Rib Fractures
In most cases, a simple, isolated rib fracture elicits sharp, knife-like pain, and respiratory distress; however, as the patient relaxes and begins to breathe with their diaphragm, the respiratory distress subsides. Depending on the location of the fracture and it's severity, if there are multiple rib fractures especially to the same rib or ribs (flail chest), the patient may present with or develop respiratory distress due to lung damage and/or internal bleeding.

Isolated Rib Fracture S/Sx

• Sharp knife-like pain on inspiration that resolves with abdominal breathing.
• Lung damage and/or internal bleeding are possible.

Isolated Rib Fracture Treatment

• Position patient in position of comfort. Reassure & coach abdominal breathing.
• Begin a Level 3 EVAC. Depending on pain, patients may be able to self-evac; minimize patient’s work load (no/light pack). Do not bind patient’s ribs; instead, encourage them to take a deep breath every 20 minutes; both help prevent a secondary pneumonia.
• Begin an urgent, level 1 evacuation if lung damage and/or volume shock is suspected.

Multiple Rib Fractures S/Sx

• Sharp knife-like pain on inspiration that is usually not relieved by abdominal breathing; lung damage and/or internal bleeding are likely.

Multiple Rib Fractures Treatment

• Position patient in position of comfort: sitting if awake; lying on injured side if voice-responsive, pain-responsive, or unresponsive.
• Reassure & coach patient to abdominal breathe. Do not bind the patient’s ribs; instead, encourage them to take a deep breath every 20 minutes; both help prevent a secondary pneumonia.
• Begin an urgent, level 1 evacuation if lung damage and/or volume shock is suspected.

You are the trip leader for a two-week high school snowshoe trip in the Adirondack mountains of New York state. It's day four. There was six inches of new snow on the forest road at the beginning of the trip. Last night it snowed three feet and it is still snowing hard. Looking closely at your map you realize that your original route crosses a few potential avalanche paths. After talking it over with your co-leader and considering the ever-increasing snowfall, you decide to reverse your route and head back. You have no satellite or cell phone reception during the storm.

After a day of struggling through the deepening snow, everyone is exhausted and wet from either sweat or snow when you reach your evening camp. You notice that two 16 year-old girls are particularly tired and shivering.

What are your concerns and what should you do? Click here to find out.

You are a trip leader on a five-day winter break backpacking trip in Linville Gorge, NC. It's day three of the trip when the gorge is hit unexpectedly with 14 hours of freezing rain. The rocks, trails, and trees are covered with an inch of ice; numerous trees have fallen, leaving the trails littered with trees and tree limbs, further increasing the difficulty of foot travel.

You are camped at the bottom of the gorge and scheduled to be picked up at 10 AM on the fifth day. To reach the pick-up at the scheduled time, you need to hike most, if not all, of the day.

What are your concerns and what should you do? Click here to find out.

Pathophysiology
Numerous types of fungi live on and in our bodies without causing harm; they are held in check by competing bacteria and our immune system. Disease-causing fungi can be divided into two groups: filamentous fungi and yeasts. Filamentous fungi are made up of branching threads known as hyphae; yeasts are single-celled organisms. The most common fungal infections are superficial and caused by Tinea, a filamentous fungi and Candida albicans, a yeast. Heat, humidity, immunocompromised states, long term antibiotic use, diabetes, and steroid therapy predispose people to both types of fungal infections. Fungal infections are more common in the summer and exerted by wearing synthetic clothing and sweating.

Tinia Infections
Tinea infections are caused by a group of fungi (ringworm) that live on keratinous structures and invade dead layers of the host's skin, hair, and nails; the transmission routes are direct contact with an infected person or animal or with contaminated soil. Clinically, tinea infections are classified according to the body region involved/infected: tinea capitis (scalp), tinea corporis and versicolor (trunk and extremities), tinea manuum and tinea pedis (palms, soles, and interdigital webs), tinea cruris (groin), tinea barbae (beard area and neck), tinea faciale (face), and tinea unguium (nails).

Candida Albicans (Yeast) Infections
Candida albicans skin infections may closely mimic tinea crurisare but are usually moister, more inflammatory, and associated with satellite macules, pustules, and scales. Unlike Tinea, Candida may also infect the mucus membranes of the mouth, vagina, penis, and eye. These infections are red, itchy, moist and often associated with a yeasty odor and a white cheese-like discharge. Most mucosal infections result from long-term antibiotic use.

Prevention

• Avoid communal baths.
• Keep potentially affected areas (between toes, genitals, skin folds) clean and dry.
• People participating in contact sports are pre-disposed to tinea infections.

Assessment

• Both Tinea and Candida skin infections present with localized itching and red rash. Candida may exhibit satellite lesions and pustules.
• Vaginal Candida infections typically present with white, cheesy discharge and yeasty smell.
• In the mouth, Candida shows up as thick, white lacy patches on the tongue, lips, gums, or inside of the patient's cheeks. The lesions are painful and swallowing may be difficult.
• Candida infections on the scrotum often present as red bumps.

A 35 year-old man hits a tree while skiing out of bounds. Bill is awake, alert, and reliable but fails your focused spine assessment due to cervical pain (8) and tenderness with no neurological deficit. Ski patrol is available to assist with transport via a Cascade toboggan and snow mobile. Estimated arrival to scene is 45 minutes and transport to an ambulance is expected to take another two hours with arrival at a local hospital in another hour. Total response and transport time to the hospital is estimated at roughly ± 4 hours. The outside temperature is 22º F and the patient has additional thermal layers in his pack. His remaining injuries are compatible with self-evacuation.

Geoff Jones, 52, is swept away in a medium sized soft snow avalanche while skiing in the backcountry. He travels approximately 400 feet and is recovered partially buried. He is awake, alert, and reliable with cervical spine pain and tenderness. He reports a tingling, electric-like pain in his right arm when his neck moves; he cannot distinguish between pinprick pain and light touch on his right hand; and, there is noticeable weakness on his right side when executing the motor exams on his hands. His remaining injuries are compatible with self-evacuation. There is no cell service and no one in the group is carrying bivy equipment with them or on their snowmobiles six miles away. Help is roughly twelve hours away. It's 3:30 pm in mid-January; sunset is within the next hour. The current air temperature is 21º F. Clouds are moving in, the wind is picking up, and it looks like it's going to snow.

Should you keep Geoff quiet and immobile and go for help or begin a self-evacuation? Click here for answers.

You are leading a week-long backpacking trip for a local high school. During the night a cold front with high winds passed through breaking tree limbs and blowing down trees. A six-inch limb split off an overhead tree and landed on a student tent, hitting one of the students a glancing blow on his head while in his sleeping bag.

When questioned, James said the storm had just woken him up when  something hit the tent, collapsed it, and hit him in the head through his sleeping bag. The commotion woke his tent mate and together they managed to push the branch off the tent. They came to get you because James said he had a headache and a big lump on his head. Other than the lump and a headache (3), James says he feels okay. He has no spine pain or mid-line spinal tenderness, normal motor and sensory exams on his hands and feet, and no tingling or electric shooting pain in his arms or legs. His skull feels intact beneath the swelling.

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