You are en route to a backcountry lean-to managed by the forest service in the summer. Although the current temperature is in the low single digits after a cold front moved in early this afternoon, the weather yesterday was warm, above freezing, with bouts of hard rain. The snow is crusty and heavy on the forest road leading to the hut. You are two days from your car and it will take another day to reach the lean-to. You are carrying two weeks of supplies and hoping for new snow and fresh tracks after you reach the lean-to.
When you arrive at the forest service campground two of the shelters are occupied by a high school group who have been touring in the park the past week leaving an older, half-buried one for you and your friend. After setting up camp and eating dinner, you wander over to the high school group to say "Hi." They are starting to eat dinner when you arrive. The leader, one of the school's teachers, tells you much of their gear is frozen from yesterday's rain. You notice that a student is huddled in their sleeping bag in one of the shelters, everyone else is eating dinner. The group leader tells you the student, a 15-year-old female, was very cold when they arrived, immediately went to bed, and said she wasn't interested in dinner. While your gear is dry, you can see that many of the students' sleeping bags are frozen. The group leader is concerned about the drop in temperature and unsure how to keep the students warm at night.

What can you do to help? Click here to find out.

Deaths due to opioid overdoses continue to rise. Opioid abuse knows no age, race, or economic barriers; and, abuse is often hidden, making it difficult to know who is at risk for an overdose. In April 2018 U.S. Surgeon General, Dr. Jerome Adams, issued a public health advisory urging more Americans to learn to use and carry naloxone. Most states have approved Narcan® Nasal Spray for over the counter sales and publicly encourage addicts, family, and friends to carry it. Communities provide training and naloxone to police and place naloxone in public places with AEDs; some public health agencies provide it for free. Colleges and universities provide training and naloxone to staff and students. While still uncommon, opioid overdoses have occurred in wilderness settings. This begs the following questions:

1. Should I carry naloxone in my wilderness first aid kit? Answer: Maybe. It makes sense to carry naloxone if you use high dose opioids, or if you are a friend, family member, or person who comes into contact with people at risk for an opioid overdose. Theoretically, the list could include almost everyone; that said, the risk of encountering an opioid overdose is likely higher for ski patrollers, outdoor therapy/substance abuse staff, park rangers, campground hosts, etc. and anyone who attends a party where alcohol and drugs are likely to be present.
2. If so, how should I administer it? Answer: Narcan® Nasal Spray. While one ml vials and ampoules of naloxone are slightly less expensive than  Narcan® Nasal Spray, they require a prescription and take more training to use.
   

What are Opioids?
Heroin, morphine, codeine, and thebaine are naturally occurring opioids made from the resin of poppy plants; hydromorphone, hydrocodone, and oxycodone are derived from resin in a lab setting. Fentanyl, pethidine, levorphanol, methadone, tramadol, and dextropropoxyphene are synthetic. All opioids depress the central nervous system (CNS) and cause feelings of euphoria; when used correctly, for short periods of time, they are effective pain medicines. All are physiologically addictive. Chronic opioid users develop a tolerance for the drug and require increasingly higher doses to achieve the same level of pain control or well-being. (Note: Opioids are often mixed with other drugs for recreational purposes.) Withdrawal signs and symptoms are the result of excessive stimulus of the sympathetic nervous system and include: increased pulse rate and blood pressure, restlessness, tremors, sleeplessness, muscle and bone pain, abdominal pain, diarrhea, vomiting, sweating, and shivering; patients in acute withdrawal may become combative. As opioid tolerance increases so does dependence…and the severity of withdrawal S/Sx.

An opioid overdose typically occurs when someone takes a large amount of an opioid or a drug containing an opioid, mixes opioids with alcohol, or had a recent change in their level of tolerance. Life-threatening signs and symptoms of an opioid overdose include:

• decreased level of consciousness from drowsiness to unresponsiveness
• decreased pulse rate
• slow, irregular, or no respirations
• low blood pressure
• the person’s skin is often pale or cyanotic (blue-tinged) from the lack of oxygen in their blood

Death due to an opioid overdose is usually due to respiratory arrest and the subsequent lack of oxygen to vital organs as the central nervous system shuts down.

What is Naloxone?
Naloxone is an opioid antagonist; it binds with and blocks opioid receptor sites in the brain, reversing the signs and symptoms of an overdose. In order to be effective, naloxone must be given before the patient goes into cardiac arrest. Except in extremely rare cases when someone is allergic to naloxone, administering naloxone to a patient who is not suffering from an oipoid overdoese does no harm. Naloxone will not prevent deaths caused by other drugs: alcohol, speed, cocaine, or sedatives (e.g.: benzodiazepines like Xananx®, Valium®, etc.).

While there are numerous delivery methods only two are conducive to using in a remote setting: intranasal spray and intramuscular (IM) or subcutaneous (SQ) injection. Of the two, only Narcon® nasal spray is available over the counter in most states, making the choice easy for lay people, outdoor educators, and guides.

Naloxone delivered as a nasal spray or injection takes roughly 3-5 minutes to act. If there is no response after five minutes, give another dose. Naloxone is metabolized in the liver within 30-90 minutes and its metabolites excreted in the urine over the next 3-4 days. Because naloxone is metabolized faster than most opioids—especially long-acting opioids like methadone or sustained-release pain compounds—it’s vital to carry more than one dose. Patients should be monitored for 2-3 hours as further doses may be necessary to treat a relapse. Acute withdrawal symptoms are possible but rare with intranasal administration of naloxone but cause for concern should they occur as the the patient may become combative and a danger to themselves and others.  
Naloxone slowly loses its potency over time or if it is exposed to too much heat, cold, or sunlight. That said, using expired naloxone will not cause harm but you may need more doses to reverse the S/Sx of an opioid overdose. Ideally you should replace expired all expired drugs, and store naloxone in a dark and dry place between 80°F (25°C) and 40°F (5°C)...you want to make sure that it is easily accessible should you need it.

When should I administer naloxone?

• Give naloxone at as early as possible when an opioid overdose is suspected.
• If no response after five minutes, give another dose.
• If the patient’s breathing is slow, and they are cyanotic and obtunded (VPU), assist their breathing and give naloxone.
• If the patient is in respiratory arrest, begin rescue breathing and give naloxone.
• If the patient has no pulse and appears to be in cardiac arrest, begin CPR. Detecting a pulse in opioid overdose patients can be difficult and it may be reasonable to give naloxone based on the possibility that the patient is not in cardiac arrest (2015 AHA guidelines); note that naloxone alone will not reverse cardiac arrest.

You are a trip leader for a week-long snowshoe trip over winter break. You are responsible for a coed group of high school juniors and seniors; your assistant, Steve Hall, is a 38-year-old math teacher from the school with some outdoor experience. As you are setting up camp on the third day of the trip, you notice that Steve stops what he is doing to stretch and rub the left side of his lower back. When you ask him what's wrong, he says he thinks he strained it earlier in the day when helping one of the students put their pack on after a break. 

Forty-five minutes later as you are beginning to assist the students with dinner preparation, Steve says his back is hurting more and he needs to lie down. Roughly an hour later, dinner is ready and you send one of the students to get Steve. After a few minutes, the student comes running back saying Steve is curled on his side in his sleeping bag moaning in pain. You tell the students to start eating while you go and check on Steve.

You find Steve in curled his sleeping bag as reported by the student. He can barely talk through the pain. Gradually you come to understand that the pain started slowly on the left side of his lower back and, over time, began to move down into his groin and scrotal area. He has never experienced pain like this before; changing his position does nothing to relieve it. His history is unremarkable. At 5:48 p.m. Steve's vital signs are: pulse rate: 92 and regular, respiratory rate: not taken due to pain, blood pressure: not taken, skin: pale, cool, & slightly moist, core temperature, 98.4º F, AVPU: awake, alert, and in extreme pain.

What is wrong with Steve and what should you do? Click here to find out.

The progression from a local infection to septic shock typically requires weeks, and once diagnosed, the mortality rate is 25-50% during the following month. While the immune system in healthy adults is typically capable of dealing with the index infection, the immune system of infants, immunocompromised persons, and persons 65 years old and older, may not be.

In a wilderness environment where minor wounds are, unfortunately, all to common, thorough wound cleaning and subsequent monitoring are important. Local inflammation—mild pain and tenderness, redness, and warmth—are normal but should not extend more than a millimeter or two beyond the site. Increased inflammation and pus at the site after 24 hours indicate a local infection; red streaks and fever indicate a systemic infection.

MRSA thrives in crowded, unsanitary conditions and outbreaks have occurred in children’s camps and on expeditions where poor personal and group hygiene was the norm. Be aware that MRSA infections—Methicillin-Resistant Staphylococcus aureus—are highly contagious and can be acquired through contact with the contaminated clothing or the skin of an infected person. MRSA bacteria may enter the body at the site of a minor wound or present as swollen, painful bumps that resemble pimples or a spider bite. This may quickly turn into a painful abscess that requires surgical draining. A few cases will continue to progress to a systemic infection, and fewer still to sepsis.
Lower respiratory infections are also relatively common in the outdoors, especially on longer expeditions; fortunately most resolve with simple rest and fluids. That said, some, particularly those associated with a flu virus, may progress to a pneumonia. Symptoms of a pneumonia vary from mild to severe but typically include a dry or productive cough, fever, chills, fatigue, and respiratory distress. Some people experience a sharp or stabbing pain that gets worse with a deep breath or cough.
Urinary tract infections (UTI) are relatively common among females in the outdoors and are often linked to poor hygiene and/or chronic dehydration. Treatment with antibiotics is recommended to prevent the infection spreading to the kidneys and blood. Once active in the blood, sepsis is possible.
Travelers diarrhea caused by some strains of E. coli may lead to a systemic infection and sepsis, as can any intestinal infection that results in a perforated bowel: diverticulitis, appendicitis, ulcerative colitis, Crohn’s disease, strangulated hernia (which can result in poor blood flow to the intestines), peptic ulcers, etc. All require an urgent evacuation to a hospital for physician assessment and follow-up treatment; refer to the “Red Flag” signs and symptoms for an urgent—level 1 or 2—evacuation listed in our Wilderness Medicine Handbook.
Sepsis is rare on wilderness expeditions for a number of reasons:

• Sepsis rarely occurs in healthy adults with good personal and group hygiene. (Focusing on personal and group hygiene goes a long way to preventing the index infection.) That said, remember that the risk of sepsis from a local infection increases in immunocompromised individuals and patient’s greater than 65 years old, especially those in poor health.
• Patients with a local infection are typically evacuated early in the continuum in order to prevent a systemic infection; or if one already exists, starting a course of broad-spectrum antibiotics during the evacuation helps prevent the infection from worsening.

Sepsis S/Sx

• A probable or confirmed local skin, lung, GI or GU infection plus two of the following:
• Core temperature greater than 102º F (38.9º C) or below 96.8º F (36º C)
• A pulse rate greater than 90/min; a patient’s pulse rate increases roughly 10 beats/min for every degree increase in core temperature.
• A respiratory rater higher than 20/min; a patient’s respiratory rate increases roughly 2 beats/min for every degree increase in core temperature. (Breathing fast “blows off” carbon dioxide; lab results in a patient with sepsis will show low levels of blood CO2 (PaCO2 < 32; normal = 38-42).

White blood cell production increases in an effort to combat the infection by releasing nitrous oxide and cytokines and engaging in phagocytosis (cell eating). Nitrous oxide causes the blood vessels to dilate and increase the permeability of their walls leading to plasma leaks. And, as plasma leaks into tissue spaces, it takes oxygen longer to diffuse into individual cells. Cytokines are proteins that activate the patient’s cellular defenses and immune system. Pulse and respiratory rates increase in patients with a fever to increase oxygen delivery to tissues. The increased pulse rate also helps maintain the patient's blood pressure.

Severe Sepsis S/Sx
The S/Sx of Sepsis plus one of the following—which may indicate initial organ failure:

• Significantly decreased urine output indicates kidney failure. As kidneys fail, urine output drops and the kidneys are no longer able to clear toxins from the blood or balance blood pH. (In the hospital decreased urine output with fluid bolus via large-bore IVs indicate sepsis.)
• Abrupt change in mental status
• Respiratory distress indicates damage to the blood vessels in the patient's lungs.
• Irregular pulse or heart sounds indicate heart damage.
• Severe abdominal pain often indicates a perforation.

Septic Shock S/Sx

• S/Sx of Severe Sepsis plus a drop in blood pressure. (Initially, the patient’s pulse rate increases in an effort to maintain BP; however, if septic shock progresses and the heart is damaged, the pulse rate and blood pressure will drop. Death will ensue.)

You are leading the eighth pitch of a 12-pitch climb on chossy rock when your rope dislodges a small pillar of loose rock. Your belayer is hit on her helmet by a chunk of the falling rock the size of a baseball; the remaining fragments shatter into small shards. Janey is initially unresponsive but awakens quickly. Despite the generally poor quality of the rock on this pitch, you are able to construct a solid anchor and within a few minutes Janey is able to give you enough rope to rappel down to her belay stance. Careful not to dislodge any more rock, you head down. When you reach the belay station she is awake and alert with a cracked helmet; she cannot remember the rockfall or being hit. During the focused spine assessment she reports both pain (4/10) and tenderness in her neck around C-3, says her entire neck is stiff, and she doesn't want to move it; she passes all the motor and sensory exams. Aside from a few superficial scratches from small rock shards and a headache (3/10), she has no additional injuries. From the base of the climb it is an hour hike over third and fourth class terrain to your vehicle and another three hours to the hospital. There is no cell coverage and there is roughly four hours of light left. It's cool on the route, and you need a thin insulated shell to stay warm while climbing. Nighttime temperatures are expected to drop below freezing and a front is expected to arrive sometime tomorrow morning bringing wind, rain, and perhaps some snow.

What's wrong with Janey and what do you do? Click here to find out.

On a functional level, the nervous system is divided into two divisions: the voluntary (somatic) nervous system and the involuntary (autonomic) nervous system. The voluntary division of the nervous system contains both sensory and motor nerves. Sensory nerves carry input to the spinal cord and brain, while motor nerves carry messages from them. Through its nerves, the somatic nervous system controls conscious functions, principally high-level thought and striated muscle contractions. The autonomic division  maintains or restores homeostasis by regulating smooth muscle contractions and the glandular secretion of hormones. Most autonomic functions are beyond conscious control.
The autonomic division of the nervous system is subdivided into the sympathetic and the parasympathetic systems. The sympathetic system stimulates effectors (cells or organs) while the parasympathetic system inhibits them. Both systems continually transmit impulses to the same effector and act in an antagonistic manner, with the stronger impulse assuming control. Under normal conditions, the sympathetic system is responsible for waking us up and the parasympathetic system is responsible for sleep and digestion.

If the sympathetic nervous system is engaged during a stress response, the body prepares for “fight or flight”: pupils dilate to increase vision; pulse, respiration and blood pressure rates rise to meet an intense physical demand; awareness, often seen as anxiety, increases; sweating increases, while vasoconstriction leaves the skin pale, cool and moist; and endorphins are released to block pain. Over stimulation of muscle fibers often results in uncontrollable shaking. A strong sympathetic response decreases cognitive function leaving patients unable to process complex information and feeling overwhelmed and often fearful. A patient experiencing a sympathetic ASR cannot give accurate information about their injuries. In most cases, they are unaware of any physical injuries and may not exhibit abnormal signs or symptoms upon examination. Their vital sign pattern may mimic or mask volume shock.

If the parasympathetic nervous system is stimulated, the patient becomes nauseated, dizzy, and may faint. Blood pools centrally around their digestive tract and their pulse, respiratory and blood pressure rates fall. Their skin is pale and cool. Upon awakening, the patient is often confused. A parasympathetic ASR may mimic the signs and symptoms of a concussion and make accurate assessment of a traumatic head injury difficult.

A serious medical incident is often stressful to all involved: rescuers, care providers, patients, and bystanders; and, any or all involved may have both immediate and lingering effects: Post Traumatic Stress Disorders (PTSD) are common, although individual reactions vary considerably. Your actions as a rescuer or care provider can mitigate your patient's stress in both the short term and long term. And as a scene leader, the same strategies apply to working with expedition members or your rescue team and bystanders. The term "Psychological First Aid (PFA)" has been used in recent years to identify strategies that have proven to help prevent or reduce both the short and long term effects of stress (PTSD). While the term may be new, the strategies discussed below should not be: Psychological First Aid is—and has been—an intentional and integral part of our Patient Assessment System. The strategies on the right side of the diagram below align with current PFA principles.

Create as safe an environment as possible in the aftermath of an overwhelming event by mitigating scene threats and calming patients, bystanders, and rescuers as necessary. It's vital not to lie to patients, bystanders, or team members but to be realistic and focus on what you—and they—can do, and are doing to keep them safe. This may include removing select people from the scene or shielding them from a chaotic scene.

Remember that stress affects everyone, including rescuers and care providers. You must first reduce your sympathetic ASR (fight or flight response) before attempting to help others. Again, be truthful and focus on the present. As much as possible, radiate calm. Following the Patient Assessment System and using SOAP notes help caregivers reduce their ASR by providing an organized, step by step thought process, that also acts to calm their patients.

It's easy for both patients and rescuers to feel powerless or helpless in what they perceive as extreme situations where no clear avenue forward is visible. Care providers can empower patients by involving them in their care and evacuation decisions where appropriate, and where appropriate in the care of others. And team leaders can empower rescuers, care providers, and bystanders by assigning clear—step by step—practical, and doable tasks.

Team leaders can also build an on-scene support network by assigning a care provider to each patient and have them remain with the patient throughout their assessment, treatment, and evacuation (they do not have to be the primary care provider). The relationship between a care provider and patient provides a very real lifeline for severely stressed patients. Both team leaders and care providers can also work to extend the support lifeline beyond the scene by helping patients and bystanders connect with their friends, family, and pets as soon as possible.

ln combination with shared, relevant stories, all of the above combine to help inspire hope for the current situation.

In combination with our patient assessment system and field handbook, we use SOAP notes to help teach students how to assess and treat patients. They quickly see the benefit in a well-designed SOAP note, especially for complex problems; however, they often question if a SOAP note should be used for every patient? After all they take time to complete (and everyone hates paperwork, particularly if it's seen as unnecessary). So...what's necessary and what isn't?

Sometimes the answer is obvious: The problem is serious and/or complex and a SOAP note is necessary. But what about minor problems, for example: blisters, strains and sprains, cuts, etc.; and problems that may, or may not, develop into something more serious, like hymenoptera stings that may progress to anaphylaxis, a blow to the head that may turn out to be a mild concussion, or a drowning patient who was awake throughout their rescue but coughing, etc. These are not so obvious, usually because they don't require an evacuation at the moment...but could in the future. What about them?

There are a couple of ways to proceed; both are valid:

1. Complete a SOAP note and incident report. After all, it only takes a few minutes. While a SOAP note may ultimately turn out to be unnecessary, you've covered your bases. And, it's programmatically important to keep track of even minor incidents in case they might point to field or administrative errors that need addressing.
   
2. Write down basic information in your notebook (patient's name, presenting S/Sx, problem, and treat/monitor the patient. If developing S/Sx warrant closer attention, transfer the information to a SOAP note and continue from there. Remember to complete an incident form.