# Summer Marathon Hypothermia



## AllGoode (Sep 22, 2016)

It's mid-June, around 1030. You and your partner are running a first aid standby station at Mile Marker 17 of a mountain marathon. The morning was a bit chilly, but it is quickly climbing to the day's high of 80 degrees F. It's clear and sunny now, but there are clouds on the horizon. Your station is situated at about 8,000 ft above sea level.

As runners begin passing your station, you see two people approaching your station. One is a mid-30s male who appears to be in pain- he is limping slightly. He tells you that his plantar fasciitis is acting up, and he would like to sit down while he waits for his brother to pick him up in a car. He also asks for some water and ibuprofen, which you instruct him to take from your stand-by box (protocols do not allow you to dispense medication, but patients can take what they want.)
The other runner is a mid-30s female complaining of fatigue. She had oral surgery 1 week before, and says she hasn't completely recovered. She appears to be in good spirits, and wants to help hand out water and Gatorade until her husband can pick her up.

You and your partner busy yourselves helping the nearby water station and keeping an eye on the 2 runners waiting for pickup. After ~20 minutes, a late 53 y/o female approaches your station. She complains of dizziness, and shows slight SOB, which resolves itself after a few minutes of rest. The dizziness persists though, even following a couple cups of Gatorade and electrolyte candies (at her request.) She also begins to complain of cold, so you fetch her a blanket and continue to talk to and monitor her (on orders from OLMC) while your partner tends to other runners. 

While talking to the patient, you're able to gather a history. She ran another marathon 2 weeks earlier, at sea level in her hometown. A couple days after the first marathon, she came down with a bad case of strep, which she took a week's course of unknown antibiotics for. She flew out to your city for the marathon just the day before, and hadn't yet adjusted to the altitude. At the last marathon, she said she had "issues with dehydration," citing "overhydration" as the cause.
She reported no allergies to medications, and was only taking Celexa for a chronic anxiety disorder.

After you finish your history, you are sitting with your patient when you and your partner receive a report of a collapsed runner about 50 meters up the course from your station. You ensure that your current patients are stable before running to assist your partner. The collapsed patient is a mid-20s F, who suffered serious leg cramps and "just decided to lay there for a bit" to recover. She is A/Ox3 and reports no injury secondary to the fall. You and your partner assist her back to the station, where she drinks some Gatorade, eats some candies, and denies further treatment before continuing the run. You radio ahead to Mile Marker 18 and give them her bib number, just to keep an eye on her.

Upon returning to your station, you and your partner switch off duties. He sits with the SOB patient, who reports still being "chilly," despite being wrapped in a blanket. She also is experiencing depressed thoughts, feeling that she "failed the marathon."

You continue to monitor the other patients and assist other runners with minor issues. Shortly, the other 2 patients are picked up by their family members.

After a further 15-20 minutes, your partner calls you over. The SOB patient has started to shiver violently and is developing cyanosis around her mouth and fingertips. You quickly take a set of vitals and radio OLMC. OLMC decides that 911 is not necessary at this point, and suggests that we transport her to his station at the end of the marathon in a personal vehicle, which is against protocols AND state law. You decide not to risk your licenses, and continue to monitor the patient. Her vitals are as follows:
HR 70, RR 16/adequate, BP 110/80. 

10 minutes later, her vital signs have not changed significantly, but she is showing AMS- namely, having trouble remember exactly where she is.

What do you do?


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## AllGoode (Sep 22, 2016)

Forgot to mention- Throughout the process, she is becoming cold to the touch.

Also, as you are on the radio with OLMC, it begins to rain heavily.


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## Summit (Sep 22, 2016)

First, I put on 02.

N: Temperature? Pupils? Slurred speech? Balance issues? Veritgo? headache?
R: Do I have a pulse ox? Breath sounds? Any crackles?
C: Pulse rate regular, auscultate hear any funky beats gallops rubs murmurs? Chest pain/pressure/back pain? Do I have an EKG, and if not does the pulse ox have a pleth I can interp?

Any other pertinent medical history or medications?
When did she arrive at altitude? At what altitude did she sleep? Does she smoke? When did she last pee and what color/any abnormality?

DDx:
Acute Mountain Sickness with profound Hypoxia
AMI
HAPE
Pneumonia
Hypovolemia and Electrolyte Imbalance
Hypothermia


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## DesertMedic66 (Sep 22, 2016)

To make it easier on other here is the relevant info:
It's mid-June, around 1030. You and your partner are running a first aid standby station at Mile Marker 17 of a mountain marathon. The morning was a bit chilly, but it is quickly climbing to the day's high of 80 degrees F. It's clear and sunny now, but there are clouds on the horizon. Your station is situated at about 8,000 ft above sea level.

A late 53 y/o female approaches your station. She complains of dizziness, and shows slight SOB, which resolves itself after a few minutes of rest. The dizziness persists though, even following a couple cups of Gatorade and electrolyte candies (at her request.) She also begins to complain of cold, so you fetch her a blanket and continue to talk to her and monitor her.

She ran another marathon 2 weeks earlier, at sea level in her hometown. A couple days after the first marathon, she came down with a bad case of strep, which she took a week's course of unknown antibiotics for. She flew out to your city for the marathon just the day before, and hadn't yet adjusted to the altitude. At the last marathon, she said she had "issues with dehydration," citing "overhydration" as the cause. She reported no allergies to medications, and was only taking Celexa for a chronic anxiety disorder.

After a further 15-20 minutes, your partner calls you over. The SOB patient has started to shiver violently and is developing cyanosis around her mouth and fingertips. You quickly take a set of vitals and radio OLMC. OLMC decides that 911 is not necessary at this point, and suggests that we transport her to his station at the end of the marathon. Her vitals are as follows:
HR 70, RR 16/adequate, BP 110/80.

After 10 minutes the patient starts to become altered.


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## luke_31 (Sep 22, 2016)

DesertMedic66 said:


> To make it easier on other here is the relevant info:
> It's mid-June, around 1030. You and your partner are running a first aid standby station at Mile Marker 17 of a mountain marathon. The morning was a bit chilly, but it is quickly climbing to the day's high of 80 degrees F. It's clear and sunny now, but there are clouds on the horizon. Your station is situated at about 8,000 ft above sea level.
> 
> A late 53 y/o female approaches your station. She complains of dizziness, and shows slight SOB, which resolves itself after a few minutes of rest. The dizziness persists though, even following a couple cups of Gatorade and electrolyte candies (at her request.) She also begins to complain of cold, so you fetch her a blanket and continue to talk to her and monitor her.
> ...


I'm going with possible hypoxia secondary to altitude sickness.


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## zzyzx (Sep 23, 2016)

8000 ft doesn't seem very high for HAPE. Altitude sickness should take a while to progress to that stage anyway.
Is she actually cyanotic due to hypoxia? What is her SpO2? Do we hear crackles?


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## EpiEMS (Sep 23, 2016)

OP, I take it we don't have trending vitals?
How about breath sounds?


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## Summit (Sep 23, 2016)

zzyzx said:


> 8000 ft doesn't seem very high for HAPE. Altitude sickness should take a while to progress to that stage anyway.


It would be a rare case of HAPE at that altitude, but not impossible. Acute Mountain Sickness would not be rare at 8000ft. We don't know how long she has been at altitude, or how high she has been, only that she is now at 8000ft.



> Is she actually cyanotic due to hypoxia?


Hypoxemic hypoxia is the most likely explanation for the cyanosis . Why is she hypoxic? Is it just the altitude?


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## Carlos Danger (Sep 26, 2016)

Flew from sea level to 8000 ft the night before, probably already dehydrated and still sick, then enagged in high intensity exercise? Sounds like a perfect setup for AMS.


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## AllGoode (Sep 27, 2016)

Sorry for the delay! My computer took a crap on me, and I just got a new one.



Summit said:


> First, I put on 02.
> 
> N: Temperature? Pupils? Slurred speech? Balance issues? Veritgo? headache?
> R: Do I have a pulse ox? Breath sounds? Any crackles?
> ...



You don't have access to O2, EKG, a thermometer, or pulse ox.
Your volunteer service is trying really really hard to not be bad, but it's kind of struggling, tbh.
Pupils are PERRL, speech is slow, but not slurred. Balance is not an issue. Headache is present and described as her "whole head."
Breath sounds are clear.
Upon auscultation, heart sounds good. No gallops, rubs, murmurs, or other fresh funky beats.
No chest or back pain/pressure.

Pt reports no other pertinent medical history, and insists she is only on her anti-anxiety medication. She arrived at altitude the night before, and slept in a hotel at ~7000 ft. Most recent urine output was this morning, and it was a "healthy light yellow" color.


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## Summit (Sep 27, 2016)

AllGoode said:


> You don't have access to O2, EKG, a thermometer, or pulse ox.
> Your volunteer service is trying really really hard to not be bad, but it's kind of struggling, tbh.
> Pupils are PERRL, speech is slow, but not slurred. Balance is not an issue. Headache is present and described as her "whole head."
> Breath sounds are clear.
> ...



Since the patient is shivering violently, I'd apply blankets, heat packs, get rid of wet clothes, and give warm sugary liquids (assuming your OLMC is OK with that) until the ambulance arrives.

Now call an ambulance that can actually provide some medical services.  You can't really do anything for this patient.

This hypoxemic patient likely has Acute Mountain Sickness that is exacerbated by the shivering (possibly mild hypothermia) and she needs immediate O2, a warm environment, and further evaluation since even basic diagnostic equipment is not available at your aid station.


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## AllGoode (Sep 27, 2016)

You remove the clothes you can and wrap her several blankets. You radio OLMC for an ambulance transport (you don't have cell reception) are are told that a bus will get to you in 60 to 90 minutes.

Given the extended time you'll be with your patient before she can get to definitive care, will you do anything different? How will you manage both her and any other incoming patients during that time?


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## Summit (Sep 27, 2016)

60-90 minutes for an ambulance and no other aid station has any O2 or diagnostic tools that they can bring to you?

Well guess what the top 3 treatments for altitude illness are:
1. Descend
2. Descend
3. Descend

Get someone to drive the cyanotic shivering altered patient to a lower altitude in a car with cranked heaters where the ambulance can rendezvous.

You are not equipped to assess or intervene above the first aid level, so leave you partner to attend to completely minor ailments coming by your station tell them to keep handing out the gatorade since they cannot provide anything besides bandaids and blankets.


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## johnrsemt (Oct 31, 2016)

I have worked mini marathons that had a 30 minute wait for transporting EMS in a major city;   I can totally believe 60-90 minutes in a rural mountain area.  

 Call for a bird


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## Summit (Oct 31, 2016)

johnrsemt said:


> I have worked mini marathons that had a 30 minute wait for transporting EMS in a major city;   I can totally believe 60-90 minutes in a rural mountain area.
> 
> Call for a bird



You think this patient needs HEMS and a $15,000 bill??


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