Case Study: Chest Injury with Fall

The Setting

You are on a climbing trip in Red Rocks, Nevada. You’ve spent the last week dialing in your climbing, swapping beta with new friends at the crag and soaking up the desert sun. Today, you decide to take a break from long routes and focus on bouldering. 

You’re chalking up, eyeing a new problem, when a sudden commotion breaks the calm about 300 feet/100 meters away. A voice cuts through the air, “Does anyone know first aid?”

This feels exactly like a WFR scenario and without hesitation, you grab your first-aid kit and move towards the voices, already in scene size-up mode as you approach.

SOAP Report

Subjective: The patient is a 20-year old female whose chief complaint is pain in the ribs. The mechanism of injury is a 10-foot fall while bouldering, landing on the patient’s right side. The patient is currently A+Ox4. 

Objective

Patient Exam: The patient is found laying on the ground on her right side. The physical exam reveals bruising and tenderness on the right rib cage. There is a small abrasion on the patient’s right arm and hand. Circulation, sensation, and motion (CSM) are intact in all extremities.

Vital Signs

TIME	1645
LOR	A+Ox4
HR	88, strong, regular
RR	24, regular, labored
SCTM	pink, warm, dry
B.P.	radial pulse present
Pupils	PERRL
T°	Not taken

History

Symptoms:	Pain on the right rib cage. The patient is also complaining that she feels short of breath.
Allergies:	Pineapple (none consumed today), seasonal allergies
Medications:	Daily multivitamin, Zyrtec as needed for seasonal allergies and for pineapple ingestion.
Pertinent Hx:	None.
Last in/out:	The patient has had breakfast, lunch, snacks, and water throughout the day. Urination and defecation are unremarkable.
Events:	The patient’s hand slipped while bouldering and she fell approximately 10 feet.

What is your Assessment and Plan? Think about this before scrolling down.

Assessment

• Possible right-sided chest-wall injury
• Possible lung involvement (pneumothorax) based on shortness of breath
• Abrasions to right arm and hand
• Possible spine injury 

Plan

• Complete a full patient assessment and then conduct a focused spine assessment if appropriate. 
• Place the patient in the position of comfort and monitor her breathing. Encourage the patient to take deep breaths.
• Clean and bandage abrasions on the patient’s right hand and arm. 
• Consider evacuation if respiratory status worsens. 

Anticipated Problems: 
Increasing respiratory issues complicating evacuation.

Comments

• Chest injuries range from relatively minor rib fractures to severe, life-threatening injuries to the lungs. Chest injuries are particularly concerning because they can impair respiratory or cardiovascular function. Treatment options in the backcountry are limited, so as a Wilderness First Responder, your priorities are to recognize the injury, assess whether breathing or circulation is compromised, and make an informed decision about evacuation.
• Treatment principles include stabilizing the injured area. Placing the patient in a position of comfort, sealing open wounds, or considering a sling and swathe are all options. We want to support the patient’s breathing by encouraging them to take deep breaths. We should monitor all patients with chest injuries for increasing shortness of breath–and if we see that, evacuate! 
• Signs and symptoms of rib fractures include: point tenderness, anatomical splinting, pain on inspiration, shallow breathing, and shortness of breath during exertion. 
• Signs and symptoms of a lung injury include: shortness of breath, especially at rest, pain and tenderness, wounds, bruises, deformity or instability of the chest wall, and elevated heart rate, respiratory rate, and pale/cool/clammy skin. As things get worse, the patient may have respiratory distress, subcutaneous emphysema, diminished breath sounds on the injured side, worsening vital signs, cyanosis, jugular vein distention, and tracheal deviation. 

What Happened? 

Her worsening presentation raises concerns, and you know it’s time to get this patient to the hospital. You are worried that this patient doesn’t just have a chest injury, but underlying lung injury. You place a call to 911, sharing your location and the status of the patient. You’re about a half a mile from the nearest road, and with the help of some other climbers, start moving the patient towards the road.

EMS intercepts you as you’re walking. You give a quick patient report and then breathe a sigh of relief. The EMTs commend you on your recognition of the shortness of breath and working to get the patient out of the backcountry quickly.