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

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Wilderness and Rescue Medicine

Case Study 6: River Trip Disaster Scene

River kayak day trip, Quebec, 12 kilometers from the nearest road. Weather: 5°C, overcast and windy with snow flurries. A group of three kayakers encounters a second group on the riverbank with one guide performing CPR on another. There were five other kayakers lying and sitting around, appar- ently unconcerned. The exhausted guide reports that he has been doing CPR on his unresponsive assistant for 15 minutes and asks for help. His group of six clients had also been in the water helping with the rescue. He did not know if any of them were injured. He has been unable to call for help because there is no cell phone service. S: The patient was pulled from the water after a 40-minute entrapment fully submerged. He was last seen upright just before dropping into a large hydraulic. No other history is obtained. Five other people were noted in various stages of altered mental status and reduced level of consciousness. One was appar- ently missing. O: A male in his 30s, unresponsive. CPR in progress. VS: Pulse: undetectable, Resp: absent, Skin: pale, Temp: cold. Helmet cracked. Deformity noted above right eye. A: 1. Multiple casualty incident with one fatality. 2. Multiple people in mild to severe hypothermia. 3. Missing person. 4. Cold, no shelter, high-risk evacuation. P: 1. Discontinue CPR. 2. Push sugar and fluids for the other patients and build a fire; improvise shelter. 3. Initiate a hasty search of the nearby riverbank for the missing person. 4. Activate your personal locater beacon. Discussion: The most serious medical problem in this scene was not the unresponsive subject of CPR. His chance of survival after a 40-minute submersion and 15 minutes of CPR is extremely low, whereas the risk of severe hypothermia in the other six is quite high. And, there is still one person missing. This was a clear case for recognizing the limits of CPR in the wilderness context and for focusing on the people who need immediate care and protection. Activating a beacon or employing other means of declaring an emergency was justified in this case even though you have stopped CPR. Your ability to treat six exhausted and cold people with inadequate equipment and supplies, while searching for a seventh, is severely limited. You are dealing with high-risk problems in a high-risk environment.