Case Study 29

The Answer

Assessment

  • Hyperglycemia
  • Altitude illness
  • Dehydration
  • Gastrointestinal illness with vomiting

The Plan

  • Request helicopter evacuation.
  • Use the second team to move the patient to an LZ.
  • Monitor the patient, allow her to drink.

Anticipated Problems

  • Patient’s condition worsens.
  • Helicopter is unavailable and we need to begin a litter evacuation.

Comments

We expect to see this scenario in the urban context, not on the side of a wilderness trail, yet people do hike into the wilderness carrying their medical history along with their backpack.

The WFR’s role is to perform a thorough patient assessment (PAS), identify immediate life threats (there are none present), identify pertinent medical interventions and treatments (in this case oral fluids only), and determine the need for and urgency of evacuation (which needs to be done promptly due to the apparent hyperglycemia and her altered mental status). 

The patient has multiple ongoing medical conditions that the WFR can identify, but for which there are no interventions in the WFR’s scope of practice other than monitoring, airway maintenance, and evacuation.  

The hyperglycemia appears to be the most urgent problem.  The WFR, unsure if the patient can make a good decision about her insulin dose, asked her to wait until she saw the doctor. The patient agreed.  

Diabetics who are untreated, who have defective or insufficient insulin, or who become ill may develop a high level of sugar in the blood. Consequences of this may be dehydration and electrolyte disturbances as the kidneys try to eliminate the excess sugar, and acid-base disturbances as cells starved for sugar turn to alternative energy sources.

Hyperglycemia tends to develop more slowly than hypoglycemia, but it can come on within a few hours. The first symptoms are often loss of appetite, nausea, vomiting, thirst, and increased volume of urine output. The patient's breath may have a fruity odor from the metabolism of fats as an energy source, although this doesn’t happen in every patient. The patient may also have abdominal cramps or pain and signs of dehydration, including flushed, dry skin and intense thirst. Unresponsiveness is a late and serious sign.

End of the Tale

When the second team arrives the patient is packaged in a litter and carried a few hundred yards to the LZ. Luck is on our side this day and the life flight arrives promptly.  She indeed was hyperglycemic and spent several days in the hospital. Her companions hiked out the day after her evacuation and reported her missing. We think she needs different companions, but giving her that advice is not in our WFR scope of practice.