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.

Human health is linked to the health of the environment, including its plants and animals (yes, insects are classified as animals: Kingdom Animalia > phylum Arthropoda). Infectious diseases in humans are caused by viruses, bacteria, parasites, or fungi, and transmission is via one of four routes:

1. Direct human to human transmission is often via contaminated body fluids: fecal matter, saliva, respiratory droplets, vaginal fluids, sperm, and blood (HIV/AIDS, tuberculosis, measles, STDs).
2. Direct animal to human transmission is typically via insects and mammals (rabies). Indirect, vector-borne transmission between humans and humans is usually insect- (malaria, dengue fever, yellow fever) and water-borne (cholera, Giardia).
3. Indirect water-borne infections are usually transmitted between humans via ingested contaminated drinking water or food, or through immersion (Leptospirosis, Schistosomiasis).
4. Indirect, vector-borne transmission between humans and mammals is usually via insects (bubonic plague, Lyme disease) or the urine and feces of infected rodents (Hantavirus).

Each pathogen, animal vector, and host has an optimal climate in which they thrive with warm, moist temperate, subtropical, and tropical environments being the best. Global warming has increased, and will continue to increase, both temperature and precipitation worldwide leading to a proliferation of many infectious diseases. While this trend—the increase in infectious diseases—is predictable, the exact type and location of an emerging disease is not. It’s likely you will be exposed to an infectious disease where there is no historical data. To this end, you should take care to protect yourself by ensuring good personal and expedition hygiene, taking precautions against insect-borne diseases (see this blog article for details), and avoiding potentially infectious animals and their habitat. Keep in mind that although the Centers for Disease Control (CDC) and the World Health Organization (WHO) are monitoring the situation worldwide, (and it is worthwhile to visit their sites to see if the area you live, or intend to visit, is endemic to a specific disease) specific outbreaks are impossible to predict. Be cautious and take precautions.

Pathophysiology
While posterior hip dislocations are somewhat common in head-on motor vehicle accidents and occasionally occur in elderly people with prosthetic hip joints during a minor slip or fall, they are quite rare in a wilderness environment. Most posterior hip dislocations require a significant traumatic MOI and many patients die from internal injuries to the pelvis, abdomen, chest, and head. Greater than 50% of patients have long-term disability after reduction. The femoral head is highly vascular and may die if not quickly reduced. Posterior hip dislocations are increasing along with the popularity of extreme sports; one study indicated that snowboarders were more likely to suffer a posterior hip dislocation than skiers.

The hip joint is a ball-and-socket synovial joint: the ball is the femoral head, and the socket is the acetabulum. The adult hip is quite stable. As such, knee and lower leg injuries are often seen in conjunction with posterior hip dislocations. Due to the potential for significant complications, an attempt should be made to reduce posterior hip dislocations in the field.

Posterior Hip Dislocation Signs & Symptoms

• Patient presents on back or side with hip slightly flexed and the leg on the affected side shorter and rotated inward.
• Moderate to severe pain; associated nerve injury and loss of nerve function is possible.
• Patient may have fractures to the knee, patella, femoral head, neck, shaft, or socket (acetabulum).

Posterior Hip Dislocation Treatment

• If the leg on the side of the dislocation has no significant fracture, one rescuer stabilizes patient’s hips while the second squats with arms crossed under patient’s knee and lifts, using their legs, until femoral head relocates.
• If reduction is successful, there is no nerve damage, and no indication of internal injuries, begin a Level 3 Evacuation.
• Begin a Level 2 Evacuation for patients with an unreduced posterior hip dislocation; death of the femoral head and permanent nerve damage may occur anytime within the following 24 hrs without reduction.
  

While mountain biking down a steep single track your friend catches his front wheel and is thrown forward with his bike. During the fall the handlebars smash into the left side of his chest. Asa has difficulty sitting up and catching his breath, and appears to have injured his left wrist. After assisting him to a sitting position and coaching him to breathe with his abdomen, his respiratory distress appears to resolve. During your physical exam, he reports a sharp pain (7) in the ribs on his lower left chest when he tries to take a deep breath. While his left wrist hurts (4) and has a slightly decreased ROM with good distal CSM, it appears weak: Asa is unable to easily hold and lift a full 1-liter water bottle. His helmet is cracked, he reports feeling a bit woozy, and has a headache (4); the remainder of his physical exam is unremarkable. With abdominal breathing, the pain in his ribs is manageable (3). 20 minutes after his accident his pulse is 94 and regular and his respiratory rate is 22 and remarkably easy; he reports his normal pulse rate is in the mid-60's and he doesn't know his normal respiratory rate. While awake, he still feels a bit "out of it." A focused spine assessment reveals cervical pain and tenderness at C-7 with no shooting pain and normal motor and sensory exams.

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

While skiing back to your vehicle after a day of touring in the backcountry, your friend skis directly into a 10-inch lodgepole pine at a moderate rate of speed. When you reach her, she is out of breath and struggling to sit up. You carefully assist her to a sitting position and begin your assessment. Jenny's breathing quickly returns to normal. She tells you she got the wind knocked out of her and the right side of her chest is sore (2); on exam, her chest is slightly tender. She did not hit her head. Her pulse and respiratory rates are normal. A focused spine assessment reveals no spine pain, tenderness, or shooting pain and normal motor and sensory exams. Jenny doesn't think she is badly injured and is ready to continue skiing, albeit slightly slower and under better control.​

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

While on a day tour in the backcountry, one of your snowboarding friends landed on their right shoulder after grabbing some air off a terrain feature. Jose says his shoulder hurts (6) and he doesn't want to move it. Removing his outer and inner layers, you take a quick look (see photo below), and then carefully replace his clothing. He did not hit his head. After roughly ten minutes the pain in his shoulder abates to a mild, deep throbbing (4) and