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

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Section VI: Backcountry Medicine

and the effect of treatment, or to initiate a less urgent evacuation. If no serious problems exist right now, you will still want to observe and measure the function of the three critical systems to detect any anticipated problems that may become serious. A patient with a cough, for example, may have a respiratory infection with the anticipated problem of respira- tory distress. A complaint of diarrhea carries the anticipated problem of dehydration and volume shock. A person with a headache may be on the way toward elevated ICP. A person who is sick, but not serious, may be uncomfortable but will continue to think, eat, drink, pee, and poop more or less normally. These patients are not particularly worrisome, and your primary job will be to keep her comfortable and to monitor for change. It is when your patient stops eating and drinking, loses interest in her surroundings, and is unable to take care of her- self that you should consider the situation serious regardless of the diagnosis. Pain is another complaint worth careful inves- tigation. The location and character of the pain will sometimes lead you to a more specific diag- nosis. Any pain out of proportion to the apparent problem should be taken as a serious sign until proven otherwise.

investigate any complaint of pain. This process should detect the presence of any serious condi- tion and the need for basic life support (BLS) and urgent evacuation. Or, the primary assessment may reassure you that the patient is okay, at least for now, and guide your secondary assessment toward a specific problem list and plan. Risk Versus Benefit Deciding what to do about serious illness is easy: BLS and evacuation. If you cannot evacuate, you need to bring medical care to the patient, or at least get expert advice. The obviously benign problems are easy too: treat the symptoms and observe. It is the illness in between, where you are not sure if it is serious or not serious, that presents the greatest challenge. Unless your patient needs immediate life-saving treatment, there is little risk in taking the time to perform a thorough and thoughtful evaluation of an illness. You do not need to be an experienced clinician to perform a basic assessment of criti- cal system and normal body function or to listen carefully to what your patient is telling you. The questions outlined above, along with the rest of the SAMPLE history, will usually point you in the right direction. When an experienced practitioner makes an incorrect or incomplete diagnosis, it is often not by failure to ask the right questions, but by failure to listen to the answers and to examine the patient thoroughly. There is danger, also, in assuming too quickly that you know what the problem is. This can lead to grievous errors, especially when deal- ing with patients who may be prone to malinger- ing, deception, or drama. Remember the Generic to Specific Principle and the three critical systems. Take any complaint as legitimate until proven otherwise. Never be afraid to reevaluate and change your assessment.

Illness Generic Assessment Critical System Problem? Mental Status? Ins and outs? Pain?

General Principles

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Wilderness Perspective

Not Serious

Serious

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“In the field our working diagnosis may remain as

Your primary assessment of the ill patient begins with an evaluation of the circulatory, respira- tory, and nervous systems, looking for existing or anticipated problems. Your history evaluates the patient’s regular functions of food and fluid intake and the output of urine and feces. Finally,