Case Study 17

The Scenario: A Spill on Skis

The Setting

You and three companions are on an afternoon cross-country ski of a marked, but un-groomed trail system in the local national forest. The temperature has been hovering in the low teens Fahrenheit, the day made beautiful by a blue sky, the absence of wind, and plenty of fresh snow. Blue wax is gripping well. You’ve been skiing for several hours and reach your planned turn around point 5K from the trailhead.

“Check this guy out!” 

A lone skier cuts turns down the steep hillside above the trail. He’s moving smoothly on a course to cut right in front of you until he takes a terrain feature that launches him in the air. His skis go up, his butt goes down, and he lands hard on his back. You’re impressed when he bounces, stands, and glides for a few moments. You’re concerned when he sits awkwardly and rolls onto his side.   

“Hey, are you ok?”  

There is no answer and the skier seems to be moving awkwardly. In less than a minute, you ski to his side. The skier is gasping for air. One of your companions takes control of his head and asks, “Can you breathe?” The skier gasps in response, “wind….knocked…... out.”  “Relax,” you plead as you look at his airway, sweep for obvious injuries and blood, and check for chest injury at the prompting of your companion. All these are negative, which is positive. 

Over the next couple of minutes his breathing calms and you make sure he has a clear airway. He knows his name, where he is, the time and date, and what happened. Belatedly you introduce yourselves and ask if you can help. He answers “I’m ok”, tries to move, and cries out in pain. “My back hurts.”  He agrees to an assessment. You begin by removing his pack, checking his back, and rolling him onto a couple of short pads extracted from our packs. The NOLS Wilderness Medicine water bottle with the PAS triangle lying on the snow catches your eye. A quick drink allows you to look surreptitiously at the triangle and organize yourself for the assessment.

SOAP Report

Subjective

The patient is a 30-year-old male who we witnessed fall hard on his back while skiing. He may have hit a stump. He stood under his own power, skied a short distance, then collapsed.

 

Objective

Patient Exam:

Patient was found on his right side gasping for air. This resolved after a few moments and was attributed as “wind knocked out.” At present he has no shortness of breath. He has pain across his lower back with tenderness on one lumbar vertebrae. No other injuries were found. He did not lose responsiveness and denied any rib tenderness. At present he has good CSM x 4 but did report a tingling sensation run down his legs for a few minutes after the fall. His feet and hands are warm.

 

Vital Signs
TIME

1500

1520

LOR

A+Ox4

A+Ox4

HR

100, regular, strong

100, regular, strong

RR

20, gasping

12, regular, easy

SCTM

Pale WD

Pale, WD

B.P.

radial pulse present

radial pulse present

Pupils

PERRL

PERRL

Skin is warm

Skin is warm

 

 

 

 

History

Symptoms:

None stated

Allergies:

Pollen in summer

Medications:

Ibuprofen 400 this morning, no regular medications

Pertinent Hx:

None stated

Last in/out:

Pt has had 2 liters water today, snacking all day

Events:

Pt fell while skiing

 

Stop ...

What is your Assessment and Plan?

DO NOT click/peek at the next page without answering this first.