Wilderness Scenario #1 - 23yo fall victim

[ptAltered]

It was suggested on another thread that some scenarios might be set forth for us to game through. I'm a huge fan of scenario based training especially when it involves a lot of critical thinking and making patient decisions over the course of hours or days rather than a brief ambulance ride to the hospital. I'm taking this scenario directly from my W-EMT class. Consider the immediate life threats, the environmental hazards, the extended (possibly definitive) treatment of the patient and the evacuation methods. Play the game as realistically as possible, in these scenarios you've got whatever you'd usually have with you outdoors and your current level of training. It's also interesting to consider some of the legal and ethical aspects of patient care in wilderness settings.

Here's how I'll set these up; You'll be provided a scenario that includes a rescuer, scene and basic patient size up. If access to the patient is assumed (I'll state it) then I'll give a basic set of vital signs. As you progress you'll be provided only what you ask me or what you see, so its important to check interventions and vital signs! "If you don't document it, it didn't happen!" Assume that YOUR friends present are trained to administer "first aid" and that the patients friends or family have no medical training.

What I'm looking for: Each responders first post should mention the gear they'd be carrying and their level of training. Specifically describe your examinations, both how you'd perform them and what you'd be looking for. Describe your interventions, the on-going assessment of the interventions and potential problems with the intervention.

After you've completed your assessment and interventions, you'll need to write out a SOAP note that you'd give to another rescuer or a 911 dispatcher (or just for your own notes regarding the issue, especially if your care is definitive)

"Critical thinking is a survival skill! So is communication!"

I'm really excited about this and I'd love to get any feedback possible from you fine folks regarding the specific scenarios, the format, whatever!

And here we go
-
You and a friend are returning from a summit hike when you hear someone shouting for help at the base of a large (30`) boulder. As you walk over a male in his early twenties, wearing a climbing harness and helmet, comes out and waves at you screaming "My girlfriend fell! Help!!". You assess the scene and determine it to be safe. As you walk to the boulder you see a female, about the age as her partner, lying supine on the dirt. The boyfriend states that she was climbing without protection, he went into the trees to find a bathroom, came back and saw her lying face-down, he helped her over onto her back and then went for help. The incident occurred less than five minutes ago.

You approach the patient and notice that her eyes are open and that she is tracking you with them. Kneeling by her head you introduce yourself and ask if she's ok. She mumbles "... hurts..." and her eyes are fluttering.

Her skin is pink, hot to the touch and has a light layer of sweat. 135 strong in quality, regular in rhythm beats per minute. 24 rapid shallow respirations per minute.

What's next?!

[Showtime]

I'll bite.... I guess since I am just hiking I have a basic first aid kit to include gauze, triangle bandages, pocket facemask, common size OP or NP, splint for 1 appendage, tape, etc and stuff in the "in case I get stuck outside overnight kit" (blanket, tarp, fire, etc)

1- Call 911 - How long is response time? What level of care is coming?
2- Have bystander hold c-spine and monitor breathing. Any change?
3- Head to toe trauma assessment, expose PT, look for any DCAP-BTLS, Racoon Eyes, Battles sing, fluid. Any Found?
4- Check PMS for each extremity. Positive or Negative?
6- Obtain new set of vitals including BP(estimated via carotid/femerol/radial method cuz I don't carry a BP cuff while hiking) and pupils. Make judgement of GCS. What are they?
7- Begin PT interview - What happened? SAMPLE? OPQRST? LOC? Have friend attempt bystander interviews for PT knowledge.
8- At this point start treating for shock by covering PT with a blanket...... and wait for the answers from 1-7.

[Ninja Medic]

Dont forget your ABC's brother.

Her breathing as shallow- that's ALWAYS considered inadequate.

SO, while you have the guy holding C Spine for you, your FIRST priority should be PPV. Without a BVM, that means mouth to mouth. Everything else you assessed is secondary, and meaningless, if she becomes hypoxic.

Army Combat Medic,
Civilian EMT B

[croaker260]

Dont forget your ABC's brother.

Her breathing as shallow- that's ALWAYS considered inadequate.

SO, while you have the guy holding C Spine for you, your FIRST priority should be PPV. Without a BVM, that means mouth to mouth. Everything else you assessed is secondary, and meaningless, if she becomes hypoxic.

Army Combat Medic,
Civilian EMT B

May be easily correctable with gentle stimulation (done during your primary assessment - LOC) or simply jaw thrust (which if done right is painful stimulation all of its own).

So...
PRIMARY ASSESSMENT (30 seconds)
LOC -> sternal rub, or verbal stimuli....assess what is altered/how altered her LOC/Mental status is.
A -> Jaw Thrust while maint C-Spine.
B -> If breathing still shallow, direct PPV...granted "SHALLOW" is a very subjective statement. "SHALLOW" is not "ALWAYS" inadequate, it could be physiologic splinting of a chest injury. I am way more concerned about the altered LOC.
C -> Check/compare radial pulses vs carotid. Sweep for lifethreatening bleeding. Stop it if you find it.
D -> your rapid no bullshit neuro ... "Can you move your fingers? Can you move your toes?"

Then Your Rapid Trauma Assessment (2 minutes) .. Head to Femur for life-threatening injuries and DCAPP-BLS-TIC. Includes a more complete neuro/PMS check of course. Based on what you find , specific treatment.
'
In the coarse of all the above. Improvise a C-Collar with what you have...(Foam sleeping pads work well. As do blankets. SAM Splints work for this too. )
Work on Evac. There are several good guides on field improvised litters that will maintain basic spinal restriction using common camping gear. Since these guys probably have basic climbing gear (1" webbing, belay rope, pads, prussic cord, what ever) you are probably in better shape that you would be otherwise. Though waiting for help may be a better option if you have some form of communication.

As far as the clinical information you have given, too little info to make a decision yet. The hot skin is a bit odd. Regardless, As stated above, begin your primary, followed by your rapid trauma survey, then SAMPLE and basic interview questions to narrow down the important and immediate concerns.

[AZMedic]

Too little details to do anything really besides evac her. Is she hawt? If so call in everyone hawt chicks are hard to come by. In all seriousness now what are her injuries besides shallow breathing at 24? Did she land on her head? Cause well the strong majority of falls that I have been on in a decade over 15 feet land on their head and its game over for them in a week.

[SCBrian]

Standard first aid gear/overnight gear if just me. More if I have scouts with me up to sam splints...

Might be over looked in the other assessments, but how about a quick "What happened" to the girl. She's obviously somewhat conscious, and no one saw her fall. What's the weather like? Could it be overexertion on a hot summer day... only because I've carried plenty of people off the paintball field with it, I'm wondering if the conditions are right for simple heat exhaustion/dehydration ...

Don't forget the legal "Can I help you..."

[offcamber]

I had something very similar to this happen in Seneca Rocks WV in '96.

The only difference is we were climbing and a group went off hiking.. during the hike a girl grabbed a dead tree for balance on a steep trail.. it broke and she fell 25' and landed on her head.

There was no rescue in our location and we had to stabilize her and carry her out on a makeshift stretcher. Luckily, we a had a 4X4 in our group and they were able to cross the swollen stream at the base of the mountain and close the distance of our hike by about 1/2.

She was immediately taken to a very small clinic, then airlifted to Richmond.

In the end she broke her back, but made a full recovery.

I don't really have any fancy details for ya, we were not medics or first responders.. we had to take some risks with a fall victim that I didn't like much, but at the end of the day, it was our only option with no local rescue available.

[VXMerlinXV]

Good one! Way to take the lead.

Ok, first and foremost EVAC like it's going out of style. I want a helicopter quickly, unless she fell off a boulder in the zen garden of her local trauma center. (I'm starting given the info you already collected, if not ABC's blah blah blah) I would determine my interventions based on the ETA of transport. 5 minutes? I would SAM a C-collar. I would also take a second to determine if she was shedding or collecting heat (no climate data given). If she was getting colder I would help her keep heat through insulation between her and the ground and her and the air. I would not get her 100% exposed in every (almost any) situation as I do not usually climb with a ton of blankets, and her staying clothed may be a prudent move if we are climbing in Colorado or Alaska. If it was hot, I would build some shade, and think about a wet cloth across the forehead for comfort. I would watch her loc, watch her A's and B's. I would find any ortho injuries I could and get them stabilized to facilitate her packaging once help arrives (this speeds up the process a lot, prevents further injury to the pt, and adds a degree of comfort.) If we were talking about a 2-3 hour ETA the situation would be... pretty much the same minus documentation. That's right, I said it, I'd write things down. PMS in the extremities, approx BP and other signs, Neuro status, all tracked q15 or better. I would also figure out a way to deal with her inevitable bathroom requirements. A casualty laying in their own waste is an unhappy casualty. Also, given the environment, laying in a puddle in wet clothes may lead to hypothermia. I would also keep the pt NPO if we were talking an hour or two. If we venture into 12 hour transport time I would call in for medical direction regarding her hydration. I think that's it for now.

I think that's all for now.

[ptAltered]

Great participation guys and gals! Sorry for the delayed response, you've all been very patient and it's appreciated! I'll go through a few of the posts then wrap it up, next time you'll get more interaction from me. Thanks again everyone!

Showtime - Great assessment! 911 says they'll be able to deploy SAR but they have no timeline and no air assets. Your partner maintains C-spine stabilization while you perform your rapid trauma assessment. (+) PMS in extremities x4, DCAP-BTLS - Goose egg on pt's right forehead, raised and tender to the touch Road rash lacerations on her upper shoulders,arms and legs. Negative blood, raccoon eyes, Battles sign or presence of any fluid. Strong radial and pedal pulses. GCS after fall (per boyfriends description) 3, GCS now 14. Patient answers questions appropriately, Alert PPTE. No known allergies, ate breakfast of oatmeal early this morning. Complains of pain in her head, no neck pain, no spine pain, able to recall detailed description of the climb up to the fall. Good job on the blanket! She's now wanting to sit up and drink some water. What do you do?

Ninja Medic - Good call for street medicine. A higher respiration rate combined with pink, warm skin can mean many things; shock-y trauma to recent physical activity. In this situation I'd chalk both findings up to the physical activity lacking any other findings of shock or injury.

croaker260 - Jaw thrust opens her airway and she becomes more alert. The rest of the findings are shown above. You're scan for life threats is negative (good job mentioning that scan SPECIFICALLY and differentiating between a detailed scan and a life-threat scan!! +500) Another +500 on detailing how to improvise the C-collar and the gear you'd use. As for the hot skin, she's out in the sun, she's working out and she's got some sweat on her. In the absence of any findings to the contrary I'd assume that she's producing a lot of heat.

AZMedic - She's smoking hot, yoga pants and a halter top hot.

SCBrian - Heat exhaustion is a good finding from the > rate of breath, warm, sweaty skin and known physical activity.

offcamber - Wilderness (and Zombie) situations call for improvisation man, it's just the nature of the beast. The best motto for wilderness emergencies, whether as a professional or lay responder, is "It's their emergency, not mine!". If the best you can do is rig up a poncho and paddle stretcher and carry them out then you've done your best. If they wanted to have a backboard evacuation they should have brought their own LSB! Most likely you contributed to the chain of events that saved her life. Righteous!

VXMerlinXV - Thanks for the kind words partner! I think that an evacuation might be a bit premature, let me go over the way this actually turned out.


The patient gradually became more responsive and remembered all events taking place up to the fall event. She was not restrained or tied into any protection and fell from about ten feet with the natural curvature of the boulder slowing her fall and causing the lacerations to her shoulders and legs. A complete neurological function test was administered and she was cleared to have cervical and spine protection removed. Her increase pulse rate, warm skin and sweaty body were due to the physical exertion and demonstrate how all vital signs need to be taken in the context of the situation. Head injuries in the back country are scary events and it's important to stay calm and do a thorough assessment. If the GCS is rising from 3 (i.e. shes knocked out) to 13-15 (she's a little groggy but is improving) that's a great sign. I wouldn't initiate any sort of evacuation or call to 911/SAR at this point. The thing that I wanted to talk about here was Intracranial Pressure (ICP) and the signs of a worsening head injury.

http://en.wikipedia.org/wiki/Intracranial_pressure

Minimal increases in ICP due to compensatory mechanisms is known as stage 1 of intracranial hypertension. When the lesion volume continues to increase beyond the point of compensation, the ICP has no other resource, but to increase. Any change in volume greater than 100–120 mL would mean a drastic increase in ICP. This is stage 2 of intracranial hypertension. Characteristics of stage 2 of intracranial hypertension include compromise of neuronal oxygenation and systemic arteriolar vasoconstriction to increase MAP and CPP. Stage 3 intracranial hypertension is characterised by a sustained increased ICP, with dramatic changes in ICP with small changes in volume. In stage 3, as the ICP approaches the MAP, it becomes more and more difficult to squeeze blood into the intracranial space. The body’s response to a decrease in CPP is to raise blood pressure and dilate blood vessels in the brain. This results in increased cerebral blood volume, which increases ICP, lowering CPP and perpetuating this vicious cycle. This results in widespread reduction in cerebral flow and perfusion, eventually leading to ischemia and brain infarction. Neurologic changes seen in increased ICP are mostly due to hypoxia and hypercapnea and are as follows: decreased level of consciousness (LOC), Cheyne-Stokes respirations, hyperventilation, sluggish dilated pupils and widened pulse pressure.

The whole article is worth a read and is well written but the emphasized parts are what really applies here. If this young lady had chronically worsening conditions throughout the evening, specifically the findings associated with Cushings Triad, the decisions regarding care and evacuation would be vastly different.

http://en.wikipedia.org/wiki/Cushing's_triad - hypertension, bradycardia, irregular respirations

It's important to know these s/s because they differ so widely, especially at their early stages, from shock. Shock-y patients are hypotensive in later stages and exhibit tachycardia in early stages. It's important to manage a head wound in the back country with a very high index of suspicion. Do you stop a multi-day climbing trip because someone has fallen and knocked their head? Stop an expedition? Evacuate or send a runner for help? Those are the questions that make wilderness medicine a different animal than street medicine.

Thanks again guys for participating, you all did a great job. I'll have another one in a few days after we get some boats wet and some new guides broken in.

As a quick post script, I'd say that the most important part of the detailed physical examination here is the neurological examination.
http://cloud.med.nyu.edu/modules/pub/neurosurgery/
Excellent links to a great nearly tool-free assessment of a patient.

http://www.wrems.com/Downloads/Educatio ... andout.pdf
And another one...

Again, thank you all very much! Please post any questions or criticisms you may have.

Regards

[VXMerlinXV]

Good lord man...great write up!
A little education on ICP never hurt anyone. Can't wait to see what case you put out next.

[TAB]

I'd tell the boyfriend that I'm getting out of the way of the lawsuit that will ensue should she survive as a parapalegic... her suing him for everything he's got and everybody else at the scene who "helped" turn her over onto her back, thus severing her spinal cord with a jagged piece of broken neck bone. There are no laws protecting "good samaritans" that I know of and rightly so.

[VXMerlinXV]

Well, I don't know about Cali, but in NJ:

Good Samaritan Act - NJSA 2A:62A-1
Immunized from civil liability - Any Good Samaritan rendering care (in good faith and without thought of
consideration) at the scene of an accident or emergency or while transporting the victim for further
treatment; in a health care facility if your actual duty, including on call duty, doesn’t require a response to a
patient emergency situation. Immunity is granted from liability for failure to inform when emergent situation
necessitates action in absence of the ability to properly inform the patient or an authorized representative.
Not immune from liability are acts or omissions by you in such situations which are determined to involve
gross negligence, recklessness or willful misconduct.

[ptAltered]

I'd tell the boyfriend that I'm getting out of the way of the lawsuit that will ensue should she survive as a parapalegic... her suing him for everything he's got and everybody else at the scene who "helped" turn her over onto her back, thus severing her spinal cord with a jagged piece of broken neck bone. There are no laws protecting "good samaritans" that I know of and rightly so.

There are some legal issues here that merit discussion. If you announce that you're a care provider then you are, in my state, held to those protocols and standards of care. I wouldn't hesitate responding, scene considerations notwithstanding, at the first aid level. An assessment performed with few if any diagnostic tools isn't outside the scope of first aid. Any further aide would depend on the situation.