Case Study: Abdominal Pain on the Trail

The Setting

It’s day 5 of a planned 12 day wilderness trip for teenagers in a western U.S. wilderness area. The closest road is 12 miles away, and the weather has been warm and dry for the whole trip—perfect for enjoying the mountains. You’re one of the trip leaders with current WFR training.

At 6:30 in the morning, just as your alarm goes off, some of your participants come and tell you that their tentmate is complaining of abdominal pain. So, you go to their tent to investigate.

SOAP Report

Subjective

The patient is a 17-year-old male who is complaining of abdominal pain. The patient’s tentmates woke you at 6:30 a.m. and said the patient had severe belly pain. Patient states the pain began yesterday at 10:00 a.m. as “a bad belly ache cramping-like” but is now “sharp.” He thought it was indigestion. It persisted all night and became “really uncomfortable” about 10:00 p.m. last night. The pain is across the lower abdominal quadrants, does not radiate, and is presently an 8 on a 1-10 scale.

Objective

Patient Exam

Patient is obviously uncomfortable from the pain. Patient states the pain is worse when he walks, especially when he walks down hill or hops. There is no point tenderness or rebound pain. No signs of injury or rigidity to the belly.

Vital Signs

History

STOP READING!

What is your assessment and plan? Take a few minutes to figure out your own assessment and make a plan. Don’t cheat—no reading on without answering this first!

Assessment

This is acute abdominal pain that triggers our program’s evacuation protocols. The pain is increased with movement and jarring and has persisted for more than 12 hours.

Plan

Use the cell phone to contact the program base and request helicopter evacuation for evaluation of this patient by a physician. If the cell does not work, a party of four will hike to the trail head and call on a land line.

Patient will be kept as comfortable as possible. If evacuation is delayed clear fluids will be given if tolerated to prevent dehydration and shock. Otherwise nothing by mouth.

Anticipated Problems

Dehydration and shock. Continued pain and patient discomfort.

Comments from NOLS on Abdominal Complaints

Generalized abdominal complaints are common in backcountry settings. The NOLS data shows that 27% of reported illness is some type of gastrointestinal complaint, most often simple nausea, diarrhea and cramping, and another 7% is acute abdominal pain. Other studies of outdoor programs and expeditions also show that gastrointestinal complaints are common.

Gastroenteritis, the most common cause of abdominal discomfort, is typically cramping, intermittent and diffuse, not consistently reproducible by palpation but, at times, severe. It is often accompanied by vomiting and/or diarrhea, malaise, fatigue, muscle aches, and low-grade fever.

In contrast, the classic history of appendicitis is dull, constant, diffuse pain becoming localized to the right lower quadrant and associated with nausea or vomiting, lack of appetite, and low-grade fever. However, the presentation and course of appendicitis, or any abdominal complaint for that matter, is seldom classic or straightforward.

Good decisions are based on good information. The SOAP note is a useful tool to review and make sure you did a thorough assessment. You’ll notice the chief complaint of abdominal pain is assessed with the OPQRST model (onset, provokes/palliates, quality, radiate/region, severity and time), which examines and helps us understand the complaint.

Evaluating whether abdominal pain is a medical or surgical emergency, or is simple gastroenteritis that will resolve in the field, can be challenging. Outdoor leaders must be diligent in the interview and examination of this patient and focus not on trying to figure out what the problem is, but rather on identifying if the patient is presenting critical evacuation triggers. It’s an analytic process in which we use the Patient Assessment System (PAS) to gather the information. We then look for the evacuation triggers, which, if we follow our protocols, are a pre-determined decision.

NOLS’ Suggested Evacuation Guidelines for Abdominal Pain

Any patient who has:

• Pain inconsistent with a simple UTI or gastroenteritis
• Signs and symptoms or the possibility of pregnancy

A patient with:

• Persistent or worsening gastroenteritis (crampy, diffuse, or intermittent pain) over 24 hours, spiking fever, bloody diarrhea, or dehydration
• Inability to tolerate any oral fluids more than 24 hours, especially if accompanied by diarrhea volume losses, or fever.

Rapid evacuation for a patient with abdominal pain that is:

• Persistent for 12 hours, especially if constant, localized or worsening
• Accompanied by guarding, tenderness, distension, rigidity
• Produced or aggravated by movement, jarring or foot strike
• Accompanied by blood in the urine, vomit, or feces
• Accompanied by fever > 102°F (39°C)
• Accompanied by signs and symptoms of shock

End of the Tale

The cell phone connection worked this time and a helicopter was arranged. The UTM coordinates you read off the USGS topographical map were accurate, and a nearby meadow the size of a football field was an excellent landing zone. The weather held and by noon the patient was in the local emergency room.

After several hours of diagnostic work it was decided to take the patient to surgery where an inflamed appendix was removed. You feel good that your assessment and plan led to a good outcome for the patient, but you also know that many episodes of abdominal pain resolve without being identified. Even if this turned out to be one of those, you still made a sound decision, based on sound criteria and process.

Keep your skills fresh: Recertify with NOLS.