Kmtyw Science for Survival - MEDICAL EMERGENCIES-gctid47234

[Agbede]

MEDICAL EMERGENCIES
 
Knowledge of basic first aid can be helpful in any situation. As with all other skills, perfect practice makes perfect.
 
Scene Size-Up
 
The first thing to do if you find yourself the potential rescuer in a medical or trauma emergency is to size up the scene. It is helpful to take a deep breath and think before acting, the scene size-up can help you with that. To size up a scene consider the following 5 points:
 
1. I'm number one. Your safety comes before the safety of your patient. If you're in a winter survival situation and somebody is exhibiting the signs/symptoms of hyopthermia do you give that person your coat? If you do, there may be two patients (i.e. you will not be able to help others as effectively if you become part of the emergency).
 
2. What's wrong with you? This is the mechanism of injury (MOI) - basically, what does it look like happened to the person.
 
3. Don't get any on me. Be cognizant of blood, urine, faeces, vomitus, amniotic fluids, kwk. Gloves, goggles, gowns, kwk may be needed to protect yourself and the patient from infection.
 
4. Are there any more? How many patient's are you dealing with in this situation. You may have to triage. If so, remember, that the loudest person is not necessarily the one who has the greatest need.
 
5. Dead or alive? What is your general impression of the person? Do they look sick, does it look like you can assist them, or does it look like it is too late to help.
 
Initial Assessment
 
ABCDE's
 
Airway - Is the patient's airway open and clear of obstruction? If they can talk, it is open. Make sure they are not chewing gum or eating something that could become lodged in their airway if they were to lose consciousness.
 
Breathing - Is the patient (pt) breathing? Look for chest rise. Listen/feel for breath sounds/breathing.
 
Circulation - Does the patient have a pulse? What is the quality of the pulse (weak, thready, strong, kwk)?
 
Disability - Could the patient have a possible neck/spinal injury? Did she fall? Did he hit his head? If so, you may need to hold their head still in place so that the spine does not move out of alignment and cause paralysis.
 
Environment - Is it really hot/cold? Is it raining? Are there a pack of pit bulls roaming around? You will need to remove your patient from any environmental situation that could make their condition worse.
 
Vital Signs
 
LOR, HR, RR, BP, SCTM, Pupils
 
Level of Responsiveness (LOR) - Use the AVPU scale
Awake (A+Ox1 - pt knows who they are; A+Ox2 - pt knows who they are & the date; A+Ox3 - pt knows who, when, and where they are; A+Ox4 - pt knows who, when, where, and what they were doing right before the incident)
Verbal - Pt responds to verbal commands but does not stay awake
Pain - Pt responds to pain only
Unresponsive - Pt is not responsive to pain
 
Heart Rate - count their pulse beats for 15 seconds then multiply by 4.
 
Respiratory Rate - count their breaths (in + out = 1 breath) for 30 seconds then multiply by 2.
 
Blood Pressure - If you dont have a cuff, a general rule is: if pt has a pedal pulse (top of the foot) then they have at least a 90 mm Hg systolic, if pt has a radial pulse (the wrist) then the systolic (top BP number) is at least 80 mm Hg, if pt has a femoral pulse (groin) then the systolic is at least 70 mm Hg, and if the pt has a carotid pulse then the systolic BP is at least 60 mm Hg. This is useful for trauma patients but not for routine BP checks because a healthy person should have all of these pulses present.
 
Skin Color Temperature and Moisture - Check the inside of the eyelids, the lips, the tongue, the palms, the soles of the feet, and the nailbeds - these should all be pink. If these are yellow-brown or the skin appears ashy (ashen) then this could indicate a problem (or a lack of shea butter). A blue color in the nailbeds or lips could indicate that the patient is not getting enough oxygen in their bloodstream. Skin should be warm, dry, and properly melanated.
 
Pupils - Pupils should be PEARL - Pupils Equal And Reactive to Light. If the pupils do not react to changes in light or one is larger than the other this could indicate neurological trauma.
 
SAMPLE History
S - signs/symptoms - what can you see is wrong, and what do they tell you is wrong
A - allergies - does the pt have any allergies (food, plants, medicines, kwk)?
M - what medications is the patient taking (both natural & western)?
P - does the pt have any pertinent medical history?
L - last in/out - when was the last time they ate/drank and went to visit the palace?
E - events leading up to - what were they doing before the incident?
 
After you have collected all of this information make an assessment as to what you think could possibly be wrong with this person and make a plan to treat her/him.

[Agbede]

CASE STUDY
 
You and three friends have been traveling 18-20 miles a day for three days in an arid region.  It's been hard and hot as anticipated, but not scorching hot.  You've found water every day.  This afternoon you traveled over a steep sun drenched sandstone ridge and down into a cottonwood glade.  One of your companions has been lagging behind and eventually stops and sits by the side of the trail.  He looks ashy and sweaty and says he feels awful.  Your scene size up is brief; no hazards, one patient who looks sick and sat down. The patient agrees to your assessment, has a sound airway, is breathing without distress, is dressed in only shorts and t-shirt, is obviously not bleeding, has a strong radial pulse and is on dry ground in the shade on a nice warm day.  
 
SOAP Report

Subjective
The patient is a 24 year old male who states he "feels lousy."  He has been traveling long distances for three days in hot weather (high's in the low 90'sF) and this afternoon became too weak to hike.  


Objective
Position found: Patient sat down by the side of the trail.  There is no mechanism for injury.

Patient Exam:  No obvious injuries were found in a head-to-toe assessment.  Patient is pale and sweating.  Skin is not hot to the touch and the patient has a normal mental status.
 

Vital Signs
TIME          1300
LOR           A+Ox4
HR            100, strong, regular
RR            18, easy and regular
SCTM       pale, warm and moist
BP            strong radial and pedal pulse
Pupils      PEARL
 
History            
Symptoms: Patient states he is dizzy, nauseous and "feels lousy"
Allergies: None stated
Medications: None stated
Pertinent Hx: Patient denies any ongoing medical conditions.
Last in/out: Patient drank 3 liters of fluid so far today, ate breakfast and ongoing trail snacks, urinated a light yellow urine twice today and stated this is normal on long hikes.  He had a normal bowel movement this morning.  Denies recent diarrhea or vomiting.
Events: Patient has been traveling in hot dry weather for three days, 18-20 miles per day without problems.   He has not fallen or suffered any injuries.
 
What is your Assessment and Plan?

[Agbede]

CASE STUDY
 
Assessment
· Possible heat illness/exhaustion.  Normal mental status suggests heat stroke is unlikely.
· Possible flu-like illness

Plan
· Rest in shade and repeat assessment: carefully exploring hydration history.
· Have patient drink fluids and eat salty snacks, monitor urine output
· Make a decision on continuing journey or evacuation based on patient condition.
 
Anticipated problems
· Patient does not improve.
 
Comments

The vague complaint of "feel lousy" could be any number of things, although the environment makes you think of heat and hydration problems.  The head-to-toe didn't reveal any obvious abnormalities.  As you've been with this person for three days and you've all been diligent about hydration you're considering that they should not be under or over-hydrated.   They look like they could be sick, but this came on suddenly and your group has been healthy on the hike.  It's low enough that altitude illness is not high on your list of possibilities.  The patient is not diabetic and seems to have been eating well, so blood sugar abnormalities are not obvious.
 
You considered a worst case scenario of heat stroke, but note the normal mental status.  Your plan is to explore the hydration history again.  Assuming he is well hydrated without confirming intake and output can lead to poor decisions and treatment plans.  Three liters today might be too little today, and as well, dehydration can be cumulative over several days. Since there are no obvious evacuation triggers, you decide to monitor the patient to see if he get better or worse.
 
The Tale Continues

Vital Signs            
TIME     1300                          1330                          1400                        1500
LOR       A+Ox4                       A+Ox4                       A+Ox4                     A+Ox4
HR         100, strong, regular   100, strong, regular   84, strong, regular   76, strong
RR         18, easy, regular       16, easy, regular        14, easy, regular      14, easy
SCTM     pale, warm, moist     pale, warm, moist      pale, warm, dry        pale, warm
BP         strong radial pulse     strong radial pulse     strong radial pulse   strong radial
Pupils    PEARL                      PEARL                      PEARL                     PEARL
       
History            
Symptoms: As the afternoon progressed the patient felt better, although still tired and low on energy.  Denies headache.   Mental status remains normal.
Allergies: Patient continued to deny allergy.
Medications: Patient re-stated only occasional ibuprofen use and none today.
Pertinent Hx: Patient denies any ongoing medical conditions.
Last in/out: Patient has been drinking 5-6 liters of fluid daily for the past three days, eating regular meals and snacks.  He states his urine volume and color has been normal.  
Events: Patient denies recent illness and says he has been feeling fine.


Assessment
· Possible heat exhaustion.  Normal mental status suggests heat stroke is unlikely.
· Possible flu-like illness.

Plan
· Rest in shade and stop here for the night.
· Have patient drink fluids and eat salty snacks, monitor urine output
· Make a decision in the morning on continuing travel or evac based on patient condition.
 
Anticipated problems
· Patient does not improve.
 
Comments

Wilderness medicine is commonly low drama and routine problems; flu-like illness, mild/moderate stages of environmental problems, sore muscles, minor cuts and scrapes.  Early intervention keeps these minor problems from becoming significant concerns.  So much of sound wilderness medicine is also sound outdoor leadership.

When there is nothing obviously dire in the patient's presentation, we consider the worst case, see if we can rule anything out, treat for multiple problems and see if the patient gets better or worse.  A worst case would be heat stroke, which is not apparent in this patient whose skin is not hot and who has normal mental status. The hydration history suggests that hyponatremia from drinking too much, or dehydration from drinking too little are both unlikely.  
 
Trends in vital signs are vital to assess.  The first set establishes a baseline.  Changes, or stability, are both important pieces of information.  In this case the vital sign trend tells us the patient is stable and even improving.  A HR that stays elevated or trends faster, with pale moist skin and perhaps a weakening radial pulse or altered mental status tells us something is going on, perhaps some form of shock.  A patient who continues to complain of being weak and feeling ill is obviously not improving.
 
Maybe this is just a mild flu-like illness, low blood sugar or fatigue from the heat.  We often treat for multiple problems at the same time, throwing a wide net over the problem.  Heat stress and possible dehydration are managed by seeking shade, resting and supporting hydration, which also treats a possible flu-like illness.  If our net doesn't help the patient get better, we evacuate.
 
End of the Tale

The patient felt much better within a few hours and wanted to get on down the trail, but the group decided to move only a short distance to a nicer campsite for the night.  In the morning the patient, well hydrated, rested and fed, was able to resume the hike.
 
Patience with our patients is a virtue in wilderness medicine.  We want to fix problems quickly, yet we often get ill slowly, and better slowly.  People may be physically in wilderness, but often act like they are in a city, with expectations for quick solutions to inconveniences, let alone real problems.  This group acted as if they were in the wilderness.   They changed their plans, stopped the hike and rested and cared for their companion.