NOLS Wilderness Medicine Case Study 15 Answer

Case Study 15

The Answer

Assessment

Possible heat illness/exhaustion. Normal mental status suggests heat stroke is unlikely.
Possible flu-like illness.

The Plan

Rest in shade and repeat assessment, carefully exploring hydration history.
Have patient drink fluids and eat salty snacks; monitor urine output.
Make a decision on continuing hike or evacuation based on patient condition.

Anticipated Problems

Patient does not improve and we have to evacuate.

Comments

The vague complaint of “feeling lousy” could be any number of things, although the environment makes you think of heat and hydration problems. The head-to-toe didn’t reveal any obvious abnormalities. As you’ve been with this person for three days and you’ve all been diligent about hydration, you’re considering that they should not be under or over-hydrated. They look like they could be sick, but this came on suddenly and your group has been healthy on the hike. It’s low enough that altitude illness is not high on your list of possibilities, nor is a hangover. The patient is not diabetic and seems to have been eating well, so blood sugar abnormalities are not obvious.

You considered a worst case scenario of heat stroke, but note the normal mental status. Your plan is to explore the hydration history again. Assuming he is well-hydrated without confirming intake and output can lead to poor decisions and treatment plans. Three liters today might be too little today and furthermore, dehydration can be cumulative over several days. Since there are no obvious evacuation triggers, you decide to monitor the patient to see if he get better or worse.

The Tale Continues

Vital Signs

TIME 1300 1330 1400 1500

LOR A+Ox4 A+Ox4 A+Ox4 A+Ox4

HR 100, strong, regular 100, strong, regular 84, strong, regular 76, strong

RR 18, easy, regular 16, easy, regular 14, easy, regular 14, easy

SCTM pale, warm, moist pale, warm, moist pale, warm, dry pale, warm

BP strong radial pulse strong radial pulse strong radial pulse strong radial

Pupils PERRL PERRL PERRL PERRL

T° not taken not taken not taken not taken

History

Symptoms: As the afternoon progressed the patient felt better, although still tired and low on energy. Denies headache. Mental status remains normal.

Allergies: Patient continued to deny allergy.

Medications: Patient re-stated only occasional ibuprofen use and none today.

Pertinent Hx: Patient denies any ongoing medical conditions.

Last in/out: Patient has been drinking 5-6 liters of fluid daily for the past three days, eating regular meals and snacks. He states his urine volume and color has been normal.

Events: Patient denies recent illness and says he has been feeling fine.

Assessment

Possible heat exhaustion. Normal mental status suggests heat stroke is unlikely.
Possible flu-like illness.

Plan

Rest in shade and stop here for the night.
Have patient drink fluids and eat salty snacks; monitor urine output.
Make a decision in the morning on continuing hike or evacuating based on patient condition.

Anticipated problems

Patient does not improve.

Comments

Wilderness medicine is commonly low drama and routine problems: flu-like illness, mild/moderate stages of environmental problems, sore muscles, minor cuts and scrapes. Early intervention keeps these minor problems from becoming significant concerns. So much of sound wilderness medicine is also sound outdoor leadership.

When there is nothing obviously dire in the patient’s presentation, we consider the worst case, see if we can rule anything out, treat for multiple problems, and see if the patient gets better or worse. A worst case would be heat stroke, which is not apparent in this patient whose skin is not hot and who has normal mental status. The hydration history suggests that hyponatremia from drinking too much, or dehydration from drinking too little, are both unlikely.

Trends in vital signs are vital to assess. The first set establishes a baseline. Changes, or stability, are both important pieces of information. In this case the vital sign trend tells us the patient is stable and even improving. A HR that stays elevated or trends faster, with pale moist skin and perhaps a weakening radial pulse or altered mental status tells us something is going on, perhaps some form of shock. A patient who continues to complain of being weak and feeling ill is obviously not improving.

Maybe this is just a mild flu-like illness, low blood sugar, or fatigue from the heat. We often treat for multiple problems at the same time, throwing a wide net over the problem. Heat stress and possible dehydration are managed by seeking shade, resting, and supporting hydration, which also treats a possible flu-like illness. If our net doesn’t help the patient get better, we evacuate.

End of the Tale

The patient felt much better within a few hours and wanted to get on down the trail, but the group decided to move only a short distance to a nicer campsite for the night. In the morning the patient, well-hydrated, rested and fed, was able to resume the hike.

Patience with our patients is a virtue in wilderness medicine. We want to fix problems quickly, yet we often get ill slowly, and better slowly. One of the traps of the short scenarios common in wilderness medicine courses is the illusion that people get better quickly. People may be physically in wilderness, but often act like they are in a city, with expectations for quick solutions to inconveniences, let alone real problems. This group acted as if they were in the wilderness. They changed their plans, stopped the hike, rested, and cared for their companion.