Columns, Patient Care

Treating Patients in Austere, Remote Settings

Issue 1 and Volume 43.

Considerations when treating patients in austere, remote settings

You glance over at your partner who’s driving to the call and ask if he knows where he’s going. He tells you he knows the area but not the location of the specific address. He thinks you’re still about 20 minutes away.

You look back at the map and locate the trailhead where the caller is supposed to meet you. A 24-year-old male riding an ATV meets you at a trail marker. You key the microphone to let dispatch know you’ve made contact and you hear, “Last unit repeat, unreadable.”

You repeat your transmission and dispatch responds with the time. As the search and rescue (SAR) team arrives, the man tells you his dad crashed his ATV about five miles up the trail. He tells you his dad is “bleeding bad” and his brothers are still with him.

After adding extra dressings and confirming you have a tourniquet in your first in bag, you grab a portable oxygen tank and a blanket. You get on the back of the ATV and, followed by one of the SAR team members, head up the trail. The plan is for you to assess the patient and situation and then let your partner and the rest of the SAR team know what you need.

After a 15-minute ride up a rugged trail, you find John, a 55-year-old man, lying under a tree with two younger men next to him. John’s clothes are saturated with blood and there’s a notable amount of blood around the area. The two younger men, John’s sons, have a significant amount of blood on them and have used their shirts to help stop their father’s bleeding.

John is pale but responds to your voice. He’s oriented to his name and place but unsure about time. His pulse is rapid and weak and his skin is cool to the touch.

You immediately place a nasal cannula and administer O2 at 3 Lpm. Although more may be appropriate, you’re aware that the size of oxygen tank you have with you can only supply high flow oxygen for about 15 minutes, and you expect to be with John for longer than that.

John’s sons tell you the right front wheel of the ATV their father was riding hit a deep hole in the road. John’s ATV quickly pulled to the side and he fell forward and was stabbed by his handlebars. He flipped over the top of the ATV and landed on his back. He was wearing protective clothing and a helmet.

Physical exam reveals a deep abdominal laceration just to the right of the umbilicus, or the right lumbar region of the abdomen. External bleeding appears to be controlled but it’s unclear if there’s internal bleeding.

John’s pulse is 130, his blood pressure is 102/88 mmHg and respirations are uncompromised at 20 per minute. His right wrist appears to be deformed, but he has movement and distal sensation. There’s a weak radial pulse.

Attempts to reach your partner and the rest of the rescue team by radio is unsuccessful. Based on your location, radios aren’t transmitting or receiving.

The SAR technician heads back down the trail to update the team and gather equipment to begin moving John down the trail for transport to the trauma center. It will be an hour or so before they return and it will take quite some time to carry John out to the ambulance.

You redress the abdominal wound with medical gauze. External bleeding is still controlled. You establish an IV port but don’t attach saline. His blood pressure is maintained and fluid may drop his body temperature. You cover him with a blanket and John’s sons build a fire to help keep him warm.

It will be dark soon. The determination whether to carry John out tonight or wait until the morning will need to be made when the rest of the team returns. Luckily, there’s no bad weather predicted.

Rescue workers need to be prepared with equipment but should be cautious to not pack excessive supplies.

Location Challenges

Calls outside of city limits offer a variety of challenges. Response times are extended and transport times can be even longer. In this case, transport will take place in several phases.

First, John will need to be carried to the waiting ambulance. The ambulance will then transport him to the hospital for evaluation or to a waiting helicopter for transport to a trauma center. This will require a safe landing site: flat, free of rocks and trees. This can be difficult to find in a mountainous area.

Running back to the ambulance is usually not an option, and coordination of equipment and supplies is crucial. Emergency personnel need to be prepared with equipment but should be cautious to not pack excessive supplies, hampering the extrication of the patient. In the case here, radio communication wasn’t an option so EMS workers communicated via a SAR team member acting as a messenger moving between the scene and ambulance. This delays on-scene time, so long-term patient management needs to be considered—such as conserving O2 as done in this case.

Keep in mind that basic patient care may be the best. In this case, keeping the patient warm, supine and oxygenated are the priorities.