Photo by Eryn Pierce

While walking a trail to a local rock climbing area you notice a person in the group just ahead collapse. Quickly, someone is kneeling at the patient’s side, fingers on the carotid pulse while they yell at him. Even from a distance you can see the patient is gray in color with blue lips. The rescuer aggressively removed the patient’s pack and began chest compressions. You estimate less than 30 seconds passed before CPR was started.

SOAP Report


The patient is a 60-year-old male who collapsed while walking and is in cardiac arrest. 


Patient Exam

The patient was not submerged and has no apparent injuries.

Vital Signs


11:00 AM

Level of Responsiveness (LOR)


Heart Rate (HR)


Respiratory Rate (RR)


Skin Color, Temperature, Moisture (SCTM)

gray skin and blue lips

Blood Pressure (BP)



not assessed

Temperature (T°)

not taken








Pertinent Hx:


Last in/out:




Pause here!

What is your assessment and plan? Take a few minutes to figure out your own assessment and make a plan before you read further.

Photo by Gates Richards.


  • Patient is in cardiac arrest.
  • There is no sign of injury, no mechanism for spine injury.


  • Continue CPR
  • Initiate access to AED, Advanced Life Support and evacuation
  • Move patient onto a pad. Use clothing to insulate him (no sleeping bag available)

Anticipated problems

  • Continuing CPR during a litter carry will be very difficult. If patient awakes, we will need to keep him warm (the weather is cool, the ground cold). We may need to start rescue breathing with the chest compressions.


These comments are from a person who was on the scene of the actual event that this case study is based on.

“The CPR looked nothing like what I expected or had practiced. For the first minute the person giving chest compressions (a physician) did >100 compressions/minute and no breaths. The compressions were amazingly deep. I know we practiced how deep to push but now I really know what it looks like. He paused very briefly (I think he checked for a pulse) then did >100 compressions and no breaths for another minute. He was focused on the patient and said nothing while he did compressions.” 

“The patient made guttural noises with each compression (that was also unexpected). After the second or third set of compressions (I’m assuming because he found a pulse) the doctor shook the patient vigorously and yelled the patient’s name. At that point the patient took a huge gasping breath, opened his eyes and spoke.” 

Comments from NOLS Wilderness Medicine:

This is a great example of two hallmarks of an effective response to cardiac arrest; early recognition and early and effective compressions.

Early recognition includes scene size-up, in this case a witnessed collapse, and the check for responsiveness and ABC’s that are part of the initial assessment. Assessing a pulse in the patient who may have a cardiac arrest is challenging, so we also look for “signs of life” (coughing, breathing, movement) in the patient. 

Early and effective compressions are a key to success. Start compressions as soon as cardiac arrest is recognized. “Push hard, push fast” – with minimal to no interruptions in the compressions, at least 2″ deep, lower half of sternum, complete recoil, minimum rate of 100/min. It’s clear the doctor who was giving the compressions knew this – he was focused and relentless until the patient awoke. We can make an educated guess that the early and aggressive compressions kept the brain alive and allowed the heart to resume pumping. 

In the Circulation, Airway, Breathing (CAB) approach of urban CPR, the common cause of cardiac arrest is the heart, thus the emphasis on chest compressions. If the collapse is witnessed there is enough oxygen in the blood to preserve heart and brain function for a few minutes if it is circulated with effective chest compressions. It’s even okay to do compression-only CPR. But in the wilderness, it may be more likely for cardiac arrest to be secondary to hypoxia from airway obstruction (avalanche, drowning). These people, and those who have been in cardiac arrest for more than a few minutes, benefit from rescue breathing: combine compressions with rescue breathing (mouth-to-mouth or mouth-to-mask) in a 30:2 ratio. 

Two other hallmarks of effective response to a cardiac arrest – early AED and early access to Advanced Life Support (ALS) – were not possible in this wilderness scenario, but the responders called 911 immediately and initiated the response that would bring the AED and ALS as soon as possible to the patient. Where is your nearest AED?

CPR is not a pretty sight. Effective compressions are deep, the patient’s skin color is awful, guttural sounds and vomit are common. This should not deter the rescuer. 

The success rate from out-of-hospital cardiac arrest remains low. Statistics for wilderness CPR are dismal. But for miracles like this to happen, the people on the scene, like this physician and the WFR trained companions, need to recognize the cardiac arrest immediately and immediately start “pushing fast and hard.” 

What Happened? 

The patient collapsed at 11:00 am. The companions were able to call 911 from the scene. After the patient awoke they completed the patient assessment (which had stopped in the initial assessment phase) moved the patient onto a pad, kept him warm and checked vital signs. Paramedics arrived at 12:00 noon. The patient was evacuated by helicopter at 12:30. He had remained responsive since awakening. The patient had surgery on several blocked coronary arteries and has recovered well.

Is your CPR training current? Could you have reacted as quickly as these rescuers?

Keep your skills fresh: Recertify with NOLS.

Source link: by Gates Richards at