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Patient Assessment:
The Key to Making Critical Wilderness Medicine Decisions

By Tod Schimelpfenig, WMI Curriculum Director
Reprinted from The Leader, Summer 2002, Vol. 17, No. 3

It's been months since you completed your Wilderness First Responder (WFR) course when you encounter two people off to the side of an Absaroka Wilderness trail. One of these folks says that the other person, who is apparently asleep, isn't feeling well. You offer to help and switch into WFR mode. Thoughts about your remoteness, the incoming weather, evacuation, communication and shelter possibilities swirl through your brain. In this leadership role you are about to make decisions that could affect the safety and well-being of the patient and your companions. The foundation of those decisions is in your patient assessment.

In your WFR, Buck taught you several pneumonics to help remember assessment points; MOI (mechanism of injury), the initial assessment sequence of ABCDE (airway, breathing, circulation, disability, environment/expose), BSI (body substance isolation), and SAMPLE (symptoms, allergies, medications, pertinent history, last intake/output, recent events). Let's take a moment to review AVPU, a reminder for assessment of a key vital sign, level of consciousness.

We begin assessing level of consciousness (LOC/AVPU) when we introduce ourselves, say "Hello," and ask if we can help. We're being polite, and we're finding out if the patient is obviously awake, asleep or possibly unconscious.

Alert

Normally we're awake (or we wake quickly from sleep), alert and we know who we are, where we are, the date, time and recent events. This is described as A (awake) A (alert) and O (oriented) times 0, 1, 2, 3 or 4 if the patient knows who they are, where they are, what date or time it is and recent events.

AAOX4 The person knows person, place, time and event.
AAOX3 The person knows person, place and time, but not event.
AAOX2 The person knows person and place, but not time and event.
AAOX1 The person knows person, but not place, time and event.
AAOX0 The person is awake and alert, but is disoriented.

Verbal

This patient is not awake and alert but responds to a strong verbal stimulus, such as the rescuer saying "Hello, how are you." If the patient does not respond, repeat louder: "Hey! Sir (or Ma'am)! Wake up!" The patient's response may be opening their eyes, talking, grunting, or moving. Higher levels of brain function respond to verbal input and lower levels to pain. If a strong verbal stimulus doesn't elicit a response, try a painful stimulus.

Pain

This patient is not awake, does not respond to verbal stimuli but does respond to painful stimuli, perhaps by moving, opening eyes or groaning. To stimulate for pain, pinch the muscle at the back of the shoulder or neck, or rub the sternum.

Unresponsive

The patient is not awake and does not respond to voice or painful stimuli.

You approach this patient, who is lying on their side.

"Hello, I'm Jane, a Wilderness First Responder. Can I help you?"
The patient opens his eyes and responds, "Yes, I feel lousy."
"OK, What's your name?"
"Bob."
"Do you know where you are Bob?"
"I'm in the Absaroka Mountains."
"Do you know what day and time it is?"
"I think it's Tuesday afternoon" (the correct response).
"What have you been doing?"
"Hiking for a few days."

Bob is awake, alert and oriented times four. He is oriented to person and place, time and recent events. You're reassured by this response, breathe a sigh of relief and proceed with a thorough assessment. You learn that Bob is uninjured, but feeling weak and dizzy. His vital signs are within normal limits and he doesn't have any significant medical history, nor is he allergic to or taking medications. Your SAMPLE questions uncover that he has only been drinking a liter of water a day, and he hasn't been eating well. You combine your WFR and your NOLS skills, make a camp, cook Bob a nice meal of macs and cheese, and encourage him to drink water. Bob feels better and sleeps well. The next morning, after a hearty breakfast, and advice from you on hydration, Bob continues on his journey.

Wild Side's regular correspondent Buck Tilton is currently on patrol with the Denali National Park rescue team. Tod Schimelpfenig most recently served as NOLS Rocky Mountain director and is now the new WMI curriculum director.


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