Case Study: Sea Kayaking Slip 

The Setting

You are enjoying an amazing day of paddling on Prince William Sound in Alaska. The views have been incredible and you’ve spotted amazing wildlife on the shore. You and your buddies decide it’s time for a break, so you pull over to a nearby beach. One of your friends says she wants to get a better view of the sound, so she climbs up a small hill. On the way down, she loses her footing and you watch her tumble down the steep hill. She comes to a stop at the bottom and you immediately hear lots of moaning. You grab your first aid kit, put on your gloves, and get ready to help. 

SOAP Report

Subjective: The patient is a 28 year old female whose chief complaint is pain in the right wrist. The mechanism of injury was a 12 foot tumbling fall and the patient is currently A+Ox4. 

Objective

Patient Exam: The patient was found lying on her back. The physical exam reveals deformity and redness on the right wrist. Small abrasions were found on the face, hands and arms. No other injuries were found. The CSMs are intact in the legs and left hand, however the right wrist has reduced motion and a weaker grip.

Vital Signs

TIME	1300
LOR	A+Ox4
HR	86, strong, regular
RR	18, regular, easy
SCTM	pink, warm, dry
B.P.	radial pulse present
Pupils	PERRL
T°	Not taken

History

Symptoms:	Pain and tenderness in the right wrist.
Allergies:	The patient states she is allergic to tree nuts. She has not been exposed today, but has anaphylaxis if exposed.
Medications:	The patient carries an EpiPen for her tree nut allergy. The patient states she does not take any other medications.
Pertinent Hx:	No relevant pertinent history.
Last in/out:	The patient has had 2 liters of water, a bowl of oatmeal, and snacks throughout the day. Urine and bowel movements have been unremarkable for the patient.
Events:	The patient says she slipped on a rock while coming down the hill and felt fine beforehand.

STOP READING!

What is your Assessment and Plan? Think about this before moving on.

Assessment:

• Possible unusable right wrist injury.
• Possible spine injury.

Plan:

• Conduct a focused spine assessment. 
• Assess the right wrist for usability. Use a supportive wrap or tape if usable, splint if unusable.

Anticipated Problems: 

• If the patient has an unusable wrist injury and/or a spine injury, we’ll need additional help and supplies to get out of the backcountry. 

What Happened?

You complete your patient assessment and your friend is only complaining of pain in the right wrist. After taking a deep breath, you feel ready to conduct a focused spine assessment since you’re in the wilderness, have completed a full patient assessment, and your patient is not showing any signs or symptoms of a spine injury. You then recheck that the patient is A+Ox4, is sober, and is able to focus on the assessment. You recheck circulation, sensation and motion (CSM) in all 4 extremities, and then re-roll the patient to check their spine. You find no pain or tenderness on palpation. Based on the results of your focused spine assessment, you feel good discontinuing protection of the spine. Your friend asks if she can sit up, so you assist her.  

Next, you assess the wrist for usability. It quickly becomes apparent that your friend will not be able to use her wrist. You start looking through the gear you have in your drybag to build a splint. You remember that you want a splint that is well padded, rigid, adjustable, allows you to check the CSMs, and immobilizes the long bones above and below the injury since this is a joint injury. You’re able to use your foam sit pad, some layers, an ace wrap, and two cravats to make a great splint. 

Lastly, you irrigate the abrasions on your friend’s face, hands and arms, and cover them with a few bandages. You are very happy you brought your first aid kit along, even though you’re only on a day paddle.

Feeling proud of your assessment skills, you now begin the task of figuring out how to get out of the backcountry. One of your group members was paddling a double kayak and offers to have the patient sit in the front of their boat. This seems like a doable plan. 

After a few hours of exhausting paddling, you make it back to the car and head to the nearest clinic to have your friend’s arm assessed. 

Comments:

This scenario involved multiple elements and challenges. From figuring out how to get out of the backcountry to deciding what is needed to build a good splint, you had to make a lot of decisions and remember a lot of steps! 

Having a resource with you in the backcountry can be incredibly helpful, especially when things are going sideways. Using something like the NOLS Wilderness Medicine Field Guide can allow you to double check your work and make sure you’re not missing anything.

We encourage you to think about what you’re bringing into the backcountry, even for just a day adventure. Having supplies with you made this situation much easier.