Heat Exhaustion – Case Study

Yolo Abuelo Case Study

It is day two of a four-day trek to Ciudad Perdida, or the Lost City, in the foothills of Colombia’s Sierra Nevada mountains.  There are 17 of you, 15 gringos (almost all from Europe) and two local guides.  Everyone is trekking with just daypacks as the food and lodging are provided at the various camps where the treks overnight.  With one exception, all are in their 20s or 30s.

The one exception, a sixty something, slightly overweight father, who came with his two twenty-something kids, is a persistent old cuss, but he’s been lagging behind the whole time.  At a break the guides realize no one has seen him for an hour or so.  The one guide who speaks some English, asks you to head back with him to check on “Abuelo,” as they affectionately have started calling the older guy.  You walk back down the trail for 15 minutes, maybe a kilometer, and find Abuelo sitting on the side of the trail.  He slowly stands up when he sees you and insists on continuing, mumbling “You only live once.”

Scene Assessment: Other than an occasional Wiwa Indian leading a string of pack mules on the narrow trail, the scene appears safe, but it is definitely hot.  No clear MOI and there is just one patient.

Primary Assessment: No clearly significant threats to ABCs.  He is soaking wet from what you assume is sweating.

SAMPLE: He complains of being hot, and having an upset stomach/GI system, with a mild case of the runs.  He has no allergies and tells you he is on some kind of cholesterol meds and an over the counter daily acid reducer, which he has been taking more or less regularly. He tells you he feels weak; that normally he keeps right up with folks and he has no major chronic issues. You ask him if he has been eating and drinking and he tells you he is almost out of water. He ate part of his breakfast and little bit of lunch, but he just doesn’t have much of an appetite.  He doesn’t remember when he last peed and his last bowel movement was after breakfast and it was runny (but no blood). He said he stopped because he just needed to sit down.  He has one liter-sized water bottle that is one-quarter full (he drank the rest, but that is all the water he has consumed since breakfast.  He doesn’t remember how long he’s been sitting there.

Secondary Physical: Other than being wet, secondary physical normal.

Vitals: HR 88, RR 24.  Skin flushed.  AOx4 but he seems a bit slow in responding.

Setting: About 2500 feet in elevation.  It is 85-90 degrees with humidity in the 90% plus range.  It’s 2:30 in the afternoon in late March.  There is faint thunder in the distance, but almost no wind and intermittent sun and shade from scattered clouds.  The muddy trail you are on has been going up and down, with virtually no level sections, but mostly up.  It is accessible by foot or horse, but that is it.  You are a WFR, but you doubt the guides have much if any, first aid training.  You have very little first aid gear (bandaids and some ibuprofen), a granola bar left over from lunch and less than half a liter of water, about the same as the guide.  Your guide tells you it is another 1.5 hours up a steep climb to the next (and final) camp where the rest of the group is heading and where there is food, drinking water, and shelter.  You think you remember a small mountain stream about 20 minutes back towards the trailhead, which the guide confirms and he tells you there is another stream about a half hour before the final camp.

It’s 15 km back down to the original trailhead on a muddy and up and down, but decent, trail, and another one and a quarter hours on a rough and steep dirt road to pavement and then 45 minutes to a small hospital.

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

RSPONSE

What are your first thoughts and worries?  Is this a hike or helicopter (horse?) situation. 

Me, I am initially worried about heat issues, dehydration, and his diarrhea.  More about these later….  I am leaning more towards hiking than helicoptering, but keeping an open mind. 

Assessment: 60 year old male complaining of heat, nausea, diarrhea, and weakness.  Not altered mentally but seemingly a little slow to respond.  Slightly elevated RR and HR.

Anticipated problems: Heat exhaustion or stroke, dehydration, hypoglycemia, GI infection.

Plan:

Immediately – Cool Abuelo down.  Get him out of the sun, sprinkle half your limited water on him, and fan him.  Have him slowly drink what is left of his water and give him your granola bar to eat. 

Secondarily – If one of the local Wiwas with a horse comes by, see if you can rent the horse to transport Abuelo to the final camp up ahead.  If not, and assuming he doesn’t get any worse, take his pack and slowly start hiking with him towards the final camp.  Send the guide ahead to get more water, both to cool Abuelo with and to treat for oral consumption.  As you are walking find out how long he has been traveling and where all he has been.

Once at camp – Continue to monitor for heat stress.  Continue hydration.  Make sure Abuelo gets at least some dinner in him

Keep him out of the kitchen and isolated as possible.  Use lots and lots of hand sanitizer and ensure that he does, too.

Monitor his diarrhea.  Any blood?  Encourage lots and lots of hydration. 

Check with his two kids, make sure they don’t have any of the symptoms.  Get them involved in his care. 

For the remainder of the trek encourage him to start earlier in the day.  Don’t let him carry a day pack or at least lighten what he does carry.  Ask him if he would prefer to ride horse rather than hiking and encourage it if he doesn’t feel better.