The Setting
Five days into sea kayaking with friends in Prince William Sound, Alaska, you feel lousy; some diarrhea, some vague abdominal cramping, not much appetite. You assume it’s a touch of the flu and don’t say anything. The next day you feel better and paddle all day.
That night you wake with the worse abdominal pain you have ever experienced. You endure it quietly and it subsides after 30 minutes. At breakfast you tell your companions about it. The Wilderness First Responder (WFR) in the group begins a series of questions, which he writes into a document he calls a SOAP report. You don’t think you’re very ill, but he’s your friend, so you allow him the chance to do his “patient assessment.”
SOAP Report
Subjective/Story/Summary
Patient is a 26-year-old male whose chief complaint is, “I don’t feel great, but I’ve felt worse.” He appears pale, with normal mental status, and can walk. He states he has been feeling poor for the past two days with occasional diarrhea. He has been able to paddle his sea kayak on several long days. Last night he had 30 minutes of the “worst hard cramping pain he has ever experienced.” “I have a new 10 on a 1-10 scale.” He also reported his “belly was hard as a rock”. The episode subsided and the patient was able to sleep the remainder of the night.
Objective
Patient Exam:
Patient denies any recent injury and we have been together and have not witnessed any injury. He refuses a head-to toe exam, but agrees to an abdominal exam. He has some tenderness throughout his abdomen, no localized pain, but sharp pain in his lower right belly upon a tap on his right foot.
Vital Signs
| TIME | 7/23 8:30 AM | 7/23 9:30 AM |
| LOR | A+Ox4 | A+Ox4 |
| HR | 90 strong, regular | 94 strong, regular |
| RR | 15 regular, easy | 15 regular, easy |
| SCTM | pale, warm, dry | pale, warm, dry |
| B.P. | strong radial pulse | strong radial pulse |
| Pupils | not taken | not taken |
| T° | 98.4°F (36.8°C) oral | not taken |
History
| Symptoms: | At present he has constant and dull generalized abdominal pain that is a 2 compared to last night’s 10. States he has general feeling of being “sick”. |
| Allergies: | Denies |
| Medications: | Has been taking 400mg ibuprofen 4x a day for the past week for shoulder aches. |
| Pertinent Hx: | None. Patient has his appendix. |
| Last in/out: | Has been well-hydrated with clear yellow urine past several days. Drank several cups of water this morning, no BM. He ate a light breakfast. |
| Events: | Feeling ill past several days. |
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 gastroenteritis
- Possible appendicitis or other bad abdominal problem
The Plan
- Convince the patient to be evacuated.
- Arrange the evacuation with our marine band radio.
- Monitor vitals.
Anticipated Problems
- Gastroenteritis worsens into a debilitating illness.
- Abdominal pain returns.
Comments
This is a true tale. This group of friends was sea kayaking. One became ill and the WFR in the group was very concerned about the episode of localized pain during the night and argued that it triggered one of the evacuation guidelines in his Wilderness Medicine Field Guide. Using OPQRST to evaluate the pain he found:
- Onset: over several days with an acute episode last night.
- Provoked and Palliated: by nothing obvious.
- Quality: “hard cramping.”
- Region: abdomen, no radiation.
- Severity: A “10”, at present is a “2.”
- Time: The pain episode lasted 30 minutes, the overall illness three days.
Generalized abdominal complaints are common in backcountry settings. Most of these are gastroenteritis, uncomfortable but not urgent, yet some could be a more serious problem that is beyond the skills and experience of a WFR to evaluate. These difficult cases need to be seen by a physician, but sorting which episodes of belly pain can stay in the field and which ones need to be evacuated is not easy. Our approach, as lay wilderness medicine practitioners, is to perform a thorough assessment, review the information, and use an abdominal pain evacuation protocol to make a sound decision. NOLS Wilderness Medicine’s suggested evacuation guidelines for abdominal pain are based on expert opinion and have served NOLS instructors well as guidance for this decision.
NOLS’ suggested evacuation guidelines for abdominal pain are:
Gastroenteritis with:
- Persistent or worsening abdominal pain over 24 hrs, spiking fever, bloody diarrhea, or dehydration.
- Inability to tolerate any oral fluids more than 48 hours, especially if accompanied by diarrhea or vomiting.
Abdominal pain with:
- Duration longer than 12 hours.
- Localized pain, especially with guarding, tenderness, distension, or abdominal rigidity.
- Peritoneal signs (movement pain or pain with foot strike).
Associated s/s:
- The signs and symptoms of shock.
- Blood in the vomit, feces, or urine.
- Nausea, vomiting, or diarrhea persisting for longer than 24 to 72 hours.
- A fever above 102°F (38.8 °C).
- Signs and symptoms of pregnancy.
The Tale Continues
The WFR argued that the severe localized pain last night warrants an evacuation. The patient was reluctant to leave the trip and asked that they not use their marine radio to arrange an evacuation. He thought the episode was over and he was feeling better; however, he agreed to the group beginning to paddle back toward the nearest town, just in case.
They broke camp and started the paddle. Initially the patient felt fine, and paddled with strength, but after a few hours he began to feel ill and developed abdominal pain. As they paddled swells, the pain worsened with every bump of the kayak until he was obviously uncomfortable and vomited his breakfast, without blood. His friends said, “enough is enough” and used the radio to contact the Coast Guard. They paddled to a nearby fish hatchery where a helicopter picked up the patient.
End of the Tale
This patient had a ruptured appendix. In hindsight the surgeon believed it ruptured in the severe pain episode the previous night. He developed a serious abdominal infection and had a long hospital stay. He has completely recovered.
The protocol would not have caught this appendix before it ruptured, but the evacuation would have been sooner if they had agreed to it on the beach. Human dynamics come to play in every decision, and the stoic endurance of the pain, while admirable, was in this case, unwise. The patient remarked that this experience, his first serious medical problem, has made him aware that he has a tendency to deny physical complaints. His friend, the WFR, was proud of his skills and mulled over whether he could have been more persuasive at the camp. Lessons for all.
