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

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Section IV: Trauma

Case Study 7: Summer Ski Trip

S: A 43-year-old man complains of pain and instability of the left knee after he caught an edge, causing a tumbling fall. He felt a pop and a brief burning pain. On attempting to stand, the knee “gave out.” He did not hit his head and has no neck pain. He has full memory of the event. He has an allergy to Vicodin, takes ibuprofen for headaches, has never injured the knee before, and has no significant past medical history. His last meal was 40 minutes ago. The descent was at the end of the day, with only a kilometer to go. He attempted to ski further, but the left knee “gave out” when he tried to stand and became more painful and began to swell. Weight bearing became very uncomfortable. O: The guide was found sitting upright in stable position with the left knee flexed. He was fully alert, warm, and reasonably dry. He had no spine tenderness. The left knee was tender and moderately swollen. He was able to flex and extend the knee somewhat with moderate discomfort. Distal CSM was intact. There was no other obvious injury. Vital signs at 1610 were normal. A: 1. Unstable injury left knee A’: Distal ischemia due to swelling A’: Pain and further injury from continued use 2. Decaying weather A’: Lightning strike A’: Hypothermia P: 1. Discontinue walking or standing; stabilize knee at the vehicle. 2. Controlled extrication by slide and carry. Discussion: Although the temptation to limp the last kilometer was very strong, the patient agreed to the appropriate treatment, considering both the condition of the knee and the environmental threats. This injury fit the criteria for unstable injury because of the history of a “pop” during injury, the sense of instability, rapid swelling, and the inability to bear weight. This story is typical of an anterior cruciate ligament rupture exacerbated by further injury. The risk of lightning strike and cold motivated the deferral of further examination and stabilization until a safe zone could be reached. Fortunately, the evacuation route was downhill on snow, allowing the clients to remove the guide quickly by sliding him on a tarp almost all the way to their vehicles. The guide’s knee will require surgery and months of rehabilitation but will recover. The guide’s pride may not. Scene A guided ski trip to a popular summer snowfield in the Canadian Rockies. The guide suffers a knee injury in a fall while leading his group out of the high country in the face of rapidly developing afternoon thunderstorms. The scene is exposed alpine tundra 1 kilometer from the trailhead. At 1605 hours the weather is cloudy with light rain and approaching lightning. Winds are west at 10 m/s and the temperature is 10°C and rapidly falling.