1. Expedition Medic Responsibilities: Medical practitioner Educator1
Responsibilities:
Medical practitioner
Educator
Safety officer
Medical screening
Medical equipment officer
Rescue and evacuation coordinator
Photo: Robb Evis. Rupert River, Quebec.
It is helpful to this discussion to create a scenario; you have been selected to be the medical officer for climbing trip in Nepal, or an offshore voyage.
You may be taking on more roles than you realize. *

2. Expedition Medic Prevention and Early Intervention: Medical screening2
Prevention and Early Intervention:
Medical screening
Hygiene protocols
Basic medical skills training for the group
Medical hazard assessment and briefing
Personal medical equipment expectations
Depending on the group, a good place to again bring up questions about angina, asthma, allergies, seizure disorders or anything else that effects risk of participation.
Hygiene protocols include hand washing, hand cleaners, how to deal with illness.
Are you going to train your group, or advise/require a level of training as a prerequisite for the trip? Medical personnel are often invited to avoid having to train everyone. Where does that leave you if you are injured or ill?
Medical hazard assessment requires research on everything from terrain to vectors to toxic creatures to the location of medical facilities.
Personal medical equipment requirements for each group member can relieve some of the burden for the medical officer. Require that each participant carry their own bandaids, mole skin, ibuprofen, etc.
How much responsibility are you going to accept?
Is liability insurance an issue? *
“You will need a working knowledge of local environmental conditions, medical resources, and the condition of your crew.”

3. Expedition Medic Planning: Anticipated problems3
Planning:
Anticipated problems
Emergency communications
Expectations and limitations
Evacuation routes and methods
Group medical supplies and equipment
Photo: Iceland.
Expectations and limitations – good to discuss this with other expedition participants and/or the employer. Exactly what services are you expected to provide?
When something goes wrong, who is in charge?
Who is responsible for group medical gear.

4. Illness Generic Assessment1
Critical System Problem?
Mental Status?
Ins and outs?
Pain?
Is there a serious problem with the circulatory, respiratory, or nervous system? Is mental status normal? Is this an emergency?
This spectrum can also contain the middle ground: Serious, Not Serious, or I don’t know.
Are body maintenance functions more or less normal? Does a change or problem point to a system or region to investigate?
Does pain point to a system or region that can be investigated?
There are lots of other questions to be asked in the SAMPLE history that may contribute to the generic diagnosis.
If not, there is an emergency.
Plans for serious or not-serious problems are usually straightforward. It’s the “I don’t know” that represent the difficult decisions.
Wilderness Perspective *
Not Serious Serious
“In the field our working diagnosis may remain as generic as serious, not serious, or I don’t know.

5. Wilderness Perspective
Serious or Not Serious? 1
High Risk or Low Risk? Emergency or No Emergency? Unstable or Stable?
This is the question on everyone’s mind. How do I tell the difference?
It is a primary goal of this course is to provide the information and develop the skills necessary to make this distinction.
This is the most generic and important diagnosis in medicine and rescue.
Note and mention that the terms “diagnosis”, “assessment”, and “problem” are often used interchangeably.
Assessment moves from generic to specific as time and medical care progresses. We may never be able to make a specific diagnosis in the field, but we should be able to decide if it is serious or not serious.
DJ uses the terms precision and clarity to describe this principle. We don’t need to be precise, but we do need to be clear.
Wilderness Perspective *
High Risk Low Risk

6. Oxygenation and Perfusion1
How do we make critical decisions in difficult circumstances?
Critical thinking requires understanding and perspective, not just memorized terms and procedures.
This is not difficult. We will begin with a few principles that will help you understand what you are seeing, what you are doing, and why.
Oxygen is essential to life. Respiration oxygenates the blood. Perfusion carries the oxygenated blood to the body cells.
Adequate oxygenation requires a functioning respiratory system and a steady supply of outside air.
Adequate perfusion requires that the circulatory system generates enough pressure to circulate blood through many kilometers of capillary beds in the lungs and other body tissues.
Anything that interferes with oxygenation and perfusion is a major problem.
The preservation of oxygenation and perfusion is the basic goal of emergency medical care.
Acknowledge that the physiology is much more complex than indicated by this brief discussion and cartoon drawing. However, this level of understanding is all that is necessary to make good field assessments. Even advanced practitioners can benefit by an elemental approach to field medicine. *
“Anything that interferes with this is a major problem.”

7. Describing Brain Function2
AVPU:
A – Awake (describe mental status – oriented,
confused, anxious, combative, lethargic, etc.)
V – Verbal
P – Pain
U – Unresponsive
The AVPU scale is one of the commonly used descriptions of level of consciousness. The other common language is the Glasgow Coma Scale, but it is more complicated and difficult to remember.
Verbally responsive is defined as a generic response to verbal stimulus. Verbal does not mean that the person is talking to you.
A patient who is talking to you, or able to track with their eyes and somehow acknowledge the environment is Awake. *
“In describing mental status, plain language is usually better…”

8. Physical Exam SAMPLE History
Secondary Assessment 5
Complete Then Treat
Physical Exam SAMPLE History
Vital Signs
Secondary
Assessment
A slower, more complete assessment of the whole patient.
With an obvious isolated injury, a full body exam is not necessary.
Be alert to mechanisms of injury that require a more complete exam; a primary complaint of wrist pain after falling off of a horse, for example. *
“Get the whole picture, complete your list, then return to treat each problem in order of priority.”

9. Patterns and Trends 3 * Compensated Decompensated
This slide serves to introduce the idea of looking for patterns in signs and symptoms associated with an MOI rather than focusing on any single vital sign measurement, sign, or symptom.
This example is the volume shock pattern: a constellation of signs and symptoms that include both compensation mechanisms and problems. Combined with a positive mechanism of injury like abdominal trauma, this would indicate volume shock.
Evaluating weather is a good analogy. You don’t just look at temperature or barometric pressure, you look at temp, pressure, humidity, clouds, wind direction, and trends over time to evaluate weather.
Other patterns are associated with the development of elevated ICP, respiratory distress, systemic infection, etc.
Accurate assessment of critical system function involves the recognition of patterns and trends. *
Compensated
Decompensated

10. SAMPLE History S – Symptoms A – Allergies M – Medication8
S – Symptoms
A – Allergies
M – Medication
P – Pertinent History
L – Last Ins and Outs
E – Events
This slide serves as a backdrop while you fill in the details.
The SAMPLE history can be very brief, or very involved depending on the situation.
Last ins and outs can include last menstrual period. *

11. BEHAVIORAL CHANGES AS AN EMERGENCY
Critical system problems
Underlying medical/psychiatric problems
Medications
Symptoms

12. CHANGE OF BEHAVIOR AKA MENTALSTATUS CHANGE
What is the cause?
Is it new?
Were there any predictable preceding events?
Is it serious or not?

13. RED FLAGS Multiple medication Unstable vital signs
Violent behavior/threats
Confusion
Suicidal thoughts or gestures
Prior history of a similar serious event
Distinct change or worsening behavior
Critical system involvement

14. Brain Failure Mechanisms: S – Sugar T – Temperature O – Oxygen3
Mechanisms:
S – Sugar
T – Temperature
O – Oxygen
P – Pressure
E – Electricity
A – Altitude
T – Toxins
S – Salts
The STOPEATS acronym covers most of the causes of impaired brain function.
Altitude and Pressure may be redundant since HACE is increased ICP.
Oxygen refers to hypoxia – suffocation or oxygen deprivation secondary to drowning, CO poisoning, etc.
Pressure refers to increased intracranial pressure or to problems with perfusion pressure (shock).
Electricity could be lightning or man-made current. E can also include epilepsy.
Altitude refers mostly to the cerebral component of altitude illness: AMS and mild and severe HACE.
Toxins; alcohol, recreational drugs, poisons, gas like carbon monoxide, or the result of sepsis or multi organ failure.
Salts; hyponatremia.
Photo: Al Hickey; on the ice.
“The numerous causes of impaired brain function can be summarized … with the mnemonic STOPEATS.” *

15. WORRISOME DIAGNOSES/CONDITIONS
Schizophrenia
Major depression
History of suicide
Substance abuse
History of violent behavior
Recent medication change (new or discontinued)

16. ASR Sympathetic: Parasympathetic: Mediated by epinephrine17
Sympathetic:
Mediated by epinephrine
Increases pulse, respiration, reduces skin perfusion; increases anxiety
Can look like shock or respiratory distress
Parasympathetic:
Multiple chemical mediators
Slows pulse, causes fainting
Can look like TBI or other mechanism for mental status changes
Either type of ASR can cause pain masking – an important consideration in assessment (leads into spine assessment later).
Acute stress Reaction – Sympathetic
The flight or fight response
Principle problem for us is that it looks like shock or respiratory distress.
Principle advantage we have in wilderness medicine is time – it will get better with reassurance and relief of pain.
ASR can co-exist with a critical system problem – in fact – you’d expect it to.
Acute stress Reaction – Parasympathetic
The fainting response
Temporary loss of brain perfusion due to sudden drop in cardiac output.
Principle problem for us is that it looks like brain failure from a more serious mechanism. *

17. EXCITED DELIRIUM Agitation/violent Insensitivity to pain
Irrational behavior
Will not respond to reason
Abnormal vital signs including sweats along with elevated pulse, respiratory rate and body temperature
Often associated with recreational drug use
This can lead to heat stroke

18. ANXIETY/PANIC Think about sympathetic ASR
Variety of somatic complaints
Feeling out of control
Often associated with an irrational fear (phobia)
Usually preceded by a stress event
Often have a past history and may be on medication for it
Usually last less than 30 minutes
Reassurance

19. DEPRESSION Often a chronic condition with exacerbations
Can be associated with mania (bipolar)
Stress can worsen or bring out prior symptoms
Hopelessness, crying, lack of energy, indecisiveness, somatic complaints
Stress or change in environment can provoke feels of suicide

20. PARANOIA Exaggerated feels of threat or persecution
This is a symptom rather than a diagnosis – what else is going on
Can be associated with schizophrenia

21. SCHIZOPHRENIA Generally a chronic condition – on medications
Symptoms of poor control include paranoia, anger, inappropriate behavior
Their medications put patient at risk for heat related illnesses

22. VIOLENCE – INWARD DIRECTED
Mutilation
-Gestures of frustration, anger or attention seeking (punctures, scratches, no-lethal cuts)
Suicide
-Take all threats seriously
-Protect and transport
Substance abuse and past history are important risk factors
Always be non-judgmental and supportive

23. VIOLENCE – TOWARD OTHERS
Can occur spontaneously
Drugs, based history, frustration are important risk factors
Watch for agitation, erratic behavior, clenched fist, threats
Are their weapons
Stay calm; use non-threatening, non-judgmental speech
TAKE CARE TO PROTECT YOURSELF

24. SEXUAL ASSAULT Forced, non-consensual sexual contact
Local pain, trauma, bleeding
Often dazed, unusually withdrawn
Clothing torn or removed
This is an invasive, personal crime
Compassionate care by a person of same gender
Preserve all evidence e.g., torn clothing
No bathing
Transport

25. DEMENTIA
Dementia – associated with confusion, forgetfulness, disorientation, emotional lability
Multiple causes (e.g., Alzheimer’s) – generally progressive with worsening symptoms when under physical and emotional stress, new medication, acute illness
Be patient and use a calm, clear voice.
Look for underlying medical issues

26. COGNITIVE IMPAIRMENT (e.g., DOWN SYNDROME)
Intellectual impairment, often genetic
Don’t be judgmental about the person’s ability based on appearance or speech
Be patient, clear and supportive but not demeaning

27. PHYSICAL DISABILITIES
Be clear about the nature and extent e.g., deafness can have a wide range of limitation
Do not be judgmental
Ask how you can help/communicate most effectively
Avoid “speaking slowly with a loud voice.”