Wilderness Scenerio - C-Spine Injury w/ Nausea & Vomiting

[Mountain Res-Q]

NOTE: This is in no way a divulgence of a real life scenario.

You are the Medical Team Leader for a Wilderness SAR Team. At 0800 you are paged out for a possible spinal injury at a backcountry camp (elevation 7000). Pretty remote. Drive time from main population center: 1.5+ hours on mountain highway and dirt roads to the trailhead. 30-45 minutes hike to the camp.

Your teams inital response assembles together and are briefed. This is a 12 y/o male that was jumped on by another youth and hit his head last night. Complained of neck pain initially and has been vomiting and nauseous all night long. He is part of some oganized summer camp. The camp has sent in one of their Nurses to the pt. and it is believed at this time (without very good communications with the RP) that you will need to hump it in, evaluate the pt., probably board him, and carry the pt. out. Your initial response is the Sheriff's Deputy assigned to SAR and 4 team members, including yourself. Level of training? You have 1 Medic, 1 EMT, and 2 First Aiders. You can choose to be the Medic or EMT for the scenerio, depending on your level of training... just we aware that it won't matter, becasue SAR is BLS-level equipped only. An additional response of SAR folks is expected (2-4 rescuers). You have also request that the Forest Service send out an engine crew for manpower (~4 FF's). An ALS Ambulance is also being dispatched out.

You get at the trailhead and are met by two members of this backpacking group. New details emerge and you are advised that they were participating in "trust exercises" (you know, fall backwards... I'll catch you) and the pt. hyper-extended his neck in the processes. He has been in pain all night, localized to the upper back and radiating up the neck. He is currently lying supine, with 2 nurses (unknown if they are CNAs or MCNs - you know how that goes) attending to him; and they do not want to move him until the "Wilderness EMS Experts" evaluate him... but they believe that he has a serious spinal injury. The trail is mild to moderate in difficulty, crosses a 20 foot stream, and (according to the RPs) the pt. can not walk it ("NO WAY!"). The Forest Service Engine Crew is 25-20 minutes out. The additional SAR resources and the Ambo are 35-45 minutes out. Horses and ATVs are not advised. A Helicopter can be requested if needed, but shorthauling is not advised at this point due to the location; and the closest suitable LZ could be miles away. Based on what you know... what do you do? How do you respond; with what and who? What plans are you formulating to "save this kid"?

I say "at this point, based on what you know" because like all good calls... things are not always as they appear on inital report.

So... continuing...

You have initiated your initial plans of attack in this scenerio. In my case, hypothetically, it consisted of sending in the Medic and EMT (with BLS equip)to evaluate and keeping the FAers at the trailhead to await additional resources and to standby on additional equipment... a plan that was revised about 15 minutes in to the hike, when the RPs stated that the pt. would be totally unable to move or walk anywhere. At that point the folks at the trailhead were advised to start hiking in c-spine gear, backboard, and a stokes.

That second team, soon joined by the FF's and other SAR folks, was cancelled on the trail and asked to standby their location about 20 minutes later. WHY?

Medic and EMT arrive on sceen and find an 18 y/o (not 12 y/o) lying supine on a foam pad. The two nurses (sure ) are "forcing" the adult to reamin still and to not move his head at all. They have a BP cuff permanently attatched to his arm and a thermometer strip fastened to his forhead. They have 2 pages of 15 minute vitals. All normal. The medic and emt evaluate...

pt. is A+Ox4. No LOC.
vital normal and stable
pt. denies neck pain.
pt. complains of lower back pain, difused to the flanks, and not midline.
pt. denies and nausea or vomiting

hmmm... could any thoughts of a helicopter flight to a pediatric facility have been premature? ^_^

The pt. has been "immobilized" for 18 hours after packing a heavy pack for miles the day before. Yes he hyperextended his neck and it was sore for a hour... but was fine thereafter...

What to do now? Helo, Mutual Aid, wheeled stokes, ropes work, swiftwater team... or a kick in the azz and a "Go dirrectly back to school, do not pass go" for our 18 y/o CNAs (I don;t know their age, really).

 

[Summit]

Medic and EMT arrive on sceen and find an 18 y/o (not 12 y/o) lying supine on a foam pad. The two nurses (sure ) are "forcing" the adult to reamin still and to not move his head at all. They have a BP cuff permanently attatched to his arm and a thermometer strip fastened to his forhead. They have 2 pages of 15 minute vitals. All normal. The medic and emt evaluate...

pt. is A+Ox4. No LOC.
vital normal and stable
pt. denies neck pain.
pt. complains of lower back pain, difused to the flanks, and not midline.
pt. denies and nausea or vomiting

hmmm... could any thoughts of a helicopter flight to a pediatric facility have been premature? ^_^

The pt. has been "immobilized" for 18 hours after packing a heavy pack for miles the day before. Yes he hyperextended his neck and it was sore for a hour... but was fine thereafter...

Awesome. Diffuse lower back pain with no compromise sounds like a sore muscle problem from his pack and/or how he was laying for the last 18 hours. I'd go through the Nexus c-spine clearing protocol (if allowed), repalp the back, and report all findings to medical control and ask to walk him out... unless he wants to refuse care since he is 18.

All units not on scene may stand down.

 

[Afflixion]

Came into this one kind of late so I'm cheating a tad.

You only need four people to do a manual litter carry though any extras are great seeing as this is a 30-45min hike on moderate terrain I'd venture a guess at no more than 5Km distance. I'd bring a Talon II Liter, and a back board plus an aidbag. Hold off on calling in medevac until the pateint can be fully evaluated as I can think of very few situations why anyone would call in a helo prior to PT contact, also I'm not sure about civilian helo's but the UH60s around here will only state they have a flight time of three hours. So any delay's or hiccups and you may be out one helo and will have to defer care even longer. If it was serious trauma any level 1 or 2 trauma centers around my area will accept a peds Pt.

Upon making Pt contact determine the true c/c and MOI, go from there. If the Pt truly has any C-spine compromise board and haul out. Seeing as you said it was an 18 y/o Pt with a c/c of lower back pain who strained his neck with his pack and has since had the pain recede I would get a true temperature other than the little forehead strips, assess for further injuries depending on the finding of any other significant injuries explain the Pt the situation at hand and see if he would like to terminate medical care, If not dependent on protocols have him walk out at a nice and slow pace, see about getting an ATV as close as possible to help alleviate some of his pain.

 

[Mountain Res-Q]

Okay... so end result...

Medic evaluated as stated above. Once ruling out a spinal injury (as much as is possible without radiographs) he asked the pt. if he would like to try sitting up and then standing. No issues what-so-ever. In fact when asked how he felt following standing for the first time in 18 hours, the pt. breathed a sign of relief and said, "Oh god, that feels so much better." Additional incoming resources were advised to remain at their locations along the trail. 45 minutes, and with assistance, the pt. walked his way out w/o his pack weighing him down. Basiclly we took every available SAR member in county, one of only 7 in county Forest Service Engines, and one of only 5 ambos in county out of service and way out of position for a probably strained muscle in the neck that lasted only 1 hour, but was complicated by the fact that he was restrained by the overzealous all night. Anyone that has ever backpacked knows how sore you can get after a full day of hiking around (especially if you are not experienced). Now combine that with being immobilized for 18 hours... you think you are going to be a little painful? Just goes to show, that the initial dispatch report is often so far from reality...

12 year old was jumped on last night. Has had neck pain, nausea, and vomiting all night long...

VS

... 18 year old who hyperxtended his neck. Sore neck for 1 hour. No other complaints except a sore lower back from the hiking followed by inactivity...

Oh, and on a side note, when approaching that stream mentioned, the pt. was apprehensive about getting his feet wet, so the Medic said jokingly, "Would you like me to carry you?"

"Yes, would you?"

And would you believe it... our medic put the 18 y/o on his back and carried him across the creek! When they got back to the trailhead and the medic told everyone that... OMG there was nothing anyone could do to contain the laughter. The Medic has been in EMS for 20 years, but is on probation as a newbie (<12 months) on the team. He might get a gold star on going above and beyond, but will never live it down.

I KNOW: The end result is somewhat of a dud... but I like seeing everyones response to the initial reports. Sounded serious...

 

[Owenscott]

As stupid as this sounds .. it is proly more fun than a man down call thats really a vomiting and diarrhea homeless person lying in the street.

Fresh air and a nice hike.

 

[mycrofft]

The initial report is invariably* wrong (measured against what you find):.

1. Reporter was wrong initially.
2. Condition changed between intial report and arrival.




*3. Can be right only if the reporter got it wrong, but the situation turned into what was initially/erroneously reported. Generally occurs when a report of "not breathing and no pulse" was initially sent but there actually were faint VS's, and either CPR was started and obliterated the VS, or no resuscitation was attempted and the pt died.