Wilderness Medicine Case Study 6

You are snowboarding in the backcountry with one of your close friends, Joe, in roughly two feet of new powder on a 35º timbered slope. The trees are Lodgepole Pines with trunk diameters varying between six and ten inches. Some are closely spaced. Your friend chooses a rather tight line and takes off. Unfortunately it's a bit too tight, and he crashes into an eight-inch tree hitting his head—he's not wearing a helmet—and injuring his arm. When you finally reach him, he is partially buried upsidedown in a tree well and struggling to release his bindings with his left arm. He has a two inch gash across his forehead over his left eye that, while not deep, is bleeding freely.

As you approach, you ask him to stop struggling and then free him from his board, and help him into a sitting position. After asking him to hold a trauma dressing to his forehead to stop the bleeding and then move forward with his assessment. Joe tells you he feels sick and might vomit, can't move his right arm, and that both his right shoulder and wrist hurt. He estimates the pain in his shoulder is a three and his forearm a six. He confirms that he has no allergies, is not taking any medications, has indeed been drinking water and is not dehydrated (his urine was light yellow at the top of the run). He admits to having been hospitalized for a concussion a few years ago when he totaled his car. He tells you he didn't "black out" when he hit the tree and proceeds to describe his fall in detail.

Upon exam, his right forearm is tender and while he can move the fingers of his right hand, it hurts quite a lot and he is unable to hold onto a one liter water bottle due to the pain in his forearm. The laceration on his forehead has stopped bleeding and upon close inspection is more a scratch than a serious wound. His right shoulder is sore but he can move it without pain.

By now, twenty minutes have passed and his arm, although throbbing, doesn't hurt quite a much (3 on the 10 scale) as long as he supports it against his chest. He also says his nausea is gone and he feels better. His pulse is 68 and regular, his respirations 16 and easy, the skin on his face and hands is a bit pale and cool (it is cold out after all), and he is able to easily carry on a discussion with you regarding his injuries. He says his back doesn't hurt. While he is able to resist pressure applied to his ring and index finger equally on both hands, the fingers of his right hand are significantly weaker than those on his left even with his hand supported. His feet show no weakness when asked to push down or pull up. He has a no spine tenderness and no shooting or electric-like pain.

What are his current problems, anticipated problems, and your treatment plan? You and Joe are about two miles from your vehicle. 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.