The Setting
SOAP Report
Subjective/Story/Summary
The patient is a 45-year-old male who fell off the back of his rearing horse, landing on his head and left shoulder. He was not trampled by the horse. The patient’s chief complaint is a dull headache he rates as a 4 on a scale of 1-10. The headache began shortly after his fall.
Objective
The patient was found lying on his back on the trail. Initially the patient was not awake, but was responsive (he moaned) to a verbal stimulus. Shortly thereafter he began to wake up and within one to two minutes he became A+OX4.
Patient Exam:
Patient has a golf ball sized bruise/swelling on the back of his head and a 3” bruise on his left shoulder. The patient is moving his arms and legs, denies pain on palpation of the spine and has good circulation, sensation, and motion (CSM) in all four extremities. No other injuries found.
Vital Signs
| TIME | 10:15AM | 10:45AM |
| LOR | Responsive to verbal stimulus | A+Ox4 |
| HR | 84, strong, regular | 72, strong, regular |
| RR | 12, regular, easy | 12, regular, easy |
| SCTM | Pale, Warm, Dry | Pink, Warm, Dry |
| Pupils | PERRL | PERRL |
| Temp | not taken | not taken |
History
| Symptoms: | Patient states he has a headache and is slightly nauseous. |
| Allergies: | Patient is allergic to peanuts with no recent exposure. |
| Medications: | Patient takes a medication for high blood pressure. He took his normal dose today. |
| Pertinent Medical History: | High blood pressure. Peanut Allergy. |
| Last intake/output: | Patient reports he drank a liter of water this morning, ate breakfast, and had a normal bowel movement. He vomited once shortly after the accident. |
| Events relevant to the incident/illness: | None. |
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
- Patient has a mechanism for a spine injury, a possible head injury, and a bruised shoulder
The Plan
We will control the spine and monitor the patient for a developing head injury. We will RICE the shoulder. Local EMS/SAR will be contacted and we will await their arrival and support their evacuation. We have log rolled the patient onto a foam pad and are using a cervical collar improvised from a pile sweater and head blocks from clothing-filled stuff sacks to immobilize the neck. We are monitoring for vomiting, change in mental status, and bodily function needs.
Anticipated Problems
- Patient may develop signs of a serious head injury and need a rapid evacuation.
Comments
Possible Spine Injury and Wilderness Protocols
The focused spine assessment (spine clearing protocol) is commonly taught as a wilderness protocol. It is also used by a number of urban EMS systems. When is it appropriate to use the focused spine assessment in an urban context, or on the local ski hill?
Focused Spine Assessment
These leaders had wilderness medical training and considered using their focused spine assessment protocol to make a decision on the need for spinal immobilization. The patient was A+OX4, sober, without distractions, denied spine pain or tenderness, and had good CSMs in all four extremities. In a wilderness context he would be a candidate for the focused spine assessment. However, due to proximity to the road, these leaders decided not to do so, and instead to engage the local emergency medical or search and rescue system in the evacuation. The leaders had a protocol from their medical advisor for their wilderness program that supported the use of a focused spine assessment, but it was not intended to extend to the general public or to be used in a non-wilderness context.
Our advice to our WFA, WFR, and WEMT students is that in non-wilderness situations we should support the practices of the local EMS system, rescue group, or ski patrol. Use your wilderness medicine skills to immobilize the patient with an MOI for a spine injury and then access the local EMS system. When EMS arrives they may be able to apply a focused spine assessment, or they may need to immobilize the patient for transport. It’s their turf and our role is to work within their system.
Possible Head Injury
The signs and symptoms of a mild head injury include:
- A brief change in LOR with a return to normal mental status
- Short-term amnesia, temporary blurred vision, or “seeing stars”
- Nausea and/or isolated vomiting
- Headache, lethargy, dizziness
- The treatment for a mild head injury is to monitor for developing signs of a serious head injury. You can let the patient rest as long as you wake them periodically to assess their mental status.
The signs and symptoms of a serious head injury include:
- Obvious changes in mental status (disoriented, irritability, incoherence, combativeness)
- Unresponsiveness
- HR decreases and bounds
- RR may be hyperventilation and erratic patterns
- SCTM may be warm and flushed
- Pupils become unequal
- Blood pressure increases
- The patient may experience a worsening headache, vision disturbances, protracted vomiting, lethargy, excessive sleepiness, ataxia, and seizures.
The treatment for a serious head injury is to manage ABCs, especially the airway; to immobilize the spine and elevate the head of the litter 6-8”; to administer oxygen if available; and to arrange for a rapid evacuation.
This patient has signs of a mild head injury. Monitoring for worsening head injury and arranging evacuation is an appropriate treatment plan.
End of the Tale
The local SAR team responded in an hour with a initial group of three rescuers. They were shortly followed by an additional four folks with a wheeled litter. The patient was evacuated on this litter with spine precautions (the SAR team did not have a selective spine immobilization protocol), and with the assistance of the leader and the students.
The evacuation was uneventful. The patient continued to have a headache and complain of nausea and vomited once. He was evaluated in the local emergency room. He did not have a spine injury but was kept overnight for observation for a mild head injury.
The leader and the students camped at the road head, sad they were not further in the wilderness, but happy with the experience they had gained and the help they rendered the horseman, and full of pride from the compliments of the local SAR team leader.
