 It's the end of the summer and you are paddling a shallow, rocky Class II rapid with a couple of your SUP friends. Partway through the rapid Rosa's board abruptly stops on a submerged rock launching her over her board and onto some exposed downstream rocks; she landed on her left shoulder and helmet. Rosa is unable to use her left arm during the rescue. Once on shore, she is able to describe her accident in detail and says her left shoulder hurts a lot (8) and she can't move it without extreme pain.  You carefully remove her lifejacket and paddling shirt to get a good view of her shoulder (see photo); running your fingers gently along her left clavicle, you note some mild crepitus. Rosa also complains of a slight headache (2) and feels a bit out of it; there is a chip out of her helmet. On exam she has no spine pain or tenderness, normal sensory exams on both hands and feet, and normal motor exams on her feet; however, both motor exams in her hands show clear weakness on her right side and she has an electric-like tingling that shoots down her right arm when she moves her head. Her pulse and respiratory rates are normal, and she is breathing easily. 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.
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