Sweet View – It is 5 pm on a late June day up in the Central Rockies.  You and your BFF are on a hiking trail at about 8500 feet when you come across a gentleman sitting alone, right in the middle of the trail.  As you approach you say hello, but he doesn’t respond.  Something isn’t right.

Scene and Primary Assessment: The scene appears very safe; the thunderstorms moved off to the east about an hour ago.  Nothing above you.  The patient appears to be alone and his ABCs look good.

Secondary Physical: You introduce yourself and ask if you can help and he says “Isn’t the view sweet?”  You think about implied consent and examine him, finding no evidence of trauma and no injuries.  But something is wrong; this guy is out of it. 

SAMPLE:  You are not able to get anything from the patient, except something about how sweet the view is and how pretty the wildflowers are.  He appears to be in his 50s, or maybe 60.  You look in his daypack to see if that is helpful.  You see a half empty water bottle and what looks like a full brown bag lunch.  His name is apparently Bob, but that is all you learn.  You look but he does not appear to have a cell phone. 

Vitals: Round 1- HR 76, RR 18, He is confused and AO x 1 on AVPU scale.  Round 2, 5 minutes later – Same.

Setting: 8500 feet on USFS trail, about 2 miles from and 500 feet above trailhead.   You and your buddy each have small daypacks with a raincoat, a sweater, an extra candy bar, a small first aid kit, some water, and not much else.  Your patient has basically the same.  Your cell phone gets no service.  The weather is just about perfect, maybe 70 degrees, no wind, blue skies. 

Response: 

What do you think is going on? 

Clearly the patient has altered mental status.  Why?  This is a great opportunity to pull out the acronym STOPEATS or AEIOUTIPS, tools to try to figure out why someone has altered mental status when there is no obvious trauma.

S – Sugar                                           
T – Temperature                                 
O – Oxygen                                         
P – Pressure                                   
E – Electrical                                        
A – Altitude                                         
T – Toxin                                              
S – Salts                                                                                                     

A – Altitude or Allergies
E- Environment or Epilepsy
I- Infection
O- Overdose
U- Underdose
T- Trauma or Toxin
I – Insulin
P – Psychological
S – Stroke

You can’t ask Bob questions as he is out of it.  He is on his own so no one else to ask, either.  You look for a medical alert necklace or bracelet; nothing.  You start to go down the STOPEATS list, playing detective doc.

Sugar – Hmmm, he has a pretty full brown bag lunch.  You decide to get some sugar on board Bob in case that is the issue.  He is sitting up and appears able to swallow on his own.  You offer him the candy bar in the bag and suggest he eat it.  He is able to open the wrapper and he eats the candy bar.

Temperature – It is very mild out and Bob is dry.  His skin feels normal.  You already have him sitting on his now emptied pack.  Doesn’t seem like temperature is

Oxygen – Bob’s airway and breathing appear normal

Electrical – There was a thunderstorm that went through but Bob has no burn marks and there are no other signs of a lightning strike, but you certainly can’t rule it out.  You use the acronym BFAST to test him for a stroke and all is normal.

Altitude – Hmmm, you are at 8500 feet so it’s possible, but it seems low for HACE and he appears to be on a day hike. Could his camp be higher?  Not a lot of camping areas too far above you, with the highpoint in the area less than 10,000 feet.  As you can’t rule it out you talk about descending with Bob if you can’t figure anything else out.  Regardless if it is altitude or not you’ll want to head down and back to the nearest town if you can’t figure things out.

Toxins – You don’t see any signs of pills, snakes, partially eaten wild plants, or other signs of poisons or toxins.

Salts – He only has one water bottle and it’s half empty so it seems very unlikely he has hyponatremia.

Thankfully, by the time you finish with your STOPEATS assessment Bob seems to be getting a bit more oriented.  You give him half his PB&J sandwich and suggest he drink some of his water.  He mentions he is diabetic and that he ended up hiking a lot farther than he thought he was going to and that he just had one of those instant oatmeal packs for breakfast.  You ask if he has a headache, just to make sure it isn’t also altitude and he has none.  A half hour after you stop to help Bob he is AOx4 and seems to be fine.  You assume the problem was hypoglycemia.

What do you do? 

As Bob is alone you suggest he head back down and head for home.  He says he is staying at a campground about three miles from the trailhead, where is wife is hanging out for the day.  While you were hoping to continue your hike you decide you should accompany him, just in case.  You have him finish his sandwich and eat his apple, as well as finish his water bottle and off you go.

If Bob had a friend with him what would you ask?

– Any idea what is going on?  Has this ever happened to Bob before?
– Does Bob have any underlying medical issues?
– Has Bob been eating and drinking normally?
– Where is Bob from and how long has he been in Colorado?  Where is he staying (what elevation)?
– No lightning strikes, right?