The Setting
You’re day hiking with two friends, Nate and Mark, on a little used trail in steep timber. It’s a cool June day with lingering snow in the shaded north-facing slope. The plan is to cover 8-10 miles, challenging your fitness and reconnoitering a possible future trip with spouses and children. The day has gone well when you hear Nate, hiking ahead of you, say something we can’t repeat in polite company. You look up and see him slip on a patch of snow, slide down slope, hit a rock, flip over, and slam pack-first into a thick old pine tree. It’s an impressive tumble.
You and Mark look around and quickly decide you can avoid the snow and descend to Nate without kicking rocks onto him. Nate has rolled away from the tree onto a flat pine needle covered bench. You and Mark arrive at his side, drop your packs, and wait for the other to do something. This void needs a leader. You step in, trying to recollect what you learned in last year’s Wilderness First Aid course. Mark kneels at Nate’s side and tells him to stop moving. You remember the souvenir patient assessment bandanna wrapped around your head. Taking a look at this helps you to focus and enter the Patient Assessment System.
SOAP Report
Subjective/Story/Summary
The patient is a 42-year-old male who tumbled about 20 yards down a steep slope, flipped once, and struck a tree pack-first. He says his left hip and elbow and right shoulder hurt, but he thinks he’s ok.
Objective
Patient Exam:
The patient rolled over once after he landed. We found him on his right side with no bleeding. We removed his pack and kept his head and back stable. Initially he would not answer our questions although his eyes were open. He does not think he lost consciousness, but he seemed stunned when we arrived at his side. Currently he is awake and his level of consciousness seems normal.
The head-to-toe revealed pain to his left hip and elbow and right shoulder but there was no obvious injury and he can move those limbs. The pain is a 4-5 on the 1-10 scale. There is no pain in his back and he can move his legs and arms, denies any tingling or odd sensations, and can feel when fingers and toes are touched.
Vital Signs
| TIME | 1300 hrs |
| LOR | awake and oriented |
| HR | 90, regular |
| RR | 20 not labored |
| SCTM | pale, warm, dry |
History
| Symptoms: | none |
| Allergies: | lots of hay fever allergies, not a problem at this time |
| Medications: | Claritin for his allergies, Ibuprofen as needed but not today, something for cholesterol taken daily |
| Pertinent Hx: | none |
| Last in/out: | 2 liters on the trail today, not thirsty, urinated 30 minutes ago |
| Events: | we have been hiking for 4 hours, Nate was not dizzy, he just slipped |
Stop...
What is your Assessment and Plan?
Take a few minutes to figure out your own assessment and make a plan.
Don’t cheat—no reading on without answering this first!
Assessment
- Mechanism for a spine injury
- Minor injury (no obvious fracture or dislocation) to hip, elbow and shoulder
The Plan
- Roll Nate onto a pad, keep him warm
- Keep spine immobilized
- Monitor and access help
Anticipated Problems
- Shock
- Weather change (we don’t have a lot of gear)
Comments
These folks are Wilderness First Aid (WFA) trained, not Wilderness First Responder (WFR). Their scope of practice is not as robust as a WFR. They have done as they were trained. They checked for life threats, identified obvious injuries, obtained a basic set of vital signs and medical history, and stabilized the patient while accessing assistance. The patient is in good hands.
The focused spine assessment, the WFR’s tool for making a decision on spine management in the scenario of a spine injury mechanism without signs or symptoms of a spine injury, is not in the scope of practice of a WFA trained in a 16-hour course. It takes additional training to be competent in this critical skill.
NOLS has conducted and published the first ever study of retention from wilderness medicine courses. This shows that our skills and knowledge deteriorate over time. We now recommend the use of a memory aid in the field. There is nothing demeaning about using a memory aid; indeed, it’s a measure of wisdom to admit that we all forget.
The Tale Continues
You log roll Nate onto a foam pad, cover him with your spare layers and elevate his legs with bent knees 6″ to make his back comfortable. Cell phone reception is good and you are able to activate the Search and Rescue (SAR) unit. You give them coordinates and a good description of your location, which is only a mile from the trailhead. You deliver your SOAP report and ask for a provider who can make a spine assessment. You tell the dispatch operator that the patient does not seem to have any serious injuries and should be able to walk.
At 1330 hours you repeat the Patient Assessment and update the written SOAP report.
Patient Exam:
The patient is comfortable on a pad on his back and has no spine pain and can move and feel hands and feet. He complains of soreness 4-5 on a 1-10 scale in left hip, left elbow and right shoulder. There is now bruising in all three places. The patient can move all these joints and there is no sign of fracture or dislocation. Currently he is awake and his level of responsiveness seems normal. He wants to get up and walk to the car.
| TIME | 1300 hrs | 1330 hrs |
| LOR | awake and oriented | awake and oriented |
| HR | 90, regular | 84, regular |
| RR | 20 not labored | 20 not labored |
| SCTM | pale, warm, dry | pink, warm, dry |
Comments:
If you are with the patient for an extended time it’s common to re-measure the vital signs. Repeating the whole patient assessment, including checking inside splints and under bandages, may reveal signs such as these bruises, which develop over time.
End of the Tale
An hour later a team of three from the local SAR unit arrive on the scene. One is a WEMT, the other two WFRs. They listen to your SOAP report. The WEMT repeats the patient assessment with no significant new findings. Nate asks to be allowed to walk. The WEMT asks him to be a patient patient and maintains spine immobilization while conducting a focused spine assessment (FSA). The WEMT finds no signs of a spine injury; Nate is alert, sober and reliable, he has good CSMx4, and denies spine pain. After checking with the patient and his medical control physician the decision is made to allow Nate to stand and walk. Nate is able to do so, albeit with a sore hip. The hike to the trailhead takes an hour. The SAR folks check Nate one more time. He’s feeling stiff and sore and looks forward of the hot tub and a massage. As you part ways, you thank the SAR folks who in turn complement your competent handling of the situation.
