WMI Case Study 
Fall from a Horse – Possible Spine and Head Injury – When to use a Wilderness Protocol

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Assessment: Patient has a mechanism for a spine injury, a possible head injury, and a bruised shoulder   

Plan: We will control the spine and monitor the patient for a developing head injury. We will RICE the shoulder. Local EMS/SAR will be contacted and we will await their arrival and support their evacuation.  We have log rolled the patient onto a foam pad and are using a cervical collar improvised from a pile sweater and head blocks from clothing filled stuff sacks to immobilize the neck.  We are monitoring for signs of hypothermia, vomiting, change in mental status, and bodily function needs.

Comments:

The focused spine assessment (spine clearing protocol) is commonly taught as a wilderness protocol. It is also used by a number of urban EMS systems.  When is it appropriate to use the focused spine assessment in an urban context, or on the local ski hill?

Focused Spine Assessment

These leaders had wilderness medical training and considered using their focused spine assessment protocol to make a decision on the need for spinal immobilization.  The patient was A+OX4, sober, without distractions, denied spine pain or tenderness and had good CSM’s in all four extremities.  In a wilderness context he would be a candidate for the focused spine assessment.  However, due to proximity to the road, these leaders decided not to do so, and instead to engage the local emergency medical or search and rescue system in the evacuation.  The leaders had a written protocol from their medical advisor for their wilderness program that supported the use of a focused spine assessment, but it was not intended by their medical director to extend to the general public or to be used in a non-wilderness context. 

The context of wilderness medicine is defined by the Wilderness Medical Society as more than an hour from definitive care.  Our advice to our WFA, WFR and WEMT students is that in non-wilderness situations we should support the practices of the local EMS system, rescue group or ski patrol. Use your wilderness medicine skills to immobilize the patient with an MOI for a spine injury and then access the local EMS system. When EMS arrives they may be able to apply a focused spine assessment, or they may need to immobilize the patient for transport.  It’s their turf and our role is to work within their system. 

The signs and symptoms of a mild head injury include:

• A brief change in LOC with a return to normal mental status.
• Short term amnesia, temporary blurred vision or “seeing stars”
• Nausea and/or isolated vomiting
• Headache, lethargy, dizziness

The treatment for a mild head injury is to monitor for developing signs of a serious head injury.  You can let the patient rest as long as you wake them periodically to assess their mental status.

The signs and symptoms of a serious head injury include:

• Obvious changes in mental status (disoriented, irritability, incoherence, combativeness)
• Unresponsiveness
• HR decreases and bounds
• RR may be hyperventilation and erratic patterns
• SCTM may be warm and flushed
• Pupils become unequal
• Blood Pressure increases
• The patient may experience a worsening headache, vision disturbances, protracted vomiting, lethargy, excessive sleepiness, ataxia and seizures.

The treatment for a serious head injury is to manage ABC’s especially the airway, to immobilize the spine and elevate the head of the litter 6-8”, to administer oxygen if available and to arrange for a rapid evacuation.

This patient has signs of a mild head injury.  Monitoring for worsening head injury and arranging evacuation is an appropriate treatment plan.

The End of the Tale

The local SAR team responded in an hour with a initial group of three rescuers.  They were followed by an additional 4 folks with a wheeled litter.  The patient was evacuated on this litter with spine precautions (the SAR team did not have a selective spine immobilization protocol), and with the assistance of the leader and the students. 

The evacuation was uneventful.  The patient continued to have a headache and complain of nausea and vomited once.  He was evaluated in the local emergency room.  He did not have a spine injury but was kept overnight for observation for a mild head injury.  

The leader and the students camped at the road head, sad they were not further in the wilderness, but happy with the experience they had gained and the help they rendered the horseman, and full of pride from the complements of the local SAR team leader. 

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