Going for the Gold – It is a beautiful September afternoon and the aspen are aglow.  You and three friends (the “over the hill” gang of 50-somethings) are mountain biking down an old mining road up near Telluride.  The brilliant fall foliage ignites your spirits and you and let ‘er rip.  You are doing Mach 3 or 4 when you hit a large loose rock and get thrown over your handlebars.

Scene and Primary Assessment: Scene is safe; your friends find nothing on primary assessment; environment is dry and warm.

Secondary Physical: Upon examination you are V on the AVPU scale with bleeding and unstable ankle injury.  Your LOC steadily improves and within 5-10 minutes you are A on AVPU and soon AOx4.  There is a scratch on your helmet but on exam your head appears as normal as it ever does.  Your leg really hurts as your LOC improves.

SAMPLE: No other symptoms besides those described.  No allergies.  You are on a daily aspirin (81 mg) and Viagra (for the “altitude”).  You blew out your ACL on that same leg 15 years ago, but you have never broken anything before, if that is what is going on.  Last ins and outs normal.  You were feeling great until you went flying.

Vitals: Round 1 – HR 96, RR 24, V on AVPU scale.  Round 2 – HR and RR 88 and 20, and AOx4.

Setting: Old mining road (only accessible by foot, horse, bike, and probably ATV), 5 miles from trailhead and your parked car.  Weather sunny, and warm, except in the shade where it is starting to get a bit chilly.  Trail dry.  No cell phone coverage where you are, but you did have it at the pass, about a mile away and 500 feet above you.

What do you do?  What is your assessment, anticipated problems, and plan?

Answers: 

Okay, first of all, take a deep breath.  Is your patient going to die on you?  No.  So take your time and do things right.  Slow is smooth and smooth is fast. 

Treatment: Get patient in the sun, off the ground, and in warm clothes and off the road if there is other mountain bike traffic.  Monitor for head injury and ICP.  Clean blood on ankle, ensuring it was external scratch and not an open fracture, and splint.  Treat for pain (max dose of Tylenol and ibuprofen).  Get some high calorie food and water on board patient if tolerated. 

Assessment: 50 something year old male was thrown over handlebars of mountain bike at a high rate of speed.  Patient initially V on AVPU scale but rapidly improved to AOx4.  Scratch on helmet; may have hit head.  Patient complains of unstable left ankle.  Ankle splinted and max dose of Tylenol and ibuprofen administered. 

Anticipated Problems: Hypothermia, altitude illness.  No sign of significant head injury but head to be monitored.

Plan: Make sure caregivers are warm, fed, and hydrated. Continue to provide supportive care to patient.  Send two friends, carrying copy of SOAP note, map, and essentials, up on bike to the pass where there is cell phone reception (parking lot may or may not have reception).  Friends to call local sheriff’s office to report accident, location/situation, and request ATV or evacuation method recommended by sheriff’s office.  Have them also call loved ones to report situation and fact that they won’t be home until late that night.  Ideally they would return to accident scene to report plan and assist with any further care.  Alert any other mountain bikers passing by of situation and request any assistance needed (additional warm clothes, communication, head lamps, etc.).  Depending on caregivers energy level, what clothing/supplies are with group, and what might be in cars at trailhead, consider sending two down to get stuff and return.  Prepare for a long evening but know you did what could and the patient is in as good hands as possible