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WMI Case Study: Shock vs. Stress
The Setting
There you were, hiking through the San Juan Mountains in Colorado, when suddenly there appeared a rider on a pale horse galloping across a meadow. You watch apprehensively and try to remember something you read about pale horses. This passes as you become focused the beauty of the horse and rider when the horse stumbles and falls on its front legs. The rider pitches over the shoulder of the horse, lands on their back, tumbles on the ground, gets up and runs a few steps before finally collapsing in a heap.
You start to run to the scene before your friend says “Slow down! Scene size-up!”. This kicks in your WFR response and you survey the scene and see that the horse is long gone. You approach the one patient, open your first aid kit, put on your gloves, introduce yourself, and start your assessment. Your friend holds her head, while you assess level of responsiveness. Her airway is clear and her breathing, while fast, appears adequate and unlabored. Your blood sweep doesn’t find anything, and you find a fast radial pulse. The weather is warm and the ground dry, so you decide you don’t need to move her right away. You roll back on your heels, take a deep breath, check in with your friend, and proceed with your assessment.
SOAP Report
Subjective
The patient is a 25 yr old female whose chief complaint is abrasions on the right upper back and shoulder area. We witnessed the patient being thrown from a galloping horse, land on her back tumble once, rise to her feet, run a few steps, then collapse. We were at the patient’s side within 2 minutes.
Objective
Patient Exam: Patient was found on her back. The head-to-toe exam revealed a 6” by 6” abrasion over her right scapula without point tenderness. She has good CSM x4 and normal ROM in her right shoulder. She does not think she lost responsiveness. She denies spine pain. No other injuries are found.
Vital Signs
TIME |
1530 hrs |
1545 hrs |
1630 hrs |
LOR |
A+Ox4 |
A+Ox4 |
A+Ox4 |
HR |
120, regular, weak |
98, regular, weak |
88, regular, strong |
RR |
24, regular, shallow |
22, regular, shallow |
14,regular, easy |
SCTM |
Pale, Cool, Clammy |
Pale, Cool, Clammy |
Pale, Warm, Dry |
BP |
Radial pulses present |
Radial pulses present |
Radial pulses present |
Pupils |
PERRL |
PERRL |
PERRL |
T° |
Not taken |
Not taken |
Not taken |
History
Symptoms: |
Patient is anxious and nauseated. |
Allergies: |
Denies. |
Medications: |
Denies. |
Pertinent Hx: |
None. |
Last in/out: |
Patient reports normal urine and bowel movement today, ate lunch and drank 2 liters of water today plus some tea. |
Events: |
Denies any dizziness/other symptoms prior to fall from horse. |
What is your Assessment and Plan?
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