The Setting
You and three friends have been hiking 18-20 miles a day for three days in the desert Southwest. It’s been hard and hot as anticipated, but not scorching hot. You’ve found water every day. This afternoon you backpacked over a steep sun-drenched sandstone ridge and down into a cottonwood glade. One of your companions has been lagging behind and eventually stops and sits by the side of the trail. He looks pasty white and sweaty and says he feels awful. Your scene size-up is brief: no hazards, one patient who looks sick and sat down. You think about BSI but keep your limited glove supply in your first aid kit for now. The patient agrees to your assessment, has a sound airway, is breathing without distress, is dressed in only shorts and t-shirt, is obviously not bleeding, has a strong radial pulse, and is on dry ground in the shade on a nice warm day.
SOAP Report
Subjective/Story/Summary
The patient is a 24-year-old male who states he “feels lousy.” He has been backpacking long distances for three days in hot weather (highs in the low 90s F) and this afternoon became too weak to hike.
Objective
Position found: Patient sat down by the side of the trail. There is no mechanism for injury.
Patient Exam:
No obvious injuries were found in a head-to-toe assessment. Patient is pale and sweating. Skin is not hot to the touch and the patient has a normal mental status.
Vital Signs
| TIME | 1300 |
| LOR | A+Ox4 |
| HR | 100, strong, regular |
| RR | 18, easy and regular |
| SCTM | pale, warm and moist |
| BP | strong radial and pedal pulse |
| Pupils | PERRL |
| T° | not taken |
History
| Symptoms: | Patient states he is dizzy, nauseous, and “feels lousy” |
| Allergies: | None stated |
| Medications: | Occasional ibuprofen at 400-600mg for muscle soreness, none today |
| Pertinent Hx: | Patient denies any ongoing medical conditions. |
| Last in/out: | Patient drank three liters of fluid so far today, ate breakfast and ongoing trail snacks, urinated a light yellow urine twice today, and stated this is normal on long hikes. He had a normal BM this morning. Denies recent diarrhea or vomiting. |
| Events: | Patient has been hiking in hot dry weather for three days, 18-20 miles per day without problems. He has not fallen or suffered any injuries. |
Stop...
What is your Assessment and Plan?
Take a few minutes to figure out your own assessment and make a plan.
Don’t cheat—no reading on without answering this first!
Assessment
- Possible heat illness/exhaustion. Normal mental status suggests heat stroke is unlikely.
- Possible flu-like illness.
The Plan
- Rest in shade and repeat assessment, carefully exploring hydration history.
- Have patient drink fluids and eat salty snacks; monitor urine output.
- Make a decision on continuing hike or evacuation based on patient condition.
Anticipated Problems
- Patient does not improve and we have to evacuate.
Comments
The vague complaint of “feeling lousy” could be any number of things, although the environment makes you think of heat and hydration problems. The head-to-toe didn’t reveal any obvious abnormalities. As you’ve been with this person for three days and you’ve all been diligent about hydration, you’re considering that they should not be under or over-hydrated. They look like they could be sick, but this came on suddenly and your group has been healthy on the hike. It’s low enough that altitude illness is not high on your list of possibilities, nor is a hangover. The patient is not diabetic and seems to have been eating well, so blood sugar abnormalities are not obvious.
You considered a worst case scenario of heat stroke, but note the normal mental status. Your plan is to explore the hydration history again. Assuming he is well-hydrated without confirming intake and output can lead to poor decisions and treatment plans. Three liters today might be too little today and furthermore, dehydration can be cumulative over several days. Since there are no obvious evacuation triggers, you decide to monitor the patient to see if he get better or worse.
The Tale Continues
Vital Signs
| TIME | 1300 | 1330 | 1400 | 1500 |
| LOR | A+Ox4 | A+Ox4 | A+Ox4 | A+Ox4 |
| HR | 100, strong, regular | 100, strong, regular | 84, strong, regular | 76, strong |
| RR | 18, easy, regular | 16, easy, regular | 14, easy, regular | 14, easy |
| SCTM | pale, warm, moist | pale, warm, moist | pale, warm, dry | pale, warm |
| BP | strong radial pulse | strong radial pulse | strong radial pulse | strong radial |
| Pupils | PERRL | PERRL | PERRL | PERRL |
| T° | not taken | not taken | not taken | not taken |
History
| Symptoms: | As the afternoon progressed the patient felt better, although still tired and low on energy. Denies headache. Mental status remains normal. |
| Allergies: | Patient continued to deny allergy. |
| Medications: | Patient re-stated only occasional ibuprofen use and none today. |
| Pertinent Hx: | Patient denies any ongoing medical conditions. |
| Last in/out: | Patient has been drinking 5-6 liters of fluid daily for the past three days, eating regular meals and snacks. He states his urine volume and color has been normal. |
| Events: | Patient denies recent illness and says he has been feeling fine. |
Assessment
- Possible heat exhaustion. Normal mental status suggests heat stroke is unlikely.
- Possible flu-like illness.
Plan
- Rest in shade and stop here for the night.
- Have patient drink fluids and eat salty snacks; monitor urine output.
- Make a decision in the morning on continuing hike or evacuating based on patient condition.
Anticipated problems
- Patient does not improve.
Comments
Wilderness medicine is commonly low drama and routine problems: flu-like illness, mild/moderate stages of environmental problems, sore muscles, minor cuts and scrapes. Early intervention keeps these minor problems from becoming significant concerns. So much of sound wilderness medicine is also sound outdoor leadership.
When there is nothing obviously dire in the patient’s presentation, we consider the worst case, see if we can rule anything out, treat for multiple problems, and see if the patient gets better or worse. A worst case would be heat stroke, which is not apparent in this patient whose skin is not hot and who has normal mental status. The hydration history suggests that hyponatremia from drinking too much, or dehydration from drinking too little, are both unlikely.
Trends in vital signs are vital to assess. The first set establishes a baseline. Changes, or stability, are both important pieces of information. In this case the vital sign trend tells us the patient is stable and even improving. A HR that stays elevated or trends faster, with pale moist skin and perhaps a weakening radial pulse or altered mental status tells us something is going on, perhaps some form of shock. A patient who continues to complain of being weak and feeling ill is obviously not improving.
Maybe this is just a mild flu-like illness, low blood sugar, or fatigue from the heat. We often treat for multiple problems at the same time, throwing a wide net over the problem. Heat stress and possible dehydration are managed by seeking shade, resting, and supporting hydration, which also treats a possible flu-like illness. If our net doesn’t help the patient get better, we evacuate.
End of the Tale
The patient felt much better within a few hours and wanted to get on down the trail, but the group decided to move only a short distance to a nicer campsite for the night. In the morning the patient, well-hydrated, rested and fed, was able to resume the hike.
Patience with our patients is a virtue in wilderness medicine. We want to fix problems quickly, yet we often get ill slowly, and better slowly. One of the traps of the short scenarios common in wilderness medicine courses is the illusion that people get better quickly. People may be physically in wilderness, but often act like they are in a city, with expectations for quick solutions to inconveniences, let alone real problems. This group acted as if they were in the wilderness. They changed their plans, stopped the hike, rested, and cared for their companion.
