Wilderness and Rescue Medicine 8th Edition

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Section III: Critical System Problems and Treatment

protecting the airway from fluids and vomit while assessment and treatment continue. In trauma patients, the spine is also protected as part of BLS. This usually takes the form of restoring and maintaining normal spinal align- ment while treatment of any life-threatening condition continues. However, spine management should not take precedence over patient protec- tion, adequate ventilation, or circulatory support. A major critical system problem carries a high risk of death and the benefit to the patient of almost any BLS/ALS treatment is obvious. What is less obvious, sometimes, is the risk to the rescu- ers performing the treatment.

External injury highlights the anticipated prob- lem of internal bleeding. However, significant blunt force trauma may leave no visible signs. Even in the urban context, the global risks are often discounted in favor of low-yield procedures. Consider, for example, the AED-equipped police cruiser responding to a cardiac arrest call. The officer knows that a fast response is beneficial to the patient’s chance for survival. But, at the same time, their code 3 race through town substantially increases the risk to drivers on the road, children and dogs in crosswalks, and bicyclists turning to watch the excitement. Add an ambulance, engine company, and helicopter to the response and the risks really start to pile up. In the backcountry and offshore setting, the risk associated with rescue and evacuation is often extreme. It is incumbent on the medical officer to balance the chance of successful medical treat- ment against these risks to the rescuers as well as the patient. There will be situations where remain- ing on scene and performing good basic medical care while risks are mitigated and a safe rescue is organized will give everyone a better chance of survival. There will also be situations where rapid removal of the patient from the scene before initiating any medical care will be required. And, of course, there are situations where access to the patient is impossible without exposing res- cuers to unreasonable hazards and rescue efforts must be abandoned. Deciding which is which requires an objective, unemotional, concise val- uation of probability and consequence and risk versus benefit.

General Principles

BLS – Brain Failure

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Altered Mental Status: • Treat the cause – STOPEATS • Maintain normal body temperature • Secure and monitor the airway

• Maintain ventilation • Maintain hydration • Protect the spine as needed

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“ There is no real way to treat this other than to treat the cause .”

© 2018 WMA

Risk Versus Benefit in BLS Any rescue effort, even the most desperate, must consider the overall probability and consequence of an adverse event. Performing CPR under a hang fire avalanche, for example, is a very low- yield procedure in a very high-risk environment. Discontinuing resuscitation under such a circum- stance would certainly be appropriate but would be one of the most difficult decisions a medical officer would have to make.