Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

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Wilderness and Rescue Medicine

quickly become the specific diagnosis of appen- dicitis with a few lab tests and a CT scan. But, if your examining room is the salon of a small boat 200 miles offshore, it is nearly impossible to distinguish an ectopic pregnancy from appendi- citis or any one of a dozen other problems. The practitioner is often left working with a generic diagnosis of serious abdominal pain for the dura- tion of field treatment and evacuation.

are being challenged to come up with a plan that makes sense for the environment in which you are operating.

General Principles

Ideal to Real

General Principles

Generic to Specific

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Altered Mental Status

Low blood sugar Hypothermia Hypoxia Increased ICP Electrical injury Altitude illness Intoxication Hyponatremia

“…create a plan that makes sense for the environment in which you are operating.”

©2018WMA

It is certainly helpful to have the ideal treatment in mind, but you must be able to forgive yourself for not being able to provide it. In some cases, you may be able to come close. In most cases you will have to accept compromise and be willing to execute a plan that is real for the patient’s situation. For example, the ideal treatment for a trauma patient with neck injury might involve spine sta- bilization with a cervical collar and vacuum mat- tress; however, if your problem list includes being 20 meters down a crevasse in an Antarctic glacier, your patient may freeze to death before this can be accomplished. Helping the patient climb out may be the only real treatment for a situation like this. Focus on Important “The patient is the one with the disease.”This time- honored medical school quip is another way of saying don’t panic, you are not the one injured and in need of help. You are the help. You will function more efficiently and safely by remembering this important fact, and by remaining objective and task oriented. The more confusing and complicat- ed the problem, the more important this behavior is. This can take considerable self-discipline. Rescue scenes are full of distractions courtesy of radio traffic, bystanders, fellow rescuers, and anyone suffering pain and acute stress reaction. Your attention will be drawn in a dozen different directions. Learn to focus your attention on the problems that are truly urgent and important and

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“Altered Mental Status is just one example of a generic diagnosis with a lot of possible specific causes.”

©2018WMA

Nevertheless, an important component of this generic-to-specific principle is the need to con- sider and treat, if possible, all likely causes of a problem until a specific diagnosis can be rendered. This is especially important when a critical body system is involved. For example, altered men- tal status in an alpine climber could be caused by high-altitude cerebral edema, hypothermia, intoxication, brain injury, or low blood glucose. Some of these may treatable on scene. As further investigation is conducted, and the results of treatment are observed, some of the pos- sible causes can be ruled out and the treatment directed at those that are left. Considering the generic diagnosis first avoids the oversight caused by puddle vision—that is, inappropriately focus- ing on one specific diagnosis or puddle of blood to the exclusion of all else. Ideal to Real Medical practitioners are fond of the excuse, “If I just had my jump kit, or nurse, or defibrillator….” In a wilderness rescue situation, you are not being quizzed on the ideal hospital or ambulance treat- ment for the condition you have identified. You