Wilderness and Rescue Medicine 8th Edition

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Section I: General Principles

voluntarily. The fingers are warm and pink and can be wiggled with slight pain felt at the wrist. The patient can feel the light touch of a cotton swab on the end of each finger. X-ray shows a non-displaced mild- ly angulated fracture of the distal radius. Vital signs: P: 80; R: 18, easy; O 2 : 99%; BP: 122/72; S: warm, dry, pink; T: 37.1°C; C: P: Wrist splint. Rest, ice, and elevation. Acetaminophen 500 mg every 6 hours for pain. Follow up with an orthopedic sur- geon within 3 days. Return to the hospital if fingers become blue or cold, or if the tingling becomes at all worse. This format paints a clear picture of the situation. In just a few words, you get a sense of who the patient is, what happened, and what the practi- tioner is going to do about it. There is also a brief description of problems that might develop and what the patient’s response should be. The SOAP format is perfectly adaptable to the backcountry setting. It performs the same vital function that it does in the emergency depart- ment. SOAP organizes your thoughts and allows you to communicate your ideas and plans. Now, let’s take this same case into the backcountry: S: A 19-year-old man performed a slow fall over the handlebars on a mountain bike ride near Horse Thief Canyon about 1 hour ago. He complains of pain in his right wrist and tingling of his fingers. He has no complaints of pain anywhere else. He did not hit his head and has full mem- ory of the event. No allergies, no medica- tions, no history of previous wrist injury, last meal 12:00. He feels cold and hungry. It is now 18:30 and getting dark. The air temperature is 48°F. It is raining lightly. The scene is a 3-hour bike ride from the trailhead. There is no good off-road vehi- cle access. awake, alert, and oriented. A: Fractured right radius.

Creating a Problem List: SOAP The information you have gathered in your sur- veys should be organized in a format abbreviated SOAP: Subjective, Objective, Assessment, and Plan. This is a common way to organize medical information and will be recognized by practitio- ners worldwide. Using this method, information regarding the patient assessment and history are divided into two groups: what you learn from your survey of the scene and talking to the patient and witnesses (subjective) and what you learn from your examination of the patient (objective). This report also provides the answer to the all-impor- tant question: What’s wrong here and what you are going to do about it (assessment and plan)?

SOAP Note

Subjective: • Story • SAMPLE history, if relevant Objective: • Exam findings • Vital signs Assessment: • Problem list (A) • Anticipated problems (A’) Plan: • Treatment for each existing problem • Evacuation and/or monitoring for anticipated problems

Using this system, a typical brief SOAP for an emergency room case might look like this: S: A 19-year-old man fell off his bicycle when he rode over a curb at slow speed. He complains of pain in his right wrist and tingling of his fingers. He has no com- plaints of pain anywhere else. He was not wearing a helmet but did not hit his head and has full memory for the event. No allergies, no medications, no history of previous wrist injury; last meal 12:00. O: An alert, oriented, but uncomfortable man. The right wrist is swollen and tender to touch. There is no other obvious inju- ry. The patient refuses to move the wrist