How would you handle this situation?
Things are a bit slow this time of winter so I will throw out this actual situation in hopes of generating some discussion.
A couple of years ago I was leading an extended wilderness river trip. We had six people in three boats (catarafts) and were on a nineteen day trip. There were two women and four men. Five members of the group were on the cusp of their 50th birthday and I am ten years older. Every member of the group had extensive wilderness/river/expedition experience. We were in a designated grizzly bear protected area and all of the usual bear precautions applied.
We carried our fecal material with us and we burned all burnables and organic trash down to charcoal. Since you can get more user days out of your toilet system if toilet paper is not included (folders vs. waders), all toilet paper was burned. As TL, I took on the unsavory chores of dealing with the toilet, burning the orgo, and burning the tp. I was also the nominal trip medic.
To get trash to burn completely, it is placed on a grate above the wood fire (not in the fire) and turned and stirred until it is completely burned. This gives ample time to examine things, including the tracks on the tp. About day seven of the trip I began to see faint tinges of blood on some of the tp. This raised no alarms since I assumed that someone simply had a case of bleeding hemorrhoids. By day ten the blood was getting more obvious but still raised no alarms since an alternate assumption was that one of the ladies was spotting or had started her period. I did not see tampons or pads however, and those would have been indluded in the burnables. Nevertheless, it was conceivable that one of the peri-menopausal ladies simply had an unpleasant surprise and she was dealing with it (as a side note, I always include tampons and pads in my medical kit as they are useful for many things besides their intended purpose). The bloody tp was present at every burn for the next seven days but I was not concerned since I thought I had identified the cause. I am a curious sort though and I ruled out the hemmohroids since I was sure the blood was arterial and not venous.
Finally - I became alarmed on the fourteenth day as I was packing the toilet in preparation to head down river. The last person to use the toilet had deposited a loose stool that was covered with frank arterial blood.
Here is the setup: We were scheduled for four more days on the river with pick-up by air taxi on the fifth day but we were far enough downriver that we had several options. The river was fast enough that we could have continued to the take out by late afternoon where we could have called for an early pick up. We could have reached an airport by evening where AK airlines flights were scheduled for either Anchorage or Juneau/Seattle so immediate evacuation would have been possible. I also had satellite phone and aircraft radio at hand.
Would you have considered this a medical emergency? What would you have done? After we have discussed it a bit I will tell you the rest of the story and let you know how it turned out.
Under the circumstances described, I would have arranged immediate evacuation. The key, to me, was arterial bleeding as opposed to say, a bleeding ulcer. Getting to the pick up point and calling for early pick up would have been my choice, and to the first medical facility. I don't think I would have waited to get to Anchorage or Fairbanks unless that were the only options.
OK, Andy whats the rest of the story
The presence of blood is a concerning matter. I believe I would have to have a consult with the responsible party though. AS, this decision will affect the time schedule and plans of all parties on this trip. In a normal
situation this could be a life threatning. BUT, If the person with the problem isn't extremely concerned, maybe he knows what the problem is and it is not life threatning. Sounds like you had your bases covered though and help was a phone call away. He might have drank unfiltered water and developed a microbial infection, these can become extremely serious, or maybe he likes something with high concentrations of red food dye, or continued injestion of very hot spicy foods. You gotta be there !
Two very good, albeit opposing, viewpoints. I do not think there are any other alternatives beyond carrying on as planned or evacuation. Either suggestion is correct and both approaches can be convincingly defended.
Lets think for a moment. Is this a life-threatening situation?
...Well, it could be life-threatening but probably not immediately. Although the blood had been apparent for about seven days it was not a dramatic amount and was not sufficient to cause any overt symptoms in any of the group (remember, at this point I didn't know which person was bleeding). An e.r. physician I consulted with later told me he would have identified the person and performed postural blood pressure checks to determine whether blood loss was sufficient to cause hypertension. We had the equipment and expertise to perform such an exam.
We presume the bleeding was lower g.i., most likely colon since the blood was sourrounding the stool and not mixed in with it or partially digested (yeah, I looked).
What are your hypotheses? What can cause bloody stool?
...Among the differential diagnoses that came to my mind at the time the one I fixated and anchored on was colorectal cancer. My father and three close friends died from the disease and my friends on the trip were all of the age where that was a real possibility. If colorectal cancer were present and if it had progressed to where it was bleeding it is possible that a delay of as little as one day seeking medical and surgical intervention could be the difference between death and recovery from the disease. In that case, we could have had the individual in a hospital and under medical care by that same evening.
Can you think of any other condition that would justify immediate evacuation? Or do you suggest that any idiopathic bleeding justifys evacuation?
Brav01 likes the idea of consulting with the affected individual and with the group. That is a very good idea since patient care is always ultimately the patient's responsibility as long as said patient can make rational decisions for him/herself.
How do you suggest identifying the affected individual? Do you talk to each one individually and privately?
How do you suggest determining the wishes of the group? Do you call a group meeting and lay it out to the potential embarassment of the affected individual?
I'll be back later. In the meantime I'll let these ideas soak and see if we can get some more responses.
If you don't know who it is you won't know who to evacuate anyway. A person with colal-rectal cancer already probably knows it and it past anything you can do in the bush and is not immediately life threatning (2 days won't matter). As I said you gotta be there. I'm not sure what your med kit includes but a spygmometer would be a good item with such a large group (so you are covered there).But you still gotta know who to use it on.You can't do much until you know who to do it to.
brav01 has good points. It would be necessary to determine who is the one with the problem. In my admittedly limited experience, I've known people with serious problems that either they didn't realize how serious it was, wouldn't want anything done because it would ruin the trip, or purposely downplayed the problem. As brav01 states, you would have to be there. Aterial bleeding from what ever source is usually something to be very concerned about. To me that was the deciding factor.
I would privately talk to each person to determine who the person is and dicuss it with them. I am not a doctor so I do not know all the potential casues of bloody stool. I also would try not to fixate on what the casue may be since I am not a doctor and abviously cannot conduct a medical examination in the field. If the problem started person know and is being treated for it before the trip, that is another situation. But your observation that the problem is getting worse would drive me for an early end to the trip. To prevent embarresment, I'd even go to the extent of finding another reason to end the trip if it came to that. So eager to hear what actually happened and the cause of the blood.
I lose a lot of friends this way. (not really)
Seeing the age of the people involved and the type of people involved, I would just confront the group as a whole. I would bring it up under the catagory of group meeting (I have been involved with this on trips). I would start by stating that as a part of my trip duties I have become aware that someone in the group is having a medical issue, and due to multiple people on the trip there is an issue of identifying the individual. If you are feeling ill would you please let me know the seriousness of the situation so that a decision can be made.
Were not talking about 15 year olds with embarresment problems, this is a group of adults. Experienced outdoorsman know that expedition behavior involves letting the trip leader know about any illness, as one sick person can cause a dangerous situation for other people.
I have never met a group that got angry with a sick or injured person for making a trip end early.
After the situation was undestood a decision could be made. In this situation, unless the person allready know the problem wasn't serious, I would consider it undiagnosed, and get to medical help asap.
The rest of the story.......
I guess this has gone on long enough and has generated as much discussion as it is going to. Here is how it turned out:
I did nothing immediately. We finished packing and loading the boats while I surreptitiously monitored the group for any signs that somebody might not be well. We then boated three hours downriver while I mulled over all the possibilities. Bear in mind that this was a private expedition and not a commercial trip. Had it been a commercial trip I would have immediately called for evacuation without discussion, debate, or consultation.
At out lunch stop I called a group meeting and explained the situation. I described my observations and explained the logistics that would permit us to get any person to a major hospital later that same day even though we were five days away from our scheduled take out and pick up.
The affected individual immediately spoke up and was adamant that he was aware of his situation, that it was a long-standing intermittent condition that caused him no concern. He appreciated the concern but there was no reason not to continue as planned.
We continued the trip and flew out as scheduled.
Why did I bring this up? I have been involved in many evacuations where the choice to evacuate was clear. In this case, the choice was not so clear but had the decision been made to evacuate, nobody would have criticized that decision - except, of course the person directly concerned and he understood his condition better than any of us. Nor has the decision to continue the trip received any criticism.
We could have kept the situation private and not invited criticism but I thought there were lessons to be learned here so I have discussed the case with river guides and physicians to ascertain whether any would have handled it differently. My reason for posting here was as a learning exercise and nothing more. I enjoy reading case histories and I think we can all learn from the experiences of others.
Thanks to Bill, Brav01, and Chris for your thoughts and comments.
Thanks for sharing Dan. I may have had a slight advantage. I have been in the medical field at a point in my past. I worked as a RVT (Registered Veterinary Technichian) for 10 years. Nope doesn't qualify me to do humans but a lot of simularities in both fields. ONLY my patients can't tell me where it hurts.
I was hunting and had three days of what can only be described at violent runny bloody (bright red) diarhea coupled with debilitating stomach cramps.
The symptoms finally went away, I started feeling better, the hunt was over.... and I've never been to the Dr. about it.
Strange things happen in the wild.