We have many resources for Wilderness First Aid graduates and future students available for free. Check them out and also check out our Online Wilderness First Aid courses here.
Scenario Saturday. Almost every Saturday I release a new scenario that enables you to practice your first aid sleuthing skills. Check out this week’s scenario, “The Pale-Red Runner.”
Patient Care Flow Diagram. I’ve updated the Patient Care Flow Diagram and added bonus content accessible with hyperlinks and for the printed version, QR Codes. Bonus Content includes video demonstrations and lectures from the WFA Course that you can view on your cell phone or computer.
Bleeding Control Course. Review the Day 2 Bleeding Control lectures and demonstrations by viewing the free Bleeding Control Course. Included is a downloadable, updated Bleeding Control Flow Diagrams (with Bonus Content) and Wound Packing and Hemostatic Dressing demonstrations that I began including in my 2020 classes
You are working the first aid tent at the finish line for a 5K road race on a Saturday morning. As the runners are finishing the race they are provided bottled water. The tent is full of runners and volunteers. You notice one runner because her skin is pale. You recognize that is unique because the runner just completed 5K and most other runner’s skin is pink if not slightly flush. You go on about your work handing out water bottles. It is sunny and the temperature is 80 degrees Fahrenheit (26 degrees Celsius) and about 80% humidity.
About 10 minutes later you notice this same runner sitting on a bench in the sun, bent over and supporting her head with her hands. You are concerned, so you walk over to the runner. You identify yourself by saying your name, that you are certified in first aid and asking if you can help her. She says yes and you ask her for her name. She hesitates and you soon realize that she does not know her name. You also notice that the skin color on her arms, legs and face is red.
SAMPLE History
You ask the runner SAMPLE History questions and she is acting confused.
Signs and Symptoms – Altered level of consciousness. The skin is red. The patient is thirsty.
Allergies – The patient does not know
Medications – The patient does not know
Past Medical History – The patient does not know
Last In/Last Out – The patient tells you she is drinking water now.
Events Leading Up to the Present Crisis – The patient run a 5k race
Vitals
You ask the patient if you may take her pulse. She agrees.
Heart Rate: 116
Respiratory Rate: 28
Skin Presentation: Red, Hot and Moist
Level of Consciousness: A+0x2. She is not able to tell you her name. She is visibly frustrated by this. She does know that it is Saturday and the name of the city where the 5K race is taking place.
Time: 10:45 AM
Physical Exam
None required at this time. The patient did not fall and is not complaining of abdominal pain or nausea.
What is possibly wrong with this patient?
Let’s evaluate the clues we discovered during our interaction with the patient.
Skin. The weather is 80 degrees F, 80% humidity and sunny. The patient has just completed a 5K road race. Her skin should be pink – maybe slightly flushed, warm and moist. When she first entered the tent after the race her skin was pale, cool and moist. She is vasoconstricted. She is hypovolemic. Since she is dehydrated, her blood volume is down and the body has to compensate for lowered blood pressure by constricting the blood vessels in the patient’s extremities and skin. She is dehydrated and probably suffering from heat exhaustion.
Ten minutes later you notice the patient sitting on the bench in the sun. This is not a good place for someone to be when they are presenting with the signs and symptoms of heat exhaustion. The patient should be in the shade or an air-conditioned area, sipping water and actively cooled by being sprayed with water and fanning. This is not the case for this patient. She continued to become hotter sitting in the sun. The body recognizes that the only way to rid itself of excess heat is to vasodilate the blood vessels to hopefully radiate all the heat in the body out into the atmosphere. By the time you walk up her skin is now presenting red, hot and dry. She is vasodilated and transitioning into heatstroke. With the blood vessels in the body vasodilated, her blood pressure is dropping.
SAMPLE History. The patient is confused and not able to answer questions. She does not know the answers to the questions you are asking her.
Vital Signs.
Level of Consciousness. When you asked the patient her name she hesitated and could not remember. This is upsetting to her. She does know the day and the city she is in. She is A+Ox2. Her consciousness is altered because her blood pressure is falling and the brain is not getting enough oxygen. This results in an altered level of consciousness that will only get worse if she does not receive immediate medical attention.
Heart Rate. Elevated. The normal heart rate for an adult is between 60 and 90 beats per minute. Even though it has been a good 15 minutes since she completed the race, her heart rate should be back into the normal adult range. You measured 116 beats per minute. The body is attempting to compensate for the falling blood pressure by increasing the heart rate.
Respiratory Rate. Elevated – 28 breaths per minute. The normal respiratory rate for an adult is between 12 and 20 breaths per minute. The body requires more oxygen because of the increased heart rate.
Skin. Red, hot and moist, The patient is vasodilated because the body is attempting to radiate excess heat into the atmosphere.
The patient is presenting with an altered level of consciousness, so let’s start on page 19.
We see the signs and symptoms the patient is presenting in this flow diagram – disoriented, thirsty, altered level of consciousness and not acting like themselves. We look through the list of possible causes of these signs and symptoms and the one that makes the most sense in this situation is Temperature – the patient is too hot. That leads us to page 22 – Heat Illnesses.
On page 22 we very quickly identify what is wrong with the patient. She is presenting with the signs and symptoms of Heat Stroke. She requires immediate medical care. Call 911 or since this is a road race, EMS should already be at the race so notify them. While you wait on EMS to arrive, remove the patient from the sun and place her in a shaded or cooled area. Remove any excess clothing, spray the patient with water and fan her vigorously. Back off of fanning if she begins to shiver. Provide the patient with water and or electrolyte drink, encouraging her to drink small, frequent sips. Continue providing care until you are relieved by EMS.
A tornado cut a five-mile-long path of destruction through a city of 50,000. You and your neighbors are working together to help each other find and collect personal possessions. A non-profit, disaster response organization brought box lunches and bottled water to the neighborhood about two hours ago. It’s approximately 2:00 PM, 80 degrees Fahrenheit (27 C), 90% humidity and sunny.
You have been working with your next-door neighbor, Sean since 9 am. He is 42 years old, 5 foot 9 inches tall, and weighs approximately 200 lbs. Your neighbor complains that he feels nauseous and his upper back is starting to hurt. You suggest that you both sit down in the shade, take a break and drink some water.
You notice that Sean’s skin is pale and moist.
While you both rest and drink water, you explain to Sean that you graduated from a Wilderness First Aid Course and a big part of the course is deciphering illness signs and symptoms, You tell Sean that you may be able to help if you can ask him some questions. Sean agrees.
SAMPLE History
You ask Sean SAMPLE History questions.
Signs and Symptoms – Nausea and pain in the upper right back near the shoulder.
Allergies – Seasonal allergies
Medications – Allegra for seasonal allergies.
Past Medical History – Sleep apnea. Uses a CPAP nightly. You ask if what he is feeling now has ever happened before. Sean says he can’t remember.
Last In – Box lunch at around 12 noon. Cold cut sandwich with mayonnaise, potato chips, and the chocolate chip cookie. Sean has been drinking bottled water all day. The bottle he drank at lunch was his fourth bottle of the day. You ate the exact same lunch.
Last Out – He peed right before lunch and his pee was clear with no smell. He says he pooped this morning and it was normal.
Events Leading Up to the Present Crisis – Cleaning up the neighborhood since 9 am and feeling fine until about an hour after eating lunch. After lunch, he felt nauseous and he started feeling a sharp, stabbing pain in his upper right back.
Vitals
You ask Sean if you may take his pulse. You explain that just like when we visit the doctor, this is part of understanding why a person is not feeling well. Sean agrees. He tells you the pain in his upper right back shoulder is increasing. Remember, we never tell the patient that we are measuring their respiratory rate. Patients have a tendency to slow down their breathing if they know their respiratory rate is being measured – another nugget of information you’ll learn in the Wilderness First Aid course.
Heart Rate: 76
Respiratory Rate: 16
Skin Presentation: Pale, Cool and Moist
Level of Consciousness: A+0x3
Time: 2:15 PM
Physical Exam
You explain to Sean that you learned in the first aid class you attended that nausea is sometimes caused by an abdominal organ not functioning properly. You explain the technique you learned in class about dividing the abdominal area into four quadrants, gently pushing in and quickly releasing pressure in each quadrant. If there is something wrong Sean may feel pain. You explain that this could help understand if Sean has a serious condition that requires immediate medical attention. You did a great job in explaining your training because Sean agrees to lay on his back and allow you to examine him.
You start with the Left Lower Quadrant, slowly pushing in and quickly releasing pressure. Sean reports no pain. Left Upper Quadrant – no pain. Right Lower Quadrant – no pain. Right Upper Quadrant – Sean complains of pain when you push in. You push in again on the Right Upper Quadrant and Sean asks you not to push again. It hurts.
Conclusion What is possibly wrong with Sean? Let’s evaluate the clues we discovered during our exam.
Skin. The weather is 80 degrees F (27 C), 90% humidity and sunny. Sean has been working since 9 AM. His skin should be Pink, Warm and Moist. His skin is presenting Pale, Cool and Moist. Sean is vasoconstricted. This is your first clue that something is wrong.
Last In/Last Out. Sean has been drinking all day, so he is probably not dehydrated. However, he reports that he began to feel nauseous and began feeling a sharp pain in his upper right back near the shoulder. That is your second clue that Sean may have a serious illness.
Physical Exam. In our Wilderness First Aid courses, we teach that anytime a patient complains of nausea and/or abdominal tenderness, perform a physical exam of the abdominal area. Divide the abdominal area into four quadrants that are created by drawing a vertical and horizontal line that intersects at the patient’s belly button. Then gently push into each quadrant and quickly release pressure. If the patient complains of any pain then the patient needs to seek definitive medical care.
Abdominal Pain Considerations where you learn that Sean possibly has gallstones and needs to see a medical professional. Gallstones are not a medical emergency so you encourage Sean to see a doctor as soon as possible.
