Medical question: how would an MD treat someone who fell down a rocky formation?

If the physician had a splint, the she probably would put it on the ankle, even though she could tell by touch that the ankle probably was not broken. If she hadn't brought a splint, then she would bandage it. I understand that severe sprains often hurt more than breaks.

She would lok at whether his pupils dilated normally as a test for a concussion. Blood pressure check probably wouldn't be necessary; although she would look for signs of shock.

Ifyou aren't familiar with the procedures, then you might want to gloss over the details.

She's bring a stethescope and opthalmoscope, along with bandages, antibiotic ointment, stitches and the like. Also epinephrine, a injectable antibiotic, and a few other things unlikely to come up in your story.

The first issue is the ABCs: airway, breathing circulation. She may not say it aloud, but she'll think it. You can get airway problems from the freakiest things. Asking someone mental status questions (person/time/place: what's your name, what day is it, tell me where you are right now) addresses the airway and level of consciousness issues, at least as a beginning. Palpating the front of the neck at the airway tells you if it is still midline or under pressure.

[Then, vitals. See below.] She's listen to his chest for heart and lung function (all fields, insofar as she can without moving him) and check for head injury next. If he isn't already sitting up, she would not have him sit up. If he is sitting up, she'll have him sit still. This is important because ABC problems can kill you immediately, and head or neck problems can kill you very soon -- the latter via airway compromise mostly. But an ankle wouldn't kill you immediately, so it gets turfed for the immediate period.

Pupils tell you about brain swelling, because you can see the optic nerve entering the retina, and if it is swollen, then there is likely swelling all along the nerve tract back to the brain. You also check for symmetry of responses between the pupils -- if the brainstem is at risk or avctively herniating through the base of the skull, one or both pupils will remain "blown," or not contract to light flashed in them. Pupils and talking tells you a lot. [Added: and the moving of the eyes back and forth to follow a finger while the head stays still is about assesssing cranial nerves by assessing a whole set of eye muscles. This tells you about possible brain swelling, as well.]

Next, neck injury. First you check consciousness and mentation (see questions above), then peripheral strength and sensation without moving the neck -- so, "grab my fingers and squeeze as hard as you can." "Can you feel this? What about here?" "Move your big toe up and down." Then you palpate the neck for point tenderness at bone or asymmetric spasm of the muscles. Then check isometric strength without moving it, then active range of motion, then a few special compression tests, then postural stability, then more detailed questions to assess mental status.

Then, the rest of the body. You want to know if there is intenral organ damage before you move to the less exciting bits.

Then, the ankle.

Now, if he is up walking around, someone may be more or less rigorous about the prior steps. Is she a keener, by the book type? Or a fly by the seat of her pants person? That makes a difference. Also, level of experience matters.

The ankle exam is about testing sensation and blood supply to the toes, ability to move things on his own, ability to move against resistance, and palpating for bony point tenderness. Whether he can bear weight on it is a big question. Many people use the Ottawa Ankle Rules to decide whether or not to get an x-ray if there is a machine available, which it sounds like there wouldn't be for your physician. However, you can think of that as proxy for determining whether it is possibly a fracture or just a sprain/strain.

Blood pressure would be checked with other vital signs. [but Maryn is right, and you would expect it to be high. However, if it isn't, that matters in terms of shock. All vitals get assessed immediately because that's why they are called "vital." Pulse, respirations, blood pressure. Oxygen level if you have the equipment, which she wouldn't.]

Just reread your original post. If he can't walk on it, she can't rule out a fracture. It would need to be splinted as well as possible and not bear weight for the time being. Of course, if they get set upon by a bear, aliens, or a succubus (not sure of your genre), then all bets are off. You run 'cause you have to, and you do the best you can with it.

Sat Nam! (literally "Truth Name"--a Sikh greeting)

I'm no doctor, but I did have a torn Achilles tendon many years ago. Doesn't show on x-ray, and can't walk on it. Didn't have a cast. Wasn't splinted either, though it might have been, had the injury been out in the wilderness.

Gives you another option.

Blessings,

Siri Kirpal

Chiquita Banana said:

"Of course, if they get set upon by a bear, aliens, or a succubus (not sure of your genre), then all bets are off."

Too funny! This really made me laugh. Mine is just straight-up romance with a New Age twist.

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My pleasure.

http://libby-mercer.blogspot.com/ (I keep forgetting to add this thing.)

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I keep forgetting the password to update mine, and life is such that winding my way through resetting it just isn't worth it yet. Ah, well.

Life remains a ceaseless challenge.

One does what one can and then calls it a night.

It would depend upon the specialty of the Dr as to whether she would have a personal supply of injectable agents such as epinephrine or IV supplies of any sort. If she takes it from a hospital that could be stealing, unless she tells whoever is in charge what she's doing and then brings the patient back so they can bill him for the supplies.

Why wouldn't she just call an ambulance and ride with them to the scene? They come fully stocked including backboards and people to carry the patient. Trying to walk somebody out of a canyon is a medically inadvisable scenario. If he's got internal injuries or unstable fractures that will exaccerbate it. The thing to do is immobilize him, keep him warm and hydrated and wait for help.

Anecdotal evidence alert: the only difference between the accident where I sprained my ankle and the accident where I broke my foot was hearing a cracking sound when the latter accident happened. Not sure what you mean by the ligament/cast thing - I tore ligaments every time I "sprained" my ankle and only had an ace bandage/crutches, never a cast. Basically, I just had to RICE (rest, ice, compression, elevation) until it was better. I know a lot of people who don't go to the ER for sprained ankles b/c they know how to deal with them and don't feel like it's worth the trip.

ETA: I've been told that one of the signs you've broken a bone, rather than sprained an ankle, is when your foot does/doesn't hurts. Supposedly, if it stops hurting when you aren't standing on it, it's likely to be broken. By contrast, a sprain hurts all the time, whether or not you're standing on it. Don't know if that's really true/true all the time, but it was true in my experience.

GeorgeK said:

It would depend upon the specialty of the Dr as to whether she would have a personal supply of injectable agents such as epinephrine or IV supplies of any sort.

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Granted.

If she takes it from a hospital that could be stealing, unless she tells whoever is in charge what she's doing and then brings the patient back so they can bill him for the supplies.

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Hmmmm. I have not seen that one cannot bill for supplies unless they are used in a specific geographic place, but more that one cannot bill for supplies unless there is documentation of use for a specific person, regardless of where used. Paperwork is the emperor of all things.

However, my sight has been limited to certain contexts, so, there it is. Certainly this concern may be a factor, depending on the system.

Why wouldn't she just call an ambulance and ride with them to the scene? They come fully stocked including backboards and people to carry the patient. Trying to walk somebody out of a canyon is a medically inadvisable scenario. If he's got internal injuries or unstable fractures that will exaccerbate it. The thing to do is immobilize him, keep him warm and hydrated and wait for help.

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But where is the romance in that?

Actually, I had assumed there was a specific reason in the plot to set up the encounter between the two. It's worth highlighting that such reasons would need to be at least waved at in the story.

If you don't want a hospital scene, then you might want to gloss over the injury and the physician part and slide to the recovery part as fast as possible.

How far in is he? What is the terrain like? How much guts (stupidity) does he have? How much experience does the doc have with emergency medicine including wilderness emergency medicine?

If she has any experience, one device she will have is a SAM splint. See SAM Splint - Wikipedia, the free encyclopedia and SAM SPLINT: The gold standard in splinting

Doesn't weigh much, fits easily into a pocket, and can be used in a pinch on any suspected fracture. (If you do a lot of hiking it's a great thing to have in your backpack.)

Second would be a space blanket -- Space blanket - Wikipedia, the free encyclopedia. Broken ankle won't kill you. Shock and hypothermia will and are the big worries.

If he's got the guts, doesn't mind a bit of pain, and is a bit crazy, you splint the leg in a SAM, cut a crutch for one arm, and do a lot of hobbling. If you don't have a SAM, a couple of branches for support wrapped with a t-shirt works almost as well. This is not approved medical treatment, but people do it. If you don't want the hospital, this is the way to go. (Which is why people do it.)

If the rescue squad comes in to help him, they use a Stokes -- Litter (rescue basket) - Wikipedia, the free encyclopedia. Patient is backboarded, then placed in the Stokes. Stokes are a lot easier to carry. Walking out with a patient is a time-consuming experience. Depending upon terrain, if you can average a mile in an hour with a crew of ten you're doing good.

One question you ask the patient is, "Did you hear a crack?" A lot of times when a bone breaks, the person will hear a distinct crack.

As far as in the field treatment is concerned, broken or sprained doesn't make a bit of difference. If an ambulance crew or rescue squad bring him out, he will go to the hospital. Period.

Best of luck,

Jim Clark-Dawe

Chiquita Banana said:

1. What should she do to his ankle to determine that it isn't broken? Should she have him move it this way or that? Ask him if it hurts when she does this or that? I guess I want him to have a sprain (thought about torn ligaments, but I did that as teen and I had to have a cast. Don't want to put him in a cast.) If anyone has any other suggestions apart from the sprain, please let me know. Would she wrap up his ankle in Ace bandages or something? I may be forgetting something. Any other thoughts/comments on this would be greatly appreciated!

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There isn't any way she can tell whether or not it's broken in the field, unless she packed along an X-ray machine. The signs and symptoms of a strain, a sprain, a dislocation, and a fracture are exactly the same. Fortunately, the field treatment is the same for all of those injuries. She's going to splint it. She isn't going to take his boot off, because it'll never go back on, and it's providing stability. (Even if they were sitting in an ER, and it was fractured, she wouldn't cast it. Not before the swelling went down.)

2. Would she conduct other tests on him? For example, would she check his blood pressure? I'm thinking she's worried he's injured his head (even though he says he hasn't - it only has a couple of scrapes). I thought she might have a little flashlight with her to shine in his eyes, but what would this determine? Is it something about contracting/enlarging pupils? When the doctor asks you to follow something with your eyes, is it about reaction time or something?

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Checking pupil reaction is a test for brain injury. Checking eye tracking is part of a neuro check. She might not bother with either, because there isn't diddly she can do about head injuries in the field.

The only questions in her mind are going to be: 1) Is he breathing? and 2) Is this a walk-out or a carry-out?

She might check blood pressure if she thought he was going into shock, but a drop in blood pressure is a late sign. By that point he'd already be in deep trouble, and she would have had to miss a lot of other signs and symptoms first. If this is a carry-out, she's going to treat him for shock, because there are two kinds of patient: Those who are already in shock, and those who are going to be in shock.

Has this physician had specialized training? Most physicians are worthless in field emergency/wilderness situations.

Snick said:

If you don't want a hospital scene, then you might want to gloss over the injury and the physician part and slide to the recovery part as fast as possible.

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Ohhh, that gives me an idea. Something like "after 6 hours in the ER..."

Four hours of which were in the waiting room, LOL!

If you've ever seen footage of Uncle Jim porting someone over rough territory, you know who you want directing your rescue.

Chiquita Banana said:

Ha! My romantic hero is going to hate this. He's super proud/competitive and this will make him feel utterly humiliated. I am just torturing the hell out of this poor guy. He's been thrown into this wellness center against his will by colleagues on account of his workaholism, he's been forced to give up caffeine cold turkey (and he was an 8 cups a day guy) and now this. Not only the injury but the humiliating procession out of the woods. Egads.

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I'm all for the "take a character and throw 'em in hell, then turn up the heat" approach to writing. You want conflict? That will give you some conflict.

Sounds like a smashing way to direct the story. Go for it. And I'd be happy to read it at some point along the way, if you need readers. I can generally commit to reading a lot and giving feedback in a given short burst of times, just not for long hauls at this point.

It sounds like a fun yarn, though, and I'd love to see what happens.

Chiquita Banana said:

Hey, thanks for weighing in, guys. I have a lot to work with, which I am so thankful for. Answers to your questions:

The doctor's wilderness experience - pretty much nada. She worked as an ER doc in NYC for 5 years. If she's from the city, how the hell is she going to find him? If she does a lot of hiking, or is interested in hiking, she could (and probably would) read quite a bit about wilderness issues. If she doesn't have any interest in the wilderness, you're more likely to have two lost hikers then a couple getting together. It's hard finding a specific point in the wilderness, unless you know what you're doing. That's why geocaching is so popular. Even with known measurements, getting from here to there isn't easy.

I'm not sure how much they're supposed to be alike, but basically are they both idiots, or does he actually know what he's doing in the wilderness? If she's an idiot about the wilderness and he isn't, he's not going to be impressed. But doctors study, and it would not be unreasonable for her to plan dealing with injuries in the wilderness even in New York. She'd probably have some sort of fancy gadget, which probably won't work, but use the SAM and space blanket for her to impress him. And I've got to say, the first time you use a SAM it's a bit baffling for a few seconds.

How far in is he?
This is flexible. He's been wandering around all day, but he could have been wandering around in circles. A quarter mile in or two miles in doesn't make much difference. Twenty miles in does.

What is the terrain like?
They're up in Vermont actually, so there are lot of hills and valleys, forests, etc. It's springtime, daytime so no worries about hypothermia New England, if you're off a trail, is frequently more about having to push through the brush. You're constantly stepping over, around, and through small trees. Terrain can be fairly steep. In some places, the locals swear the deer have legs of different lengths so that they can stand level.

In New England, you worry about hypothermia pretty much year round. And is this spring before black flies (and with lots of mud), black fly season, or after black fly season? In May, the average daytime temperature is in the sixties, which in a patient with compromised ability to deal with the weather, is enough to begin causing problems.

How much guts (stupidity) does he have?
This is about the SAM splint/tree branch crutch thing I gather? I think the doc wouldn't let him do something that's not medically approved. Course he's headstrong and all, but he's also thrown by her impressive capability, so he'd listen to her. Besides, they have to hang around and wait for the paramedics and obviously bond and have all sorts of romantic stuff going on while they wait. Really good to know about these things though. Thanks so much for the links! If she's got an interest in sports medicine, she'll have some idea of how to treat him. Athletes are not big into solid casting. It results in a loss of muscle strength, and slows down your ability to get back to competitive form. She would be able to tell if there was a gross deformity by feel.

If he's headstrong, and she's a bit on the flexible side of medicine, I'd splint it and let him walk out himself. Provides a wonderful bonding experience as she goes back and forth from calling him an idiot to wanting to kiss his boo-boo and make it better.

And there is a two person carry. Basically victim puts his arms over the shoulders of two people, using them for support. Good leg is used for additional support. And one person can do this in a pinch.

Understand that you've got ideal medical practice, and then what your patient will tolerate. Guys have come out of the woods on the shoulders of their buddies for years, and will continue to do so far into the future. If you're going to make things worse, unless your victim is under the influence, the making it worse will usually cause you to stop.

When I broke my wrist on a bicycle ride, I finished the ride (about 20 - 30 miles) and it took my wife another 24 hours to convince me that I should see the doctor (and we were on really good health insurance -- doctor's visit cost exactly what I expected -- nothing -- so money was not an issue). Nice thing about pain is you know you're still alive. Other then that, some grunt candy (aspirin, Tylenol, whatever) and you're good to go.

She isn't going to take his boot off, because it'll never go back on, and it's providing stability.
Extremely good to know. I'd assumed she'd take it off to assess the damage.

I spose I can work in him going to the hospital no problem. Actually think I might not even bother with a hospital scene - just a summary in dialogue about what happened. Don't know why I was resisting this so much!

As far as in the field treatment is concerned, broken or sprained doesn't make a bit of difference. If an ambulance crew or rescue squad bring him out, he will go to the hospital. Period.
Ha! My romantic hero is going to hate this. He's super proud/competitive and this will make him feel utterly humiliated. I am just torturing the hell out of this poor guy. He's been thrown into this wellness center against his will by colleagues on account of his workaholism, he's been forced to give up caffeine cold turkey (and he was an 8 cups a day guy) and now this. Not only the injury but the humiliating procession out of the woods. Egads. He's going to come out to the woods on his own power. Hell, he'll probably drive himself to the hospital.

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Unless the guy has no wilderness experience, or is a wimp, I don't see him coming out in a Stokes, a female nagging him, no matter how hot, not withstanding.

Best of luck,

Jim Clark-Dawe

Chiquita Banana said:

Pyekett, I would love for you to read. I haven't shown it to anyone yet except for the first chapter and definitely need to start getting feedback. Thanks so much. I'll PM you.

Uncle Jim, many thanks for your thoughts. Here's what I've got: Understand that Uncle Jim and me are two different people, and ain't no one going to call me "genial" without a whole crapload of Sam Adams on board. And I doubt they'd do it even then. But we're both from New Hampshire.

Re: the doctor's wilderness experience. Seriously, I've got everything covered. She's from the city, but has been living at the wellness center for 1.5 years, so she knows the land. I'm not worried about whether you've got it covered, but trying to figure out what to reasonably expect from your characters. For instance, if she's been at a wellness center for a year and a half, and she's a doctor, it's reasonable to assume she's going to put together some sort of jump kit for this type of situation. That gives you more room to work with.

And he's got a tracking device on him (this is how she finds him). He's 3 or 4 miles in, max. I'm assuming by "tracking device," you mean a GPS. And as you may be aware, many cell phones have a GPS unit in them. But so she gets his coordinates, enters them into a GPS, and goes find him. Sounds so easy. When the weather gets warmer, try it. This is an area where you can add in some conflict with Mother Nature and some serious relief when she actually finds him that will be believable, and enhance your character.

Hypothermia when the temperature is in the sixties? Really? I'll have her bring a blanket, but I honestly don't think either of them need to be too concerned about this. They'll all be out of the woods (ba da bing) by sunset. Plans can go downhill quickly and things don't always follow them. A space blanket easily fits into a pocket, and is easy to carry. Problem with injuries is they cause a patient to want to go into shock, with the worse the injury the more likely shock is going to happen. As you start going into shock, your ability to maintain temperature starts getting compromised. At sixty, you're right, not much to worry about, although depending upon what you're wearing, it could become an issue. But the sixty-five degrees you start with could easily drop to fifty degrees. Smart doctors, smart rescue people, think about what can go wrong and try to cover it.

I like it when things go right, but ...

Ick, I forgot about those horrible black flies. Think one of my friends or I sat on a nest of them or something years ago in Boston at a free concert on the river. Those bastard bugs seriously latched on, so friends and I ran frantically through the crowds, slapping our faces, trying to get them off us. Must have looked like we were seriously drugged out. I got something like a dozen bites. It was awful. Just remember that in northern New England they form a distinct season and you want to miss them. But if you're in the woods before black flies, it's going to be a lot colder, a lot wetter, and even some patches of snow/ice in the sheltered areas. A way to add realism to your book is a comment that "Oh, boy, glad the black flies are over."

Anyway, back to the story.

I think I misread your previous post. Thought you meant that the rescue team would definitely carry him out of there. I'm so glad to know that's not the case because it seemed a bit unnecessary to me. Maybe they can try to get him on a Stokes and he'd refuse. Anyway, good to know. You try to get them on a Stokes, but some patients just aren't going to cooperate. And he sounds like one of them. Personally, the way you're describing your character, if he has any sort of wilderness experience, I find it hard to believe he'd call the rescue, short of being dead. It may be being a tough guy, it may be just not wanting to ask for help, it may be about getting the job done, but you're going to need to ratchet down a bit to make it believable that he's going to ask for help.

A few weeks ago, while working outside on a project, I rolled my ankle. Put it down on the side of a whole. Did a nice job of it. By the next day, twice its normal size and all sorts of colors not normally encountered in a foot.

Net result on getting the job done? Hopped back to the tractor, swore passionately for five minutes, then was willing to use the tractor to get around instead of walking. Quit maybe ten minutes early because the pain was annoying me that much (after doing another hour of work). Couldn't walk on the thing for a week or so.

Could I have walked out four miles if I had to? Absolutely. And by having to, this includes not calling the rescue. But my wife says I'm pigheaded (which I'm assuming is the less then polite way of saying I'm headstrong). It's just not worth the aggravation of dealing with the rescue.

My wife did convince me to take a Tylenol with codeine that night. I must be getting old.

"Nice thing about pain is you know you're still alive."


Quote from the film, Shirley Valentine. When Shirley asks the restaurant owner how his day is going, he responds, "I feel a little pain in the back, but at least it means I'm not dead."

Thanks again, one and all. This board is so amazingly helpful. Seriously, what did writers do before the internet?!? It must have taken aaages to look up every single thing in the library. Ten minutes to fact check little things that take us ten seconds to do now, not to mention travel time, long distance phone calls. We're so lucky these days. If you can, see if you can find someplace where you can see some training for wilderness rescue. You can't get the feel right just by reading about it. And they love to have practice patients.

http://libby-mercer.blogspot.com/

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Best of luck,

Jim Clark-Dawe