Medicine for the Outdoors
Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Hospitalito Atitlan 3

The man appeared at the entrance to the emergency room (literally, a small room) at the Hospitalito after having been delivered in a tuk-tuk (pronounced “took took”), a three wheeled taxi popular in many of the small villages surrounding Lake Atitlan. These small conveyances were usually driven by teenagers, and sometimes piloted by children as young as 8 years of age, so on more than one occasion, I nearly got picked off walking the streets on my way home from the hospital at the end of the day, particularly during the busy evening hours.

Instead of arriving at the hospital by ambulance, with his neck immobilized in a restraining, protective cervical spine collar, oxygen administered through a facemask or nasal prongs, and an intravenous catheter in place through which to provide fluid and pain medications, this man was a passenger in a little cramped vehicle powered by the same sort of engine one would find in a riding lawn mower. He had fallen off a roof approximately 15 feet straight onto his head. He was obviously in agony, complaining of pain in his neck and back. He was also having difficulty breathing, his chest hurt, and he was dizzy.

The man couldn’t recall the moment of impact when he had struck the ground or if he had been knocked unconscious, but he was making sense at the moment, which was important, since there was no CT (computed tomography) scan to image his brain. A physical exam showed that he could move, and had normal sensation and reflexes, in both arms and legs, which was good given that he had severe neck pain and a mechanism of injury from which he could have easily broken his neck. When I listened to his chest with my stethoscope, it seemed like he had diminished breath sounds on the right side, which might be indicative of a collapsed lung. I examined his chest and felt along every rib. He wasn’t tender on his chest wall, but he was hurting badly in his mid-back, and complained about tenderness when I felt his spine in his mid-thoracic region. So now, in addition to a possible concussion and broken neck, and perhaps a collapsed lung, I was worried about a spinal fracture. His abdomen (“belly”), pelvis, and legs looked to be OK.

With our limited x-ray capabilities, we settled for a chest x-ray, three views of his cervical spine (neck), and two views of his thoracic spine. The chest film showed that his diaphragm was elevated on the right side, so his lung volume was possibly diminished, but there were lung markings all the way out to the periphery of his chest. If he had a collapsed lung, it was a small collapse. I didn’t see any obvious broken ribs. The neck films were terrific, and the technician shot a perfect odontoid view, a direct result of his success learning the technique earlier in the week. I was very concerned to see that three cervical vertebrae might be compressed. It was impossible to tell if this was a new finding (e.g., because of the fall) or “old” degenerative change, so we kept him in the cervical collar that we had placed when we first examined him. With administered oxygen, his oxygen saturation was acceptable, so there was no rush to pursue a collapsed lung or need to place a chest tube. The lateral x-ray of his spine showed a probable compression fracture of one of his vertebrae, which accounted for his pain. The film was a bit underexposed, so it was difficult for me to interpret, until the technician showed me his method for viewing such an x-ray without having to shoot another. He rolled up the paper x-ray jacket in which the film was destined to be stored, and we examined the film through the tube, which eliminated all ambient light and highlighted the details. With a much better look at the film, if fortunately looked to be a “stable” injury, but a broken bone in a man’s back really hurts.

With an adequate supply of pain medications, the ability to do the necessary CT scans to delineate the nature of the possible cervical spine and definite thoracic spine injuries, and further imaging and close observation for the possible collapsed lung, we might have been able to keep this patient, but these modalities were not available to us in Santiago. So we packaged him as best possible, and sent him to a more fully equipped facility in Guatemala City, where he could receive a further evaluation and the ongoing care that he deserved.

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Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.