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Wilderness Medicine | Patient Assessment

Wilderness Medicine | Patient Assessment

Hi, I’m Todd Schimelpfenig. I’m the curriculum director
for the wilderness medicine institute at NOLS. We are going to shoot an educational video here today to demonstrate our patient assessment system and then our focused spine assessment, our tool for gathering information and making a decision about whether we need to continue spine immobilization in a patient who’s got a spine mechanism of injury. We’ve got a beautiful day here at zero
degrees fahrenheit outside, so we are going to be able to demonstrate how we do this, manage the cold, keep the patient in a sleeping bag, zip and unzip layers, deal with our hands and body substance isolation, and gloves in a real winter environment. We hope you enjoy the video. You can totally climb this. No, I can’t do this. Do it. I bet you can. You climb harder than this all the time. This is just like a 5.Tree. Oh yeah, you totally got it. Oh yeah, go big, go big! I did it! Oh Jeeze! Charlie! Are you okay? Uh. I think so. Okay, that was quite a fall. I’m going to go get help. Lay still and don’t move.
>>Okay. This is my buddy. He fell out of the tree up there and landed on his back. From all the way up there? Like 10 or 15 feet? Okay. The scene looks safe to me. I just see him. Is there anybody else who is hurt? No. Nobody else. I have gloves in my pocket. Do you have gloves as well?
>>I’ve got gloves in my pocket. Hi Charlie. I’m Shana. I’m wilderness EMT and a friend of Travis’. Can we help you? Yes. Great. And you remember Travis? Yup. What’s your last name Charlie? Manganiello. And what happened to you?
>>I was up in the tree and I just fell down. Can you open your mouth and stick out your tongue? Did you bite your tongue? Do you feel like you have any broken teeth?
>>No. Any food or gum in your mouth?
>>No. Okay. Take a big deep breath for me. Is that painful or difficult? No. Im going to go ahead and just see if I can find a pulse here at your wrist. You are nice and warm and you have a good strong pulse.
Do you feel like you are bleeding anywhere? No not at all. Okay, do you mind if I get underneath this waterproof layer and I double check? Go ahead. Okay. I’m just going to reach my hands in underneath these clothes. Okay. No blood. I’m just going to reach my hands down the side of your pants. Okay? Okay. I’m not finding any obvious blood. Charlie, I’m just going to peel back your hat for a second. So no obvious bleeding. You took a pretty big fall, Charlie, so what we are going to do is keep you stabilized until we can do more assessment, okay?
>>Okay. Is there anything that is hurting you right now? No. Okay Travis. Let’s consider E, expose and the environment. He’s not complaining of any injury, so there is nothing for us to expose, and though it is cold outside, the environment does not pose an immediate threat to life so we’ll attend to getting him off the snow after we’ve completed a head to toe exam. I’m just going to peak inside your ear. Nothing coming out. No bruising back there. Go ahead and bite down. Does it hurt your jaw at all? Not at all. Okay great. I’m going to move your glasses for just a minute. Close your eyes. Open up your eyes. Pupils look round, equal, and reactive to light. I’m going to unzip you one more time and take a look at your neck. I don’t see any obvious injury. You don’t wear any medical alert necklaces, bracelets, anklets, do you? No. I’m going to check your shoulders.
How does that feel? Fine.
Good. I’m going to put my hands right up in your armpits. Take a big deep breath. Any pain? No. Second one. Any pain? Nope. Final one. No pain? Okay great. Do me a favor and point to your belly button. Alright I’m going to press on your belly. Anything uncomfortable? Nope. Check your pelvis. Is there any reason I need to check your genitals? Did you injure them on the fall? I don’t think so. Legs feel good? Yup. Go ahead and push down on the gas. Pull up for me. Im gonna go ahead and unlace and loosen up your boots so I can reach my fingers in there. Okay? Okay. Okay Charlie. Both of your feet feel warm to me. Do they feel warm to you? Yes. Can you tell me what side of your foot I am touching? The inner side or right side. On which foot? The left foot. How about here? Can you tell me what I am pinching? The right big toe. Okay great. So we have good circulation, sensation and motion in his feet. I’m going to leave your shoes undone because eventually we are going take those boots off and get you into a warm sleeping bag. Okay?
Okay. Let me finish up with your arms. Give my fingers a squeeze. Good. Wiggle your fingers. Your hands feel nice and warm to me. Do they feel warm to you? Yes. Nice strong pulse. So good circulation, sensation, and motion in the hands as well. So I think what I would like to do Travis is let’s roll him up on his side and check his back and we’ll get him back on a pad and a sleeping bag when we do that. So Travis, what I want to do is roll him up on his side. Let’s make sure we roll him a little more than vertical so we can get all of this packaging underneath him. I’m going to zip your jacket, Charlie, so that I can feel along your spine. I’m going to take your shoes off so that when we get you back down we can get your feet tucked into that sleeping bag. Does that work for you? Yes. So I’m going to unzip this one all the way. And this one as well because I think I can feel through this fairly thin layer. Your job, Charlie, is to give yourself a big hug. Okay excellent. And can you cross this right foot over your left leg? Okay, we are going to go on your count. We will go on my three. One, two, three. So Charlie, I’m just going to walk my fingers down your spine. You tell me if I cause you any discomfort or if i’m not on your spine. Am I still on your spine? Yes. No pain? No pain. I’ll check the rest of your back. Good?
>>Good. Okay, on your count, Travis. One, two, three. Can you bend this knee for me, Charlie? Actually bend both of them. Great. I’ll take this boot off. Go ahead and bend your knees a little bit more. Let’s get your feet tucked in here. Go ahead and rest your legs on this bag to get them off the snow. Is that comfortable for you? Yup. Alright, so Travis, on the head to toe exam I didn’t find any pain, any obvious wounds, or deformities. How about vital signs? His vitals look great at 1/12. He was awake and oriented to who he is, where he is, what time of day it is,
and what the events were leading up to his fall. His heart rate was 76 strong and regular. His respiratory rate was 16 regular and unlabored. His skin was a little pale, but warm and dry. Okay. And his pupils were equal and reactive to light. His pupils were equal, round and reactive to light? Okay, great. So Charlie, we have a couple more
questions to ask you. Do you have a chief complaint
right now? Is there anything that’s hurting you? No. So you took a fall of about 15 feet.
That’s what we understand. Is that what you understand? Yes, yes. So you have no complaints.
No symptoms that you are feeling? You are not tired, hungry, nauseous, headache? Anything like that? None. Okay. Are you allergic to anything like
medications? I’m allergic to sulfur drugs. Okay. Have you had any today? No. Okay what happens when you take sulfur drugs? Hives and rash. Are you allergic to any animals? No. Foods? Nope. Do you take any prescription medications? No. How about over the counter medications? Just Advil when I have a sore ankle or leg or if I hurt myself. Okay, have you had any Advil today? No. Do you take any herbal medications or supplements? No. Okay. How about any alcohol or drugs
today? No. Okay great. So symptoms, allergies, medications … past medical history.
Do you have any problems with your heart? No. How about your breathing? No. How about belly stuff? Like ulcers? Nope. Ever had a seizure? No. Are you diabetic? Nope. Have you ever hurt your spine or
your head before from a fall? Never. Okay great. No pertinent medical history. What’s the last thing you had to eat, Charlie? I had a sandwich at lunch. At lunch. So right now it’s about one o’clock
so do you eat lunch at noon or 11? Right around noon. How about fluid intake today? What have you had? Just coffee in the morning and a glass of water with lunch. Okay, how much exercise have you been doing today? Not much at all. So is that a pretty typical amount of fluid for you? Yes. Okay great.
Then urination today? About mid-morning. Okay, normal for you? Yes. Okay. Defecation? Same question. No. Not yet. Okay. Normal though? Yes. Great. So last ins and outs and events. We got the fact that you fell out of the tree. Did anything cause you to fall out of the tree? Did you get dizzy or did you slip? I just slipped on the snow. Slipped on the snow. Okay. Anything unusual in the last 24
hours we need to be aware off? No. Great sample history. Is there anything else you wanted to ask? No. That sounded good to me. Okay. I do you have one last question.
How old are you Charlie? I am 25 years old.
Thanks. So at this point we have a full physical exam. We have a full set of vital signs and a good medical history and I have no evidence right now that he has any signs or symptoms of an injury to his spine. If we were in town we would maintain spinal stabilization and wait for medical help to arrive. However, since we were in the wilderness, it is
appropriate for us to utilize the focused spine assessment to make a decision about immobilization.

26 thoughts on “Wilderness Medicine | Patient Assessment”

  1. Thanks NOLS for posting this. I watched this a few times as a great refresher before and during my WFR recert. Keep these great videos coming…

  2. Excellent training video! WFR recert. tomorrow–this is fantastic. I agree with binkerboo; video on any WMI processes or skills is awesome.

  3. She didn't approach from the feet this is a possible spine/neck injury you should always approach from the feet so the person sees you coming and does not move their neck or head to see you… also and she asked a possible spine/neck injury patient to move his own leg? video was okay, I learned differently and we did not ask so many questions on our primary assessment

  4. Great video, only addition I would do that I don't think was included was asking the pt or bystanders if there was any loss of consciousness during the fall.

  5. Not sure whether it's just for clarity but mentioning bleeding and blood in front of a patient isn’t especially good to keeping them calm.

  6. It is extremely interesting how the PAS system changes over just a few years. I am taking my wilderness first responder course and there are about half a dozen things either missing or different from what I am learning now.

  7. This is an educational video, hence they have to do everything by the book.

    Its' like how EMT/Medic school has to teach NREMT standard despite no one does exactly that way on the street.

  8. I took an equivalent of a St-John's Ambulance First Aid/responder and CPR (Canada) course (private company) many years ago. I witnessed a horrible collision between a car and a cyclist where the cyclist was thrown violently from his bike. He was squirming uncontrollably on the road. There was no other traffic so I approached him and asked him not to move, and mentioned how dangerous it was but wouldn't stop squirming. Another person came in on the scene and told me to beat it while I was speaking to him. I didn't touch him. What does one do!? I was mortified. Felt so helpless.

  9. Forgive the dumb question, but why would a short fall like this, expecially with zero evidence of injury of any kind, necessitate further stabilization and eventual evacuation. Is it simply judged by someone who saw the fall and their judgment as to whether they think it was accident causing? Or are we simply assuming here, for the video demonstration's sake, that an injury was likely? Thanks.

  10. In the United States, where are there places of employment for being a wilderness EMT? Rocky Mountains, anywhere in New Hampshire, Connecticut? Do you stay in a station during a shift like a regular fire/ems company? I'm really interested in becoming a wilderness EMT

  11. This is just an educational video. One of the better ones out there. Regardless in there being an injury that warrants C-Spine or not they are simply going through the steps. Good vid.

  12. This is painful to watch. I get the teaching but this is so unrealistic it is actually a challenge to learning. He has no pain.

  13. At least make a injury to work around. Nothing is hurting him. Hard to watch as a WFR…. the key word is pertinent patient history you talked about tons of non pertinent history. The guy would get up and walk away WFR would never show up. .please make a bit more real.

  14. No need for C-spine this is not how this works..did he indicate he had spine back or neck pain ,,,NO .he has no injury WTF hard to watch…

  15. Why doesn’t the EMT ask how he landed first?? The video shows feet first then a roll onto his right hip. It would have helped if his friend gave more details. And why didn’t the EMT ask if he’s in pain?? She took a minute to ask if he feels like he’s bleeding anywhere! By the time she got to the body check he could of gone into shock. You don’t need to reply, I’m taking the course end of October.

  16. Please consider redoing this video. It’s not realistic. You should of had the patient say he injured or is in pain somewhere on his body.

  17. The examination and evaluation was thorough and exhaustive. I found the absence of a scribe troubling. In a genuine wilderness emergency, I compare and contrast serial, objective evaluations and subjective complaints. This means a baseline set of values, followed by regular and recurring metrics, until the person is out of the wilderness setting.

  18. This is an excellent example of a comprehensive patient assessment. Shana communicated clearly with her partner and with the patient, asked the right questions, and protected the patient's spine. She was very smooth and that's the mark of somebody who knows her stuff.

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