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

Wilderness and Rescue Medicine 190

Case Study 11: Ocean Voyage

S: A 20-year-old student is found huddled at the base of the foremast at dawn. He was last seen at watch change at 23:00 the previous day. He appears to be unconscious. The watch officer is summoned. Scene Transpacific voyage aboard a 135-foot sailing school vessel 500 miles northeast of Midway Island. The weather has been cold, wet, and windy for the past 24 hours.

O: The student is responsive to painful stimuli. His foul weath- er gear is open in front, and he is soaked to the waist. A bruise is noted below his left eye. There is no other obvious injury. Vital Signs at 05:30: BP: 110/70, Pulse: 60, Resp: 10, C: P on AVPU, Temp: felt cool, Skin: pale. An empty bottle of Dramamine tablets was found in his jacket pocket. According to his medical screening form, the student has no known allergies, he is not on medication, and he has no history of significant medical problems. His last meal would have been a snack at 21:00 the previous day. A: 1. P on AVPU. Consider low blood sugar, hypothermia, traumatic brain injury, toxins. 2. Spine cannot be cleared. P: 1. Hypothermia package, external rewarming 2. Monitor AVPU and airway 3. Monitor respiration 4. Sugar orally when airway can be protected 5. Spine protection until cleared. Discussion:

Wet clothing was removed, and the patient was wrapped in a sleeping bag. Hot water bottles were rotated into the package. Although the patient was breathing, ventilations were assisted by mouth to mask. A rectal temperature of 31°C was measured, confirming the suspicion of severe hypothermia. The patient responded to treatment, improved to V on AVPU, and began to shiver. As soon as he was able to take liquids safely, he was given warm tea and honey. After 3 hours, he was A on AVPU with normal mental status and a normal core temperature. He was able to explain what happened. There had been no trauma. He had not been climbing the mast. The bruise below his eye had developed after being struck in the face by a flailing jib sheet two days before. He had taken twice the normal dose of Dramamine to treat his sea sickness and had fallen asleep in the location where he had been found. Although this problem could have been avoided, it was handled appropriately once discovered. The watch officer’s plan initially considered all the possible causes of reduced level of consciousness, includ- ing severe hypothermia. As the patient responded to treatment, the other causes could be ruled out by exam and history leaving only the hypothermia and successful recovery.