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

52

Wilderness and Rescue Medicine

Discussion: This patient is worrisome because of the extent of memory loss and the delayed return to normal mental status. The diagnosis of TBI is clear and increased ICP is anticipated. Even if the team medic cannot do anything about the increasing ICP, she can improve oxygenation by maintaining a clear airway and giving supplemental oxygen by cannula. At this elevation it will help even if the patient’s respiratory system is already working fine. The ability to maintain airway and oxygenation, along with body core temperature, while transporting is key to determining the evacuation method. In this case, the medic felt comfortable managing the patient enroute and chose to evacuate by ground. She also called an air medical helicopter to meet the team at the trailhead because the patient would be better served by evacuation to a trauma center rather than a small community hospital. At the same time, she is reducing the risk associated with possible cancellation of the helicopter due to weather by proceeding immediately to the trail head. If there is no helicopter and trauma center, at least there is an ambulance and hospital. Case Study 4: Illness at Sea Scene A cruising catamaran 250 nautical miles ESE of North Carolina bound for Saint Martin. One of the four crewmembers complains of shortness of breath upon returning from a sail change. The weather is fair with west winds at 20 knots and seas of 1 to 2 meters from the southwest. The temperature is 22°C. The boat is making 12 knots at 096 degrees true. S: A 36-year-old woman is found awake and responsive sitting in the cockpit at 2300 hours. She is initially breathing hard and coughing but settles down after a few minutes. She complains of becoming short of breath and dizzy while raising the reefed mainsail and had to sit down on deck before recovering enough to return to the cockpit. She reports “coming down with a cold” 5 days ago before departure but has felt much worse over the past 5 hours with fevers and chills, persistent cough, and chest pain. The

cough is occasionally productive of thick green sputum. She admits an allergy to penicillin. She has been taking over-the-counter cough medica- tion with little success. She reports little appetite and has not been eating or drinking normally. She last produced a small amount of urine at 1700. She gives no history of asthma or other respiratory problems. She denies trauma. She denies any pos- sibility of pregnancy with a last menstrual period (LMP) of one week ago. O: Subdued but awake, cooperative, occasion- al cough noted. Auscultation of the chest with a stethoscope reveals fine crackles and a slight

General Principles

©2018WMA

wheezing in both lungs. The abdomen is soft and nontender with normal bowel sounds. Vital Signs: Pulse: 120, Resp: 24, Temp: 38°C, Skin: warm, moist, pink, C: Awake and oriented but subdued, BP: 110/68.