Cold, Wet and Hurt

     Attack One responds to a report of a hunting accident with a patient hurt in a fall. Additional information indicates the patient is severely injured from a fall from a tree, and identifies a rendezvous point for a hunting buddy who has hiked out of the woods where the accident occurred to summon assistance. Additional equipment dispatched includes an engine and a ladder truck for manpower and transport equipment, and an EMS unit.

     It's a cold December day, with snow covering the ground. The Attack One crew and arriving EMS unit find a hunter on a rural road. He tells them the victim fell about 25 feet from a deer stand in a tree. The injured man is at least a mile off the road, and it may require some effort to find him again. The crew asks the hunter what type of injuries may have occurred, and he indicates the man fell on his back and can't move or feel his legs. The injured man had soaked his hunting suit with urine, so his friend had covered him with his own outfit before leaving to seek help. He estimates his friend's weight at 200 pounds.

     There are other immediate challenges to address as well. The hunter seeking help is already very cold, having sacrificed his suit for his injured friend. His assistance will be needed to find the man, so he has to be outfitted with warm clothing to hike back into the woods and out again. Additionally, his description of the accident gives great concern about spine injury, hypothermia and potentially other trauma. The crew will need to carry in spine-immobilization gear, a basket to carry the victim out, first aid gear and plenty of blankets. Tracking the pathway will be difficult, and air support could be beneficial. The closest available helicopter is an air ambulance that can be utilized for both location assistance and victim removal-if the initial report is accurate and a landing site can be found.

     Several crew members are familiar with the wooded location and feel they may be able to move ahead more quickly to find the victim with the aid of the hunter. The rest of the crews can then follow with the gear from the ladder truck and the manpower to do a long carry. Two members take the first aid gear and blankets and make their way into the woods. Radio communications will be maintained, and the advance members' hiking pathway will be crudely tracked. Air ambulance personnel can also determine the fastest removal pathway, so all crews and the helicopter are assigned a common tactical channel.

     Seventeen minutes later the first crew locates the victim. He is a 25-year-old man, and his description matches the initial information. He is cold, in severe pain from a back injury, and has no sensation or movement below his belly button. He is incontinent of urine. Crude examination reveals a broken left wrist, but no other injuries. The pulse oximeter finds a pulse rate of 50, saturation of 95% in his fingers and a respiratory rate of 18. A palpable blood pressure of 90 is obtained through his clothing.

     At this point the helicopter and the rest of the caregivers with the immobilization gear are about five minutes away. The decision is made to rapidly package the injured hunter in blankets, remove his wet clothing and have him prepared for complete immobilization when that gear arrives. This can be done safely without moving his spine or exposing him to the ambient air, which is about 25ºF. His wet clothing is leading to rapid heat loss, and lying in it has begun to blister his skin where it's in contact with the frozen ground.

     The rescuers remove the wet clothing by placing the oldest blanket under the patient-carefully, so as to avoid moving his spine. His wet clothing is split with trauma scissors. Several more blankets are wrapped around him (with caution taken to keep them dry), then his clothing and the first blanket are peeled away (again carefully, to prevent spine movement). By the time the additional crew arrives, he is ready to be placed on their backboard and into the basket.

     The helicopter finds the crew in the woods, but after an aerial survey can find no better landing zone than where the vehicles are parked. But the air crew does identify a quicker pathway out and is able to guide the ground crews back to the rendezvous point. The ground crews rotate the carrying duties. (If the original report of the victim's size had indicated a larger patient, more personnel would have been requested for safe movement.)

     An Attack One crew member remains with the patient through the carry. No further medical care can be performed during the trek, as intravenous fluids can't be warmed adequately. This department does not routinely perform wilderness rescues and is not in an area that has prolonged or profound cold conditions, so fluid warmers are not part of its routine equipment (other areas where colder conditions and rescues occur on a routine basis may have these devices). Medical control is contacted to discuss the use of intramuscular pain medication, but the potential vasodilation could worsen the patient's hypothermia and further lower his blood pressure, so it is withheld.

     Helicopter transport will save about 20 minutes to the regional trauma center, and this is explained to the patient. Rendezvous and transfer of care occur near the response vehicles, and the helicopter crew also opts for rapid removal. They had picked up some warm bags of intravenous fluid and placed them in a cooler as they left their quarters, but on rapid assessment of the patient in the helicopter, they decide the best use of the fluids is to place them around the victim in his blanket cocoon, and use warm humidified oxygen to begin the passive rewarming process.

Hospital Course
     The hunter is responsive but very cold as he enters the emergency department. His core temperature is 88ºF. His injuries include a fractured vertebra at the 10th thoracic level, with a spinal cord injury at the same level, and a fractured left wrist. His buttocks developed a partial-thickness frostbite injury where his wet clothing met the cold ground. He also has a closed fracture of his lower leg.

     His spine injury is permanent, but he enters the rehabilitation center with plans to walk again. The rapid work in preventing full-thickness frostbite wounds allows him to recover without grafts and skin damage that would be difficult later in his life. His fractures heal appropriately.

Scene Management and Medical Decision-Making

     Command was established, and a timely rescue effected. The rapid-access crew made its way to the patient with very little equipment, but fortunately chose the most important elements. The secondary crew brought all the packaging tools and enough bodies to safely transport the patient. A helicopter was added to provide aerial guidance in a remote environment, and then a more rapid hospital transport.

     Hypothermic patients need to be dried to prevent further heat loss. Intravenous fluids and supplemental oxygen should be administered only if they can be warmed. Medication must be carefully chosen so as to not worsen the hypothermia. Our current knowledge is that best patient outcomes occur if the victim is only rewarmed once. Intravenous access may be difficult in very cold patients, and the most important passive warming is done via the respiratory tract, with warmed, humidified air. Severely hypothermic patients will be placed on some form of bypass system.

Case Discussion
     The Attack One crew was faced with critical decisions in a rural rescue, with a severe injury in a cold environment. Care rendered was matched to environmental conditions, and involved decisions about what not to do as well as what actions to take.

Critical Decisions

     What other clues from the scene or patient presentation could have helped the diagnosis here? A careful history from the injured person's friend allowed timely access and correct equipment to be brought to the scene. Communications were arranged appropriately for safe access to the patient and for the crews involved in the rescue.

     Was this the only treatment path? Hypothermia and major trauma are a very dangerous combination. This patient could not be cooled further, so intravenous hydration was avoided. The best management path was rapid assessment, appropriate packaging and immediate movement to a warm environment and then a hospital prepared for immediate intervention. The spine injury to the patient was suspected from the original story, so the rescuers packaged and moved him very carefully.

     What communications are critical for the patient? The communication steps most critical to the outcome of this patient were those involved in the rescue, allowing timely access to the patient and then correct basic treatment and movement.

     Would different equipment or medication have helped? EMS services that routinely work in cold climates have a variety of specialized tools for warming patients, intravenous fluids and other resuscitative gear. In departments with less cold-environment exposure, those tools may not be available. Crew members must be protected regardless of typical weather conditions, and EMS leaders must insist that crew members working in extreme weather have appropriate clothing for safe operations.