Burn Out Case Study – It’s late January and it’s been a long couple of weeks at work; you’re feeling a bit crispy after lots of holiday family visits and way too much overtime.  You decide to head out for a weekend ski tour to a “secret” old mining cabin up above Breckenridge that you’ve been wanting to check out for years.  You and your three mid-twenties Denver buddies arrive to the one room primitive cabin after a long and tiring climb, ecstatic to find the cabin at the end of a long and very cold day.  After a quick snort from the flask passed around, and putting your sleeping bags in the rustic bunks, Pete breaks out his backpacking stove and tries to start it.  Nothing – he curses an empty gas cartridge and throws another one on the stove and lights it.  A few moments later there is a blinding flash and a big “WHUMP” as a flash fire engulfs the room.  You and your buddies grab your sleeping bags and beat out the flames around the stove.  You see Pete on the floor looking dazed, but amazingly he seems okay, at least at first glance.

Scene and Primary Assessment: The fire is out and there is surprisingly little smoke.  Everyone is accounted for.  Other than a bit of wheezing by Pete, he has good ABCs and no apparent other primary issues.

Physical: On exam Pete complains of a very sore left ankle.  Apparently he badly twisted it when he stumbled from the flames.  He has a blister on the back of his right hand about the size of a silver dollar that is super painful.  He voice is bit raspy and he says his throat is kind of sore so you look more closely at his face.  You laugh as you see that his long bangs are singed, as is his part of his scraggly beard.  He is shivering a bit in the cold cabin, otherwise nothing else of note.

SAMPLE: Symptoms as described; Pete is allergic to cats and dogs and pollen.  He is on some kind of anti-allergen medicine, but doesn’t know what it is (he took his daily dose today).  No relevant history.  He had lunch 5 hours earlier and probably got a liter of water down over the day—it was too cold to drink much.  In terms of E, Pete was starting to put a pan of water on the stove when there was the big “whump.”  You figure that maybe the “empty” stove canister wasn’t really empty and that it leaked and the gas ignited from the stove flame.

Vitals: Round 1 – HR 88, RR 24 and “wheezy,” AOx4.  Round 2, 10 minutes later – HR 92, RR 28 and “wheezy,” AOx4, but a bit anxious.

Setting: About 11,500 feet, it’s now 6 pm.  Calm and clear skies, but cold—about 5 degrees F. below.  You are 3.5 miles from, and maybe 1500 feet, above the trailhead.  It is a moderate ski down through trees on a broken trail.  While you are a beginner backcountry skier, the other three of you are competent and experienced skiers.  You have a cell phone but there is no cell service, at least at the cabin; there was at the trailhead.

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

Response: 

Okay, snapshot time: At this moment, what are you worried about?  What is your big concern(s)?

Assessment: Pete, a 25 year old male, complaining of sore throat after flash fire from backpacking stove.  Raspy voice and singed facial hair.  Unstable right ankle from stumble and partial thickness burn about two inches in diameter on back of left hand.  Burn on hand treated with water and snow

Treatment: The oxymoron of wilderness medicine?  What can you really do?  Make sure fire is truly out and that everyone else is okay.  In terms of potentially burned and swollen airway, not much.  Carefully exam mouth and throat to look for burns, swelling, etc.  Douse hand in water, removing any jewelry. Splint ankle (if unstable enough that he can’t stand/walk without).  Treat for pain (max dose of Tylenol and ibuprofen).  Get some high calorie food and water on board patient, if tolerated, and feed/water everyone.

Says Dr. Elaine Reno, “I would evacuate an airway burn immediately.  They are bad airways that can swell quickly.  Nothing much to do for it in the field except get them out ASAP. Things that concern me: burn/flames in an enclosed space, smoke inhalation, facial burns, singed facial hair, soot in the mouth/oropharynx, voice changes, difficulty swallowing. Airway burns are some of the hardest airways to manage.”

Anticipated Problems: Respiratory distress, hypoglycemia and dehydration, hypothermia, altitude illness, environment (cold, daylight, distance from trailhead) and evacuation.

Plan: Critical decision: Do you keep Pete at hut and send two for help or do all four of you head down.  Clearly best to get Pete out ASAP, but worst thing would be to get halfway down and he can’t go any further.

Does Pete think he can handle his twisted ankle, burned hand, and airway issues and still ski down?  If he does, feed and hydrate everyone.  Once heading out, be ready to turn around in the first 5-10 minutes if there is any sign Pete might be having problems.

If Pete doesn’t think he can make it or has reservations about doing so, send your best two skiers down (after feeding and hydrating them) with copy of SOAP note, cell phones, car keys, enough clothing and supplies to take care of themselves.  Have them try cell phone for coverage every 15 minutes or so on the way down.  Friends to call local sheriff’s office to report accident, location/situation, and request snowmachine evacuation or whatever 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 head to trailhead to stay warm at car and await rescuers so at least one of them could lead them to hut.

Back at the hut continue to provide supportive care to Pete.  Prepare for a long evening but know you did what could and the patient is in as good hands as possible.