Case Study – August Newsletter 2019
Race to the Finish – You are working the medical tent at the finish of the Cascade Mountains Ultra Marathon. It is Washington and around 5000 feet (1500 meters) so not hideously hot, but it is August so it’s definitely still hot with afternoon temps in the 90s. The race started at 5 am to avoid the worst of the heat and it is now 2 pm and the top finishers have been in for an hour or so but the bulk of the runners are just now completing the race. One of the officials calls you over to look at three runners who have stumbled across the finish line. You guide them to the medical tent where they collapse to the ground.
Scene Assessment: Scene is safe, 3 patients, MOI?
Primary Assessment: Initially looks good other than Environment. It’s hot outside and they all look and feel hot.
Secondary Physical: Nothing of note other than their skin feels hot
Vitals: See below. Heart rates and respirations are elevated (HR 110 and RR 26). V on the AVPU scale. Skin hot and flushed.
SAMPLE: Patient #1 (Jeannie): 36 year old female. Vitals – HR 110, RR 26, AO x 3. Chief complaint: nausea, being hot. Allergic to tree nuts. No medications other than oral contraceptives. She has done previous marathons and ultra marathons, but never ones in this kind of heat and she has never collapsed like this before. She isn’t sure how much water she has consumed, but she stopped at every aid station and drank at each, as well as emptied her camel-back “several times” (she can’t tell you its capacity). Jeannie ate a couple of energy bars towards the start of the race but puked them up so she didn’t eat any more. She thinks she peed an hour or two ago; and doesn’t remember she last bowel movement. Her last menstrual period was a year or two ago. She doesn’t remember crossing the finish line or the last half hour of the race.
Patient #2 (Will): 28 year old male. Vitals – HR 100, RR 22, AO x 4 (though a little fuzzy). Complains of exhaustion and being hot. Gluten intolerant. First ultra marathon, never felt this way before. States that he has been drinking about a liter an hour. He ate “four or five” packets of Goo, and orange, and several small bags of nuts throughout the race. He says he was doing fine until about an hour ago when he “tanked” and started to lose it. He said he felt dizzy and fell a couple of times over that last hour. He was walking across the finish line when he came in.
Patient #3 (Tony): 43 year old male. Vitals – HR 120, RR 28, AO x 1. Complains of exhaustion and being hot and mumbles “just leave me alone.” His friend with tells you that Tony has done lots of marathons but this is his first ultra marathon and that he thinks Tony is on some kind of cholesterol medicine . He mumbles “lots” when you ask him how much he has had to drink and the same when you ask him about food. He can’t answer your question about going to the bathroom and he becomes V in terms of mental status.
Setting: You are in a gravel parking lot at the end of a gravel road. About 30 miles to the nearest clinic in a small town just outside the National Park. Fifty miles to the nearest small hospital and 80 miles to a major hospital outside Seattle. One generator, but otherwise no electricity. Plenty of water and food.
No cell phone reception but you do have sat phones.
What do you think is going on with your three patients? What do you do?
Patient #1 (Jeannie) – Assessment – 36 yr old female just finished ultramarathon complaining of nausea and being hot. Initial concern: hyponatremia. Could also be “mild” heat stroke. Anticipated problems: Transport. Treatment: Cool patient down by wetting and fanning. Administer salty foods. Continue to monitor and evacuate patient for further assessment.
Patient #2 (Will) – Assessment – 28 yr old male just finished ultramarathon complaining of being hot and exhausted. Initial concern: heat exhaustion. Could also be “mild” heat stroke. Anticipated problems: Transport. Treatment: Cool patient down by wetting and fanning. Administer salty foods. Continue to monitor and evacuate patient for further assessment.
Patient #3 (Tony) – Assessment – 43 yr old male just finished ultramarathon with altered mental status (AOx1) and complaining of being hot. Initial concern: heat stroke. Could also be hyponatremia or dehydration. Anticipated problems: Transport, hydration level. Treatment: Immediate and aggressive cooling of patient by placing in ice bath or wetting and fanning. Use sat phone to call for immediate helicopter emergency evacuation while continuing to monitor and cool patient.