It’s been awhile, hasn’t it? I’ve been so busy with paramedic school lately, I haven’t really had the time or energy to post. And energy really is the bigger issue. I worked (either in class, in a clinical shift, or actually at work) from March 31st to May 5th without a day off. I then had May 5 and May 10-11 off, and I’ve been at it again since. Looks like I’ll go until June 16 without a break this time.
There is finally a light at the end of the tunnel, however. I’ll be done with hospital clinicals on June 16, and ready to start my field rides where I will finally begin precepting as a medic. We will do the practical test on August 9, and if we pass we will proceed to the NREMT Paramedic written exam. If I pass that, I’ll finally be a paramedic.
On to what I actually wanted to talk about.
I work and live in Richmond, VA which is a river city. We say Richmond is 63 square miles, 61 of which are dry land. The James River runs through town, neatly bisecting it into Northside and Southside. One of Richmond’s claims to fame (in addition to hipsters, tattoos, craft breweries, beards, the Civil War, and crack cocaine/heroin) is that we are the only town (I think…) to have class IV rapids within the city limits. Due to the large volume of use the James sees, the fire department conducts many water rescues each year.
This is the latest. An depressed individual leaped off one of the several bridges that cross the river. The fall did not kill him, but he was injured and ended up floating down the river to one of the rocks. The water rescue team found him, packaged him…and then called for the calvary!
That’s MedFlight I, flown by the Virginia State Police. It’s an awesome rescue, and a hell of a feat of airmanship on the part of the pilot. However, I think what I love most about this video is how much style the chopper pilot has. If it’s not enough to set the bird down precisely on that very small bit of rock, notice how he touches down, decides he dosen’t quite like the feel of it, and moves the helicopter forward about six inches to a more stable spot. That’s just class.
Proof that medical emergencies that are distinctly “wilderness” in flavor can occur in a city of 2 million, with 9 medical centers and an EMS system that is makes it to emergencies within 9 minutes of 911 call 90% of the time!
Here is a story (with some cool video footage in the link) about a North Carolina National Guard chopper lifting a climber off a cliff in North Carolina. As you might guess, some of the comments (which I try not to read…but I got sucked in) are predictably angry and bitter, to the tune of “these lunatics are costing me tax money!” We could debate the actual cost to tax payers (who pay taxes anyway…) all day, but I digress.
At any rate…
ABC News’ Steve Osunsami and Doug Vollmayer report:
Officials used a Black Hawk helicopter Monday afternoon to save a man who fell nearly 40 feet off a North Carolina mountain.
The unidentified climber, 23, was rappelling off Shortoff Mountain in Pisgah National Forest in Banner Elk, N.C., when he fell and bounced off one mountain ledge before landing on another.
The man’s friend and another climber called 911.
“I’m on the side of the mountains and I just watched a climber take about a 45 foot fall, had a pretty bad impact,” the climber told the 911 dispatcher in calls released by Burke County officials.
The injured climber’s precarious position forced emergency crews to call in a Black Hawk helicopter, from which rescuers repelled down to reach him.
“The ledge was small,” Gaston County EMS Capt. Chris Hendricks said of the spot where he and two other members of the North Carolina Helo-Aquatic Rescue Team found the climber. “There was barely enough room for all three of us.”
The Black Hawk helicopter is best known for having served in combat areas that include Somalia, Afghanistan and Iraq.
Hendricks’ colleague, David Bowman of the Charlotte Fire Department, spoke with the climber, who was still conscious after the fall.
“I had a short conversation with the patient and let him know we were here and going to take care of him,” Bowman said.
Hendricks, Bowman and a third rescuer pulled the climber back into the Black Hawk, from which he was transferred to a medical helicopter and flown to an Asheville hospital.
The climber is reported to have suffered critical injuries, including broken bones.
The third man who rescued the climber says, for him and his colleagues, the dramatic rescue was all in a day’s work.
“This is what we train for,” Capt. Maurice Taylor of the Charlotte Fire Department said. “We developed a plan in the back of the helicopter and then we executed that plan.”
And now its time for Patient Care Tuesday…on Wednesday! I do have issues with time management at times, but in this case, the late post isn’t my fault. I had the whole post written and ready, and then my USB drive decided not to communicate with the computer anymore. So, on to the reason you’re here!
The basic rules, in case you’ve never done this before. I’ll post a scenario involving a patient who has suffered injury or illness in a back country setting. You’ll read the scenario, then write your treatment plan in the comments. Later in the week, probably around Thursday or Friday (though you shouldn’t hold your breath), I’ll post my treatment plan for the scenario. As usual, wilderness medical protocols will prevail. However, front country EMS protocols can be used as well. If you can make a good enough case for why a procedure should or should not be used, I’ll accept that too. Please keep your comments civil. The aim is education rather than denigration.
This is going to be a slightly different type of scenario that the others. Instead of just one section, I’m going to have you read half the scenario, then make some initial decisions. I’ll share my two cents later in the week, then give you the second half of the story.
It’s a beautiful day in the backcountry! During the night, about eight inches of fresh powder fell, turning the slopes of the high country resort into a winter wonderland. You and your fellow ski patrollers are enjoying the powder day as much as the guests that are starting to gather on the slopes, and in the aspen groves and other back country areas. The weather is perfect; bluebird skies, with wispy high altitude clouds, a light breeze, and temperatures in the mid 30’s F.
As you relax in the ski patrol hut at the top of the ridge after several patrol runs, the telephone rings. The patroller staffing the Ski Patrol Aid Room at the main ski lodge, located at the bottom of the mountain, is on the other end of the line. He tells you that a guest came into the Patrol Aid Room and reported that another skier has skied into a tree in the aspen grove about 500 vertical feet below you. You grab your response bag, and drop off the ridge towards the aspen grove.
It takes you five minutes to get to the area of the accident; as you enter the grove, you see a small group of people gathered around a tree. They start waving and calling to you when they see you. On your arrival you find a male, about 30 years old, laying at the base of a larger aspen tree. The group reports that as they skied through the grove, he caught a tip, lost control, and skied straight into the tree. They say that the accident happened about five minutes ago. Nobody knows exactly how fast they were going, but the general consensus is “pretty fast.”
The patient is semi-conscious; he can tell you that his name is Darrell, but he can’t tell you what happened or where he is. Other than that, he just groans. He is wearing a helmet, which is cracked and damaged. Your initial assessment finds a large hematoma over his right eye, just under the helmet, and several other abrasions on his face. He groans louder when you touch his right shoulder and ribs. His right leg is angulated just above the ski boot; when you unbuckle the boot and feel inside, you find that the foot is grayish and cool, with no palpable pulse at either the distal tibial site or the dorsal pedis location.
Vitals: 0935 Hrs.
-LOC: AO x 1, with slurred speech.
-BP: 136/82, taken in the upper left arm.
-Pulse: 96 BPM, strong/regular.
-Respirations: 16 BPM, with lung sounds of equal volume bilaterally.
-SCTM: pink/warm/slightly moist, with exception of right foot, which is cool and grayish.
-Pupils: equal, with slightly sluggish response to light. Pupils are 3 mm.
You decide to request additional responders. Two additional patrollers leave the patrol hut, with a sled. Each of the patrollers is trained to the National Ski Patrol (NSP) Outdoor Emergency Care provider (OEC) level, which is roughly equivalent to the EMT level. They, as well as you, carry a first responder pack. This contains wound management equipment (gauze, tape, cravats, ABD pads, etc.), cold packs, oral glucose, a CPR rescue mask, nasal and oral airway adjuncts, diagnostic equipment (stethoscope, BP cuff, SPO2 finger clip, pen light, trauma shears), a SAM splint, and exam gloves. The sled they are bringing has additional equipment. This includes a “D” sized oxygen bottle with associated delivery equipment (bag-valve-mask, non-rebreather oxygen masks, nasal cannulas, etc.), a long spine board with associated patient packaging equipment (head blocks and straps, spider straps, and variously sized cervical collars), long bone splints, a femur traction splint, a sleeping bag, a tarp, and two blankets.
Additionally, one of the patrol paramedics also responds. Patrol paramedics are providers trained to the paramedic level. They can provide more advanced care on the slopes. in addition to the equipment in the basic first response pack, the patrol paramedics carry two liters of normal saline IV fluid, and the associated IV tubing and needles needed to deliver it, as well as a basic drug kit (Fentanyl for pain management, Zofran for nausea management, D50 for diabetic emergencies, Aspirin, and an Epi-Pen/Epi-Pen Jr.). They also carry an airway kit, with a laryngoscope, intubation blades, ET tubes, and BLS rescue airways (King LTS, sizes 2.5-6). They do not carry cardiac drugs.
Some other information to take into account:
1) Additional personnel is available; if you request it, three additional OEC level patrollers can respond from the ridge, along with one additional patrol paramedic. Should you need further patrollers, they will have to respond from the base of the mountain. It will take them 20 minutes to get to you by either snowmobile or ski lift.
2) The Patrol Aid Room at the main ski lodge is staffed with paramedic level patrollers, who have all the equipment a typical ALS ambulance has, including a cardiac monitor/ECG, a local EMS council level drug supply, and rapid sequence intubation (RSI) capabilities (hey, its my scenario! I can dream!).
3) It’s a 15 minute trip from your location to the Ski Patrol Aid room with a patient loaded in a sled.
4) There is no way for motorized vehicles to get to your location. The furthest a motorized vehicle other than a snowmobile can go is the main ski lodge. The closest ambulance would be on scene in 10 minutes, via a good, clear road. The ambulance is staffed by a paramedic and an EMT. The closest trauma center is 40 minutes away by ambulance, and there is a small community hospital in the local town, which is a 15 minute ambulance ride.
5) You also have helicopter assets. The local medevac helicopter is based at the trauma center. Once it’s called, it can be on station in 15 minutes. The helicopter is staffed with a flight nurse, a flight paramedic, and a pilot. It can land at either a prepared helipad at the main ski lodge, or at a rougher landing spot halfway up the mountain. The rough landing spot is about 200 vertical feet lower on the mountain, which is about a 5 minute trip with a loaded sled from you.
6) Due to excellent pre-season preparation, you’re able to talk to the ground ambulance and the medevac helicopter on your portable patrol radios.
Your First Decision:
So, here is where you make your first set of decisions. What is your initial assessment of the patient? What is your initial treatment plan? What does the patient need? How do you think the patient’s symptoms and injuries will develop and change in the next 15-30 minutes?
I’ll share my answers on Thursday or Friday. Then we’ll move on to the rest of the scenario!
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I don’t make my living in mountain rescue and wilderness medicine. Few people I know are able to. Most of us have some other job. In my case, my normal 9-5 gig (it’s actually a 0730-1930, four days a week gig) is riding a 911 ambulance in a very busy mid-Atlantic, inner city EMS system (guess which one…guess…).
A few folks, however, have managed to turn wilderness medicine into a sort of career. And so today, I’d like to give a shout-out to someone who has.
Back when I lived in Harrisonburg, I met a guy named Pearce. Pearce was a PA at the local hospital, and was also a climber/mountaineer. He volunteered for the SAR team I was part of for awhile, and I really looked up to him. He had lots of knowledge, and lots of advice, and I really enjoyed my conversations with him. My wife and I ended up going to the church he was part of for awhile as well. He then moved with his family to Portland, Oregon.
Recently, he started a medical guiding and consulting company called Vertical Medicine Resources. Basically, in the words of their “About Us,”
Vertical Medicine Resources is a medical guiding and consulting team dedicated to provide training and support for clients in a vertical environment. Whether at the local crag, a desolate alpine ridge, or trekking through remote highland villages, our mission is to assist individuals and groups for their adventures in vertical and mountainous terrain, prevent injuries while in these surroundings, and overcome challenges to succeed in their personal and professional summits.
We accomplish this mission by providing a host of services and products for individual climbers and mountaineers, guiding and rescue companies, and expeditions. We offer a variety of training opportunities that are customized to the needs of our clients and range from our popular one-day climbing medicine clinic and Climb Prepared series of climbing medicine/self-rescue offerings to Wilderness First Responder (WFR) courses and re-certifications and personalized fitness training programs for individuals.
I think it’s an awesome idea, and I wish them the best. Visit their website, check out “The Cache” (where you can buy all manner of medical and rescue toys), and give them some love. I’ve linked to their website in the sidebar under “Wilderness Medicine.”
Pearce, if you read this, I hope you and your family are doing well. Congrats, and keep up the great work!
On Tuesday, I posted a scenario, and invited readers to suggest possible treatment plans. Today, I’m sharing how I would do it. As before, and as always, wilderness medical protocols will prevail, however, standard EMS protocols are good too. Beyond that, if you can justify why a procedure should/should not be used, and make a good enough case for it, I will accept it. If you haven’t read the scenario yet, you can do so here.
To recap: You and your team have responded to a tumble off a ridge. The patient is a participant in a youth backpacking trip, was startled, and tumbled about 40 feet off a ridge. He came to rest against a tree, landing with his backpack against a tree. He has multiple scrapes/laceration/bruises, and one large abrasion/laceration on the back of his thigh.
This is another excellent case for the thinking wilderness medical provider, and provides me another chance to get up on my “Don’t leap straight to spinal immobilization!” soapbox. This case provides some excellent contrast between a typical front country EMS treatment response and a back country medical treatment response. Basically, on the front lines of your typical EMS system, a patient displaying this type of mechanism of injury (MOI from now on) will be fully immobilized on a long spine board regardless of presentation and presence of signs/symptoms of spinal injury. MOI is typically considered reason enough, and most systems don’t give their medics and EMT’s enough credit to trust them to adequately determine if a patient has suffered a spinal injury. Additionally, with a full emergency department located within about 20 minutes of most incidents, back-boarding a patient until definitive care is reached is really not that big of a deal.
Not so in the backcountry. Definitive care is at minimum an hour away, and so confining a patient to a backboard that doesn’t need it is a much bigger issue. Additionally, once your immobilize you are forced to evacuate, and that takes huge amounts of resources. The point of this scenario is not to make an argument for clearing spinal injuries; I did that in another post, and you should read it if you haven’t already. It will help you understand my treatment plan.
So, here we go. The patient’s head is being immobilized by his leaders due to MOI; I’d keep that as I do my exam. My primary exam does not reveal any immediate threats to the patient’s life. His airway is patent (unobstructed), he’s breathing adequately, his heart is pumping just fine and I can’t find any life-threatening bleeding. Lots of superficial soft tissue damage, but nothing really dangerous. They physical exam didn’t find any broken bones or additional deformity, and he’s not at any immediate risk from his environment. Excellent.
The secondary survey (SAMPLE, etc.) doesn’t reveal any hidden medical issues that may have contributed to his fall. He didn’t have an allergic reaction, and there are no cognitive issues that may have caused him to suddenly loose his ability to walk. It appears he was simply startled, and took a bad step.
As we watch his vital signs, we see that he is starting to return to normal. His first set of vitals show an elevated heart rate and a more rapid breathing rate; this is entirely consistent with a person who has been startled, and then taken a frightening 40 foot tumble down a hillside. Basically, we’re seeing the physical reactions consistent with a “fight or flight” response. As he calms down, we see his vitals return to a more normal state. Now, we’ll keep watching them just to make sure, but I don’t see anything there to make me think he’s in any danger.
What about spinal injuries? Yes, there is certainly MOI, and it appears that his head did contact something at some point (there is, after all, a lump on the back of the head). I’d perform a focused spinal exam, and perform a spine clearing protocol. If he passes, let’s let him out of inline immobilization. Immobilizing him won’t affect a possible head injury; the only way to be sure there is to watch him for a bit and look for any changes.
I’d then take care of those annoying scrapes/cuts. Even the large one dosen’t appear that bad; some soap/water and a dry, clean dressing changed every several hours or so should do it. Infection could become a concern, especially on a backpacking trip. However, as long as he keeps it clean, this shouldn’t be a large issue.
I’d release him back to his group at this point. I don’t see any injuries or additional signs that he needs to be evacuated in any way. I also don’t see any reason why I would have to observe him personally. I think I would talk to his leaders for a bit, explain to them what to look for in terms of head injuries and infection, and then let them watch him for the next several hours or day.
There you have it! Sometimes scenarios really are as simple as they sound. In this case, while there was great potential for serious injuries, the patient did not seem to sustain any injuries requiring advanced interventions.
I will post another scenario on Tuesday!
Aaaannnndddd we’re back! Back in the day, I used to do Patient Care Mondays; basically, I’d post a scenario, give you a bunch of equipment, and ask you to figure out a patient care treatment plan. I’m going to start this again, but we’re going to change the day to Tuesday. The rationale behind the day change is that I have paramedic school on Tuesdays, so I know I’ll have internet connectivity. We may have to change the name…”Patient Care Tuesdays” doesn’t have a nice ring to it. On to the scenario.
The rules: as always, wilderness medical protocols will prevail, however, standard EMS protocols are good too. Beyond that, if you can justify why a procedure should/should not be used, and make a good enough case for it, I will accept it. My suggestions for treatment will be posted later in the week (probably around Thursday or Friday). Please keep your comments civil, and oriented towards education rather than subjugation (I like that…).
You and your team are on a weekend trail patrol. You are 15 miles into the backcountry, patrolling an area with ridges up to 9,000′. While the terrain is rugged, the trails are well built and carryouts tend to be long but low-tech. In the middle of a training session (your team is learning how to use the new Petzl ascenders you’ve just been supplied with), your radio crackles. NPS dispatch informs you that they have received a satellite call from a youth program further down the ridge. A participant has fallen off the ridge, and suffered some injuries. Dispatch informs you that the group leaders are providing basic first aid, but sound a bit frantic. You and your team immediately pack your equipment back into your packs, and head down the trail.
You arrive on scene to find seven teenagers sitting on their packs, with an adult leader. When they see you, they all point down off the side of the ridge. 40 feet down a fairly steep slope, you see an eighth teenage participant sitting against a tree, with two additional adult leaders providing basic first aid. There are no visible hazards (beyond the steep terrain), so your team heads down the slope.
The adult leaders report that the participant was startled by a bird taking off from the underbrush next to the trail, and stepped off the side of the trail. He then tumbled forty feet down the slope, and landed against a tree, striking the tree with his backpack. His leaders immediately responded, and found the patient lying on his side against the tree. He was found awake and alert, with no obvious difficulty breathing or serious bleeding. His leaders report that he did not loose consciousness at any point.
Your exam reveals numerous small scrapes, lacerations, and bruises on the patient’s arms and legs. The patient has a large scrape on the back of his thigh (picture inserted). He also has a large, 2″ swelling on the back of his head, but no pain or deformities in his neck and spine. The patient denies any numbness, tingling, or altered sensation in any extremities. He also denies nausea and headache.
The rest of the physical exam is unremarkable.
The adult leaders have taken two sets of vitals.
First set of vitals: 1500 hrs.
-LOC: AO x 4
-HR: 90 BPM, strong/regular.
-Respirations: 18 Breaths/minute, regular/unlabored.
-Skin Color/Temp/Moisture: pale, warm, moist.
-Blood Pressure: No cuff, but he has a strong radial pulse.
-Temp: Not taken.
Second set of vitals: 1520 hrs.
-LOC: AO x 4
-HR: 72 BPM, strong/regular.
-Respirations: 18 Breaths/minute, regular/unlabored.
-SCTM: pink, warm, dry
-Blood Pressure: No cuff, but he has a strong radial pulse.
-Temp: Not taken.
When you arrive on scene, you take a third set of vitals at 1540 hrs.
-LOC: AO x 4
-HR: 70 BPM, strong/regular.
-Respirations: 18 Breaths/minute, regular/unlabored.
-SCTM: pink, warm, dry
-Blood Pressure: 122/64
-Temp: 98.0 F
The results of your patient history are as follows:
Medications: OTC Ibuprofen for muscular soreness, no prescription meds.
Past, Pertinent History: None.
Last Oral Intake: Breakfast and lunch, three liters of water throughout the morning/early afternoon.
Events: Startled, and fell of trail. Tumbled 40 feet to stop against tree.
Now it’s up to you. What’s your plan for treatment and evacuation? Some information to guide your thinking.
Your team is made up of six individuals trained to the WEMT/WFR level. You are carrying the equivalent of a standard EMS jump bag, as well as supplemental oxygen and splinting materials. You have a rescue cache at a cabin approximately 1 mile away with additional medical gear as well as a stokes basket, back board, high angle rescue equipment, and evacuation equipment (a wheel which mounts on the bottom of the basket). Higher levels of medical care (up to and including paramedic level providers) and additional personnel are available should you need them. Your crew is carrying enough food and equipment to permit a four day patrol. From your current position, the trailhead is 15 miles away and is accessed by a well-made, well-maintained road. From the trailhead, a patient in an ambulance could be at a trauma center in an hour. You have access to helicopter resources; the park you’re working in has access to a rescue helicopter with hoist capabilities. It is staffed with a paramedic and two additional crew members. If you launch the helicopter, it will take it 45 minutes to spool up and be on station.
Based on your assessment of the patient, you may either evacuate the patient (by any means you have available), stay in place to treat/evaluate, or release the patient to the care of his group. You may provide any medical care covered by wilderness medical protocols, or front country protocols if you choose to implement them.
Have at it! My take will be posted on Friday or Saturday.