Wilderness Medicine and Abdominal Pain: Serious or Not?
By Susan Purvis
A day at the ski clinic treating more than thirty patients with an assortment of ailments including double wrist fractures, a boot-top crack, an outbreak of herpes simplex viral infection on the lips, and a couple of “I don’t feel so goods,” wears me out.
With minimal time to pee or eat, my patience wanes to the verge of fraying. Two-year-old Tasha, my certified avalanche dog lies on the waiting room carpet with her head between her front paws. “I know. It’s been a long day.”
Hours beyond her normal feeding time, she had already hounded me by nibbling her front teeth up and down on my lower pant leg, as if she is fleecing me or eating corn on the cob. She senses the difficulty of the day.
I look up to our last patient. The young woman coughs up frothy pink sputum into a plastic bucket. By my second season at the clinic that sits at 9500 feet above sea level, I’ve seen the same symptoms plenty of times.
Tasha’s tail thumps the floor once, as she watches me turn back to work on the woman. On this day, Dr. Tom is away in Aspen performing surgery. Dr. Tom, the owner of the clinic trusts me enough to keep an eye on the new guy, the practitioner in charge—Scott Smith, a physician’s assistant, recently arrived from Maine and with years of ski trauma and rescue experience.
Standing at the door of the coughing woman’s room, Scott plans to give her Tylenol for what he diagnoses as a cold or bronchitis. He intends to send her home to her ski condo at 10,000 feet for the night. I foresee tragedy.
“Scott, wait.” I grab his arm before he enters the room. My voice crackles as I summon bravery to tell him something he might not want to hear. After all, I’m an Emergency Medical Technician not a physician.
“Yeah?” He squares his shoulders.
“Um … ah … I know we’ve had a big day, and it’s late. But …” I pull him toward me, so the patient can’t hear my words. To reassure myself, I eye the patient’s chest x-ray hanging in the light box. Healthy lung tissue on x-ray normally looks black. This woman’s tissue is snow white, and the lungs are full of fluid. She lives at sea level, but she’s skiing at 11,000 feet. If I don’t say something, tonight she will drown in her own fluid tonight at her condo.
The sudden raspy cough, pink frothy sputum, fever, weakness, and rapid heart rate confirm my diagnosis: High Altitude Pulmonary Edema (HAPE), an illness we frequently see at the clinic. HAPE happens at high altitude. The only cure is transporting the patient to a lower elevation. The oxygen I have been giving her isn’t helping. The woman must go to the hospital in Gunnison, seventeen hundred feet below the clinic.
I face Scott. The uber-smart, driven perfectionist now carries a streak of Napoleon complex on his tense, short frame. My experience in the clinic doesn’t measure up to his fifteen years as a physician’s assistant, his decade of ski trauma work, and his position as curriculum director at the largest wilderness medical organization in the world. He has preached to thousands of students the dangers of HAPE, yet on this day he fails to recognize a classic example in the coughing woman.
From behind the wall, the young woman sits up to cough. Her inhalation rattles from fluid stuck in her chest. She gasps, coughs again, and falls back into the gurney.
“Scott. That lady can’t stay here. We need to call her an ambulance and get her to Gunnison. She’s got HAPE.” There, I said it. I mustered courage to intervene. I hold my breath for his response.
In the silence, Scott scratches his head. Glancing at the x-ray, he spins from me toward the reception room. His footsteps circle the clinic floor. Tasha’s eyes follow and I prepare for a thrashing. I just questioned his authority, his position, his knowledge. I’m dead. Or at least soon to be unemployed.
He faces me. “You’re right, Sue. I’ve been teaching this stuff for years, and I couldn’t see it in front of me. Respiratory distress! How could I have missed that?!”
The air leaves my body in one big exhale, and my shoulders lower as tension dissipates. A weak smile twitches my mouth.
Scott adds, “You just saved her life.”
The year was 1997 when I first found courage to speak up and save that woman’s life. That was 23 years ago. I was 34, searching for passion and purpose, and questioning my career as a gold exploration geologist in the Dominican Republic with my husband.
Scott became influential in my search for purpose when our friendship and respect grew on that cold and snowy night while we treated the woman for respiratory distress. He saw something in me that I couldn’t see in myself. Over the next decade while I worked at the clinic and became his wilderness medicine teaching assistant, Scott mentored me. “You don’t have to go to medical school to understand medicine,” he told me. I quickly realized knowledge is power and I could help and heal patients using my Emergency Medical Technician skills.
He taught me the general principals of pathology, physiology, structure, and function of the human body. His simple explanations of how the major body systems work empowered me to learn as much as I could about medicine. The application of these principals applies to both urban and wilderness settings.
Scott had a lot to teach me. Little did I know my life would move toward medicine.
I traded my rock hammer as a geologist looking for gold in Latin America for a pair of skis and a chance to save a life. I chased a career as a wilderness and rescue medicine specialist working in the ski clinic, as a professional ski patroller, an ambulance medic, a search and rescue team K-9 handler, a ski guide, and a wilderness medicine educator. I opened Crested Butte Outdoors, my outdoor education company which specializes in wilderness medicine and avalanche education. My dog Tasha and I became one of the top high-altitude search dogs in Colorado. We found people buried in avalanches, submersed in the water and lost in the mountains. After Tasha died, I wrote Go Find: My Journey to Find the Lost—and Myself about our career together in Colorado and how at the end she saved my own.
Paying It Forward
One of the most useful things I learned from Scott had to with the generic structure and function of the abdomen (the stuff inside your stomach). I’ve been teaching this lecture for twenty years and this knowledge helped me become a more skillful practitioner. I want you to know this because knowledge is power. If you find yourself in a remote area or even in the urban setting and you have abdominal pain, here is a tool to determine if you need to seek immediate medical care.
The TOOL:
The difference between serious and not serious abdominal pain.
When you die you either die of shock, respiratory failure, or brain failure. The woman with HAPE could have died that night of respiratory failure then brain failure had we sent her back to the ski condo. Soon after the HAPE incident, I learned about shock, the other thing that can kill you. It was an early morning at the clinic when a healthy, athletic man in his 40’s stumbled in and groaned, “Help me. I think I’m going to die.” Doubled over in pain, he looked pale, sick and was breathing fast. “This pain won’t go away.”
“What the heck happened to you?” I asked, escorting the patient to the gurney. “Did you fall?” I had no idea what was wrong with him. I had never seen serious abdominal pain before. Upon examination, Scott bumped the gurney purposefully. Immediately, the patient screamed, “What the fuc.?” Then doubled over to protect his lower guts.
“This guy needs bright lights and cold steel,” Scott shouted at me, his signal that the patient needs to see a surgeon now. “Call the ambulance, Sue.”
Later, I asked, “How did you know he had serious abdominal pain?”
“Susan, he presented with most red flags for serious abdominal pain.” As a wilderness medical practitioner, Scott had to be satisfied with the generic assessment; serious or not serious. I did not matter what the cause.
The word abdomen means in Latin means hidden. If you show up into the ER with generic stomach pain, making a specific diagnosis can be a challenge for experienced clinicians, even when using laboratory data and sophisticated imaging equipment. Doctors can’t tell if you are suffering from early cholecystitis, diverticulitis, gastroenteritis, menstrual cramps, an extra helping of Thanksgiving dinner, constipation, or a big ole fat fart. The question is, how do we tell the difference between serious and not serious abdominal pain?
General Principal of Wilderness Medicine– Obstruction to Infection.
I learned there are basically three major structures inside the abdomen: hollow organs, solid organs, and the peritoneum.
If you obstruct a hollow organ long enough it will become infected. Here is why. The human body is full of hollow organs that store, transport, or excrete fluids of all types. These include sweat glands, intestines, bladder, and all the associated ducts. If the drainage from these organs is obstructed by swelling, deformity, or a foreign body, the accumulation and pressure causes inflammation and pain.
If the obstruction persists, any bacteria present can begin to grow out of control in whatever substance is trapped, an infection will develop. Take for an example, a zit on the face. A sweat gland is an external hollow organ infection becoming obstructed. Appendicitis is the more serious example of the same pattern. If that infection is inside your abdomen, like in the case of appendicitis, there is no place for the infection to go except into your abdominal cavity. Hollow organ infection inside the abdomen can kill you and you die of shock. Many illnesses have their origins in obstruction and their cures is in relieving it.
Hollow organs in the abdomen have a lot of nerves and when stretched it hurts. You may have felt it before after your stomach or intestines distend after eating a giant tub of popcorn. You vow to never do it again, but you do. Stretching a hollow organ stimulates muscular contraction, causing the pain of distention to become worse, but temporarily. We call this generalize crampiness that comes and goes. The pain is non-specific, poorly localized at the general level of nerve innervation. Because peristalsis (the excretion and movement of fluids and food through the digestive system using rhythmic muscle contractions) increases the pain in waves, the discomfort tends to be intermittent. This type of abdominal pain–intermittent, non-specific, and generalized is less likely to be serious. This non serious abdominal pain is usually associated with conditions that are well contained within the hollow organs, not affecting the abdominal cavity itself.
Besides hollow organs what else is in the abdominal cavity?
Peritoneum
If you were to dissect the peritoneum from the body, it would fill the surface area of half a tennis court. This huge, beautiful membrane lines the abdominal wall and surrounds the guts allowing them to move around freely. The peritoneal lining can be irritated by bacteria, blood, and digestive fluids that have leaked into the abdominal cavity. When inflamed, the peritoneum gets pissed-off and tells you about it. “It hurts right there.” The patient will complain of severe pain that is localized, constant and aggravated by movement and palpation. With inflammation, a person can lose a large volume of fluid in a short period of time and this causes volume shock. Likewise, if the hollow organ contents continue to spill out of the container, it will spread through the abdomen. Shock and death are often the result. Peritoneal signs indicate a serious abdominal problem regardless of the location or cause.
Solid Organs
The liver, spleen and kidneys are like blood-filled baby watermelons hanging inside of the abdomen. They have a variety of functions and associated diseases, but we worry most about their potential for rupture in abdominal trauma. Unlike hollow organs, solid organs have few nerve endings that sense pain. Most of the discomfort with solid organ problems come from irritation of the organs peritoneal lining due to infection or bleeding. Both are serious. Solid organs if hit hard enough, enough to knock the wind out of you, can fracture and bleed on impact. The abdomen offers a large enough space into which blood can be lost to cause volume shock. This event can be fatal. As a first responder one should be alert to the development of peritoneal signs following significant blunt trauma to the abdomen. With constant pain and localized tenderness, volume shock from internal bleeding is the anticipated problem.
Conclusion: Real problems begin when whatever is happening inside the gut begins to irritate the peritoneal lining inside the abdomen. In the case of our 40-year-old patient, his problem began with obstruction to infection principal of the appendix (hollow organ), in his lower right abdomen. We found in the patient’s history that two days prior, he complained of generalized cramps and discomfort typical of hollow organ stretching. He felt sick, stopped eating and brushed it off to an upset stomach. No need to seek urgent care as a doctor would have said, “Come back in if you have signs of serious abdominal pain.” By the next morning, the crampiness changed to local pain as the appendix continued to swell and slowly leak. Luckily for the patient his hollow organ didn’t completely burst and spill digestive enzymes and pus onto his entire abdominal cavity. That event may have killed him. Instead, he sought medical care just in time. He presented at the clinic with persistent localized pain and signs and symptoms of shock: high heart and respiratory rate, fever, pale, cool and clammy skin. The appendix was swollen, pressing against the peritoneum, perhaps leaking and ready to burst wide open. His quick action to seek medical help saved his life. So it doesn’t matter if you’re in the woods, at home, or in the clinic, recognition of serious abdominal pain is the key to recognizing a life-threatening problem. The treatment of a serious intro-abdominal problem requires a hospital and surgical care. Evacuation should be urgent.
Abdominal Pain Red Flags
Serious:
- Persistent fever
- Bloody vomit or diarrhea
- Constant, localized pain and tenderness
- Fast pulse and respiratory rate, pale, cool and clammy skin.
- Lasts more than 24 hours
Treatment for Serious Abdominal Pain
- Anticipate
- Volume shock
- Systemic infection
Treatment
- Keep the patient comfortable
- Maintain hydration
- Maintain body core temperature
- Restrict foods to easily absorbed sugars
- Emergency evacuation </BL>
<B Head> If you’d like to learn more about shock, respiratory distress, changes in brain function or serious abdominal pain and its application in the wilderness, check out one of Susan’s upcoming wilderness medicine courses and special retreats at www.cboutdoors.com.
Interested in Susan’s Wilderness Adventures Newsletter? If so, sign up by logging onto www.susanpurvis.com. The first part of her essay is from an excerpt of her best-selling memoir, Go Find: My Journey to Find the Lost—And Myself published by Blackstone. Susan also narrates her audio book.
A big thanks goes out to Wilderness Medical Associates for the use of their teaching materials.