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

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Section III: Critical System Problems and Treatment

S: A 16-year-old girl is carried into the staff hut with the report of difficulty breathing for the past 2 hours and getting worse. She is no longer able to speak. Friends reported that she had complained of chest tightness and dizziness and had been asking around for an asthma inhaler with no success. No allergies or other medication use was listed on her medical screening form. No one had observed any recent trauma or respiratory illness. Her friends denied seeing any recreational drug use or smoking. Her last meal was lunch at 1300. O: Awake, but subdued and incoherent. Unable to sit upright without help. VS: Pulse: 138, Resp: 24, shallow and labored with an audible wheeze, Skin: pale, lips blue, Temp: feels cool. No obvious severe injury noted on primary assessment. A: 1. Respiratory failure due to lower airway constriction. A’: Respiratory arrest 2. Cold patient A’: Hypothermia 3. Hazardous evacuation P: 1. Oxygen by mask at 12 liters/minute. Wilderness Protocol for severe asthma initiated with 0.3mg epinephrine IM by autoinjector. 2. Bag-valve mask readied for positive pressure ventilation if necessary. Albuterol and prednisone available. 3. Patient wrapped in sleeping bag, and the hut stove is fired up for heat. 4. Staff member tasked to initiate contact with the Coast Guard for a possible emergency evacu- ation by larger vessel. Discussion: Respiratory failure is a primary assessment problem requiring immediate treatment. The secondary assessment can wait. Wheezing suggests lower airway constriction as the generic problem meaning that epinephrine will be required. Based on a limited history, asthma was presumed, but anaphylaxis is also a possibility.The problem list was compounded by the weather, resulting in a cold patient at risk for hypothermia. Warming was therefore an important part of the primary treatment. In this case, field treatment was successful, and a high-risk evacuation was not necessary, but the staff had been wise to initiate the process early. It is usually safer to call off an evacuation in progress than to rush an evacuation started too late. In this case, the availability of a warm hut, oxygen, and medical sup- plies allowed for good basic medical care on scene. It was later determined that the patient has a history of asthma and normally carries medication. This significant element was omitted from her screening form for fear that it would have disqualified her from participating in the program. Case Study 5: Incomplete Medical Screening Scene Maine Island base camp, 8 kilometers offshore, 1930 hours. Weather 15°C, winds ENE 30 knots, visibility 0.5 nautical miles in fog and rain.