Assessing Medical Problems in the Field

There are tens of thousands of possible medical problems. Providing an accurate diagnosis and treatment plan for some problems can require years of training, access to a computer database, laboratory analysis, and sophisticated diagnostic tools, few of which are generally available in a wilderness setting. Prevention of common expedition-based medical problems typically requires an in-depth participant medical form and screening, attention to personal and camp hygiene, safe food preparation, water purification, and foreknowledge of any endemic infectious disease. Regardless of prior training and experience, it is more important to determine if the presenting medical problem is serious enough to require an evacuation and, if so, the urgency of that evacuation, than it is to accurately diagnose a specific problem. Follow the standard Patient Assessment System protocol and rule out traumatic and environmental mechanisms before considering a medical mechanism. 

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General Assessment & Treatment Strategies for Medical Problems

• Rule out traumatic and environmental mechanism
• Look closely at the patient’s S/Sx, their personal history, and any potential contact with an infectious disease. In assessing medical mechanisms the majority of diagnostic errors occur because rescuers fail to take a thorough history, perform a physical exam, or take the patient's vital signs. Do not make this mistake.
• Pain is a common chief complaint and it is vitally important to rigorously examine its: onset (When did it start? Was the onset sudden,  gradual or part of an ongoing problem?); provocation (Does anything make the pain better or worse? Is it relieved with rest?); quality & character (What does the pain feel like? Describe it. Common descriptions include: dull, sharp, achy, burning, crampy, bloated, varies, colicky (comes & goes), stabbing, tearing, ripping, pressure, squeezing. Is the character diffuse (wide-spread) or local?); region & radiation (Point to where it hurts. Does the pain move or radiate?); severity (On a scale of 1-10, how severe is the pain? Have you ever felt pain like this before? If so, when? What were the circumstances? Has it changed since its onset? What do you think is causing it?); timing (Is the pain constant or intermittent? If intermittent, time the intervals. Are the intervals getting closer or further apart?), what makes it worse or better, and all associated S/Sx.)
  
• While it's typically not necessary to complete a head-to-toe physical exam on every medical patient, it is important to examine all areas where the patient complains of pain. Abdominal pain and tenderness may be difficult to diagnose; inflamed abdominal organs are tender. When the muscles of hollow organs or capsules surrounding solid organs in the abdominal cavity are overly stretched or shortened, they produce a diffuse dull pain or ache usually described as crampy. Most abdominal pain is diffuse as an organ swells and becomes sharp & localized when the abdominal lining becomes irritated or the bowel ruptures. Peritoneal pain is intense, highly specific, sharp, often described as stabbing, and presents with tenderness, guarding, or rebound pain. Referred pain occurs when nerve pathways overlap causing pain to appear at a site away from its actual cause. The abdomen is divided into four quadrants. Begin an abdominal exam in the quadrant furthest from the pain and palpate the painful quadrant last. Overlap your hands; use the top hand to push and the bottom hand to feel. Look for rebound pain by gently pressing the patient’s abdomen then releasing the pressure suddenly. If patient complains of pain upon release, the organ may be close to rupturing or recently ruptured. 
  
• Identify any urgent red flags that require a Level 1 or 2 Evacuation (see below).
  
• Identify any conditions —heart attack, asthma, diabetes— that require emergency medications and administer them.
• If NO urgent red flags exist attempt to diagnose and treat the problem or its individual signs & symptoms: nausea, pain, diarrhea, fever, etc. or begin a Level 3 Evacuation for physician evaluation.

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 Red Flags for Urgent Medical Evacuations
The urgency of an evacuation depends on the degree of involvement, or potential involvement, of any critical system. The greater the degree or potential, the more urgent the evacuation. If possible, consult with a physician. When in doubt, take them out. Diagnostic patterns for a non-urgent Level 3 Evacuation and red flags for an urgent Level 2 or Level 1 Evacuation are discussed below.

Level 3 Evacuation

• Consider a Level 3 Evacuation for patients with severe diarrhea and/or vomiting and upgrade if you are unable to keep the patient hydrated.
• If there are no red flags for an urgent evacuation (Evac Levels 1 & 2); use the diagnostic charts in the Wilderness Medicine Handbook (pp 89-90 for abdominal pain & tenderness; and, pp 84-85) and attempt to diagnose and treat the problem or its S/Sx. Begin a Level 3 Evacuation for all minor problems that are persistent, uncomfortable, and not relieved by your field treatment.

Level 2 Evacuation

• For abdominal pain, loss of appetite and fever ± non-specific tenderness and chills that is NOT accompanied by diarrhea.
• For abdominal pain and tenderness accompanied by stomach or intestinal bleeding (e.g., coffee ground vomitus or black tar-like stools).
• For abdominal pain accompanied with a positive heel-drop test.
• For pain that begins slowly and gradually gets worse over a period of days.
• For intracranial, thoracic, and abdominal pain, even mild pain, from an unknown medical mechanism in persons over 60 years old.
• For an open globe injury to the eye.

Level 1 Evacuation

• Abrupt change in mental status that does not spontaneously resolve within a few minutes or reoccurs.
• For all V, P, or U patients. Consider hypoglycemia & administering glucose.
• For pain that is abrupt, new, and severe.
• For chest pain or pressure not clearly attributable to heartburn. Consider heart attack and administering aspirin and prescribed (Rx) nitroglycerin.
• For acute respiratory distress from an unknown cause. Consider asthma and administering any prescribed (Rx) medications.
• For large amounts of bright red blood from the mouth or anus.
• For vaginal bleeding when bleeding exceeds 5 soaked maxi-pads per day.
• For severe abdominal pain with guarding. Bleeding into the abdominal cavity causes severe abdominal pain and tense (rigid) abdominal muscles. Patient typically presents on back with knees bent. Movement increases the pain.
• For abdominal pain that becomes specific or is accompanied by rebound pain. As perforation or rupture becomes imminent, pain becomes specific to one or two quadrants and/or patient shows pain on release of pressure during an abdominal exam (rebound pain).
• For abdominal pain and tenderness with the clinical pattern of volume shock.

Want more information on this and other wilderness medicine topics? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.

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