You and one of your friends are thinning trees on a remote piece of property you hope to build on some day. While cutting a leaning tree in some thick brush, Jeep's chainsaw jumped cutting deeply into his left leg. In seconds, his jeans were soaked with blood. You have a couple of tourniquets in your first aid kit along with two hemostatic dressings, gauze, and elastic wraps courtesy of your grandfather. (Too bad you didn't take his advice and purchase protective gear....) Tearing open Jeep's jeans all you see is blood welling up from what appears to be a deep wound. Wiping away the blood with a trauma dressing from the kit, you can see the wound is deep. It quickly filled with dark blood again and direct pressure didn't seem to help very much. Your truck is close by but it's a good four hours to the nearest clinic with no cell reception. What should you do? Click here to find out. Click here to read a blog article on the field management of severe bleeding. Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
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You are skiing in the backcountry when one of your friends, Jane, catches an edge and crashes into a tree hitting her head—she is wearing a helmet—and upper chest. She is awake, struggling to breathe, and holding her head when you reach her. Her helmet is cracked. After catching her breath, she is confused, has a throbbing headache (6), and doesn't remember her fall, hitting the tree, or the events immediately preceding it. While the left side of her upper chest hurts as you examine her, she is able to take a deep breath without pain. While it is difficult for her to focus during your spinal assessment, she has no spine pain, no mid-line spine tenderness, and normal motor and sensory exams. The rest of her physical exam is unremarkable. Jane plays lacrosse for her college and was hospitalized for a brief period after a concussion three years ago. Her pulse roughly fifteen minutes after the accident was 58 and regular; her respiratory rate 16 and easy; she reports her normal pulse rate is 56. It's a few hours ski to your vehicles, the nearest hospital or clinic is another two hours beyond that, and your cell phone has no bars. There are a total of three people in your party, including Jane. What is wrong with Jane and what should you do? Click here to find out. Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available. Major traumatic mechanisms often cause life-threatening injuries. If not controlled, those that cause significant internal or external bleeding lead to volume shock and potentially death. It's VITAL that you do everything in your power to keep your patient warm. Here's why: The body responds to blood loss by constricting peripheral blood vessels and increasing their pulse and respiratory rates in an effort to maintain adequate perfusion pressure and a constant supply of nutrients and oxygen to critical organs. As a patient's blood volume drops, their ability to maintain their core temperature also drops and they become increasingly disposed to hypothermia, even in neutral or warm environments. As hypothermia sets in, it interferes with the clotting cascade causing the bleeding to continue further reducing the amount of oxygen reaching the cells. As cells become oxygen-starved, they resort to anaerobic metabolism that ultimately lowers blood pH causing metabolic acidosis that, in turn, damages tissue and organs throughout the patient's body. As organs become damaged, their ability to function also drops, further predisposing the patient to hypothermia. It's a vicious cycle that often ends in death. As such, the importance of keeping trauma patients, especially volume depleted patients, warm cannot be understated. It's important to recognize that injured patients need more insulation—and potentially external heat—than those who are healthy and uninjured; most require a full hypothermia package. That said, be careful not to go overboard and overheat your patient. The skin on their extremities, both hands and feet, should feel warm to the touch when inside the hypothermia package (ensure that your hands are warm); and, if awake, they should not complain of being cold. Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
PathophysiologyThe mechanism of injury (MOI) is a direct blow to the patient’s head or a direct blow to another part of their body where the force is transmitted to their brain via their spinal column, cord, and associated soft tissue (aka: whiplash). The brain essentially floats inside the skull in cerebral spinal fluid (CFS). The fluid acts to protect and cushion sensitive brain tissue from minor impacts in much the same way as egg white protects the yolk. If the force generated by the traumatic event is strong enough, the brain will bounce off inside of the skull damaging sensitive brain tissue (as shown in the illustrations below). A concussive injury, should it occur, can be functional or structural. A person with a functional concussive injury will present or develop S/Sx, typically within two hours; however, standard imaging techniques (CT, MRI) show no structural damage. The S/Sx of a functional injury—see the chart below—are likely caused by axional stretching and disruption of ion channels, follow a predefined progression, and usually resolve on their own within 7-10 days; although, in some cases, S/Sx may persist for months. That said, structural damage is possible and may lead to increased intracranial pressure (ICP) and potentially death in rare cases. The concern from a field perspective is whether a person with an apparent positive MOI can remain in the field or requires an evacuation. And, if an evacuation is necessary: What is its urgency? Emergency department physicians typically rely on one of seven clinical algorithms to decide if a patient requires imaging or not (Click here to read an article that discusses the pros and cons of each rule), only the High Risk Criteria for the Canadian CT Head Injury Rule and the NEXUS II can be easily extrapolated to aid evacuation decisions in the field; both may be used in the presence of a significant mechanism of injury. It's important to remember that the guidelines are conservative and few concussed patients go on to develop increased ICP. Assessment All people with a positive mechanism must be evaluated for a potential traumatic brain injury (TBI). TBIs can be grossly subdivided into concussion and increased ICP. Concussions can be further subdivided into mild, moderate, and severe, while increased ICP can be broken down into early and late. After a traumatic MOI a patient may present with any of the problems discussed below and progress, or not, from that point. Note that the problems are mutually exclusive and a patient may only have one problem—concussion or increased ICP—at any given time. Seizures are possible at any point especially in infants and young children and common in unresponsive patients with late increased ICP prior to posturing. Patient's with serious head injuries typically have obvious soft tissue damage to their head including:
Mild Concussion
Moderate Concussion
Severe Concussion The distinction between a moderate and severe concussion is important as the mechanism MAY have been severe enough to structurally injure brain cells or small blood vessels, cause intracranial leaks and swelling, and lead to increased ICP. Worsening S/Sx over the next 24 hours indicate a more severe injury (severe concussion) and can be difficult to recognize if the patient is not closely monitored. Pay close attention to the patient’s overall function: Are their S/Sx severe enough that they interfere with their daily function (severe concussion)? When doubt, choose the worst reasonable case scenario.
Early Increased ICP
Late Increased ICP
Treatment Mild Concussion
Moderate Concussion
Severe Concussion
Early Increased ICP
Late Increased ICP
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
At times, the evacuation of a patient may be necessary for their further assessment, definitive treatment, and/or simply additional recovery time. All evacuations in a wilderness environment carry some inherent risk to members of the rescue party and the decision to evacuate a patient should NOT be taken lightly. The need for evacuation depends on the severity of the patient’s injury or illness and your resources. The type of evacuation depends on the mobility of the patient, the size of your party and its resources, the difficulty of terrain, the weather and the distance involved. Any evacuation, regardless of the type—self, assisted, simple carry, litter, vehicle—should not endanger either you or your patient beyond your capacity to deal effectively with the risk presented during the evacuation. In most cases, your field treatment for minor non life-threatening injuries will be effective and rapid evacuation will not be necessary. By contrast, your field treatment for most life threatening illnesses or injuries may simply buy you and your patient some time. In these situations, focus on a quick accurate assessment and fast evacuation. The “medical window” for life-threatening problems is often specific to the particular illness or injury. If an emergency evacuation is not possible, your field treatment will usually be limited to treating the patient’s signs & symptoms and supporting their critical systems; this is often ineffective and your patient may die. In general, any problem that causes a change in the patient’s level of consciousness is very serious. If a patient reaches definitive medical care (major hospital) while they are still awake they have a reasonable chance for complete recovery. If they reach definitive care with a significantly decreased level of consciousness (voice responsive, pain responsive, or unresponsive) their chances for a complete recovery, or a recovery at all are respectively reduced. In today’s world of rapid communication via cell or satellite phones, it may be possible to consult with medical or rescue professionals prior to initiating an evacuation. This type of consult should be encouraged and part of any emergency action plan (EAP). When in doubt, it’s always better to seek a consult sooner rather than later. A thorough patient assessment is required prior to any medical consult and the use of a detailed patient SOAP note will facilitate both accurate patient assessment and communication. At minimum, your location (GPS coordinates), party resources, and the current weather are required for a rescue consult. Conserve your batteries and set a communication schedule prior to signing off. When you are uncertain if a evacuation is necessary and a consult is unavailable, the following general evacuation guideline may be useful: any problem that is persistent, uncomfortable, is not relieved by your treatment—or cannot be effectively treated in the field—requires an evacuation. The speed of the evacuation depends on the degree of involvement, or potential involvement, of any critical system(s). The greater the degree or potential, the faster the evacuation. The following definitions for levels of evacuation are correlated to the severity of the patient’s injury or illness and hence the urgency and speed of their evacuation. Every effort should be made to accurately diagnose the patient’s current and anticipated problems since an incorrect diagnosis may lead to a false sense of urgency and a willingness on the part of the rescuers to accept more risk than the situation warrants. In general, rescuers should ONLY be willing to accept a level of risk they believe they can safely manage based on their skill and the foreseeable problems. Unfortunately, not all problems are foreseeable and the amount of risk any given rescuer is willing to accept tends to rise with the severity of the patient’s injury or illness. Since it is impossible to legislate judgment, rescuers, when in doubt, must base their decisions on the “worst realistic case” situation both in diagnosing the patient and evaluating the risk associated with the evacuation. That said, the risk of a minor injury or illness to a rescuer is generally present during most evacuations and unavoidable under the circumstances. WMTC Urgent Evacuation Levels Level 1 The patient’s injury or illness is immediately life threatening and the patient may die without rapid hospital intervention, e.g.: increased ICP, volume shock, severe respiratory distress, respiratory distress in a near drowning patient, advanced disease, moderate to severe hypothermia, HAPE/HACE etc. All VPU patients require a Level 1 Evacuation. Level 2 The patient’s injury or illness is potentially life threatening or will result in a permanent disability; the patient may develop a life threatening problem that requires hospital intervention, e.g.: concussion that is getting worse, systemic infection, spine & cord injuries, near drowning (no respiratory distress), etc. WMTC Non-urgent Evacuation Levels Level 3 The patient’s injury or illness is NOT life threatening, has little or no potential to become life threatening, and may be successfully treated in the field with no permanent disability; however, the patient is unable to resume normal activity within a reasonable length of time and/or requires advanced assessment. (E.g.: concussion that is getting better, unstable injuries with good CSM, reduced shoulder (dislocation) with good CSM, etc.) Level 4 (no evacuation) The patient’s injury or illness is NOT life threatening, may be successfully treated in the field with no permanent disability, and the patient is able to resume normal activity within a reasonable length of time, e.g.: minor wounds, minor stable injuries, minor environmental injuries, etc. There is typically little or no difference in the how a urgent evacuation is conducted. The difference lies in the mental preparedness and realistic expectations of the rescuers. If rescuers are not prepared for a patient death—as in a Level 1 Evacuation—research has shown that they will likely require more time to recover from post traumatic stress (PTSD) than those who recognize and accept that a patient’s death is a real possibility. Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
You and your partner are planning a three day canoe trip with your five year-old son. He has been car camping multiple times over the past two years and enjoys sleeping in a tent and playing outside. He has also been in a canoe on a small lake near your home in northern Florida multiple times last summer and enjoyed it. You are considering taking the trip on 30 mile stretch of river with moving water and some Class I rapids. You and your wife are proficient expedition canoe paddlers with a number of 2-3 week trips in your resume and are comfortable paddling a loaded canoe in easy Class III whitewater. What should you keep in mind as you prepare for the trip? Click here to find out. Click here to read a blog article about keeping children safe in the outdoors. Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available. You are leading a two-week canoe trip in the Boundary waters of northern Minnesota. On day seven of the trip, one of your female students, Jane, suddenly sits down next to her canoe just prior to entering it after lunch. When you reach her she complains of abdominal pain (4 out of 10). She tells you her menstrual period started yesterday with bloating, cramping, and mild abdominal pain and, although it is slightly worse right now, it's pretty normal for her. She adds that she is unusually tired today and while she had a normal bowel movement this morning, she found it difficult to urinate. An abdominal exam reveals tenderness in both her lower quadrants; her lower back is non-tender. She reports that ibuprofen and rest usually help. What do you think is wrong with Jane and what should you do about it? Click here for answers. Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available. You are the trip leader on a day rafting trip on the Penobscot River in Northern Maine. One of the rafts in your trip flips in Exterminator hole at the top of the Staircase rapid (Class IV) shortly after putting-in at the power station. One of the guests, a 52 year-old man, was trapped under the raft and only released at the bottom of the rapid. James was pulled onto the top of his raft by the guide weak and coughing. After a few minutes, the coughing subsided and, aside from numerous scrapes on his lower legs from contact with the rocks in the rapid, your physical xam is normal and he says he feels okay. He is currently alert with no spine pain or tenderness and normal motor and sensory exams. His history is also unremarkable and after resting for ten minutes, he wants continue with the trip. What do you think is wrong with James and what should you do about it? Click here to find out. Click here to read a blog article on drowning. Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available. You are on a private, mid-summer river trip when one of your friends, Adam, is stung by a wasp on the back of his throat as he was drinking a can of Coke. Adam immediately coughed and spewed soda and the wasp onto the sand. Apparently the wasp had entered the open can while it was sitting next to his camp chair when he went to get a second sandwich during lunch. Roughly fifteen minutes later Adam is hoarse and tells you in a mild panic that his throat is swelling and it is becoming difficult for him to breathe. There are two expired EpiPens in the first aid kit and no oral antihistamines. One of the EpiPens is ten years old and the epinephrine is cloudy with a reddish hue. One of the group members has asthma and carries an albuterol multi-dose inhaler (MDI) that is also out of date by a few years. What is wrong with Adam and what should you do? Click here to find out. Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available. You are backpacking on the Appalachian Trail through the Great Smoky Mountains National Park when one of the members of your group disturbs a yellowjacket nest and is stung numerous times on both her lower legs. While she has no history of allergies, roughly five minutes after being stung, she developed hives in her groin that quickly spread to her flanks and back. Retrieving the group first aid kit you see that the EpiPens—there are two—expired four years ago. The epinephrine appears clear with no particulate matter. The kit does not contain an oral antihistamine; however, one of the group members has hayfever, is taking Claritin daily, and has a small vial with five caplets. What is wrong with Laura and what should you do? Click here to find out. Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available. |
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