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Blog

Wilderness Medicine Case Study 75

12/3/2019

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Returning to the snowmobile you left parked on WA Route 20, you stop to watch a pack of snowmobilers highmarking on a bowl above and to the south of your route. Just as you finish your break, one rider and sled reach the apex of their attempt, roll over, and release an avalanche. Both the rider and his machine disappear. As the snow settles, you see a portion of his sled sticking out of the snow; you turn your transceiver to receive, and you join the rest of the pack to begin a search for the buried rider. One rescuer gets a signal near the machine, and the digging begins.

Roughly ten minutes later, you uncover Sam's face. There was a small sickle-shaped air pocket around his mouth and nose. He is unresponsive, not breathing, and he has no pulse. Elapsed time is less than twenty minutes. You give a couple of quick rescue breaths as others free his chest and begin chest compressions.

During the second round of compressions, Sam abruptly starts breathing and awakens shortly afterward with no memory of the event. Once Sam is completely free of the snow, you do a complete patient assessment. Sam is 42 years old and appears to be in good physical health; his SAMPLE history is unremarkable. He complains of a mild headache (3), a slightly sore chest (2), severe pain in his right knee (8), mild pain in his lower left ribs (2), and a sore neck (2). Your physical exam reveals an angulated, swollen, and extremely tender right knee with no range of motion and good distal CSM, and tender lower-left ribs; he is able to take a deep breath without pain. His focused spine assessment shows a tender neck C-3 through C-7 with normal motor and sensory exams. At 2:35 pm, Sam's pulse rate is 82 and regular and his respiratory rate is 20 and easy; both within his normal self-reported range. His temperature was not taken; oxygen saturation and blood pressure were also not taken. He is wearing an insulated snowmobile suit and says he is warm.

What is wrong with Sam and what should you do? Click here to find out.
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Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.

Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
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Pre-trip Medical Forms: Types, Formats, and Pros & Cons

11/5/2019

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Introduction
Trip medical forms can reduce program liability and help administrators and field staff prevent injuries and illnesses. In most cases, prevention is accomplished through appropriate screening of participants and modifying the structure of a trip by adjusting the trip’s activities and routes to accommodate individual medical conditions or concerns. The type and format of a trip medical form affects the quality of information received and the ability of program administrators and field staff to prevent and treat injuries and illness in the field.

Why require medical forms for trips?
  • Accident/illness prevention via screening
  • Accident/illness prevention via course design/structure by program administration (preferred and requires time to prepare/adjust)
  • Accident/illness prevention via individual & group management by field staff (may be necessary if discovered during the trip). If a physical disability or an ongoing medical problem are discovered during the trip, it may be necessary to assess both the group's and the individual's abilities in light of the newly discovered disability or problem as well as the proposed activity progression and environment before continuing with the trip as planned.​

How is client medical information collected?
Medical information may be collected orally from the client or via a written medical form. Collection is more effective if all involved—client, guide/instructor, healthcare provider, etc.—know why the information is important and how it will be used.
There are two basic types of written medical forms: Those completed by a health care professional (physician, PA, or nurse), and those completed by the client (self-reporting).
Medical forms completed by a health care professional—especially if they are the client's personal physician—tend to be the most accurate. Those completed by professionals with little or no previous knowledge of the client—college or university clinics, for example—can miss some conditions if the providers rely heavily on patient self-reporting.
Self-reporting may be oral or written. Oral self-reporting typically takes place the day of the trip, often as clients are ready to embark on the trip. The accuracy of oral self-reporting is questionable as it's easy for clients to forget something important or simply not mention it for fear they will not be permitted to go on the trip. Clearly written self-reporting forms are better than oral self-reports.
Written forms—regardless of whether completed by a healthcare professional or by the client—tend to be more effective when a combination of check boxes and open-ended questions are used. For example, here's a question with Yes/No checkbox followed by a series of open-ended questions asking for more information:

"Are you taking any prescription medications?" (Yes/No)

"If you answered "yes" to the above question please:
  • List the medication, dose, the reason for taking it.
  • Are you current with each medication?
  • If you plan to carry this medication with you on the trip, are there any storage requirements we need to be aware of?

If client medical information is so important, why don't all outdoor programs collect it?
  • Personal health information is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). While there are hundreds of ways that HIPAA rules can be violated, the most common with respect to outdoor programs is an organization's failure to control access to a client's personal health information (PHI) this includes the online transmission of PHI data. While a HIPAA violation is easy to avoid by simply not requesting clients to complete a written medical form, the lack of personal health information may have significant consequences in a remote setting if clients or guides are not prepared to address an emerging medical problem. The Family Educational Rights and Privacy Act of 1974 (FERPA) prohibits student trip leaders—but not professional trip leaders—from receiving medical information of other students. In some cases, a FERPA violation can be avoided if the student contractually waives their FERPA rights for the purpose of attending a student-led outdoor trip.
  • Forms completed by a healthcare provider may cost the client additional money. As such, they are typically reserved for longer, more remote trips where the medical form is part of an overall admissions process. Once received, each form is reviewed by a trained person who may contact the individual or their provider for additional information. Outward Bound and NOLS are two organizations that require prospective students to meet with their personal physician and have them complete the organization's medical form as part of their admissions process. Some colleges and universities require trip participants to go to the college or university health system to have a medical form completed.
  • Simple checklist forms with a few open-ended questions are easy to complete and, as such, are often used by outfitters on day or weekend trips that will have access to 911 systems. Clients are typically asked to complete them the day of the trip or bring the completed form with them.
  • More detailed forms tend to yield more usable information. Usable meaning being able to guide a potential client to the trip that best suits them or adapting an existing trip to meet their medical and/or physical needs. The earlier a medical form is received by an outfitter, the more time they have to respond.
As mentioned earlier, it is extremely important for outdoor programs and outfitters to accurately describe the trip and its associated hazards and to share how a client's Personal Health Information (PHI) will be used. Consider integrating PHI information into the program's release form to obtain permission to treat the client should it become necessary during the trip, permission to allow the program/outfitter to share and transmit PHI information with guides etc. for the protection and safety of the client during the trip, as well as release the organization from any known and unknown hazards.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
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California & Washington State Epinephrine Laws and WMTC Epinephrine Certification

10/1/2019

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Washington State Epinephrine Law
WMTC is recognized by Washington State Department of Health as an authorized Epinephrine Auto-injector & Anaphylaxis Training Provider. The law permits healthcare providers to prescribe epinephrine auto-injectors to certified lay providers and REQUIRES the lay provider to report the use of epinephrine within five days of an incident via the departments Epinephrine Auto-injector Incident Reporting Survey online at https://fortress.wa.gov/doh/opinio/s?s=EpinephrineAutoinjector

California State Epinephrine Law

WMTC is an approved California state epinephrine auto-injector training program. WMTC students issued a WMTC Epinephrine card after April 29, 2019, may apply for a California epinephrine auto-injector certification card and should visit https://emsa.ca.gov/epinephrine_auto_injector/ for information and an application form.
​

Applicants must include a WMTC epinephrine certificate with their application; the certificate is different from the WMTC epinephrine card issued at their course. To obtain a WMTC epinephrine certificate for the State of California application please email office@wildmedcenter.com. Put CA State Epi Certification in the subject line. In the body of the email include:
  1. The type of WMTC course taken: WFA, WAFA, WFR, WEMT, or Recert­.
  2. Student's name as it appeared in the course registration.
  3. The location of the course.
  4. The course sponsor.
  5. The dates of the course.
  6. The name of the instructor.

​Upon receipt of the email, our office will verify the student's WMTC epi certification using the above information and send them a pdf file of the certificate for them to print and include in the application for California State Epinephrine Certification; this service is fee of charge to all WMTC graduates. We will also send each student a pdf file summary of our auto-injector curriculum and CA Auto-injector laws. NOTE: California Epinephrine Certificates expire two years from the date a student graduated from their WMTC course.

Businesses and other organizations may obtain a prescription and stock epinephrine auto-injectors if they employ or utilize a volunteer that is an EMSA-certified lay rescuer. To receive the epinephrine auto-injector(s), the business must take the EMSA certification card to a physician to receive a prescription. The prescription can then be filled by a pharmacy. A business that stocks epinephrine auto-injectors is required to keep records, create and maintain an operations plan, and report to EMSA when an epinephrine auto-injector is used.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
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Drowning

9/3/2019

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Introduction

The Act of Drowning
Contrary to how it is often depicted in movies, the act of drowning often goes unnoticed. There appear to be three separate actions or body positions people adopt when confronted with the possibility of drowning. Depending on their swimming ability, injuries, or illnesses, some will progress through all three of these stages, while others will not.
  1. Those who have some swimming ability (perhaps due to a flotation device) often call for help and are able to actively aid in their rescue. They may be vertical (treading water) or horizontal (actively swimming). 
  2. Those who are unable to help themselves assume a vertical position in the water with their arms flailing laterally in a futile attempt to keep their head above water; most do not kick with their legs. They will alternately sink below the surface of the water and reappear. Their mouths are not above the surface of the water long enough for them to speak or breathe and they will quickly sink, usually within 30-60 seconds. They are unable to wave, call for help, or actively aid in their rescue.
  3. Those who are unresponsive tend to float on or below the surface of the water.   
​Drowning
In drowning, the victim is submerged under or immersed in water and requires rescue or assistance; not all drowning victims are unresponsive during their rescue; they may be awake, voice responsive, or pain responsive.

Drowning is a process with three possible outcomes:
  1. Death
  2. Survival with brain damage
  3. Survival without brain damage
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Ultimately, drowning patients die from a lack of oxygen. Our lungs cannot extract oxygen from water.

Anatomy & Physiology

The lungs are essentially tubes that either contain air or blood.
  • The air tubes (bronchioles, bronchi, trachea) terminate in small air sacs (alveoli) where the gas exchange takes place.
  • The tubes and air sacs are attached to one another by elastic connective tissue and surrounded by a membrane (pleura).
  • The walls of each alveolus are one cell thick and fragile.
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  • Type 1 alveolar cells are curved and comprise the majority of the surface area of each alveolar sac.
  • Type 2 alveolar cells are squarish and release surfactant. Surfactant covers the interior surface of each alveolus and lowers the surface tension where the air interfaces with the alveolar wall; it acts to prevent alveolar collapse at the end of each expiration.
  • Large white blood cells (macrophages) roam the interior of the alveoli; they attack and destroy any foreign debris or organisms.

Pathophysiology

Contrary to popular belief, very little water enters the lungs of most drowning victims:
  • The majority of non-fatal drowning patients aspirate less than 30 ml (or 1 oz) of water.
  • During the autopsy of fatal drowning patients only 1-2 ml/kg of water is typically found in in the lungs; For example, a 200 pound (or 90 kg) person will only aspirate between 90-180 ml (or 3-6 oz).

                                              Why so little?

When water enters the drowning victim's mouth and nose, their epiglottis immediately closes and covers the trachea and they reflexively swallow. As a result, literally liters of water has been found in the stomachs of fatal drowning victims. This reflexive protection typically remains intact until the patient becomes runs out of oxygen and gasps for air or becomes unresponsive, and even then, little water actually enters the victim's lungs.

Unfortunately, it doesn't take much aspirated water to cause problems and interfere with the gas exchange in the alveoli. Patients who have a pulse and are breathing after rescue or resuscitation, may develop respiratory complications severe enough to cause death minutes to hours after the incident if they aspirate enough water.
Aspirated water irritates the lining of the lower airway and is absorbed by the alveolar capillaries. As the process unfolds it contributes to hypoxemia (low blood oxygen):
  • Irritating the lining of the bronchioles causes inflammation and bronchial constriction (similar to asthma).
  • Disrupting and washing out the surfactant eventually leads to alveolar collapse.
  • Damaging the alveolar-capillary interface causes inflammation and subsequent dilatation of the pulmonary capillaries causing plasma to leak into the alveoli.
  • As surfactant mixes with the plasma, foam is created and issues from the patient’s mouth and nose.
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  • Oxygen and overall metabolic requirements in some patients may be lowered by immersion in cold water (< 68° F/20° C) due to core hypothermia or a diving reflex and preserve brain & organ function for 30-90 minutes.
  • The amount of central nervous system damage—due to lack of oxygen and corresponding acidosis (high carbon dioxide levels)—will determine the patient’s ultimate outcome.
  • If the period of oxygen loss is limited, the acidosis minimal, or the victim rapidly develops core hypothermia (or a diving reflex), the damage may be limited and the patient may recover with no or only minor neurologic sequelae.

Basic Life Support Assessment & Treatment

  • If the patient is not breathing, begin rescue breathing; focus on getting oxygen to the patient’s brain ASAP. Start with five rescue breaths; patients typically respond after a few breaths; trained rescuers should consider rescue breathing while the patient is in the water. The epiglottis is attached to the tongue—combine the head-tilt, chin-lift, & jaw thrust maneuvers when rescue breathing to ensure airway is open.
  • Begin immediate CPR if the drowning victim is pulseless and not breathing if they have been submerged for less than 30 minutes in water warmer than 43º F (6º C) and less than 68º F (20º C) or those submerged for less than 90 minutes in colder water. Start with five rescue breaths and continue alternating 30 compressions and two breaths. Less than 10% of drowning patients need defibrillation.
  • Use supplemental oxygen if it's available and you are trained in it's use. If the patient is V,P,U assist their breathing using a bag valve mask or connect oxygen to the oxygen port in a simple face mask. If the patient is awake, use a non-rebreather mask or nasal cannula.
  • Consider stopping resuscitation efforts after 30 minutes.
  • If the patient is VPU and trauma is a potential MOI, support the patient's spine during rescue and transport; however, spinal support should not delay resuscitation efforts.
  • Anticipate foam issuing from the patient’s the mouth and nose (right) or vomiting during resuscitation: Breathe through the foam; roll and suction any true vomit or water.
  • Treat for hypothermia as necessary.

Follow up Assessment, Treatment, & Evacuation

  • Continue to treat for hypothermia as necessary.
  • Be prepared for vomiting.
  • Rule out traumatic problems as usual in awake patients.
  • Even with poor water quality, patients who self-rescue are typically at low risk of developing pulmonary edema (0.6-5%). If a patient is asymptomatic with no S/Sx of respiratory distress and a normal mental status, no evacuation is needed.
  • Begin a Level 3 evacuation for patients who present with mild S/Sx post rescue that do not immediately resolve—mild respiratory distress, rales, abnormal mental status—or those that present with foam in their upper airway. Monitor for six hours; if S/Sx worsen, upgrade to a Level 2 evacuation.
  • Begin a Level 2 evacuation for all awake and asymptomatic patients after a successful resuscitation (CPR or rescue breathing); upgrade a to a Level 1 evacuation if the patient presented with foam in their upper airway and presented with or develops a severe cough, moderate or severe respiratory distress, or low blood pressure.
  • Although poor water quality increases the chance for pulmonary edema and subsequent respiratory infections in non-fatal drownings, prophylactic antibiotics are not recommended.  Antibiotic treatment should be considered if the patient is symptomatic—fever, increased sputum, and abnormal lung sounds—days after the initial event.

Interested in learning more about wilderness medicine? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.

Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
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Assessing Behavioral & Psychological Distress

9/3/2019

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Introduction
Stress is inherent in outdoor trips and activities. People can often adapt to mild stress and return to their baseline relatively quickly; however, chronic, moderate, or severe stress may overwhelm an individual’s coping mechanisms and result in a mental health problem. S/Sx include increasing inability to cope with the challenges of the trip, activity, or group. The graphic below depicts the different levels of distress and their associated evacuation levels with respect to a mental health event
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To help avoid a mental health crisis on expeditions or trips, it is critical to identify and evaluate an individual’s distress early. Check in with the group or individuals daily or after potentially stressful events as part of the expedition culture and stress management. Consider using colors as a tool to help group members self-identify their current stress level.

     Green = no distress
     Yellow = distressed and actively compensating or coping
     Orange = overwhelmed having difficulty compensating or coping
     Red = severely overwhelmed and no longer compensating or coping

People who self-identify as distressed, overwhelmed, or severely overwhelmed need support and should be encouraged to seek out and speak with staff or the trip leaders privately. Similarly, if staff or trip leaders observe behaviors that indicate a participant may be in distress or crisis, they should speak privately with the individual. Depending on the participant’s story and presenting S/Sx, they may  elect to support them in the field or begin an evacuation.   

S/Sx of Potential Behavioral & Psychological Distress
  • Does not participate in group discussions or decision making.
  • Has little or no interest in maintaining friendships or participating in daily activities.
  • Withdrawn, seeks solitude whenever possible.
  • Shunned by group members.
  • Constantly fidgets, appears anxious or afraid.
  • Appears easily annoyed, irritable, or unusually critical.
  • Appears distracted, speaks unusually slowly, or rambles.
  • Appears sad or unhappy, exhibits episodes of crying.
  • Poor appetite or overeating.
  • Shares beliefs that other group members find unusual or bizarre.
  • Sudden or noticeable change in daily functioning.
  • Exhibits disruptive behavior.
  • Unusually emotional.
  • Exhibits on-going conflict with group members or staff.
  • Exhibits on-going irrational behavior.
  • Complains of numerous unexplained physical ailments.
  • Exhibits an inability to cope with daily problems and activities.
  • Self-identifies as distressed (yellow), overwhelmed (orange) or severely overwhelmed (red).

Support Guidelines
Participants who are in distress but actively compensating (yellow) may remain in the field if supported and their daily functioning monitored. Support participants by:
  • Creating a calm, safe environment
  • Carefully listening to their story and concerns
  • Involving them in problem-solving and self-care
  • Helping them build stronger relationships with staff or trip leaders and group members
  • Working with them to create practical step-by-step solutions with measurable (visible) outcomes

Evacuation Guidelines
  • If any of the following conditions are met, the participant should be evacuated and seen by a mental health professional; closely monitor them during evacuation.
  • Field staff—or those providing patient care­—are uncomfortable with the situation.
  • Patient exhibits an on-going or growing inability to cope despite interventions and support.
  • Patient’s behavior negatively affects other trip members’ experience.
  • Patient is prescribed Rx meds for a mental health condition and is not taking them.
  • Patient appears to have the potential to harm themselves or others.
  • Patient wishes they were dead or expresses suicidal thoughts.
Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.

Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
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Community Emergency Response Teams

9/3/2019

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(What are they and should I join one?)
With the worldwide increase in natural disasters, wilderness medicine graduates are uniquely poised to help their neighbors in the event of a local disaster. Communities in all 50 states have organized Community Emergency Response Teams (CERT). CERT members are volunteers, and teams are structured so that local managers have the flexibility to adapt the program and their training to the specific needs of their community. The concept originated with the Los Angeles City Fire Department in 1985 and went national through the Federal Emergency Management Agency (FEMA) in 1993. Contact your local fire, police, or sheriff department for more information or visit the CERT website.

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Wilderness Medicine Case Study 74

8/6/2019

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You are part of a search and rescue team looking for survivors a day after a devastating wildfire passed through your town. It's been raining non-stop for the past 12 hours making your task more difficult. Mud slides have closed a number of roads slowing evacuation and exacerbating the entire situation.

As you walk the shoreline of one of the nearby lakes, you see someone waving in an attempt to attract your attention from an island roughly half a mile from shore. Borrowing an aluminum rowboat from one of the burned-out cabins, you and your partner row to the island. Once there, you are confronted by a 32-year-old mother who is wet, shivering, and seeking help for her six-year-old daughter, Jolene. Jolene is huddled in a leaky, make-shift shelter, swathed in a wet blanket. She responds to your questions with short, mumbled phrases. Her mother, Trish, reports that they fled the fire by swimming to the island yesterday, that both she and Jolene are uninjured, and that they have had no food since early yesterday. Trish said she had to swim with Jolene most of the way. The water temperature is in the mid-60s F. It's now 4:30 pm and the rain is not letting up. You are in communication with Incident Command via satellite phone.

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

Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.

Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
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Death in the Field

7/2/2019

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(What to do when someone dies in the backcountry.)
Deaths in the backcountry are rare, exactly how rare is up for debate. Much depends on how you define backcountry and where you get your numbers (outside of the National Park Service, accurate statistics are hard to find). That said, a few hundred people appear to die each year while recreating in the outdoors. Given the number of people who play outside annually, statistically, death is pretty rare. While the order often changes annually, the top ten causes of death in the backcountry appear to be:
  1. Falls
  2. Drowning
  3. Avalanche
  4. Heart Attack
  5. Hypothermia
  6. Heat Illnesses: heat stroke, exertional rhabdomyolysis, exertional hyponatremia (low sodium)
  7. Lightning
  8. Infectious disease (typically transmitted by biting insects)
  9. Anaphylaxis
  10. Wild animal attacks

So what should I do if I'm with a person who is dying?

There is no single answer that applies to all people other than support their process to the best of your ability. For many, this means holding their hand and simply being present. For some, it may include praying with or for them. If the person is awake, it may mean taking notes to share with relatives and friends. The specifics vary from individual to individual.

How do I know when a person is dead?

They will not have any signs of life: no pulse at their carotid artery, no chest rise, and no air coming from their mouth or nose. Over time their body will cool until it reaches the ambient air temperature and rigor mortis and liver mortis will set in.
Rigor Mortis: When energy is no longer being produced, muscles contract and stiffen beginning with the small muscles of the face, neck, arms, and shoulders and gradually encompassing larger muscles until the person's body is completely stiff. Rigor is typically fully set within eight hours and remains in place for roughly eighteen hours before reversing itself to pre-rigor status, starting with the large muscles.
Liver Mortis: When a person's blood stops circulating after death, gravity causes the red blood cells to settle leaving dark "bruising" in areas of the patient's body that are in contact with the ground. The process begins roughly thirty minutes after death and is fixed after approximately six hours.

What should I do after a person is dead?

Keep in mind that your first priority is yourself and the living members of your party. Make sure everyone is safe. Then, if possible, note the GPS coordinates of the body's location and notify the local authorities via radio, cell phone, satellite phone, or other communication device and follow their instructions. If the dead person was your patient, complete a SOAP note. If they were a client or student, also complete your program's accident/incident report form. Take pictures of the site and body, especially if the mechanism was trauma, and do your best to preserve the scene for the authorities; most states prohibit moving a dead body from the scene of the accident without the authority of the coroner. Of course, some scenes cannot be preserved due to weather or terrain. If you can't contact and receive direction from local authorities and find you must leave the scene, your photos become evidence and part of any subsequent investigation. If you decide to leave the scene and the body, do your best to protect the body from scavengers and clearly mark its location both visually and on a map. Although rare, some expeditions have decided to transport the body of the deceased out of the backcountry. Treat the body with respect and be sensitive to the cultural mores of the deceased and those around you.

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Wilderness Medicine Case Study 73

6/4/2019

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You are leading a three-week summer backpacking trip for 18-21 year-old college students. While on a day hike to a local summit on day 13 of the trip, one of your students, Geoff, falls and cuts his leg on a sharp rock. There is not much bleeding and he can bear weight and walk with minimal pain. You are roughly a mile from your campsite with two days left until your next resupply.

What should you do? Click here to find out.

Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.

Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
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Wilderness Medicine Case Study 72

4/22/2019

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You are on a 6-day preseason guide training trip for a commercial river company operating on the Colorado River in the Grand Canyon. There is a party on the 3rd evening of the trip and many of the guides are drinking. When you head for bed around 10 pm there are still a few souls by the fire. An hour and a half later you are awakened by a drunken guide and asked to examine a 28 year-old male trainee who they cannot arouse.

You find Jim lying on his side on a sleeping pad near the fire. He is unresponsive with slow, irregular breathing; his pulse rate is 36 and regular, his skin is pale and his nail beds are blue-tinged. The night is slightly cool, likely in the mid-60s °F but it's warm by the fire where Jim is lying. You remember seeing Jim with a beer in hand but no one can remember how much he drank or if he had some of the whisky that had been passed around. Going through Jim's personal belongings reveals a bottle with a number of unidentified tablets.


What is wrong with Jim and what should you do? Click here to find out.
Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.

Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
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