Archive for the ‘Ecotourism’ Category

IX. Patient Assessment System – Checklist

April 29, 2008

Part 9 of 9: PATIENT ASSESSMENT CHECK LIST:

SCENE SURVEY:
Is the SCENE SAFE?
Is the PATIENT SAFE?

PRIMARY SURVEY: 
Are they CONSCIOUS?
Do they have an OPEN AIRWAY?
How is their BREATHING?
Do they have a PULSE? 
Are they BLEEDING?
Are there any serious injuries on the CHUNK CHECK?
Is their neck and spine STABLE?
Do they need to be MOVED?
Do we need to protect them from the ENVIRONMENT?
How is everyone else DOING?

SECONDARY SURVEY – VITAL SIGNS:
What is their RESPIRATORY RATE & EFFORT?
What is their HEART RATE & EFFORT?
What is their LEVEL OF CONSCIOUSNESS?
What is their SKIN COLOR, TEMPERATURE, & COLOR?

SECONDARY SURVEY – PATIENT EXAM:
HEAD  – scalp, face, eyes, nose, mouth.
NECK  – spine, trachea.
CHEST – clavicles, shoulders, ribs.
ABDOMEN – compress the abdomen.
PELVIS – compress the pelvis anterior/posterior and lateral.
LEGS  – circulation, sensation, and motion.
ARMS  – circulation, sensation, and motion.
BACK  – log roll and palpate the length of the spine.

SECONDARY SURVEY – AMPLE HISTORY:
ALLERGY – allergy to drugs, foods, insects, etc. 
MEDS  – prescription and non-prescription drugs.
PREVIOUS – significant past medical history, surgeries, etc.
LAST   – last intake & last output.
” EVENT – events leading up to this crisis.

SOAPnote:
Putting it all together and creating a treatment plan.

RESCUE PLAN:
” Looking at all factors and creating a rescue or evacuation plan.

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VIII. Patient Assessment System – Rescue Plan

April 22, 2008

Part 8 of 9: PAS – STOP – RESCUE SURVEY: Do we need help?

Are we staying or going?
What is our plan to get help?
Who is going to go to get help?
What do we do to protect the patient while waiting for help to arrive?
What do we do to protect ourselves while waiting for help to arrive?
Is the scene safe?

RESCUE PLAN: Do we need help?

Group’s condition:
How well is each individual in the group doing?
How well prepared is the group to stay put and bivouac?

Decisions:
Do we need to evacuate the patient or can we all go on?
If evacuation is needed, send for help.
While waiting for rescue – build a bivouac.

Sending for help:
Send two to get help if possible.
Send out a SOAPnote on the patient.
Send out a list of the rest in the group and how well prepared you are to bivouac.
Send out a map with your exact location and time marked on it.

While waiting for help to arrive:
Know where everyone is; pair people up to massage each other’s feet, etc.
Keep everyone busy.
Create shelter for everyone.
Get water or melt snow and make something warm to drink.
If food available, make a meal & eat.
Keep spirits up, be positive, reassure, make sure everyone has something to do.
Create light and warmth; build a fire.
Make yourselves big, easy to find.
Continuously monitor your patient.
Continuously monitor everyone else in the group.

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VII. PAS – Secondary Survey – SOAPnote:

April 15, 2008

Part 7 of 9: PAS – SOAP note: What is our patient care plan? 

The SOAP note is organized into the Subjective date, Objective date, the Assessment, and the Plan.

Subjective:
The subjective date is their age, sex, the mechanism of injury (MOI), and the chief complaint (C/C), i.e., what they are complaining of.

Objective: 
The objective date consist of their vital signs, the patient exam, and the AMPLE history.

Vital signs: 
Time the vitals signs are taken:   
RR & Effort    
HR & Effort(BP)    
LOC    
Skin: C/T/M    

Patient exam:  Describe locations of pain, tenderness & injuries.
                                                                                                                                               
AMPLE history:
Allergies:           
Medications:             
Past pertinent medical history:         
Last intake & output:           
Events leading up to accident:         

A – Assessment:  (problem list)
1.                                                                                                                                                  
2.                                                                                                                                                   

P – Plan:  (plan for each problem on the problem list)
1.                                                                                                                                                   
2.                                                                                                                                                  
3.  MONITOR – reSOAP your patient every 5 – 15 minutes.

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VI. PAS – Secondary Survey – AMPLE History:

April 8, 2008

Part 6 0f 9: PAS – AMPLE History: What is their past medical history?

ACTION:
Talk with your patient or others to determine the following information:

A – Allergies:
Are they allergic to any medications, foods, insects, etc.? 
If they are what happens and how is it treated?

M – Medications:
What medications are they taking, both prescription and over-the-counter?
If they are taking medications, how often and how much do they take and have they taken their meds today?

P – Previous Injury or Illness:
Is there any recent or past injury or illness that could contribute to the current problem?
Have they ever been hospitalized over night for any medical problems, is so what?

L – Last Input and Output:
When was the last time they had anything to eat or drink?
What did they eat and drink?
When was the last they voided or had a bowel movement?

E – Events leading up to the crisis:
What lead up to or occurred just prior to the critical event?

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V. PAS – Secondary Survey – Patient Exam:

April 1, 2008

Part 5 of 6: PAS – PATIENT EXAM: What are their injuries?

PRINCIPLES OF THE PATIENT EXAM:
You are trying to discover all possible injuries by:
LOOK:
Inspect:  Is there any bleeding, wounds, impaled objects, or deformities?
Compare:  Are their body parts symmetrical?
LISTEN:
Complaints: Are they complaining of pain or tenderness, if so, isolate where it hurts?
FEEL:
Palpation: Is there tenderness in muscles, bones, or joints?
Circulation:   Are there pulses in all four extremities?
Sensation:   Is there normal sensation in all four extremities?
Motion:   Is there normal range of motion is all four extremities?

ACTION:
Keeping the above principles in mind do a hands on head-to-toe exam:
HEAD:  scalp, face, eyes, ears, nose, mouth.
NECK: cervical spine, trachea.
CHEST: clavicles, gently compress the rib cage.
ABDOMEN: compress the abdomen in all four quadrants.
PELVIS: compress the pelvis front to back and laterally.
ARMS: palpate the muscles and flex the joints.
LEGS: palpate the muscles and flex the joints.
BACK: palpate the length of the back.

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IV. PAS – Secondary Survey – Vital Signs:

March 25, 2008

Part 4 of 9: Patient Assessment System – Vital Signs:

STOP – SECONDARY SURVEY: How hurt are they?
The Secondary Survey consist of:
How well are they? Vital Signs
What are their injuries? Patient Exam
What is their past medical history? AMPLE History
What is our patient care plan?  SOAPnote

VITAL SIGNS: How well are they doing? 

Respiratory Rate and Effort:
Respiratory rate and effort shows us how well the Respiratory System, the airway and lungs, is doing at oxygen exchange and in particular, in supplying the brain with O2.
LOOK – Do they look like they are having difficulty breathing?
LISTEN – Are they complaining of shortness of breath or difficulty breathing?
FEEL – Is the chest moving properly with breathing?

Heart Rate and Effort (blood pressure):
The heart rate and effort, blood pressure, tells us how well the Circulatory System, the heart and blood vessels, are doing.
LOOK – Do they look shocky?
LISTEN – What is there heart rate, beats per minute.
FEEL – Take a blood pressure by palpation (systolic), if you do not have a BP cuff.

Level of Consciousness:
Level of consciousness tells us how well the Central Nervous System, the brain and spinal cord, are doing.

Action:
Level of Consciousness (LOC) is determined using the AVPU scale:
Awake, Verbal, Painful, Unresponsive.

Conscious: “The lights are on, is anyone home?”
Awake, their eyes are open but, are they alert oriented times 3, person, place, and time?
Person, do they know who they are?
Place, do they know where they are?
Time, to they know the day, week, and year?

Unconscious: If their eyes are closed they are unconscious, but how responsive are they?
Verbal stimuli, “Hello, anyone in there?”
Speak to them, do they react to hearing their name?
Do they follow simple commands?
Painful stimuli, “That’s got to hurt.”
A knuckle rubbed on their sternum?
Is it an appropriate response to pain?
Unresponsive, “Speak to me; say something.”
No response to verbal or painful stimuli.

Skin color, temperature, and moisture:
Skin color varies by individual and race.
Look – What is their skin color, pale, ashen, cyanotic?
Listen – Are they complaining about feeling hot or cold?
Feel – Is their skin dry, moist, clammy, hot, or cold?

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III. Patient Assessment System – Primary Survey

March 18, 2008

Part 3 of 9: Patient Assessment System – Primary Survey

STOP – PRIMARY SURVEY: Are they alive, and are they going to stay alive?

A: Approach and Assess – Are they conscious and can they speak?
A: Airway – Do they have an open airway?
B: Breathing – Are they breathing?
B: Breathing – How well are they breathing? 
C: Circulation – Do they have a pulse? 
C: Circulation – Are they bleeding?
D: Deformity – Are there any obvious deformities?
D: Disability – Is their neck or back at risk of injury?
E: Environment – Can they stay where they are?
E: Everyone Else – How is everyone else in the group doing?

A: Approach and Assess – status of the central nervous system
Are they conscious and can they speak?
Look – Are they awake; are their eyes open; what position are they lying in?
Listen – Speak to them. Do they speak back?
Feel – What is your general impression of the situation?

A: Airway – status of the respiratory system
Do they have an open airway?
Look – Is there anything in their airway?
Listen – Can you hear air moving in and out of the airway?
Feel – Can you feel air moving in and out of the airway?

B: Breathing – status of the respiratory system
Are they breathing?
Look – Is their chest wall moving as they breathe?
Listen – Can you hear any adventitious breath sounds indicating a partially occluded airway, such as wheezing, gurgling, or snoring?
Feel – Is the chest wall moving appropriately with respirations?

B: Breathing – status of the respiratory system
How well are they breathing?
Look – Is their chest wall moving as they breathe?
Listen – Can you hear any adventitious breath sounds indicating a partially occluded airway, such as wheezing, gurgling, or snoring?
Feel – Is the chest wall moving appropriately with respirations?

C: Circulation – status of the circulatory system
Do they have a pulse?
Look – Is there any bleeding?
Listen – Can you hear a heartbeat?
Feel – Can you feel a carotid pulse?

C: Circulation – status of the circulatory system
Are they bleeding?
Look – Is there any bleeding?
Listen – Can you hear a heartbeat?
Feel – Can you feel a carotid pulse?

D: Deformity
Do they have any obvious injuries or deformities?
Look – Do you see any obvious injuries or deformities?
Listen – Where are they complaining of pain?
Feel – Where does it hurt? As you touch them, where can you cause pain?

D: Disability
Is their neck or back at risk of injury?
Look – What was the mechanism of injury (MOI)? Can they move their extremities?
Listen – Are they complaining of any neck or back pain?
Feel – Do they have normal sensation in their extremities?

E: Environment
Can they stay where they are?
Look – Where are they lying?
Listen – Are they complaining about being hot, cold, or wet?
Feel – Is their skin warm, dry, cold, or wet?

E: Everyone Else
How is everyone else in the group doing?
Look – How does the rest of the group look?
Listen – Is anyone complaining of being cold, wet, hungry, or thirsty?
Feel – What is the emotional status of the group?

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Musculoskeletal Trauma – Fractured Pelvis:

August 27, 2007

EXAMINATION & EVALUATION of the Pelvis and Sacrum:

Principles of Management:
The Pelvic bowl is a very vascular area.
A fractured pelvis can be a source of severe internal bleeding.
Can only shift a fractured pelvis once.
MOI: The pelvis is injured by direct impact and/or compression.

Level Of Consciousness:
To properly evaluate the pelvis the patient needs to be awake & alert with no other distracting injuries.

Signs and Symptoms:
Typically in severe pain and unable to walk.
They will have guarding, in that they will not be willing to move their legs or try to sit up.

Physical Exam:
Place your hands on the sides of the pelvis, over the iliac wings, and gently lean on the pelvis pushing it towards the floor or ground and then with you hands in the same position compress the pelvis by pushing your hands towards each other, lateral compression, as if trying to close and open book.
Any motion and/or pain indicates a fractured pelvis.

Treatment:
You can only move a fractured pelvis once, due to the risk of internal bleeding.
The pelvis is lined with a great many of blood vessels, it is very vascular and can therefore be the source of a major internal bleed and hypovolemic shock.
During exam if the pelvis shifts, like closing a book, do not let go, hold the pelvis closed until a pelvic binder can be applied or improvised.
A pelvic binder is a 6″ – 8″ wide piece of fabric that is wrapped around the pelvis and then secured to prevent the pelvis from falling open. This can be improvised from any 6″ – 8″ wide piece of cloth and secure it with cravats or belts to hold the pelvis still and prevent it from falling open.
There are also commercially available pelvic binders.
In the long-term care setting you should also wrap the abdomen with two 6″ wide ACE bandages to shrink the potential space for blood to collect in the abdomen if internal bleeding were to occur.
MAST or Pneumatic Anti Shock Garments also work very well to stabilize a fractured pelvis and control internal bleeding.
Treat for shock:
 Keep flat on their back.
 Adminster O2
 IV fluid for shock if indicated.
Monitor vital signs.
Transport ASAP.

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Musculoskeletal Trauma: Spinal Cord Injury Mangement:

May 2, 2007

Pre-hospital personnel are trained to treat all possible spinal cord injuries based on the Mechanism Of Injury (MOI) as well as symptoms and complaints.

It is important in the wild environment for rescuers to recognize a possible back injury based on MOI, but, it is equally important that they be able to rule out a spine injury or “clear the spine” by a proper history and physical exam in order to avoid an unnecessary litter evacuations.

SPINE EXAMINATION & EVALUATION:

1.  Mechanism of injury (MOI):
The neck, cervical vertebra, is broken by flexion and axial loading (C4/5)
The upper back, thoracic vertebra, by direct force.
The lower back, lumbar vertebra, by compression or rotation (T12/L1)

2.  Level of Consciousness (LOC):
AVPU scale: Awake, Verbal, Pain, Unconscious
Are the conscious, coherent, sober, or in any way obtunded.
Monitor every 15 minutes until stable, every 1 hour x 24 hours.
If unconscious or obtunded, treat as if injured until AWAKE & ALERT.

3.  Pain & Guarding:
Is there a “distracting” pain.
Are they complaining of pain anywhere in the vertebral column.
Is there radiating pain, numbness, paresthesias into the hands/arms.
Are they guarding or is there paravertebral muscle spasm.

4.  Tenderness (tenderness = pain on palpation):
Is there pain on palpation over the vertebra or in the vertebral muscles.

5.   Circulation, Sensation, & Motion (CSM):
Can they feel and move all four extremeties.
Can they move their neck and back,
With movement, is the back pain free,
With movement, is there any locking sensation or impairment.

TO CLEAR THE SPINE & BACK, they must be:
Awake, alert, oriented x 3, completely sober, have no distracting pain.
Be pain free and no palpable tenderness on physical exam.
No palpable step-offs or malalignments.
Have full C/S/M in all 4 extremeties (not caused by another injury).
Active range of motion without pain or locking.

Spinal Cord Injury Management:
Move patient into proper anatomical position = supine.
Maintain alignment = move as a unit when lifting or rolling.
Keep supine, unless an airway problem that requires the “Recovery position”
The most dangerous cervical motion is flexion.
The most dangerous thoracic & lumbar motion is rotation out of alignment.
Provide cervical immobilization with bulky, conforming, comfortable materials.
Keep supine on ensolite pad in bivouac.
If unconscious, monitor airway, if unable to monitor place in recovery position.
Transport on well-padded but rigid/stiff back supporting materials.

Cervical Collars:
Long-term cervical collars can become very uncomfortable.
You can improvise a very comfortable and immobilizing collar with a soft blanket or
clothing such has a pile jacket.  They provide support, comfort, and warmth.

Backboards:
Backboards or litters are only necessary for the carry-out. 
They will become very painful over time so they require extra padding especially behind the knees and in the small of the back.
Backboards are not required in litters.
 
While waiting for help to arrive simply keep the patient still and comfortable.
Remember not to flex the neck and keep the spine straight by log rolling the patient.

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The Principles of Managing Musculoskeletal Trauma in the Backcountry

April 2, 2007

Assessment:  Look, Listen, and Feel

Look: 
Look at possible fracture sites.
Remove clothing, remove boots, and socks.  
Do you see any wounds, deformity, angulation, discoloration, or swelling?
Look around: 
What was the Mechanism of Injury (MOI)?
If the MOI indicates a possible fracture, treat as such. 
Listen: 
Talk to the victim. 
Did they feel anything break, snap, crack, or pop? 
Is there decrease in normal function? 
Is there guarding?
Feel: 
Check Circulation, Sensation, and Motion (CSM)?
Is there any point tenderness or crepitus?
WHEN IN DOUBT, SPLINT!

The Principles of Splinting:

Circulation, Circulation, Circulation
Is there good circulation distal to the site of the injury?
Can the injury be immobilized in the position found?
If not, pull traction-in-line to slowly and gently move the extremity into proper anatomical alignment. This is to establish and maintain good circulation distal to the site of the injury.
Create a rigid but very well padded splint.
Splints should be BUFF; Big, Ugly, Fat, and Fluffy.
It is more important for a splint to be well padded than rigid.
Immobilize the entire extremity, the joint above and below the site of the injury.
Monitor all splints, check C/S/M distal to the site of the injury every fifteen minutes for the duration of the evacuation.
In the cold winter environment beware of the risk of frostbite in immobilized extremities, may have to apply chemical heat packs to the hands and feet. 

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