Butts, Guts, & Get Me a Chopper - Assessing Abdominal Pain in the Wilderness

There you are, on day 4 of an 8 day canoe trip with your family through the beautiful Algonquin Park.  The weather has been spectacular, the scenery stunning... "This is a perfect vacation," are the words going through your mind, when your husband starts complaining of stomach pain. 

Avoiding the temptation to roll your eyes, you put on your Wilderness Medic Toque (TM), and assess the situation.  You remember that there are two main reasons for abdominal pain. This could be gastro-intestinal pain - or food poisoning - that you can try to wait out, or it might be an acute abdominal illness - like appendicitis - that requires an evacuation... but that Wilderness First Aid course was a while ago, and you can't remember how to tell the difference!  (Hmmm... maybe it's time for recert...)

The Least You Need to Know

Generally speaking, pain that comes on quickly, and is accompanied by vomiting, diarrhea, or both, calls for wait-and-see.  Monitor your patient carefully, quarantine them with their own cooking and latrine areas, and everything should pass (heh, heh) in 24-48 hours.  Pain that is slower onset - whether or not there are other symptoms - could be an acute abdominal illness, and evacuation should be initiated.  

No matter the onset, any indication of a gastro-intestinal bleed is an emergency and requires immediate medical assistance. Vomit might have bright red blood in it, but you will more likely see partially digested blood, looking like coffee grounds. Stool that is bloody from a GI bleed can best be described as black and tarry. It is distinctive.

Nice to Know

Abdominal_Quadrants

The abdomen is divided into four quadrants that intersect at the belly button. 

To fully assess the abdomen, first take a look and see if there is any swelling or bruising that might indicate an internal bleed.  If your patient is alert, have them indicate where the pain is.  

Have your patient lie down, so all the organs of the abdomen squish into the right places.  Starting in the non-painful quadrants, use your hands to push down firmly into the abdomen, checking to see if there is any pain response when you push down - tenderness - or when you release the pressure - rebound tenderness.  **Note that the bottom quadrants extend to the bones of the pelvis, not the top of your patient's pants.  This would, in some cases, make for very short abdomens indeed!

This assessment can give you a better idea of what might be causing the pain.  Here are where the organs of the abdomen tend to settle when we lie supine.

 
abdominal-quadrants-organs-in-the-abdominal-quadrants.jpg
 

So, liver and gallbladder are likely candidates for upper right quadrant pain, pancreas and spleen for upper left quadrant, and appendix for pain in the lower right quadrant.  In women, lower left or lower right pain might be ovarian cysts, but ectopic pregnancy is a life-threatening possibility that must be considered - sexual activity, a missed period, or any indication of shock should be getting you worked up..  

Bowel obstruction is also common in wilderness environments, where increased activity tends to lead to persistent dehydration, and dried foods are common because of their convenience.  Questioning about recent bowel movements can help you identify this.  ** Important: if you suspect bowel obstruction, ask about flatulence as well.  (That's right, you just got done questioning someone about their poop, now you're going to ask about their farts.  Glamorous.)  Bowel obstruction without farting indicates that there might be a gas buildup in the bowel, that will rupture much more quickly. **

Remember that these are starting points; there are dozens of possible causes of abdominal discomfort, and comprehensive assessment impossible in a wilderness environment - and often difficult even with advanced medical tools. Your careful assessment of your patient's condition is an attempt to answer this important question: “Does this patient need immediate evacuation?” 

When in doubt, err on the side of caution, and… get them to a choppa!