It is a beautiful late August day and you are mountain biking on a single-track trail in Upstate NY.  Your friend Laura is doing about Mach 7, hits a big root and spectacularly flies over the handlebars to land on her belly.  You find her on her side on the ground.  You are happy she was wearing a helmet, but it’s her stomach she is complaining about.

Scene and Primary Assessment: You know there are other bikers behind you so you hold her head and neck spine steady and let her carefully and completely move off the trail.  Airway good, breathing rapid but a bit shallow.  You see no blood. You tell her to keep his head and neck still and begin a secondary exam.

Secondary Physical: You check her back before helping her (by holding his C-spine hand stable with a solid head squeeze) roll over to lie on her back.  You wish you had a sleeping pad to get her off the ground, but at least the ground is dry and relatively warm.  You start your physical and find nothing of note until you get to the belly when you find a very tender upper left abdomen and sore ribs on that side.  All else is normal.

SAMPLE: Laura appears a bit anxious and her breathing remains rapid.  Symptoms as noted.  No allergies.  She tells you he is taking Coumadin, some medicine for atrial fibrillation (whatever that is) and clots and oral birth control.  She thinks she just had the wind knocked out of her, at least that’s what if felt like.  Last ins and outs all normal.  Events as described above.

Vitals: First round – HR 80; RR 18, AOx4.  Second round – HR 96, RR 28, AVPU normal but he is a bit agitated.   Third round – HR 112, RR 30, AVPU = AOx1.

Setting: You are 6 miles from nearest trailhead, at about 1000 feet of elevation. The nearest hospital is about 20 miles from the trailhead, the first three miles of which are a gravel road. It is 1 in the afternoon, humid and about 85 degrees.  It is starting to cloud-up, and it looks like a thunderstorm is brewing.  You don’t have cell phone service but you can text.  Two mountain bikers stop to see if they can help.

What do you think is going on?  What are you really worried about?  List anticipated problems.  What do you do?


What do you think is going on?  Given a significant MOI, her tender upper left abdomen, and especially her vitals, you guess that she has significant internal bleeding.

What are you really worried about?  You should be really worried that she may have damaged her spleen and that she is bleeding internally, which could lead to or be causing shock. You should be really worried that the only real treatment for shock is evacuation and that is going to be tough given where you are.

Anticipated problems:  Spinal issues and any accompanying neurological deficit.  Evacuation.  Thunderstorm?

What do you do?  If you aren’t far enough off the trail to be sure you won’t get hit or cause other bike crashes, have the other mountain bikers block the trail in both directions.  Elevate Laura’s legs and keep her as warm.  Minimize spinal movement.  Send the most reliable of the two mountain bikers, along with a copy of SOAP note and map, to get help.  Tell the mountain biker that speed is not the issue, but the certainty of the message getting through so ride very conservatively.  Consider sending both mountain bikers if you don’t need additional hands.