The Setting
You’re on a high ridge forming the east border of Yellowstone National Park, hours into a long walk to the trailhead and the end of this 12-day backpack. Behind you are seven teenagers, your clients, and your lead instructor. Sweat drips from your forehead as you hike the steep wooded trail on a hot summer afternoon. No one is talking. Lost in thoughts of sore feet, thirst, their first burger, and how many emails might be waiting, they pound the dust and pay little attention to the beautiful surroundings.
Sensing something ahead, you look up and see large black-colored bear right in the middle of the trail and too close for comfort. Inhaling loudly, you stop, then tumble onto the trail as the fellow following you stumbles and hits your pack. Someone belatedly yells, “Bear!” Branches snap and crack as the bear bashes the underbrush in haste, heading downhill at an impressive speed. Woven into this confusion is another scream and crash. One of your participants has stepped off the trail and is rolling downhill.
You unclip your pack, throw caution to the wind, and move with surprising grace and speed down the hill. There is John, his roll stopped by a tree. You stabilize him with you hands and try to find those breaths you forgot to take. Your lead instructor, still on the trail, yells that the bear is gone. Scene safety! Yes, of course! Lost for a moment, you find presence and begin the scene-size up and the initial assessment drill. You order another student to carefully descend to the side of the patient and instruct him to maintain spine control. The slope is steep but the patient is stable in the hollow in front of the tree.
SOAP Report
Subjective/Story/Summary
The patient is a 17-year-old male who rolled with a 40lb backpack down a 40’ hill. He stopped by striking a tree with his backpack. The event was witnessed and we arrived on scene immediately. The patient states that he is “OK, I think.”
Objective
The patient was found on his right side. He was awake and alert with no obvious serious injuries and no respiratory distress or active bleeding.
Patient Exam:
Revealed numerous small scrapes and abrasions on his knees and forearms; the worst is a large abrasion on the back of his right thigh. He has a 2” diameter swelling on the back of his head. He denied loss of responsiveness, headache, shortness of breath, numbness, tingling, or any abnormal sensations in his extremities. He denies spine pain and his spine is not tender to touch.
Vital Signs
| TIME | 1500 | 1520 |
| LOR | A+Ox4 | A+Ox4 |
| HR | 90, strong, regular | 72 strong, regular |
| RR | 18, regular, easy | 18, regular, easy |
| SCTM | Pale, warm, moist | Pink, warm, dry |
| B.P. | Strong radial pulse | Strong radial pulse |
| Pupils | PERRL | PERRL |
| T° | Not taken | Not taken |
History
| Symptoms: | none |
| Allergies: | denies |
| Medications: | occasional ibuprofen for musculoskeletal pain, none taken today |
| Pertinent Hx: | none pertinent |
| Last in/out: | patient ate breakfast and lunch, reports 3 liters of water today and clear urine |
| Events: | patient was hiking and fell off the trail |
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
- Mechanism for spine injury
- Multiple minor abrasions
The Plan
- Make sure the bear is gone.
- Move the patient back to the trail, a more stable platform.
- Clean and dress the abrasions.
- Perform a focused spine assessment and make a decision about the need for continued spine control.
Anticipated Problems
- Nothing significant anticipated.
Comments
The Tale Continues
While you perform the patient assessment, the lead instructor cleans up the mess on the trail and watches for the bear. Everyone breathes easier watching it running across a meadow a hundred years away. Your lead instructor descends to the scene, listens to your verbal SOAP, asks a few clarifying questions, and chats with the patient, who wants to stand and walk back to the trail. You both agree he seems remarkably without wear and tear, yet you both want to be sure about his spine.
You perform the focused spine assessment checking, for a second time, for the following:
- Reliable patient: A+O x 3 or 4, sober, and not distracted.
- Normal CSM in all four extremities:
- Circulation (warm, pink digits or good pedal/radial pulse).
- Sensation (can they feel, no numbness, tingling or unusual hot or cold sensations).
- Motion, unless otherwise explainable by another injury or illness.
- Patient must deny spinal pain and tenderness on palpation of the entire spine.
The patient met all these criteria, and when this was explained to him, he willingly agreed to allowing release of spine control. “I’m fine. Let me walk back up the hill.”
On the trail the abrasions are cleaned by irrigating with water and light scrubbing and the worse ones dressed with gauze impregnated with antibiotic cream. You’re short on water and decide to hike another mile down the trail to a stream where you can hydrate and more thoroughly clean some of the abrasions. The patient is fine on the hike, sharing the drama of the event with his companions. You walk with your head up and your eyes on the woods, chastising yourself for your momentary lapse of attention at the start of this tale.
End of the Tale
In the early 1970s urban emergency medical services systems adopted a standard approach to possible spine injury that was based on mechanism of injury (MOI), not, as it is in extremity fractures, on signs and symptoms. This led to the entrenched practice of backboarding.
Descriptions of spine MOI are elusive, open to interpretation, and at times run in the face of common sense when the patient has no signs of injury.
The need for this conservative approach is increasingly questioned and from this conversation comes the development of decision tools based on evaluating signs and symptoms of spine injury. These tools were formalized for the wilderness context and are now appearing in urban systems as selective spine immobilization protocols.
This is one of the few areas in pre-hospital emergency medicine where we have a sound evidence-based protocol to use1, 2
The focused spine assessment, our system for assessing the spine at NOLS, is an intentional, careful, evidence-based assessment. We seek the inconspicuous spine injury by checking twice for patient reliability, abnormal CSM’s, and spine pain or tenderness. We check once in our patient assessment, then again in a focused spine assessment. We use this information to make a reasonable, thoughtful, evidenced-based decision.
Selective spine immobilization protocols have the support of organizations such as the National Association of EMS Physicians3, Wilderness Medical Associates4, International Commission for Mountain Emergency Medicine5, and the Wilderness Medical Society6. The American Red Cross allows students of a 16-hour course, as young as 14, to make this decision7. There are a number of EMS systems with “spine clearing” protocols. The focused spine assessment is very helpful in wilderness medicine, where prolonged immobilization and the need to carry a patient can be tough on both patient and rescuer. At the same time the gravity of this decision is clear. We teach this protocol carefully, intentionally, and with multiple practice sessions. Our experience tells us that it is used correctly and appropriately in the field.
1. Hoffman JR, Mower WR: “Out-of-hospital cervical spine immobilization: Making policy in the absence of definitive information.” Annals of Emergency Medicine. 37:632–634, June 2001
2. The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. Stiell et al, N Engl J Med 349;26 December 25, 2003
3. Indications For PreHospital Spinal Immobilization Robert M. Domeier, MD, for the National Association of EMS Physicians Standards and Clinical Practice Committee Position Paper. National Association Of EMS Physicians PreHospital Emergency Care July/September 1999 Volume 3 / Number 3
4. Ellerton, Tomazin, Brugger, Paal. Immobilization and Splinting in Mountain Rescue Official Recommendations of the International Commission for Mountain Emergency Medicine, ICAR MEDCOM, Intended for Mountain Rescue First Responders, Physicians, and Rescue Organizations High Altitude Medicine & Biology Volume 10, Number 4, 2009
5. Wilderness Medical Associates Spine Protocol Accessed 12/1/2004. Www.Wildmed.Com/Medical_Topics/Spine_Protocol.Html
6. Forgey, W.W. Wilderness Medical Society Practice Guidelines For Wilderness Emergency Care. 5th Ed Ch
7. Forgey, W.W Boy Scouts of America Wilderness First Aid Curriculum and Doctrine Guidelines March 2010 Edition Health and Safety Support Committee Wilderness First Aid Task Force
