MED-02 — Lesson 5 of 6

Austere & Wilderness Considerations

Environmental factors, resource rationing, and evacuation decisions

Environmental Context in Assessment

Every OPQRST finding must be interpreted against the environmental backdrop. The same pain pattern means different things in different contexts — altitude, temperature, hydration status, and physical demands all influence symptoms.

Heat and Exertion

Heat illness exists on a spectrum from heat cramps through heat exhaustion to heat stroke. OPQRST patterns track this progression.

• Heat cramps: Localized muscle cramping, usually legs. Onset during or after exertion. Improves with rest and fluid/electrolytes.
• Heat exhaustion: Dull headache, nausea, dizziness, weakness. Gradual onset during prolonged heat exposure or exertion. Skin pale and sweaty. Improves significantly with shade, rest, and oral hydration.
• Heat stroke: Confusion, altered mental status, possible hot dry skin. Severity sudden and severe. This is a life threat — aggressive cooling is urgent.

Cold and Hypothermia

Cold exposure impairs both the patient’s ability to report symptoms accurately and the assessor’s ability to interpret them. Shivering, confusion, and behavior changes are early warning signs that precede the more obvious symptoms of severe hypothermia.

• Mild: Shivering, fine motor impairment, mild confusion. Patient may deny feeling cold.
• Moderate: Uncontrollable shivering stops (a dangerous sign — the body can no longer shiver). Increasing confusion, poor judgment, paradoxical undressing.
• Severe: Rigid muscles, loss of consciousness, cardiac arrhythmia risk.

Altitude

Altitude illness affects all systems and can mimic multiple other conditions. It must always be in the differential at elevations above approximately 8,000 feet (2,400m), especially in the first 24-72 hours after ascent.

• Acute Mountain Sickness (AMS): Headache, fatigue, nausea, dizziness. Onset 6-12 hours after ascent. Improves with descent or acclimatization.
• High Altitude Pulmonary Edema (HAPE): Shortness of breath at rest, cough, low energy. Can deteriorate rapidly — descent is the definitive treatment.
• High Altitude Cerebral Edema (HACE): Severe headache, ataxia, confusion. Life-threatening. Descend immediately.

Dehydration and Water Quality

Dehydration compounds every other condition and degrades decision-making. Giardia and other waterborne pathogens present 1-3 weeks after exposure — well into a prolonged event.

• Dehydration: Headache, fatigue, dark urine, dizziness. Onset tied to insufficient intake relative to exertion and heat. Improves rapidly with oral rehydration.
• Giardia: Gradual onset of cramping, bloating, diarrhea, nausea. Onset 1-3 weeks post-exposure. Check E of SAMPLE for contaminated water source.
• Waterborne illness (bacterial): More acute onset, fever common, multiple group members may be affected.

The Austere Decision Check

After completing SAMPLE + OPQRST, apply the austere decision check. This is a structured five-question framework for making management decisions when professional care is not immediately available.

Resource Rationing Through Assessment

Medical supplies in an austere environment are finite. Good assessment prevents waste — both under-treatment and over-treatment consume resources without benefit.

Medication Decisions

• Pain management: OPQRST severity and quality guide analgesic selection. Mild-moderate musculoskeletal pain (6/10, improves with rest) may respond to non-pharmacological measures — position, heat, cold, splinting — before using limited medications.
• Antibiotics: Reserve for confirmed or strongly suspected bacterial infection. SAMPLE past medical history and OPQRST pattern help distinguish bacterial from viral causes. Allergy history (A of SAMPLE) is essential before any antibiotic is given.
• Epinephrine (EpiPen): Single-use and irreplaceable. Use only for confirmed anaphylaxis, not mild allergic reactions.

Workload and Exertion Assignments

SAMPLE past medical history should directly determine work assignments in an austere group:

• Cardiac disease, COPD, or deconditioning — no heavy lifting, no high-intensity exertion, no high-altitude tasks
• Seizure disorders — no driving, operating heavy equipment, climbing, or working near water unsupervised
• Insulin-dependent diabetes — assigned partner to monitor; not last person in the field
• Blood thinners — no high-risk trauma exposure (point positions, vehicle operations in hazardous terrain)

Reassessment Cycles

Reassessment is not optional in prolonged care. It is the mechanism by which you detect deterioration before it becomes a crisis. Establish and maintain a schedule.