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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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. You are on a three-week canoe expedition in the boundary waters. One of your students, Ximena, approaches you before breakfast complaining of pain and swelling in her ankles; she thinks it's a reaction to the black fly bites she received a couple of days ago when she forgot to reapply DEET after swimming. Yesterday the bite sites were slightly red and itchy. This morning, upon awakening, both her ankles are swollen with red streaks moving up her lower legs. She is tired and feels sick. Her core temperature is 101º F (38.3º C). It's day 14. What is wrong with Ximena 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. You are leading for a week-long rafting trip for a drug addiction program in Costa Rica. It's 6 PM and one of your students, Amalia, does not respond to your call for dinner. A quick search finds her lying in her shelter on her sleeping bag apparently asleep. She does not fully awaken when you call her name and lightly shake her. Her breathing is slow and easy, at 8 breaths per minute and her pulse rate is 46 and regular. Her medical form shows her normal resting pulse is 78 and regular and her normal respiratory rate is 16 and easy. She is in your program for opioid abuse after getting injured in an automobile accident a year ago. What is wrong with Amalia 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. You are en route to a backcountry lean-to managed by the forest service in the summer. Although the current temperature is in the low single digits after a cold front moved in early this afternoon, the weather yesterday was warm, above freezing, with bouts of hard rain. The snow is crusty and heavy on the forest road leading to the hut. You are two days from your car and it will take another day to reach the lean-to. You are carrying two weeks of supplies and hoping for new snow and fresh tracks after you reach the lean-to. When you arrive at the forest service campground two of the shelters are occupied by a high school group who have been touring in the park the past week leaving an older, half-buried one for you and your friend. After setting up camp and eating dinner, you wander over to the high school group to say "Hi." They are starting to eat dinner when you arrive. The leader, one of the school's teachers, tells you much of their gear is frozen from yesterday's rain. You notice that a student is huddled in their sleeping bag in one of the shelters, everyone else is eating dinner. The group leader tells you the student, a 15-year-old female, was very cold when they arrived, immediately went to bed, and said she wasn't interested in dinner. While your gear is dry, you can see that many of the students' sleeping bags are frozen. The group leader is concerned about the drop in temperature and unsure how to keep the students warm at night. What can you do to help? 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. Deaths due to opioid overdoses continue to rise. Opioid abuse knows no age, race, or economic barriers; and, abuse is often hidden, making it difficult to know who is at risk for an overdose. In April 2018 U.S. Surgeon General, Dr. Jerome Adams, issued a public health advisory urging more Americans to learn to use and carry naloxone. Most states have approved Narcan® Nasal Spray for over the counter sales and publicly encourage addicts, family, and friends to carry it. Communities provide training and naloxone to police and place naloxone in public places with AEDs; some public health agencies provide it for free. Colleges and universities provide training and naloxone to staff and students. While still uncommon, opioid overdoses have occurred in wilderness settings. This begs the following questions:
What are Opioids? Heroin, morphine, codeine, and thebaine are naturally occurring opioids made from the resin of poppy plants; hydromorphone, hydrocodone, and oxycodone are derived from resin in a lab setting. Fentanyl, pethidine, levorphanol, methadone, tramadol, and dextropropoxyphene are synthetic. All opioids depress the central nervous system (CNS) and cause feelings of euphoria; when used correctly, for short periods of time, they are effective pain medicines. All are physiologically addictive. Chronic opioid users develop a tolerance for the drug and require increasingly higher doses to achieve the same level of pain control or well-being. (Note: Opioids are often mixed with other drugs for recreational purposes.) Withdrawal signs and symptoms are the result of excessive stimulus of the sympathetic nervous system and include: increased pulse rate and blood pressure, restlessness, tremors, sleeplessness, muscle and bone pain, abdominal pain, diarrhea, vomiting, sweating, and shivering; patients in acute withdrawal may become combative. As opioid tolerance increases so does dependence…and the severity of withdrawal S/Sx. An opioid overdose typically occurs when someone takes a large amount of an opioid or a drug containing an opioid, mixes opioids with alcohol, or had a recent change in their level of tolerance. Life-threatening signs and symptoms of an opioid overdose include:
What is Naloxone? Naloxone is an opioid antagonist; it binds with and blocks opioid receptor sites in the brain, reversing the signs and symptoms of an overdose. In order to be effective, naloxone must be given before the patient goes into cardiac arrest. Except in extremely rare cases when someone is allergic to naloxone, administering naloxone to a patient who is not suffering from an oipoid overdoese does no harm. Naloxone will not prevent deaths caused by other drugs: alcohol, speed, cocaine, or sedatives (e.g.: benzodiazepines like Xananx®, Valium®, etc.). While there are numerous delivery methods only two are conducive to using in a remote setting: intranasal spray and intramuscular (IM) or subcutaneous (SQ) injection. Of the two, only Narcon® nasal spray is available over the counter in most states, making the choice easy for lay people, outdoor educators, and guides. Naloxone delivered as a nasal spray or injection takes roughly 3-5 minutes to act. If there is no response after five minutes, give another dose. Naloxone is metabolized in the liver within 30-90 minutes and its metabolites excreted in the urine over the next 3-4 days. Because naloxone is metabolized faster than most opioids—especially long-acting opioids like methadone or sustained-release pain compounds—it’s vital to carry more than one dose. Patients should be monitored for 2-3 hours as further doses may be necessary to treat a relapse. Acute withdrawal symptoms are possible but rare with intranasal administration of naloxone but cause for concern should they occur as the the patient may become combative and a danger to themselves and others. Naloxone slowly loses its potency over time or if it is exposed to too much heat, cold, or sunlight. That said, using expired naloxone will not cause harm but you may need more doses to reverse the S/Sx of an opioid overdose. Ideally you should replace expired all expired drugs, and store naloxone in a dark and dry place between 80°F (25°C) and 40°F (5°C)...you want to make sure that it is easily accessible should you need it. When should I administer naloxone?
Directions for administering an intramuscular injection of naloxone Carry naloxone in a 1 ml snap-top vial (they are easier to use than a 1 ml ampoule); dose is 0.4 mg/ml. Consider carry a vial and syringe in a capped PVC pipe container; use the capped pipe as a sharps container to safely carry the used needle and syringe out of the backcountry for disposal. Use a 21 to 23 gauge needle 1 to 1.5 inches long for an adult.
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. You are a trip leader for a week-long snowshoe trip over winter break. You are responsible for a coed group of high school juniors and seniors; your assistant, Steve Hall, is a 38-year-old math teacher from the school with some outdoor experience. As you are setting up camp on the third day of the trip, you notice that Steve stops what he is doing to stretch and rub the left side of his lower back. When you ask him what's wrong, he says he thinks he strained it earlier in the day when helping one of the students put their pack on after a break. Forty-five minutes later as you are beginning to assist the students with dinner preparation, Steve says his back is hurting more and he needs to lie down. Roughly an hour later, dinner is ready and you send one of the students to get Steve. After a few minutes, the student comes running back saying Steve is curled on his side in his sleeping bag moaning in pain. You tell the students to start eating while you go and check on Steve. You find Steve in curled his sleeping bag as reported by the student. He can barely talk through the pain. Gradually you come to understand that the pain started slowly on the left side of his lower back and, over time, began to move down into his groin and scrotal area. He has never experienced pain like this before; changing his position does nothing to relieve it. His history is unremarkable. At 5:48 p.m. Steve's vital signs are: pulse rate: 92 and regular, respiratory rate: not taken due to pain, blood pressure: not taken, skin: pale, cool, & slightly moist, core temperature, 98.4º F, AVPU: awake, alert, and in extreme pain. What is wrong with Steve 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. Pathophysiology Sepsis is a potentially life-threatening complication of an infection that eventually leads to temporary or permanent organ dysfunction; septic shock is a drop in blood pressure caused by systemic inflammation and vasodilation. Sepsis and septic shock are at the far end of a continuum that often begins with a local wound or a MRSA infection, influenza that results in a pneumonia, a urinary tract infection that leads to a kidney infection, traveler’s diarrhea caused by some strains of E. coli, or from an intestinal infection that leads to a perforated bowel. While the invading organisms can be bacteria, viruses, fungi, and parasites, the most common sepsis-causing pathogens are the bacteria Staphylococcus aureus (staph), Escherichia coli (E. coli), and some forms of Streptococcus. SEPSIS PROGRESION Local Infection > Systemic Infection > Sepsis > Severe Sepsis > Septic Shock > Death The progression from a local infection to septic shock typically requires weeks, and once diagnosed, the mortality rate is 25-50% during the following month. While the immune system in healthy adults is typically capable of dealing with the index infection, the immune system of infants, immunocompromised persons, and persons 65 years old and older, may not be. In a wilderness environment where minor wounds are, unfortunately, all to common, thorough wound cleaning and subsequent monitoring are important. Local inflammation—mild pain and tenderness, redness, and warmth—are normal but should not extend more than a millimeter or two beyond the site. Increased inflammation and pus at the site after 24 hours indicate a local infection; red streaks and fever indicate a systemic infection. MRSA thrives in crowded, unsanitary conditions and outbreaks have occurred in children’s camps and on expeditions where poor personal and group hygiene was the norm. Be aware that MRSA infections—Methicillin-Resistant Staphylococcus aureus—are highly contagious and can be acquired through contact with the contaminated clothing or the skin of an infected person. MRSA bacteria may enter the body at the site of a minor wound or present as swollen, painful bumps that resemble pimples or a spider bite. This may quickly turn into a painful abscess that requires surgical draining. A few cases will continue to progress to a systemic infection, and fewer still to sepsis. Lower respiratory infections are also relatively common in the outdoors, especially on longer expeditions; fortunately most resolve with simple rest and fluids. That said, some, particularly those associated with a flu virus, may progress to a pneumonia. Symptoms of a pneumonia vary from mild to severe but typically include a dry or productive cough, fever, chills, fatigue, and respiratory distress. Some people experience a sharp or stabbing pain that gets worse with a deep breath or cough. Urinary tract infections (UTI) are relatively common among females in the outdoors and are often linked to poor hygiene and/or chronic dehydration. Treatment with antibiotics is recommended to prevent the infection spreading to the kidneys and blood. Once active in the blood, sepsis is possible. Travelers diarrhea caused by some strains of E. coli may lead to a systemic infection and sepsis, as can any intestinal infection that results in a perforated bowel: diverticulitis, appendicitis, ulcerative colitis, Crohn’s disease, strangulated hernia (which can result in poor blood flow to the intestines), peptic ulcers, etc. All require an urgent evacuation to a hospital for physician assessment and follow-up treatment; refer to the “Red Flag” signs and symptoms for an urgent—level 1 or 2—evacuation listed in our Wilderness Medicine Handbook. Sepsis is rare on wilderness expeditions for a number of reasons:
Sepsis S/Sx
Severe Sepsis S/Sx The S/Sx of Sepsis plus one of the following—which may indicate initial organ failure:
WORSENING SYSTEMIC INFECTION Systemic vasodilation + increased vascular permeability > Systemic leakage > Increased pulse & respiratory rates > Organ failure > Decreased BP > Death Treatment
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. 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. 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. 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 (ASR) and long term (PTSD) effects of stress. 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 below align with current PFA principles. As much as possible, rescuers should strive to 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. 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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Our public YouTube channel has educational and reference videos for many of the skills taught during our courses. Check it out!
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