Case Study: Burn in the Backcountry

The smell of the morning coffee your co-instructor is brewing wakes you from a great sleep. This is immediately followed by a loud scream from one of the student camps. It’s a spring morning in the Gila Wilderness in New Mexico, and you’re about to earn your pay.

You bolt out of your sleeping bag, stumble and fall in the process, and curse your clumsiness. Your co-leader runs to the sound of the howls and commotion. You grab the first aid kit, pull on your shoes and a layer of clothes. While walking to the scene you keep your breathing under control and your head up while your eyes scan the camp. You mentally review the scene size-up and initial assessment.  

You find one of your students, 25-year-old Denise, howling in pain and trying to pull off her long underwear while another student is pouring water on her foot. At the same time one of the students is standing to the side sobbing “I’m sorry.  It was an accident.” Apparently, he tripped while carrying a pot of hot water and spilled the water into the patient’s boot.

You quickly figure out that this is a spilled hot water burn and continue the cool water irrigation and help the patient to pull off long underwear, socks, and shoes. After 20 minutes of water irrigation, which required several relays of people back and forth to the stream (which of course was more than 200 meters from the camp) you decide it’s time for a complete patient assessment.

SOAP Report

Subjective

Objective

Patient Exam

The patient has 5% superficial burns to the back of the left lower leg and a 2” x 3” partial thickness burn to the heel of the left foot. The burn is not circumferential. The blister has ruptured. CSM is good in the left toes. No other injuries found.

Vital Signs

History

Pause here!

What is your assessment and plan? Take a few minutes to figure out your own assessment and make a plan before you read further.

Assessment

• Patient has 5% superficial burns to the back of the left lower leg and a 2” x3” partial thickness burn to the heel of the left foot.

Plan

• We will dress the partial thickness injury with the 2nd Skin® in our kit and clean gauze. 
• The patient is uncomfortable. It will be difficult to keep the wound clean. The patient cannot wear their boots. We are concerned with the location of the partial thickness burn on the heel. We will evacuate the patient. 
• The patient is able to walk in running shoes with the heel folded down. We will hike to the trailhead, which we should reach tomorrow, and have this burn evaluated by a medical professional.

Anticipated problems

• Wound infection.
• Inability to walk.

Comments

Other than a sunburn, the most common cause of a burn on a NOLS course, and on many wilderness trips, is a scald from spilled hot water. The pot of hot water is a concentrated source of energy, which if applied to skin, can burn. Stoves, lanterns, and fires are also sources of burns. 

Minor burns may be no more than a trivial nuisance, yet they represent a potential site of infection.  A large burn may rapidly cause shock. 

The treatment principles begin, of course, with safety. Ensure the scene is safe. Remove the patient from immediate danger. Put out the fire and heat. Cool water may reduce the extent of the injury and help with pain management, but use common sense and be careful of hypothermia, especially with burns covering significant total body surface area (TBSA). Remove clothing and constricting objects such as jewelry, watches, and belts.

Assess the ABC’s, being suspicious of burns on the face/neck, soot in the mouth/nose, singed hair, and a dry cough as indicating an airway burn. Assess, monitor, and treat for shock.

Estimate the depth of the burns.

• Superficial: Red, painful, swollen.
• Partial thickness: Red, painful, swollen, and blistered.
• Full Thickness: Painless, without blisters, can be pale or charred.

Estimate the extent of the burns, using the rule of nines or the rule of palmar surfaces. The patient’s palm and fingers are roughly 1% of the patient’s TBSA. You’ll see this “rule” described as palm only, or palm and fingers. Consensus on this seems elusive in medical texts.  Regardless, it’s a ballpark estimate for us. A physician will use a much more detailed body surface area map.  

Assess the location of the burns. Burns to the face, neck, hands, feet, armpits, groin, and circumferential burns are particularly dangerous.

Clean the burn with gentle irrigation.  

Cover the burns with the cleanest available dressings, burn gel or sheets, or products such as 2nd Skin®. In extended care situations clean the wound daily, debride dead skin around blisters that have self-drained (but don’t drain intact blisters). 

Give pain medications as needed (NSAID's are often recommended) and keep the patient hydrated.

Non-adherent dressings are easier to change than coarse gauze. If you only have coarse gauze, consider smearing your water soluble antibiotic cream onto the gauze. Spenco 2nd Skin® is a hydro-gel that absorbs fluids, wicks serum and secretions from wounds and helps healing.

NOLS recommends evacuating all full thickness burns. Consider, as in this case, evacuating partial thickness burns, especially to the hands, feet, face, armpits, or groin for pain management and wound care. Rapidly evacuate any patient with partial and/or full thickness burns covering more than 10% TBSA, any patient with partial or full thickness circumferential burns, and any patient with signs and symptoms of airway burns.   

What Happened? 

The student was able to walk slowly to the trailhead with the help of trekking poles and some creative bridge building to get her over small streams. The wound healed well and in a few weeks she was back hiking.

Keep your skills fresh: Recertify with NOLS.