<h1>Longleaf Wilderness Medicine Interactive Case Study</h1>
The following case study is an exercise of your critical thinking skills given a wilderness medical scenario. Use the patient assessment system to reveal issues facing your patient and to formulate a plan.
To complete the case study follow the in text prompts. If you need to go back to review information, use the back button in the scenario and not your browser. Refreshing your browser will restart the scenario.
Document your findings using a SOAP note or other record keeping method. If you would like a SOAP note to fill out as you complete the case study click <a href="https://www.longleafmedical.com/uploads/1/3/6/7/13679433/2018_soap-wfr.pdf" target="_blank">here</a>
[[Start->Scene]] <h1>Scene</h1>
You are leading a small group on a bike tour in the Oglala and Buffalo Gap National Grasslands of Northern Nebraska and South Dakota. The trip will cover a roughly 126 mile loop of dirt roads and double track over five days. Your bikes are loaded with camping gear, food, and water. Each bike is fitted with four 1 ½ liter water bottles.
There is minimal water on the first leg of the route, except for a refill station you plan to reach afternoon of day two and one more in the last 50 miles of the journey.
[[Check Weather Conditions->Weather Conditions 1]] <br>
[[Next->Patient Presentation (Day 1)]]
[[Back->Trauma 1]]
<progress value="1" max="13"></progress>
<h1>Weather Conditions</h1>
It is early June, temperatures reaching high-70s during the day and low-50s overnight. The forecast for the next three days is sunny and warm, with temperatures steadily rising.
[[Back->Scene]] <h1>Patient Presentation (Day 1)</h1>
Shortly before reaching your first campsite you witness one of the members of your group slide on a loose patch of gravel and lose control while on a steep section of road. You watch as they slide to a stop on their right side, with their hands down for balance.
[[Scene Safety]]
[[Back->Scene]]
<progress value="2" max="13"></progress> <h1>Initial Assessment</h1>
Your initial assessment reveals no issues with airway or breathing.
Your patient has open abrasions on both palms and the right forearm, which are bleeding slowly. A blood sweep reveals an additional abrasion on the outside of their right thigh, but no life threatening bleeding.
Your patient denies losing consciousness or impacting their head or neck. An examination of their helmet shows no damage or abrasions.
Your patient is currently sitting on the ground, shaded by pine trees.
<b>Consider the gear that you might have with you in this scenario. Using this gear and your surroundings, describe the steps you would like to take to protect this patient from the environment.</b>
[[I'm ready to make a focused assessment->Focused Assessment 1]]
[[Review Weather Conditions->Weather Conditions 2]]
[[Back->Scene Safety]]
<progress value="4" max="13"></progress><h1>Focused Assessment</h1>
Consider the case and decide in what order you would like to complete the focused assessment.
[[Take a set of vitals->Vitals 1]] <br>
 [[Take a second set->Vitals1.1]] <br>
[[Collect a SAMPLE history->SAMPLE 1]] <br>
[[Perform a physical exam->Physical Exam 1]] <br>
<br>
[[I'm done with my focused assessment->What's next 1]]
[[Back->Initial Assessment 1]]
<progress value="5" max="13"></progress><h1>Vital Signs</h1>
You find the following vital signs, taken at 16:23: <br>
<b>HR</b> - 108 <br>
<b>RR</b> - 18 <br>
<b>SCTM</b> - Flush, Hot, Sweaty <br>
<b>LOR</b> - A+O x 4 <br>
[[What is normal?->Normal]]
[[Back->Focused Assessment 1]]
<h1>SAMPLE History</h1>
A SAMPLE History reveals explainable pain in all injury sites and no other issues. Your patient has no allergies, medications, or past pertinent history. Your patient reports eating, drinking, and using the bathroom normally. According to their history, their rear tire slipped on a loose patch of sand and gravel, they hit their brakes, causing them to lose control and skid.
[[Back->Focused Assessment 1]] <h1>Physical Exam</h1>
A focused physical examination reveals the following: <br>
An abrasion approximately 2” wide and 7” long on the pinky side of the right forearm, running lengthwise from wrist to elbow. The abrasion is bleeding slowly and show signs of foreign debris lodged into and under the skin. <br>
Abrasions covering the lower third of each palm, slowly bleeding and containing lodged foreign debris.</br>
Slight pain on flexion of the left wrist, but the patient has full range of motion and is able to hold a full water bottle.</br>
An abrasion, approximately 3” wide by 8” long, on the outside aspect of the right thigh. It is no longer bleeding actively and shows no sign of foreign debris.</br>
[[Back->Focused Assessment 1]]
<h1>What's Next?</h1>
Take a moment to review your findings for this patient.
<b>Make a prioritized list of problems for this patient<br><br>
Make a list of anticipated problems for this patient<br><br>
Does this patient require an evacuation?<br>
 [[Yes->Evac]] or [[No->Stay]]</b>
[[Back->Focused Assessment 1]]
<progress value="6" max="13"></progress><h1>Action</h1>
Your group decides to set up camp in a nearby clearing for the night. Despite the injuries, the group member is in good spirits. Rocks and debris are removed from the wound with tweezers and a safety pin. The abrasions are then gently washed with soap and around a 1 liter of potable water from your water supply.You note that you have around 1 ½ liters remaining. A thin layer of antibiotic ointment is applied to the abrasions, before wrapping them in clean gauze.
[[Next->Patient Presentation (Day 2)]]
[[Back->What's next 1]]
<progress value="7" max="13"></progress><h1>Patient Presentation (Day 2)</h1>
After breakfast on the second day, you dress your group member’s wounds with clean gauze. A thin clear yellow scab has formed over much of the abrasion and the borders are light pink.
Shortly after breaking camp and resuming your ride the injured group member hails you and explains that they are having difficulty gripping the handlebars without causing pain.
[[Initial Assessment->Initial Assessment 2]]
[[Back->Action 1]]
<progress value="8" max="13"></progress><h1>Initial Assessment</h1>
A quick assessment reveals no issues with airway, breathing, circulation, or injury to the head or spine. Your patient is dressed appropriately for the conditions and is protected from the environment with a long sleeve shirt and sunglasses.
[[Focused Assessment->Focused Assessment 2]]
[[Back->Patient Presentation (Day 2)]]
<progress value="9" max="13"></progress><h1>Review</h1>
<b>What new concerns do you have regarding your patient’s condition?<br><br>
Create a plan to address or prevent each of the problems listed.<br><br>
Does this patient require an evacuation?<br>
 [[Yes->Evac2]] or [[No->Stay2]]</b><br>
[[Back->Focused Assessment 2]]
<progress value="11" max="13"></progress><h1>Resolution</h1>
After discussing the situation with the trip leaders, the group member chose to voluntarily withdraw from the activity. While the injury was managed appropriately in the field, the injured participant raised concerns about completing the remaining 83 miles without further injuring the area, noting that they were having difficulty effectively holding the handlebars and braking.
After cleaning and changing the gauze wrapped around the right palm, additional gauze was added to help pad the area. Athletic tape was then wrapped around the palm to keep the gauze intact and provide more protection.
A plan was put into place to have a vehicle meet the group at a nearby access road to pick up the injured group member.
<b>Form a short report to reference during a call to the on-call program supervisor, who will be meeting the injured group member. Include the current condition of the patient and any additional resources that you would like to receive or have resupplied.<br>
[[What is a short report?->Short Report 2]]</b>
[[Discussion->Discussion]]
[[Back->Review]]
<progress value="12" max="13"></progress><h1> Discussion </h1>
Evacuation decisions can be very difficult to make in the field. LWM includes evacuation decisions in each course to guide the choice to leave the field based on injuries and illnesses that require being seen by higher levels of medical care. Although this patient did not meet the requirement for evacuation, a decision was made based on ability to safely participate in the activity. Include possible safety concerns when completing a problem and anticipated problem list. Carefully assess the participant and staff ability to manage any change in risk. It is appropriate to consider changes to the activity or intended route if you are unable to prevent additional injury
Consider the impact of the accident on the group’s supplies. Six liters of water per person was packed in, knowing that a refill station would be available on the afternoon of day two. A single liter was used to clean the patient’s abrasions. Wounds of this size, particularly ones contaminated by dirt and debris, may take many more liters. Unexpected events can change a well planned trip into a serious problem. What if the patient’s water bottles had spilled during the crash or if the refill station was closed unexpectedly? Depending on the circumstances, it may be necessary to change plans to accommodate unexpected changes. For example, the instructors in this example may choose to send one staff member ahead to refill the group’s water supply. The treatment of medical issues is only one aspect of the situation. A thorough patient assessment broadly considers anticipated problems, including resources and conditions in addition to the patient’s injury or illness.
[[Done->Finished]]
[[Back->Resolution]] <br>
<progress value="13" max="13"></progress><h1>Weather Conditions</h1>
It is early June, temperatures reaching high-70s during the day and low-50s overnight. The forecast for the next three days is sunny and warm, with temperatures steadily rising.
[[Back->Initial Assessment 1]] <h1>Normal Vitals</h1>
Normal vital signs for adults typically fall within these ranges:
<b>Heart Rate (HR):</b> 60-100 beats per minute<br>
<b>Respiratory Rate (RR):</b> 12-20 breaths per minute<br>
<b>Skin Color, Temperature, Moisture (SCTM):</b> Pink, Warm, Dry<br>
<b>Level of Responsiveness (LOR):</b> Awake & Oriented (A+O) to person, place, time, and event<br>
There are many reasons why a value you measure could fall outside of these ranges. For example, the heart rate ranges above are considered normal for patients at rest. A patient who is standing, walking, or who has recently exercised can have higher than normal heart rate without concern. Take the patient's situation into account when deciding whether these vitals are expected for your patient.
[[Back->Vitals 1]] <h1>Evac</h1>
You discuss your recommendation to evacuate the patient with your co-leader. In the course of the conversation, your co-leader suggests that they believe that an evacuation may not be necessary. They advise that, while the issue persists, the patient’s condition is being effectively managed and none of the evacuation criteria have been met. Special consideration is paid to whether the patient can continue the activity and whether their experience is overall positive.
Because they have not met any medical evacuation criteria, you and your co-leader give the decision to stay in the field to the patient. The patient states that they would like to remain on the trip and an agreement is made that the patient will advise the trip staff of any new symptoms or difficulty completing activities
<b>What red flags will you need to watch for that indicate that an evacuation will be necessary?</b>
[[Next->Action 1]]
[[Back->What's next 1]]
<progress value="6" max="13"></progress>
<h1>Stay</h1>
You discuss your recommendation not to evacuate the patient with your co-leader. Your co-leader agrees that no medical evacuation criteria have been met. They suggest that the trip staff keep a close eye on the patient’s condition and reassess if any new signs or symptoms arise.
<b>What red flags will you need to watch for that indicate that an evacuation will be necessary?</b>
[[Next->Action 1]]
[[Back->What's next 1]]
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<h1>Focused Assessment</h1>
Before continuing with your focused assessment, you confirm with the patient that there are no new issues. Because you are reassessing the existing injury, a set of vitals and medical history are not performed in this case.
A focused physical examination of the palms and right forearm and thigh, reveals a small amount of blood and yellow fluid soaking into the gauze on the right palm, where the abrasion has re-opened.
[[I'm done with my focused assessment->Review]]
[[Back->Initial Assessment 2]]
<progress value="10" max="13"></progress><h1>Evacuate</h1>
You discuss your recommendation to evacuate the patient with your co-leader, who agrees that an evacuation seems necessary.
Consider what method of evacuation is appropriate (walking, meet vehicle at a trailhead, helicopter, etc) and what additional resources you require.
[[Next->Resolution]]
[[Back->Review]]
<progress value="11" max="13"></progress><h1>Stay</h1>
You discuss your recommendation not to evacuate the patient with your co-leader. Your co-leader suggests that an evacuation is appropriate in this case based on your organizations’s policies and evacuation guidelines. They advise you that, while no rapid evacuation criteria are met, the patient's condition is likely to prevent them from safely continuing the activity. Following this, you and your co-leader discuss this decision with the patient, who advises that they agree they likely cannot continue on the trip.
Consider what method of evacuation is appropriate (walking, meet vehicle at a trailhead, helicopter, etc) and what additional resources you require.
[[Next->Resolution]]
[[Back->Review]]
<progress value="11" max="13"></progress><h1>Scene Safety</h1>
While there is very little traffic on the remote, unpaved road, you notice that the participant has slid to a stop on a blind corner. You send your co-leader around the bend to warn any oncoming vehicles of the accident, until you can get the group member safely off the road.
Describe any additional steps you wish to take to ensure that the scene is safe for yourself, your group, and other users of the road.
[[Initial Assessment->Initial Assessment 1]]
[[Back->Patient Presentation (Day 1)]]
<progress value="3" max="13"></progress>
<h1>Vital Signs</h1>
A second set of vitals, taken at 16:35, reveals the following: <br>
<b>HR</b> - 74 <br>
<b>RR</b> - 14 <br>
<b>SCTM</b> - Pink, warm, Sweaty <br>
<b>LOR</b> - A+O x 4 <br>
[[Back->Focused Assessment 1]] <h1>End of Scenario</h1>
Congratulations on completing this scenario. Remember to periodically review your patient assessment system and wilderness medicine skills in order to keep your memory (and skills) sharp.
You can find many more resources on the <a href="https://www.longleafmedical.com/resources.html" target="_blank">Resources</a> page of our website. Stay safe out there, we look forward to seeing you in a course soon!
[[Start Over->Trauma 1]] <br>
[[Back->Discussion]] <br>
<h1>Patient Reports</h1>
A Headline Report is used to quickly provide information about the patient's condition to another person, such as a supervisor, 911 dispatcher, or first responder.
My Name is <b>(name)</b>.<br>
I am located at <b>(location)</b>.<br>
I have a medical emergency with a <b>(description of patient)</b>.<br>
Patient experienced <b>(describe mechanism of injury or illness)</b>.<br>
We need <b>(describe plan and resources needed)</b>.<br>
[[Back->Resolution]]