The Setting
You are day hiking in local backcountry with a companion. A rider on a pale horse gallops into view. Your attempt to access a memory about a mythical pale horse passes into a realization that the rider is not in control of the horse. The horse stumbles, bucks and turns. The rider ejects from the saddle and lands on their back. You cringe at the impact. The rider pops up, walks several steps, then slowly kneels.
You and your companion stand there for a few seconds – “wow” – then approach the rider. In the back of your mind the voice of your NOLS Wilderness Medicine instructor is saying, “Walk. Look. Scene size-up.” This kicks in your Wilderness First Responder (WFR) training. The horse is long gone. You kneel next to the one patient who is obviously gasping for air and in apparent distress. Your companion says “airway…breathing, check the chest.” The airway appears open as the patient is obviously moving air. Your hands don’t find any obvious chest injury and a quick look under the rider’s shirt shows a heaving chest but no obvious injury. There is a radial pulse. The blood sweep doesn’t find anything. There isn’t an obvious injury to expose and examine.
On the edge of your self-control you hear the patient gasp “wind…knocked…out…” That makes sense. You patiently wait for the patient to slow and control their breathing. This gives you time to slow and control your breathing.
After an eternity, but probably only a minute or two, you can introduce yourself and ask the patient for permission to help. They agree.
SOAP Report
Subjective/Story/Summary
We witnessed the patient being thrown from a galloping horse, land on their back, rise to their feet, walk a few steps, then kneel. We were at the patient’s side within a minute. They were in apparent respiratory distress which appears to have been “the wind knocked out” and has now resolved. There was no loss of responsiveness.
Objective
Patient Exam:
The patient is a 31-year-old whose chief complaint is pain on the right upper back and shoulder area. The patient was found kneeling. We assisted them onto their back. The head-to-toe exam revealed a 6” by 6” bruised area over their right scapula without point tenderness. They have good CSM x4 and normal ROM in their right shoulder. There was no loss of responsiveness. They deny spine pain and the spine is not tender to touch. No other injuries are found.
Vital Signs
| TIME | 1530 hrs |
| LOR | A+Ox4 |
| HR | 130, regular, weak |
| RR | 24, regular, shallow. Initial gasping for air has resolved and breathing is now quiet and easy. |
| SCTM | pale, cool, clammy |
| B.P. | radial pulses present |
| Pupils | PERRL |
| T° | 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. |
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
- Due to the mechanism of injury, this is a possible spine injury.
- Possible shock.
- Bruise on right upper back.
The Plan
- Patient is on a sleeping pad, is covered with spare clothing and is warm. Their legs are elevated 8” with knees bent. They are drinking water. We will monitor vital signs. We are using our packs as head blocks to protect the spine.
- Monitor vital signs.
- Perform a focused spine assessment and make a decision on the need for continued spine protection.
- Develop a plan for evacuating the patient.
Anticipated Problems
- Developing shock. Is there an internal injury?
- Evacuation support if we need to continue to protect the spine.
Comments
Shock and Acute Stress Response (ASR)
It looks like the patient got through this without any long bone or pelvic fractures, but we still need to worry about an internal injury, especially with an initial vital sign pattern suggesting shock.
A patient in shock classically has a rapid pulse rate that may feel weak and irregular. The skin is pale, cool, and clammy. These signs and symptoms are a product of our “fight or flight” response: our body’s response to danger. The “adrenaline rush” increases heart rate and respiratory rate, causing the skin to pale and sweat, and the nausea and restlessness. These changes pump the blood faster, reduce the size of the blood vessels, and route the blood to essential organs, hopefully helping the body to compensate for the shock.
If the circulatory system is unable to compensate to the injury, a spiral of deterioration may begin in which first tissues, then organs, and finally entire systems fail from poor perfusion. These patients need to be transported quickly to the hospital; our wilderness shock management tools–leg elevation, oral fluids, stabilizing injuries, and keeping the patient warm and comfortable–may not be enough.
Most people, when frightened, injured, or ill, have a “fight or flight” or acute stress response that mimics shock. This is the familiar fast heart rate, sweaty pale skin, nervous shakes, and queasy gut from the adrenaline rush. If you’re not seriously ill or injured and your circulatory system is healthy, this response should abate in short order. The heart rate slows, you relax, and the skin returns to its normal color.
Positional (orthostatic) vital signs refer to our ability to compensate for changes in position and the effect gravity has on our cardiovascular system. Healthy people can stand from a supine position with little or no problems. People in shock may not react well to the position change. We teach a positional (orthostatic) vital sign test to help find patients with low volume status who don’t have obvious signs and symptoms of shock. Have the patient stand, then wait one minute and measure vital signs. An HR increase of 30 beats/min or more in adults, or the presence of dizziness or fainting suggests shock. Evaluating the patient’s symptoms is as critical as measuring numbers. Regardless of their heart rate, if the patient becomes pale, woozy and nauseated with a position change, lie them down and treat for shock.
Spine Protection
It’s tempting to rule out a spine injury because the patient was seen walking, but people can do amazing things when reacting to stress. The fact that the head-to-toe assessment does not reveal any spine pain or tenderness and the normal CSMs in all four extremities suggest the spine is injury-free. The focused spine assessment can be done on this reliable, sober and alert patient to gather the information needed to make a decision on the spine. Until this decision is made the spine is protected by gently assisting the patient onto their back and using soft head blocks to limit neck motion. A cervical collar is unnecessary, but if used as a precaution, a soft rolled collar is fine.
The Tale Continues
Over 30 minutes the patient relaxes, their breathing remains easy, vital signs return to normal. The patient wants to try to stand and walk.
| TIME | 1530 hrs – supine | 1540 hrs – supine | 1600 hrs – standing |
| LOR | A+Ox4 | A+Ox4 | A+Ox4 |
| HR | 130, regular, weak | 100, regular, weak | 76, regular, strong |
| RR | 24, regular, shallow. Initial gasping for air has resolved and breathing is now quiet and easy. | 18, regular, shallow | 14, regular, easy |
| SCTM | pale, cool, clammy | pale, warm, clammy | pink, warm, dry |
| BP | radial pulses present | radial pulses present | radial pulses present |
| Pupils | PERRL | PERRL | PERRL |
| T° | Not taken | Not taken | Not taken |
You explain your concerns about shock and spine injury and ask the patient if you can first do a focused spine assessment, then if you and the patient agree there is no further need for spine protection, to have the patient stand and check positional vital signs.
The sober, reliable, and alert patient is able to focus on the assessment. Their CSM’s are good in all four extremities and they deny spine pain or tenderness on palpation. You and the patient agree they do not need spine protection.
They first sit, then stand. Initial dizziness quickly resolves and there are no vital sign changes.
End of the Tale
Although sore, the rider is able to walk, and seems to be physically well. It’s a slow walk to the trailhead where the rider takes up your offer to drive them to the emergency room for further evaluation. Later you find that the physician cleared the patient of injury and released them from the emergency room. As for the horse, it was recovered the next day, no worse for the wear.
