Case Study 4

The Answer

Assessment

  • Acute abdominal pain that triggers our program’s evacuation protocols. The pain is increased with movement and jarring and has persisted for more than 12 hours.

The Plan

  • Use the cell phone to contact the program base and request helicopter evacuation for evaluation of this patient by a physician. If the cell does not work, a party of four will hike to the trailhead and call on land line.
  • Patient will be kept as comfortable as possible. If evacuation is delayed, clear fluids will be given if tolerated to prevent dehydration and shock. Otherwise, nothing by mouth.

Anticipated Problems

  • Dehydration and shock.
  • Continued pain and patient discomfort.

Comments

Generalized abdominal complaints are common in backcountry settings. The NOLS dataset shows that 27% of reported illness is some type of gastrointestinal complaint, most often simple nausea, diarrhea, and cramping; another 7% is acute abdominal pain. Other studies of outdoor programs also show that gastrointestinal complaints are common.  

Gastroenteritis, the most common cause of abdominal discomfort, is typically cramping, intermittent, and diffuse, not consistently reproducible by palpation, but, at times, severe. It is often accompanied by vomiting and/or diarrhea, malaise, fatigue, muscle aches, and low-grade fever. In contrast, the classic history of appendicitis is dull, constant, diffuse pain becoming localized to the right lower quadrant and associated with nausea or vomiting, lack of appetite, and low-grade fever. However, the presentation and course of appendicitis, or any abdominal complaint for that matter, is seldom classic or straightforward.

Evaluating whether abdominal pain is a medical or surgical emergency, or is simple gastroenteritis that will resolve in the field, can be challenging. Outdoor leaders must be diligent in the interview and examination of this patient and focus not on trying to figure out what the problem is, but rather on identifying if the patient is presenting critical evacuation triggers. 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 for more than 48 hours, especially if accompanied by diarrhea or vomiting.

Abdominal Pain with:

  • The signs and symptoms of shock.
  • Duration longer than 12 hours.
  • Localized pain, especially with guarding, tenderness, distension, or abdominal rigidity.
  • Peritoneal signs (movement pain or pain with foot strike).
  • Blood in the vomit, feces, or urine.
  • Nausea, vomiting, or diarrhea persisting for longer than 24 to 72 hours.
  • A fever above 102F (35C).
  • Signs and symptoms of pregnancy.