in the amazon

 
 
 
Napo River, Ecuador

Napo River, Ecuador

 

Setting: Nueva Providencia Community, Napo River

A group of 16 South African tourists are in the Providencia Community, downriver from the Coca City in the Napo River, on the shores of the Shipati River, which runs into the Napo River and is several hours downstream from the city of Coca (approximately 3 hours). The group is currently visiting the Nueva Providencia Community and is at the interpretation center. The rain has been constantly pouring down for the last 3 days, there is a lot of mud and the floor is pretty slippery. Around noon, the group decides it is time to go back to their lodge and they start to descend from the interpretation center to the pier to board the canoe that would take them back one by one. One of the guides of the group is helping the guests board the canoe while the second guide has stayed behind to help the guests step down from the interpretation center. As one of the guests was walking down, she slipped on the staircase and fell to the floor. The guide that stayed behind tries to help but the guest is unable to stand up. The guide in the back of the group notifies the guide that is down by the pier of the situation, this guide now becomes the rescuer. The rescuer reaches the patient, does a scene safety and checks for any threats to life to the patient and with the help of the other group members they carry the patient under a roof to protect her from the rain.  

Subjective:

The patient is a 69-year-old female. She slipped down a staircase, injuring her right ankle. The patient does not lose consciousness, she is alert and oriented. Her chief complaint is severe pain to her right ankle.

Objective:

Once they manage to cut open her rubber boot with a hot machete, the physical exam revealed that the patient has an exposed fracture on her right ankle, the bone is clearly sticking out. There is mild bleeding. Patient has good CSM’s, but diminished motion on her right ankle. The patient is alert and oriented, is aware of her situation, and despite the pain she is collaborating with her rescuer.

Vital Signs:*

Time: 12h00

LOR A+Ox4

HR 76 Strong, regular

RR 18 Regular, easy

Skin Pink, warm and dry 

Symptoms: Pain and tenderness in her right ankle. 

Allergies: None

Medications: None

Pertinent Medical Hx: None

Last ins/outs: 2 liters of water throughout the day, normal peeing. No food intake since 5 am.

Events: The fall was not caused by fainting but rather from a slippery staircase.

 

WHAT IS YOUR ASSESSMENT AND PLAN?

DO NOT peek at the next section without answering this first.

 

Assessment:

Exposed fracture to right ankle 

Plan:

  • Stabilize the right ankle, using the PFDs (life vests) from the canoe and rain ponchos.

  • Monitor bleeding

  • Monitor CSMs

  • Evacuate

Anticipated Problems:

  • If bleeding gets worse, it can lead to a hypovolemic shock

  • Traction in line was attempted, but not possible due to pain; leaving the bone exposed can promote infection and/or death of the bone

  • The Napo River has grown a lot, making the way back to Coca complicated

  • Loss of CSM’s

The tale continues:

The rescuer rapidly used the resources available to him to make a good splint. At the same time he delegated the responsibility to the rest of the guests to emotionally support the patient's husband, as the husband had some pre-existing conditions of Parkinsons and was emotionally stressed with the situation. The rescuer used the people from the community to help him load the patient and the husband into the canoe. Once on the canoe, the rescuer notifies the lodge via radio of the current situation with the emergency and requests that the lodge have a boat ready to take them back to Coca City. The captain of the canoe manages to maneuver in difficult conditions back to the lodge, and they do a transfer of boats. On the ride towards Coca City, the rescuer keeps checking for CSM’s constantly and makes a call to have an ambulance ready for them. At 10 pm the patient finally goes into surgery, the next day the patient and her husband fly to Quito for better healing in Hospital Metropolitano.

Take away points:

  • A good splint was made using the resources available.

  • Exposing the fracture to skin level helped to understand the severity of the situation and make the evacuation decision more efficient.

  • There was good communication with the lodge and outside help, making the evacuation more efficient. 

  • The main rescuer delegated responsibility to the people around him, helping him, the situation and the patient’s husband to stay calm.

  • The main rescuer had training in wilderness medicine.

  • There was no documentation of vital signs or symptoms. This would have helped the hospital personnel if it had been delivered by the rescuer.

Case Study: Andrés Holguín Naranjo

*Vital Signs Parameters

*Vital Signs Parameters