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.

You are holed up in a snow cave waiting out a heavy winter storm at 10,500 feet in the Colorado Rockies. Your sleeping area is raised a few feet above your entrance. You have been cooking outside with your stove sheltered from the wind by strategically placed snow blocks. A ski pole poked through the roof of the cave provides much needed ventilation. To save batteries, you have been using two candle lanterns to provide enough light to read and play cards. After a day, the air inside the cave is slightly stuffy and both you and your partner have a slight headache.

What's wrong and what can you do about it? Click here to find out.

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