Case Study 26

The Answer


  • Mechanism for a spine injury
  • Minor injury (no obvious fracture or dislocation) to hip, elbow and shoulder

The Plan

  • Roll Nate onto a pad, keep him warm
  • Keep spine immobilized
  • Monitor and access help

Anticipated Problems

  • Shock
  • Weather change (we don't have a lot of gear)


These folks are Wilderness First Aid (WFA) trained, not Wilderness First Responder (WFR). Their scope of practice is not as robust as a WFR. They have done as they were trained. They checked for life threats, identified obvious injuries, obtained a basic set of vital signs and medical history, and stabilized the patient while accessing assistance. The patient is in good hands.

The focused spine assessment, the WFR's tool for making a decision on spine management in the scenario of a spine injury mechanism without signs or symptoms of a spine injury, is not in the scope of practice of a WFA trained in a 16-hour course. It takes additional training to be competent in this critical skill.

NOLS has conducted and published the first ever study of retention from wilderness medicine courses. This shows that our skills and knowledge deteriorate over time. We now recommend the use of a memory aid in the field. There is nothing demeaning about using a memory aid; indeed, it's a measure of wisdom to admit that we all forget.

The Tale Continues

You log roll Nate onto a foam pad, cover him with your spare layers and elevate his legs with bent knees 6" to make his back comfortable.  Cell phone reception is good and you are able to activate the Search and Rescue (SAR) unit.  You give them coordinates and a good description of your location, which is only a mile from the trailhead.  You deliver your SOAP report and ask for a provider who can make a spine assessment.  You tell the dispatch operator that the patient does not seem to have any serious injuries and should be able to walk.
At 1330 hours you repeat the Patient Assessment and update the written SOAP report.

Patient Exam: The patient is comfortable on a pad on his back and has no spine pain and can move and feel hands and feet.  He complains of soreness 4-5 on a 1-10 scale in left hip, left elbow and right shoulder.  There is now bruising in all three places.  The patient can move all these joints and there is no sign of fracture or dislocation.  Currently he is awake and his level of responsiveness seems normal.  He wants to get up and walk to the car.

Vital Signs

1300 hrs

1330 hrs


awake and oriented

awake and oriented


90, regular

84, regular


20 not labored

20 not labored


pale, warm, dry

pink, warm, dry

Comments: If you are with the patient for an extended time it's common to re-measure the vital signs. Repeating the whole patient assessment, including checking inside splints and under bandages, may reveal signs such as these bruises, which develop over time.

End of the Tale

An hour later a team of three from the local SAR unit arrive on the scene. One is a WEMT, the other two WFRs. They listen to your SOAP report. The WEMT repeats the patient assessment with no significant new findings. Nate asks to be allowed to walk. The WEMT asks him to be a patient patient and maintains spine immobilization while conducting a focused spine assessment (FSA).  The WEMT finds no signs of a spine injury; Nate is alert, sober and reliable, he has good CSMx4, and denies spine pain. After checking with the patient and his medical control physician the decision is made to allow Nate to stand and walk. Nate is able to do so, albeit with a sore hip. The hike to the trailhead takes an hour. The SAR folks check Nate one more time. He's feeling stiff and sore and looks forward of the hot tub and a massage. As you part ways, you thank the SAR folks who in turn complement your competent handling of the situation.