Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

Wilderness and Rescue Medicine 230

Case Study 12: High Altitude Hunting Scene

S: A 63-year-old man complains of pressure in the lower chest and upper abdomen, mild shortness of breath, and nausea since eating breakfast an hour ago. He denies any pain but describes the discomfort as radiating through to his back and slightly worse over the past 15 minutes. Although he is certain that his symptoms are indigestion related to breakfast and that a good burp will fix it, he admits to not feeling well since arrival at camp last evening. He denies allergies and takes medi- cation for high blood pressure and elevated cholesterol. His history is also significant for mild exercise- induced asthma and one episode of altitude illness on a hunting trip 12 years ago. He smoked a pack of cigarettes a day from age 16 to 55. He quit the day his father died of a heart attack. He underwent a cardiac evaluation after an episode of chest pain two years ago, but claims he was given a clean bill of health. None of the other members of the hunting party complain of similar symptoms. O: Alert and oriented, sitting upright without obvious respiratory distress. The patient appears slightly pale and sweating. He is fit and muscular for his age. Auscultation of the chest reveals clear lungs with- out crackles or wheeze. The abdomen is not tender to palpation and not distended. Bowel sounds are normal. Vital signs: Pulse: 90 and regular, Resp: 24, Temp: 37°C, Skin: cool, moist, and pale, O2: 90%, C/MS: Awake and oriented, BP: 162/98. A: 1. Myocardial ischemia (heart attack). A’: Cardiogenic shock 2. Remote location and adverse weather A’: Prolonged evacuation 3. High elevation A’: Decreased oxygenation P: 1. One adult aspirin by mouth 2. Begin evacuation on horseback 3. Request Mountain Rescue to respond up the trail with oxygen and advanced life support capability to meet the evacuation in progress. Discussion: Given the disruption to the camp and crew, it would have been very tempting for the guide to accept the patient’s diagnosis of indigestion, or at least wait to see if a burp solved the problem. However, there are enough concerning symptoms and risk factors in the patient profile and history for myocardial isch- emia to be at the top of the problem list. Immediate evacuation to definitive care has the best chance of A hunting camp in the western United States at 0830 on day four of a week-long horse pack trip into the high country. One of the parties, a 63-year-old male, complains of mild indigestion and shortness of breath. The camp is at 3200 meters in elevation and 9 kilometers from the trailhead over a single-track horse trail. The weather is cold with low overcast and visibility is restricted to 500 meters in moderate snow. The group is sheltered in a wall tent heated by a portable wood stove.