A New Tool for the Humanitarian Emergency Medical Kit - How To Use

Wilderness Medicine Emergency SOAP Note Introduction In graduate school I learned about clinical/medical charting. The classic approach is what is called a “SOAP note” wherein SOAP is an acronym for Subjective Objective Assessment Plan. There are dozens freely available on the web, so do feel free look at others and edit this one to better fit your needs and situation. A few years back I took the NOLS Wilderness Medicine Training and then attended the National Conference on Wilderness Medicine. I then wanted to combine what I had learned and create a form that can serve a prompt for users when providing emergency first aid – when one may not be thinking the most clearly or be at one’s best yourself. It also is a way for you to be able clearly communicate to an EMT or other medical professional when they arrive or the patient is transported to care. Clear information combined with proper emergency first aid can literally be a life saver.

Use I developed this "Wilderness Medicine SOAP Note" based on a NOLS course I took. I find it to be of use in any medical emergency with or without a handy 911 availability. This version steps you through its use and “decodes” any acronyms and shorthand terms you may not yet be familiar with. The companion version does not have this additional information and is meant to be concise to be printed duplex on one page for ease of use and carrying in your backpack. I keep a few in my car’s glove box and my bike’s saddlebag, and I give them to friends and family for use, as well as being freely available via LinkedIn and Facebook. If you cannot print out mine, just email me DrChrisStout@gmail.com and I’ll send you my kit at no cost. There is also a app version from The Wilderness Medicine Training Center available here. Please feel free to share, and if you wish to edit and make improvements, please feel free and send me your version. Thx! – Chris Stout Scene: Safe? How many? How bad ? MoI for spine? EVAC Numbers: 628.521-1510, RedPoint Emergency - AAC Method of Injury: Secure head/neck Look/Ask/Feel Patient ABCDE Stop + Fix When you come upon an emergency/injury situation or scene, first be sure it is safe—Is the bear gone? Is the fire out? Is the shooter gone? Etc. How many are injured?

How bad are they injured? Are there others present that can be of help?

The EVAC Number is for American Alpine Members, and is an example, as I’m an AAC Member.

MoI = Method of Injury for the spine-- Is their next/spine OK? If not, do not move them unless you really have to.

Method of Injury: Make note of how you think the patient was hurt.

Be sure to secure the patient’s head and neck, even if you believe there may be no direct injury.

Look at the patient.

Ask the patient how they feel and what happened.

Feel the patient for any fluids or anything physical that is out of the ordinary.

Do “ABCDE” = Airway Breathing Circulation (“Blood Sweep” visually or tactile [ideally with gloved hands] “sweep” for obvious and nonobvious signs of bleeding) Disability/Decision Environment/Exposure (see next for explanation) SUB Name:

Age:

Airway: Breathing: Disability/decision (If no MoI):

Sex: M/F Chief Complaint: _________Circulation/Blood Sweep:__________________ Env/ Exposure:_

________ ____,

Tattoo /Med-A-Lert: ______________________ Head-to-Toe Exam revealed: SUBJECTIVE Patient’s name Patient’s age Patient’s sex Patient’s injury/injuries or what they are complaining of.

Airway – is it clear, intact and unobstructed? Have they coughed-up blood? Bit tongue? Broken or lost teeth?

Breathing – is the patient breathing? Have they been breathing the entire time you have been with them? Is it labored, raspy, wheezy, or problematic in any way?

Circulation/Blood Sweep (“Blood Sweep” visually or tactile [ideally with gloved hands] “sweep” for obvious and non-obvious

signs of bleeding) – how is their pulse? Is there bleeding? Where? Active? Judgment of blood loss.

Disability/Decision – is the patient mobile? Are they oriented/know who they are, where they are what happened?

Environment/Exposure: any indication as to what caused the injury like a wrecked bicycle, evidence of an animal attack, etc.?

Tattoo /Med-A-Lert: Any visible tattoos or medical bracelet indicating conditions like diabetes, epilepsy, etc.?

Head-to-Toe Exam revealed – note relevant finding from the prior examination points.

OBJ Vitals

Time Alert (Person/Place/Time/Event) Level of R +O__ ___+O__ HR x4= x4= RR x2= x2= kin olor emp oisture S C T M

/Verbal/Pain/Unresponsive ___+O__ ___+O__ x4= x4= x2= x2=

Reg/Irr : Strong/Weak Labored/Unlabored: Shallow/Deep

OBJECTIVE Log the times you took your measurements Make note if the patient was oriented x4, to Person (who are you?), Place (where are you?), Time (what day/date is it?) and Event (what happened or what were you doing?)

Is the patient verbal, complaining of pain (where), or unresponsive?

Level of Responsiveness and orientation (O), e.g., V +O x4 means Verbal and alert/oriented to person, place, time and event HR = Heart Rate/pulse. Time it for 15 seconds and multiply x4 for heart rate. Make note, if possible if it is regular or irregular, and if it is strong or weak.

RR – Respiration Rate. Time for 30 seconds and multiply x2 for respiration rate. Make note if it is labored or unlabored, and if it is shallow or deep.

Make note as to skin color (look for bluing of fingertips/lips [poor circulation due to hypoxia/altitude, cold/frostbit/nip, etc.], temperature (cold, hot, normal), and moisture (calmy, dry, normal).

Include signs in the objective information. Make sure to also include symptoms in your notes as well.

SX: Allergy: What: Exposure? Y/N/Unk Reaction: Tx: Medications: Name: For: Last Time Taken: Name: For: Last Time Taken: Name: For: Last Time Taken: Include dosage questions in the medications section: what, when, why, how much, did you have it today Hx: has this happened before, do you see a doctor on a regular basis for anything Food/ H2O: Last In/Out: What: Output Color/Consistency: PG? Y/N/Unk Blood Type, and Rh factor, if known: _____ Events: Recent Illness/Injury: events of the last 48 to 72 hours SX = Symptom(s) As if they have any allergies, if so to what. Were they exposed to allergen or stung (yes/no/unknown)? What is there general reaction to exposure – anaphylactic shock, spelling, sneezing, breathing difficulty, etc. Are the symptoms presenting? How are they generally treated once exposed? EpiPen, antihistamine oral tablet, topical medication? Do they have such medications available (purse, backpack, glove box, parent, etc.?)

Are they taking any medications (prescription or OTC)? If so, what, to treat what, when was the last time taken?

What is the typical dosage for each medication, when do they take it, when was their last dose, what is it for?

HX- History Has this happened before (in cases of fining the patient initially unconscious or disoriented or suspected seizure and the like)?

Are they under the care of a physician and if so, what for?

When did they last eat or have something to drink? What was it?

Have they urinated, had a bowel movement and/or thrown-up recently? Anything notable as to those fluids/material vis-à-vis amount, color and consistency?

Are they pregnant? If known, how far along? Any prior problematic issues with the pregnancy?

What is their blood type and Rh factor in case they need a transfusion.

In the last 2 or 3 days has there been any recent illness of injury (prior head trauma, car accident, medication reaction, hospital release, etc.)?

Focused Spine Assess: A+ O 3 /4 N/Y→ Sober? N/Y→ Free from distraction (pain): N/Y→ CirculationSensationMovement: N/Y (in all 4 extremities)→ Free of Spine Pain on palpation? Y/N (if yes to all then OK to move or release head) A+O3/4 means the patient is alert and oriented person, place and time, and if so, scores a 3 and if also event, then scores a 4.

Have they taken any drugs or drank prior to the injury?

Any complaints of pain or discomfort?

Circulation Sensation Movement – does the patient have good color in all four extremities, able to feel touch there, and able to gently move them?

Any pain when spine is palpated?

If all yes, then OK to move patient or release head.

ASSESS: Based on MoI, Possible Possible Possible Possible ASSESSMENT Make note you assessment as to what you think may be possible Method(s) of Injury.

There can me more than one.

PLAN, TX: (TREATMENT) PLAN TX = Treatment If you are properly trained, you may do (if possible) or recommend what should be done to help the patient.

EVAC PLAN: Evacuation Plan This depends on where you are, dangers and risks if in exposed area, and are you in an area available to rescue or have access to EMTs/911.

ANTICIPATED PROBLEMS Make note of any obvious and non-obvious aspects that could or will be problematic.

TX Tips: Mild head injury: Amnesia A=O2,3,4→Nausia→Headache→Dizzy→Tired→Vomit OK to sleep, but say remember “fuzzy dinosaur” and then wake every 20’ & ask what nonsense phrase was used isoriented rritable D I Combative head dark color behind ears/raccoon eyes/ might want to include evacuate with any decrease in LOR Sx as above Tx: monitor ABCs/backboard/elevate head 6-8”/EVAC Shock: A+O3,4 (unless otherwise explained)/^HR/^RR/pale+cool+clammy = Compensatory | O↓/agitated/HR↓/RR^/PCC = Decomp | Causes: dehyd/ bleeding. Tx: find and treat the underlying cause control bleeding/maintain airway/calm/ warm/elevate legs12”/fluids in extended situations.

Emergency Treatment Tips if you feel confident of what you are doing and the intervention is proper to the need.

Mild head injury, based on: SX: Amnesia, alert but may be only oriented x2 (but could be x3/4)→ Nausea→ Headache→ Dizzy→ Tired→ Vomiting OK to sleep, but tell them to memorize “fuzzy dinosaur” and then wake them every 20 minutes and ask what nonsense phrase was used.

Disoriented-Irritable-Combative head (so called DIC-head) SX: dark color behind ears and/or raccoon eyes, might want to include evacuate with any decrease in their Level of Responsiveness and look for amnesia, alert but may be only oriented x2 (but could be x3/4)→ Nausea→ Headache→ Dizzy→ Tired→ Vomiting TX: Monitor Airway Breathing Circulation, but on a backboard, elevate head 6-8”, and evacuate ASAP Shock: Alert but may be only oriented x2 (but could be x3/4, unless otherwise explained), increased heart rate, increased respiration rate, skin is pale, cool and clammy if their shock is compensatory.

Poor orientation, agitated, decreased heart rate, increased respiration rate, skin is pale, cool and clammy if their shock is decompensating.

Consider dehydration and/or bleeding.

TX: Determine and treat the underlying cause, control bleeding, maintain their airway, keep them calm and warm, elevate their legs 12”, push drinking fluids in extended situations.

CPR: 2 breaths; √ pulse; 30 comp+2br (rept 5x ); re √ pulse/resp Cardio-Pulmonary Resuscitation Give two breaths with patient’s nose pinched Check for pulse Do 30 compressions and 2 breaths Repeat process x5 Recheck pulse and respiration Continue as long as need be, or until certain it is not going to revive the patient.

Diabetes: Give sugar Determine if the patient is hypoglycemic and give sugar, sugary drink, candy, etc., if available. If not, then high-fructose fruits, like bananas, if available. See if they, or bystanders, have insulin and hypodermic available.

Abdominal EVAC? Abdominal pain+ S/SX of shock+ Blood in vomit/,urine/feces+ Continuous pain>24O+ Localized gut pain, rigidity/guarding/tenderness, Pain on movement, Nausea/ vomit/ runs causing dehydration or lasting >720,Fever >1020, S/SX of PG (any of these individually should constitute an evacuation Serious abdominal/gut issues in need of evacuation Abdominal pain, sign or symptoms of shock, blood in vomitus, urine and or feces, continuous gut pain for more than 24 hours, localized gut pain, rigidity, guarding, and/or tenderness of abdomen, pain on movement, nausea, vomiting and/or diarrhea causing dehydration or 0 lasting more than 72 hours. fever of 102 , of higher, sign or symptoms pregnancy. Any of these individually should constitute an evacuation.

Musculoskeletal Test: Look/Ask/Feel→ CirculationSensationMovement→ Passive RoM → Active RoM → Bear weight?→ Unstable TX: HyRICE : Hydrate, Rest, Ice , Compress, Elevate.

(NSAID) TX for “unusables” & fracture: Traction → normal position STOP Traction if resistance or marked increase in pain • Splint: rigid , padded. Immobilize joints above & below fracture ( Bones above & below joint injury) • Splinting: Simple/Padded/Adjustable/fingers-toes available • Monitor CirculationSensationMovement before and after splinting For open fracture: Irrigate and dress 1st!

Start antibiotics!

TX for dislocations: Reduce ASAP+ Slow, steady traction-in-line. Relaxation is key+ HyRICE , work ROM 3x/day this should not be done before consulting a physician for a first time dislocation EVAC: ↓ CirculationSensationMovement, unusable & 1st time dislocations.

Musculoskeletal Concern Test by Looking, asking, and feeling vis-à-vis circulation-sensation-movement Check passive Range of Motion (you move patient’s extremities and check for pain or issues) Check active Range of Motion (have the patient move their extremities and see if there are any issues or pain in doing so) Can the patient bear weight?

Is the patient unstable If minor, the TX with HyRICE : Hydrate, Rest, Ice , Compress, Elevate. Consider use of NSAID, if available and no allergy.

TX for a patient who has an unusable limb or a fracture: Traction: in the normal, unbent position but STOP traction if there is resistance or marked increase in pain when doing so Splint: rigid and padded. Immobilize joints above and below the fracture (bones above and below if a joint injury).

Splinting: Simple, padded, adjustable, fingers or toes available Be sure to monitor Circulation-Sensation-Movement before and after splinting.

Open fracture: Irrigate and dress 1st and start antibiotics if possible.

Dislocations: NOTE - Reducing a dislocation (or popping it back in) is not a first aid skill. In most states it is not an EMT-level skill. ONLY PROPERLY TRAINED INDIVIDUALS SHOULD ATTEMPT THIS TECHNIQUE. Reducing a shoulder incorrectly carries a non-trivial risk of permanent harm to nerves and blood vessels. If you are not trained, then: Slow, steady traction-in-line. Relaxation is key and the HyRICE protocol (see above), work Range of Motion 3 times a day this should not be done before consulting a physician for a first time dislocation.

EVAC: if decrease in Circulation-Sensation-Movement, if unusable or 1st time dislocation.

Wounds Control bleeding Pressure & elevate; pressure on injury point Tourniquet: loosen/ retighten if needed these can be left in place for 2 hours without damage, if you are applying a tourniquet to a wound you should be planning an evacuation for this patient Prevent infection: clean it!

Soap / H2O around wound Remove foreign matter; scrub abrasions if needed Pressure irrigate- only H2O Dress & bandage; gaping>1/2” pack w/damp gauze Promote healing Puncture: leave and stabilize in place Remove if: in face-cheek, extremity, cold metal from body core EVAC: Impaled, Packed, Dirty/contaminated / bites, cosmetic, in joints/genitals Control bleeding Apply pressure and elevate; direct pressure on injury point Tourniquet: loosen and retighten if needed, these can be left in place for up to 2 hours without damage, if you need to apply a tourniquet to a wound, then you should also be planning an evacuation for this patient Prevent infection: clean it!

Soap and water around the wound Remove any foreign matter; scrub abrasions if needed Pressure irrigate using only clean water Dress and bandage; leave a 1/2” space and pack with damp gauze to promote healing Puncture: leave in and stabilize it in place.

Remove if it is in face-cheek, an extremity, or if it is cold metal in body core EVAC: If impaled, dirty or contaminated, a bite, disfiguring, in joints or genitals Heat Exhaustion: A+Ox4, HR/RR↑↓, SCTM: hot/red or pale/cool/clammy or dry TX: cool pt/salty foods H2O/Electrolytes Stroke: Change in LoR (- sign) Disoriented Irritable Combative head, SCTM: red/hot/dry this can vary, may be red/hot/moist, pale/hot/dry. TX: rapidly cool pt Life threatening: EVAC Cold DO NOT RUB frost-nip Mild: “the Umbles” poor motor skills Moderate: ↓LoR (bad sign) uncontrolled shiver, ↑ Umbles Severe: NO shiver, stupor/unresponsive, NO CPR Life threatening: EVAC Tx: warm/dry/no wind/warm food & drink/exercise if able, heat packs, hypo-wrap Frostbite Rewarm in 1060 F H2O/ H2O in wrapped bottles in sleeping bag in groin, arm pits/or skin-to-skin Heat Exhaustion: May or may not be oriented and alert, heart rate and respiration rates go up and down/unstable, skin is hot/red or pale/cool/clammy or dry TX: cool patient, provide salty foods, water with electrolytes Stroke: Change in Level of Responsiveness (negative sign), Disoriented-Irritable-Combative head (so called DIC-head), skin is red, hot, and dry but this can vary and may be red, hot, moist or even pale, hot, and dry.

TX: rapidly cool patient Life threatening: EVAC Cold DO NOT RUB frost-nip areas Hypothermia - When core temperature goes below 90 degrees, the patient may lose the ability to walk, can fall unconscious, and their breathing and pulse may be very difficult to detect. Some of the common initial stages of hypothermia are often referred to as the “Umbles”. These include: Stumbles – loss of control over movement, slowed motion, stiffness in extremities Mumbles – slurred, slowed, or incoherent speech, sleepiness or confusion Fumbles – slow reaction time, dropping objects, poor coordination Grumbles – change in behavior, expressing a negative attitude

Moderate: Decreased Level of Responsiveness (bad sign), uncontrolled shivering, increase in the Umbles TX: warm, dry, no wind, warm food and drink, exercise and movement, if able, heat packs, hypo-wrap in any appropriate material that is available.

Severe: NO shivering or shivering formerly present now ceases, stupor or unresponsiveness, DO NOT DO CPR, Life threatening: EVAC Frostbite Rewarm extremities in 1060F water, use same temp water in wrapped bottles in place in patient’s sleeping bag in groin area, arm pits and/or skin-to-skin

Rev: 30 June 2022, Chris E. Stout