Wilderness Scenerio - C-Spine Injury w/ Nausea & Vomiting

[Mountain Res-Q]

NOTE: This is in no way a divulgence of a real life scenario.

You are the Medical Team Leader for a Wilderness SAR Team. At 0800 you are paged out for a possible spinal injury at a backcountry camp (elevation 7000). Pretty remote. Drive time from main population center: 1.5+ hours on mountain highway and dirt roads to the trailhead. 30-45 minutes hike to the camp.

Your teams inital response assembles together and are briefed. This is a 12 y/o male that was jumped on by another youth and hit his head last night. Complained of neck pain initially and has been vomiting and nauseous all night long. He is part of some oganized summer camp. The camp has sent in one of their Nurses to the pt. and it is believed at this time (without very good communications with the RP) that you will need to hump it in, evaluate the pt., probably board him, and carry the pt. out. Your initial response is the Sheriff's Deputy assigned to SAR and 4 team members, including yourself. Level of training? You have 1 Medic, 1 EMT, and 2 First Aiders. You can choose to be the Medic or EMT for the scenerio, depending on your level of training... just we aware that it won't matter, becasue SAR is BLS-level equipped only. An additional response of SAR folks is expected (2-4 rescuers). You have also request that the Forest Service send out an engine crew for manpower (~4 FF's). An ALS Ambulance is also being dispatched out.

You get at the trailhead and are met by two members of this backpacking group. New details emerge and you are advised that they were participating in "trust exercises" (you know, fall backwards... I'll catch you) and the pt. hyper-extended his neck in the processes. He has been in pain all night, localized to the upper back and radiating up the neck. He is currently lying supine, with 2 nurses (unknown if they are CNAs or MCNs - you know how that goes) attending to him; and they do not want to move him until the "Wilderness EMS Experts" evaluate him... but they believe that he has a serious spinal injury. The trail is mild to moderate in difficulty, crosses a 20 foot stream, and (according to the RPs) the pt. can not walk it ("NO WAY!"). The Forest Service Engine Crew is 25-20 minutes out. The additional SAR resources and the Ambo are 35-45 minutes out. Horses and ATVs are not advised. A Helicopter can be requested if needed, but shorthauling is not advised at this point due to the location; and the closest suitable LZ could be miles away. Based on what you know... what do you do? How do you respond; with what and who? What plans are you formulating to "save this kid"?

I say "at this point, based on what you know" because like all good calls... things are not always as they appear on inital report.

 

[8jimi8]

since i don't have time to properly respond i'll just do it quickly.

take the medic, i'm the emt and the two first aid (and hopefully we have radio / cell phone contact and i'll bring my personal GPS unit... otherwise, a topographic map and a smoke canister).

have FF's move in and set up the LZ.

Hump in the basket litter and enough rope/ high angle gear for a tyrolean across the river.

After the FF set up the LZ two of them can start hiking toward us to help us carry the litter faster.

hike in, immobilize the pt and hike him out to the LZ. Chopper take him away.

Was there something huge that I am missing? You said BLS only right, no iv's or meds right?

 

[Mountain Res-Q]

since i don't have time to properly respond i'll just do it quickly.

take the medic, i'm the emt and the two first aid (and hopefully we have radio / cell phone contact and i'll bring my personal GPS unit... otherwise, a topographic map and a smoke canister).

have FF's move in and set up the LZ.

Hump in the basket litter and enough rope/ high angle gear for a tyrolean across the river.

After the FF set up the LZ two of them can start hiking toward us to help us carry the litter faster.

hike in, immobilize the pt and hike him out to the LZ. Chopper take him away.

Was there something huge that I am missing? You said BLS only right, no iv's or meds right?

Cell Phones are useless. We all have radios and can all communicate great. GPS? Sure... prefer map and compass, but to each his own. You are SAR and are properly equipped for the wilderness (could live out there for days on a search), have 3 trucks full of tech gear, BLS gear, and other SAR related gear. But, yes... BLS gear only. Although you do have the SAR medic with you and the ambo is XX minutes away and ALS gear can be humped in for use if need be.

River? Seasonal stream that, while being 20 feet wide, can be walked across (12 inches) and is moving very very slow... doesn't meet the criteria for Swiftwater and Ropes would be an ill-advised waste of time.

FFs are not on scene yet and have no clue what we have going on. Likewise the addtional SAR resources are not on scene yet and communications with incoming resources are spotty until they get closer.

Locating an LZ could take some time and the closest likely LZ would be a hike that would be the same as or greater than a hike out to the trailhead to the Ambo. On top of that... while a helo is a great idea... the pt. has had this injury for 12-16 hours. Would you prefer to hike the 30 minutes in and evaluate before requesting a higher risk option of a helo in the mountains. Is that 35-40 minutes delay gonna really matter? mind you, we are basing our respons so far off of reports coming from a non-EMS hiker, who told a camp dirrector what a non-EMS told him to say, who then told a Dispatcher, who then (after spotty communications) told a Deputy, who told the team. that informaton changes slightly when you get on scene and talk to the otehr hikers. How might it change in 30 minutes?

NOTE: There are no wrong answers. I am curious to see what you all would do, some of you coming from a Street EMS standpoint, some from a (through everyhting we have at them) FF standpoint, and a few of you having a more SAR-rooted background.

Once enough people explain their initial response to the reports... I will take you to the scene and give you the assessment...

 

[medicdan]

I would start hiking in with the litter and board, and whatever manpower I have at the time. If thats 3 other people right now, thats fine. Make sure when i go in, I mark my trail for other responders.

Start the hike in, when I reach the patient, get a report, get boarding. By the time that is done, I hope to have other rescuers. Even if we dont, we might try to start moving back to trailhead. I would try to get one of the nurses or other staff to help carry the litter. The patient is 12 years old, so cant be that heavy-- so I presume we dont need a 6-member team at all times. My presumption, based on the initial reports, is that the patient suffered a serious head injury, and the sooner I can get them to a hospital safely, the better.

I hope by the time we reach the difficult terrain, or river crossing, I will have additional team members, and then I dont anticipate a problem.

Am I wildly off base here? If its only a 45 min hike in, I hope to be able to get out 1.5-2 hours after making patient contact. I would make sure the ALS transport truck is ready, and get them transporting.

You didnt mention how far a Pedi Level I hosp is, but depending on that, I would consider a helo from the trailhead.

 

[8jimi8]

That makes sense. I didn't realize the stream was so shallow! I thought you threw that in there to confound the issue.

If an LZ is just as far away as an ALS unit, then I'd make those medics hike in with their lifepak and jump bag and then i'd help them drag his a** out of there! I kind of felt that the story was supposed to be tricky somehow.

Doesn't really seem too bad of a scenario to me, other than the delay in communications and the difficulty in getting to/ out of the scene. If two nurses told me that the patient had a serious neck injury, plus the addition of a likely head injury / IICP that is reason enough to launch the bird for me (it doesn't matter if they are an LVN or not). Being that the ALS ambulance is as close as any likely LZ for the helicopter, i'd hike him out to the box and then have them rendezvous with the chopper. If we are talking remote, like I go remote... there is no hospital that the ambulance can get to faster than the chopper and I am sure we are more likely to find a spot big enough to land the chopper near a road.

 

[CAOX3]

Cell Phones are useless. We all have radios and can all communicate great. GPS? Sure... prefer map and compass, but to each his own. You are SAR and are properly equipped for the wilderness (could live out there for days on a search), have 3 trucks full of tech gear, BLS gear, and other SAR related gear. But, yes... BLS gear only. Although you do have the SAR medic with you and the ambo is XX minutes away and ALS gear can be humped in for use if need be....

I give you wilderness searchers the most credit. I could never do that.

How the hell do you watch sportcenter when your out there?

 

[Mountain Res-Q]

I would start hiking in with the litter and board, and whatever manpower I have at the time. If thats 3 other people right now, thats fine. Make sure when i go in, I mark my trail for other responders.

Start the hike in, when I reach the patient, get a report, get boarding. By the time that is done, I hope to have other rescuers. Even if we dont, we might try to start moving back to trailhead. I would try to get one of the nurses or other staff to help carry the litter. The patient is 12 years old, so cant be that heavy-- so I presume we dont need a 6-member team at all times. My presumption, based on the initial reports, is that the patient suffered a serious head injury, and the sooner I can get them to a hospital safely, the better.

I hope by the time we reach the difficult terrain, or river crossing, I will have additional team members, and then I dont anticipate a problem.

Am I wildly off base here? If its only a 45 min hike in, I hope to be able to get out 1.5-2 hours after making patient contact. I would make sure the ALS transport truck is ready, and get them transporting.

You didnt mention how far a Pedi Level I hosp is, but depending on that, I would consider a helo from the trailhead.

Good use of the group leaders and nurses on scene!!! The only problem with hiking out a pt. on a board/litter is the terrain and the fatigue that comes with trying to safely move a pt. More hands on the litter is safer and having the manpower to rotate out the fatigued and be able to clear out obsicles along the way is helpful.

Level 1 pedi? By ground? 3-4 hours, I believe.

That makes sense. I didn't realize the stream was so shallow! I thought you threw that in there to confound the issue.

If an LZ is just as far away as an ALS unit, then I'd make those medics hike in with their lifepak and jump bag and then i'd help them drag his a** out of there! I kind of felt that the story was supposed to be tricky somehow.

Doesn't really seem too bad of a scenario to me, other than the delay in communications and the difficulty in getting to/ out of the scene. If two nurses told me that the patient had a serious neck injury, plus the addition of a likely head injury / IICP that is reason enough to launch the bird for me (it doesn't matter if they are an LVN or not). Being that the ALS ambulance is as close as any likely LZ for the helicopter, i'd hike him out to the box and then have them rendezvous with the chopper. If we are talking remote, like I go remote... there is no hospital that the ambulance can get to faster than the chopper and I am sure we are more likely to find a spot big enough to land the chopper near a road.

I do nothing to confound the issue… god did when he put the stream in my “imaginary” scenario. Medics are not supposed to leave their unit, however… and if they do… they shouldn’t go out further than one mile. Plus what can they do that you can’t… other than an IV and drugs (none of which are indicated yet and/or could wait).

Helicopter? Launch them too soon and they will be waiting for hours until you can rendezvous… 30 minutes of hike time to evaluate won’t increase their response time. I’d wait, but I can see your point… initially, I want a bird too… especially with a 3-4 hour ground transport time to pedi facility.

I give you wilderness searchers the most credit. I could never do that.

How the hell do you watch sportcenter when your out there?

NBA season is over. Makes it a lot easier. Pager gets turned off during the playoffs… ^_^

 

[Summit]

Team 1: EMT & Medic
Equipment: BLS kit
Orders: Move fast, make contact, evaluate patient, create plan, advise command of further needs

Team 2: FA & FA
Equipment: full body vacuum splint strapped to the wheeled litter, short rope, and a hypo bag
Orders: Assist team 1 in packaging patient and transport if possible

That's probably all the resources you need to transport on a wheeled litter, especially if the bystanders will help you with the stream. Still it would be nice to have Team 3 with 2-4 people coming to assist with carry just in case he is a heavy 12 y/o. (no technical terrain was mentioned)

My primary concern with known information is swelling going up the spinal cord and compromising breathing, although this is probably unlikely since it hasn't happened already. I'd be more worried if we were responding to something that just happened, not something 16 hours old. Because of this, I'm not feeling the air assets. Special attention must be paid to the patient so that they can be rolled if N/V returns during transport.

 

[Summit]

Oh, I forgot to mention, all teams bring O2 cylinders since the N/V *could* be altitude related. Probably not, but if O2 reduces N/V during transport, that's gooooooood.

 

[8jimi8]

you would "roll" a spinal injury with possibly IICP on the ground out of a forest?

i know he didn't say technical terrain, but he also didn't say, "sidewalk."

just curious.

your plan seems good to me other than the wheeled litter.

 

[Mountain Res-Q]

Team 1: EMT & Medic
Equipment: BLS kit
Orders: Move fast, make contact, evaluate patient, create plan, advise command of further needs

Team 2: FA & FA
Equipment: full body vacuum splint strapped to the wheeled litter, short rope, and a hypo bag
Orders: Assist team 1 in packaging patient and transport if possible

That's probably all the resources you need to transport on a wheeled litter, especially if the bystanders will help you with the stream. Still it would be nice to have Team 3 with 2-4 people coming to assist with carry just in case he is a heavy 12 y/o. (no technical terrain was mentioned)

My primary concern with known information is swelling going up the spinal cord and compromising breathing, although this is probably unlikely since it hasn't happened already. I'd be more worried if we were responding to something that just happened, not something 16 hours old. Because of this, I'm not feeling the air assets. Special attention must be paid to the patient so that they can be rolled if N/V returns during transport.

I like you Summit!!!!! Only two things for me... no full body vacuum splints (not in protocol - not allowed) and no wheel (the powers that be decided that it was a waste of money given our usual mission type - I don't agree, but it is what it is and I am not sure if it would have been useful on this particular trail). But in a perfect world I want the equipment you describe... and the wheel will be in my next budget request in the fall. But if you have them... hell ya... use them!!!

But I LOVE the fact that you want to be helicopter conservative given the cirrcumstances. Also, you seem to undertand that 12 y/o means nothing. I've seen 12 y/o's that weighed more than me at 190... and how often does a 12 y/o turn out to actually be 21? How often is the initial report COMPLETELY different from reality? Which is probably why the additional resources from Forest Service were requested.

Oh, and O2 is available in in the small portable cylinders (4 in the SAR trucks, at least one on the engine, and 3 on the Ambo). In fact the BLS bag in the SAR trucks that we would take out with us have a very small cylinder in them (complete with a demand valve... I know... I am using my power to get them off the rigs). Altitude related? As you say, probably not, but who knows...

 

[Summit]

you would "roll" a spinal injury with possibly IICP on the ground out of a forest?

i know he didn't say technical terrain, but he also didn't say, "sidewalk."

just curious.

your plan seems good to me other than the wheeled litter.

If your patient is going to vomit, you "lean" the wheeled litter in which the patient is secured, just as you would a backboarded patient. Done properly (patient in the hypo bag in the vacuum splint strapped in the litter) you could invert it and the patient shouldn't move.

You'd be surprised what you can move a decent wheeled liter over. Unless you are in high angle, offtrail on offcamber terrain, on swampy ground, or off trail in heavy brush, it is much easier than hand carrying. You still end up hand carrying over some obstacles.

This is a very simple one:

Nice ones have excellent handle setups on the front and the back with cable v-brakes (you also use a short line to have a sort of walking belay on downhills). Really nice ones have hydraulic disc brakes and I've heard some even have suspension. You operate these with 4-8 people, usually 6. 8 rescuers can move a patient out twice as fast as 16 rescuers doing a hand carry, more than twice as fast if you are going for miles. They also allow faster movement of equipment into the field by fewer people.

 

[Mountain Res-Q]

you would "roll" a spinal injury with possibly IICP on the ground out of a forest?

i know he didn't say technical terrain, but he also didn't say, "sidewalk."

just curious.

your plan seems good to me other than the wheeled litter.

One way or another, you have to move the patient out of the area, either to the trailhead or LZ, both of which are miles away. Carrying the litter creates the potential for droping. Wheeling them out can have it's own issues. But in this environment... lesser of two evils... which is why wilderness medicine is a completely different monster than street ems.

The trail is moderately used mild to moderate in difficulty... not a sidewalk... wilderness used in summer, inaccessable in winter and covered in 15 feet of snow. Clearly defined and relatively clear, but rocky in parts, muddy in parts, crosses a creek, etc... A wheeled litter would work in certain areas, but might be in teh way on certain parts... but if you could have gotten an ATv in close enough, the use of a wagon on the ATV to transport might be considered... and was...

If your patient is going to vomit, you "lean" the wheeled litter in which the patient is secured, just as you would a backboarded patient. Done properly (patient in the hypo bag in the vacuum splint strapped in the litter) you could invert it and the patient shouldn't move.

You'd be surprised what you can move a decent wheeled liter over. Unless you are in high angle, offtrail on offcamber terrain, on swampy ground, or off trail in heavy brush, it is much easier than hand carrying. You still end up hand carrying over some obstacles.

This is a very simple one:

Nice ones have excellent handle setups on the front and the back with cable v-brakes (you also use a short line to have a sort of walking belay on downhills). Really nice ones have hydraulic disc brakes and I've heard some even have suspension. You operate these with 4-8 people, usually 6.

If you have this available, probably is the way to go in this case. I WANT ONE!!! Just have to convince the old timers with their 150 years of combined experience in SAR.

 

[Summit]

I like you Summit!!!!! Only two things for me... no full body vacuum splints (not in protocol - not allowed) and no wheel (the powers that be decided that it was a waste of money given our usual mission type - I don't agree, but it is what it is and I am not sure if it would have been useful on this particular trail). But in a perfect world I want the equipment you describe... and the wheel will be in my next budget request in the fall. But if you have them... hell ya... use them!!!

Ah, if I don't have the full body vacuum or wheel, then Team 2 brings in spine board, 2 piece titanium stokes litter, and padding in place of the wheel/litter and vacuum. Also, I want as many rescuers (like 12 more!) as we can following team 1 & 2 in because you can never have too many people on a hand carry. Hand carry = fast fatigue = rescuers tweaking their backs if they don't have relief to rotate out of the carry.

 

[Mountain Res-Q]

Ah, if I don't have the full body vacuum or wheel, then Team 2 brings in spine board, 2 piece titanium stokes litter, and padding in place of the wheel/litter and vacuum. Also, I want as many rescuers (like 12 more!) as we can following team 1 & 2 in because you can never have too many people on a hand carry. Hand carry = fast fatigue = rescuers tweaking their backs if they don't have relief to rotate out of the carry.

I REALLY LIKE YOU SUMMIT!!! Gotta love the titanium stokes, eh? As far as rescuers go... as many as possible for a carry out in wilderness terrain. We ran a swiftwater recovery two months ago. ~2 miles fromt the trailhead is where we recovered the remains of a 350 pound guy. OH MY GOD, talk about painful!!! 5 SAR members, 4 forest service FFs, and a two LEOs... and we were in pain by the end!!! In this case you would have had (in the end) 7 SAR team members, 1 deputy, 5 Forest Service FFs, and the Ambo Crew (if they went in) for a total of 15, in addition to the nurses and other adult group leaders you could have used.

 

[Summit]

If you have this available, probably is the way to go in this case. I WANT ONE!!! Just have to convince the old timers with their 150 years of combined experience in SAR.

Send them to talk to us. We'll help you convince them! I don't know any teams in my area that don't have one, and we are in the ROCKY mountains. PM me your email, I'll send you some pics of our team in action with our wheeled litter (which is nicer than the one I pictured above).

And, yep, Ti stokes = win.

 

[8jimi8]

LOL completely my bad.

i was thinking "wheeled cot."


i wasn't thinking a litter on a tractor wheel lol.

Anyway. My point was not about clearing them for vomit, it was about the wheel vs. IICP... if indeed the patient is suffering from an increased intracranial pressure, bumping them along (rolling) down the trail will further increase ICP and brain damage. I know it gets bumpy on a hand carry, but it seems it would be less jarring than a wheel.

But, again, I now understand what you meant and I have no experience with that equipment. If it has some good suspension my worries may be unnecessary.

 

[Mountain Res-Q]

LOL completely my bad.

i was thinking "wheeled cot."


i wasn't thinking a litter on a tractor wheel lol.

Anyway. My point was not about clearing them for vomit, it was about the wheel vs. IICP... if indeed the patient is suffering from an increased intracranial pressure, bumping them along (rolling) down the trail will further increase ICP and brain damage. I know it gets bumpy on a hand carry, but it seems it would be less jarring than a wheel.

But, again, I now understand what you meant and I have no experience with that equipment. If it has some good suspension my worries may be unnecessary.

LOL... ya... I think I would veto the gurney idea as well should someone suggest that. The image in my head rocks though! Likewise, I have no personal experience with the wheels, but from what I understand it is far more comforatable (usually) than carrying them out. Carrying with that many hands on a rocky and not-level terrain can be quite a ride; you rock, you bounce, you lean, you may fall, and there is a constant need to switch out people to carry and/or set down the litter, which creates more movement issues... but sometime ya gotta do what ya gotta do... in wilderness SAR, the rules often go out the window and it becomes a matter of what works best here and now to ge the job done in a safe manner.

 

[rescuepoppy]

LOL... ya... I think I would veto the gurney idea as well should someone suggest that. The image in my head rocks though! Likewise, I have no personal experience with the wheels, but from what I understand it is far more comforatable (usually) than carrying them out. Carrying with that many hands on a rocky and not-level terrain can be quite a ride; you rock, you bounce, you lean, you may fall, and there is a constant need to switch out people to carry and/or set down the litter, which creates more movement issues... but sometime ya gotta do what ya gotta do... in wilderness SAR, the rules often go out the window and it becomes a matter of what works best here and now to ge the job done in a safe manner.

My feelings exactly no crew I have ever seen can carry a stokes through rough terrain without some jarring and tilting of the basket. We do not have a wheeled litter but I have used them while providing mutual aid. In this scenario I would like to get my first strike team which in my area would most likely have at least one I or P to the patient as quickly as possible with medical equipment. Our wilderness packs are pretty well stocked, and rotated so we would be able to provide advanced level care. Then I would have the rest of the teams start carrying in the gear needed for the carry out. This would include setting up any rope assists that might be needed. They would also be setting up staging areas for extra hands to trade out hands as needed. Also I would have dispatch on the phone rounding up all of the mutual aid they could find. You can never have too many hands when doing a long carry out. As for the chopper I would wait until we were out of the woods to make that call.

 

[Mountain Res-Q]

My feelings exactly no crew I have ever seen can carry a stokes through rough terrain without some jarring and tilting of the basket. We do not have a wheeled litter but I have used them while providing mutual aid. In this scenario I would like to get my first strike team which in my area would most likely have at least one I or P to the patient as quickly as possible with medical equipment. Our wilderness packs are pretty well stocked, and rotated so we would be able to provide advanced level care. Then I would have the rest of the teams start carrying in the gear needed for the carry out. This would include setting up any rope assists that might be needed. They would also be setting up staging areas for extra hands to trade out hands as needed. Also I would have dispatch on the phone rounding up all of the mutual aid they could find. You can never have too many hands when doing a long carry out. As for the chopper I would wait until we were out of the woods to make that call.

It is always interesting how variopus SAR teams are set up and equipped given the various areas and mission types they perform. We ran a call for a missing person (foul play) several years ago (still missing - FBI case now) where she crossed 4 countied before her car was found in our county. Two of those other counties are in Nevada (high desert) and they wanted to assist us. COOL! We need dogs, trackers, and some major ropes work (1200 foot rappelling and such). They offered us the use of their 20+ ATVs, dune buggies, and jeeps... yah... not really needed or useful in our area. But for them, they need those kind of assests; whereas, our swiftwater team, dive team, and such would be useflees in their area.

In this particular call, however, no I's. We have P's and (on some calls) our ER MD; but all BLS level equipment. Ropes were not needed. Phones? No cell coverage. Sat phones never seem to work for us in our area. Radios? Spotty at best. We often have to have Forest Service relay messages for us (if we can even get ahold of them. And we have an issue of requesting too much non-SAR "assistance" as the various Fire agencies, LEOs, and Forest Service folks all like to think they are in charge. And since they usually get on scene first, they tend to make some really bad desisions. Last month they lauched a night-time 3-4 mile hike/search before we got on scene and ended up getting lost in the woods. They had 4 engine crew, 3 chiefs, the medics, and the USFS LEOs on scene (and in the woods getting lost) when all that was needed was one SAR truck with four rescuers. Two weeks ago they used a helo to short haul an ankel sprain and almost killed the pt. by failing to properly hook up the rigging and almost dropping the pt. in a lake! All for an ankel that needed 30 minutes to hike them out to a waiting boat.

I too prefer to be helo conservative. Not taying that they don't have their place, but they need to be used properly... they are not a substitute for real SAR logical and skill. Example... I just got back (one hour ago) from a call for two missing hikers. The SAR response was great, but a lot of work would have been involved in locating them (days maybe on the ground). After 2 hours, the helo saved us a lot of work (and poision oak) by locating and extracting the victims.