If you’ve been following this blog for a bit, you’ve probably noticed that things are dragging behind a bit; my normal posting schedule is off, my posts are a bit sporadic, and I’m not nearly as active on twitter as I normally am. We’re going through some transitions here at Mountain Medic HQ, all of them good, but also a bit overwhelming. My job is transitioning from being a street paramedic on an ambulance towards being more EMS/pre-hospital education focused, and we’re planning on moving to a different part of Virginia in the next month. As I’ve been jokingly telling people about my career change, “those who can paramedic do; those who have nagging back pain and grouchyness issues due to paramedic-ing teach.” The result of these transitions has been that my attention has been a bit divided lately. I crave your patience, and wish to assure you that The Mountain Medic will return to normal soon.
That said, let’s talk about the last “What Would You Do?” Wednesday I posted.
If you haven’t had a chance to watch the video, take a few minutes to do so. It’s not very long, and the patient’s presentation is fairly simple. I asked you to consider what you’d do for this patient if he were a member of your party.
Most of us got into wilderness medicine, EMS, or medicine looking for the high-acuity calls; the gunshot wounds, the heart attacks, and the traumatic injuries; you know, the sexy stuff. The stuff that makes the adrenaline start pumping, that makes you use all the assessment and treatment tools in your toolbox, and that forces you to the edge of your comfort zone. These types of illnesses and injuries surely happen, and its critical that we be prepared to deal with them through frequent practice and simulation.
If we’re honest with ourselves, however, we’d be forced to admit that 90% of what we deal with, in any medical setting you wish to choose (from the trail to the ambulance to the hospital ER, A and E for my UK friends), is more in line with this scenario; fairly low acuity, nagging illness, which develops slowly over several days. Here is the important bit; it’s not sexy, but these patients demand every bit as much of your attention, training, and treatment as the high acuity patients.
So, here’s what I notice:
- “I think I have a cold…”: In my experience, the patient usually has a pretty good idea of what may be going on with them, even if they don’t know specifics. How many times has a patient told you “I think its my heart,” and then it turned out they were having a heart attack? I’ve seldom found it productive to reject a patient’s self-diagnoses out of hand, if at nothing else it gives you a place to start by asking “Why do you think that?”
- URI Symptoms: As it so happens, I tend to agree with the patient. The symptoms he’s describing sound a lot like an upper respiratory infection, with sinus congestion (you can hear it in his voice, and he’s sniffling as well), report of a headache (possibly caused by sinus pressure secondary to sinus congestion), and a sore throat (possibly brought on by post-nasal drip).
- Fever? About halfway through, he makes a throw-away statement I actually found pretty interesting. He says “I was in the shade in my sleeping bag for five hours this afternoon, and I even had my puffy [jacket] on…I felt like I was going from hot to cold…” He’s at a decent altitude, and granted, it is the mountains in California, but it looks pretty warm there to me. That sounds an awful lot like fever symptoms.
- General malaise: Backpackers always look just slightly tired. This guy looks a bit more wiped than normal. In his words, “I look like crap.”
So, how are you going to manage this patient? Here are my thoughts; bear in mind, I’m writing this as if this patient is part of a group backpacking trip, NOLS or Outward Bound style.
- Go, or No Go? One of the most important decisions we have to make in wilderness medicine is “can this patient remain in the backcountry, or does this patient need to be evacuated to definitive medical care?” The follow-up question is “If this patient does need to be evacuated, how quickly and in what way does this evacuation have to happen?” As I watch this patient, I don’t feel that he needs to be evacuated immediately, and I feel that his symptoms, as they are currently, can be adequately managed in the backcountry. If I start seeing symptoms of dehydration that cannot be readily managed, high fever, shortness of breath, or (God help us) altered mental status, I will evacuate at that point.
- Prevention: I feel like this is part of every treatment plan I write; that should tell you something about the priorities of wilderness medicine. You should be making sure your group is practicing good personal and group hygiene. Finding some way to wash hands after toileting and before food prep is critical. Individual snack bags can prevent one patient’s minor illness from becoming a group epidemic. Cleaning and boiling group food utensils and cooking/eating pots and bowls can kill bacteria and other germs that can spread. Finally, as cruel as it sounds, limiting physical contact with sick group members can keep germs from spreading. This doesn’t mean you’re cutting your sick group member off from the group; maybe we’re just not hugging him, high-fiving him, or borrowing his coffee cup until he feels better?
- Rest and recover: This is a difficult balancing act. On the one hand, backpackers tend to be driven, goal-oriented individuals who really don’t like taking days off. On the other hand, the best treatment for an illness like this is taking a day off, and getting lots of sleep and fluids. I think I’d try to cut the mileage, maybe lighten his pack a bit. If he felt really bad and really tired, I’d probably hold the group in place for a day or so, and just give him a day in camp to sleep and recover.
- Symptomatic Relief: There really isn’t any way to “fix” a URI other than to give it time and let the body fight it off. You can make the patient a bit more comfortable during this process. Tylenol goes a long way towards helping that headache, and dealing with the “achy” pain. If the patient has a fever, Tylenol is also a great fever reducer. Bear in mind that the fever is one way the body is fighting the bug, so you may choose to ignore the fever if it’s not too high, and if the patient is comfortable. I’d also consider some OTC decongestants; there are tons of these on the market, so you can choose whichever one you like the best. Personally, I use the DayQuil/NyQuil combination for myself.
- Hydration: Patients with URIs should drink lots of fluids. This seems like a no-brainer, but a good thing to remind the patient of.
- Watch for evolution of symptoms: Pay attention to changes in symptoms. If the fever starts going up to dangerous temperatures, you should consider getting the patient to a doctor. Likewise, if the patient becomes dehydrated to the point that you’re unable to keep up with oral fluids alone, and you don’t have the ability to give IV fluids, the patient should be evacuated. If the patient develops nausea/vomiting or diarrhea, they should be watched carefully for signs of dehydration. Finally, if the patient doesn’t feel better in a reasonable amount of time (I’m going to leave this fairly vague, as this is a judgement call; “several days”), you should consider getting them to a doctor.
So, there you have it. Not a complicated treatment plan, but one based on common sense and looking for change over time. If this patient rests and stays hydrated, he should feel much better in a few days. He probably won’t have to come off the trail.
Several serious questions for my readers, for the education and edification of us all; what medications do you carry in your backcountry kit, and why? Do you carry decongestants? If so, what do you carry, and why? You can reply here in the comments, or on Twitter.