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

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Section I: General Principles

S: A subdued and ill-looking 18-year-old female is found lying in her berth. She admits to being sea sick for the past three days with nausea and vomiting. She has been able to eat and drink very little. She last urinated eight hours ago. She complains of almost fainting on trying to stand, a mild headache, and abdominal pain. History reveals that her last menstrual period was eleven weeks ago and that there is the possibility of pregnancy. She describes herself as otherwise healthy and using no routine medica- tions. She denies difficulty breathing. O: Awake and subdued with normal mental status. Her skin appears pale and her lips and mouth are somewhat dry. Breathing appears easy and lung sounds are clear on auscultation with a stethoscope. There is mild abdominal tenderness and subdued but present bowel sounds. There is no kidney tender- ness. There is no other obvious abnormality on physical exam. Vital signs at 1300: P: 122, R: 22 and easy, O2: 98%, BP: 96/62, S: pale and cool, T: normal, C: awake and oriented. A: 1. Compensated volume shock due to sea sickness and dehydration. A’: Decompensated shock 2. Possibility of pregnancy. A’: Complications due to shock, limits medication options 3. No early evacuation options. P: 1. Begin oral hydration. Consider intravenous or subcutaneous hydration if not successful. 2. Urine pregnancy test when patient can produce urine. Discussion: Compensated volume shock is a serious problem. When the MOI is dehydration from a treatable cause, it may be a problem you can fix in the field. A positive urine pregnancy confirmed the potential compli- cation, but was not a serious problem at this point. An electric Relief Band for nausea was suggested by a shoreside doctor and offered by another trainee. The nausea was reduced, and rehydration is successful without medication. The patient elected to leave the ship when she made port five days later. Scene A 40-meter sail training vessel located 500 nautical miles east of Bermuda bound for the Azores. A trainee has reported ill and unable to stand watch. The medical officer is called to evaluate. The weather is overcast with occasional squalls. Winds are west at 25 to 30 knots with seas of 2 to 4 meters. Case Study 2: Offshore Illness This case is interesting because the concern for shock was made based on the mechanism and pulse rate alone. The urgent response might have been usual in the ambulance context but was not appropriate in this high risk backcountry scene. The rest of the volume shock pattern was not present. There was no severe external bleeding or pain and tenderness that suggested internal bleeding. Removing volume shock from the problem list would have allowed the medical officer to make a better risk/benefit decision, perhaps to remain on scene until the evacuation could be carried out in daylight with more equipment and personnel.