Backstory

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.

Diagnosis. Using the flow diagrams in Wilderness First Aid Made Easy you are directed to Page 11,

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.

Save your family in times of medical emergencies.

Twenty-three percent of people who suffer a traumatic injury or illness die while waiting for EMS to arrive. A disaster can delay EMS for hours.

Learn to be prepared and be someone’s hero. http://urban.udtwfa.com #BESOMEONESHERO

Here are two PPE items you need to add to your first aid kit today.

Eye Protection. You want to add anti-fog goggles to your tool kit to protect you from patient liquids and respiratory aerosols. We recommend the DEWALT DPG82-11/DPG82-11CTR Concealer Clear Anti-Fog Dual Mold Safety Goggle. If you are not a fan of the Dewalt yellow color on the goggles, our other recommendation is NoCry Safety Glasses with Clear Anti Fog Scratch Resistant Wrap-Around Lenses and No-Slip Grips, UV Protection. Adjustable, Black & Green Frames

Face Covering. If a face covering is not part of your first aid kit, you need to add it now. Our suggestions include the N95, but they are impossible to procure due to being sold only to hospitals and medical providers as of this writing so check out the Respirator for Dust, Pollen, Allergies, Paint.

Keep yourself safe out there.

Wilderness Medical Society Clinical Practice Guidelines for Diabetes Management discusses treatment for patients presenting with severe hypoglycemia. Backcountry guidelines state that for a patient that can swallow, 15 – 20 grams of sugar should be administered to the patient through oral administration. Most wilderness medical schools instruct students that best practice treatment for patients who are unable to swallow or are unresponsive is to place the patient in the recovery position. Mix 15 – 20 grams of sugar with just enough water to create a paste.  Using your gloved fingers, rub the sugar paste into the patient’s gums. 

You may find during the primary or secondary assessment that your patient has a Glucagon emergency injector kit which requires the caregiver to deliver an intramuscular injection to the patient. You should familiarize yourself with the instructions for use if you have a family member or you are leading an outdoor group where a member carries an emergency injector.

However, you may find the patient has a Glucagon intranasal delivery device. One that you may see currently advertising on television is Eli Lilly’s BAQSIMI™.  Lilly’s website states: “BAQSIMI is a prescription medicine used to treat very low blood sugar (severe hypoglycemia) in people with diabetes ages 4 years and above.” “BAQSIMI should be used when someone is having a low blood sugar emergency, where the person is unable to eat or drink and needs help from someone else.”

BAQSIMI is administered by inserting the applicator tip into one nostril and pressing the device plunger all the way in until the green line is no longer showing. The dose does not need to be inhaled.

Instruction for Use: PDF download and video instructions. 

For patient that is presenting with severe hypoglycemia, you should activate the EMS System and the patient requires immediate evacuation to the hospital.

The BAQSIMI and Got Your BAQ designs are trademarks of Eli Lilly and Company.