding with him on Clear Creek. I judged him to be an excellent guide, not only in river skill, but also in his ability to bond with a crew and get the best from them. This to me is what separates the good guides from the really great guides. Good guides can take a group of raft guides with prior training and run hard rivers with them. Great guides can take unskilled clients with backgrounds of enormous variety and meld them together into a cohesive team to run hard rapids. And they can do it within an hour. 
The second guide, Mark, I’d just met the day before while safety boating for his trip. He had good lines the day before and worked in a calm collected manner. I was confident in his abilities because I’ve only ever seen crack guides working for the company on Gore. Furthermore, like me, he was a ski patroller for a large resort in the winter. This meant that his medical knowledge and skills were undoubtedly up to date. 
For my part, I’d been kayaking for 4 years and raft guiding for 5. Four years isn’t a long time to be a kayaker, but I’d put 100+ days on the river for each of those 4 years. I’d safety boated the Pine Creek section of the Arkansas many times and felt comfortable in my abilities. The 26th was my 14th trip down Gore that season at 1050 cfs or above. I had previously taken a swift water certification course and I felt confident and fairly experienced. I was also an EMT-B and in nursing school at the time. Furthermore, I had just finished my first season as a ski patroller, where I got to deal with lots of trauma. We had a good crew that day.
Applesauce went smooth for all parties and I was feeling good so I caught the wave just below to please the crowd. The rafts portaged Gore rapid while I ran the sneak. Scissors and Pyrite were clean and uneventful. As we pulled into Tunnel, I was absolutely amazed that the wind had still been howling the entire trip. This can make Tunnel trickier because all of the waves before the lip throw spray into the air when it’s windy. That wind blown spray turns the conditions into whiteout for the guide. Also, the objective of Tunnel is to get off the lip with as much speed as possible and the wind can make that task much more difficult in a raft. Finally, as often happens at Tunnel, the sun was shining directly on the lip of the drop, but a high cliff kept it from shining upstream of the lip. This means that right at the critical moment, your eyes are dilating and making it hard to perceive distance. I’d run Tunnel during these exact circumstances before, but you always hope for the clear day.
The guests went up to the lip of Tunnel and watched me run it. After a discussion of the line and its dangers with their guides, they all decided that they wanted to drop it. I was up on the seal launch rock as Alex dropped in. Right at the lip, the wind caught his boat and stalled it so that when they went over, the raft was near vertical and completely disappeared into the maw. Alex and one of the guests from the back were violently ejected from the rear out the front of the raft. Since they both surfaced in the current, I launched and escorted them back to river right. After I climbed back onto the rock, Mark’s boat dropped off the lip. He managed to have a little more speed and grabbed both sides of the perimeter line to keep from being ejected. Toilet Bowl was uneventful even though I was scared with the wind and we pulled onto the beach above Kirshbaum’s for a break. We took a good break and explained the next rapid to the guests. 
Kirshbaum proper was also uneventful and both guides managed to thread the Goal Posts beautifully. During the run-out to da Bomb is a move referred to as Crack-of-Dawn. It’s the two large rocks on the river right side of the shallow run-out. At this point it was still extremely windy. Mark made it past the boulders by making the move to the left. Alex followed, but either his crew wasn’t together or the wind was too strong. He didn’t get around and hit the boulder that is more upstream and mid-river. Often times when a raft hits a rock, it slowly rides up and then rolls over. Not this time. The raft flipped lightening quick without a pause. I immediately paddled over to the most downstream client and started yelling, “Swim towards me, swim, swim!” He wanted to grab my boat, but he was swimming well so I just had him follow me to the river left. He hit a small pour-over rock with little water and managed to grab it and get on. I told him to stay there and took off toward the next client who had just passed us. 
This client was following us to river left, but he had given up. He had hit a lot of shallow rocks, had some blood trickling down his forehead, and had swallowed a lot of water. He was just floating and appeared extremely disoriented. I paddled over to him and said, “Grab the back!” With what appeared to be his last bit of energy he took one stroke and grabbed my stern loop. I started screaming, “Kick, kick, kick,” and pulled him to shore. While pulling him to shore, I noticed that there was a yellow helmet downstream of me, which meant that there must be another guest who was not swimming. When we got to a deep eddy on river right, I yelled, “Let go, get on shore, I gotta go!” He took a few seconds to get oriented and let go, so I yelled again, “Let Go! I’ve gotta go!”
I peeled out of the eddy and quickly caught up to the other guest. This third guest was floating in the current about 10 feet from the right bank and was right next to the raft, which was just to the river left of him. I could see Alex was downstream and at the midline of the raft. The client had sunglasses and a helmet on, so it was hard for me to see any facial expressions even though I was only a few feet away. I started yelling at him to let go of the raft and swim for shore. It can be tough to climb into a raft, especially if you’re tired and haven’t done it a thousand times so I thought it would be easier to swim the ten feet to shore. Right then the raft bumped him and he rolled over face down in the water. I don’t think I’ve ever seen anything as spooky as watching someone float face down in water without trying to roll himself over. 
My first thought was that he was unconscious. That sounds stupid on paper now, but it got the gears in my head and adrenaline in my muscles cranking. My second thought was, “He’s dead.” I don’t mean that like I was giving up on him as dead, but rather I thought at that moment he had a 10% chance of making it to the take-out alive. 
Some people call me a pessimist or negative. I feel that my thought process isn’t negative. Rather I think about all the worst shit that can happen and then think backwards about how I’m going to fix it. That’s the difference between pessimism or negativity and me – I’m going to fix it. 
Of course, those two thoughts happened before I even took my first paddle stroke towards him, which was immediate. It only took me two or three strokes to reach him when I saw him roll over. Alex also saw him roll over and screamed, “Joe!” Alex then abandoned the raft and swam to the guest. I just barely beat Alex to the guest and rolled him over. I then grabbed my rescue tether and clipped the top buckle on his life jacket. I drug him to shore with about 5 strokes. I then jumped out of my boat on the bank. We weren’t really in an eddy and I accidentally got the boat between the client and me. I didn’t want to loose my boat because it had my first-aid kit in it. The client was still in the current and his weight was nearly dragging me back out into the river. Alex helped me get untangled from the boat and pull the client up onto the rocks. At this point I discovered that the client was probably around 275 pounds. Alex gave three long blows on his whistle to alert anyone around that we had a life-threatening emergency. The flattest spot that we could access with this client was a rock that had a flat surface angled about 45 degrees back into the river. The flat surface of the rock was about 2 feet wide and 3 feet long. Not an ideal CPR surface. Also, the unconscious guest was still in the river below his hips. It was the best we had and he needed oxygen. At this point Alex and I are also breathing hard and fatigued. 
My next thought was, “This guy is completely gray and limp – he’s definitely dead.” Then, I thought, “ABC.” My EMT instructor told me that when shit hits the fan, you need to be trained to the point where you don’t think. Your hands just start moving through the motions that they’ve done on dummies a million times. Hands have amazing little brains of their own, kinda like other parts of the male anatomy. From ABC on out, my brain shut off and my hands just did everything that they’d been trained to do. 
ABC is taught in every one of the 10 CPR classes I’ve taken. I would like to make the point that if you don’t know what ABC stands for then you shouldn’t be a kayaker or raft guide. Airway, Breathing, Circulation. Alex gave two mouth-to-mouth breaths. I told him that I had a CPR mask in my boat and he should get it. I used the time to see how the patient’s head was positioned. It was hanging a little bit off the back of the rock, which was good because that position brings the tongue off the back of the throat. Alex handed me the mask and I gave another two breaths through it. I couldn’t see his chest rise, so we unbuckled his life jacket. I gave two more breaths. I felt like they were going in, but still couldn’t see his chest rise so I told Alex to put his hand on the patient’s chest to see if he could feel the chest rise. I then gave two more breaths. They were going in – the patient had an airway and artificial breaths. We move to Circulation. I couldn’t get a corotid pulse in the patient’s neck. Alex couldn’t get a radial pulse in the patient’s wrist. We tried both locations for about 30 seconds while giving breaths and couldn’t get one. His capillary refill in his finger nail beds was slow – definitely longer than the normal 2 seconds.
I felt like the patient had a pulse. I had no reason to think that, it was just a gut feeling. Still, without being able to obtain one, I told Alex to start compressions. Alex put his hands on the lower sternum and began compressions. Alex did two sets of compressions and I gave two breaths between them. 

As a side note, recently in nursing school I learned that CPR is effective at reviving people between 13-30% - in the hospital with cardiac drugs, defibrillation, and professionals who have spent years perfecting technique on real patients. Our patient was near hypothermic, on a small rock, and in the wilderness many hours from a hospital or even ambulance. We did have one thing on our side. In the hospital most patients die of cardiac arrest at old age or severely decreased general health. Our patient appeared to be unconscious and not breathing due to near drowning. This meant that his heart and body were in good shape to restart if we could keep the blood flowing and oxygen in his lungs. Boaters remember that – lightening and near drowning victims stand a good chance of resuscitation.  
After the second set of compressions, the patient started moving. Not conscious or purposeful moving, but his fingers were contracting a little and his lips started to slowly move. This was good because people without a pulse don’t move. We stopped compressions. The patient was still not breathing. I continued giving breaths at about 1 every 5 seconds. This continued for about 3-4 minutes. Meanwhile the client that had held my boat while I pulled him to shore arrived on scene. We were yelling at the patient to start breathing. I pinched his hand hard to see if he was responsive to pain. We couldn’t give a sternal rub because we didn’t want to take his wet suit off. I checked for a carotid pulse again, but couldn’t get one. The client who arrived told me the patient’s name was Dave, but I heard Dennis and started cheering for Dennis to breathe. The client corrected me and again said Dave. Finally, Dave started breathing after we gave him breaths for about 3-4 minutes. He started salivating at the mouth, so I put on latex gloves from my kit and tried to take some of the spit from his mouth without reaching between his teeth.  
Dave was breathing fast and shallow at about 26-30 breaths per minute. I supplemented with a couple of deep breaths every minute. I looked at my watch – 2:36pm. Mark and the clients on his raft arrived on scene after rescuing the other two clients off the rocks they ended up on. I asked one of the clients to push hard on all of Dave’s limbs to see if they could feel any broken bones. I also asked him to look for any blood. He found neither. With the added help we placed my upside down kayak as level as we could get it and moved Dave onto it. Mark then took a crew in his raft to the other side of the river where the flipped raft had miraculously pinned. He towed it back to us. We deflated the thwarts on the raft and placed Dave in the middle after buckling his life jacket back on. I wanted a backboard, but we didn’t really have anything that would have been safe to strap Dave to. If the raft flipped or pinned again and Dave was strapped to something he most likely would have died. Me holding his neck in a neutral inline position would have to do. After Mark gave a short pep talk to two of the clients, Alex pushed us off and guided while the two clients paddled. I sat in the raft and supplemented Dave’s breaths, tried to get a pulse and routinely checked his capillary refill, which remained slow.  
Thankfully, we were near the end of the canyon, with one easy class III to go. I covered Dave’s mouth with my hand several times to prevent waves from washing in. It is also unreal how bad someone’s breath is once they’ve died and been resuscitated. The upstream wind was still brutal and probably doubled the time that it would have taken to paddle out. The two clients were completely exhausted and barely able to put in a stroke by the time we made it to the takeout. During the ride out, Dave started screaming in agony. The screams were not in response to anything and he still was not responsive to painful stimuli initiated by me. His breaths remained fast and shallow at about 24. I still was unable to get a pulse, so I remained counting breaths, cheering on the crew, and holding Dave’s head inline.
While we were paddling out, Mark and crew cleaned up the scene. They grabbed my paddle, kayak, and helmet, which was full face and had to be removed to perform CPR. A group of kayakers caught up to Mark and at the lead was a hand paddler named Ed. Mark gave him my paddle and asked him to paddle out and call 911. Ed passed us and beat us out by about 5 minutes.
We arrived at the takeout at 3:30, just a few minutes ahead of Mark (he had a crew of 7 now). Both of the guides ran to the upper parking lot to send someone to call 911 and get the van. I remained in the raft on the beach with Dave. Just then Dave opened his eyes slowly and I asked, “Do you know where you are?” He slowly rasped, “Fuck no.” Inside my head I started jumping for joy. One of the other clients asked me how they could help and I told them that I needed a backboard or anything long, flat and hard. I also asked for a pen and paper. After a few moments, one of the clients, who was a ski patrol buddy of Mark’s, came running down to the beach with a tailgate from a pick-up truck. He had just jacked it from a random truck in the lot. I thought to myself, “Damn fine work.”
Alex pulled up with Mark in the van. Some of the clients began stripping the van of its seats, while others helped Mark, Alex, and I move and strap Dave onto the tailgate with cam straps. We then moved Dave into the van and took off with the clients who knew him and Alex driving. I wanted to head toward Vail because it was the nearest hospital, but Alex was sure that they were sending an ambulance from Kremmling. I agreed then that we should head toward the ambulance because Dave needed a helicopter anyway. During the drive, Dave became more alert, but was still thoroughly confused and requested that we stop many times. He also said he was going to puke, which was scary because I didn’t want to turn his neck in case he had a spinal injury. With our limited space in the van we couldn’t roll the whole tailgate to help him puke either.  
We met the ambulance at the top of the hill just before the 20mph turn. I gave report to the paramedic and one of the clients handed him a sheet with a SAMPLE history and all the vitals we had collected. As I was holding Dave’s head, I helped the ambulance EMT put a C-collar on Dave and cut off his life jacket with the trauma shears. The team then moved Dave off the tailgate and onto the ambulance bed and a backboard. Dave again said he was going to puke and this time he did, but we managed to roll him onto his side. He puked all over my legs. Finally, we loaded him into the back of the ambulance. The medic asked if I was sure that Dave was pulse-less and I replied no, but I was sure that he was apnic. In the ambulance, the EMT primed a bag, the medic stuck his antecubital vein and I applied spider straps to the backboard. The paramedic told me that the chopper was 15 minutes out. I got out of the ambulance and had people start closing the road so the chopper could land. A few minutes later several other emergency services personal arrived along with several law enforcement cars. They closed the road a mile down because it was a better LZ and the ambulance took Dave there. It was approximately 5:30.  
That night, while we had a stress de-briefing, Alex got a call from someone at the hospital saying that Dave was alert and telling jokes in the ER. I had lunch with Dave and his girl friend six days later. He was tired, sore and shaken up, but walking, smiling, and his color and breath were much better since we’d last seen each other.



Several things worked out just perfectly to keep Dave alive. We were at the end of the canyon. I had a rescue vest and CPR mask. The flipped raft pinned without a guide and without washing downstream of us. All of the clients and guides remained extremely calm. Mark’s scene command was extraordinary.  
Another aside. In the extreme high water year of 1995, 20+ people died in the class III Brown’s canyon – the most commercially run stretch in the country. However, since Brown’s is only class III, it attracts older and less fit clients. When they fall in the freezing waters, they generally panic, which drives their blood pressure and heart rate to extreme levels that their unfit heart can’t handle. A heart attack ensues. These people have little chance of resuscitation. Dave survived because he was relatively in shape. My guess was that he weighed 270lbs, but he was about 6’5” and a firefighter. I think he simply swallowed too much water. He was definitely conscious while swimming – Alex had a conversation with him while Dave was swimming and Alex was flipping over the flipped raft. It appears to me that Dave’s heart never quit, he simply panicked, swallowed too much water, had a lyringospasm and became unconscious from not being able to breathe. Remember, kids, lightening victims, and near drowning victims have excellent chances at being resuscitated. Not true for heart attack victims, especially without a defibrillator.  

Several things could have happened better. This is not to say that I don’t think our response was excellent. I think we did an awesome job with the tools and situation we had presented. It could have been better with a few more tools. I think that raft companies ought to carry oralpharangeal airways (OPA) and nasalpharangeal airways (NPA) in their sweep kits. The kits could also carry a C-collar that we could have used. I believe that most companies don’t have these in their kits because extreme trauma and even near drownings are relatively rare. Furthermore, these things can be expensive, especially for raft companies operating on narrow margins.  
We needed a backboard on scene. Backboards are available after rapids on many heavily rafted rivers and Gore is starting to find its way into that category. The outfitters and government should agree upon where to put them and who should pay for them. At the very least there should be one available at the take out.  
A satellite phone would have been an awesome asset, especially because if the incident had occurred anywhere above Kirshbaum’s we would have most likely been out after dark. Cost is most likely prohibitive, however. 
It would have been awesome if raft companies had a written, pre-planned arrangement with Flight for Life. We should collect GPS information for possible LZs. Even without a sat phone, it would be easy to have one member of the party paddle out and call the helicopter without moving the patient if we had pre-identified LZs.
Finally, it was an important fact that the guests did not do a second swim through the first class III. I think that we made the right call that day. If they had done the swim, they would have been near hypothermic before even getting into the canyon. This would have decreased their paddling abilities and mental capacities, thereby making dangerous incidents more prone to happening.  
However, the company could have provided the clients with added layers. The guides did have some added layers and offered them routinely, but not enough for everyone if they had been put through a second swim. With the unrelenting upstream wind, it was simply too cold to run the canyon that day. This could not have been predicted because I judged the ambient temperature as reported by weather services to be adequate. I would have guessed 65-70 degrees. It was simply the localized, unexpected, unpredictable heavy upstream wind that continued throughout the entire run. 
The names have been changed…..


As I remember it: Joe Keck, 10/10/05