CASES IN BLS CARE
LONG WAY OUT
Considerations when treating patients in austere, remote settings
By Dennis Edgerly, MEd, EMT-P
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 con-
trolled. 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
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. JEMS
Dennis Edgerly, MEd, EMT-P, began
his EMS career in 1987. He’s currently
the EMS academy director for Arapahoe
Community College. He can be reached at
Rescue workers need to be
prepared with equipment
but should be cautious to
not pack excessive supplies.