Case Study – January 2020 Newsletter
Rafting is a Gas – You are camped during a private raft trip on the Colorado, in the heart of the Grand Canyon. You are still pissed at the large party that pulled in late the night before, taking up most of the great campsite you were first at. You vow next time to take the middle of the campsite and then to spread out to discourage such losers. You barely mutter a civil good morning when one of your new neighbors comes up to you and asks if any of you are doctors or know about first aid. You roll your eyes and resignedly admit you recently took a WFR class. He asks you to come over and look at some of his sick friends.
Scene and Primary Assessment: You walk with him to his campsite. The scene appears to be safe. There are a dozen people sitting or sprawled on the beach, near the groover. All have good ABCDEs.
Secondary Physical: They all complain of intense diarrhea—the worst case of the “Hershey squirts” ever. Suddenly, you wish you had your gloves. A few of them vomited and most of them complain of cramping. They look sick, sallow, hollow-eyed, withdrawn.
SAMPLE: Signs and symptoms as described. An assortment of mild allergies and medications. Everyone says this is the worst case of the runs they have ever had. They ate dinner last night but almost all were too sick to eat breakfast this morning. They’ve had diarrhea since last night. In terms of events, they all have been eating and drinking the same food, nothing special that they had, that the few other healthy members of their party didn’t.
Vitals: Normal except for several of them have pulses in the high 90s, and respiratory rates in high teens, both of which seems elevated for otherwise healthy people.
Setting: You are two days rafting from Phantom Ranch where there is an NPS ranger station, a place where a helicopter can land, mules, and a five-mile 4,000 vertical hike out to the rim. Your new “friend” says he has a Personal Locator Beacon; you have no other communication devices. It is 10 am, temps about 60 in the shade; hotter in the sun.
What is your Assessment? What are Anticipated Problems? What are you really worried about? What is your plan?
What is your Patient Assessment?
Twelve patients, out of a group of 15, with varying degrees of serious diarrhea. All are stable but miserable. It appears to be some kind of gastroenteritis.
In considering differentials, it could be food poisoning from Staphylococcus (from poor hand hygiene or high protein foods that aren’t kept cold) or E-coli, or Salmonella but everyone ate the same thing and not everyone got sick. Also onset is usually pretty quick, just hours after consumption. Finally, everyone ate the same thing and only some are sick. Water-borne illnesses such as giardiasis take one to three weeks for incubation and would unlikely result in such a near simultaneous onset. No one had traveled outside the country in the previous weeks so it’s also unlikely to be travelers’ diarrhea.
In the end, the treatment, supportive care (mainly hydration), is all basically the same. A specific diagnosis may not be possible, or all that important.
What are Anticipated Problems?
Main anticipated problem is dehydration of the patients. Then there is the issue of those in the patients’ friends who are still healthy; can they avoid getting sick? And don’t forget scene safety! Can you keep yourself and your team from getting sick?
What are you really worried about? What is your plan?
I would mainly be worried about the dehydration of the patients, particularly in the heat of the Grand Canyon. I would also be very worried about contracting whatever they had.
I would also want to be sure the diarrhea was not bloody (it’s not).
I would ensure the patients are well hydrated, particularly with something like diluted sports drinks (50% water, 50% sports drinks) and that they eat lightly.
My plan would be to ensure the other rafting team didn’t get any worse. Symptoms should start to resolve themselves after 24 hours with good supportive care. I would recommend to them that they rest in the shade until the next day. Those that were well should isolate themselves as much as possible and be the only ones in the kitchen. I might also recommend setting up a separate “groover” (bathroom) for the still healthy.
I would be super-careful about interacting with any of them or their camp and would consider heading down river as soon as possible if their team seemed stable. I would recommend to them that they inspect their food, just in case it is some kind of food poisoning, and re-check their water treatment, again just to be sure that isn’t the culprit.