X-cs: From: Self To: chris@bison.RANGE.ORST.EDU (Chris) Subject: Re: survival food Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Sun, 10 Sep 1995 10:23:42 On 19 Aug 95 at 21:01, Majordomo@list.pitt.edu wrote: > > Thoughts? Sources for pemmican (and I don't mean that fruit and nut > > stuff) other than making it myself? > > I know REI used to keep some of that stuff in stock, but the last time > I ever looked for foods at REI was several years ago. They're too overpriced > nowadays. Another idea would be to check with your local Boy Scout council. > Seems back in my scouting days there were always troops making beef jerkey, > pemmican and other things like that. If REI no longer stocks it, they might > be able to tell you where to find some, perhaps. I can check with the REI > stores here in Atlanta, or get the REI number for you if you like. > > > > Keith Conover, M.D. (NSS 12893, WD4PSY) > > -Chris Kuivenhoven > Thanks, Chris-- I've already called REI and they don't carry meat pemmican any more. With the Boy Scouts found recipies for do-it-yourself but no source of store-bought meat pemmican. But thanks. -- End -- X-cs: From: Self To: JSilver374@aol.com Subject: Re: Wilderness EMS in NY and NJ Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Fri, 22 Sep 1995 07:48:16 On 21 Sep 95 at 23:57, JSilver374@aol.com wrote: > Hi all: > > I'd like to be in touch with anyone with information about the state of > wilderness EMS in NY and NJ, including it's legal status and offical > recognition. > > Thanks... > > Jonathan Silver EMT-D, WEMT > Highland Park, NJ > jsilver374@aol.com > One thing I know; we've been discussing wilderness EMS problems at meetings of the Atlantic EMS Council which includes NJ but not NY. The NJ EMS director has been participating in these discussions with thoughtful commentary and is sympathetic to the needs of wilderness rescuers but at present NJ doesn't have any provisions for WEMS. I suggest you contact NJ EMS and volunteer to help them with working on the problem. Doing some research on the scope of backcountry SAR and wilderness-related EMS calls would be the first place to start and you could maybe work with NJ EMS on this. NY I know nothing about, but I do know that one of WEMSI's Wilderness Command Physicians lives in Glens Falls and is very interested. You might contact him and see what he has found out: Robert Desiderio, M.D. Pilot Knob Rd., P.O. Box 99 Kattskill, NY 12844 Not much, but hope it helps. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: (Fwd) Rib Fractures -- What Can a Caver/Climber Do? Cc: EMED List Reply-to: kconover+@pitt.edu Date: Sat, 23 Sep 1995 18:28:13 ------- Forwarded Messages Follow ------- Date sent: Mon, 18 Sep 1995 20:58:04 -0700 (PDT) From: "Arthur J. Fortini" To: kconover+@pitt.edu Subject: Re: Rib Fractures -- What Can a Caver/Climber Do? On Mon, 18 Sep 1995, Keith Conover, M.D. wrote: > Art-- I'd like to quote your rescue report in the following post to be > sent to the wilderness-emergency-medicine list. May I have your > permission to do so? Feel free to quote the report. I'd interested in hearing any responses you get so that I can share the with the attending physician (she's not on line). > Thank you. Thank *YOU* for asking, Art Fortini -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- Rib Fractures -- What Can a Caver/Climber Do? Here is an interesting rescue report, which I'm cross-posting from the Cavers' Digest mailing list. The emergency physician at the scene had to make a hard decision on the spot, and I'm not trying to second-guess her. But this is a question that has not been prospectively answered in a definitive way: when in the backcountry, how much and what kind of activity is safe with a rib fracture (single rib, no evidence of lung injury, pneumo- or hemo-thorax, or liver/spleen/other abdominal injury)? And should we consider taping the ribs for a self-evacuation, because it decreases pain without the sedation of a large dose of narcotics, even though two studies showed an increased (slightly) incidence of complications with a rib belt? This decision can make a _big_ difference in the risk to the patient, others in the party, and rescuers due to risks from continued exposure/exhaustion, rockfall, and flooding. Here are the references I have handy: 1. Quick G. A randomized clinical trial of rib belts for simple fractures. Am J Emerg Med 1990;8(4):277-81. Shows hemothorax more frequent with displaced rib fx if use rib belt. 2. Lazcano A, Dougherty J, Kruger M. Use of rib belts in acute rib fractures. Am J Emerg Med 1989;7(1):97-100. Shows higher incidence of complications, including atelec- tasis and bloody pleural effusion, with rib belts. My thoughts at this point are that (1) these studies show an increased incidence of hemothorax/bloody pleural effusion, which in these studies was not of the big, hilar-bleed life-threatening type nor is a single rib fracture likely to cause such an injury, (2) these studies didn't show an increase in pneumothorax, which if it turns into a tension variety can be cured by any sharp object (but probably _not_ by a litter tender on a vertical evacuation unless the tender is also a well-trained medic or doctor), and (3) as I remember these studies were small and might lack power to show infrequent complications such as pneumothorax. (Sorry, I don't have them with me and I'm currently taking a break from "hill walking" on the Isle of Arran off the west coast of Scotland - aren't laptops and off-line readers such as Pegasus handy?) At any rate, this report suggests to me that the Wilderness EMS Institute needs a well-thought-out answer to this question for our protocols, even if just some principles for decision-making by those at the scene. Our current protocols are ambiguous on the topic: "If a team member or patient appears to have one or two rib fractures without other injury, do not splint or tape the ribs. Provide pain medication if you are permitted to give it." But this assumes that the person is going to be carried out, and that's not always appropriate. I routinely tell my ED patients with rib fractures not to tape their ribs unless they're playing a very active sport such as basketball or football, but wouldn't climbing a rope out of the cave be similar? I will be interested to hear your replies. Please don't quote this whole article as the report is rather long. -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- Forwarded by: cavers@CS.YALE.EDU Date sent: Tue, 29 Aug 1995 18:31:07 -0400 Subject: CAVERS-DIGEST digest 5201 Forwarded to: kconover+@pitt.edu To: Multiple recipients of list Send reply to: cavers@CS.YALE.EDU CAVERS-DIGEST Digest 5201 Topics covered in this issue include: [snip] 9) Lech accident by "Arthur J. Fortini" [snip] Topic No. 9 Date: Mon, 14 Aug 1995 21:03:45 -0700 (PDT) From: "Arthur J. Fortini" To: "Cavers' Digest" Cc: dale_pate@nps.gov, jason_richards@nps.gov, caca_cave_resources@nps.gov Subject: Lech accident Message-ID: Congratulations to Peter Jones for making it clear that his info was third hand and should not be considered God's given word. Unfortunately, the media in Canada did not exercise such restraint. Apparenlty, a co-worker of the subject's girlfriend heard that Brad (the victim) had taken a 300 foot fall! Not bad considering there were no reporters to be found during the rescue, and there WAS an official press release made soon after the evacuation was completed. Anyway, here's my two cents worth... I wasn't there when the injury occurred, but it is my understanding that Brad was climbing over some breakdonw in the Yellow Brick Road area when his foot slipped off a hold. His torso then fell a short distance (I'm guessing ~6") landing his ribs on the rock. I'm not sure how long it took him, but he made it to Boulder Falls with only the assistance of his 3 team members. He was just starting to climb up Boulder Falls when I arrived. He was using an ascending system similar to a Mitchell, but not quite; he called it a Yosemite system. He was moving up slowly when the others on his team started expressing concern over his injury. This was the first anyone in my team heard about it. When he was ~60' up the rope, he became exhausted and could climb no further. Fearing inversion or harness induced unconsciousness (a la the French experiments), we decided to take action. Brad was considering doing a change over, but we felt it would be safer if someone were up there with him. Rick, an NCRC instructor, was at the top and sent down the second rope. (A spare rope is kept at the top of BF just in case of something like this.) I went up, did a pick-off, and lowered Brad to the ground. We had an emergency room doctor (Shadi Farbin) in the group at the bottom who examined him and gave us a working diagnosis of a rib fracture with no signs of lung involvement. She said it would be safe to haul him up in a seat/chest harness, but exertion (ie, heavy breathing) would have to be avoided due to the risk of puncturing a lung with a broken bone end. >From my position on the rope, I could easily communicate with both the people at the bottom and Rick at the top. With Brad (the patient) now under a doctors care, Randy Brown (a trip leader) was appointed to start getting people to the top of BF. Rick was to marshall the troops at the top and assume control of the operation. When I arrived at the top, Rick and I looked over potential anchor points and concluded that we would need an additional rope and some additional hardware to do the haul in a safe manner. Since the patient was stable, the cave was warm (68 F), and everyone had bivy bear, we had the luxury of time. I exited the cave to alert the park service and return with the necessary equipment. It was agreed by myself and Rick that if he didn't hear from the surface in 3 hours, he should start sending people out in groups of 2 every hour or so for/with updated information. I found Dale Pate (CCNP Cave Specialist) and informed him of the situation. He alerted the appropriate people, and within ~1 hour, an initial response team of ~5 CCNP personnel and the few cavers on the surface (~5) were heading to the cave. I don't know the details of what happened in the cave during my absence, but everyone except the patient, the doctor, and two other caver, were at the top when we returned. Harry (CCNP) and I went to the bottom of BF, Jason (CCNP) remained on top of BF initially. Some of the others began ferrying loads into the cave, and some remained on the surface. Since I was at the bottom of BF, I'm not sure of these details. When harry and I arrived, things on the bottom were pretty low key; the patient had been given some pain killers, and everyone was trying to get some sleep. In spite of the doc giving the green light for a harness evacuation, Harry elected to do a vertically oriented Sked evac to minimize the size of the target exposed to rock fall danger (BTW this is what Boulder Falls got named for). The Sked, bolting gear, and radio headsets were brought into the cave. The patient was hauled on a 3:1 system using cavers to do the pulling, and the litter attendant (me) climbed a separate rope. Upon reaching the top of BF, the patient was unpackaged and allowd to walk to the entrance pit. The patient was then re-packaged and hauled up the entrance drop using the same technique as at BF. Since the current treatment for broken ribs is to simply wait for them to heal (no casting, taping, binding, etc), the patient decided not to go the hospital. Since there was no indication of lung involvement, this appeared to be a sound decision. Besides, once he returned to Canada, health care would be free. Lessons learned: 1. During Emily's rescue, [a previous rescue in the same cave --KC] it was decided that the natural anchors at Boulder Falls were unsuitable for rescue work. (I wasn't there, so that is second hand information.) As a result, 4 bolts were placed for the current rescue. 2. All of the cavers were taking initiative and getting things done. These included glamorless things like relaying messages, carrying in gear, food, water, ropes, etc. No one was frantic, but everyone was showing enthusiasm. 3. Things were running smoothly before the NPS arrived, so they generally let the cavers continue to do what they were doing. As a result, things continued to run smoothly. It was clear to everyone that Jason and Harry were charge when they arrived, but the roles of the individual cavers changed very little. The cavers in leadership positions continued to provide leadership, and the cavers shuttling gear continued to shuttle gear. 4. In every rescue, there is a need for leaders and worker bees. We had enough leaders and no one complained about being one of the worker bees. No ego rose to the surface in search of a more glamorous role. 5. There was good communication among everyone involved, both within the cave and on the surface. I'm assuming this played a major role in how smoothly things went. The wireless headsets were worth their weight in gypsum at Boulder Falls. A few personal observations: 6. This was one of the smoothest rescues I've seen in a long, long time. There was good communication and a very real atmosphere of teamwork and cooperation. This is significant considering that none of the cavers had ever done any rescue training together. 7. The Park Service provided enough man power to get the job done, but did not let things get out of hand. They had additional resources at their fingertips if the need were to arise (CCNP personnel, the BLM cave rescue team, etc), but elected not to use them. IMHO, this was a good call. I'm sure there are plenty of things that occurred that I did not address because I was not aware of them. What is written above is simply one person's perspective. If anyone who was at the rescue would like to add to this, please feel free. Once again, my thanks to everyone for not letting the rumor mill go wild before the facts were in. And of course Brad sends his thanks to all who helped out. Art Fortini -- End -- Received: from post-ofc01.srv.cis.pitt.edu (post-ofc01.srv.cis.pitt.edu [136.142.185.10]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.12/cispop-1.6.1.2) ID for ; Mon, 25 Sep 1995 17:03:06 -0400 Received: from local (daemon@localhost) by post-ofc01.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 25 Sep 1995 17:03:04 -0400 Received: via switchmail for kconover+@pitt.edu; Mon, 25 Sep 1995 17:03:03 -0400 (EDT) Received: from astro.ocis.temple.edu (astro.ocis.temple.edu [155.247.165.100]) by post-ofc01.srv.cis.pitt.edu with ESMTP (8.6.12/cispo-2.0.1.1) ID for ; Mon, 25 Sep 1995 16:57:07 -0400 Received: (from pacer@localhost) by astro.ocis.temple.edu (8.6.12/8.6.12) id QAA20004; Mon, 25 Sep 1995 16:52:43 -0400 Date: Mon, 25 Sep 1995 16:50:27 -0400 (EDT) From: Barry Burton To: kconover+@pitt.edu cc: wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: (Fwd) Rib Fractures -- What Can a Caver/Climber Do? In-Reply-To: <199509242043.QAA15718@post-ofc01.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Keith I've received the post from 18 September relative to "simple" rib fratures. I think I tend to agree with you...the climber/caver is not the 'couch potatoe" we tend to treat in the ED. My understanding of the risks of taping fractured ribs is the resultant atalectasis from failure to breath deeply, etc, following the taping. Let me tell you, from personal experience two years ago: 1. Fractured ribs hurt like a b**** 2. Yes Sam, if I hadn't been so anal and forced myself to breath, the pain probably would have killed me...through complications 3. Though I didn't tape the ribs, I surely splinted them actively with my arms....frequently 4. Still probably got a little hypostatic, until I recognized and initiated self-pulmonary hygeine (ie Cough and deep breath, no matter how m much it hurt) 5. I don't think I could have actively climbed at all during this event. (Especially since I didn't know how, then) With this in mind, I'd suggest a-Temporary splinting (taping) with concomitant pulmonary hygeine (cough/ forced deep breath every 20 minutes, for example) for the short duration of the evacuation (1-2 days) with release of the tape during periods of inactivity, is probably safe, and should be investigated. Especially when "no lung trauma" ie hemoptyiss, open wound, breathlessness, rales, etc. b. Such an individual should honestly evaluate their personal physical capacities at that time. IE: Walk out /crawl out OK, climb out, HIGHLY DUBIOUS. Consider a "haul" Thanks for allowing me to express myself, perhaps not too scientifically, but practically, today. Barry > On Mon, 18 Sep 1995, Keith Conover, M.D. wrote: > > > Art-- I'd like to quote your rescue report in the following post to be > > sent to the wilderness-emergency-medicine list. May I have your > > permission to do so? > -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.12/cispop-1.6.1.2) ID for ; Mon, 25 Sep 1995 19:48:29 -0400 Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 25 Sep 1995 19:48:28 -0400 Received: via switchmail for kconover+@pitt.edu; Mon, 25 Sep 1995 19:48:28 -0400 (EDT) Received: from JEFLIN.TJU.EDU (jeflin.TJU.EDU [147.140.128.114]) by post-ofc03.srv.cis.pitt.edu with SMTP (8.6.12/cispo-2.0.1.1) ID for ; Mon, 25 Sep 1995 19:47:28 -0400 Received: from JEFLIN.TJU.EDU by JEFLIN.TJU.EDU with SMTP; Mon, 25 Sep 1995 19:46:19 -0400 (EDT) Date: Mon, 25 Sep 1995 19:46:17 +0000 From: "Jack T. Grandey" X-Sender: GRANDEYE@ To: Barry Burton cc: kconover+@pitt.edu, wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: emed-l Re: (Fwd) Rib Fractures -- What Can a Caver/Climber Do? In-Reply-To: Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII On Mon, 25 Sep 1995, Barry Burton wrote: > > With this in mind, I'd suggest > > a-Temporary splinting (taping) with concomitant pulmonary hygeine > (cough/ forced deep breath every 20 minutes, for example) > for the short duration of the evacuation (1-2 days) with > release of the tape during periods of inactivity, is > probably safe, and should be investigated. > > Especially when "no lung trauma" ie hemoptyiss, open > wound, breathlessness, rales, etc. > > b. Such an individual should honestly evaluate their personal > physical capacities at that time. > IE: Walk out /crawl out OK, climb out, HIGHLY DUBIOUS. > Consider a "haul" > > Barry > I think this is an excellent basis for a rib fx protocol for delayed evacuation/extended transport. How about re-formatting it in such a fashion? JTG -- End -- X-cs: From: Self To: Barry Burton ,wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: (Fwd) Rib Fractures -- What Can a Caver/Climber Do? Reply-to: kconover+@pitt.edu Date: Tue, 26 Sep 1995 15:26:31 On 25 Sep 95 at 16:50, Barry Burton wrote: > > My understanding of the risks of taping fractured ribs is the resultant > atalectasis from failure to breath deeply, etc, following the taping. That's the theory -- but the studies, as limited as they are, also suggest that other complitations (e.g., hemothorax) are more common with a rib belt, too. > 2. Yes Sam, if I hadn't been so anal and forced myself to breath, > the pain probably would have killed me...through complications Too bad you were so anal; we might have had a case to go against Sam Chewning's famous and oft-repeated "pain never killed anyone" (P.S. for those who don't know, Sam is a spine surgeon in Charlotte, NC and a Wilderness EMS Institute command physician as well as being the national medical advisor for the National Cave Rescue Commission. And we all _did_ laugh when at a cave rescue he asked if I anyone had an aspirin handy for his headache.) > 4. Still probably got a little hypostatic, until I recognized and > initiated self-pulmonary hygeine > (ie Cough and deep breath, no matter how > m much it hurt) > > 5. I don't think I could have actively climbed at all during > this event. (Especially since I didn't know how, then) But what if you'd had better analgesia, too? You might have had an easier time getting out. -- End -- X-cs: From: Self To: "Jack T. Grandey" ,kconover+@pitt.edu, wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: emed-l Re: (Fwd) Rib Fractures -- What Can a Caver/Clim Reply-to: kconover+@pitt.edu Date: Tue, 26 Sep 1995 15:33:26 On 25 Sep 95 at 19:46, Jack T. Grandey wrote: > > > > > With this in mind, I'd suggest > > > > a-Temporary splinting (taping) with concomitant pulmonary hygeine > > (cough/ forced deep breath every 20 minutes, for example) > > for the short duration of the evacuation (1-2 days) with > > release of the tape during periods of inactivity, is > > probably safe, and should be investigated. > > > > Especially when "no lung trauma" ie hemoptyiss, open > > wound, breathlessness, rales, etc. > > > > b. Such an individual should honestly evaluate their personal > > physical capacities at that time. > > IE: Walk out /crawl out OK, climb out, HIGHLY DUBIOUS. > > Consider a "haul" > > > > Barry > > > > I think this is an excellent basis for a rib fx protocol for delayed > evacuation/extended transport. How about re-formatting it in such a fashion? > But, if you've got adequate analgesia, what's the _risk_ of trying to climb/walk out? Yes, you may need some people along to help and a belay (remember the latter part of the Crossroads rescue? No, I guess not, because you'd rotated out of the cave by that time. Earle had Toradol and quite a bit of morphine in him after we reduced the shoulder; we put him in a seat harness with short belay lines fore and aft, and plugged "holes" in the floor with cavers, and he moved a _lot_ faster than if he'd been in a litter.) I think that if someon _can_ move with taping and analgesia, we should let them; and that probably wouldn't include ascending a fixed line, but could certainly include being hauled up just in a harness with hands and legs free to assist. Don't think it requires a litter evacuation. -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.12/cispop-1.6.1.2) ID for ; Tue, 26 Sep 1995 18:46:05 -0400 Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Tue, 26 Sep 1995 18:46:05 -0400 Received: via switchmail for kconover+@pitt.edu; Tue, 26 Sep 1995 18:46:05 -0400 (EDT) Received: from astro.ocis.temple.edu (astro.ocis.temple.edu [155.247.165.100]) by post-ofc03.srv.cis.pitt.edu with ESMTP (8.6.12/cispo-2.0.1.1) ID for ; Tue, 26 Sep 1995 18:42:59 -0400 Received: (from pacer@localhost) by astro.ocis.temple.edu (8.6.12/8.6.12) id SAA25350; Tue, 26 Sep 1995 18:39:39 -0400 Date: Tue, 26 Sep 1995 18:38:50 -0400 (EDT) From: Barry Burton To: kconover+@pitt.edu cc: wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: (Fwd) Rib Fractures -- What Can a Caver/Climber Do? In-Reply-To: <199509261927.PAA25278@post-ofc02.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Keith.. On Tue, 26 Sep 1995, Keith Conover, M.D. wrote: > On 25 Sep 95 at 16:50, Barry Burton wrote: > > > > > My understanding of the risks of taping fractured ribs is the resultant > > atalectasis from failure to breath deeply, etc, following the taping. > > That's the theory -- but the studies, as limited as they are, also > suggest that other complitations (e.g., hemothorax) are more common > with a rib belt, too. > References! Please? Do you know the postulated mechanism? > > 4. Still probably got a little hypostatic, until I recognized and > > initiated self-pulmonary hygeine > > (ie Cough and deep breath, no matter how > > m much it hurt) > > > > 5. I don't think I could have actively climbed at all during > > this event. (Especially since I didn't know how, then) > > But what if you'd had better analgesia, too? You might have had an > easier time getting out. This is VERY true. I sort of resisted heavy analgesia (had to drive the family home from the site) and thus "tolerated" the disconfort with self splint (forearm at times of paroxysmanl pain) and APAP Analgesia is the MOST important part, from the patients stand point. And it DEFINATELY would make it easier to comply with the pulmonary regimen (cough, etc) Oft thought (and on trauma, DID PROVIDE) that a IC nerve block would be the best analgesia for a few isolated rib fx, without pulmonary findings. Risk of ptx, in best hands, is real. In the field? Don't think I could routinely justify the risk for the benefit. (On trauma, we loaded the pleura with Marcaine at the time of Chest Tube placement, sort of like a pleural wash. Don't think that would be ideal out back) In case I've been too obtuse, I AGREE with pain control, systemically, for the caver/climber with isolated rib fractures. I don't see OVERWHELMING risk from short term (until 'out' of the risk zone, only) splinting, ie taping, if it significantly facilitates the evacuation phase. BUT, the decision to use this modality goes hand in hand with meticulous pulmonary hygeine. Thanks for forwarding the references on Hemothorax, Keith. 73 Barry N3VOW -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.12/cispop-1.6.1.2) ID for ; Tue, 26 Sep 1995 18:51:33 -0400 Received: from local (daemon@localhost) by post-ofc02.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Tue, 26 Sep 1995 18:51:32 -0400 Received: via switchmail for kconover+@pitt.edu; Tue, 26 Sep 1995 18:51:31 -0400 (EDT) Received: from astro.ocis.temple.edu (astro.ocis.temple.edu [155.247.165.100]) by post-ofc02.srv.cis.pitt.edu with ESMTP (8.6.12/cispo-2.0.1.1) ID for ; Tue, 26 Sep 1995 18:47:11 -0400 Received: (from pacer@localhost) by astro.ocis.temple.edu (8.6.12/8.6.12) id SAA27831; Tue, 26 Sep 1995 18:44:16 -0400 Date: Tue, 26 Sep 1995 18:43:10 -0400 (EDT) From: Barry Burton To: kconover+@pitt.edu cc: "Jack T. Grandey" , kconover+@pitt.edu, wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: emed-l Re: (Fwd) Rib Fractures -- What Can a Caver/Clim In-Reply-To: <199509261937.PAA16288@post-ofc01.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Keith, and the "group" On Tue, 26 Sep 1995, Keith Conover, M.D. wrote: > On 25 Sep 95 at 19:46, Jack T. Grandey wrote: > > > > > > > > > With this in mind, I'd suggest > > > > > > a-Temporary splinting (taping) with concomitant pulmonary hygeine > > > (cough/ forced deep breath every 20 minutes, for example) > > > for the short duration of the evacuation (1-2 days) with > > > release of the tape during periods of inactivity, is > > > probably safe, and should be investigated. > > > > > > Especially when "no lung trauma" ie hemoptyiss, open > > > wound, breathlessness, rales, etc. > > > > > > b. Such an individual should honestly evaluate their personal > > > physical capacities at that time. > > > IE: Walk out /crawl out OK, climb out, HIGHLY DUBIOUS. > > > Consider a "haul" > > > > > > Barry > > > > > > > I think this is an excellent basis for a rib fx protocol for delayed > > evacuation/extended transport. How about re-formatting it in such a fashion? > > > > But, if you've got adequate analgesia, what's the _risk_ of trying > to climb/walk out? Yes, you may need some people along to help and > a belay (remember the latter part of the Crossroads rescue? No, I > guess not, because you'd rotated out of the cave by that time. > Earle had Toradol and quite a bit of morphine in him after we > reduced the shoulder; we put him in a seat harness with short belay > lines fore and aft, and plugged "holes" in the floor with cavers, > and he moved a _lot_ faster than if he'd been in a litter.) > > I think that if someon _can_ move with taping and analgesia, we > should let them; and that probably wouldn't include ascending a fixed > line, but could certainly include being hauled up just in a harness > with hands and legs free to assist. Don't think it requires a litter > evacuation. > That was my point. Hands and legs for assist, (such a precious notion..letting the conscious defend for themselves) but provide some mechanical power assist ("haul") on the lines. Didn't think the litter was necessary, either, if that is the isolated injury. Sorry if my language skills are a bit sloppy. I'm still learning to crawl with you guys. Barry > -- End -- X-cs: From: Self To: Barry Burton ,wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: (Fwd) Rib Fractures -- What Can a Caver/Climber Do? Reply-to: kconover+@pitt.edu Date: Wed, 27 Sep 1995 11:11:22 On 26 Sep 95 at 18:38, Barry Burton wrote: [snip] > > > My understanding of the risks of taping fractured ribs is the resultant > > > atalectasis from failure to breath deeply, etc, following the taping. > > > > That's the theory -- but the studies, as limited as they are, also > > suggest that other complitations (e.g., hemothorax) are more common > > with a rib belt, too. > > > References! Please? Do you know the postulated mechanism? I put these in the original post, but maybe you missed it when Temple decided that the new undergraduates needed your email address :-) 1. Quick G. A randomized clinical trial of rib belts for simple fractures. Am J Emerg Med 1990;8(4):277-81. Shows hemothorax more frequent with displaced rib fx if use rib belt. 2. Lazcano A, Dougherty J, Kruger M. Use of rib belts in acute rib fractures. Am J Emerg Med 1989;7(1):97-100. Shows higher incidence of complications, including atelec- tasis and bloody pleural effusion, with rib belts. [snip] > > But what if you'd had better analgesia, too? You might have had an > > easier time getting out. > > This is VERY true. I sort of resisted heavy analgesia (had to drive the > family home from the site) and thus "tolerated" the disconfort with self > splint (forearm at times of paroxysmanl pain) and APAP > > Analgesia is the MOST important part, from the patients stand point. And > it DEFINATELY would make it easier to comply with the pulmonary regimen > (cough, etc) Aha. So if you weren't so worried about being able to drive afterwards, you could have been drugged and gotten out relatively safely under your own power? Exactly my point. It's a lot easier to find a ride home for someone than involve 100+ people in a difficult rescue operation. > > Oft thought (and on trauma, DID PROVIDE) that a IC nerve block would be > the best analgesia for a few isolated rib fx, without pulmonary findings. Absolutely. That's why I carry bupivicaine in my "physician extras kit" to supplement my standard WEMSI personal medical kit. (Yes, I finally have an official WEMSI kit just like all our medics, neatly organized, without lots of extra junk in it. It was really hard leaving out all the extra goodies that I want to take and so I put them, things like Fentanyl and Versed and Ketamine and a Gerber camp saw for amputations and a people-sewing kit, in a separate bag.) But, IC nerve blocks are a physician-level, not wilderness-medic level skill. True, the most likely complication is a nontension PTX and the medics are probably better than the docs at recognizing and caring for them, but -- it takes a bit of practice and a fair bit of anatomical knowledge above the EMT-P level to do this. Maybe it's a skill for the special advanced Wilderness EMT module? > > Risk of ptx, in best hands, is real. In the field? Don't think I could > routinely justify the risk for the benefit. (On trauma, we loaded the > pleura with Marcaine at the time of Chest Tube placement, sort of like a > pleural wash. Don't think that would be ideal out back) Yes, but I can see situations where IC block might literally be lifesaving, even if you do have to stick a needle in the chest and have the person keep on going. I've needled the chest in minimally symptomatic patients in the ED who were getting worse after a spontaneous PTX and the surgical resident, to whom I'd promised the procedure of putting in the chest tube, wasn't able to get down to the ED yet. The patient suffered minimal if any pain (used a little lidocaine) and felt a lot better waiting for his chest tube. > > In case I've been too obtuse, I AGREE with pain control, systemically, > for the caver/climber with isolated rib fractures. > > I don't see OVERWHELMING risk from short term (until 'out' of the risk zone, > only) splinting, ie taping, if it significantly facilitates the > evacuation phase. > > BUT, the decision to use this modality goes hand in hand with meticulous > pulmonary hygeine. > Is this a sort of consensus? -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.12/cispop-1.6.1.2) ID for ; Wed, 27 Sep 1995 17:08:12 -0400 Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Wed, 27 Sep 1995 17:08:12 -0400 Received: via switchmail for kconover+@pitt.edu; Wed, 27 Sep 1995 17:08:12 -0400 (EDT) Received: from astro.ocis.temple.edu (astro.ocis.temple.edu [155.247.165.100]) by post-ofc03.srv.cis.pitt.edu with ESMTP (8.6.12/cispo-2.0.1.1) ID for ; Wed, 27 Sep 1995 17:05:14 -0400 Received: (from pacer@localhost) by astro.ocis.temple.edu (8.6.12/8.6.12) id RAA08543; Wed, 27 Sep 1995 17:02:35 -0400 Date: Wed, 27 Sep 1995 17:01:51 -0400 (EDT) From: Barry Burton To: kconover+@pitt.edu cc: wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: (Fwd) Rib Fractures -- What Can a Caver/Climber Do? In-Reply-To: <199509271518.LAA11279@post-ofc01.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Keith... On Wed, 27 Sep 1995, Keith Conover, M.D. wrote: > On 26 Sep 95 at 18:38, Barry Burton wrote: > [snip] > > [snip] > > > But what if you'd had better analgesia, too? You might have had an > > > easier time getting out. > > > > This is VERY true. I sort of resisted heavy analgesia (had to drive the > > family home from the site) and thus "tolerated" the disconfort with self > > splint (forearm at times of paroxysmanl pain) and APAP > > > > Analgesia is the MOST important part, from the patients stand point. And > > it DEFINATELY would make it easier to comply with the pulmonary regimen > > (cough, etc) > > Aha. So if you weren't so worried about being able to drive > afterwards, you could have been drugged and gotten out relatively > safely under your own power? Exactly my point. It's a lot easier to > find a ride home for someone than involve 100+ people in a difficult > rescue operation. > Yup. I agree...triage rules would suggest not putting the centurians (100 people) at risk if you can facilitate, safely, self assisted evac > > > > Oft thought (and on trauma, DID PROVIDE) that a IC nerve block would be > > the best analgesia for a few isolated rib fx, without pulmonary findings. > > Absolutely. That's why I carry bupivicaine in my "physician extras > kit" to supplement my standard WEMSI personal medical kit. (Yes, I > finally have an official WEMSI kit just like all our medics, neatly > organized, without lots of extra junk in it. It was really hard > leaving out all the extra goodies that I want to take and so I put > them, things like Fentanyl and Versed and Ketamine and a Gerber camp > saw for amputations and a people-sewing kit, in a separate bag.) > I'm jeolous. See, Jack. All you guys have got more toys tahn I. I think I deserve to lose the "geek gadget" moniker NOW! > But, IC nerve blocks are a physician-level, not wilderness-medic > level skill. Yes > True, the most likely complication is a nontension PTX > and the medics are probably better than the docs at recognizing and > caring for them, but -- it takes a bit of practice and a fair bit of > anatomical knowledge above the EMT-P level to do this. Maybe it's a > skill for the special advanced Wilderness EMT module? > Special consideration, special candidate. > > > > Risk of ptx, in best hands, is real. In the field? Don't think I could > > routinely justify the risk for the benefit. (On trauma, we loaded the > > pleura with Marcaine at the time of Chest Tube placement, sort of like a > > pleural wash. Don't think that would be ideal out back) > > Yes, but I can see situations where IC block might literally be > lifesaving, even if you do have to stick a needle in the chest and > have the person keep on going. I've needled the chest in minimally > symptomatic patients in the ED who were getting worse after a > spontaneous PTX and the surgical resident, to whom I'd promised the > procedure of putting in the chest tube, wasn't able to get down to > the ED yet. The patient suffered minimal if any pain (used a little > lidocaine) and felt a lot better waiting for his chest tube. > Done it myself, without lido. He tahnked me for letting him breath. > > > > In case I've been too obtuse, I AGREE with pain control, systemically, > > for the caver/climber with isolated rib fractures. > > > > I don't see OVERWHELMING risk from short term (until 'out' of the risk zone, > > only) splinting, ie taping, if it significantly facilitates the > > evacuation phase. > > > > BUT, the decision to use this modality goes hand in hand with meticulous > > pulmonary hygeine. > > > > Is this a sort of consensus? > I think so, of two. What do the other WCP's and vested parties have to say? Speak (write) up! (Dr) Barry -- End -- X-cs: From: Self To: JSachter@aol.com Subject: Re: Wilderness EM fellowships Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Sat, 30 Sep 1995 11:24:48 On 30 Sep 95 at 3:49, JSachter@aol.com wrote: > Does anyone know of any Wilderness EM fellowships open to graduates of EM > Residency training programs ? One of my residents is interested in pursuing > this upon graduation this spring. > > Many thanks... > > Joseph J Sachter, MD, FACEP (jsachter@aol.com) > Program Director, Emergency Medicine Residency > The Brooklyn Hospital Center There are none. Can't think of anyone who'd be willing to fund a fellowship in a noncertified nonsubspecialty that is for an activity that is essentially completely unfunded. Nobody pays docs to do wilderness medicine, except a little in-kind support like I get here in Pittsburgh. We have a one-month rotation for R-2/3/4 EM residents in wilderness EMS (not EMS and not "wilderness medicine" in general). Had planned to offer it this November but as I'm taking the written boards then have cancelled it; next one will be in March. There is a wilderness medicine elective for FP residents in Boise, ID and at the University of Maine but that's about it. However, encourage your resident to join the Wilderness Medical Society and go to their annual conferences; that's where the real wilderness medicine action is. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: medical kit packaging Reply-to: kconover+@pitt.edu Date: Sun, 1 Oct 1995 11:08:25 Notes on Packaging of Personal Wilderness Medical Kits Version 0.1, October 1, 1995 This is a preliminary draft, for discussion, to be added to a future version of the WEMSI Personal Wilderness Medical Kit docu- ment. comments to: wilderness-emergency-medicine@list.pitt.edu or, if you don't have electronic mail, to: Keith Conover, M.D., WEMSI Medical Director 36 Robinhood Road Pittsburgh, PA 15220-3014 1. Snap-Off Ampules Many drugs come in these ampules which are opened by snap- ping off the top. They have the advantage of being very compact and light, but the disadvantage that they are fragile and diffi- cult to pack. I've tried many different means of packaging. Most of these have been on small packages I've found in my "junk" box and therefore can't generally be reproduced by others. We're looking for something that is: - cheap - easy to make - provides moderate protection against breakage (note that the outer packaging of one's medical kit should also provide some protection, so this inner packaging need not be "bombproof" or "caveproof") - light - not bulky Most recently, I have made a package using the cardboard "rack" in which ampules are shipped in the box (in this particular case, for 100 microgram Fentanyl ampules). I cut this down to the right size for four ampules (the number I needed, though this will work for any number). I then cut a piece of stiff 3/8" closed-cell foam the same size as the "rack" and used duct tape to tape it on the front of the rack. I also duct-taped the bot- tom, but left the top open. I could then slide the ampules in from the top. They seem to stay in just fine without taping the top. I suppose one could tape some foam or an additional piece of stiff material to the back to provide additional protection, especially from flexing that might break the neck of the ampule. But that would add to the bulk and weight. 2. Inner packaging Prescription medications are in separate blister packaging from the hospital pharmacy, with an expiration date marked on each tablet's packaging. Nonprescription medications are also in blister packaging, except for ibuprofen, which I can't find that way; it's in a small bottle. Most but not all of the blister packs have expira- tion dates on them. I've used a laundry marker to put expiration dates on each individual pill's packaging when not put there by the manufacturer. For generic Pepto-Bismol I also had to put the name on the cellophane inner packaging, too. Acetaminophen (Tylenol) I got in small paper envelopes from the hospital, and each has an expiration date on it. 3. Outer Packaging I've found that for general use, bags from Atwater-Carey (1- 800-359-1646) work nicely for organizing the WEMSI Personal Wilderness Medical Kit. The Minimum and Advanced modules fit nicely in the Trekker II kit bag ($19.95 US). The Search Module fits nicely in the Expedition kit bag ($15.25 US). I've put my extra physician goodies in a Family kit bag ($12.50 US), though it's a bit tight. These bags have the great advantage of keeping things better organized, important if you're using the bag all the time. (I seem to attract medical problems when in the back- country, so this is important to me.) For above-ground rescue, just putting these bags in a plastic bag deep in one's pack should be adequate protection. For caving, I'd dump the contents out into a Pelican case, ammunition box, or Tupperware box that can be sealed with duct tape. Please add your comments and reply to wilderness-emergency- medicine@list.pitt.edu. Thank you. C:\TEXT\WEMS\PACKAGE.DOC -- End -- X-cs: From: Self To: CPT_Kevin_Coonan@ftdetrck-ccmail.army.mil Subject: Re: medical kit packaging Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Sun, 1 Oct 1995 17:37:46 On 1 Oct 95 at 14:23, CPT_Kevin_Coonan@ftdetrck-ccm wrote: > REI carries a variety of zip-out folding cases (you can also get them > pre-packed with a variety of kitchen gadgets) that I have used for two > different medical kits. The smaller one fits nicely in my book > bag/brief case/overnight bag/carry on luggage for not-so-wild trips as > well. They offer little in the way of crush or water protection, but > have performed well under a variety of field conditions (mostly > backpacking and climbing). > > I also have a "micro" kit that fits into my fanny pack w/ my lunch, > water and rain gear for longer climbs, containing epi (1 amp 1:1000 > and a Tb syringe), decadron (2x 4 mg), Tylenol (6), a single ASA, > ibuprofen (four 600mg), superglue, alcohol swabs, tylox (2), > cephadrine (2x500 mg), Steristrips, bandaids, a foil pack of triple > antibiotic goop, a Tegaderm and some 4x4s. It all fits into a heavy > duty zip-lock sandwich bag, stuffed into a very small stuff sack. > > Kevin Coonan, M.D. > There are lots of different bags that work well for medical kits; REI and Adventure Medical are two that I've played with before. But the Atwater-Carey bags seem a little nicer. And I think MRA teams and related wilderness SAR teams can probably get a good deal on them by talking to Phil Carey directly. -- End -- X-cs: From: Self To: Barry Burton ,@ASRC.PML Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: @AMRG.PML,wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Thu, 12 Oct 1995 09:52:51 On 25 Sep 95 at 16:16, Barry Burton wrote: > Keith > > > I'll buy into the low level of need for the actual rescue mission, in > that the people you're looking for are generally in a more fit condition > than the general populace. Well, actually, lots of the people the ASRC looks for are older and have coronary disease. And lots of the loacl volunteer searchers are fat hypertensive volunteer firemen who smoke. > > Agree that the base camp should be set up as medical resource for the > camp, and would propbably be recognized as such by the "unknowing" public. > > My real issue would be at training programs, where 'unknown' individuals > with less than perfect fitnes may attempt to participate while under our > supervision. In fact, didn't the last Camp Soles episode deal with a > student with chest pain? Yes indeedee. We did have a case of cardiac-sounding chest pain on the mountain, and gave him aspirin in the field, and were considering giving heparin. P.S. since we were considering heparin in the field, we also considered that the team medical kit might need to have the following in addition to heparin (we would have give 15,000 units SQ as per the European protocol, and hoped we were out and at the ED, at least, in 6 hours): a tiny monitor that can do a 12-lead, and a way to transmit it over a standard handheld stool guaiac cards and developer (to check for previously-undetected GI bleeding in a patient before starting heparin) Eminase, so we could start thrombolysis in the field > > >From a 'system' perspective, AED's may make sense where risk is high and > resources low. I'm not convinced this would be the BEST utilization at > wilderness base camp. In view of the plethora of medical types (those > damn wilderness docs) and the ALS paramedics from WEMSI that I here tell > show up at all these evolutions, it would make more sense, IMHO, to find > some used/ refurbished LP5's for base ops. (like mine). Just make sure to > get them from the old squads BEFORE the manufacturer rep makes a trade in > deal (FDA regs get in the way). > > This positin is potentially strenghtened by the concept of using the > wilderness teams in the event of civilian catastrophe, interfacing with > local and national Disaster Medical Response systems (PEMA, FEMA, NDMS. > etc) and thus, also opens an avenue for funding. > [snip] > Food for thought, IMHO > > Barry > I'm posting this to the wilderness-emergency-medicine list as well as sending to members of the ASRC. I'd be interested in getting some "outside" perspectives on our discussion about whether wilderness SAR teams need automatic external defibrillators, at least at Base Camp. Thanks. -- End -- X-cs: From: Self To: @AMRG.PML,ralson@isnet.is.wfu.edu (Roy Alson, MD) Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: @ASRC.PML,wemsi-staff@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Thu, 12 Oct 1995 12:21:07 On 12 Oct 95 at 11:55, Roy Alson, MD wrote: [snip] > I would agree that at the base camp, full ALS capability should be > maintained. While the team medical personnel have to be concerned about the > health and well-being of the victim, I still believe their first > responsibility is to the search personnel. > > If you look at a major (or minor) search operation and the numbers of people > involved, with multiple backgrounds and ages, the possibility of serious > illness, including cardiac problems, becomes very real. > > I think being prepared to handle these types of problems is the least we can > do for those involved in the operation > > Roy > Roy L. Alson, PhD, MD, FACEP > "Res-Q-Roy" > Department of Emergency Medicine > Bowman Gray School of Medicine > Winston-Salem, NC 27157 > raslon@isnet.is.wfu.edu > And I guess that the principle that we take care of our search personnel and rescuer first means we should be prepared to deal with a problem that is rare, but lethal, and can sometimes be corrected by a simple though expensive tool (the automated external difibrillator). I'll post your comments to the ASRC maillist and the wilderness-emergency-medicine lists, too, Roy. Thanks. --Keith -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu,@AMRG.PML Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: @ASRC.PML Reply-to: kconover+@pitt.edu Date: Sat, 14 Oct 1995 20:41:28 On 13 Oct 95 at 8:35, Jack T. Grandey wrote: > [snip] > > > > My real issue would be at training programs, where 'unknown' individuals > > > with less than perfect fitnes may attempt to participate while under our > > > supervision. In fact, didn't the last Camp Soles episode deal with a > > > student with chest pain? > > > > Yes indeedee. We did have a case of cardiac-sounding chest pain on > > the mountain, and gave him aspirin in the field, and were considering > > giving heparin. > > > > P.S. since we were considering heparin in the field, we also > > considered that the team medical kit might need to have the following > > in addition to heparin (we would have give 15,000 units SQ as per the > > European protocol, and hoped we were out and at the ED, at least, in > > 6 hours): > > > > a tiny monitor that can do a 12-lead, and a way to transmit it over a > > standard handheld > > > > stool guaiac cards and developer (to check for previously-undetected > > GI bleeding in a patient before starting heparin) > > > > Eminase, so we could start thrombolysis in the field > > > > > [snip, snip, snip] > > Though this event gets referred to frequently, I'm not sure that it > represents a good case in support of "more stuff" since the general > collective opinion of all /p evaluation in the ED is that the patient was > non-cardiac. Having been on scene, I'll support that care @ the time was > correct since MI could neither be confirmed nor RO. That said, I'm not > convinced that more agressive tx would have been appropriate had the toys > been present. Lysing & heparinization (or heparinization & lysing, but I > digress) are not /s risks, particularly when a an evacuation (possibly > extended)over rough terrain is required. Even all that assumes that 12l > MDs worth $13k would survive or that we want to manage a litter patient > /c central line, full monitoring,....etc. > > I'm mindful also of a recent discussion on another list about an acute > HA, LP- patient who was DC'd and died 48 hrs later of a SAH. To quote > the doc from Oz, "some people are just damn unlucky". All HAs should not be > MRI'd (Any extra room in the Range Rover, Keith?) > > /c For Reals, we need to keep yield/weight, factored by risk of procedure > in mind. /c classes, we should consider better medical screening for risks. > > Remember... > > ALL patients eventually die... > all bleeding eventually stops... > if you drop the baby...pick it up. > > AND > > In the wilderness...You carry what you have. > > JTG Cogent observations, Jack. We (SAR teams planning to improve their medical capabilities, I mean) have limitations in terms of weight, expense, and training time. We need to pick and choose what we carry based on: how often will we need it? how much of a difference will it make? will we have enough people with enough training to use it? Splinting limbs makes a fair difference. Giving pain medications makes a fair difference (except for orthopedic surgeons who believe that "pain never killed anyone"). For cardiac chest pain, giving aspirin makes a BIG difference, saving as many lives as thrombolysis in the (big, good) studies. None of these cost much, in terms of weight or expense. And in terms of how often something occurs: we aren't likely to see cardiac chest pain in the backcountry, but if you _do_ see it and don't have an aspirin handy and the person dies, how would you feel? That's probably as important as the other considerations: how bad would you feel if you didn't have it with you and the patient needed it? I wouldn't feel bad if I didn't have an MRI with me in the wilderness. But if I were at a Base Camp and someone coded and I didn't have a defibrillator and the patient died I'd feel pretty bad. Since defibrillators are very expensive, I wouldn't feel as bad as if the patient had chest pain and I didn't have an aspirin, which is cheap. But I'd still feel bad. So we're not likely to see such an event very often? Remember those overweight tobacco-smoking hypertensive firefighters. A save once every 10 years is enough to justify a defibrillator, I think. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu,@ASRC.PML Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: @AMRG.PML Reply-to: kconover+@pitt.edu Date: Sun, 15 Oct 1995 10:51:29 On 13 Oct 95 at 9:26, Jack T. Grandey wrote: [snip] > > > I would agree that at the base camp, full ALS capability should be > > > maintained. While the team medical personnel have to be concerned about the > > > health and well-being of the victim, I still believe their first > > > responsibility is to the search personnel. > > > > > > If you look at a major (or minor) search operation and the numbers of people > > > involved, with multiple backgrounds and ages, the possibility of serious > > > illness, including cardiac problems, becomes very real. > > > > > > I think being prepared to handle these types of problems is the least we can > > > do for those involved in the operation > > > > > > Roy > > Agree on all counts. > > > > And I guess that the principle that we take care of our search > > personnel and rescuer first means we should be prepared to deal with > > a problem that is rare, but lethal, and can sometimes be corrected by > > a simple though expensive tool (the automated external > > difibrillator). > > Disagree here. The AED still does not pass the yield/weight+ cost test. > $200 gets a team a handheld GPS that is useful on every mission and > survives just about anything but being run over by a 4x /c deep knobbies > (it gets caught in the tread). $4,500+ (+training, MD dir., etc.) gets a > device that can be used once in a blue and chartreuse striped moon, does > NOT like to be wet & weighs 4-5 KGs. GPS units actually aren't that useful (look at the thread about GPS units currently going on in the Computers in SAR mailing list, especially at Chuck Kollar's and Gene Harrison's tests). And best, they aid in SAR, maybe helping find some lost people a little faster. But an AED could save searchers (even if they could be local firefighters instead of SAR team members). So trying to compare $ amounts for something that can directly save a life with something that helps you navigate in the woods isn't a good comparison. > > Teams should be excellent @ BLS skills, which include recognition of the > infrequent OHSHIT case. They should have reliable comm to a base that is > equipped to handle said cases. Look at the table on page XII-22 of the WEMSI WEMT Curriculum (Wilderness Medical Problems) Lesson Plan. (Call Pam Westfall at the Center for Emergency Medicine at 412-578-3203 if you'd like to order a copy of this, or email her at ) Cardiac Arrest Survival Times: Time to ALS <8 min 8-16 min >16 min Time <4 min 43% 19% 10% to 4-8 min 27% 19% 6% BLS >8 min N/A 7% 0% If you extrapolate this, then if the time to ALS is more than about half an hour, then there's no point in even starting CPR, unless the patient has one of those few causes of cardiac arrest that can be cured by basic CPR (e.g., lightning strike, some cases of near-drowning), or the patient is severely hypothermic. Remember that basic CPR provides 30% of normal cerebral perfusion, but that filling of the coronaries occurs during diastole, and even with perfect basic CPR the diastolic pressure id 0. Which means that with CPR the entire heart is infarcting the whole time you're doing CPR. Which means that if an AED or other ALS is more than half an hour away, forget it. But I think you misunderstood; I never argued for AEDs in the field, just having one at every Base Camp. > > Fall not prey to the "technological imperative" (thanks to Steve Davidson, > MD). > > Restated: "We can, therefore we should." > > Jack T. Grandey, NREMT-P > -- End -- X-cs: From: Self To: WEDOSAR@aol.com Subject: Re: (Fwd) Re: Defibrillators for SAR teams Reply-to: kconover+@pitt.edu Date: Mon, 16 Oct 1995 12:41:26 On 14 Oct 95 at 23:41, WEDOSAR@aol.com wrote: > Keith, > > We can have all the ALS gear we want at base, the local ambulance will > provide it (if not, fire the IC and get somwone who can get resources). In > the field, we cannot afford it ($$$ as patch will confirm), and we really > have very little need for it. > >Mark Jones Ah, but in rural settings, can we depend on having local _ALS_ at base? They may have better things to do, or be out in the field. And it may be a BLS service in the area. --Keith Conover -- End -- X-cs: From: Self To: @AMRG.PML Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: wilderness-emergency-medicine@list.pitt.edu,@ASRC.PML Reply-to: kconover+@pitt.edu Date: Mon, 16 Oct 1995 12:43:44 On 14 Oct 95 at 23:41, WEDOSAR@aol.com wrote: > Keith, > > We can have all the ALS gear we want at base, the local ambulance will > provide it (if not, fire the IC and get somwone who can get resources). In > the field, we cannot afford it ($$$ as patch will confirm), and we really > have very little need for it. > >Mark Jones Ah, but in rural settings, can we depend on having local _ALS_ at base? They may have better things to do, or be out in the field. And it may be a BLS service in the area. Your comment about $$$ for AEDs is quite appropros for almost every SAR team I know (except maybe for BRMRG and the Park Service teams), spending your team's entire budget for five years on an AED may not make sense. -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.12/cispop-1.6.1.3) ID for ; Mon, 16 Oct 1995 16:43:34 -0400 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 16 Oct 1995 16:43:33 -0400 Received: via switchmail; Mon, 16 Oct 1995 16:43:33 -0400 (EDT) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 16 Oct 1995 16:43:21 -0400 (EDT) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.6.12/cisls-2.4) ID ; Mon, 16 Oct 1995 16:43:04 -0400 Received: from JEFLIN.TJU.EDU (jeflin.TJU.EDU [147.140.128.114]) by list.srv.cis.pitt.edu with SMTP (8.6.12/cisls-2.4) ID for ; Mon, 16 Oct 1995 16:43:01 -0400 Received: from JEFLIN.TJU.EDU by JEFLIN.TJU.EDU with SMTP; Mon, 16 Oct 1995 13:16:40 -0400 (EDT) Date: Mon, 16 Oct 1995 13:16:34 +0000 From: "Jack T. Grandey" X-Sender: GRANDEYE@ To: kconover+@pitt.edu cc: wilderness-emergency-medicine@list.pitt.edu, ASRC.groups.and.members@pitt.edu, AMRG.Members.and.Others@pitt.edu Subject: Re: (Fwd) Re: Defibrillators for SAR teams In-Reply-To: <199510161511.LAA01455@post-ofc02.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 On Mon, 16 Oct 1995, Keith Conover, M.D. wrote: > On 13 Oct 95 at 9:26, Jack T. Grandey wrote: > [snip] > > > > > Disagree here. The AED still does not pass the yield/weight+ cost test. > > $200 gets a team a handheld GPS that is useful on every mission and > > survives just about anything but being run over by a 4x /c deep knobbies > > (it gets caught in the tread). $4,500+ (+training, MD dir., etc.) gets a > > device that can be used once in a blue and chartreuse striped moon, does > > NOT like to be wet & weighs 4-5 KGs. > > GPS units actually aren't that useful (look at the thread about GPS > units currently going on in the Computers in SAR mailing list, > especially at Chuck Kollar's and Gene Harrison's tests). And best, > they aid in SAR, maybe helping find some lost people a little > faster. > > But an AED could save searchers (even if they could be local > firefighters instead of SAR team members). So trying to compare $ > amounts for something that can directly save a life with something > that helps you navigate in the woods isn't a good comparison. > The point is that $200 for useful navigational device is difficult to come up with. Where do you project that teams will get the $4,500+? Also-who will carry it? Who will keep it dry & check its batteries??? I'm a very big proponent of the device, I just don't see it in the woods. > > > > Teams should be excellent @ BLS skills, which include recognition of the > > infrequent OHSHIT case. They should have reliable comm to a base that is > > equipped to handle said cases. > > Look at the table on page XII-22 of the WEMSI WEMT Curriculum > (Wilderness Medical Problems) Lesson Plan. (Call Pam Westfall at the > Center for Emergency Medicine at 412-578-3203 if you'd like to order > a copy of this, or email her at ) Actually, I do have a passing familiarity /c the document. > > Cardiac Arrest Survival Times: > > Time to ALS > <8 min 8-16 min >16 min > Time <4 min 43% 19% 10% > to 4-8 min 27% 19% 6% > BLS >8 min N/A 7% 0% > > If you extrapolate this, then if the time to ALS is more than about > half an hour, then there's no point in even starting CPR, Yup! > unless the > patient has one of those few causes of cardiac arrest that can be > cured by basic CPR (e.g., lightning strike, some cases of > near-drowning), or the patient is severely hypothermic. Remember > that basic CPR provides 30% of normal cerebral perfusion, Beg to differ. I believe the references indicate that it provides 30% of normal CARDIAC OUTPUT. There's been no documentation of how much cerbral perfusion is achieved and there is no reason to assume that the same 30% would apply. > but that > filling of the coronaries occurs during diastole, and even with > perfect basic CPR the diastolic pressure id 0. Which means that with > CPR the entire heart is infarcting the whole time you're doing CPR. It's certainly anoxic and infarction follows ischemia. > > Which means that if an AED or other ALS is more than half an hour > away, forget it. Probably more like 15 min. > > But I think you misunderstood; I never argued for AEDs in the field, > just having one at every Base Camp. Ok. Actually, I think ALS is needed @ base camp. Not just BCLS /c AED. > > > > > Fall not prey to the "technological imperative" (thanks to Steve Davidson, > > MD). > > > > Restated: "We can, therefore we should." > > Jack T. Grandey, NREMT-P -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.12/cispop-1.6.1.3) ID for ; Mon, 16 Oct 1995 14:56:23 -0400 Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 16 Oct 1995 14:56:22 -0400 Received: via switchmail for kconover+@pitt.edu; Mon, 16 Oct 1995 14:56:22 -0400 (EDT) Received: from JEFLIN.TJU.EDU (jeflin.TJU.EDU [147.140.128.114]) by post-ofc03.srv.cis.pitt.edu with SMTP (8.6.12/cispo-2.0.1.1) ID ; Mon, 16 Oct 1995 14:54:41 -0400 Received: from JEFLIN.TJU.EDU by JEFLIN.TJU.EDU with SMTP; Mon, 16 Oct 1995 13:26:47 -0400 (EDT) Date: Mon, 16 Oct 1995 13:26:41 +0000 From: "Jack T. Grandey" X-Sender: GRANDEYE@ To: kconover+@pitt.edu cc: wilderness-emergency-medicine@list.pitt.edu, AMRG.Members.and.Others@pitt.edu, ASRC.groups.and.members@pitt.edu Subject: Re: (Fwd) Re: Defibrillators for SAR teams In-Reply-To: <199510161510.LAA01381@post-ofc02.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII X-PMFLAGS: 34078848 On Mon, 16 Oct 1995, Keith Conover, M.D. wrote: > On 13 Oct 95 at 8:35, Jack T. Grandey wrote: > > [snip] > > > > > > My real issue would be at training programs, where 'unknown' individuals > > > > In the wilderness...You carry what you have. > > > > JTG > Cogent observations, Jack. We (SAR teams planning to improve their > medical capabilities, I mean) have limitations in terms of weight, > expense, and training time. We need to pick and choose what we carry > based on: > > how often will we need it? > > how much of a difference will it make? > > will we have enough people with enough training to use it? > > Splinting limbs makes a fair difference. Giving pain medications > makes a fair difference (except for orthopedic surgeons who believe > that "pain never killed anyone"). For cardiac chest pain, giving > aspirin makes a BIG difference, saving as many lives as thrombolysis > in the (big, good) studies. None of these cost much, in terms of > weight or expense. Agree /c all except lysing. Lot's of risks are attendant /c that therapy. Careful clinical judgement is needed here. > > And in terms of how often something occurs: we aren't likely to see > cardiac chest pain in the backcountry, but if you _do_ see it and > don't have an aspirin handy and the person dies, how would you feel? > > That's probably as important as the other considerations: how bad > would you feel if you didn't have it with you and the patient needed > it? I wouldn't feel bad if I didn't have an MRI with me in the > wilderness. But if I were at a Base Camp and someone coded and I > didn't have a defibrillator and the patient died I'd feel pretty > bad. Since defibrillators are very expensive, I wouldn't feel as bad > as if the patient had chest pain and I didn't have an aspirin, which > is cheap. I believe in monitor/defribrillators @ base camp. I believe in ASA in personal packs. > But I'd still feel bad. So we're not likely to see such > an event very often? Remember those overweight tobacco-smoking > hypertensive firefighters. A save once every 10 years is enough to > justify a defibrillator, I think. Well, you haven't disqualified frequency as a criteria, just put in $ context. For once every 10 years, it's worth it @ $4,500 (what about the $12,000 for the 12-lead to rule-in lysing?) MRIs are $4,500,000. One bleed every 10 years, same # die, but you "wouldn't feel bad". JTG -- End -- X-cs: From: Self To: Steve Hoffman ,@ASRC.PML Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: @AMRG.PML,wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Mon, 16 Oct 1995 21:45:56 On 16 Oct 95 at 13:35, Steve Hoffman wrote: > > Short (cheap) answer: call the local defib-equipped ambulance for a > standby at the base camp. If the SAR organization has the budget, > training, protocols and medical control supervision, this standard > of care can be improved on in many ways, including a defibrillator > and ACLS skills. > > :> Teams should be excellent @ BLS skills, which include recognition of the > :> infrequent OHSHIT case. They should have reliable comm to a base that is > :> equipped to handle said cases. > > I'd rather spend the $$$ on better gear and better radios and on > repeater and communications systems that will see regular and > potentially immediately life-saving measures. > > :Look at the table on page XII-22 of the WEMSI WEMT Curriculum > :(Wilderness Medical Problems) Lesson Plan. > > :Cardiac Arrest Survival Times: > : > : Time to ALS > : <8 min 8-16 min >16 min > :Time <4 min 43% 19% 10% > :to 4-8 min 27% 19% 6% > :BLS >8 min N/A 7% 0% > : > :If you extrapolate this, then if the time to ALS is more than about [snip] > :CPR the entire heart is infarcting the whole time you're doing CPR. > > CPR isn't particularly effective save as a temporary stabilizing > operation, and -- under the local WEMT protocols -- can be stopped > after 30 minutes for the `degenerative' cases. > > And the survival times shown above indicate that one needs nearly > immediate access to a defibrillator for it to be effective. > > >Which means that if an AED or other ALS is more than half an hour > >away, forget it. > > There is far more to ALS than defibrillation -- I suspect those > `ALS' numbers are actually numbers that reflect time to ACLS. > Without ACLS (`Ninja' or `classic'), the defibrillator enjoys > only limited success. But without the defibrillator (the only really heavy item) all the rest is basically useless. > > quotes from various sources including Barry Burton and Keith Conover. > > :> I'll buy into the low level of need for the actual rescue mission, in > :> that the people you're looking for are generally in a more fit condition > :> than the general populace. > : > :Well, actually, lots of the people the ASRC looks for are older and > :have coronary disease. > : > :And lots of the loacl volunteer searchers are fat hypertensive > :volunteer firemen who smoke. > > > > :> >From a 'system' perspective, AED's may make sense where risk is high and > :> resources low. I'm not convinced this would be the BEST utilization at > :> wilderness base camp. In view of the plethora of medical types (those > :> damn wilderness docs) and the ALS paramedics from WEMSI that I here tell > :> show up at all these evolutions, it would make more sense, IMHO, to find > :> some used/ refurbished LP5's for base ops. (like mine). Just make sure to > :> get them from the old squads BEFORE the manufacturer rep makes a trade in > :> deal (FDA regs get in the way). > :> > :> This positin is potentially strenghtened by the concept of using the > :> wilderness teams in the event of civilian catastrophe, interfacing with > :> local and national Disaster Medical Response systems (PEMA, FEMA, NDMS. > :> etc) and thus, also opens an avenue for funding. > > :I'm posting this to the wilderness-emergency-medicine list as well as > :sending to members of the ASRC. I'd be interested in getting some > :"outside" perspectives on our discussion about whether wilderness SAR > :teams need automatic external defibrillators, at least at Base Camp. > > Having a defibrillator at base camp could be potentially useful, and > having access to one is generally considered necessary, but blindly > carrying one into the woods seems wasteful, save for those cases where > you know (or suspect) you are likely to encounter a cardiac-related > situation. (I can think of better uses for the space in my pack.) Agree. It would be nice to have one to carry in (I mean, have someone _else_ carry in) if you had a known hypothermic patient -- just in case you might be able to get them warm enough to jumpstart if needed. > > Ambulances are trucks, and are designed to haul volumes of seldom-used > and occasionally very necessary equipment around -- and in the EMS > vernacular, this equipment is often called `toys' or `gadgets'. If > you've got a plethoria of help, or you've got pack animals or ATVs, > you've can more reasonably consider carrying a defibrillator. > > In particular, hauling around an LP5 seems wasteful -- they're too > heavy. (No ill will intended here, I've worked with and like using > the LP5. It's just HEAVY.) > > I'd also consider telemetry to be wasteful in the general case -- most > (all?) of what can be done in the field for a cardiac patient can be > done under standing orders and/or on-site rhythm interpretation. > (Telemetry would certainly be a `it would be nice to have' capability, > but its perceived value needs to consider the economics of finance, > use, training and upkeep costs, battery costs, the ever-present > pack mass and pack volume considerations. And when considering > telemetry, one needs to consider the cost of the telemetry equipment > used both in the field and at the medical control base(s).) On-site rhythm interpretation, no problem. On-site 12-lead interpretation for deciding whether to give heparin or not? A bit different. It is potentially possible to have an inexpensive light monitor that will allow you to do 12-leads and transmit them over a 2-meter ham or VHF mountain rescue radio. I'll be we could persuade Gene Harrison or Frank Reid to build one from scratch. Pantridge used such a device (light, cheap monitor) in Northern Ireland in the early days of prehospital care, though docs rode on the flying car (ambulance to us) to interpret. > > At the BLS level, a cardiac rhythm is `shockable' or `not shockable', > and any of the available semi-automatic defibrillators differentiate > the rhythm. At the ALS level, any paramedic or cardiac tech should be > able to operate and should have the protocols to operate fully off-line > -- on-line consultation is often useful, but it is not always available. > Particularly in the backwoods. > > If folks have the training and the dedication to use a defibrillator > and the local service has the budget -- go for it. But without ready > access to ACLS (`Ninja' or classic), a defibrillator may not provide > a particularly large increase in survivability given the expected > and typical duration of these calls. (One recent study showed that > the stacks of shocks followed by a one-drug-at-a-time standard ACLS > regime can lower the potential patient survival rate; that the shocks > can and do damage the patient's cardiac system. See the discussion > of `Ninja' ACLS in a recent JEMS issue.) > > And -- though I'm certain Keith and most (all?) other ALS-level folks > already know this -- those `overweight and oversmoked' degenerative > heart diseases aren't the best situation for cardiac survivability. > The damage has already been done by the time the heart is fibrillating. > The younger folks -- those that suffer from the effects of extreme > hypothermia or a nearby lightening strike -- are better candidates > for successful defibrillation. > > Steve Hoffman > NREMTI, WEMT, BCLSI, N1THN, hauler of LP5 and Heartstart > But some of those overweight hypertensive smoking firefighters are young, and when they knock off a small portion of an obtuse marginal off the LAD and get V Tach -- those are the people who you can save! And scare the s__t out of them and make them change their lifestyles and make longterm survivors out of them. That was the original idea of CPR: "the heart too good to die." -- End -- X-cs: From: Self To: "Robert J. Koester" ,@ASRC.PML Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: @AMRG.PML,wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Mon, 16 Oct 1995 21:45:25 On 16 Oct 95 at 14:11, Robert J. Koester wrote: > Dear Defib types, > What is the bottom line in the autodefib argument? > Do we require the ASRC to purchase an AED? This is > still no guarantee it will make it to that one search every 10 > years where it is needed> > > Do we require every ASRC to own an AED? What if they > can't afford it? Is this the best allocation of resources. > Can every team always send an EMT-B or EMT-D with every > response. > > These are the only two questions that must be answeared > as they relate to the ASRC. Whould an AED be anice thing to > have at base? Of course. But perhaps as technology improves > and the need is seen to be greater pocket AED for personnal use > may become the thing of the future (much like epi kits). Then > the argument for mandating them whould be more clear. Interesting thought. But due to power considerations, even with lithium-ion batteries, a "pocket defib" still will make you lean at 45 degrees. Until we have cold fusion that is. > > The current cost benefit analysis goes something like > this. We have never had someone to my knowledge code at base > in twenty years.--Maybe someone with better access to stats can > figure out the likelyhood of a code at base figuring about 25 > searches a year, lasting on average 24 hours, with 100 people, > with an age breakdown of 50% 16-25, 25% 25-40, 15% 40-50, and > 10% greater than 50. All of these core facts are skewed to > create a greater chance of a heart attack than actual facts. > Considering the AED whould serve little purpose if the patient > coded during a task. For the sake of argument lets say we find > one code every 20 years whould occur in base. How often can we > rely on the local rescue squad? Currently, I would say I have > ALS on scene on about 50% of all searches. I have BLS on the > remaining 40%. With the advent of EMT-B, and priorities of at > least Virginia Rescue squad assisatnace funding, almost all BLS > squads are expected to have AED's in the next two years. > Therefore, I think it is safe to say that in the next two years > I will have an AED present at base 90% of the time based upon > current search practices. If IC's make this more of a priority > I'm almost certain this could be raised to 95%. This means the > oppurtunity for an ASRC owned AED would be about once every 400 > years. This is assuming the ASRC responeded to every search > with an AED. This is true on larger searches. But on fast > local searches, equipment is often left behind due to a lack of > space in vechicles. If an AED was not owned by every ASRC > group the chances of it arriving on scene whould also drop. > Let us also consider an AED does not always "save the person" > (lets define a save as survival after one week). Using the > standard figure we can then calculate the number of saves if we > only get to use our AED every 400 years. For the sake of > argument lets say it saves the person 50% of the time ( I know > thats far to high). This means AED owned by the ASRC whould > save someone about once every 1000 years by my crude > calculations. > > Now ask yourself the only two important questions? > Does the ASRC buy an AED or seven? > Does the ASRC require groups to carry an AED? > > Does the ASRC require members to carry Aspirin? > Can we find a method of spending the same amount of > money that will "save" even more lives (training, methods to > find or evac pts faster, other medical courses or equipment, > etc.) > Bob Koester Since aspirin cost basically nothing, weighs basically nothing, is as effective as coronary thrombolysis in preventing mortality after a MI, is unlikely to cause harm unless someone has a head bleed or ruptured spleen or aspirin allerge (and is also good for eyestrain headaches), and your figures are convincing, I vote we forget about AEDs and all carry an aspirin (or better yet just half an aspirin) in our pockets all the time. We will probably save more lives that way. When and if we become independently wealthy, or someone donates defibrillators, then it makes sense for each ASRC Group to have both manual and automatic defibs at Base, but not plan to carry them in the field. Thanks for all taking part in this discussion. Since the question of whether SAR teams should carry defibrillators has been brought up, I'm glad we discussed it. But in terms of reasonable cost/benefit ratio for leveraging the medical skills of our members and medics, AEDs aren't where it is at. And that seems to be a reasonable consensus and conclusion to this thread unless someone still has violent objections. Again, thanks. -- End -- X-cs: From: Self To: WEDOSAR@aol.com,75714.1425@compuserve.com, rjk5a@avery.med.virginia.edu,dcarter@varic.ang.af.mil Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Tue, 17 Oct 1995 18:59:05 On 17 Oct 95 at 17:27, WEDOSAR@aol.com wrote: > Is Aspirin an authorized med for BLS to be giving to patients without medical > control? > I belive the answer is no because an unresponsive patient cannot tell you if > they are allergic to aspirin (half a tablet or not) No, you can't give ASA (aspirin) without practicing medicine. However, for responsive patients with cardiac-sounding chest pain you can use the "stump" method. Place half an aspirin on the stump. Tell the person with chest pain "It sounds to me like you might be having a heart attack. And we know that this can be very bad. But we also know that taking half an aspirin cuts the risk of death from a heart attack in half. So if _I_ were having chest pain that seemed like it might be a heart attack, and I found half an aspirin on a stump, I would certainly take it, unless I were allergic." This is morally, legally, and ethically appropriate, is not "practicing medicine without a license", and is a good way to get around the restriction that _giving_ medication is practicing a medicine and requires a medical license or a doctor. Letting someone have some of your own over-the-counter medications is entirely legal. _Giving_ it to someone and saying "take this, it'll make you better" is the practice of medicine, and restricted by law. Silly, but it works. -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.12/cispop-1.6.1.3) ID for ; Fri, 20 Oct 1995 01:38:46 -0400 Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Fri, 20 Oct 1995 01:38:45 -0400 Received: via switchmail for kconover+@pitt.edu; Fri, 20 Oct 1995 01:38:45 -0400 (EDT) Received: from netcom14.netcom.com (pturner@netcom14.netcom.com [192.100.81.126]) by post-ofc03.srv.cis.pitt.edu with ESMTP (8.6.12/cispo-2.0.1.1) ID for ; Fri, 20 Oct 1995 01:37:26 -0400 Received: by netcom14.netcom.com (8.6.12/Netcom) id WAA24656; Thu, 19 Oct 1995 22:36:25 -0700 Date: Thu, 19 Oct 1995 22:36:25 -0700 (PDT) From: Patton M Turner Subject: Re: (Fwd) Re: Defibrillators for SAR teams To: kconover+@pitt.edu In-Reply-To: <199510161511.LAA01455@post-ofc02.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII X-PMFLAGS: 35127424 On Mon, 16 Oct 1995, Keith Conover, M.D. wrote: > GPS units actually aren't that useful (look at the thread about GPS > units currently going on in the Computers in SAR mailing list, > especially at Chuck Kollar's and Gene Harrison's tests). And best, > they aid in SAR, maybe helping find some lost people a little > faster. Funny, I've reached the same conclusion about GPS. Anyway, do you have an address for the list? About the AEDs: Somebody mentioned how you would feel if you needed one and it wasn't available...My wife and 2 friends were in a biochem class when the prof coded. They started CPR in seconds and told someone to call 911. He told the dispatcher that the prof collapsed and 2 med students were giving CPR. They were 3 mins from the hospital where the EMS is dispatched from. To make a long story short 26 mins a BLS crew arrives and 29 mins later he is pronounced dead at the hospital. My wife and the other 2 guys still second guess the fact that they could have run to the hospital and got a defib, or transported him themselves or ... or... I know when she graduates and we move back out of the city she will buy a defib for the house or car. She'll probally never use it but the $5000 is cheap for avoiding the pain she still feels. Off my soapbox, how about local EMS personal bringing a AED and ambulance to the base camp. Seems a small price for the local comunity to pay in exchange for all of these trained people doing the rescue that would otherwise be their responsability. I am assuming that your area has ACLS units in the communities, this isn't realistic in say Alabama, but in the New England area it seems reasonable. I guess SAR teams may not need the degree of medical control given fire fighters (wildfire and structual) or urban heavy rescue teams but the medics could assume this role as well. Pat -- End -- X-cs: From: Self To: @ASRC.PML,Patton M Turner Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: @AMRG.PML,wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Sat, 21 Oct 1995 18:04:55 On 19 Oct 95 at 22:36, Patton M Turner wrote: > > About the AEDs: Somebody mentioned how you would feel if you needed one > and it wasn't available...My wife and 2 friends were in a biochem class when > the prof coded. They started CPR in seconds and told someone to call > 911. He told the dispatcher that the prof collapsed and 2 med students > were giving CPR. They were 3 mins from the hospital where the EMS is > dispatched from. To make a long story short 26 mins a BLS crew arrives > and 29 mins later he is pronounced dead at the hospital. My wife and the > other 2 guys still second guess the fact that they could have run to the > hospital and got a defib, or transported him themselves or ... or... I > know when she graduates and we move back out of the city she will buy a > defib for the house or car. She'll probally never use it but the $5000 > is cheap for avoiding the pain she still feels. > > Off my soapbox, how about local EMS personal bringing a AED and ambulance > to the base camp. Seems a small price for the local comunity to pay in > exchange for all of these trained people doing the rescue that would > otherwise be their responsability. I am assuming that your area has ACLS > units in the communities, this isn't realistic in say Alabama, but in the > New England area it seems reasonable. I guess SAR teams may not need the > degree of medical control given fire fighters (wildfire and structual) or > urban heavy rescue teams but the medics could assume this role as well. > > Pat > Having AEDs at colleges, fire stations, high schools and the like makes a _lot_ of sense to me, for exactly the reasons your anecdote suggests. I worry about the same thing happening at an ASRC (or any SAR team) Base Camp. But until SAR teams are indepently wealthy (when what freezes over?) it's just not realistic. But maybe having a formal policy in the Operations Manual that, for any operation with "a large number" of people (no sense in putting in a specific number and hamstringing ourselves) the IC should direct Logistics to try to arrange for an ALS standby as for any other mass gathering with a high risk for an ALS need. But if the local squad only has one or two ALS vehicles, this may be a problem. Not much we can do about it, though. -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with SMTP (8.7.1/cispop-1.6.1.3) ID for ; Mon, 23 Oct 1995 03:50:08 -0400 Received: from local (daemon@localhost) by post-ofc02.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 23 Oct 1995 03:50:08 -0400 Received: via switchmail for kconover+@pitt.edu; Mon, 23 Oct 1995 03:50:07 -0400 (EDT) Received: from pluto.med.pitt.edu (pluto.med.pitt.edu [150.212.2.3]) by post-ofc02.srv.cis.pitt.edu with SMTP (8.6.12/cispo-2.0.1.1) ID for ; Mon, 23 Oct 1995 03:49:29 -0400 Received: from phobos.med.pitt.edu by pluto.med.pitt.edu with smtp (5.1/6.2) id AA01317; Mon, 23 Oct 95 03:49:29 -0400 (EDT) Received: by phobos.med.pitt.edu (5.1/6.2) id AA14884; Mon, 23 Oct 95 03:49:28 -0400 (EDT) Date: Mon, 23 Oct 95 03:49:28 -0400 (EDT) From: Ronald Roth Message-Id: <9510230749.AA14884@phobos.med.pitt.edu> To: kconover+@pitt.edu Subject: AEDs X-PMFLAGS: 33554560 I'm preparing a talk on AEDs for Westmoreland Co. and I've read thru a recent document from . doc. from the AHA. Although they recommend that any one can be trained to use AEDs they doe AEDs, they don't yet recommend that they be placed on street corners, etc. They call it the fire extinguisher theory. At this point the likelyhood of having the right equipment, the right patient, and a trained responder are too low to justify the cost. Having an AED at a base camp would only be cost effective (chance of saving a life.O life) if the population was at risk for cardiac disease and ALS was available ASAP. Ron Roth, MD Liason for the City of PGH Bureau of Fire AED program -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Tue, 31 Oct 1995 11:28:23 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Tue, 31 Oct 1995 11:28:22 -0500 (EST) Received: via switchmail; Tue, 31 Oct 1995 11:28:22 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Tue, 31 Oct 1995 11:27:08 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Tue, 31 Oct 1995 11:26:38 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from vines12.acf.dhhs.gov ([158.71.1.12]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Tue, 31 Oct 1995 11:26:34 -0500 (EST) Received: by vines12.acf.dhhs.gov; Tue, 31 Oct 95 11:26:16 -0500 Date: Tue, 31 Oct 95 11:03:31 -30000 Message-ID: X-Priority: 3 (Normal) To: From: "Dave Matthews" Subject: EMED/ESAR EQUIPMENT Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 ****************************************************************************** ****************************************************************************** Dear Friends, Just a couple of brief questions for any List member(s) that might be interested in commenting: When you walk into the average camping/backpacking outfitter shop, are there any specific items of EMED/ESAR-related equipment that you'd like to find, but which are not usually there ?? What items of EMED/ESAR inventory should such shops be routinely stocking to better support the "front line troops?" Particularly, could somebody enlighten me as to the types of "walkie-talkie" radio equipment that meet applicable specifications and are most preferred by ESAR teams ?? Thanks for any comments or suggestions that you'd care to offer. Best wishes, Dave Matthews Internet: dmatthews@acf.dhhs.gov ****************************************************************************** ****************************************************************************** -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Tue, 31 Oct 1995 18:30:08 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Tue, 31 Oct 1995 15:10:57 -0500 (EST) Received: via switchmail; Tue, 31 Oct 1995 15:10:56 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Tue, 31 Oct 1995 15:07:55 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Tue, 31 Oct 1995 15:07:37 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from ug1.plk.af.mil (UG1.PLK.AF.MIL [129.238.20.32]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Tue, 31 Oct 1995 15:07:33 -0500 (EST) From: PETE_POLLOCK_at_PLE@smtpgw1.plk.af.mil Received: from smtpgw1.plk.af.mil (smtpgw1.plk.af.mil [129.238.32.86]) by ug1.plk.af.mil (8.6.10/8.6.10) with SMTP id NAA29122 for ; Tue, 31 Oct 1995 13:07:30 -0700 Received: from ccMail by smtpgw1.plk.af.mil (SMTPLINK V2.10.05) id AA815173788; Tue, 31 Oct 95 12:09:59 MST Date: Tue, 31 Oct 95 12:09:59 MST Message-Id: <9509318151.AA815173788@smtpgw1.plk.af.mil> To: wilderness-emergency-medicine@list.pitt.edu Subject: Cleaning Wounds in the Wilderness Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 What are the thoughts about cleaning wounds in the wilderness? For example: Suppose the injury involves skin and muscle tissue in an extremity (e.g. an avulsion), and there are clearly foreign objects in the wound (dirt, twigs, leaves). What steps should be taken to clean out this foreign matter? I realize this question may be a little "controversial", in that our medical system prefers to do wound cleaning in the emergency room (of course, this is always desirable where possible). But if the patient is in a remote area, evacuation to the ER may take a long time. Infection is a serious risk then. Are there any thoughts on the cleaning of wounds? Pete Pollock (EMT) -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Wed, 1 Nov 1995 17:00:55 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Wed, 1 Nov 1995 17:00:54 -0500 (EST) Received: via switchmail; Wed, 1 Nov 1995 17:00:54 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Wed, 1 Nov 1995 16:58:52 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Wed, 1 Nov 1995 16:56:25 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from JEFLIN.TJU.EDU (jeflin.TJU.EDU [147.140.128.114]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Wed, 1 Nov 1995 16:56:21 -0500 (EST) Received: from JEFLIN.TJU.EDU by JEFLIN.TJU.EDU with SMTP; Wed, 1 Nov 1995 16:58:10 -0500 (EST) Date: Wed, 1 Nov 1995 16:58:03 +0000 From: "Jack T. Grandey" X-Sender: GRANDEYE@ To: PETE_POLLOCK_at_PLE@smtpgw1.plk.af.mil cc: "Wilderness Emergency Medicine@" Subject: Re: Wound Cleansing in the Wilderness Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 > > What are the thoughts about cleaning wounds in the wilderness? > > For example: Suppose the injury involves skin and muscle tissue in > an extremity (e.g. an avulsion), and there are clearly foreign objects > in the wound (dirt, twigs, leaves). What steps should be taken to clean out > this foreign matter? > > I realize this question may be a little "controversial", in that > our medical system prefers to do wound cleaning in the emergency > room (of course, this is always desirable where possible). But if the > patient is in a remote area, evacuation to the ER may take a long time. > Infection is a serious risk then. > > Are there any thoughts on the cleaning of wounds? > > Pete Pollock (EMT) > > Actually Pete, there is little controversy in the wilderness. Clean the wound! In fact, wound cleansing via copius irrigation is favored over early antibiotic therapy for infection prevention. Good question. JTG Jack T. Grandey, NREMT-P Continuing Education Coordinator Operations Director Albert Einstein Medical Center Wilderness EMS Institute -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 19:23:57 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 19:23:56 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 19:23:56 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 19:23:38 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 19:23:19 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from post-ofc01.srv.cis.pitt.edu (root@post-ofc01.srv.cis.pitt.edu [136.142.185.10]) by list.srv.cis.pitt.edu with ESMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 19:23:16 -0500 (EST) Received: from ehdup-a1-8.rmt.net.pitt.edu (ehdup-a1-8.rmt.net.pitt.edu [136.142.20.18]) by post-ofc01.srv.cis.pitt.edu with SMTP (8.7.1/cispo-2.0.1.1) ID ; Thu, 2 Nov 1995 19:15:47 -0500 (EST) Message-Id: <199511030015.TAA08627@post-ofc01.srv.cis.pitt.edu> Comments: Authenticated sender is From: "Keith Conover, M.D." To: PETE_POLLOCK_at_PLE@smtpgw1.plk.af.mil, wilderness-emergency-medicine@list.pitt.edu Date: Thu, 2 Nov 1995 07:14:36 +0000 Subject: Re: More on Wilderness Wound management Reply-to: kconover+@pitt.edu Priority: normal X-mailer: Pegasus Mail for Windows (v2.10) Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk On 2 Nov 95 at 14:44, PETE_POLLOCK_at_PLE@smtpgw1.p wrote: > What I hear people saying is that (correct me if I'm wrong): > > i) It's a good idea to wash out the wound with sterile water. > > ii) Addition of betadine, alcohol etc. is probably NOT beneficial unless > there's a real risk of serious bacterial infections (e.g. rabies bites). > I'd say clean but not necessarily sterile water for irrigation of contaminated wounds. Let me quote from Dr. Richard Edlich, probably the country's leading expert on emergency wound management, writing in Tintinalli JE, Ruiz E, Krome RL. Emergency Medicine: A Comprehensive Study Guide, 4E, Published by the American College of Emergency Physicians. " . . .Two groups of antiseptic agents, containing either an iodophor" [e.g., Betadine(TM) --KC]" or chlorhexidine, exhibit activity against a broad spectrum of organisms and suppress bacterial proliferation. The superiority of one antiseptic agent over another has not been shown. Although these agents can reduce the bacterial contamination on intact skin, they appear to damage the wound defenses and invite the development of infection within the wound itself. Consequently, inadvertent spillage of these agents into the wound should be avoided." And Betadine is a lot better in wounds than mercurochrome, peroxide, alcohol, merthiolate, or other "antiseptics." quoting again from Edlich (one of my old mentors, I might add): "Mechanical forces are employed to rid the wound of bacteria and other particulate matter that are retained on the wound surface by adhesive forces. The two techniques used are irrigation and scrubbing. Low-pressure irrigation can be used for clean owunds, and high pressure irrigation should be reserved for dirty or heavily contaminated wounds. High-pressure irrigation is defined as 7 PSI, and low-pressure as 0.5 PSI" High-pressure irrigation is the force resulting from a 35-cc syringe with a 19-ga needle pushed by an average second-year surgical resident. Or better with one of those little clear plastic splashguards that most EDs have now; they have a needle-sized orifice, and attach to a syringe, but help prevent the bloody fluid from splashing back into your mouth, nose and eyes. You can improvise similar strength irrigation by using a PUR brand iodine-resin filter to filter water, or use iodine tablets (but then you have to wait longer); put the water into a zipper plastic bag, poke a little tiny hole in it, fold the zipper over so it doesn't explode in your face, and direct the stream at the wound. However, for clean wounds (no dirt in them) that are fresh, high-pressure irrigation will actually damage the wound slightly and make infection more likely. But it definitely helps with dirty or old wounds (more than a couple hours without cleansing and dressing). Low-pressure irrigation is basically sloshing some water on the wound, or using a standard irrigation bulb as used in OB kits for neonatal suction. Hope this helps. Keith Conover, M.D. (NSS 12893, WD4PSY) - Information Systems Coordinator, Dept. of EM, Mercy Hospital - Clinical Assistant Professor, Dept. of Emergency Medicine, Univ. of Pittsburgh (EM Residency and Center for Emergency Medicine) - Medical Director, Wilderness EMS Institute (http://www.pitt.edu/DOC/95/30/32686/Wemsi.html) (for a WEMSI-sponsored list, send "subscribe wilderness-emergency-medicine" to Majordomo@list.pitt.edu) - Eastern Region, Natl. Cave Rescue Comm./Appalachian SAR Conf. -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 08:30:58 -0500 From: KevinMTC@aol.com Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 08:30:52 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 08:30:52 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 08:29:14 -0500 (EST) Received: from emout06.mail.aol.com (emout06.mail.aol.com [198.81.10.43]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 08:28:40 -0500 (EST) Received: by emout06.mail.aol.com (8.6.12/8.6.12) id IAA05089; Thu, 2 Nov 1995 08:28:10 -0500 Date: Thu, 2 Nov 1995 08:28:10 -0500 Message-ID: <951102082808_95926803@emout06.mail.aol.com> To: owner-wilderness-emergency-medicine@list.pitt.edu, wilderness-emergency-medicine@list.pitt.edu Subject: Wilderness Wound Management X-PMFLAGS: 34603136 > > What are the thoughts about cleaning wounds in the wilderness? > > For example: Suppose the injury involves skin and muscle tissue in > an extremity (e.g. an avulsion), and there are clearly foreign objects > in the wound (dirt, twigs, leaves). What steps should be taken to clean out > this foreign matter? > > I realize this question may be a little "controversial", in that > our medical system prefers to do wound cleaning in the emergency > room (of course, this is always desirable where possible). But if the > patient is in a remote area, evacuation to the ER may take a long time. > Infection is a serious risk then. > > Are there any thoughts on the cleaning of wounds? > > Pete Pollock (EMT) > > ]Actually Pete, there is little controversy in the wilderness. Clean the wound! In fact, wound cleansing ]via copious irrigation is favored over early antibiotic therapy for infection prevention. A strong argument can be given that such wound should not be closed while in the field unless: 1) they occur on the face 2) they would interfere with evacuation i.e. a laceration in the hand would preclude effective rock/ice climbing. This means butterflies, Steri-Strips as well (although they are easier to remove when the wound becomes infected). These wounds are best managed (wilderness or ER) when packed open with a sterile dressing followed by changes daily or more frequently (depending on tissue exudate). If desired for cosmetic or functional concerns, they can be closed at a later date in a controlled environment. Emphasis should be on copious irrigation. A liter of purified water under pressure (18 ga Angiocath on a 20 cc syringe works well) is a good start. Addition of Betadine, peroxide, alcohol, etc. Probably is not useful and potentially harmful. Kevin Coonan, M.D. Frederick, MD -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 18:02:17 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 18:02:16 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 18:02:16 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 18:01:11 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 18:00:34 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from ug1.plk.af.mil (ug1.plk.af.mil [129.238.20.32]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 18:00:30 -0500 (EST) From: PETE_POLLOCK_at_PLE@smtpgw1.plk.af.mil Received: from smtpgw1.plk.af.mil (smtpgw1.plk.af.mil [129.238.32.86]) by ug1.plk.af.mil (8.6.10/8.6.10) with SMTP id QAA22022 for ; Thu, 2 Nov 1995 16:00:27 -0700 Received: from ccMail by smtpgw1.plk.af.mil (SMTPLINK V2.10.05) id AA815356959; Thu, 02 Nov 95 14:44:42 MST Date: Thu, 02 Nov 95 14:44:42 MST Message-Id: <9510028153.AA815356959@smtpgw1.plk.af.mil> To: wilderness-emergency-medicine@list.pitt.edu Subject: More on Wilderness Wound management Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34603136 Thanks for the contributions so far. Very helpful. I'd like to take this discussion one step further now - you'll see what I'm getting at in just a minute. Let me also explain that I'm not trying to "play doctor" here. Wound care is best done in the ER by a trained physician. But very real difficulties do exist for the health care provider in the wilderness. The patient could easily be 4 hrs, 24 hrs (or even 2-3 days away) from hospital care in some circumstances. Making the right decisions could save a limb ... or even a life. So, we are considering a wound involving tissue damage e.g. an avulsion. Furthermore we're assuming no damage to the underlying bone structure or internal organs. What I hear people saying is that (correct me if I'm wrong): i) It's a good idea to wash out the wound with sterile water. ii) Addition of betadine, alcohol etc. is probably NOT beneficial unless there's a real risk of serious bacterial infections (e.g. rabies bites). iii) It's better to apply an open dressing, rather than closing off the wound with butterfly sutures. { I'm not clear on why step iii) may be wrong for injuries to the face } I also assume that no-one has trouble with the idea of picking out foreign matter (dirt, twigs, leaves) from the wound with a pair of tweezers. I expect that this would be done at the same time as washing out the wound. BUT there's one big complication - BLEEDING. Obviously, bleeding is going to obscure the presence of foreign matter. Furthermore, if we apply direct pressure to the wound site, all that foreign matter is going to be compressed into the patient's tissues - doing more damage and increasing the risk of infection. Yes, if the patient's life is in danger (copious bleeding), then there may be no alternative except to apply direct pressure to the wound. However, let's suppose that blood loss isn't quite that critical (e.g. veinous bleeding, but not arterial bleeding). How about if I reduce bleeding by applying a B.P. cuff. Suppose the wound is on an extremity, and I apply the cuff closer to the trunk of the body. By partially inflating the cuff, I should be able to control bleeding for a while (say 15 min.). That should give me enough time to wash out the wound and pick out any foreign matter. Then I can apply a bandage, and release the B.P. cuff. What are the pro's and con's of this procedure? Are there better alternatives? Thanks very much! Pete Pollock Pete_Pollock@ple.af.mil -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 10:57:50 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 10:57:49 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 10:57:48 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 10:57:06 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 10:56:31 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from cap1.CapAccess.org (flong@cap1.CapAccess.org [198.69.201.50]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 10:56:27 -0500 (EST) Received: (from flong@localhost) by cap1.CapAccess.org (8.6.12/8.6.10) id KAA26441; Thu, 2 Nov 1995 10:56:43 -0500 Date: Thu, 2 Nov 1995 10:56:40 -0500 (EST) From: "Fred S. Long" To: KevinMTC@aol.com cc: wilderness-emergency-medicine@list.pitt.edu Subject: Re: Wilderness Wound Management In-Reply-To: <951102082808_95926803@emout06.mail.aol.com> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 On Thu, 2 Nov 1995 KevinMTC@aol.com wrote: [snippage] > A strong argument can be given that such wound should not be closed while in > the field unless: 1) they occur on the face 2) they would interfere with > evacuation i.e. a laceration in the hand would preclude effective rock/ice > climbing. This means butterflies, Steri-Strips as well (although they are > easier to remove when the wound becomes infected). These wounds are best > managed (wilderness or ER) when packed open with a sterile dressing followed > by changes daily or more frequently (depending on tissue exudate). If > desired for cosmetic or functional concerns, they can be closed at a later > date in a controlled environment. Emphasis should be on copious irrigation. > A liter of purified water under pressure (18 ga Angiocath on a 20 cc syringe > works well) is a good start. Addition of Betadine, peroxide, alcohol, etc. > Probably is not useful and potentially harmful. > > Kevin Coonan, M.D. > Frederick, MD > Do you mean addition of Betadine....etc to the water or in addition to the water? "Potentially harmful" in what way and why? Thanks, -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 12:34:39 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 12:34:38 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 12:34:38 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 12:33:09 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 12:32:06 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from emout06.mail.aol.com (emout06.mail.aol.com [198.81.10.43]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 12:32:03 -0500 (EST) From: KevinMTC@aol.com Received: by emout06.mail.aol.com (8.6.12/8.6.12) id MAA20090 for wilderness-emergency-medicine@list.pitt.edu; Thu, 2 Nov 1995 12:31:28 -0500 Date: Thu, 2 Nov 1995 12:31:28 -0500 Message-ID: <951102123127_80228548@emout06.mail.aol.com> To: wilderness-emergency-medicine@list.pitt.edu Subject: Wilderness wound management Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 On Thu, 2 Nov 1995 KevinMTC@aol.com wrote: [snippage] > A strong argument can be given that such wound should not be closed while in > the field unless: 1) they occur on the face 2) they would interfere with > evacuation i.e. a laceration in the hand would preclude effective rock/ice > climbing. This means butterflies, Steri-Strips as well (although they are > easier to remove when the wound becomes infected). These wounds are best > managed (wilderness or ER) when packed open with a sterile dressing followed > by changes daily or more frequently (depending on tissue exudate). If > desired for cosmetic or functional concerns, they can be closed at a later > date in a controlled environment. Emphasis should be on copious irrigation. > A liter of purified water under pressure (18 ga Angiocath on a 20 cc syringe > works well) is a good start. Addition of Betadine, peroxide, alcohol, etc. > Probably is not useful and potentially harmful. > > Kevin Coonan, M.D. > Frederick, MD > >Do you mean addition of Betadine....etc to the water or in addition to the water? >"Potentially harmful" in what way and why? >Thanks, Betadine, in a concentration strong enough to kill most bacteria, is also toxic to fibroblasts, leukocytes, etc. Thus you pay a heavy price for little gain. The goal is NOT to sterilize the wound, but to reduce (i.e. dilute) the bacteria concentration to a level that the local defenses can handle. I suppose you could make an argument that with potentially lethal virus infections, i.e. rabies, the risk of even small number of infectious particles would outweigh the damage done by your local treatment. I will try and check to see if there is anything in the literature that points one way or another. K. Coonan M.D. -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 19:58:23 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 19:58:22 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 19:58:21 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 19:57:33 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 19:57:09 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from JEFLIN.TJU.EDU (jeflin.TJU.EDU [147.140.128.114]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 19:57:05 -0500 (EST) Received: from JEFLIN.TJU.EDU by JEFLIN.TJU.EDU with SMTP; Thu, 2 Nov 1995 19:58:55 -0500 (EST) Date: Thu, 2 Nov 1995 19:58:48 +0000 From: "Jack T. Grandey" X-Sender: GRANDEYE@ To: KevinMTC@aol.com cc: "Wilderness Emergency Medicine@" Subject: Re: Wound Cleansing Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 On -1 xxx -1 SMTP%KevinMTC@aol.com@jeflin.tju.edu wrote: > > > > What are the thoughts about cleaning wounds in the wilderness? > > > For example: Suppose the injury involves skin and muscle tissue in > > an extremity (e.g. an avulsion), and there are clearly foreign objects > > in the wound (dirt, twigs, leaves). What steps should be taken to clean out > > this foreign matter? > > > > I realize this question may be a little "controversial", in that > our > medical system prefers to do wound cleaning in the emergency > > room (of course, this is always desirable where possible). But if the > > patient is in a remote area, evacuation to the ER may take a long time. > > Infection is a serious risk then. > > > > Are there any thoughts on the cleaning of wounds? > > > Pete Pollock (EMT) > > > > > ]Actually Pete, there is little controversy in the wilderness. Clean the > wound! In fact, wound cleansing ]via copious irrigation is favored over > early antibiotic therapy for infection prevention. > > A strong argument can be given that such wound should not be closed while in > the field unless: 1) they occur on the face 2) they would interfere with > evacuation i.e. a laceration in the hand would preclude effective rock/ice > climbing. This means butterflies, Steri-Strips as well (although they are > easier to remove when the wound becomes infected). These wounds are best > managed (wilderness or ER) when packed open with a sterile dressing followed > by changes daily or more frequently (depending on tissue exudate). If > desired for cosmetic or functional concerns, they can be closed at a later > date in a controlled environment. Emphasis should be on copious irrigation. > A liter of purified water under pressure (18 ga Angiocath on a 20 cc syringe > works well) is a good start. Addition of Betadine, peroxide, alcohol, etc. > Probably is not useful and potentially harmful. > > Kevin Coonan, M.D. > Frederick, MD > > Agree completely. Wound closure in the wilderness is something that we do selectively, factoring the risk of closed infection vs. additional contamination. For irrigation, we prefer a 60cc syringe /s angio + splash shield for pressure, while minimizing splash contamination of rescuer. In a pinch, use what you have. A zip lock bag /c a pin-hole in the corner works well, if you are cautious re: splash. JTG -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 17:30:04 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 17:30:03 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 17:30:03 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 17:28:50 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 17:26:36 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from post-ofc01.srv.cis.pitt.edu (root@post-ofc01.srv.cis.pitt.edu [136.142.185.10]) by list.srv.cis.pitt.edu with ESMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 17:26:33 -0500 (EST) Received: from unixs7.cis.pitt.edu (jmbst85@unixs7.cis.pitt.edu [136.142.185.45]) by post-ofc01.srv.cis.pitt.edu with SMTP (8.7.1/cispo-2.0.1.1) ID ; Thu, 2 Nov 1995 17:13:58 -0500 (EST) Date: Thu, 2 Nov 1995 17:13:57 -0500 (EST) From: Jonnathan M Busko Subject: Re: Wound Cleansing in the Wilderness To: "Jack T. Grandey" cc: PETE_POLLOCK_at_PLE@smtpgw1.plk.af.mil, "Wilderness Emergency Medicine@" In-Reply-To: Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 On Wed, 1 Nov 1995, Jack T. Grandey wrote: > > > > What are the thoughts about cleaning wounds in the wilderness? > > > > For example: Suppose the injury involves skin and muscle tissue in > > an extremity (e.g. an avulsion), and there are clearly foreign objects > > in the wound (dirt, twigs, leaves). What steps should be taken to clean out > > this foreign matter? > > > > I realize this question may be a little "controversial", in that > > our medical system prefers to do wound cleaning in the emergency > > room (of course, this is always desirable where possible). But if the > > patient is in a remote area, evacuation to the ER may take a long time. > > Infection is a serious risk then. > > > > Are there any thoughts on the cleaning of wounds? > > > > Pete Pollock (EMT) > > > > > Actually Pete, there is little controversy in the wilderness. Clean the > wound! In fact, wound cleansing via copius irrigation is favored over > early antibiotic therapy for infection prevention. > > Good question. > > > > JTG > > > Jack T. Grandey, NREMT-P > > Continuing Education Coordinator Operations Director > Albert Einstein Medical Center Wilderness EMS Institute > > To add further to this, keep in mind that there are lots of different ways to clean a wound which vary with the type of wound ("high" risk v. "low" risk. I would refer you to the _Wilderness_EMT_Curriculum_ from the Center for Emergency Medicine of Western Pennsylvania in Pittsburgh. Basically, whoice of the cleaning medium (sterility of water, content of such products as Betadine, etc.) will vary with the degree of the wound. However, as JTG states, the wound needs to be copiously irrigated, but oral antibotics and choice of the proper irrigation solution are important. Also, keep in mind that closing a wound traps an infection, converting a nice draining wound to a big, necrotic, pus-filled mess. Jonnathan Busko, NREMT-P MS I, University of Pittsburgh School of Medicine -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 17:36:23 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 17:36:22 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 17:36:22 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 17:35:13 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 17:33:42 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from post-ofc02.srv.cis.pitt.edu (root@post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by list.srv.cis.pitt.edu with ESMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 17:33:39 -0500 (EST) Received: from unixs7.cis.pitt.edu (jmbst85@unixs7.cis.pitt.edu [136.142.185.45]) by post-ofc02.srv.cis.pitt.edu with SMTP (8.7.1/cispo-2.0.1.1) ID ; Thu, 2 Nov 1995 17:28:19 -0500 (EST) Date: Thu, 2 Nov 1995 17:27:03 -0500 (EST) From: Jonnathan M Busko Subject: Re: Wilderness wound management To: KevinMTC@aol.com cc: wilderness-emergency-medicine@list.pitt.edu In-Reply-To: <951102123127_80228548@emout06.mail.aol.com> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 A note on Betadine. From the Wilderness EMT Curriculum; Subsection: Wilderness Surgical Problems, Draft 1.6, pages V-18 to V-20, "High Risk Wounds...For grossly contaminated wounds, the irrigation fluid should be 1% povadone-iodine...povadone-iodine is relatively nontoxic to wounds but only 'relatively' so...therefore, non-contaminated wounds should not be irrigated with povoadone-iodine." On Thu, 2 Nov 1995 KevinMTC@aol.com wrote: > On Thu, 2 Nov 1995 KevinMTC@aol.com wrote: [snippage] > > A strong argument can be given that such wound should not be closed while > in > the field unless: 1) they occur on the face 2) they would interfere > with > > evacuation i.e. a laceration in the hand would preclude effective rock/ice > > climbing. This means butterflies, Steri-Strips as well (although they are > > easier to remove when the wound becomes infected). These wounds are best > > managed (wilderness or ER) when packed open with a sterile dressing > followed > by changes daily or more frequently (depending on tissue exudate). > If > > desired for cosmetic or functional concerns, they can be closed at a later > > date in a controlled environment. Emphasis should be on copious > irrigation. > A liter of purified water under pressure (18 ga Angiocath on a > 20 cc syringe > works well) is a good start. Addition of Betadine, peroxide, > alcohol, etc. > > Probably is not useful and potentially harmful. > > > Kevin Coonan, M.D. > > Frederick, MD > > > >Do you mean addition of Betadine....etc to the water or in addition to the > water? >"Potentially harmful" in what way and why? > >Thanks, > > Betadine, in a concentration strong enough to kill most bacteria, is also > toxic to fibroblasts, leukocytes, etc. Thus you pay a heavy price for little > gain. The goal is NOT to sterilize the wound, but to reduce (i.e. dilute) > the bacteria concentration to a level that the local defenses can handle. > > I suppose you could make an argument that with potentially lethal virus > infections, i.e. rabies, the risk of even small number of infectious > particles would outweigh the damage done by your local treatment. I will try > and check to see if there is anything in the literature that points one way > or another. > > K. Coonan M.D. > -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 19:23:30 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 19:23:29 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 19:23:28 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 19:23:06 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 19:22:54 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from astro.ocis.temple.edu (astro.ocis.temple.edu [155.247.165.100]) by list.srv.cis.pitt.edu with ESMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 19:22:51 -0500 (EST) Received: (from pacer@localhost) by astro.ocis.temple.edu (8.7.1/8.7.1) id TAA13599; Thu, 2 Nov 1995 19:21:57 -0500 (EST) Date: Thu, 2 Nov 1995 19:21:54 -0500 (EST) From: Barry Burton To: Jonnathan M Busko cc: KevinMTC@aol.com, wilderness-emergency-medicine@list.pitt.edu Subject: Re: Wilderness wound management In-Reply-To: Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 >From the same source, recall that 1% solution is made by diluting standard (10%) betadyne with 9 additional parts of water (1:10 dilution). Grosssly contaminated is a matter of judgement. EG: horse dung in the wound, heavy vegetable conatmination (plant life), purulent (pus) discharge, etc. I will support the prior response....irrigation is the most important part of the care, along with debridement of the devitalized (dead) tissue and mechanical removal of any other foreign matter. Betadyne is toxic to the healing tissue elements, and thus should not be undertaken lightly. Likewise, I need to observe that "...antibiotic choice..." is also somewhat controversial. There is a position that 'lo risk', ie non-crushed, rapidly cared for, decontaminated wounds, do NOT require antibiotics. In fact, burn surgeons (after all, they are plastic surgeons, too) do not give 'empiric' or 'prophylactic' antibiotics, choosing in large measure to care for the wound and surveil it for early signs of infectin, then treating these (rare) infections with specific antibiotic therapy. My point, in a long winded manner, is to ask you not to jump to the conclusion that antibiotics are necessary, or desirable, in many of the wounds sustained in the wilderness, and to reinforce the curricula point to CLEAN and PROTECT the wound. I will do a lit search and pull some reeerences after this weekend's WEMT program and post to the list for your review. Barry J. Burton, D.O. EMS Fellowship Director Albert Einstein Medical Center Philadelphia On Thu, 2 Nov 1995, Jonnathan M Busko wrote: > A note on Betadine. From the Wilderness EMT Curriculum; Subsection: > Wilderness Surgical Problems, Draft 1.6, pages V-18 to V-20, "High Risk > Wounds...For grossly contaminated wounds, the irrigation fluid should be > 1% povadone-iodine...povadone-iodine is relatively nontoxic to wounds but > only 'relatively' so...therefore, non-contaminated wounds should not be > irrigated with povoadone-iodine." > > On Thu, 2 Nov 1995 KevinMTC@aol.com wrote: > > > On Thu, 2 Nov 1995 KevinMTC@aol.com wrote: [snippage] > > > A strong argument can be given that such wound should not be closed while > > in > the field unless: 1) they occur on the face 2) they would interfere > > with > > > evacuation i.e. a laceration in the hand would preclude effective rock/ice > > > climbing. This means butterflies, Steri-Strips as well (although they are > > > easier to remove when the wound becomes infected). These wounds are best > > > managed (wilderness or ER) when packed open with a sterile dressing > > followed > by changes daily or more frequently (depending on tissue exudate). > > If > > > desired for cosmetic or functional concerns, they can be closed at a later > > > date in a controlled environment. Emphasis should be on copious > > irrigation. > A liter of purified water under pressure (18 ga Angiocath on a > > 20 cc syringe > works well) is a good start. Addition of Betadine, peroxide, > > alcohol, etc. > > > Probably is not useful and potentially harmful. > > > > Kevin Coonan, M.D. > > > Frederick, MD > > > > > > > Betadine, in a concentration strong enough to kill most bacteria, is also > > toxic to fibroblasts, leukocytes, etc. Thus you pay a heavy price for little > > gain. The goal is NOT to sterilize the wound, but to reduce (i.e. dilute) > > the bacteria concentration to a level that the local defenses can handle. > > > > > > K. Coonan M.D. -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 19:23:20 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 19:23:19 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 19:23:19 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 19:22:20 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 19:22:07 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from ix8.ix.netcom.com (ix8.ix.netcom.com [199.182.120.8]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 19:22:04 -0500 (EST) Received: from by ix8.ix.netcom.com (8.6.12/SMI-4.1/Netcom) id QAA01053; Thu, 2 Nov 1995 16:21:31 -0800 Date: Thu, 2 Nov 1995 16:21:31 -0800 Message-Id: <199511030021.QAA01053@ix8.ix.netcom.com> From: celms@ix.netcom.com (Charles Elms) Subject: Another Question on Wound Care To: wilderness-emergency-medicine@list.pitt.edu Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 I've been following this discussion but have one question. I am often on one to two week canoe tripping excursions where I am 4 to 5 days from any type of medical care. I am not EMT trained, but read all I can on this type of subject. The recent issue of Backpacker Magazine had a good article on wound cleansing via irrigation with a 10 cc syringe. Here is my question: How clean does the water have to be? I always have water that has been filtered down to .1 micron or treated with iodine sufficient for drinking. Does irrigation water have to be sterile? Charles Elms celms@ix.netcom.com -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 19:58:17 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 19:58:16 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 19:58:15 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 19:56:30 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 19:56:21 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from astro.ocis.temple.edu (astro.ocis.temple.edu [155.247.165.100]) by list.srv.cis.pitt.edu with ESMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 19:56:14 -0500 (EST) Received: (from pacer@localhost) by astro.ocis.temple.edu (8.7.1/8.7.1) id TAA21253; Thu, 2 Nov 1995 19:56:04 -0500 (EST) Date: Thu, 2 Nov 1995 19:56:00 -0500 (EST) From: Barry Burton To: PETE_POLLOCK_at_PLE@smtpgw1.plk.af.mil cc: wilderness-emergency-medicine@list.pitt.edu Subject: Re: More on Wilderness Wound management In-Reply-To: <9510028153.AA815356959@smtpgw1.plk.af.mil> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 Again, Pete, I'm going to respond in a 'non academic' manner, and withold the references until after I search the database following the WEMT course this weekend. You make some good points, and I hope to help illuminate some of the 'traps' On Thu, 2 Nov 1995 PETE_POLLOCK_at_PLE@smtpgw1.plk.af.mil wrote: > > Let me also explain that I'm not trying to "play doctor" here. > Wound care is best done in the ER by a trained physician. But very real > difficulties do exist for the health care provider in the wilderness. > The patient could easily be 4 hrs, 24 hrs (or even 2-3 days away)... This is true. But, as you look into the WEMT curricula, and the original references, you will find some interesting material on wound healing. If the wound is decontaminated, and protected mechanically from further "trauma", then it can be closed at _4 days_ of age int he technique of delayed primary closure. In this technioque, the wound essentially 'matures', is inspected, devitalized (dead) tissue is removed, perhaps event he wound edges are 'prettied up' at a bedside operation, and then it is closed just as if it had occured within less than the 'magic' 6 hours. Advantages are that infection is less likely, with good care, and abscesses don't occur, because of the wide drainage. Hence the recommendation to 'pack' the wound with a dressing, changed three times a day, and mechanically protected by a dry cover from the outside. BTW: some of our local plastic sugeons do this _especially_ for wounds of the face, and find that the time for reduction of the edema is usefult o permit a better 'plastic' (cosmetic) repair. (Sorry Dr Sam, I agree, it often feels like a stalll to get some more sleep at two AM, but it has worked in some VERY busy trauma practices. > from hospital care in some circumstances. Making the right decisions > could save a limb ... or even a life. > > So, we are considering a wound involving tissue damage e.g. an avulsion. > Furthermore we're assuming no damage to the underlying bone structure > or internal organs. > > What I hear people saying is that (correct me if I'm wrong): > > i) It's a good idea to wash out the wound with sterile water. Or even _Clean_ water, ie filtered, chemically treated as per guidelines for drinking water (8 drops of 10% betadyne solution per liter), or boiled for ten minutes > > ii) Addition of betadine, alcohol etc. is probably NOT beneficial unless > there's a real risk of serious bacterial infections (e.g. rabies bites). Agrees > > iii) It's better to apply an open dressing, rather than closing off > the wound with butterfly sutures. > > { I'm not clear on why step iii) may be wrong for injuries to the face } > For complicated, crushed, large, previously grossly contaminated wounds. See above. > I also assume that no-one has trouble with the idea of picking out > foreign matter (dirt, twigs, leaves) from the wound with a pair of tweezers. > I expect that this would be done at the same time as washing out the wound. > Aabsolutely! Even 'suture' can represent a compromising foreign body! > BUT there's one big complication - BLEEDING. > I don't see it as a complication, only a challenge. > Obviously, bleeding is going to obscure the presence of foreign matter. Why? or are you talking of freely flowing blood? Direct pressure, applied at the wound margins over the 'healthy' tissue can often allow 'spot' control of the wound to allow inspection and decontamination. > Furthermore, if we apply direct pressure to the wound site, all that > foreign matter is going to be compressed into the patient's tissues - > doing more damage and increasing the risk of infection. Sure, if you grind it in. But patient's do die of exsanquinating hemmorhage from poorly controlled peripheral sites. Even in trauma centers... > > Yes, if the patient's life is in danger (copious bleeding), then there > may be no alternative except to apply direct pressure to the wound. There you go. > However, let's suppose that blood loss isn't quite that critical > (e.g. veinous bleeding, but not arterial bleeding). > > How about if I reduce bleeding by applying a B.P. cuff. Suppose the wound > is on an extremity, and I apply the cuff closer to the trunk of the body. > By partially inflating the cuff, I should be able to control bleeding for a > while (say 15 min.). That should give me enough time to wash out the wound and > pick out any foreign matter. Then I can apply a bandage, and release the B.P. > cuff. > Again, I'd refer you to the aove paragraph. With adequate numbers of hands (mine and one other set) I find local marginal pressure adequate for a large number of wounds. Slightly more brisk extremity bleeding can be controlled with that great standby, pressure point control, for the same 'brief period' you describe. (I once shut down the free arterial bleeding from an arterial line, an IV catheter in a radial artery, with brachial pressure point control...and aborted the patient's suicide attempt. Very dramatic, the essential 'on/off' natuer of this form of control). Lacking the extra hands, I can say that docs do often use BP cuff control for 'brief' 15-20 minute periods, to clean a wound and identify the bleeders. One key difference is that I am tying off the bleeders that I find, and I can give some _good_ anesthesia to the patient while I'm sacrificing blood flow to the arm or leg. (Ischemia is a potent pain inducer) Sorry, Sam, though pain never killed nobody, it still ain't nice to cause. Special considerations....pad the arm under the BP cuff with thick felt (of gauze, etc) and make sure that the cuff will hold pressure (more trouble than it's worth if it keeps dropping off the pressure, becomming a venous tourniquet, and _enhancing_ blood loss.) Inflate to a few (10) mmHg above systolic (yes, obliterate the pulse) note time, and wok quickly to keep the ischemia time short. If you've ever had this done to you, you'll realize the pain can be quite severe. Bottom line...if you feel you need to do this, it would be useful to contact a wilerness qualified medical command consultant (physician) familiar with you and your training. Take the lead, adn set up this arrangement proactively. This use of a tourniquet is _not_ in an EMT's accepted scope of practice,a nd thus can not be recommended as a universal scheme, but rather as an individually directed preocedure when clearly required. Finally, presuming that you won't be tying off bleeders, because the ability to identify closely related nerves and avoid tying them off too, for example, then you're _still_ going to need 'direct pressure' t control the bleeding after the wound cleansing. Yes, even at operation, the primary method of bleeding control is direct pressure....surgical silk 9sutures) just help to maintain it. My point is, after cleaning the wound, you will need a pressure dressing to maintian control of the briskly bleeding wound, not just a mecahnaical, kling, dressing. I personally have had problems with'ace' compression dressings inadequately applied. If it bleed through, put your hand back over the bleeding point, or reinforce it with a real pressure dressing....you remember, ...the old cravat! OK, I'll don the kevlar now, flame away. Barry Barry J. Burton D.O. EMS Fellowship Director Albert Einstein Medical Center Philadelphia WEMSI Medical Command Physician ARC Instructor circa 1973 EMT and Instructor, 1975 EMT-Paramedic, circa 1980 "Retired" Emergency Nurse -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 23:59:59 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 23:59:58 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 23:59:58 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 23:59:13 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 23:58:51 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from mail04.mail.aol.com (mail04.mail.aol.com [152.163.172.53]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 23:58:47 -0500 (EST) From: JSilver374@aol.com Received: by mail04.mail.aol.com (8.6.12/8.6.12) id XAA28200 for wilderness-emergency-medicine@list.pitt.edu; Thu, 2 Nov 1995 23:58:16 -0500 Date: Thu, 2 Nov 1995 23:58:16 -0500 Message-ID: <951102235815_11400314@mail04.mail.aol.com> To: wilderness-emergency-medicine@list.pitt.edu Subject: Auerbach book Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 Hi All: Has anyone read Paul Auerbach's book ' Wilderness Medicine: Manaagement of Wilderness Environmental Emergencies'? It showed up in a Mosby advertisment I received. It sounds like it would be interesting but it's kind of pricey ($157.00). I'd be interested to find out if it would be worth getting. Thanks... Jonathan Silver EMT-D, WEMT Highland Park First Aid Squad Highland Park, NJ -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Fri, 3 Nov 1995 04:36:12 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Fri, 3 Nov 1995 04:36:02 -0500 (EST) Received: via switchmail; Fri, 3 Nov 1995 04:36:02 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Fri, 3 Nov 1995 04:34:55 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Fri, 3 Nov 1995 04:34:46 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from Hydro.CAM.ORG (Hydro.CAM.ORG [198.168.73.132]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Fri, 3 Nov 1995 04:34:42 -0500 (EST) Received: from Ocean.CAM.ORG by Hydro.CAM.ORG with ESMTP id EAA00490 (8.6.11/8.6.9); Fri, 3 Nov 1995 04:35:12 -0500 Received: by Ocean.CAM.ORG id EAA11271 (8.6.9); Fri, 3 Nov 1995 04:35:10 -0500 From: Jean-Francois Vaillancourt Message-Id: <199511030935.EAA11271@Ocean.CAM.ORG> Subject: Re: Auerbach book To: JSilver374@aol.com Date: Fri, 3 Nov 1995 04:35:08 -0500 (EST) Cc: wilderness-emergency-medicine@list.pitt.edu In-Reply-To: <951102235815_11400314@mail04.mail.aol.com> from "JSilver374@aol.com" at Nov 2, 95 11:58:16 pm X-Mailer: ELM [version 2.4 PL24alpha5] MIME-Version: 1.0 Content-Type: text/plain; charset=ISO-8859-1 Content-Transfer-Encoding: 7bit Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 > Has anyone read Paul Auerbach's book ' Wilderness Medicine: Manaagement of > Wilderness Environmental Emergencies'? It showed up in a Mosby advertisment I > received. It sounds like it would be interesting but it's kind of pricey > ($157.00). > I'd be interested to find out if it would be worth getting. I have this book, and definitely found it worth the investment. It's well organized, lucidly edited, and simply _the_ reference for serious study of wilderness medicine. Obviously it doesn't replace your BLS and ALS books, but if you can afford it, it should make a great addition to your reference bookshelf. What is especially interesting with this book, is that while a bona-fide "heavy medical textbook", there still is much of interest for one with possibly no advanced medical training. For instance, the chapters on field water disinfection, survival, and SAR make good reading for just anyone with the interest. My only caution would be that price-wise, if all you want is the clinical stuff, you might want to check such classics as Wilkerson's Medicine for Mountaineering, likely to be available for <$20 at any decent outdoors store -- before splurging. While on the subject of wilderness medical references, you may want to look at one of Auerbach's other works: _Medicine for the Outdoors_ (Little, Brown - 1991). Not at all the same kind of beast as WM:MWEE, but it's one of the good several wilderness first aid texts out there. Enjoy! Jean-Francois, WEMT, etc. -- ----------------------------------------------------------------------- Jean-Francois Vaillancourt, REMT-P | STAT! Medical BBS STAT! Medical Consultants Ltd. | Canada's Largest Medical BBS hans@cam.org jfv@stat.mba.org | (514) 279-5145 HST/V34+ -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Fri, 3 Nov 1995 10:19:49 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Fri, 3 Nov 1995 10:19:48 -0500 (EST) Received: via switchmail; Fri, 3 Nov 1995 10:19:48 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Fri, 3 Nov 1995 10:19:40 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Fri, 3 Nov 1995 10:19:19 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from emout05.mail.aol.com (emout05.mail.aol.com [198.81.10.37]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Fri, 3 Nov 1995 10:19:16 -0500 (EST) From: KevinMTC@aol.com Received: by emout05.mail.aol.com (8.6.12/8.6.12) id KAA21689 for wilderness-emergency-medicine@list.pitt.edu; Fri, 3 Nov 1995 10:18:52 -0500 Date: Fri, 3 Nov 1995 10:18:52 -0500 Message-ID: <951103101850_80575648@emout05.mail.aol.com> To: wilderness-emergency-medicine@list.pitt.edu Subject: much more on wilderness wound care Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 Pete Pollock writes: (snip, snip, snip) BUT there's one big complication - BLEEDING. ***ALWAYS, attend to the ABCs first. ALWAYS, ALWAYS, ALWAYS. And don’t forget that shock can sneak up on you. Monitor heart rate, RR, and urine output if it is a significant injury.*** Obviously, bleeding is going to obscure the presence of foreign matter. Furthermore, if we apply direct pressure to the wound site, all that foreign matter is going to be compressed into the patient's tissues - doing more damage and increasing the risk of infection. Yes, if the patient's life is in danger (copious bleeding), then there may be no alternative except to apply direct pressure to the wound. However, let's suppose that blood loss isn't quite that critical (e.g. veinous bleeding, but not arterial bleeding). ***It will probably stop on it’s own with 5-15 minutes of firm direct pressure . Just be patient. Per Billy Crystal in ‘The Princes Bride’ “you rush a miracle man, you get a rotten miracle”*** How about if I reduce bleeding by applying a B.P. cuff. Suppose the wound is on an extremity, and I apply the cuff closer to the trunk of the body. By partially inflating the cuff, I should be able to control bleeding for a while (say 15 min.). That should give me enough time to wash out the wound and pick out any foreign matter. Then I can apply a bandage, and release the B.P. cuff. ***This is fraught with danger (and most people don’t carry B.P. cuffs, let alone several sizes). If you obstruct venous return you can increase bleeding as there is no other way for the higher pressure arterial blood to exit. Bleeding is thought to act as a natural cleansing process, as the flowing blood dilutes and washes out bacteria, crud, etc. The irrigation can wait. Don’t be surprised if washing out the wound stirs up some fresh bleeding, in my experience, this stops in 5-15 minutes. Also, folks on NSAIDs, esp. Aspirin, do tend to ooze longer. The treatment of bleeding is pressure. Elevation is also beneficial (as long as no major VEINS are injured). *Rarely* is anything else needed. The key is to apply pressure and be patient. If your dressing becomes soaked, just put another on top (as to not disturb clots forming). The pressure is the important point. A pressure dressing can help relieve finger flame-out (ace wraps are meager, the foam tape made by 3M works well but doesn’t stick to wet surfaces at all. Duct tape has no stretch, so it must be used carefully). There are some adjuvants that are worth considering in *selected* circumstances. Topical nasal decongestants such as Neo-Synephrine or Afrin will constrict blood vessels and are useful in bleeding muscle beds or large dermal abrasions. They do get significant systemic absorption so you should be familiar with their pharmacology before using. The contrary applies to lidocaine containing products. They will dilate blood vessels and increase bleeding. They do get systemic absorption with lidocaine attendant toxicities. Silver nitrate matches are best left to physicians or physician extenders (PAs, nurse Practioners) familiar with its use. Again, it must be emphasized that wound closed primarly in the wilds often (i.e. >10% of the time) get infectetd. Delayed primary closure is a much underused technique.*** ***AND*** Charles Elms writes I've been following this discussion but have one question. I am often on one to two week canoe tripping excursions where I am 4 to 5 days from any type of medical care. I am not EMT trained, but read all I can on this type of subject. The recent issue of Backpacker Magazine had a good article on wound cleansing via irrigation with a 10 cc syringe. Here is my question: How clean does the water have to be? I always have water that has been filtered down to .1 micron or treated with iodine sufficient for drinking. Does irrigation water have to be sterile? *** See the above. I use a 20 cc syringe with a IV catheter or a dental irrigating syringe, otherwise you don’t get enough pressure. A very good reference for medical professionals and nonmedicaly trained alike is “Medicine for Mountaineering” published by the Mountaineers. For physicians, PAs, EMT, etc. Who devote a significant amount of time to wilderness medicine--as much of this list surely does, or wish they could :)--Auerbach’s text is well worth the $$$.*** Kevin Coonan M.D. -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Fri, 3 Nov 1995 10:38:17 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Fri, 3 Nov 1995 10:38:16 -0500 (EST) Received: via switchmail; Fri, 3 Nov 1995 10:38:16 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Fri, 3 Nov 1995 10:37:20 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Fri, 3 Nov 1995 10:37:00 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from post-ofc01.srv.cis.pitt.edu (root@post-ofc01.srv.cis.pitt.edu [136.142.185.10]) by list.srv.cis.pitt.edu with ESMTP (8.7.1/cisls-2.4) ID for ; Fri, 3 Nov 1995 10:36:57 -0500 (EST) Received: from unixs1.cis.pitt.edu (jmbst85@unixs1.cis.pitt.edu [136.142.185.20]) by post-ofc01.srv.cis.pitt.edu with SMTP (8.7.1/cispo-2.0.1.1) ID ; Fri, 3 Nov 1995 10:27:56 -0500 (EST) Date: Fri, 3 Nov 1995 10:27:55 -0500 (EST) From: Jonnathan M Busko Subject: Re: Another Question on Wound Care To: Charles Elms cc: wilderness-emergency-medicine@list.pitt.edu In-Reply-To: <199511030021.QAA01053@ix8.ix.netcom.com> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 >From the Wilderness EMT Curriculum From the WEMSI at CEMWPA, Chapter on wilderness surgical problems, p. V-19: "Fluid for irrigation need not be sterile, but it should not have bateria or spores...water from a micropore filter with sufficiently small pores (1-micron)...will not have any pathogenic bacteria or spores, and is an ideal wound irrigant." Jonnathan Busko NREMT-P MS I, University of Pittsburgh School of Medicine On Thu, 2 Nov 1995, Charles Elms wrote: > I've been following this discussion but have one question. I am often > on one to two week canoe tripping excursions where I am 4 to 5 days > from any type of medical care. I am not EMT trained, but read all I > can on this type of subject. The recent issue of Backpacker Magazine > had a good article on wound cleansing via irrigation with a 10 cc > syringe. > > Here is my question: How clean does the water have to be? I always > have water that has been filtered down to .1 micron or treated with > iodine sufficient for drinking. Does irrigation water have to be > sterile? > > Charles Elms > celms@ix.netcom.com -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Fri, 3 Nov 1995 17:42:34 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Fri, 3 Nov 1995 17:42:32 -0500 (EST) Received: via switchmail; Fri, 3 Nov 1995 17:42:32 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Fri, 3 Nov 1995 17:40:34 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Fri, 3 Nov 1995 17:39:40 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from JEFLIN.TJU.EDU (jeflin.TJU.EDU [147.140.128.114]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Fri, 3 Nov 1995 17:39:37 -0500 (EST) Received: from JEFLIN.TJU.EDU by JEFLIN.TJU.EDU with SMTP; Fri, 3 Nov 1995 17:41:29 -0500 (EST) Date: Fri, 3 Nov 1995 17:41:27 +0000 From: "Jack T. Grandey" X-Sender: GRANDEYE@ To: JSilver374@aol.com cc: "Wilderness Emergency Medicine@" Subject: Re: Auerbach's Wilderness Medicine Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 > > Hi All: > > Has anyone read Paul Auerbach's book ' Wilderness Medicine: Manaagement of > Wilderness Environmental Emergencies'? It showed up in a Mosby advertisment I > received. It sounds like it would be interesting but it's kind of pricey > ($157.00). > I'd be interested to find out if it would be worth getting. > > Thanks... > > Jonathan Silver EMT-D, WEMT > Highland Park First Aid Squad > Highland Park, NJ > > It's an excellent book and well worth the price. It IS a reference book /c a significant amount of science in it. It is not light reading, but if you want a definitive reference on wilderness medicine, this is it. JTG Jack T. Grandey, NREMT-P Continuing Education Coordinator Operations Director Albert Einstein Medical Center Wildernes EMS Institute -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Sat, 4 Nov 1995 07:28:45 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Sat, 4 Nov 1995 07:28:44 -0500 (EST) Received: via switchmail; Sat, 4 Nov 1995 07:28:43 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Sat, 4 Nov 1995 07:28:13 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Sat, 4 Nov 1995 07:27:42 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from emout06.mail.aol.com (emout06.mail.aol.com [198.81.10.43]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Sat, 4 Nov 1995 07:27:37 -0500 (EST) From: JSachter@aol.com Received: by emout06.mail.aol.com (8.6.12/8.6.12) id HAA16799 for wilderness-emergency-medicine@list.pitt.edu; Sat, 4 Nov 1995 07:27:07 -0500 Date: Sat, 4 Nov 1995 07:27:07 -0500 Message-ID: <951104072706_12552083@emout06.mail.aol.com> To: JSilver374@aol.com cc: wilderness-emergency-medicine@list.pitt.edu Subject: Re: Auerbach book Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 In a message dated 95-11-03 00:02:01 EST, you write: >I'd be interested to find out if it would be worth getting. We purchased the book to use in our ten textbook ED "rack". I think it's a well done text, but to be honest it's the least used of the ten. Then again, we don't see alot of snakebites in downtown Brooklyn. I found the chapters on lightening and drowning better than those in Rosen (slighlty) or Tintinalli (definitely). I think its worth getting if these (ie: environmental) are problems you see relatively frequently. It is considered the definitive textbook on these matters. Sad to say, $150 is not pricey for a text these days. Hope this helps... Joseph J Sachter, MD, FACEP (jsachter@aol.com) Program Director, Emergency Medicine Residency The Brooklyn Hospital Center -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Sun, 5 Nov 1995 20:49:28 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Sun, 5 Nov 1995 20:49:28 -0500 (EST) Received: via switchmail; Sun, 5 Nov 1995 20:49:25 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Sun, 5 Nov 1995 20:47:17 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Sun, 5 Nov 1995 20:46:31 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from amauta.rcp.net.pe (amauta.rcp.net.pe [161.132.5.5]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Sun, 5 Nov 1995 20:46:25 -0500 (EST) Received: by amauta.rcp.net.pe (Smail3.1.29.1 #2) id m0tCGdY-000Jo6C; Sun, 5 Nov 95 20:46 EST Date: Sun, 5 Nov 1995 20:46:12 -0500 (EST) From: Thomas Smith To: wilderness-emergency-medicine@list.pitt.edu Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 Dear WEM, Just joined the list and am working to upgrade proactive and reactive measures to handle medical emergencies in the Andes and jungles of Peru. We have a long way to go and need a lot more advice than we are going to be able to give for awhile. I have been doing a lot of research on hypothermia, and am confused on current recommended procedures. For mild to moderate hypothermia, one text says skin to skin warming is the only way and another says a thin layer of clothing is necessary so as not to transfer moisture. Does it really make any difference? Also, I've heard of a blanket or girdle which circulates stove heated water around the body. Is it worth importing to here? Also, we need to get an education on emergency rescue beacons. Can anyone recommend sources. Thanks for any help Tom Smith -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Mon, 6 Nov 1995 08:18:51 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 6 Nov 1995 08:18:44 -0500 (EST) Received: via switchmail; Mon, 6 Nov 1995 08:18:44 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 6 Nov 1995 08:16:48 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Mon, 6 Nov 1995 08:15:53 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from JEFLIN.TJU.EDU (jeflin.TJU.EDU [147.140.128.114]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Mon, 6 Nov 1995 08:15:50 -0500 (EST) Received: from JEFLIN.TJU.EDU by JEFLIN.TJU.EDU with SMTP; Mon, 6 Nov 1995 8:17:49 -0500 (EST) Date: Mon, 6 Nov 1995 08:17:44 +0000 From: "Jack T. Grandey" X-Sender: GRANDEYE@ To: tsmith@amauta cc: "Wilderness Emergency Medicine@" Subject: Re: hypothermia Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 On -1 xxx -1 SMTP%tsmith@amauta@jeflin.tju.edu wrote: > > Dear WEM, > > Just joined the list and am working to upgrade proactive and reactive > measures to handle medical emergencies in the Andes and jungles of Peru. > We have a long way to go and need a lot more advice than we are going to > be able to give for awhile. > > I have been doing a lot of research on hypothermia, and am confused on > current recommended procedures. For mild to moderate hypothermia, one > text says skin to skin warming is the only way and another says a thin > layer of clothing is necessary so as not to transfer moisture. Does it > really make any difference? Also, I've heard of a blanket or girdle > which circulates stove heated water around the body. Is it worth > importing to here? Skin to skin contact, while potentially very pleasent, conveys very little heat to the hypothermic individual. Removal of heat loss (Warm & dry clothing, additional layers, removal from cold environment) is the preferred treatment for mild hypothermia. Moderate hypotermia is difficult to assess (too qualitative a decision) so current literature recognizes mild hypothermia as a CBT (core body temp) as <37C and Sever hyopthermia as a CBT as <30C. A hydraullic sarong uses warm water circulating through tubes to transfer heat. A charcol vest attempts the same result via heated "bricketts" A VERY detailed treatment of the subject can be found in Auerbach's Wilderness Medicine. An accurate and comprehensive(though far less detailed) discussion can be found n the Jan '95 issue of EMERGENCY magazine. If you can't find a cc: send me your address & I'll snail mail you one. > > Also, we need to get an education on emergency rescue beacons. Can > anyone recommend sources. > > Thanks for any help > Tom Smith > > JTG Jack T. Grandey, NREMT-P Continuing Education Coordinator Operations Director Albert Einstein Medical Center Wilderness EMS Institute -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Mon, 6 Nov 1995 09:04:29 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 6 Nov 1995 09:04:27 -0500 (EST) Received: via switchmail; Mon, 6 Nov 1995 09:04:27 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 6 Nov 1995 09:03:02 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Mon, 6 Nov 1995 09:02:48 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from vines12.acf.dhhs.gov ([158.71.1.12]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Mon, 6 Nov 1995 09:02:43 -0500 (EST) Date: Mon, 6 Nov 1995 09:02:43 -0500 (EST) Message-Id: <199511061402.JAA04910@list.srv.cis.pitt.edu> Received: by vines12.acf.dhhs.gov; Mon, 6 Nov 95 9:02:33 -0500 Resent-Date: Sun, 5 Nov 95 22:17:44 GMT Resent-Message-ID: X-Priority: 3 (Normal) To: From: Resent-From: "Dave Matthews" Subject: Re: hypothermia Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 Forwarded to: Internet[wilderness-emergency-medicine@list.pitt.edu] cc: Comments by: Dave Matthews@OCS.DISC@ACF.WDC Comments: ****************************************************************************** ****************************************************************************** Dear Friends, Re: "Charcoal vests," referred to below -- Any comments, pro or con, on a number of Jone-E handwarmers in the vest pockets or, alternatively, chemical heat packets -- so long as there is sufficient insulative padding and careful monitoring to ensure that the patient/victim is not getting cooked ??? Knowledgeable responses will be gratefully received. Best wishes, Dave Matthews (Layperson/Student of First Aid Arts & Science) ****************************************************************************** ****************************************************************************** -------------------------- [Original Message] ------------------------- On -1 xxx -1 SMTP%tsmith@amauta@jeflin.tju.edu wrote: > > Dear WEM, > > Just joined the list and am working to upgrade proactive and reactive > measures to handle medical emergencies in the Andes and jungles of Peru. > We have a long way to go and need a lot more advice than we are going to > be able to give for awhile. > > I have been doing a lot of research on hypothermia, and am confused on > current recommended procedures. For mild to moderate hypothermia, one > text says skin to skin warming is the only way and another says a thin > layer of clothing is necessary so as not to transfer moisture. Does it > really make any difference? Also, I've heard of a blanket or girdle > which circulates stove heated water around the body. Is it worth > importing to here? Skin to skin contact, while potentially very pleasent, conveys very little heat to the hypothermic individual. Removal of heat loss (Warm & dry clothing, additional layers, removal from cold environment) is the preferred treatment for mild hypothermia. Moderate hypotermia is difficult to assess (too qualitative a decision) so current literature recognizes mild hypothermia as a CBT (core body temp) as <37C and Sever hyopthermia as a CBT as <30C. A hydraullic sarong uses warm water circulating through tubes to transfer heat. A charcol vest attempts the same result via heated "bricketts" A VERY detailed treatment of the subject can be found in Auerbach's Wilderness Medicine. An accurate and comprehensive(though far less detailed) discussion can be found n the Jan '95 issue of EMERGENCY magazine. If you can't find a cc: send me your address & I'll snail mail you one. > > Also, we need to get an education on emergency rescue beacons. Can > anyone recommend sources. > > Thanks for any help > Tom Smith > > JTG Jack T. Grandey, NREMT-P Continuing Education Coordinator Operations Director Albert Einstein Medical Center Wilderness EMS Institute -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Wed, 8 Nov 1995 17:32:28 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Wed, 8 Nov 1995 17:32:27 -0500 (EST) Received: via switchmail; Wed, 8 Nov 1995 17:32:27 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Wed, 8 Nov 1995 17:31:21 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Wed, 8 Nov 1995 17:30:20 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from postoffice4.mail.cornell.edu (POSTOFFICE4.MAIL.CORNELL.EDU [132.236.56.12]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Wed, 8 Nov 1995 17:30:17 -0500 (EST) Received: from [132.236.155.135] (CU-DIALUP-1025.CIT.CORNELL.EDU [132.236.155.135]) by postoffice4.mail.cornell.edu (8.6.12/8.6.12) with SMTP id RAA02645 for ; Wed, 8 Nov 1995 17:30:11 -0500 X-Sender: prk5@postoffice4.mail.cornell.edu Message-Id: Mime-Version: 1.0 Content-Type: text/plain; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Date: Wed, 8 Nov 1995 17:30:18 -0500 To: wilderness-emergency-medicine@list.pitt.edu From: prk5@cornell.edu (Paul Rogers Kennedy) Subject: A basic question (R&I DEC '95) Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 This article just happens to be "On Line" on the Rock and Ice WWW page (http://www.rscomm.com/rock/num70/all_nighter.html) Check it out or e-amil me and I'll send you a copy Paul >To anyone who happens to subscribe or can get a copy of the December 1995 >"Rock and Ice" - In it is a story called "The all nighter" about a rescue >in Colorado. The events and actions of the three "rescuers" are >discussed. I found Several mistakes taken in the actions of these three - >Even though none of them (obviously) had a very high level of training, >I would be interested to know what people on the list would do given your >current level of training and provided you were "happened upon" as the >three were in the article? I am sorry I don't have a copy to post - But >if you can find it, read it and let me know? > >Paul -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Tue, 14 Nov 1995 11:25:42 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Tue, 14 Nov 1995 11:25:41 -0500 (EST) Received: via switchmail; Tue, 14 Nov 1995 11:25:40 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Tue, 14 Nov 1995 11:25:27 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Tue, 14 Nov 1995 11:24:31 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from ug1.plk.af.mil (ug1.plk.af.mil [129.238.20.32]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Tue, 14 Nov 1995 11:24:21 -0500 (EST) From: PETE_POLLOCK_at_PLE@smtpgw1.plk.af.mil Received: from smtpgw1.plk.af.mil (smtpgw1.plk.af.mil [129.238.32.86]) by ug1.plk.af.mil (8.6.10/8.6.10) with SMTP id JAA17404 for ; Tue, 14 Nov 1995 09:24:18 -0700 Received: from ccMail by smtpgw1.plk.af.mil (SMTPLINK V2.10.05) id AA816367737; Mon, 13 Nov 95 16:20:37 MST Date: Mon, 13 Nov 95 16:20:37 MST Message-Id: <9510148163.AA816367737@smtpgw1.plk.af.mil> To: wilderness-emergency-medicine@list.pitt.edu Subject: "Overniter" Rescue Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 Thanks for pointing out the interesting story in Rock & Ice (may be viewed on the Web at http://www.rscomm.com/rock/num70/all_nighter.html). I'm sure the story will draw lots of comments. On the other hand, it's always a lot easier to second guess these scenarios from the safety (and warmth) of a living room or office! Let me pick one aspect from this story ... The victim (patient) was clearly suffering from both shock and hypothermia. The victim was also in a freezing alpine environment. Normally you don't give liquids (orally) to someone in shock. On the other hand, a warm drink can really help someone who is hypothermic. In the story, the patient was apparently revived by getting a warm drink. Perhaps the rescuers were lucky in this case. The patient did not puke up the liquid. Does anyone want to comment on this problem? If a patient is suffering from combined shock & hypothermia, what are the guidelines about administering warm liquids (orally)? It almost seems like a "damned if you do, damned if you don't" scenario. Pete_Pollock Pete_Pollock@ple.af.mil P.S. By the way, I appreciated the recent advice here about upgrading to WEMT, and hope to do this in the next 12 months. -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Wed, 15 Nov 1995 11:24:29 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Wed, 15 Nov 1995 11:24:27 -0500 (EST) Received: via switchmail; Wed, 15 Nov 1995 11:24:27 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Wed, 15 Nov 1995 11:23:28 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Wed, 15 Nov 1995 11:22:51 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from emout04.mail.aol.com ([198.81.10.12]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Wed, 15 Nov 1995 11:22:48 -0500 (EST) From: MHMILLER@aol.com Received: by emout04.mail.aol.com (8.6.12/8.6.12) id LAA02754; Wed, 15 Nov 1995 11:22:17 -0500 Date: Wed, 15 Nov 1995 11:22:17 -0500 Message-ID: <951115112216_23170984@emout04.mail.aol.com> To: PETE_POLLOCK_at_PLE@smtpgw1.plk.af.mil, wilderness-emergency-medicine@list.pitt.edu Subject: Re: "Overniter" Rescue Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 Here in the Pacific Northwest many deaths if not most that occur while entertaining Mother Nature occur from hypothemia and too many seem to be potentially preventable except that someone was screwing around worrying about, e.g., the c-spine when they should have been worrying about what's really going to kill the patient. Damn the protocols, treat the real problem. -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID ; Mon, 20 Nov 1995 11:30:19 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID ; Mon, 20 Nov 1995 11:30:18 -0500 (EST) Received: via switchmail; Mon, 20 Nov 1995 11:30:18 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 20 Nov 1995 11:29:41 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Mon, 20 Nov 1995 11:29:28 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-amrg using -f Received: from post-ofc01.srv.cis.pitt.edu (root@post-ofc01.srv.cis.pitt.edu [136.142.185.10]) by list.srv.cis.pitt.edu with ESMTP (8.7.1/cisls-2.4) ID for ; Mon, 20 Nov 1995 11:29:25 -0500 (EST) Received: from ehdup-a2-7.rmt.net.pitt.edu (ehdup-a2-7.rmt.net.pitt.edu [136.142.20.37]) by post-ofc01.srv.cis.pitt.edu with SMTP (8.7.1/cispo-2.0.1.1) ID ; Mon, 20 Nov 1995 10:59:59 -0500 (EST) Message-Id: <199511201559.KAA17951@post-ofc01.srv.cis.pitt.edu> Comments: Authenticated sender is From: "Keith Conover, M.D." To: wilde+@pitt.edu, "Allegheny Mtn. Rescue Maillist" rness-emergency-medicine@list.pitt.edu, ASRC.groups.and.members@pitt.edu Date: Mon, 20 Nov 1995 10:58:24 +0000 Subject: National Wilderness First Aid Course Reply-to: kconover+@pitt.edu CC: AMRG.Members.and.Others@pitt.edu Priority: normal X-mailer: Pegasus Mail for Windows (v2.10) Sender: owner-amrg@list.pitt.edu Precedence: bulk Wilderness EMS Institute [letterhead] Reply to: Keith Conover, M.D. 36 Robinhood Road Pittsburgh, PA 15220-3014 412-561-3413 Internet: kconover+@pitt.edu October 2, 1995 Alton Thygerson Dept. of Health Sciences Brigham Young University Provo, UT 84602 Dear Alton: SUBJECT: WMS/NSC wilderness first aid class Based on your presentation about the new WMS/NSC wilderness first aid class at the World Congress in Aspen, I've been starting discussions about wilder- ness search and rescue team first aid training here. The Appalachian Search and Rescue Conference is, we believe, the country's largest operational search and rescue organization (400-500 members). Though ASRC missions now include many searches that are rural or suburban, there are still a fair number of back- country search and rescue operations, particularly near our local Groups that are in the mountains. I suggested that we consider adopting the new WMS/NSC course as our minimum for Field Team Member certifi- cation, and it certainly did spark some interesting discussions! I've enclosed some of the related elec- tronic mail discussions for you to review. There are three questions that you might be able to answer for us: 1. When will the new course be available? 2. How long will it be, and how extensive? 3. How easy (or hard) will it be for poor volunteer SAR teams, and poor outdoor clubs, to mount their own courses with volunteer resources? Thanks very much. Yours truly, Keith Conover, M.D., Medical Director member, Board of Directors, Appalachian Search and Rescue Conference C:\TEXT\WEMS\THYGER.LTR -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- Dept. of Health Sciences, Brigham Young University [letterhead] 213 Richards Building PO Box 22115 Provo, UT 84602-2115 November 1, 1995 Keith Conover, M.D. 36 Robinhood Road Pittsburgh, PA 15220-3014 Dear Keith: I apologize for my delayed response to your letter. This semester I am on a sabbatical leave and have traveled extensively. Your letter caught me while I addended the WMS Desert Medicine meeting in Tucson and the American Medical Writers Association Conference in Baltimore. Your three questions: 1. When will the new course be available? 2. How long will it be, and how extensive? 3. How easy (or hard) will it be for poor volunteer SAR teams, and poor outdoor clubs, to mount their own courses with volunteer resources? go unanswered for the immediate future. However, when the content is finally determined, then these relevant questions can be answered. Your interest in the project is greatly appreciated. The WMS writing panel is meeting in Salt Lake City this weekend, and I'll be sharing your letter with them. Cordially, [signed] Alton L. Thygerson, Ed.D. Professor of Health Science [I'll post more information to the wilderness-emergency-medicine list as it becomes available. --KC] Keith Conover, M.D. (NSS 12893, WD4PSY) - Information Systems Coordinator, Dept. of EM, Mercy Hospital - Clinical Assistant Professor, Dept. of Emergency Medicine, Univ. of Pittsburgh (EM Residency and Center for Emergency Medicine) - Medical Director, Wilderness EMS Institute (http://www.pitt.edu/DOC/95/30/32686/Wemsi.html) (for a WEMSI-sponsored list, send "subscribe wilderness-emergency-medicine" to Majordomo@list.pitt.edu) - Eastern Region, Natl. Cave Rescue Comm./Appalachian SAR Conf. -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Sun, 26 Nov 1995 11:55:20 -0500 Received: from local (daemon@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Sun, 26 Nov 1995 11:55:18 -0500 (EST) Received: via switchmail for kconover+@pitt.edu; Sun, 26 Nov 1995 11:55:17 -0500 (EST) Received: from Access.Mountain.Net (root@Access.Mountain.Net [198.77.1.3]) by post-ofc02.srv.cis.pitt.edu with SMTP (8.7.1/cispo-2.0.1.1) ID for ; Sun, 26 Nov 1995 11:53:07 -0500 (EST) Received: from svis.org (svis.org [198.77.8.11]) by Access.Mountain.Net (8.6.12/8.6.9) with SMTP id LAA20012 for kconover+@pitt.edu; Sun, 26 Nov 1995 11:52:45 -0500 Received: by svis (NetXpress 2.53) via UUCP id 7EC0E9; Sun, 26 Nov 1995 11:46:43 -0500 To: kconover+@pitt.edu From: douglas.moore@svis.org (Douglas Moore) X-Mailer: NetXpress 2.53 Date: Sun, 26 Nov 1995 10:34:00 -0500 Organization: SVIS 304-592-2682 800-SOFT-VAL Subject: Questions on Hip injuries and the Laurel Rescue 11/25/95 Message-ID: <90.201421.1@svis.org> X-PMFLAGS: 34603136 0 Keith, I'm just curious for future reference on some proper procedures for the type of injury that happened at Laurel on 11/25/95. Just so you'll know what I saw when I got on scene I'll start from there. Got to the cave and was inside to the injury within about 15 minutes. At that point didn't know anything about injuries the accident, etc. Got on site and approx. 6 people were there with commo and Ferno. John Chenger was on site so I asked him about the accident, etc. An EMT was present. My assumption was that the EMT had done all necessary vitals, etc. and the patient was ready to be packaged since that was what was being done. Dale, the patient mentioned that he was diabetic and a finger may need available if a test needed done so special precautions were made in the packaging. Packaging went smoothly except for a couple of flaws. One big one was a discussion about how to properly tie a patient in with a hip injury. This entailed after a tighting was performed and Dale was in obvious injury. I basically then told John and others that we would need to fasten the lower extremities differently than ER-NCRC standard. This entailed running the right webbing down about 8 inches along the ferno before going across for the X and some of the extra webbing being used criss-crossing a different time above and below the knees. About this time a Paramedic (or appeared to be) showed up and asked about injuries. I mentioned we would be ready to move in five. The Paramedic said okay and that we would take vitals at the Ball Room and left. I had eight people on site and had requested 12 more from the surface so we began moving. Everything went smooth to the Ball Room. Then we ran into about 50 people (fire/rescue) which slowed the train up from there out probably adding 30 minutes to the extrication. Thats some of the basics. Now the questions of the day. As a rescurer without medical background and the presence of an EMT on site upon arrival what precautions should I take in packaging and extrication? What should I ask of the medical personnel to make sure that necessary vitals etc. have been done/taken? What signs in the patient should I and other rescurers look for with a hip injury during extrication? What would be the proper tie in for a right hip injury? If the patient was smaller what would be the proper tie in since they could more easily shift in the litter during extrication? That's basically all I can think of right off. Oh yeah, one thing. Is it proper rescue procedure to elbow the head of some fire/rescue personnel into a rock after they drop a couple pound flashlight on the patients head? I heard about the flashlight being dropped on the patients head while eating dinner after the rescue and that was a comment on proper rescue procedure. ---------------------------------------------------------------------------- | /\+/\ Douglas L Moore II /\+/\ | | National Speleological Society - 33064SU | | National Association for Search & Rescue - 9501923 | | Staff - Eastern Region National Cave Rescue Commission | | Owner - Karst Sports (Caving, Climbing, & Rescue equipment) 304.592.2600 | | On the World Wide Web at http://svis.org/msc/karst.htm | ---------------------------------------------------------------------------- # Internet: douglas.moore@svis.org (Douglas Moore) # This message was processed by Software Valley (SVIS) -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Mon, 27 Nov 1995 05:16:03 -0500 Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 27 Nov 1995 05:16:03 -0500 (EST) Received: via switchmail for kconover+@pitt.edu; Mon, 27 Nov 1995 05:16:02 -0500 (EST) Received: from Access.Mountain.Net (root@Access.Mountain.Net [198.77.1.3]) by post-ofc03.srv.cis.pitt.edu with SMTP (8.7.1/cispo-2.0.1.1) ID for ; Mon, 27 Nov 1995 05:13:16 -0500 (EST) Received: from svis.org (svis.org [198.77.8.11]) by Access.Mountain.Net (8.6.12/8.6.9) with SMTP id FAA28150 for kconover+@pitt.edu; Mon, 27 Nov 1995 05:12:52 -0500 Received: by svis (NetXpress 2.53) via UUCP id 7F0724; Mon, 27 Nov 1995 05:13:28 -0500 To: kconover+@pitt.edu From: douglas.moore@svis.org (Douglas Moore) X-Mailer: NetXpress 2.53 Date: Sun, 26 Nov 1995 22:18:00 -0500 Organization: SVIS 304-592-2682 800-SOFT-VAL Subject: Questions on Hip injuries and the Laurel Rescue 11/25/95 Message-ID: <90.201514.1@svis.org> X-PMFLAGS: 33554560 0 Keith, I'm just curious for future reference on some proper procedures for the type of injury that happened at Laurel on 11/25/95. Just so you'll know what I saw when I got on scene I'll start from there. Got to the cave and was inside to the injury within about 15 minutes. At that point didn't know anything about injuries the accident, etc. Got on site and approx. 6 people were there with commo and Ferno. John Chenger was on site so I asked him about the accident, etc. An EMT was present. My assumption was that the EMT had done all necessary vitals, etc. and the patient was ready to be packaged since that was what was being done. Dale, the patient mentioned that he was diabetic and a finger may need available if a test needed done so special precautions were made in the packaging. Packaging went smoothly except for a couple of flaws. The first one was a goof on proper hypothermia packaging procedure but that was corrected in a couple of minutes with little discomfort to the patient. The second one was more serious and dealt with tieing the patient into the stretcher. The standard ER-NCRC tie-in was used until we ran into some problems cinching the straps. We had watched where the straps were touching the body due to the injury. However, the patient was in great pain during the cinching. We noticed that it appeared to only happen during the initial movement then stopped which allowed us to cinch the webbing across the upper body. We then moved to the lower straps and ran into problems from compression around the injury so I basically then told John and the others that we would need to fasten the lower extremities differently than ER-NCRC standard. This entailed running the right webbing down about 8 inches along the ferno before going across for the X and some of the extra webbing being used criss-crossing a different time above and below the knees. About this time a Paramedic (or appeared to be) showed up and asked about injuries. I mentioned we would be ready to move in five. The Paramedic said okay and that we would take vitals at the Ball Room and left (Didn't see him again). I had eight people on site and had requested 12 more from the surface so we began moving. Everything went smooth to the Ball Room. Then we ran into about 50 people (fire/rescue) which slowed the train up from there out probably adding 30 minutes to the extrication. Thats some of the basics. Now the questions of the day. As a rescurer without medical background and the presence of an EMT on site upon arrival what precautions should I take in packaging and extrication? What should I ask of the medical personnel to make sure that necessary vitals etc. have been taken? (We latter learned that most had not been taken initially.) What signs in the patient should I and other rescurers look for with a hip injury during extrication? What would be the proper tie in for a right hip injury? If the patient was smaller what would be the proper tie in since they could more easily shift in the litter during extrication? That's basically all I can think of right off. Oh yeah, one thing. Is it proper rescue procedure to elbow the head of some fire/rescue personnel into a rock after they drop a couple pound flashlight on the patients head? I heard about the flashlight being dropped on the patients head while eating dinner after the rescue and that was the comment on proper rescue procedure for that situation. ---------------------------------------------------------------------------- | /\+/\ Douglas L Moore II /\+/\ | | National Speleological Society - 33064SU | | National Association for Search & Rescue - 9501923 | | Staff - Eastern Region National Cave Rescue Commission | | Owner - Karst Sports (Caving, Climbing, & Rescue equipment) 304.592.2600 | | On the World Wide Web at http://svis.org/msc/karst.htm | ---------------------------------------------------------------------------- -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Mon, 27 Nov 1995 05:16:17 -0500 Received: from local (daemon@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 27 Nov 1995 05:16:15 -0500 (EST) Received: via switchmail for kconover+@pitt.edu; Mon, 27 Nov 1995 05:16:14 -0500 (EST) Received: from Access.Mountain.Net (root@Access.Mountain.Net [198.77.1.3]) by post-ofc02.srv.cis.pitt.edu with SMTP (8.7.1/cispo-2.0.1.1) ID for ; Mon, 27 Nov 1995 05:13:17 -0500 (EST) Received: from svis.org (svis.org [198.77.8.11]) by Access.Mountain.Net (8.6.12/8.6.9) with SMTP id FAA28154 for kconover+@pitt.edu; Mon, 27 Nov 1995 05:12:54 -0500 Received: by svis (NetXpress 2.53) via UUCP id 7F0725; Mon, 27 Nov 1995 05:13:29 -0500 To: kconover+@pitt.edu From: douglas.moore@svis.org (Douglas Moore) X-Mailer: NetXpress 2.53 Date: Sun, 26 Nov 1995 22:20:00 -0500 Organization: SVIS 304-592-2682 800-SOFT-VAL Subject: Laurel Rescue inquiry and permission to reprint Message-ID: <90.201515.1@svis.org> X-PMFLAGS: 33554560 0 KC| Boy, what a pile of questions! What better way to learn. KC| But seriously, I'd be happy to answer them all. But it'll take some | time, so please be patient. And I'd like to ask your permission to | quote your message and my replies to Cavers Digest and the NCRC and | wilderness-emergency-medicine lists so others can learn, if you'll | give your permission. I'd also be happy to add a notice allowing | unlimited distribution to other lists as people see fit. Full permission granted! KC| So please review your original post -- there is one section I don't | understand, perhaps due to a typo: Didn't make much sense to me either. I'll just rewrite it. KC| And once you let me know about this one sentence, I'll start | composing a reply, also including _my_ viewpoint on this rescue (I | was on standby in the ED in Pgh with a helicopter available) and | some thoughts from a previous rescue (with some problems with the | same fire-rescue personnel). Patty Kennedy mentioned that when I ran into her in the cave. Good to know good medical help was nearby. I just talked to John Chenger and he said that Dale (the injured caver) was doing fine at the Uniontown Hospital. The injury was to the center of the hip. He is expected to be in the hospital for a couple of days. ---------------------------------------------------------------------------- | /\+/\ Douglas L Moore II /\+/\ | | National Speleological Society - 33064SU | | National Association for Search & Rescue - 9501923 | | Staff - Eastern Region National Cave Rescue Commission | | Owner - Karst Sports (Caving, Climbing, & Rescue equipment) 304.592.2600 | | On the World Wide Web at http://svis.org/msc/karst.htm | ---------------------------------------------------------------------------- -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID ; Mon, 27 Nov 1995 09:36:15 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID ; Mon, 27 Nov 1995 09:36:10 -0500 (EST) Received: via switchmail; Mon, 27 Nov 1995 09:36:10 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 27 Nov 1995 09:36:04 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Mon, 27 Nov 1995 09:35:54 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-amrg using -f Received: from post-ofc01.srv.cis.pitt.edu (root@post-ofc01.srv.cis.pitt.edu [136.142.185.10]) by list.srv.cis.pitt.edu with ESMTP (8.7.1/cisls-2.4) ID for ; Mon, 27 Nov 1995 09:35:51 -0500 (EST) Received: from ehdup-a1-14.rmt.net.pitt.edu (ehdup-a1-14.rmt.net.pitt.edu [136.142.20.24]) by post-ofc01.srv.cis.pitt.edu with SMTP (8.7.1/cispo-2.0.1.1) ID ; Mon, 27 Nov 1995 09:24:45 -0500 (EST) Message-Id: <199511271424.JAA19731@post-ofc01.srv.cis.pitt.edu> Comments: Authenticated sender is From: "Keith Conover, M.D." To: Rob Christie <75714.1425@compuserve.com>, ASRC.groups.and.members@pitt.edu Date: Mon, 27 Nov 1995 09:23:08 +0000 Subject: Maryland Wilderness EMT/WEMS program Reply-to: kconover+@pitt.edu CC: MIEMSS Region I--David Ramsey , AMRG.Members.and.Others@pitt.edu, "Allegheny Mtn. Rescue Maillist" Priority: normal X-mailer: Pegasus Mail for Windows (v2.23) Sender: owner-amrg@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 0 Rob -- In your capacity as Medical Officer for the Appalachian Search and Rescue Conference, which operates in Maryland, you had requested some information about the new Maryland Wilderness EMS system. The planned MD WEMS program will be based in MIEMSS Region I, the western part of the state. At present, MIEMSS sees the need primarily within Region I and will base the program there. They are planning a WEMSI WEMT course in that area in the spring, as an official Maryland WEMT course, which will then allow the state to offer WEMT reciprocity with those who are WEMSI WEMTs in other states. The WEMT program in PA is a statewide medical program but not under EMS, due to legal restrictions, but I think we can still look forward to WEMT reciprocity between PA and MD, based on WEMSI WEMT certification as the equivalence. I hope that Virginia will upgrade the existing letter-of-understanding arrangement to allow ASRC advanced EMTs to perform advanced skills throughout the state to a more formal WEMT program based on the WEMSI model that would then allow reciprocity between VA, MD and PA. Steve Meyer of the Western MD Grotto rescue team will be coordinating the class. You can reach him at: Steve Meyer HCR 1, Box 177-A Barton, MD 21521 1-301-463-5881 (H/W) Dave Ramsey is the administrator for MIEMSS Region I and you can reach him by email at MIEMSS Region I--David Ramsey or David P. Ramsey Director of Regional Programs MIEMSS Region I Administrator P.O. Box 34 Grantsville, MD 21536 1-301-895-5934 (W) 1-301-746-8636 (W) 1-301-895-3618 (FAX) And Jeff Davis, M.D., of Sacred Heart Hospital, who just finished the recent WEMSI Wilderness Command Physician class, will be the Maryland Wilderness EMS Medical Director. He doesn't have email and I don't have his address, but I do have his phone number at work: 1-301-759-5161 (W) I have already made a copy of my medical license and will mail it to you today, as requested. Let me know if I can provide any further information. Keith Conover, M.D. Medical Director for PA, Appalachian SAR Conference Keith Conover, M.D. (NSS 12893, WD4PSY) - Information Systems Coordinator, Dept. of EM, Mercy Hospital - Clinical Assistant Professor, Dept. of Emergency Medicine, Univ. of Pittsburgh (EM Residency and Center for Emergency Medicine) - Medical Director, Wilderness EMS Institute (http://www.pitt.edu/DOC/95/30/32686/Wemsi.html) (for a WEMSI-sponsored list, send "subscribe wilderness-emergency-medicine" to Majordomo@list.pitt.edu) - Eastern Region, Natl. Cave Rescue Comm./Appalachian SAR Conf. -- End -- X-cs: From: Self To: DURKINTJ@ctrvax.Vanderbilt.Edu Subject: WEMSI WEMT Courses (was: national Wilderness First Aid course) Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Mon, 27 Nov 1995 10:23:08 On 26 Nov 95 at 23:00, DURKINTJ@ctrvax.Vanderbilt.Ed wrote: > > Dr Conover, > > my name is Tim Durkin. I am a member of both M/SAR and PVRG ( FTL ) > as well as a Virginia and Registry Basic EMT. I am currently > attending school in Nashville. > > While attending a recent PVRG meeting over Thanksgiving break, > the topic of SOLO Wilderness EMT / CFR Upgrade classes was disscussed > informally by myself and some other members. The main drawbacks > disscussed were cost and location. I am understand that your WEMSI > program offers a similar course, specifically created under ASRC > "Wilderness" medical protocols. I would be interested in receiving > information on when this course is given, cost and location, as > well as information of the potential to recieve CEU's. Is it > also possible, with enough funding and interest, to have the course > given at location of the student's choice, or of a hosting > organization ( possibly non-ASRC )? > > please reply to this account. > Tim, the WEMSI WEMT courses I know about are as follows: Center for Emergency Medicine of Western PA at Camp Soles (near Seven Springs in SW PA mountains) Basic Wilderness Rescue on one weekend (not needed for ASRC or VA GSAR FTMs or higher) in February, WEMT course one two-day weekend and one three-day weekend in March (exact dates TBA) Contact for further information: Pam Westfall, Administrative Asst. Center for Emergency Medicine 230 McKee Place, Suite 500 Pittsburgh, PA 15213-4904 412-578-3203 email: Pam Westfall Northcentral PA in the spring (tentative): Bradford Bason 307 E. Market St. Danville, PA 17821 717-271-1314 (H) 717-326-8185 (W) 717-271-1339 (Bason Rescue Equipment Voicemail) email: Brad Bason Philadelphia in the spring (tentative): contact: Jack Grandey, EMT-P 862 N. Beechwood St. Philadelphia, PA 19130 215-232-8105 (H) 215-456-7246 (W) email: Jack Grandey Western Maryland in the spring: contact: Steve Meyer HCR 1, Box 177-A Barton, MD 21521 301-463-5881 (H/W) email: MIEMSS Region I--David Ramsey Near Elkins, WV in June (22-30), as part of the East Region National Cave Rescue Commission weeklong training college: contact: John Appleby, ER-NCRC Regional Coordinator 899 Kulp Rd. Perkiomenville, PA 18074 1-215-541-4994 (H) email: John B. Appleby Dublin, Ireland in September: Joe O'Gorman, Training Officer Irish Mountain Rescue Association 9 Kingston Heights Ballinteer Rd. Dublin 16 Ireland 00353 1-298-9719 email: Gerard Butler There is also talk about a WEMSI WEMT course in Virginia but nothing more definite at present. contact: Rob Christie 1604 Trap Road Vienna, VA 22812 703-319-1479 (H) 703-370-4101 (W) email: Rob Christie <75714.1425@compuserve.com> The cost of the course is up the organization running the course (WEMSI doesn't actually run them, just provides the academic backing and some minor QI services). Anyone who wants to can sponsor a course, and WEMSI will provide, for the cost of copying and postage, a course guide and lesson plans and, until the textbook is commercially published, text materials at cost. The CEM course that just finished cost, including all food, lodging, texts and supplies: BWR: $150 WEMT first weekend: $150 WEMT second weekend: $175 This included a rustic but generally nice facility (YMCA camp) with good food, heated bunkrooms, and hot showers. Instructors were basically all volunteer. Someone who really worked at it could shave the cost a little but not much. If people were camping and fixing their own food, it would cost much less but then then the course would last a lot longer due to the time for fixing food, etc.; the five-day format for WEMT is _very_ intensive, starting early in the AM and going until late at night. It would cost more if you had to pay instructors instead of having volunteers. And good instructors are critical to this course; it's not one you can just have someone stand up and show slides (for one thing, we don't have many slides nor do we plan to). And there are many practical and small group sessions which require good teaching skills from the instructors. WEMSI requires that, in order to be recognized as a WEMSI course, you (1) present all the material more or less as the course guide and Lesson Plans lay out, (2) pay to have a WEMSI QI person attend the course as a monitor, and (3) administer the standard WEMSI written and practical tests. So, yes, anyone can run a WEMSI WEMT course, but it's not easy. Those running courses generally arrange for NREMT CEUs, as has been done in the past. NREMT generally gives 24 hours of Section II credit for a WEMSI WEMT course. I hope this answers some of your questions. Thank you. -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.1/cispop-1.6.1.3) ID for ; Mon, 27 Nov 1995 23:01:50 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 27 Nov 1995 23:01:49 -0500 (EST) Received: via switchmail; Mon, 27 Nov 1995 23:01:48 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 27 Nov 1995 23:00:14 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Mon, 27 Nov 1995 22:59:34 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from mail1.new-york.net (mail1.new-york.net [165.254.2.54]) by list.srv.cis.pitt.edu with ESMTP (8.7.1/cisls-2.4) ID for ; Mon, 27 Nov 1995 22:59:32 -0500 (EST) From: grenard@herpmed.com Received: from herpmed.com by mail1.new-york.net (PMDF V4.3-10 #5880) id <01HY5L2V529S00Q2IE@mail1.new-york.net>; Mon, 27 Nov 1995 22:58:52 -0500 (EST) Date: Mon, 27 Nov 1995 23:47:34 -0800 (PST) Subject: Bier Block for Snakebite Tx To: wilderness-emergency-medicine@list.pitt.edu Message-id: MIME-version: 1.0 X-Mailer: Chameleon - TCP/IP for Windows by NetManage, Inc. Content-type: TEXT/PLAIN; charset=US-ASCII Content-transfer-encoding: 7BIT Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 0 Has anyone on this list seen the article by Dr Richard Thompson in the October, 1995 issue of J of Emrgency Medicine describing the use of the Bier (regional) block --- a regional anesthesia method adapted by Thompson to administer antivenom locally? I am interested in hearing what anyone has to say about this procedure. ------------------------------------- Steve Grenard E-mail: grenard@herpmed.com http://www.herpmed.com/ POB 40825 - Staten Island NY 10304-0825 USA Telephone/Fax/Messages: 1-718-4476144 This message was sent by Chameleon ------------------------------------- -- End -- X-cs: From: Self To: Harvey Louzon ,EMED List Subject: Re: emed-l Scope of Practice Reply-to: kconover+@pitt.edu Date: Wed, 29 Nov 1995 19:05:57 On 28 Nov 95 at 13:13, Harvey Louzon wrote: > > We are starting to see our first cases of severe hypothermia of the > season in the Chicagoland area. (Now I know what Napolean's army suffered > in the Russian winter of 1812). Yeah, but he had only 5,000 left out of 500,000 at the end. > > Last night a 65 y/o male with H/O alcohol abuse and tuberculosis [snip] > immediate (oral) ET intubation. Hypoglycemia (48), hypothermia (core 85 > F) and hypotension (70) were present. He recieved D50W, thiamine, narcan, > Feel free to crtisise the above managemnt (I am fully aware of > several controversial issues in the management of these patients > particularly on the use of catacholamines and external rewarming), > however, my main question has to do with what occured subsequent to his > stabilization. I was told that no ICU (or CCU) beds were available and > that he would have to board in the ED overnight. He had been 'assigned' > to the next attending on call for 'no docs' and I had discussed the case > with him. My 'relief' refused to accept sign-out on this patient stating > that he was "not qualified to manage him." The attending refused to Maybe you need to get some new partners in the ED? A few comments on rewarming, excerpted from a chapter from our upcoming textbook. This is written for Wilderness EMTs but you might find the references of some use. The latter part of the excerpt supports active external rewarming (copyright (c) 1995 by Wilderness EMS Insitute, permission granted for limited electronic reproduction for discussion purposes). Afterdrop Afterdrop refers to the common finding that core temperatures continue to go down after rewarming starts, particularly with rapid peripheral rewarming (a hot tub). This is thought to increase the risk for complications, including ventricular fibrillation. However, it is important to note that afterdrop is not likely when "adding heat" to a wilderness patient. Such slow external rewarming is much more like so-called "passive rewarming," in which people are placed in a warm room and insulated. Such patients do not show afterdrop.183 With peripheral rewarming in particular, some authors attribute afterdrop to a local reflex in the limbs. Local skin sensors detect the warmth of the external rewarming, and this causes local vasodilation. This results in a sudden rush of cold, stagnant blood from the extremities to the core. This influx has been shown in experiments on humans, but appears to be only a small amount of flow.184,185 Because this blood may be acidotic and full of toxic metabolic products, it is thought to cause even more of a risk for ventricular fibrillation than its temperature alone would suggest. However, others suggest that vasoconstriction in severe hypothermia is so intense that there is very little blood in the extremities to be shunted to the core, and that the physics of heat transfer show that external rewarming must result in afterdrop even if there is no reflex vasodilation. Researchers have shown afterdrop in hypothermic watermelons that are being rewarmed, in large bags of Jell-O, and in a leg of beef.186 (Even though this can be predicted from a very basic knowledge of the physics of heat transfer.) The truth seems to be that a combination of the two effects causes afterdrop. Regardless of the amount of blood pooled in hypothermic extremities, increased blood flow in the extremities will cause rewarming of the extremities at the cost of the critical core regions. Also, core rewarming, even of a watermelon, will decrease afterdrop and increase temperature risein the core. Therefore, core rewarming is the ideal. An assumption by many is that afterdrop during rewarming is somehow a cause of sudden death, particularly by ventricular fibrillation. However, there is good reason to suspect that the danger of fibrillation is a simple function of how cold the heart is, and how long it stays that cold. In this view, there is nothing "magical" about an afterdrop of a degree or so; the heart was likely to fibrillate even without the slight extra cooling of the "afterdrop." If it comes to a choice of slow rewarming with an afterdrop versus having the patient stay hypothermic through a long evacuation, the choice is clear: rewarm.184 Rewarming Shock As severely hypothermic patients are rewarmed, the blood pressure, pulse, and respiratory rate generally start at low levels and gradually increase. Sometimes, the pulse gets very fast while the blood pressure goes back down, and the patient shows sign of diminished cerebral perfusion. You should interpret this as mild shock caused by the rewarming process. You will see it particularly when using rapid external rewarming, such as immersion in a hot bath (you may even see it when rewarming people with incipient hypothermia). Consider that all hypothermic patients are volume depleted and vasoconstricted, and you are applying external heat that is known to cause local reflex vasodilation. Thus, relative hypovolemia (a small amount of blood in a vascular system that used to be small, but now is big) is an obvious source of shock. To avoid rewarming shock, you could vigorously hydrate with warm IV solutions, slow the rewarming rate, or use core rewarming techniques. Sudden Death Sudden death during hot bath rewarming was reported as early as A.D. 320: Forty Christians were exposed to cold for three days, with a warm bath waiting if they would give up their religion; one who gave up and was rewarmed in the bath suddenly died. Sudden death during rewarming may be from rewarming shock or from ventricular fibrillation, but there is no good evidence pointing to any one particular cause. One paper is widely cited as supporting the idea that rapid rewarming will cause temperature differences inside the heart that lead to ventricular fibrillation.187 However, on careful reading, the paper has serious defects, and does not truly show that these temperature differences lead to ventricular fibrillation, nor that rapid rewarming will lead to ventricular fibrillation. More recent evidence, including research cited in the section on ventricular fibrillation above, suggests that the chance of ventricular fibrillation is a simple function of the depth of hypothermia and the length of time at that temperature. If we exclude deaths from rewarming shock, which can be treated with IV fluids, then the chance of ventricular fibrillation during rewarming is no more than the chances during hypothermia itself. If this is true, then rapid rewarming with fluid repletion may be no more dangerous than letting patients stay hypothermic. More research is needed, but for now, reasonable ways to minimize the chances of sudden death include the following: warm IV solutions to prevent rewarming shock, core rewarming to prevent afterdrop, and prophylactic bretylium to prevent ventricular fibrillation. Though not truly a complication of rewarming, many hypothermic patients, especially those with chronic hypothermia, develop pneumonia (or perhaps it caused the hypothermia). If your hypothermic patient faces a very long evacuation, and you find evidence of pneumonia on exam, you may wish to administer an antibiotic. Of the oral antibiotics commonly carried in a wilderness medical kit, amoxicillin-clavulanate (e.g., Augmentinr) has been recommended for this use.146 [snip] Some simple physical calculations based on the maximum temperature of an IV (104oF=40oC; higher temperatures will cause burns) and the amount that can be given shows that warm IVs do little to rewarm a patient. However, warm IVs should be used to prevent cooling the patient with cold IV fluids. Hydration should be vigorous except for patients with medical complications or chronic hypothermia. Some have noted that application of warmth to the hands and feet (not the arms and legs) allows heat to enter the deep venous circulation. Theoretically, this would provide a good means of rewarming hypothermic patients, but the method does not seem to add enough heat to be worthwhile.17 The roots of the aggressive treatment of immersion hypothermia can be traced to the military, which for years used warm bath treatment for immersion hypothermia with success. Aggressive rewarming in warm water was first recommended by the Luftwaffe based upon the infamous Dachau experiments, even though the studies are scientifically suspect.200 This treatment has been subsequently recommended and used by the British Royal Air Force and the U.S. Navy, although no recent documentation of survival rates is available.201,202,203 As MacLean and Emslie-Smith say: "Rapid active surface rewarming by immersion in warm water is becoming the accepted management of fit young adults overwhelmed by cold either by immersion or by exposure."204 Keatinge, in an editorial in the British Journal of Medicine, said "The principles of treating simple hypothermia remain straight forward and generally uncontroversial for victims who still have a carotid pulse and respiration, however slow and difficult these may be to detect. External rewarming in the horizontal position by warm air, or by a warm bath not hot enough to be painful to the rescuer's elbow, is usually effective."205 A recent report notes that warm bath immersion (40oC=104oF) was successful in a case of severe hypothermia (30.5oC=87oF) caused by a mix of immersion and exposure; there was no afterdrop.206 One study found that, for mild hypothermia, warm bath rewarming caused little afterdrop.189 In a study of acutely hypothermic dogs, rapid rewarming in a warm bath caused less rewarming shock than slow rewarming.106 The University of Chicago has used warm bath rewarming on eighteen patients with chronic hypothermia (mostly deep) with no deaths.207 Except for cardiopulmonary bypass, warm water immersion is probably the quickest way to rewarm someone. If you are using a hot bath for rapid rewarming, keep the temperature about 105-110oF (41-43oC); keep the arms and legs elevated and out of the warm water; and keep a towel soaked in the warm water around the patient's neck. It seems reasonable to rewarm the trunk first, to more nearly approach core rewarming. The one study that looked at this question showed that, for mildly hypothermic volunteers, it made no difference in rewarming rate or afterdrop whether the limbs were in the bath or not.208 Nonetheless, this only studied mild hypothermia, and for severely hypothermic patients, rewarming the trunk first still seems appropriate. If you have a patient with mild hypothermia and frostbite, this study suggests it would be best to rewarm the torso and extremities at the same time. Monitor carefully for rewarming shock (even in patients who are merely cold but with normal core temperatures); if the blood pressure begins dropping, add cool water to the bath (to slow rewarming), remove he person from the bath and place in the shock position (flat with legs elevated), or give more IV fluids. (One animal study showed that rewarming shock during warm bath rewarming was easily treated with IV fluids.106) The danger of trying to defibrillate a patient in a warm bath is cited as a reason to avoid it. However, if the patient is colder than 86oF (30oC), defibrillation is generally useless. On the other hand, trying to manage the patient while in a bathtub, especially with IVs or central lines, is complex at best. A cold but non-hypothermic person may of course make his or her own decision about a hot bath, but you might point out the problem of rewarming shock and suggest a bath rather than a shower, and suggest leaving the arms and legs out of the bathtub until last. 17. Wilson SB, Spence VA, Emslie-Smith D. Hands and feet warming in hypothermia [letter]. Lancet 1986;2(8518):1281. - 106. D'Amato HE, Kronheim S, Covino BG. Cardiovascular functions in the dog rewarmed rapidly and slowly from deep hypothermia. Am J Physiol 1960;198(2):333-5. - 146. Maclean D. Emergency management of accidental hypothermia: A review. J R Soc Med 1986;79(9):528-31. - 182. Collis ML, Steinman AM, Chaney RD. Accidental hypothermia: An experimental study of practical rewarming methods. Aviat Space Environ Med 1977 July:625-3. 183. Hayward JS, Eckerson JD, Kemna D. Thermal and cardiovascular changes during three methods of resuscitation from mild hypothermia. Resuscitation 1984;11(1-2):21-33. 184. Savard GK, Cooper KE, Veale WL, Malkinson TJ. Peripheral blood flow during rewarming from mild hypothermia in humans. J Appl Physiol 1985;58(1):4-13. 185. Mittleman KD, Mekjavic IB. Effect of occluded venous return on core temperature during cold water immersion. J Appl Physiol 1988;65(6):2709-13. 186. Webb P. Afterdrop of body temperature during rewarming: An alternative explanation. J Appl Physiol 1986;60(2):385-90. 187. Mouritzen CV, Andersen MN. Myocardial temperature gradients and ventricular fibrillation during hypothermia. J Thorac Cardiovasc Surg 1965;49(6):937-44. 188. Sterba JA. Efficacy and safety of prehospital techniques to treat accidental hypothermia. J Emerg Med 1991;20(8):896-901. 189. Romet TT, Hoskin R. Temperature and metabolic responses to inhalation and bath rewarming protocols. Aviat Space Environ Med 1988;59:530-634. 190. Dannewitz SR, Jilek J, Staten C. Warm intravenous fluid administration using hot packs [letter]. Ann Emerg Med 1984;13(10):982-4. 191. Faries G, Johnston C, Pruitt K, Plouff RT. Temperature relationship to distance and flow rate of warmed IV fluids. Ann Emerg Med 1991;20(11):1198-200. 192. Sturm JT. Microwave aids in external rewarming of hypothermia patients. Ann Emerg Med 1984;14(3):277. 193. Gong V. Microwave warming of IV fluids in management of hypothermia [letter]. Ann Emerg Med 1984;13(8):645. 194. Werwath DL, Schwab CW, Scholten JR, Robinett W. Microwave ovens: A safe new method of warming crystalloids. Am Surg 1984;50(2):656-9. 195. Anshus JS, Endahl GL, Mottley JL. Microwave heating of intravenous fluids. Am J Emerg Med 1985;3(4):316-9. 196. Aldrete JA. Preventing hypothermia in trauma patients by microwave warming of i.v. fluids. J Emerg Med 1985;3(6):435-42. 197. Leaman PL, Martyak GG. Microwave warming of resucitation fluids. Ann Emerg Med 1985;14(9):876-9. 198. Arnold J, Jenkins D. The hydraulic sarong: A new method to save hypothermia victims? Summit 1970;16(Mar):2-5. 199. Dayton LB, Arnold JW. Hydraulic sarong. Off Belay 1975;21:2-4. 200. Berger RL. Nazi science _ the Dachau hypothermia experiments. N Engl J Med 1990;322(20):1435-40. 201. Tansey WA. Medical aspects of cold water immersion, a review. Groton, CT: Naval Submarine Medical Research Laboratory, 1973NTIS AD 775-687. 202. Technical Assistant to the Chief of Naval Operations PP. Cold weather medicine. Washington: U.S. Navy: U.S. Office of Naval Operations, 1954:497. Armed Forces Medical Library Catalog Vol. 3 P. 497, 1950-54. 203. Davies LW. The deep domestic bath treatment for advanced cases of hypothermia. Ed. Clarke D, Ward M, Williams E. Proceedings of a Symposium for Mountaineers, Expedition Doctors and Physiologists. Mountain medicine and physiology. London: The Alpine Club, 1975. 204. Maclean D, Emslie-Smith D. Accidental hypothermia. Oxford: Blackwell Scientific Publications, 1977:353. 205. Keatinge WR. Hypothermia: Dead or alive? Editorial. BMJ 1991;302(6767):3-4. 206. Sullivan PG. Accidental hypothermia and frost-bite in Antactica. Med J Aust 1987;146(3):155-8. 207. Zachary L, Kucan JO, Robson MC, Frank DH. Accidental hypothermia treated with rapid rewarming by immersion. Ann Plast Surg 1982;9(3):238-41. 208. Hoskin RW, Melinyshyn MJ, Romet TT, Goode RC. Bath rewarming from immersion hypothermia. J Appl Physiol 1986;61(4):1518-22. [end of excerpt] Regarding the problem with the patient staying in the ED: In our ED we often have boarders for several hours -- the resident sees the patient, discusses with the IM attending, and the IM resident writes the orders and follows the patient in the ED. However, since we're there and the IM attending isn't, we still have responsibility for crisis intervention and in real terms, serve as consultants and supervisors for the IM residents. When things were crowded and we often had several boarders in the ED at shift change, we talked about formally rounding on all these patients and writing progress notes and billing for daily visits -- but now things aren't so crowded any more so we haven't gotten to do this. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: WEMSI Ordering Information Reply-to: kconover+@pitt.edu Date: Sat, 2 Dec 1995 21:29:19 I've had lots of requests for information on how to order Wilderness EMS Institute publications. First, we're still working on the Wilderness EMT Curriculum -- only about half of the 20 Lesson Plans are finished and available. The preliminary versions of the other ones are not publicly available -- interim versions are distributed at WEMSI-recognized classes but you can't order them. A couple of new ones will be done by the end of December. In another couple of weeks, the Course Guide version 1.0 will be available. We also have an annotated Wilderness Personal Medical Kit list available (but you may just want to look at this on our Web site; see my .SIG, below). A textbook will be commercially published next year sometime. To order publications, you should request an orderform from Pamela Westfall, Administrative Assisstant to Dr. Walt Stoy. (But I suggest you wait until the end of December to ask so you can get the updated list!) You may reach Pam at: Pam Westfall, Administrative Asst. Center for Emergency Medicine 230 McKee Place, Suite 500 Pittsburgh, PA 15213-4904 (412) 578-3203 stoy+@pitt.edu Thanks for all the interest! -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.2/cispop-1.6.1.3) ID for ; Sat, 2 Dec 1995 23:00:11 -0500 From: grenard@herpmed.com Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Sat, 2 Dec 1995 23:00:11 -0500 (EST) Received: via switchmail for kconover+@pitt.edu; Sat, 2 Dec 1995 23:00:10 -0500 (EST) Received: from mail1.new-york.net (mail1.new-york.net [165.254.2.54]) by post-ofc03.srv.cis.pitt.edu with ESMTP (8.7.1/cispo-2.0.1.1) ID for ; Sat, 2 Dec 1995 22:57:46 -0500 (EST) Received: from herpmed.com by mail1.new-york.net (PMDF V4.3-10 #5880) id <01HYCKHVT3QO00JPYA@mail1.new-york.net>; Sat, 02 Dec 1995 22:57:29 -0500 (EST) Date: Sat, 02 Dec 1995 23:40:22 -0800 (PST) Subject: RE: Websites To: wilderness-emergency-medicine@list.pitt.edu, kconover+@pitt.edu Message-id: MIME-version: 1.0 X-Mailer: Chameleon - TCP/IP for Windows by NetManage, Inc. Content-type: TEXT/PLAIN; charset=US-ASCII Content-transfer-encoding: 7BIT X-PMFLAGS: 34078848 0 Dr Conover: I dont know if you've seen our snakebite emregncy first aid website. It can be found at http://www.xmission.com/~gastown/herpmed/snbite.htm and our Australasian Snakebite Site at: http://www.xmission.com/~gastown/herpmed/aubite.htm Both sites concern first aid measures for the general public only in a dos and donts format. It is based on the theory of containment using material such as an ace bandage or elastic bandage as advocated and in use in Australia and elsewhere over the past 15 years or so. I would appreciate it if you or any other people on this list interested in snakebite have a look at this simple set of admonitions and recommendations in a snakebite situation and return any comments to me by e-mail. I notice also that WEMSI has a web site. If you provide links to other sites you may wish to include these. We intend, with your permission, to add WEMSI's site to a Medical Resources Website we maintain as well as a herpetological website we sponsor. Thank you. ------------------------------------- Steve Grenard. RRT E-mail: grenard@herpmed.com http://www.herpmed.com/ POB 40825 - Staten Island NY 10304-0825 USA Telephone/Fax/Messages: 1-718-4476144 This message was sent by Chameleon ------------------------------------- -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.2/cispop-1.6.1.3) ID for ; Sun, 3 Dec 1995 13:54:05 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Sun, 3 Dec 1995 13:54:05 -0500 (EST) Received: via switchmail; Sun, 3 Dec 1995 13:54:03 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Sun, 3 Dec 1995 13:52:09 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Sun, 3 Dec 1995 13:50:05 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from post-ofc01.srv.cis.pitt.edu (root@post-ofc01.srv.cis.pitt.edu [136.142.185.10]) by list.srv.cis.pitt.edu with ESMTP (8.7.1/cisls-2.4) ID for ; Sun, 3 Dec 1995 13:50:01 -0500 (EST) Received: from ehdup-a1-1.rmt.net.pitt.edu (ehdup-a1-1.rmt.net.pitt.edu [136.142.20.11]) by post-ofc01.srv.cis.pitt.edu with SMTP (8.7.1/cispo-2.0.1.1) ID ; Sun, 3 Dec 1995 13:46:04 -0500 (EST) Message-Id: <199512031846.NAA16812@post-ofc01.srv.cis.pitt.edu> Comments: Authenticated sender is From: "Keith Conover, M.D." To: Jay Wiseman Date: Sun, 3 Dec 1995 13:42:04 +0000 Subject: Re: Tympanic temps Reply-to: kconover+@pitt.edu CC: wilderness-emergency-medicine@list.pitt.edu, EMED List Priority: normal X-mailer: Pegasus Mail for Windows (v2.23) Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Status: U On 2 Dec 95 at 16:12, Jay Wiseman wrote: > > Hello, > > As you've probably seen, there's been a thread about the accuracy of > tympanic temps going on lately on emed-l. I was recently looking over > "your" web info on wilderness med and noticed that one particular brand > was specifically, and exclusively, recommended. I'd certainly appreciate > any further comments you might have on this matter, and I imagine others > would as well. > Maybe I've been a bit overboard in our recommendation of this one particular brand. But they are the only manufacturer that provides good data to show their thermometer is accurate and hardy enough for wilderness rescue. Most of the others (1) say their thermometers are no good except indoors, and not for hypothermia or heatstroke, and (2) have nothing to say about Exergen's good engineering presentation about why their thermometer is technically superior. However, I _still_ can't get Exergen to give us a thermometer to test in a rigorous fashion despite multiple attempts. I'd really like to do a controlled trial to see if they are as good as Exergen says; I suspect yes but until we have good controlled information it's still an educated opinion only. I'll post some excerpts from one of our draft Wilderness EMT chapters here, that may have some relevance to the ED and ambulance-based care as well: Temperature, Thermometers, and Temperature Monitors (excerpt from preliminary proprietary materials, copyright 1995 by Wilderness EMS Institute, permission granted for limited electronic circulation on the emed-l Internet discussion list.) Note: this information is primarily aimed at Wilderness EMTs but may be applicable to patients who just have come in from a hot or cold environment. Like most ambulance and ED patients. You want to know, during the evacuation, whether the patient's temperature is going up or down. For this, an accurate reading is not as important as knowing whether the temperature is going up or down. For evacuation, inexpensive ($15) improvised continuous rectal temperature monitors may be valuable. Even if the temperature that they register is a bit off, they generally will accurately measure changes in temperature. (Dr. Conover performed some highly informal experiments at a Radio Shack(TM) store on nine similar indoor-outdoor thermometers, model 63-842, which showed a range of slightly less than 1 degree C in their temperature accuracy. However, all seemed to accurately indicate changes in temperature to within 0.1 degrees C, over a 40 degrees C range. The methodology was simply t o put all nine external temperature probes together and to expose the cluster to varying hot and cold temperatures.) There are several places where you can measure a patient's temperature: the skin, the mouth, the rectum, the axilla (armpit), the tympanic membrane (eardrum), or the esophagus. In a normothermic person, there is a fairly reliable relationship between oral and rectal temperatures: oral temperatures are about 0.7 degrees F less than rectal. However, neither is a perfectly acc urate reflection of the "core" temperature. The "core" temperature is hard to define. Different parts of the body have different temperatures, and the temperature varies with different amounts of hea t stress. This applies to the "core," as well. For example, the brain has a high metabolic rate, and the brain temperature may well be higher than the heart temperature. In some studies, surprisingly , the rectal temperature was found to be higher than the temperature of blood coming directly out of the heart (the pulmonary artery).[4] In a hypothermic patient, however, oral, rectal, and axillary temperatures (and even tympanic temperature as measured with some thermometers) may be colder than the true "core" temperature, especiall y during rewarming.[5-7] And, in a patient with heatstroke from running or hiking, heat generated by the legs may make the rectal temperature much higher than the true core temperature.[8] In genera l, rectal temperature changes more slowly than "core" temperature during rapid temperature changes, possibly because it is well-insulated from the rest of the core.[9,10] If you measure a rectal temperature with the probe in the middle of a lump of stool, you merely find the temperature of a lump of stool; if you do a poor job of holding a thermometer in the mouth or axilla, the temperature you register will be lower than the actual temperature there. Skin: Feeling the forehead with the back of your hand provides useful information, though it is seldom a good measure of core temperature. It gives a rough indication of how much heat the patient's b ody is trying to lose. For instance, when a fever "breaks" (starts coming down), the forehead will be very hot and then sweaty as the body tries to lose heat to come down to a lower core temperature. A very cold forehead suggests the person is trying to retain heat; for instance, if hypothermic, or if suffering a shaking chill just at the onset of a fever. (See also the comments on disposable sk in thermometers, below.) Oral Temperature: The most routine place to measure temperature is in the mouth. It is convenient, because it ~doesn't require the patient to undress. It is rarely objectionable to adult patients. Or al temperature is affected by smoking and drinking cold or hot drinks, and is decreased by mouth breathing, and by increased respiratory rates.[11,12]) However, effects of drinking and smoking disapp ear in 15 minutes.[13] Oral temperature is also increased by about half a degree by exposure to a warm environment (95 degrees F=35 degrees C)[14], and decreases by about 2 degrees C just from sittin g in a cool (12 degrees C=59 degrees F) room for 2 hours.[15] Axillary Temperature As discussed in the section on Thermal Regulation, major blood vessels are close to the skin in the axilla (armpit). This allows a high rate of heat exchange with the core, and keeps the axilla close r to the core temperature than other parts of the skin. Having a patient hold a thermometer under the arm can provide a rough estimate of core temperature; axillary temperatures are accurate in hospi talized patients.[16] Axillary temperature can be a poor reflection of core temperature in deep hypothermia, because there is very little blood flow to the arms. It also may be hard, especially with an uncooperative patie nt, to get enough contact between the axilla and the thermometer to get an accurate reading. Several doctors recommend that you not use axillary temperatures to try to detect fevers, because they mis s so many fevers in children.[17,18] However, in the wilderness, you could reasonably use a normal axillary temperature to rule out significant hypothermia. Rectal Temperature Taking a rectal temperature is distasteful to many "street " EMTs. However, it is the accepted standard for wilderness first aid and wilderness rescue. Tympanic temperatures are superior, particularl y in cases of exertional heatstroke, where the rectal temperature might be elevated above brain temperature by heat from the legs.[19] In other situations, rectal temperatures should be a fairly reli able estimate of core temperature. There are a few reports of rectal perforation in newborns when a rectal temperature was taken, but with reasonable gentleness, there should be no such danger in adults or older infants.[12,20] There is no significant risk of infection from bacteria released into the bloodstream from rectal examination or taking a rectal temperature. (The amount of bacteria released into the blood seems similar t o that caused by a simple bowel movement: few enough that the body can clear them without difficulty.)[12,21,22] Some doctors believe that rectal examination or taking a rectal temperature may cause arrhythmias in a patient who has had a myocardial infarction. However, one large study showed that rectal exams are not likely to cause any problems in those with a recent MI.[23] Monitoring temperat ure is vitally important in the wilderness. If you have a patient with a possible myocardial infarction and possible hypothermia or heatstroke, obtain a rectal temperature if that is the only way you have to check the core temperature. Some suggest that placing a rectal temperature probe deep (15-20 cm.) within the rectum makes cold or warm blood from the lower extremities less likely to affect the readings.[24] However, we have no t been able to find any evidence to support this idea. One study showed little effect of the depth of the rectal probe.[8] Placing the thermometer in about 5-10 cm (2-4 inches) seems appropriate for most situations. Tympanic (eardrum) temperatures Tympanic (eardrum) temperatures are closer to rectal temperatures than are oral temperatures.[25] They also seem to measure temperature better than oral or rectal temperatures,[4,26] but may vary som ewhat from the "true" core temperature. (As noted above, rectal temperatures might be falsely elevated in exertional heatstroke, due to excessively hot blood from active leg muscles. A tympanic tempe rature would be an excellent choice in such a situation. In an animal model of nonexertional heatstroke, tympanic temperatures were as reliable as rectal.[27] Some early studies questioned their reli ability.[28,29] However, newer studies show these thermometers seem to be accurate in older children and adults.[30] One study found that tympanic temperatures were not reliable in infants under thre e months of age possibly due to infants' small external ear canals.[31] Another study showed tympanic temperatures to be unreliable under the age of three.[32] Modern tympanic thermometers rely on th e infrared radiation from the eardrum, and are quick and reliable. Middle ear infections (otitis media) have no significant effect on their accuracy.[33] Indoors, cerumen (earwax) has no effect on th eir accuracy.[31] The thermometer must be aimed correctly at the tympanic membrane to work correctly.[31,34,35] A tympanic membrane thermometer might seem ideal for wilderness rescue. A variety of models are now available.[36] However, there may be problems using them in the wilderness. Even for an ear thermom eter that is designed to compensate for surrounding air temperature, one study showed tympanic temperature is increased by 0.7 degrees C by exposure to a warm environment (95 degrees F=35 degrees C); for its test of a "cold" environment, this study chose 65 degrees F (18.3 degrees C), which had no effect on tympanic temperatures. However, the study did not look at the range of temperatures exper ienced in wilderness rescue.[14] Manufacturers indicate that their ear thermometers are only accurate in a controlled room temperature. (IVAC Core*Check model 2090: 65 degrees-90 degrees F; Thermosca n models Pro-1 and HM-1: 61 degrees-104 degrees F; Intelligent Medical Systems FirstTemp 2000A and Genius 3000A: 60 degrees-110 degrees F; Diatek model 7000: 64 degrees-104 degrees F.) In a very hot environment, it is reasonable to expect that very warm blood flow from the scalp and face might make the external part of the ear canal very hot, which might increase the reading on the thermometer. In a very cold environment, even if the thermometer can compensate for the air temperature, it is reasonable to suspect that cold cerumen (earwax) in the ear might cause an inaccurately cold reading. Exergen Corporation's Ototemp model 3000-SD is specially designed for the rigors of the wilderness environment including a special coating on the internal circuit boards, and will detect a wider rang e of patient temperatures than the others (65 degrees-130 degrees F); it is rated to operate at ambient temperatures from 32 degrees F (0 degrees C) to 130 degrees F (52 degrees C). (Exergen Corporat ion; One Bridge Street; Newton, MA 02158; 1-800-422-3006; (617) 527-6660.) (For temperatures below freezing, you would need to keep the thermometer inside your parka and only bring it out when you ne ed to use it.) This company's tympanic thermometers are designed to "focus" more narrowly on the eardrum itself than others, which eliminates (or at least markedly decreases) the effects of air or ex ternal ear canal temperature.[19] (Some other infrared tympanic thermometers rely on an "offset" correction factor to correct for the effects of a cooler external ear canal temperature. Because of va rying external ear temperatures, the need for this correction makes such thermometers less accurate. This "offset" correction factor would likely not be correct in a wilderness patient.) Even with a device such as the OTOTEMP 3000-SD, an ear full of cold cerumen might cause a reading to be falsely low. Nonetheless, tympanic temperature, if measured by a device such as the Ototemp 3000-SD, seems to be the best method to evaluate for heatstroke or hypothermia in the wilderness. An esophageal thermometer lies right behind the heart and is an ideal way to measure temperature, but must be placed in much the same way as a nasogastric tube. (However, some esophageal thermometers are smaller and easier to place than NG tubes.) Esophageal temperature seems to be the most reliable indicator of the core temperature. However, the thermometer must be accurately located in the eso phagus to be accurate; temperature differences of up to 6 degrees C may occur along the length of the esophagus.[10] To our knowledge esophageal thermometers have not yet been used in wilderness resc ue. For rectal, oral, or axillary temperatures, there are several types of thermometer you may carry and use in the wilderness. A standard glass-mercury thermometer (or sometimes, glass with red-dyed alcohol instead of mercury) is a standard part of most wilderness first aid and medical kits. Wilderness enthusiasts are genera lly careful to obtain low-reading "hypothermia" thermometers, because not all thermometers will register hypothermic-range temperatures. The common perception that metallic mercury is poisonous is not true. Metallic mercury is not at all toxic compared to its soluble salts, which are the source of most mercury poisoning. However, glass thermometers are fragile. Even well-padded and packed deep in the bowels of a medical kit, they seem to have a propensity for emerging in shards and little silver globules just when ne eded the most. Even without fracturing, glass thermometers may be damaged by shocks, or by excessive heat or cold; in such cases, the mercury column becomes "dislocated" from its proper position. At home this can s ometimes be cured by applying heat or cold to the thermometer, but fixing the thermometer in the wilderness can be time-consuming or impossible. Glass thermometers, as ordered from hospital suppliers, are not all accurate. Even when stored in a controlled room temperature, many become inaccurate over an eight month period.[37] In the mouth, a glass thermometer takes about three to five minutes to register its peak reading. In the axilla, however, it may take up to ten minutes.[38] The best way to be sure that you've measur ed the temperature accurately is to check the thermometer every few minutes, until you get two readings in a row that are the same.[38] To prevent cross-contamination, hospitals and clinics using glass thermometers generally have disposable lubricated covers to place over the thermometer. Because of small holes in the thin plastic sh eath, they are not a reliable way to prevent cross-contamination. Sterilizing a glass thermometer between uses is appropriate, but may be difficult in the wilderness. Electronic single-reading thermometers, either a dual oral/rectal unit or a tympanic membrane unit, are the standard in most hospitals. These units are relatively accurate, sturdy, and dependable. Ho wever, most are have rechargeable internal batteries, and for wilderness use, they should be adapted for disposable alkaline or lithium batteries. Continuous-reading thermometers with remote monitor units are very useful during wilderness evacuations. Commercial units are expensive, but you can improvise a continuous remote-reading by using an inexpensive electronic indoor-outdoor thermometer. (Indoor-outdoor thermometers are available from Radio Shack and similar appliance stores for about twenty dollars each. The small outdoor temperatur e probe may be used as a rectal probe. These thermometers are only accurate to about a degree. However, this is adequate for a reasonable estimate of core temperature, and the thermometer will give a n accurate reflection of whether the temperature is rising or dropping.> The thermometer unit itself contains a battery that is sensitive to extreme cold, so it may be placed in the packaging with th e patient, and brought out for periodic checks.) 4. Milewski A, Ferguson KL, Terndrup TE. Comparison of pulmonary artery, rectal, and tympanic membrane temperatures in adult intensive care patients. Clin Pediatr 1991;30(4 suppl):13-6. 5. Maclean D, Emslie-Smith D. Accidental hypothermia. Oxford: Blackwell Scientific Publications, 1977:292. 6. Ledingham IM. Clinical management of elderly hypothermic patients. The nature and treatment of hypothermia. Ed. Pozos RS Wittmers LE. University of Minnesota continuing medical education 2. Minnea polis: U of Minnesota P, 1983:165-81. 7. Hayward JS, Eckerson JD, Kemna D. Thermal and cardiovascular changes during three methods of resuscitation from mild hypothermia. Resuscitation 1984;11(1-2):21-33. 8. Burton AC, Edholm OC. Man in a cold environment: Physiological and pathological effects of exposure to low temperatures. Monographs of the Physiological Society 2. New York: Hafner Publishing Co., 1969 (orig. pub. London: Edward Arnold, 1955):200-3. 9. Molnar GW, Read RC. Studies during open-heart surgery on the special characteristics of rectal temperature. J Appl Physiol 1974;36:333-6. 10. Webb GE. Comparison of esophageal and tympanic temperature during cardiopulmonary bypass. Anesth Analg 1973;52:729-73. 11. Norris J. Taking temperatures: The changing state of the art. Contemp Pediatr 1985;2(11):22. 12. Tandberg D, Sklar D. Effect of tachypnea on the estimation of body temperature by an oral thermometer. N Engl Med J 1983;303:945-6. 13. Terndrup TE, Allegra JR, Kealy JA. A comparison of oral, rectal, and tympanic membrane-derived temperature changes after ingestion of liquids and smoking. Am J Emerg Med 1989;7:150-4. 14. Zehner WJ, Terndrup TE. The impact of moderate ambient temperature variance on the relationship between oral, rectal, and tympanic membrane temperatures. Clin Pediatr 1991;30(4 suppl):61-4. 15. Collins KJ, Exton-Smith AN. Oral temperature and hypothermia. Br Med J 1979;278:887. 16. Giuffre M, Heidenreich T, Carney-Gersten P, Dorsch JA, Heidenreich E. The relationship between axillary and core body temperature measurements. Appl Nurs Res 1990;3(2):52-5. 17. Ogren J. The inaccuracy of axillary temperatures measured with an electronic thermometer. Am J Dis Child 1990;144:109. 18. Weisse ME, Reagen MS, Boule L. Axillary vs. rectal temperatures in ambulatory and hospitalized children. Pediatr Infect Dis J 1991;10(7):541-2. 19. Ryan M, Pompei F. Core body temperature via the tympanic membrane: A practical method using the Exergen OTOTEMP 3000 Infrared tympanic temperature scanner. Ed. Benzinger TH Benzinger M. Newton, M A: Exergen Corporation, 1990. 20. Greenbaum EI, Carson M, Kincannon WN, O'Loughlin BJ. Rectal thermometer-induced pneumoperitoneum in the newborn: Report of two cases. Pediatrics 1969;44:539-42. 21. Hoffman BI, Kobasa W, Kaye D. Bactermia after rectal examination. Ann Intern Med 1978;88(5):658-9. 22. Tandberg D, Reed WP. Blood cultures following rectal examination. JAMA 1978;239:1789. 23. Earnest DL, Fletcher GF. Danger of rectal examination in patients with acute myocardial infarction fact or fiction? N Engl J Med 1969;281:238-41. 24. Sterba JA. Efficacy and safety of prehospital techniques to treat accidental hypothermia. J Emerg Med 1991;20(8):896-901. 25. Green MM, Danzl DF, Praszkier H. Infrared tympanic thermography in the emergency department. J Emerg Med 1989;7:437-40. 26. Ferrara-Love R. A comparison of tympanic and pulmonary artery measures of core temperatures. J Post Anesthesia Nursing 1991;6(3):161-4. 27. Tayeb OS, Marzouki ZMH. Tympanic thermometry in heat stroke: Is it justifiable? Clin Physiol Biochem 1989;7(5):255-62. 28. Ros SP. Evaluation of a tympanic membrane thermometer in an outpatient clinical setting. Ann Emerg Med 1989;18(9):1004-6. 29. Rhoads FA, Grandner J. Assessment of an aural infrared sensor for body temperature measurement in children. Clin Pediatr 1990;29(2):112-5. 30. Terndrup TE, Milewski A. The performance of two tympanic thermometers in a pediatric emergency department. Clin Pediatr 1991;30(4 suppl):18-23. 31. Chamberlain JM, Grandnre J, Rubinoff JL, Klein BL, Waisman Y, Huey M. Comparison of a tympanic thermometer to rectal and oral thermometers in a pediatric emergency department. Clin Pediatr 1991;3 0(4 suppl):24-9. 32. Muma BK, Treolar DJ, Wurmlinger K, Peterson E, Vitae A. Comparison of rectal, axillary, and tympanic membrane temperatures in infants and young children. Ann Emerg Med 1991;20(1):41-4. 33. Kelly B, Alexander D. Effect of otitis media on infrared tympanic themometry. Clin Pediatr 1991;30(4 suppl):46-8. 34. Shenep JL, Adair JR, Hughes WT, et al. Infrared, thermistor, and glass-mercury thermometry for measurement of body temperature in children with cancer. Clin Pediatr 1991;30(4 suppl):36-41. 35. Pransky SM. The impact of technique and conditions of the tympanic membrane upon infrared tympanic thermometry. Clin Pediatr 1991;30(4 suppl):50-2. 36. Schuman AJ. Tympanic thermometry: Temperatures without tears. Contemporary Pediatrics 1991;8(special issue: Technology. Four basic steps toward better patient care):54-73. 37. Abbey JC, Anderson AS, Hertwig EP. How long is that thermometer accurate? Am J Nurs 1978;78(8):1375. 38. Haddock B, Vincent P, Merrow D. Axillary and rectal temperature of full term neonates: Are they different? Neonatal Network 1986;5(1):36. Keith Conover, M.D. (NSS 12893, WD4PSY) - Information Systems Coordinator, Dept. of EM, Mercy Hospital - Clinical Assistant Professor, Dept. of Emergency Medicine, Univ. of Pittsburgh (EM Residency and Center for Emergency Medicine) - Medical Director, Wilderness EMS Institute (http://www.pitt.edu/DOC/95/30/32686/Wemsi.html) (for a WEMSI-sponsored list, send "subscribe wilderness-emergency-medicine" to Majordomo@list.pitt.edu) - Eastern Region, Natl. Cave Rescue Comm./Appalachian SAR Conf. -- End -- X-cs: From: Self To: grenard@herpmed.com,wilderness-emergency-medicine@list.pitt.edu Subject: RE: Websites Cc: Bernie Roche ,"Charles P. Kollar" Reply-to: kconover+@pitt.edu Date: Sun, 3 Dec 1995 14:27:32 On 2 Dec 95 at 23:40, grenard@herpmed.com wrote: > I dont know if you've seen our snakebite emregncy first aid website. > It can be found at > > http://www.xmission.com/~gastown/herpmed/snbite.htm > > and our Australasian Snakebite Site at: > > http://www.xmission.com/~gastown/herpmed/aubite.htm Not yet, but I'll be checking them out as soon as I get home from the EMS Agenda for the Future and PA ACEP Computer conferences. I look foward to seeing them. > > Both sites concern first aid measures for the general public only > in a dos and donts format. It is based on the theory of containment using > material such as an ace bandage or elastic bandage as advocated > and in use in Australia and elsewhere over the past 15 years or so. > I would appreciate it if you or any other people on this list > interested in snakebite have a look at this simple set of admonitions > and recommendations in a snakebite situation and return any comments > to me by e-mail. I'll take a look at your sites soon. However, based on your comments about containment, let me get on a soapbox. The soapbox says "North American Pit Vipers are Different" and has a picture of a western Diamondback with sunglasses and a Mohawk hairdo. I would suggest that those interested review the literature about _North_American_ pit viper bites and consider the relative amount of local vs. systemic toxins in North American vs. other pit vipers. (If you still have questions, talk to Findlay Russell at the University of Arizona in Tucson. He once said he is willing to serve as an expert witness against anyone who uses (one of the) Australian techniques on someone with a North American pit viper bite and the patient gets bad local tissue necrosis i.e., requiring plastic surgery for coverage, or amputation.) I'll post here a brief quote from the WEMSI WEMT Curriculum, which will be in our upcoming textbook, and in a Lesson Plan to be released to the public in a few weeks. This excerpt is (c) 1995 by WEMSI; permssion is hereby granted only for limited electronic distribution on the wilderness-emergency-medicine list. "Stasis Treatments Many first aid textbooks still call for the snakebite victim to rest and be car~ried out to a road rather than walking out, for the affected limb to be splinted at the level of the heart, and for a l ymph constric~tor to be placed on the extremity between the bite and the heart. The purpose of all these measures (and the now-discredited use of cold packs) is to retard the spread of venom, and th ereby minimize systemic effects. With the extremely poisonous reptiles found in South America, Asia, and Australia, this makes sense. (But see below on the ``Australian'' methods for better stasis treatments.) However, the systemic effects of North American pit viper bites are usually limited to nausea, vomiting, malaise, and sometimes a decrease in platelets. They are rarely life-threaten~in g, except for the very young, the very old, and those with severe medical problems. The major problem is loss of tissue and scar~ring, resulting in crippling de~formities. Therefore, in the North A merican wilderness, trying to hold the venom at the site makes little sense, except when antivenin will be available in a short time, or when the envenomation is life-threatening. Lymph Constrictors and Tourniquets Theoretically, a true lymph constrictor might be of minor bene~fit, as it might retard ab~sorption of the venom, minimizing sys~temic reactions at the cost of worsening local damage. However, there are no good studies showing a de~crease in North American pit viper bite morbidity or mortality due to use of a lymph constrictor, and at least one animal study has shown it to be of no benefit. Variations of the lymph constrictor are to apply a venous tourniquet, which will worsen the local injury, or an arterial tourniquet, which could easily cause loss of the limb. Another problem is that many first-aiders, even though they are trying to apply a lymph constrictor, end up with a venous or arterial tourniquet. Few lay people understand what the lymphatic system i s, much less how much pressure a lymphatic constrictor requires. Snakebite victims (many from non-poisonous snakes) have come into Emergency Departments with arterial or venous tourni~quets in place . And, there is no evidence that even properly-applied lymph constrictors help North American pit viper bites. Also, a lymph constrictor may become a venous or even arterial tourniquet as swelling progresses. Therefore, we should completely expunge the idea of lymph constrictors from the first aid treatment of domestic snakebite.[Snyder CC, Knowles RP, Pickens JE, et. al. Pathogenesis and tre atment of poisonous snake bite. J Fla Med Assn 1968;55:330-7.] One snakebite expert has suggested that cutting may cause enough bleeding to interfere with the pump seal on the suction device. This may be a significant problem, considering the coagulopathy (bleeding problems) caused by pit viper bites. This coagulopathy may make cutting unnecessary. The Australian Treatment In Australia, highly-toxic bites are more common than in the U.S. The venom of Australian snakes is deadly but causes little local tissue damage. For such snakebites, an arterial tourniquet mi ght be lifesaving. However, because of the pain and damage caused by an arterial tourniquet, Australians searched for better first aid treatments. These ``Australian'' techniques use less-painful a nd less-damaging methods to immobilize venom at the site of the snakebite. All use direct pressure over the bite, and some over the entire extremity. The ``CSL'' technique, named after Commonwealth Serum Laboratories, where the principal researchers work, is simple: use an elastic bandage or roller gauze, wrapping firmly but not tightly (pressure of 55 mmHg) proximally most of the way up the arm or leg, then immobilize the limb in a splint. This decreases the blood flow in the area around the bite, theoretically limiting both the spread and absorption of the venom. This might then permit the victim to survive until you can get antivenin.[Sutherland SK, Coulter AR, Harris AD. Rationalisation of first 1aid measures for elapid snake bite . Lancet 1979;1(8109):183-5.; Sutherland SK, Harris RD, Coulter AR, Lovering KE. Simple method to delay the movement from the site of injection of low molecular weight substances [letter]. Med J Aust 1980;1(2):81.; Sutherland SK, Coulter AR, Harris AD, Lovering KE, Roberts ID. A study of the major Australian snake venoms in the monkey (Macaca fascicularis) (1) The movement of injected veno m; methods which retard this movement, and the response to antivenoms. Pathology 1981;13:13-27.]Another group of Australians argue that using a firm pressure dressing over the bite (pressure of 70 mm Hg) works better than an elastic bandage, and have done experiments in humans that support this.[Anker RL, Straffon WG, Loiselle DS. First aid for snake bite [letter]. Med J Aust 1982;1(3):103.; Anker RL, Straffon WG, Loiselle DS, Anker KM. Retarding the uptake of `mock venom' in humans: Comparison of three first-aid treatments. Med J Aust 1982;1(5):212-4.] One animal experiment seemed to show that the CSL treatment worked for North American rattlesnake bites,[Sutherland SK, Coulter AR. Early management of bites by the eastern diamondback rattlesnake (C rotalus adamanteus): Studies in monkeys (Macaca fascicularis). Am J Trop Med Hyg 1981;30(2):497-500.] but Dr. Findlay Russell of the University of Arizona says he has seen a number of patients whose rattlesnake bites were made much worse by this treatment. Therefore, the best evidence is that for North American pit vipers, this method causes severe local tissue damage and you should not u se it unless willing to sacrifice the limb to save a life. If you are on a disaster response to a country with very poisonous snakes, you might use the CSL treatment for envenomated bites." Bottom line: We won't recommend stasis treatments for North American pit viper bites until a rigorous study shows it works and is confirmed by at least one other study. I haven't reviewed the literature in about 9 months so maybe there is something new out there; if so, please let me (and the rest of the list) know. > > I notice also that WEMSI has a web site. If you provide links to other > sites you may wish to include these. We intend, with your permission, to > add WEMSI's site to a Medical Resources Website we maintain as well as > a herpetological website we sponsor. > > Thank you. > > ------------------------------------- > Steve Grenard. RRT > E-mail: grenard@herpmed.com > http://www.herpmed.com/ > POB 40825 - Staten Island NY 10304-0825 USA > Telephone/Fax/Messages: 1-718-4476144 > > By all means, let's link the sites both ways. I'll copy this to our IS manager and Webmaster. Thanks. -- End -- X-cs: From: Self To: "PMB STERLING S SHERMAN, MD" Subject: Re: emed-l Military Medicine Reply-to: kconover+@pitt.edu Date: Sun, 3 Dec 1995 20:58:03 On 3 Dec 95 at 7:32, PMB STERLING S SHERMAN, MD wrote: > > We're in the process of sending about 20,000 young men and women into the > former Yugoslavia (the eastern-most "American" sector). Is there anything > new/useful for the immediate treatment/stabilization of the following: [snip] > 3. Frostbite rewarming. Well, I'd suggest you contact the Army's Dr. Murray Hamlet at the Natick, MA Research Institute of Environmental Medicine. He knows more about frostbite than anyone else I can think of. Unless you can persuade the company to start making intrarterial reserpine, the most important things are: 1. Take half an aspirin before you get frostbite, to prevent platelet aggregation. I think it's worth giving half an aspirin even afterwards; Murray doesn't think so, and so far I know of no research to tell either way. Since it probably won't hurt you might as well give it. 2. If you get frostbite, rapid rewarming is better than slow rewarming is better than very slow rewarming (I remember a MSGT medic who flew a frostbitten patient to the hospital with the helicopter doors open and the hands exposed so they wouldn't "slowly rewarm" and so he could save the frozen limbs for rapid rewarming at the aid station. Yet he was rewarming the patient's core so the arms slowly rewarmed, more slowly than if he'd directly rewarmed them. Not quite as bad as another military medic who had heard that you shouldn't rewarm patients in the field so left the _entire_patient_ uninsulated with the doors open.) Temp is 110 degrees F, or about as hot as you can keep an elbow in, for the water bath. Have lots of MS handy for pain as it hurts a _lot_ worse than slow rewarming even though there is less tissue loss. 3. Take ibuprofen 800 mg three times a day. True, those at the Univeristy of Chicago who did the studies of an NSAID for preventing secondary damage from frostbite used methimazole, and you don't want to give _it_ and make your patients hypothyroid (I really _do_ wished they'd tested a NSAID that could be clinically used) but I suppose we can generalize from methimazole given to animals, to ibuprofen given to humans. 4. Forget aloe, nifedipine, and eye of newt, though you might give allopurinol a try if you're willing to set up a study with controls. Though unpublished, the U.S. Army has tried all sorts of such things with no results except maybe allopurinol. And if people say Heggers' study supports the use of aloe in frostbite, point out that (1) topical aloe don't get into the deep tissues unless you press _very_ hard so it does nothing for frostbite, and (2) say the words "selection bias" and "lack of controls." Actually, I remember when Bern Shen said this when one of this same group presented at a conference; Bern was at the microphone after the presentation and kept trying to explain the concept of selection bias but after a while people started saying "Sit down! It's hopeless!" [Heggers JP, Phillips RI, McCauley RL, Robson MC. Frostbite: Experimental and clinical evaluations of treatment. J Wild Med 1990;1(1):27-32.] 5. As Aristotle, Napoleon's Surgeon General (Baron Larrey) and my great-grandmother all said, don't rewarm frostbite in front of a fire unless you have barbecue sauce and are hungry enough, because you'll end up with cooked meat. Frostbitten limbs are anaesthetic. 6. Give low molecular weight dextran, as per this extract from the Cold-Related Diseases chapter of our upcoming Wilderenss EMT textbook, reproduced with permission for limited electronic distribution on the emed-l and wilderness-emergency-medicine lists only: "Dextran There is good evidence from animal studies that giving intravenous low-molecular weight dextran will decrease tissue loss.[Weatherley-White RCA, Paton BC, Sjostrom B. Experimental studies in cold inj ury. III. Observations on the treatment of frostbite. Plast Reconstr Surg 1965;36(10):10-8.; Anderson RA, Hardenbergh E. Frostbite treatment in the mouse with low molecular weight dextran. J Surg Res 1965;5:256-61.; Goodhead B. The comparative value of low molecular weight dextran and sympathectomy in the treatment of experimental frost-bite. Brit J Surg 1966;53(12):1060-2; Kapur BML, Gulati SM, Talway JR. Low molecular weight dextran in the management of frostbite in monkeys. Indian J Med Res 1968;56(11):1675-81; Sumner DS, Boswick JA Jr, Doolittle WH. Prediction of tissue loss in human fr ostbite with xenon-133. Surgery 1971;69(6):899-903. (The only known human study, by Doolittle and Sumner at Bassett Army Hospital in Alaska, was terminated prior to completion. The animal studies and the excellent clinical results when dextran was used in humans convinced experimenters it was unethical to continue the study. {The study required that control patients not receive dextran.} This in formation is unpublished, and provided by Dr. Murray Hamlet of the Army's Research Institute of Environmental Medicine.) To preserve as much tissue as possible, dextran should be started as soon as p ossible, even before rewarming. Even if the frostbite has been slowly rewarmed, giving IV dextran later may help minimize damage.[Talwar JR, Gulati SM, Kapur BM. Comparative effects of rapid thawing, low molecular weight dextran and sympathectomy in cold injury in monkeys. Indian J Med Res 1971;59:242-50.] Dextran should be continued for up to five days.[Mundth ED, Long DM, Brown RB. Treatment o f experimental frostbite with low molecular weight dextran. J Trauma 1964;4:246-57.] Dextran is discussed further for the treatment of hypothermia, below. (See also the chapter on Wilderness Trauma f or more about dextran.)" 7. You _can_ treat frostbite and hypothermia at the same time. Here's a quote from the Cold-Related Diseases chapter of our upcoming Wilderenss EMT textbook, reproduced with permission for limited electronic distribution on the emed-l and wilderness-emergency-medicine lists only: "Frostbite in Litter Patients The best treatment for frostbite in a litter patient would probably be as follows. Wrap the frostbitten extremities in towels or thick pieces of clothing soaked with warm (40-42 degree C=104-110 degr ee F) water. Next, wrap waterproof plastic and pieces of closed-cell foam around the towel-wrapped extremity, then place the patient in the litter. A liter of water can be quickly heated on a stove w hile the patient is prepared for evacuation. The water will cool during evacuation; this is acceptable. There is no benefit to providing continued warmth once the frostbitten part has rapidly thawed. [Fuhrman FA, Fuhrman GJ. The treatment of experimental frostbite by rapid thawing. A review and new experimental data. Medicine 1957;36:465-87.] (If the evacuation will be very long, you may want to take the wet towels off several hours later to allow the skin to dry.) Heat packs and heating pads are well-known for the burns they cause during rewarming,[Feldman KW, Morray JP, Schaller RT. Therma l injury caused by hot pack application in hypothermic children. Am J Emerg Med 1985;3(1):38-41.] sometimes even to extremities that were not truly frostbitten. If it is so cold that you must use heat packs to prevent the wet towels from cooling too fast, even when insulated, make sure the hot packs aren't in direct contact with the skin. Some might argue against thus treating frostbite in a pat ient who is also hypothermic. True, rewarming of the periphery should be avoided in hypothermia, but the hands and feet (not the arms and legs) have direct venous connections to the core, so rewarming of the hands and feet is quite acceptable, even if the patient is hypothermic.[Wilson SB, Spence VA, Emslie-Smith D. Hands and feet warming in hypothermia [letter]. Lancet 1986;2(8518):1281.]" Hope this helps. -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.2/cispop-1.6.1.3) ID for ; Sun, 3 Dec 1995 23:02:08 -0500 From: grenard@herpmed.com Received: from local (daemon@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Sun, 3 Dec 1995 23:02:07 -0500 (EST) Received: via switchmail for kconover+@pitt.edu; Sun, 3 Dec 1995 23:02:07 -0500 (EST) Received: from mail1.new-york.net (mail1.new-york.net [165.254.2.54]) by post-ofc02.srv.cis.pitt.edu with ESMTP (8.7.1/cispo-2.0.1.1) ID ; Sun, 3 Dec 1995 22:55:56 -0500 (EST) Received: from herpmed.com by mail1.new-york.net (PMDF V4.3-10 #5880) id <01HYDYNXD7U800KLVK@mail1.new-york.net>; Sun, 03 Dec 1995 22:54:05 -0500 (EST) Date: Sun, 03 Dec 1995 23:21:30 -0800 (PST) Subject: NA Snakebite lst Aid/Pros/Cons /? To: grenard@herpmed.com, wilderness-emergency-medicine@list.pitt.edu, kconover+@pitt.edu Cc: Bernie Roche , "Charles P. Kollar" Message-id: MIME-version: 1.0 X-Mailer: Chameleon - TCP/IP for Windows by NetManage, Inc. Content-type: TEXT/PLAIN; charset=US-ASCII Content-transfer-encoding: 7BIT X-PMFLAGS: 34078848 0 I agree there is considerable controversy over the use of containment but within this response it was stated: does one want to use a method that saves ones life versus one that causes local tissue damage? How can this question be answered? So long as Dr. Findlay Russell swears he will testify against one in court after the fact, we better take the easy way out and sit on the fence. It is so terribly difficult to be choosy about whether to use ace wrap or not when you are sitting in an office while someone hundreds of miles away is getting bitten by a N.A crotalid. That person or his/her first aid givers as well as yourself have no way of knowing how serious that bite is until after the person either recovers or dies. Sure 90% of most surviving rattlesnake victims treated by this method have local tissue damage, often extensive and requiring plastic surgery. I qualify this statement by saying "surviving."Medicine is full of choices. This is one of them. BTW a lot of people not treated by containment but survive also have permanent local tissue damage although it may be less significant. In addition significant envenomation has the potential of targeting vital organs, the loss of which can be far worse in comparison with tissue loss at or near the bite site. How would the detractors respond to someone who loses a kidney or has an infarction due to ischemia when they knew this venom could've been contained and any sequelae be treated later by plastic surgery? This is clearly an area that has no right or wrong unless you are willing to answer the above question with: risk of tissue loss versus living long enough to receive antivenom treatment. I will include this discussion on our website so that people interested in snakebite first aid are informed of the pros and cons. Thank you for bringing up all the relevant arguments for and against. ------------------------------------- Steve Grenard E-mail: grenard@herpmed.com http://www.herpmed.com/ POB 40825 - Staten Island NY 10304-0825 USA Telephone/Fax/Messages: 1-718-4476144 This message was sent by Chameleon ------------------------------------- -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.2/cispop-1.6.1.3) ID for ; Mon, 4 Dec 1995 19:36:53 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.2/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 4 Dec 1995 19:36:53 -0500 (EST) Received: via switchmail; Mon, 4 Dec 1995 19:36:52 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 4 Dec 1995 19:36:47 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.2/cisls-2.4) ID ; Mon, 4 Dec 1995 19:35:07 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from emout05.mail.aol.com (emout05.mail.aol.com [198.81.10.37]) by list.srv.cis.pitt.edu with SMTP (8.7.2/cisls-2.4) ID for ; Mon, 4 Dec 1995 19:35:06 -0500 (EST) From: REBURR@aol.com Received: by emout05.mail.aol.com (8.6.12/8.6.12) id TAA02553; Mon, 4 Dec 1995 19:34:33 -0500 Date: Mon, 4 Dec 1995 19:34:33 -0500 Message-ID: <951204193333_44362024@emout05.mail.aol.com> To: kconover+@pitt.edu, jaybob@crl.com cc: wilderness-emergency-medicine@list.pitt.edu, emed-l@itsa.ucsf.edu Subject: Re: Tympanic temps Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk We have a considerable interest in field clinical thermometry. Our experieice and opinion from the experieince of others has been that typanic thermometry is unreliable. There are at least two reasons for the unreliability: (1) inadequate "visualization" of the tympanic membrane so that the thermometer registers a temperature more reflective of the auditory canal [this is a typical source of error in the office or ED setting] and (2) inadequate relationship between the typanic/auditory canal temperature and the temperature of the truncal viscera. This latter problem is due to the important dependence of the tympanic temperature on the temperature of the neck and, consequently, the enviroment. "Core" temperature can be measured with minimal intrusiveness at two sites: high in the rectal canal (at least 6 cm beyond the anal margin) or the esophagus at the level of the atria. Either of these temperatures will provide adequate monitoring during evacuation and rescusitation from hypothermia or severe heat illness. There are inexpensive, rugged small digital thermometers with long flexible probes that are well suited for this task and should be considered for inclusion in any emrgency kit. Finally, please pardon one small expression of exasperation: why do axillary temperatures still appear as a subject of discussion? This technique has been discredited for years and has no place in the evaluation of an environmental casualty. Robert E. Burr, FACP, FACEP Medical Advisor, US Army Resaerch Institute of Environmental Medicine, Natick, MA -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: Laurel Caverns Cave Rescue, Part 1 of 4 Cc: Cavers Digest Reply-to: kconover+@pitt.edu Date: Wed, 6 Dec 1995 15:07:12 November 1995 Laurel Caverns Cave Rescue Review, Part 1 of 4 [Keith Conover, M.D., Assistant Medical Director, Eastern Region, National Cave Rescue Commission; Medical Director, Wilderness EMS Institute] A recent rescue at Laurel Caverns in southwestern Pennsylvania was straightforward, but brought up a great many questions regarding the conduct of the rescue and possible medical concerns. In particular, Doug Moore of West Virginia, who took part in the rescue, emailed me a list of questions primarily about medical aspects. During my investigation of the medical aspects, certain rescue and political concerns cropped up. I promised Doug I'd answer him, but that it would take a little thought and a little time. I asked him if I could quote his questions and use them in this review, and distribute it electronically to the appropriate Internet lists as well as in printed form. I also asked Jim Kennedy, the original poster, and Dale Ibberson, the patient, for similar permission. All granted such permission. Since this discussion is interesting from several viewpoints, and at the risk of being accused of "spamming" I will post to both the wilderness-emergency-medicine list as well as Cavers Digest. >> It's probably hopeless, but try to keep _cave_rescue_ discussions >> in Cavers Digest and _medical_ discussions in the >> wilderness-emergency-medicine list. I should also note that I have not yet been able to identify the local paramedics and fire/rescue personnel so as to include their stories, but will attempt to do so by way referring this to the medical director of the EMS Institute (local EMS region). Here is the original posting from Cavers Digest by Jim Kennedy: -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- Topic Number: 3 Date: Thu, 15 Sep 1988 18:43:16 -0500 To: cavers@ditell.com From: jkennedy@batcon.org (Jim Kennedy) Subject: rescue at Laurel Caverns On Saturday, Nov. 25, long-time caver Dale Ibberson of York Grotto was injured during a resurvey trip in Laurel Caverns, a commercial cave just outside of Uniontown, PA. Laurel Caverns has about 2.5 miles of passages and is the deepest cave in Pa. at 464 feet. Dale and Jay Reich (also of York) were in the section above Petit Falls, approximately 1800 feet from the nearest entrance. According to Dale, they had just recconoitered the section of cave they were about to resurvey. He was taking the tape out to set a station and stepped down in an area he was just at. The only problem was that what he thought was a one foot step down to a rock turned out to be about two or three feet. As he fell he turned sideways and landed with his hip hitting a rock. He could not stand, and realized and evacuation was necessary. Some (paying) tourist spelunkers came by and Reich convinced them to stay with Ibberson while he went to the Visitors Center. There he found caver/employee John Chenger who called Patty Kennedy (caver/wilderness EMT/ER-NCRC staff) who intitiated a limited callout to local cavers. Chenger left for Ibberson, taking a small team to carry in a prepacked Ferno-Washington litter, IRT (Initial Response Team) kit, and field phones, all of which were on hand for such situations. Within an hour of the accident, Ibberson's condition was assessed, he was warmed, and packaged in the litter. The cavers (including caver paramedics) on hand (12-15) started the extrication (and had everything apparently under control) when things got a little messy. About 60 (!) firemen showed up from several different squads. They tried to take over, even wanting to stop the litter so one of them (who is also a newspaper photographer) could take pictures! They even brought in a second litter and more gear. No one is sure who called them out. It is obvious that they were not in communication with anyone actually involved with the operation. All-in-all there seemed to be a lack of Incident Command after the operation was underway. There was not even any type of entrance control, and some of those firemen may be wandering around in there yet! I am not bringing this up to criticise what happened to to second guess and decisions made, only to provide a short accident analysis for everyone's edification and to stress the need for cavers (especially cave rescuers) to interact with local agencies. Dale fell a total of about four feet, but his trip was cut short and worse, he is hospitalized with a fractured pelvis. This could have been any one of us. Anybody that knows Dale (hell, even if you don't!) you can send him cards, visit, or call him at the Uniontown Hospital at (412) 430-5000. He'll be there until the end of the week or so. -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- Here is Doug Moore's email message: To: kconover+@pitt.edu From: douglas.moore@svis.org (Douglas Moore) Date sent: Sun, 26 Nov 1995 22:18:00 -0500 Organization: SVIS 304-592-2682 800-SOFT-VAL Subject: Questions on Hip injuries and the Laurel Rescue 11/25/95 Keith, I'm just curious for future reference on some proper procedures for the type of injury that happened at Laurel on 11/25/95. Just so you'll know what I saw when I got on scene I'll start from there. Got to the cave and was inside to the injury within about 15 minutes. At that point didn't know anything about injuries the accident, etc. Got on site and approx. 6 people were there with commo and Ferno. John Chenger was on site so I asked him about the accident, etc. An EMT was present. My assumption was that the EMT had done all necessary vitals, etc. and the patient was ready to be packaged since that was what was being done. Dale, the patient mentioned that he was diabetic and a finger may need available if a test needed done so special precautions were made in the packaging. Packaging went smoothly except for a couple of flaws. The first one was a goof on proper hypothermia packaging procedure but that was corrected in a couple of minutes with little discomfort to the patient. The second one was more serious and dealt with tieing the patient into the stretcher. The standard ER-NCRC tie-in was used until we ran into some problems cinching the straps. We had watched where the straps were touching the body due to the injury. However, the patient was in great pain during the cinching. We noticed that it appeared to only happen during the initial movement then stopped which allowed us to cinch the webbing across the upper body. We then moved to the lower straps and ran into problems from compression around the injury so I basically then told John and the others that we would need to fasten the lower extremities differently than ER-NCRC standard. This entailed running the right webbing down about 8 inches along the ferno before going across for the X and some of the extra webbing being used criss-crossing a different time above and below the knees. About this time a Paramedic (or appeared to be) showed up and asked about injuries. I mentioned we would be ready to move in five. The Paramedic said okay and that we would take vitals at the Ball Room and left (Didn't see him again). I had eight people on site and had requested 12 more from the surface so we began moving. Everything went smooth to the Ball Room. Then we ran into about 50 people (fire/rescue) which slowed the train up from there out probably adding 30 minutes to the extrication. Thats some of the basics. Now the questions of the day. As a rescurer without medical background and the presence of an EMT on site upon arrival what precautions should I take in packaging and extrication? What should I ask of the medical personnel to make sure that necessary vitals etc. have been taken? (We latter learned that most had not been taken initially.) What signs in the patient should I and other rescurers look for with a hip injury during extrication? What would be the proper tie in for a right hip injury? If the patient was smaller what would be the proper tie in since they could more easily shift in the litter during extrication? That's basically all I can think of right off. Oh yeah, one thing. Is it proper rescue procedure to elbow the head of some fire/rescue personnel into a rock after they drop a couple pound flashlight on the patients head? I heard about the flashlight being dropped on the patients head while eating dinner after the rescue and that was the comment on proper rescue procedure for that situation. ---------------------------------------------------------------------- ---- | /\+/\ Douglas L Moore II /\+/\ | | National Speleological Society - 33064SU | | National Association for Search & Rescue - 9501923 | | Staff - Eastern Region National Cave Rescue Commission | | Owner - Karst Sports (Caving, Climbing, & Rescue equipment) 304.592.2600 | | On the World Wide Web at http://svis.org/msc/karst.htm | ---------------------------------------------------------------------- ---- I will follow this with three other messages. First is my own peripheral involvement in this rescue, then two messages with specific answers to Doug's questions, and comments on other relevant topics from my discussion with the patient and with Scott Jones, an NCRC-trained medic who has been through the WEMSI WEMT course at least twice and who was involved in the rescue. To be continued . . . -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: Laurel Caverns Cave Rescue, Part 2 of 4 Cc: Cavers Digest Reply-to: kconover+@pitt.edu Date: Wed, 6 Dec 1995 15:09:22 November 1995 Laurel Caverns Cave Rescue Review, Part 2 of 4 I heard about the rescue when Patty Kennedy called me while I was at work in the ED. She told me that the patient was not too far in, but may have a hip dislocation. Hmmm. Hip dislocations are usually posterior (the "ball" of the femur=thighbone is displaced backward from the acetabulum="socket" in the hip bone). This means that the hip is flexed and can't be straightened. Which means it sticks up out of a litter. Which may mean that the patient won't fit between some of those breakdown blocks in Laurel Caverns in the litter. And maybe won't fit through at all. I couldn't leave the ED right away, but I told Patty I'd (1) be available for medical direction, and (2) would try to arrange for coverage and try be available to fly out on one of the STAT MEDEVAC BK helicopters. My first thought was that my wife was out driving around with our Ranger Rover, which has all my caving/SAR/medical gear in it, and she doesn't have a pager. If I go, I can probably borrow some polypro and a helmet and light from someone, but what do I do for medications? Hip dislocations are notoriously difficult to reduce, even in the ED with all sorts of medications and lots of trained people to help. Patty Kennedy is trained as a Wilderness EMT but even WEMTs are cautioned that hip dislocations are often impossible to reduce in the backcountry, and certainly without medications. If our choices are between reducing the hip in the cave, versus blasting or other major cave modification to allow us to move the patient out without reduction, the choice is clear. Blasting or modification of passage takes time and is hazardous to all involved; reduction of the dislocation might be possible with trained personnel and drugs at the scene with little risk. If we could get the personnel and drugs to the scene. The helicopters carry oxygen, a portable pulse ox, and Fentanyl, all of which we could take into the cave. (Though getting the oxygen to the patient safely would be a bear.) But our helicopters don't have Versed any more; they took it off a few months ago. OK, I can bring some from the ED. (How do you sign out controlled medications for a patient in a cave whose name you don't know? Put down Joe Caver in the controlled-drug log book, I guessed at the time; later I figured I could ask Admissions to generate a blank trauma chart like we do for traumas and sign the meds out to Trauma Patient #3672 and then converting over to the proper name once the patient gets to the ED. Of course, this assumes the patient actually comes to our hospital.) Could I do a hip with help from the WEMTs there? Maybe. Might like to have more help, though. I immediately thought of Sam Chewning, an orthopedic surgeon in Charlotte, NC. Sam is not only a Wilderness Command Physician for the pilot Wilderness Medic project of the Wilderness EMS Institute, but the new national medical officer for the National Cave Rescue Commission. We could get the Civil Air Patrol or the Air Force to fly him to Pittsburgh and thence by helicopter to the cave. And Noel Sloane, a past medical officer for NCRC, is an anaesthesiologist in Indiana, and Steve Gates, an anaesthesiologist in Kentucky, is NCRC-trained. As it turns out, Dale had a small pelvis fracture, not a hip dislocation, and those at the scene were able to evacuate him in short order, so no helicopter, no signing out drugs to Joe Caver. But still, all this thinking is worthwhile. What do we do when we _do_ have a patient with a hip dislocation in a cave, beyond a low crawlway? The answer is to take the hospital to the patient. Anyone who has any potential responsibility for such a cave rescue should review their preplans and think about hip dislocations. To be continued . . . -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: Laurel Caverns Cave Rescue, Part 3 of 4 Cc: Cavers Digest Reply-to: kconover+@pitt.edu Date: Wed, 6 Dec 1995 15:11:32 November 1995 Laurel Caverns Cave Rescue Review, Part 3 of 4 [background: Laurel Caverns is a commercial cave, with lighting and tours. Unlike most commercial caves, they allow wild caving in the back sections this relatively safe cave. They rent caving gear and provide lockers and showers, and have preplanned for rescues. John Chenger is an employee-guide at the cave.] On 26 Nov 95 at 22:18, Douglas Moore wrote: > Keith, > > I'm just curious for future reference on some proper procedures for > the type of injury that happened at Laurel on 11/25/95. Just so > you'll know what I saw when I got on scene I'll start from there. > > Got to the cave and was inside to the injury within about 15 > minutes. At that point didn't know anything about injuries the > accident, etc. Got on site and approx. 6 people were there with > commo and Ferno. John Chenger was on site so I asked him about the > accident, etc. An EMT was present. My assumption was that the EMT > had done all necessary vitals, etc. and the patient was ready to be > packaged since that was what was being done. Dale, the patient > mentioned that he was diabetic and a finger may need available if a > test needed done so special precautions were made in the packaging. Well, I talked to Dale (the patient) on the phone last night. He has had cave rescue training. As a result he had some interesting observations on his care right at the time of the rescue. He says he didn't know what was wrong, exactly; he thought maybe his hip was out just a little bit. He says the accident was very simple; he was stepping from one rock to another that he thought was about a foot lower. However, it was actually about 2 feet lower, and he slipped and fell about four feet. Yes, that's all. He says he was in little pain if sitting perfectly still, but got pain in his hip/pelvis area with the slightest movement, even moving his head. He noted that this is the sort of freak accident that can happen even if you're experienced, so those who are accomplished cavers should still prepare themselves, at least mentally, for such an injury. He was able, however, to move himself over to the litter. > Packaging went smoothly except for a couple of flaws. The first one > was a goof on proper hypothermia packaging procedure but that was > corrected in a couple of minutes with little discomfort to the > patient. The second one was more serious and dealt with tieing the > patient into the stretcher. The standard ER-NCRC tie-in was used > until we ran into some problems cinching the straps. We had watched > where the straps were touching the body due to the injury. However, > the patient was in great pain during the cinching. We noticed that > it appeared to only happen during the initial movement then stopped > which allowed us to cinch the webbing across the upper body. We > then moved to the lower straps and ran into problems from > compression around the injury so I basically then told John and the > others that we would need to fasten the lower extremities > differently than ER-NCRC standard. This entailed running the right > webbing down about 8 inches along the ferno before going across for > the X and some of the extra webbing being used criss-crossing a > different time above and below the knees. Dale also said he was in all cotton (cotton longjohns under jeans), as he was surveying a known dry passage. Despite being in cotton, he never got signicantly cold, because he was dressed more warmly than usual. Nonetheless, he was a bit worried when he was packaged for the evacuation in nothing but cotton blankets. Modifying tieins for different injuries is part and parcel of real cave rescue. Variations in packaging are not usually covered in NCRC cave rescue classes, but are discussed in some detail in Wilderness EMT classes. Though there might be an argument for including more of this in NCRC training, I think the best place for it is in a WEMT course. This is where you're discussing the anatomy, physiology, diagnosis and treatment of the various injuries, and where you're already thinking about the various injuries. > About this time a Paramedic (or appeared to be) > showed up and asked about injuries. I mentioned we would be ready > to move in five. The Paramedic said okay and that we would take > vitals at the Ball Room and left (Didn't see him again). Dale noted he is a diabetic. But Dale told the first-in team he had no symptoms of hypoglycemia, and thought his blood sugar was fine; he ate some food and drank some orange juice. When the local medics reached him, though they didn't examine him, they did insist on starting an IV and checking a dextrostick; when it read 78, and even though he felt fine, they gave him some glucose. When he reached the Uniontown ED, his blood sugar was 200, which was "a bit of a problem" as far as he was concerned. The local medics didn't have a field phone, so I suppose they were running under standing orders. When the first-in team reached Dale, he basically told them the results of his self-exam: he had fallen about 4 feet, hadn't hit his head, hadn't hurt his neck, and had no injuries except to the hip/pelvis. He notes that nobody examined him nor did they take vital signs. They just took his word for what was wrong. To their defense, none of them had any medical training other than the basidc first aid in the NCRC Orientation to Cave Rescue class. According to Dale, the local medic who arrived first, and who had no in-cave experience or cave rescue or Wilderness EMT training, did not attempt to perform an exam but simply took the report of the local rescuers, who had taken report from Dale. Scott Jones says he arrived to find no BP cuff or stethoscope, and he'd not brought them with him because he was told "they were already with the patient or would be there soon." > I had eight people on site and had requested > 12 more from the surface so we began moving. Everything went smooth > to the Ball Room. Then we ran into about 50 people (fire/rescue) > which slowed the train up from there out probably adding 30 minutes > to the extrication. > > Thats some of the basics. > > Now the questions of the day. > > As a rescurer without medical background and the presence of an EMT > on site upon arrival what precautions should I take in packaging and > extrication? > > What would be the proper tie in for a right hip injury? > > If the patient was smaller what would be the proper tie in since > they could more easily shift in the litter during extrication? > Basic principle: don't run tie-ins so they cross a part that hurts. Basic principle: make sure the patient is _secure_ in the litter. Usually we run a strap under the feet, so the patient is supported when you tilt the head of the litter up. But if a patient has a leg fracture, this won't work very well, so we tend to put a loop of webbing around each thigh then to the litter rail, or put (or tie) seat harness on the patient and run webbing from it to the litter rail. But in the case of a hip or pelvis fracture, this may not work very well. In that case, I'd use the seat harness, but also run straps under each arm for support, and provide hand loops so the patient can support some weight using his arms (and keep the straps under his arms from cutting in too deeply). If the patient is small, and is in a Ferno or similar litter, the patient may tend to slide from side to side. This can be prevented by padding on either side of the patient. There's usually enough extra gear around to stuff some of it on either side of the patient. One other thing: it's sort of standard EMS practice to place patients with pelvis fractures on a backboard, the idea being that it serves as a splint. However, lying on an unpadded backboard for a several-hour evac is likely to cause necrosis ("gangrene," sort of; skin death) of the skin of the lower back, sometimes requiring plastic surgery and long hospital stays. And standard NCRC packaging in a litter, as long as there's padding on either side if in a Ferno instead of a Sked, will be just fine for splinting a pelvis fracture. I also wrote an article about general medical considerations litter tieins that was published in the Muddy Litter Letter [National Speleological Society Cave Rescue Section newsletter] and I will post it in a separate message to both these lists. > What should I ask of the medical personnel to make sure that > necessary vitals etc. have been taken? (We latter learned that most > had not been taken initially.) Say: "Even if I look like I know what I'm doing, I have minimal first aid training. Please examine this patient and take vital signs." In a rescue situation it's easy to assume that, since someone is caring for the patient already, that a complete exam has been done. I'm a big fan of re-examination in the wilderness anyway, as long as the patient is stable. Scoop-and-run doesn't make much sense when you've got a multi-hour evac, unless the patient has signs of deteriorating level of consciousness or continued or worsening shock despite PO or IV fluids. Those at the scene reportedly asked for "two medics and all the medical gear they'll need" but the paramedic who responded then left to go back to the surface, leaving the patient with not even an EMT. Since the local medics reportedly left Dale, there might be questions about abandonment. But since I think Scott was in the cave at that point, there was a trained medic nearby in case something untoward happened. Maybe someone can clarify whether there was an unbroken chain of EMTs or paramedics caring for Dale during the evacuation. Certainly I've been a proponent of the idea that, especially in cave rescue, medics must be rotated for their own safety, due to the concerns about exhaustion and hypothermia. In this case, though, the rescue was short and relatively dry. Or perhaps the local medics were inadequately equipped and clothed for the cave and had to leave for that reason? To be continued . . . -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: Laurel Caverns Cave Rescue, Part 4 of 4 Cc: Cavers Digest Reply-to: kconover+@pitt.edu Date: Wed, 6 Dec 1995 15:39:26 November 1995 Laurel Caverns Cave Rescue Review, Part 4 of 4 > > What signs in the patient should I and other rescurers look for with > a hip injury during extrication? Well, most true hip dislocations are posterior, from a fall onto the feet or knees, and the hip is in a flexed position, and can't be extended (straightened) all the way because of mechanical blockage at the hip joint. That's not at all what Dale had from my understanding. Next: "hip" is used generically by the lay public to refer to anything around the pelvic girdle including what I would call a pelvic fracture. EMTs and physicians generally use it to refer to the "true" hip joint, which is best palpated in the middle of the groin, where it is closest to the surface. However, medical people also generically refer to fractures of the proximal femur. Though drawing with ASCII characters is always difficult, look below and assume that the capital C below is the acetabulum ("socket") and the small o is the head of the femur. The backslash (\) is the _neck_ of the femur. Where it straightens out and becomes || characters is the _greater_trochanter_, the bump you can feel below the muscles in your lateral thigh, if you go down one hand's length from your beltline. (And yes I know my diagram looks dislocated. Quit cracking jokes and pay attention.) The neck of the femur is the most commonly fractured portion, and this is the common "hip fracture" seen in the elderly. (Look at this with a nonproportional font such as Courier.) Co acetabulum and head of femur \ greater trochanter | | shaft of femur | However, what Dale had is a fracture of the pelvis, the big bones that your thighbones attach to and keep your bowels from falling out your rear. These fractures can be relatively minor, as Dale's was. Or, usually after bigger falls or other high-impact injuries, pelvic fractures can be much worse, to the point where people can die from the internal blood loss without a drop escaping the body. The usual way to check for a pelvic fracture is to check the urethra for blood leaking out as a sign of a transected urethra, palpate carefully for bony point tenderness (severe tenderness in one small area), and press on the pelvis to assess its stability. To do this, first find the landmarks: the symphisis pubis, which is the part of the pelvic bones in the midline in front, just above the genitals and in front of the bladder; and the anterior superior iliac crests, which are the first bony bumps you feel as you run your hands down your sides, somewhat toward the front (you know, the ones below which you're supposed to keep your seatbelt and seat harness). If the patient is lying flat on his or her back, I 1. press downward on the symphisis pubis 2. press inward (together) on the outside of the anterior superior iliac crests and 3. press outward on the inside of the anterior superior iliac crests. Pain in the pelvis in areas other than where your hands are probably indicates a fracture. Loud crunching sounds do, too. (Don't press that hard to start with.) > That's basically all I can think of right off. > > Oh yeah, one thing. Is it proper rescue procedure to elbow the head > of some fire/rescue personnel into a rock after they drop a couple > pound flashlight on the patients head? I heard about the flashlight > being dropped on the patients head while eating dinner after the > rescue and that was the comment on proper rescue procedure for that > situation. > Dale, too, noted the conflict between the cave-rescue-trained cavers and the non-cave-rescue-trained local firefighters, even from his place in the Sked stretcher. I would be interested to hear the viewpoint of the local firefighters, though, and will see if I can get this post to them so they can reply. However, let's be correct about term and the procedure. Grammatically, the proper cave rescue term is to "flatrock" the offending person. The proper procedure is _not_ to elbow the person's head into a rock, but to take a large flat rock and apply firmly to the cranium. While some decry this form of behavior modification as crude, it appropriate to note that cave rescuers are taught to use a flat rock, as opposed to a pointy one. I believe this is designed to meet OSHA requirements to prevent unnecessary body fluid exposure. ;-) But all joking aside, this is a good example of why untrained rescuers can be a hazard to themselves and others in wilderness rescue. During other rescues, firefighters with cotton under full turnout gear have overheated, sweated into their cotton clothing, which then lost all its insulating value, then became hypothermic. Others in fire helmets have become stuck by their fire helmets in small crawlways. And having untrained personnel in a cave without proper helmets or helmet-mounted headlights is an invitation to dropping handheld lights on the patients or other rescuers, and an invitation to rescuer head injury. The firefighters arrived and "blew past" the entrance control, Patty Kennedy; they refused to give her their names because they were in too much of a hurry to get into the cave. They also insisted on bringing a litter, even though the patient was already packaged in the Sked. Dale and Scott noted that the local paramedics who came into the cave didn't have helmets or lights, but they did have a press photographer with them. We've had problems with past cave rescues with leaving rescuers in the cave, which is why all cave rescue training courses drill into students the importance of entrance control. Patty isn't sure who called the local firefighters. Scott Jones had sent a limited page to the Westmoreland County special rescue team, and suspected that someone who had quit the team but still had a pager might have decided to alert the fire department and they then "jumped the call." Scott said that John Chenger said (getting a little removed from original sources here) that the owners/managers of the cave had not called the fire department. Scott and Dale observed that "the firsfighters didn't want to take orders from the cavers" and vice versa. The Incident Command System specifies that when multiple agencies respond to an incident, the first onscene assumes the command function, and subsequently-arriving agencies report to the first-in agency. I would guess that (1) the fire department doesn't believe in the ICS and believes they should be in charge of all rescues "in their back yard" or (2) they didn't see the NCRC-trained cavers there as an "agency" and therefore could take over and start running the rescue regardless of the cavers' expertise and training. I will note that, after this rescue, lots of fire department members signed up for the NCRC Basic Cave Rescue Orientation class to be held this weekend at Laurel Caverns. Scott and I also discussed our understanding of the legal basis for rescues in commercial caves in PA. Chuck Hemple, past Eastern Region coordinator for the National Cave Rescue Commission, had told me that commercial caves were classified as deep mines in PA law, and that by state law only "certified" personnel (i.e., NCRC-certified, for caves) were permitted to perform rescues in commercial caves. Scott said his understanding was different. I don't know and would be interested to find out if anyone has the law in hand and can post the exact wording. My apologies for any inaccuracies, inconsistencies or omissions, as this is all pretty much second or third hand. Nonetheless, I hope these messages, and others' posts related to this rescue, will improve the care of future cave rescue patients. Thank you. -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.3/cispop-1.6.1.3) ID for ; Thu, 7 Dec 1995 22:28:37 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.3/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 7 Dec 1995 22:28:36 -0500 (EST) Received: via switchmail; Thu, 7 Dec 1995 22:28:35 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 7 Dec 1995 22:27:21 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.3/cisls-2.4) ID ; Thu, 7 Dec 1995 22:26:21 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from post-ofc01.srv.cis.pitt.edu (root@post-ofc01.srv.cis.pitt.edu [136.142.185.10]) by list.srv.cis.pitt.edu with ESMTP (8.7.3/cisls-2.4) ID for ; Thu, 7 Dec 1995 22:26:19 -0500 (EST) Received: from ehdup-a3-14.rmt.net.pitt.edu (ehdup-a3-14.rmt.net.pitt.edu [136.142.20.64]) by post-ofc01.srv.cis.pitt.edu with SMTP (8.7.3/cispo-2.0.1.1) ID ; Thu, 7 Dec 1995 22:20:12 -0500 (EST) Message-Id: <199512080320.WAA06627@post-ofc01.srv.cis.pitt.edu> Comments: Authenticated sender is From: "Keith Conover, M.D." To: wilderness-emergency-medicine@list.pitt.edu Date: Thu, 7 Dec 1995 22:18:29 +0000 Subject: Laurel Caverns Cave Rescue, Part 4 of 4 Reply-to: kconover+@pitt.edu CC: wilderness-emergency-medicine@list.pitt.edu Priority: normal X-mailer: Pegasus Mail for Windows (v2.23) Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 0 The previous version was accidentally cut off. Here is the complete version: November 1995 Laurel Caverns Cave Rescue Review, Part 4 of 4 > > What signs in the patient should I and other rescurers look for with > a hip injury during extrication? Well, most true hip dislocations are posterior, from a fall onto the feet or knees, and the hip is in a flexed position, and can't be extended (straightened) all the way because of mechanical blockage at the hip joint. That's not at all what Dale had from my understanding. Next: "hip" is used generically by the lay public to refer to anything around the pelvic girdle including what I would call a pelvic fracture. EMTs and physicians generally use it to refer to the "true" hip joint, which is best palpated in the middle of the groin, where it is closest to the surface. However, medical people also generically refer to fractures of the proximal femur. Though drawing with ASCII characters is always difficult, look below and assume that the capital C below is the acetabulum ("socket") and the small o is the head of the femur. The backslash (\) is the _neck_ of the femur. Where it straightens out and becomes || characters is the _greater_trochanter_, the bump you can feel below the muscles in your lateral thigh, if you go down one hand's length from your beltline. (And yes I know my diagram looks dislocated. Quit cracking jokes and pay attention.) The neck of the femur is the most commonly fractured portion, and this is the common "hip fracture" seen in the elderly. (Look at this with a nonproportional font such as Courier.) Co acetabulum and head of femur \ greater trochanter | | shaft of femur | However, what Dale had is a fracture of the pelvis, the big bones that your thighbones attach to and keep your bowels from falling out your rear. These fractures can be relatively minor, as Dale's was. Or, usually after bigger falls or other high-impact injuries, pelvic fractures can be much worse, to the point where people can die from the internal blood loss without a drop escaping the body. The usual way to check for a pelvic fracture is to check the urethra for blood leaking out as a sign of a transected urethra, palpate carefully for bony point tenderness (severe tenderness in one small area), and press on the pelvis to assess its stability. To do this, first find the landmarks: the symphisis pubis, which is the part of the pelvic bones in the midline in front, just above the genitals and in front of the bladder; and the anterior superior iliac crests, which are the first bony bumps you feel as you run your hands down your sides, somewhat toward the front (you know, the ones below which you're supposed to keep your seatbelt and seat harness). If the patient is lying flat on his or her back, I 1. press downward on the symphisis pubis 2. press inward (together) on the outside of the anterior superior iliac crests and 3. press outward on the inside of the anterior superior iliac crests. Pain in the pelvis in areas other than where your hands are probably indicates a fracture. Loud crunching sounds do, too. (Don't press that hard to start with.) > That's basically all I can think of right off. > > Oh yeah, one thing. Is it proper rescue procedure to elbow the head > of some fire/rescue personnel into a rock after they drop a couple > pound flashlight on the patients head? I heard about the flashlight > being dropped on the patients head while eating dinner after the > rescue and that was the comment on proper rescue procedure for that > situation. > Dale, too, noted the conflict between the cave-rescue-trained cavers and the non-cave-rescue-trained local firefighters, even from his place in the Sked stretcher. I would be interested to hear the viewpoint of the local firefighters, though, and will see if I can get this post to them so they can reply. However, let's be correct about term and the procedure. Grammatically, the proper cave rescue term is to "flatrock" the offending person. The proper procedure is _not_ to elbow the person's head into a rock, but to take a large flat rock and apply firmly to the cranium. While some decry this form of behavior modification as crude, it appropriate to note that cave rescuers are taught to use a flat rock, as opposed to a pointy one. I believe this is designed to meet OSHA requirements to prevent unnecessary body fluid exposure. ;-) But all joking aside, this is a good example of why untrained rescuers can be a hazard to themselves and others in wilderness rescue. During other rescues, firefighters with cotton under full turnout gear have overheated, sweated into their cotton clothing, which then lost all its insulating value, then became hypothermic. Others in fire helmets have become stuck by their fire helmets in small crawlways. And having untrained personnel in a cave without proper helmets or helmet-mounted headlights is an invitation to dropping handheld lights on the patients or other rescuers, and an invitation to rescuer head injury. The firefighters arrived and "blew past" the entrance control, Patty Kennedy; they refused to give her their names because they were in too much of a hurry to get into the cave. They also insisted on bringing a litter, even though the patient was already packaged in the Sked. Dale and Scott noted that the local paramedics who came into the cave didn't have helmets or lights, but they did have a press photographer with them. We've had problems with past cave rescues with leaving rescuers in the cave, which is why all cave rescue training courses drill into students the importance of entrance control. Patty isn't sure who called the local firefighters. Scott Jones had sent a limited page to the Westmoreland County special rescue team, and suspected that someone who had quit the team but still had a pager might have decided to alert the fire department and they then "jumped the call." Scott said that John Chenger said (getting a little removed from original sources here) that the owners/managers of the cave had not called the fire department. Scott and Dale observed that "the firsfighters didn't want to take orders from the cavers" and vice versa. The Incident Command System specifies that when multiple agencies respond to an incident, the first onscene assumes the command function, and subsequently-arriving agencies report to the first-in agency. I would guess that (1) the fire department doesn't believe in the ICS and believes they should be in charge of all rescues "in their back yard" or (2) they didn't see the NCRC-trained cavers there as an "agency" and therefore could take over and start running the rescue regardless of the cavers' expertise and training. I will note that, after this rescue, lots of fire department members signed up for the NCRC Basic Cave Rescue Orientation class to be held this weekend at Laurel Caverns. Scott and I also discussed our understanding of the legal basis for rescues in commercial caves in PA. Chuck Hemple, past Eastern Region coordinator for the National Cave Rescue Commission, had told me that commercial caves were classified as deep mines in PA law, and that by state law only "certified" personnel (i.e., NCRC-certified, for caves) were permitted to perform rescues in commercial caves. Scott said his understanding was different. I don't know and would be interested to find out if anyone has the law in hand and can post the exact wording. My apologies for any inaccuracies, inconsistencies or omissions, as this is all pretty much second or third hand. Nonetheless, I hope these messages, and others' posts related to this rescue, will improve the care of future cave rescue patients. Thank you. Keith Conover, M.D. (NSS 12893, WD4PSY) - Information Systems Coordinator, Dept. of EM, Mercy Hospital - Clinical Assistant Professor, Dept. of Emergency Medicine, Univ. of Pittsburgh (EM Residency and Center for Emergency Medicine) - Medical Director, Wilderness EMS Institute (http://www.pitt.edu/DOC/95/30/32686/Wemsi.html) (for a WEMSI-sponsored list, send "subscribe wilderness-emergency-medicine" to Majordomo@list.pitt.edu) - Eastern Region, Natl. Cave Rescue Comm./Appalachian SAR Conf. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: litter tie-ins Cc: Cavers Digest Reply-to: kconover+@pitt.edu Date: Thu, 7 Dec 1995 22:51:14 Medical Considerations for Patient Tie-ins January 5, 1993 Keith Conover, M.D. Take a minute of your time to read this, and to think about the medical aspects of how you tie patients into a litter. I'm not thinking about security: you don't want your patient to fall out of the litter, even on a nontechnical evac, so every patient needs to be secure in the litter. I'm not thinking about packaging for hypothermia, or rigging the tie-ins to secure a patient with a broken leg, broken rib, whatever. I'm thinking about the medical effects of your tying the patient into the litter. What effects will this have? Well, first, the patient can't move. Immobilization has several medical effects. For someone with a broken spine, immobilization may prevent neurological injury to the spinal cord or the nerve roots coming out of it. For other broken bones, immobilization is good, too, at least up to a point. Actually, for certain fractures, too much immobilization can be bad. For instance, assume someone who has a small fracture of the head of the radius (just beyond the elbow, on the outside of the arm). How long should it be immobi- lized? Only for about three days, and only using a sling. After this, you need to get it moving again to prevent permanent stiff- ness in the joint. It'll be rare that you care for someone with a radial head fracture for more than three days, but the point is that immobilization is not always good. Immobilization also tends to make bones weaker, but this effect occurs over weeks, and is not likely to be a problem dur- ing cave rescue. Immobilization means that blood doesn't get pumped back to the heart very well. The veins pump blood back to the heart by way of one-way valves (see Figure). They work when the surround- ing muscles alternately contract and relax, squeezing different parts of the vein. If the legs and arms aren't moving, there is no pumping action, and blood tends to stagnate in the arms and legs. This means there is less blood return to the heart, and the arms and legs may even get puffy ("edema") from the extra fluid there. For this reason, immobilization is a significant risk factor for a clot in the leg (a deep venous thrombosis or DVT). Pieces may break off the clot and travel to the lung (a pulmonary embolism or PE). When it reaches the lung, it prevents blood from getting through the lung. This usually produces chest pain, shortness of breath, and if large enough, immediate death. Another important risk factor for DVT and PE is dehydration. Cave rescue patients are almost invariably dehydrated, from cold exposure and hypothermia if from nothing else. A third risk fac- tor, quite relevant to cave rescue, is local trauma to the legs. So, you see, by tying the patient into the litter, you're taking a patient who is at high risk for DVT and PE and immobilizing him or her, making DVT and PE even more likely. Is there anything you can do? If the patient is conscious, you can prompt the patient to alternately tighten and relax the legs. If you have a long wait because some of the rigging isn't ready, and the patient doesn't have a suspected spine injury, untie the patient and let him or her move around a little. Try to hydrate the patient as best you can: IV fluids if available, Gatorade or something similar if it's OK for the patient to take oral fluids. (I'll discuss oral fluids in another article.) There are medications that may help: blood thinners will help prevent clots. However, if your patient is bleeding, or may be bleeding, blood thinners are not a good idea. (For instance, if someone suffered a blow to the head with decreased level of consciousness, then you would worry about bleeding in the brain, and not give blood thinners.) One blood thinner that you proba- bly have in your pack is aspirin. A single small dose of aspirin is all it takes. (The dose is about 40 mg., which is half a "baby" aspirin, or a small fraction of a 325 mg. regular adult aspirin.) Larger doses don't have any more effect and may have less of a blood-thinner effect. Heparin is a blood thinner that is more potent than aspirin, but must be given as an injection into muscle or through an IV. However, heparin is not a standard prehospital drug even for paramedics, and should only be given on a doctor's order. There is one final thing that you can do. Be careful of your leg tie-in. Anything tight around the leg or ankle will decrease venous flow and promote clotting. If you can leave room for the patient to wiggle his or her legs, that's even better. The next time you package a patient, think about venous flow, DVTs, and PEs. -- End -- X-cs: From: Self To: DURKINTJ@ctrvax.Vanderbilt.Edu Subject: Re: litter tie-ins Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Fri, 8 Dec 1995 15:39:54 On 8 Dec 95 at 13:05, DURKINTJ@ctrvax.Vanderbilt.Ed wrote: > > Dr Conover, > > A question. If the patient ( as in the Laurel Cave incident recently > described ) presents with a pelvic fracture , doesn't this > necessitate spinal immobilization, due to the connection of the pelvis > to the spine as well as MOI? While I relize a longboard may not > be in the pt 's best interest in a prolonged transport, wouldn't > immobilization by other means ( vacuum splint, maybe ) be indicated? > This is , as I recall, in line wiht what I was taugh as ( Non - > Wilderness) EMT. > > curious on your thoughts... > Well, people with pelvis fractures from a high-speed MVA need to be immobilized because of the mechanism of injury and chance of concomitant spinal injury. Someone who fell 4' is not likely to have a spine injury, especially if he just landed on his rear. But a vacuum splint provides great splinting for a pelvic fracture, and to immobilize the pelvis you really need to immobilize most of the patient (but not necessarily the head and neck). The patient can probably tell you whether the immobilizations' good or not. -- End -- X-cs: From: Self To: Pierre_malfait@unicall.be (Pierre Malfait) Subject: Re: litter tie-ins Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Fri, 8 Dec 1995 15:42:40 On 8 Dec 95 at 21:36, Pierre Malfait wrote: > two remarks: > - IM heparin is leaved because of hematome and irregular reorption.Thus SC or > IV > - what about the heparins with low molecular weight? > > øøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøøø > Dr.Pierre Malfait, M.D. > Vredelaan 5 > B- 8370 Blankenberge > Belgium > Tel.:++ 32 50 41 60 84 > e-mail : Pierre_Malfait@unicall.be > Pierre, I agree. The low-molecular-weight heparins seem to have good anticoagulant effects with less bleeding complications. I just read an article in The Medical Letter about Dalteparin, a new (to the US) form. I'd love to see a study in bedridden patients, not just postsurgical patients, though, as it would compare to wilderness rescue better. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: (Fwd) Re: Laurel Caverns Cave Rescue, Part 4 of 4 Reply-to: kconover+@pitt.edu Date: Fri, 8 Dec 1995 17:57:16 ------- Forwarded Message Follows ------- Date: Fri, 8 Dec 1995 17:20:48 -0500 (EST) To: kconover+@pitt.edu From: ralson@isnet.is.bgsm.edu (Roy L. Alson, MD) Subject: Re: Laurel Caverns Cave Rescue, Part 4 of 4 Kieth, Please post on the server. Best to you and Betty for the Holidays and the New year Roy >> >> Oh yeah, one thing. Is it proper rescue procedure to elbow the head >> of some fire/rescue personnel into a rock after they drop a couple >> pound flashlight on the patients head? I heard about the flashlight >> being dropped on the patients head while eating dinner after the >> rescue and that was the comment on proper rescue procedure for that >> situation. >> > >Dale, too, noted the conflict between the cave-rescue-trained cavers >and the non-cave-rescue-trained local firefighters, even from his >place in the Sked stretcher. I would be interested to hear the >viewpoint of the local firefighters, though, and will see if I can get >this post to them so they can reply. > >However, let's be correct about term and the procedure. >Grammatically, the proper cave rescue term is to "flatrock" the >offending person. The proper procedure is _not_ to elbow the person's >head into a rock, but to take a large flat rock and apply firmly to >the cranium. While some decry this form of behavior modification as >crude, it appropriate to note that cave rescuers are taught to use a >flat rock, as opposed to a pointy one. I believe this is designed to >meet OSHA requirements to prevent unnecessary body fluid exposure. >;-) > >But all joking aside, this is a good example of why untrained rescuers >can be a hazard to themselves and others in wilderness rescue. During >other rescues, firefighters with cotton under full turnout gear have >overheated, sweated into their cotton clothing, which then lost all >its insulating value, then became hypothermic. Others in fire helmets >have become stuck by their fire helmets in small crawlways. And >having untrained personnel in a cave without proper helmets or >helmet-mounted headlights is an invitation to dropping handheld lights >on the patients or other rescuers, and an invitation to rescuer head >injury. > >The firefighters arrived and "blew past" the entrance control, Patty >Kennedy; they refused to give her their names because they were in too >much of a hurry to get into the cave. They also insisted on bringing >a litter, even though the patient was already packaged in the Sked. >Dale and Scott noted that the local paramedics who came into the cave >didn't have helmets or lights, but they did have a press photographer >with them. We've had problems with past cave rescues with leaving >rescuers in the cave, which is why all cave rescue training courses >drill into students the importance of entrance control. > >Patty isn't sure who called the local firefighters. Scott Jones had >sent a limited page to the Westmoreland County special rescue team, >and suspected that someone who had quit the team but still had a pager >might have decided to alert the fire department and they then "jumped >the call." Scott said that John Chenger said (getting a little >removed from original sources here) that the owners/managers of the >cave had not called the fire department. Scott and Dale observed that >"the firsfighters didn't want to take orders from the cavers" and vice >versa. The Incident Command System specifies that when multiple >agencies respond to an incident, the first onscene assumes the command >function, and subsequently-arriving agencies report to the first-in >agency. I would guess that (1) the fire department doesn't believe in >the ICS and believes they should be in charge of all rescues "in their >back yard" or (2) they didn't see the NCRC-trained cavers there as an >"agency" and therefore could take over and start running the rescue >regardless of the cavers' expertise and training. > >I will note that, after this rescue, lots of fire department members >signed up for the NCRC Basic Cave Rescue Orientation class to be held >this weekend at Laurel Caverns. > >Scott and I also discussed our understanding of the legal basis for >rescues in commercial caves in PA. Chuck Hemple, past Eastern Region >coordinator for the National Cave Rescue Commission, had told me that >commercial caves were classified as deep mines in PA law, and that by >state law only "certified" personnel (i.e., NCRC-certified, for caves) >were permitted to perform rescues in commercial caves. Scott said his >understanding was different. I don't know and would be interested to >find out if anyone has the law in hand and can post the exact wording. > >My apologies for any inaccuracies, inconsistencies or omissions, as >this is all pretty much second or third hand. Nonetheless, I hope >these messages, and others' posts related to this rescue, will improve >the care of future cave rescue patients. > >Thank you. > > >Keith Conover, M.D. (NSS 12893, WD4PSY) >- Information Systems Coordinator, Dept. of EM, Mercy Hospital >- Clinical Assistant Professor, Dept. of Emergency Medicine, > Univ. of Pittsburgh (EM Residency and Center for Emergency Medicine) >- Medical Director, Wilderness EMS Institute > (http://www.pitt.edu/DOC/95/30/32686/Wemsi.html) > (for a WEMSI-sponsored list, send "subscribe > wilderness-emergency-medicine" to Majordomo@list.pitt.edu) >- Eastern Region, Natl. Cave Rescue Comm./Appalachian SAR Conf. > The above incident again shows problems that arise with command and control at major, multi-agency responses. While those of us in the SAR community have the special training to handle situations like this, often our agencies do not have the "legal responsibility" to handle the problem within a jurisdiction. As Kieth pointed out above, no one knows who called the "locals". It might have been wise to notify them, once the operation had begun, let them know what was going on and ask for representation at the command post, before the cast of thousands arrived. Remember, as the "pros from Dover" we are there to assist the locals in handling the incident. We need to continue to work to keep open avenues of communication. This incident needs to be used as a way to get the local agencies in the area ( who are likely to have another cave rescue in the future) to get involved and get training. It should not just become another war story about how the locals "blew it". Best wishes to all for the Holidays. Roy ========================================================== Roy L. Alson, PhD, MD, FACEP Emergency Medicine Bowman Gray School of Medicine ralson@isnet.is.wfu.edu 910-716-2193 fax: 910-716-5438 -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.3/cispop-1.6.1.3) ID for ; Fri, 8 Dec 1995 18:05:58 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.3/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Fri, 8 Dec 1995 18:05:57 -0500 (EST) Received: via switchmail; Fri, 8 Dec 1995 18:05:56 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Fri, 8 Dec 1995 18:03:57 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.3/cisls-2.4) ID ; Fri, 8 Dec 1995 18:02:03 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from post-ofc02.srv.cis.pitt.edu (root@post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by list.srv.cis.pitt.edu with ESMTP (8.7.3/cisls-2.4) ID for ; Fri, 8 Dec 1995 18:02:02 -0500 (EST) Received: from ehdup-a2-2.rmt.net.pitt.edu (ehdup-a2-2.rmt.net.pitt.edu [136.142.20.32]) by post-ofc02.srv.cis.pitt.edu with SMTP (8.7.3/cispo-2.0.1.1) ID for ; Fri, 8 Dec 1995 18:00:19 -0500 (EST) Message-Id: <199512082300.SAA03909@post-ofc02.srv.cis.pitt.edu> Comments: Authenticated sender is From: "Keith Conover, M.D." To: wilderness-emergency-medicine@list.pitt.edu Date: Fri, 8 Dec 1995 17:58:35 +0000 Subject: (Fwd) Re: Laurel Caverns Cave Rescue, Part 4 of 4 Reply-to: kconover+@pitt.edu Priority: normal X-mailer: Pegasus Mail for Windows (v2.23) Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk ------- Forwarded Message Follows ------- Date: Fri, 8 Dec 1995 17:20:48 -0500 (EST) To: kconover+@pitt.edu From: ralson@isnet.is.bgsm.edu (Roy L. Alson, MD) Subject: Re: Laurel Caverns Cave Rescue, Part 4 of 4 Kieth, Please post on the server. Best to you and Betty for the Holidays and the New year Roy >> >> Oh yeah, one thing. Is it proper rescue procedure to elbow the head >> of some fire/rescue personnel into a rock after they drop a couple >> pound flashlight on the patients head? I heard about the flashlight >> being dropped on the patients head while eating dinner after the >> rescue and that was the comment on proper rescue procedure for that >> situation. >> > >Dale, too, noted the conflict between the cave-rescue-trained cavers >and the non-cave-rescue-trained local firefighters, even from his >place in the Sked stretcher. I would be interested to hear the >viewpoint of the local firefighters, though, and will see if I can get >this post to them so they can reply. > >However, let's be correct about term and the procedure. >Grammatically, the proper cave rescue term is to "flatrock" the >offending person. The proper procedure is _not_ to elbow the person's >head into a rock, but to take a large flat rock and apply firmly to >the cranium. While some decry this form of behavior modification as >crude, it appropriate to note that cave rescuers are taught to use a >flat rock, as opposed to a pointy one. I believe this is designed to >meet OSHA requirements to prevent unnecessary body fluid exposure. >;-) > >But all joking aside, this is a good example of why untrained rescuers >can be a hazard to themselves and others in wilderness rescue. During >other rescues, firefighters with cotton under full turnout gear have >overheated, sweated into their cotton clothing, which then lost all >its insulating value, then became hypothermic. Others in fire helmets >have become stuck by their fire helmets in small crawlways. And >having untrained personnel in a cave without proper helmets or >helmet-mounted headlights is an invitation to dropping handheld lights >on the patients or other rescuers, and an invitation to rescuer head >injury. > >The firefighters arrived and "blew past" the entrance control, Patty >Kennedy; they refused to give her their names because they were in too >much of a hurry to get into the cave. They also insisted on bringing >a litter, even though the patient was already packaged in the Sked. >Dale and Scott noted that the local paramedics who came into the cave >didn't have helmets or lights, but they did have a press photographer >with them. We've had problems with past cave rescues with leaving >rescuers in the cave, which is why all cave rescue training courses >drill into students the importance of entrance control. > >Patty isn't sure who called the local firefighters. Scott Jones had >sent a limited page to the Westmoreland County special rescue team, >and suspected that someone who had quit the team but still had a pager >might have decided to alert the fire department and they then "jumped >the call." Scott said that John Chenger said (getting a little >removed from original sources here) that the owners/managers of the >cave had not called the fire department. Scott and Dale observed that >"the firsfighters didn't want to take orders from the cavers" and vice >versa. The Incident Command System specifies that when multiple >agencies respond to an incident, the first onscene assumes the command >function, and subsequently-arriving agencies report to the first-in >agency. I would guess that (1) the fire department doesn't believe in >the ICS and believes they should be in charge of all rescues "in their >back yard" or (2) they didn't see the NCRC-trained cavers there as an >"agency" and therefore could take over and start running the rescue >regardless of the cavers' expertise and training. > >I will note that, after this rescue, lots of fire department members >signed up for the NCRC Basic Cave Rescue Orientation class to be held >this weekend at Laurel Caverns. > >Scott and I also discussed our understanding of the legal basis for >rescues in commercial caves in PA. Chuck Hemple, past Eastern Region >coordinator for the National Cave Rescue Commission, had told me that >commercial caves were classified as deep mines in PA law, and that by >state law only "certified" personnel (i.e., NCRC-certified, for caves) >were permitted to perform rescues in commercial caves. Scott said his >understanding was different. I don't know and would be interested to >find out if anyone has the law in hand and can post the exact wording. > >My apologies for any inaccuracies, inconsistencies or omissions, as >this is all pretty much second or third hand. Nonetheless, I hope >these messages, and others' posts related to this rescue, will improve >the care of future cave rescue patients. > >Thank you. > > >Keith Conover, M.D. (NSS 12893, WD4PSY) >- Information Systems Coordinator, Dept. of EM, Mercy Hospital >- Clinical Assistant Professor, Dept. of Emergency Medicine, > Univ. of Pittsburgh (EM Residency and Center for Emergency Medicine) >- Medical Director, Wilderness EMS Institute > (http://www.pitt.edu/DOC/95/30/32686/Wemsi.html) > (for a WEMSI-sponsored list, send "subscribe > wilderness-emergency-medicine" to Majordomo@list.pitt.edu) >- Eastern Region, Natl. Cave Rescue Comm./Appalachian SAR Conf. > The above incident again shows problems that arise with command and control at major, multi-agency responses. While those of us in the SAR community have the special training to handle situations like this, often our agencies do not have the "legal responsibility" to handle the problem within a jurisdiction. As Kieth pointed out above, no one knows who called the "locals". It might have been wise to notify them, once the operation had begun, let them know what was going on and ask for representation at the command post, before the cast of thousands arrived. Remember, as the "pros from Dover" we are there to assist the locals in handling the incident. We need to continue to work to keep open avenues of communication. This incident needs to be used as a way to get the local agencies in the area ( who are likely to have another cave rescue in the future) to get involved and get training. It should not just become another war story about how the locals "blew it". Best wishes to all for the Holidays. Roy ========================================================== Roy L. Alson, PhD, MD, FACEP Emergency Medicine Bowman Gray School of Medicine ralson@isnet.is.wfu.edu 910-716-2193 fax: 910-716-5438 Keith Conover, M.D. (NSS 12893, WD4PSY) - Information Systems Coordinator, Dept. of EM, Mercy Hospital - Clinical Assistant Professor, Dept. of Emergency Medicine, Univ. of Pittsburgh (EM Residency and Center for Emergency Medicine) - Medical Director, Wilderness EMS Institute (http://www.pitt.edu/DOC/95/30/32686/Wemsi.html) (for a WEMSI-sponsored list, send "subscribe wilderness-emergency-medicine" to Majordomo@list.pitt.edu) - Eastern Region, Natl. Cave Rescue Comm./Appalachian SAR Conf. -- End -- X-cs: From: Self To: "parada@hsmdla.sspn.sld.ar" Subject: Re: Spine board Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover@pitt.edu Date: Fri, 8 Dec 1995 21:11:10 On 8 Dec 95 at 21:50, parada@hsmdla.sspn.sld.ar wrote: > Dear Keith: > My name is Marcelo Parada, I am a Family doctor here in Argentina > in a small town called San Martin de los Andes that is actually a ski resort > (landscape is like Telluride for example). I took the ATLS and PHTLS coarses > (actually instructor in PHTLS) and my main concern or interest is Wilderness > medicine specially Trauma. I've been training a local mountain rescue team > in PHTLS adapted to wilderness enviroment because moutain climbing is a > growing sport around here so we've been having to rescue injured people > specially from a volcano 50 miles away with increasing frecuency and our > results were not very good when we were not organized. Now we are having > some trouble trying to select the best medical equipment specially regarding > to Spine board. The problem is we do not have an helicopter because there > was an accident a year ago and it crashed killing two persons, so we have to > carry the injured on the longboard all the way down the steep slopes and > that needs a hell of alot people. I would like to know if you could help me > sort out this problem. I was shown a picture of a Spine board with a wheel > below but I cant find any reference on its pros and cons and Ive never read > about it in JEMS or Wilderness Medicine (Auerbach) or else where. Are there > any other ways to solve this problem? > It's a pleasure to read the emails youve been sending to the wilderness list > and I am very interested in trying to take a coarse up there sometime. > Thank you for any help. > > Marcelo Parada MD > Hospital Ramon Carrillo > (8370) San Martin de los Andes > Provincia del Neuquen > ARGENTINA > I will be on a trip for a couple of weeks so my reply will maybe delayed. Glad to hear of your interest. Most of the wheels I've seen attach to a wire-basket ("Stokes'") litter. There are very expensive nice ones available from California Mountain Company (CMC Rescue Equipment, PO Drawer 6870, Santa Barbara, CA 93160 USA). I also know people who attached bicycle or wheelbarrow tires to a Stokes litter. Just takes a bit of ingenuity. If you're planning on taking a course, I'd plan to go to the next World Congress on Wilderness Medicine that should be in another 2-3 years. I'm sure you will see notices on the wilderness-emergency-medicine list. However, speaking of backboards for a long carry out, the best option is a vacuum splint. Pioneered in Scandinavia, these bags of styrofoam plastic beads are floppy until you pump all the air out, then become rigid. Lay one of these in a plastic or wire Stokes basket, lie the patient in it, pump out the air, and the patient is warm, comfortable (unlike a hard backboard), and immobilized. -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.3/cispop-1.6.1.3) ID for ; Sat, 9 Dec 1995 09:45:39 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.3/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Sat, 9 Dec 1995 09:45:38 -0500 (EST) Received: via switchmail; Sat, 9 Dec 1995 09:45:37 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Sat, 9 Dec 1995 09:45:12 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.3/cisls-2.4) ID ; Sat, 9 Dec 1995 09:43:34 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from post-ofc02.srv.cis.pitt.edu (root@post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by list.srv.cis.pitt.edu with ESMTP (8.7.3/cisls-2.4) ID for ; Sat, 9 Dec 1995 09:43:28 -0500 (EST) Received: from ehdup-a3-1.rmt.net.pitt.edu (ehdup-a3-1.rmt.net.pitt.edu [136.142.20.51]) by post-ofc02.srv.cis.pitt.edu with SMTP (8.7.3/cispo-2.0.1.1) ID ; Sat, 9 Dec 1995 09:41:29 -0500 (EST) Message-Id: <199512091441.JAA23142@post-ofc02.srv.cis.pitt.edu> Comments: Authenticated sender is From: "Keith Conover, M.D." To: "parada@hsmdla.sspn.sld.ar" Date: Sat, 9 Dec 1995 09:27:53 +0000 Subject: Re: Spine board Reply-to: kconover+@pitt.edu CC: wilderness-emergency-medicine@list.pitt.edu Priority: normal X-mailer: Pegasus Mail for Windows (v2.23) Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 0 On 8 Dec 95 at 21:50, parada@hsmdla.sspn.sld.ar wrote: > Dear Keith: > My name is Marcelo Parada, I am a Family doctor here in Argentina > in a small town called San Martin de los Andes that is actually a ski resort > (landscape is like Telluride for example). I took the ATLS and PHTLS coarses > (actually instructor in PHTLS) and my main concern or interest is Wilderness > medicine specially Trauma. I've been training a local mountain rescue team > in PHTLS adapted to wilderness enviroment because moutain climbing is a > growing sport around here so we've been having to rescue injured people > specially from a volcano 50 miles away with increasing frecuency and our > results were not very good when we were not organized. Now we are having > some trouble trying to select the best medical equipment specially regarding > to Spine board. The problem is we do not have an helicopter because there > was an accident a year ago and it crashed killing two persons, so we have to > carry the injured on the longboard all the way down the steep slopes and > that needs a hell of alot people. I would like to know if you could help me > sort out this problem. I was shown a picture of a Spine board with a wheel > below but I cant find any reference on its pros and cons and Ive never read > about it in JEMS or Wilderness Medicine (Auerbach) or else where. Are there > any other ways to solve this problem? > It's a pleasure to read the emails youve been sending to the wilderness list > and I am very interested in trying to take a coarse up there sometime. > Thank you for any help. > > Marcelo Parada MD > Hospital Ramon Carrillo > (8370) San Martin de los Andes > Provincia del Neuquen > ARGENTINA > I will be on a trip for a couple of weeks so my reply will maybe delayed. Glad to hear of your interest. Most of the wheels I've seen attach to a wire-basket ("Stokes'") litter. There are very expensive nice ones available from California Mountain Company (CMC Rescue Equipment, PO Drawer 6870, Santa Barbara, CA 93160 USA). I also know people who attached bicycle or wheelbarrow tires to a Stokes litter. Just takes a bit of ingenuity. If you're planning on taking a course, I'd plan to go to the next World Congress on Wilderness Medicine that should be in another 2-3 years. I'm sure you will see notices on the wilderness-emergency-medicine list. However, speaking of backboards for a long carry out, the best option is a vacuum splint. Pioneered in Scandinavia, these bags of styrofoam plastic beads are floppy until you pump all the air out, then become rigid. Lay one of these in a plastic or wire Stokes basket, lie the patient in it, pump out the air, and the patient is warm, comfortable (unlike a hard backboard), and immobilized. Keith Conover, M.D. (NSS 12893, WD4PSY) - Information Systems Coordinator, Dept. of EM, Mercy Hospital - Clinical Assistant Professor, Dept. of Emergency Medicine, Univ. of Pittsburgh (EM Residency and Center for Emergency Medicine) - Medical Director, Wilderness EMS Institute (http://www.pitt.edu/DOC/95/30/32686/Wemsi.html) (for a WEMSI-sponsored list, send "subscribe wilderness-emergency-medicine" to Majordomo@list.pitt.edu) - Eastern Region, Natl. Cave Rescue Comm./Appalachian SAR Conf. -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.3/cispop-1.6.1.3) ID for ; Sat, 9 Dec 1995 12:55:21 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.3/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Sat, 9 Dec 1995 12:55:20 -0500 (EST) Received: via switchmail; Sat, 9 Dec 1995 12:55:19 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Sat, 9 Dec 1995 12:53:16 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.3/cisls-2.4) ID ; Sat, 9 Dec 1995 12:51:37 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from mail06.mail.aol.com (mail06.mail.aol.com [152.163.172.108]) by list.srv.cis.pitt.edu with SMTP (8.7.3/cisls-2.4) ID for ; Sat, 9 Dec 1995 12:51:35 -0500 (EST) From: Wb7qni@aol.com Received: by mail06.mail.aol.com (8.6.12/8.6.12) id MAA26605; Sat, 9 Dec 1995 12:51:04 -0500 Date: Sat, 9 Dec 1995 12:51:04 -0500 Message-ID: <951209125104_129082191@mail06.mail.aol.com> To: parada@hsmdla.sspn.sld.ar cc: wilderness-emergency-medicine@list.pitt.edu Subject: Spine board rescues... Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 0 > I was shown a picture of a Spine board with a wheel below but I > can't find any reference on its pros and cons and Ive never read > about it in JEMS or Wilderness Medicine (Auerbach) or else where. > Are there any other ways to solve this problem? Marcelo, In the Pacific Northwest, we for years hiked out Stokes litters with our bare hands, necessitating (if I remember correctly) six fresh rescuers per mile. About 1985, someone found and purchased a new system which used aluminum and plastic pack frames (minus the backpacks) which had been designed to clip into a webbing system which attached directly to the Stokes. With this system, we could pack a Stokes out with four people total. (No need for fresh rescuers.) An added advantage was that it was much easier to use on inclines, in snow, and on narrow trails, because the webbing system allowed much more individual movement and was much more stable if one rescuer lost a grip. This system is commercially available, though I don't have the manufacturer's name at my fingertips. If you're interested, I'll call and find out. Perhaps someone else on this list knows. Incidentally, we also have a wheel system for litter packing. It never worked well for the evacuation conditions we were asked to participate in (rough terrain and snow), so we have hardly ever used it though we still bring it to rescues last I heard. The pack frame system turned out to be far superior. James Li, MD Resident, emergency medicine Charity Hospital, New Orleans (wb7qni@aol.com) -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.3/cispop-1.6.1.3) ID for ; Sun, 10 Dec 1995 12:36:27 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.3/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Sun, 10 Dec 1995 12:36:26 -0500 (EST) Received: via switchmail; Sun, 10 Dec 1995 12:36:26 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Sun, 10 Dec 1995 12:34:24 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.3/cisls-2.4) ID ; Sun, 10 Dec 1995 12:33:10 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from mail02.mail.aol.com (mail02.mail.aol.com [152.163.172.66]) by list.srv.cis.pitt.edu with SMTP (8.7.3/cisls-2.4) ID for ; Sun, 10 Dec 1995 12:33:08 -0500 (EST) From: EMSIMAGES@aol.com Received: by mail02.mail.aol.com (8.6.12/8.6.12) id MAA26873; Sun, 10 Dec 1995 12:32:37 -0500 Date: Sun, 10 Dec 1995 12:32:37 -0500 Message-ID: <951210123236_69001837@mail02.mail.aol.com> To: parada@hsmdla.sspn.sld.ar cc: wilderness-emergency-medicine@list.pitt.edu Subject: Re: Wheeled litter Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 0 James Li, MD- Discussing litter wheels you wrote: >>This system is commercially available, though I don't have the >>manufacturer's name at my fingertips. If you're interested, I'll call and >>find out. Perhaps someone else on this list knows. FYI Ferno Washington Mfg. of a litter wheel (albeit cost prohibitive at beyond $400?) that will accomodate most litters... perhaps others are available... Ken Kerr EMSIMAGES@AOL.COM EMTP- Jefferson County EMS East TN -- End -- Received: from post-ofc01.srv.cis.pitt.edu (post-ofc01.srv.cis.pitt.edu [136.142.185.10]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.3/cispop-1.6.1.3) ID for ; Mon, 11 Dec 1995 01:38:59 -0500 Received: from local (daemon@localhost) by post-ofc01.srv.cis.pitt.edu (8.7.3/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 11 Dec 1995 01:38:58 -0500 (EST) Received: via switchmail for kconover+@pitt.edu; Mon, 11 Dec 1995 01:38:57 -0500 (EST) Received: from tpoint.net (tpoint-gw.tpoint.net [204.29.207.2]) by post-ofc01.srv.cis.pitt.edu with SMTP (8.7.3/cispo-2.0.1.1) ID ; Mon, 11 Dec 1995 01:35:24 -0500 (EST) Received: from LOCALNAME by tpoint.net with SMTP (8.6.10/25-eef) id GAA26912; Mon, 11 Dec 1995 06:35:21 GMT Date: Mon, 11 Dec 1995 06:35:21 GMT Message-Id: <199512110635.GAA26912@tpoint.net> X-Sender: jgreen@tpoint.net X-Mailer: Windows Eudora Version 1.4.5 Mime-Version: 1.0 Content-Type: text/plain; charset="us-ascii" To: kconover+@pitt.edu From: jgreen@tpoint.net (John Green) Subject: compartment syndrom? Cc: wilderness-emergency-medicine@pitt.edu X-PMFLAGS: 34078848 0 I'm trying to find inforamtion in papers or books on compartment syndrom - both in pathological aspects and the systemic outcomes, such as trapped in crack/crevice or hanging in a seat harness.. I heard the Canadians had done a study with the seat harness and came up with some really low numbers...this is for a self resQ curriculum... thank you.. -- John Green cave hard..cave safe NSS#39986 jgreen@tpoint.net -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.3/cispop-1.6.1.3) ID for ; Mon, 11 Dec 1995 11:23:58 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.3/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 11 Dec 1995 11:23:57 -0500 (EST) Received: via switchmail; Mon, 11 Dec 1995 11:23:56 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 11 Dec 1995 11:21:48 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.3/cisls-2.4) ID ; Mon, 11 Dec 1995 11:19:59 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from mail13.digital.com (mail13.digital.com [192.208.46.30]) by list.srv.cis.pitt.edu with SMTP (8.7.3/cisls-2.4) ID for ; Mon, 11 Dec 1995 11:19:57 -0500 (EST) Received: from us2rmc.zko.dec.com by mail13.digital.com; (5.65v3.2/1.0/WV) id AA30035; Mon, 11 Dec 1995 11:10:52 -0500 Received: from xdelta.enet by us2rmc.zko.dec.com (5.65/rmc-22feb94) id AA13504; Mon, 11 Dec 95 09:13:06 -0500 Message-Id: <9512111413.AA13504@us2rmc.zko.dec.com> Received: from xdelta.enet; by us2rmc.enet; Mon, 11 Dec 95 11:07:43 EST Date: Mon, 11 Dec 95 11:07:43 EST From: Steve Hoffman To: wilderness-emergency-medicine@list.pitt.edu Cc: hoffman@xdelta.ENET.dec.com Apparently-To: wilderness-emergency-medicine@list.pitt.edu Subject: RE^2: Laurel Caverns Cave Rescue Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 0 >The above incident again shows problems that arise with command and control >at major, multi-agency responses. While those of us in the SAR community >have the special training to handle situations like this, often our agencies >do not have the "legal responsibility" to handle the problem within a >jurisdiction. >As Kieth pointed out above, no one knows who called the "locals". It might >have been wise to notify them, once the operation had begun, let them know >what was going on and ask for representation at the command post, before the >cast of thousands arrived. >Remember, as the "pros from Dover" we are there to assist the locals in >handling the incident. We need to continue to work to keep open avenues of >communication. This incident needs to be used as a way to get the local >agencies in the area ( who are likely to have another cave rescue in the >future) to get involved and get training. "Keeping open avenues of communication" is a good start, but it's usually not sufficiently proactive. Emergency services priorities -- in descending order -- are: Safety of emergency personnel; Rescue of victims; Preservation of property. Determining legal responsiblity is something for the legislatures to debate and decide and -- when somebody gives at least the appearance of screwing up -- to occupy the time of the courts and the lawyers. SAR and cave teams do need to acquire some sort of standing with the legislature(s), but more importantly, they must acquire standing with the local emergency services. The Laurel Caverns Cave Rescue situation clearly points to the need for pre- and post-incident training, and for additional work in the SAR community to understand basic local firefighting procedures and to work with the local community emergency services. SAR and various specialist teams can become a trusted primary participant in an incident, rather than -- and I say this having trained with some SAR folks myself :-) -- a bunch of strangely-dressed, strangely-equipped, and unfamiliar folks, using communications gear set on some strange radio frequency. Various local firefighters and local EMS personnel have no clue how to conduct or to assist with SAR -- SAR is typically not included in any standard fire nor EMS training. SAR organizations can and should (attempt to) change this. And SAR teams may not be aware of what the local services have access to or are trained or required to do -- some of the stuff a rural fire or EMS service can "acquire" in an emergency is really quite amazing. (One rural northeastern US fire company I am familiar with had access to a military-surplus Sno-Cat.) What can a SAR or cave-rescue team do? Offer training sessions to local fire and emergency services departments, covering topics in environmental emergencies, in basic search-and-rescue procedures, and in the various SAR and cave-rescue resources available to them -- see "Sno-Cat", above. And as was pointed out in the original message, include information in these sessions in how to detect the initial onset of hypothermia, how to correctly dress for exertion in cold weather, and on the key points of ICS and how your service uses ICS to operate in these situations -- and even if this knowledge is never used in a SAR or cave situation, this information will be of value to the local services personnel. And the SAR and cave-rescue team can and should learn about those "Sno-Cat" resources. In an emergency (and IMNSHO), SAR and cave-rescue teams can and should be treated the same as a HazMat specialist or team -- SAR teams are the experts in their area(s) of knowledge and are correctly equipped to deal with the situation, and are and should be called in to "assist" the local emergency services teams. Not to run the scene. The minute an unfamiliar and/or untrusted SAR, caver, or HazMat team even tries to "run the scene", they run the risk of being ignored and/or removed from the scene. And this situation will have unfortunate implications to all parties -- to any ill-trained and ill-equipped rescuers, and to the victim(s) alike. Start by offering to make a presentation to the regional fire chiefs' or mutual aid organization. Press on the personnel safety aspects, and the general applicability of the knowledge. And keep after the various organization(s) -- personnel turnover can be quite common, and having a "familiar face" is important. Steve Hoffman NR EMT-Intermediate, WEMT, N1THN, former firefighter -- ps: I have no delusions that this, ICS, or any other approach will solve the "entire" interagency problem. The local fire chief may not trust you or may not believe in the ICS "fad", and it does take a long time and a lot of work to change beliefs such as this. (And ten minutes to blow it.) pps: New Hampshire has centralized all SAR operations under the command of the Department of Fish and Game. (These fine folk are lovingly called the `Carp Cops'. :-) New Hampshire has also placed command and command responsibilities on the highest-ranging fire service officer in (non-SAR) emergencies. These simple regulations greatly reduce command squabbles. -- End -- X-cs: From: Self To: Steve Hoffman ,hoffman@xdelta.ENET.dec.com Subject: Re: RE^2: Laurel Caverns Cave Rescue Reply-to: kconover+@pitt.edu Date: Thu, 14 Dec 1995 19:32:26 On 11 Dec 95 at 11:07, Steve Hoffman wrote: > The Laurel Caverns Cave Rescue situation clearly points to the need > for pre- and post-incident training, and for additional work in the > SAR community to understand basic local firefighting procedures and > to work with the local community emergency services. SAR and various The reports seem to suggest to me that the problem is not that the cavers didn't understand firefighting, but that the firefighters didn't understand cave rescue or the cave environment (e.g., using handheld lights and dropping one on the patient's head). [snip] > > Various local firefighters and local EMS personnel have no clue how to > conduct or to assist with SAR -- SAR is typically not included in any > standard fire nor EMS training. SAR organizations can and should > (attempt to) change this. [snip] > What can a SAR or cave-rescue team do? Offer training sessions to > local fire and emergency services departments, covering topics in > environmental emergencies, in basic search-and-rescue procedures, > and in the various SAR and cave-rescue resources available to them > -- see "Sno-Cat", above. And as was pointed out in the original > message, include information in these sessions in how to detect the > initial onset of hypothermia, how to correctly dress for exertion > in cold weather, and on the key points of ICS and how your service > uses ICS to operate in these situations -- and even if this knowledge > is never used in a SAR or cave situation, this information will be of > value to the local services personnel. And the SAR and cave-rescue > team can and should learn about those "Sno-Cat" resources. I found out after my original posts that "quite a few" members of the Hopwood Fire Department had taken an NCRC Basic Cave Rescue Orientation, which includes all these things, given by NCRC at their fire hall in years past. I don't know how to square this with what was reported. Perhaps none of the NCRC-trained firefighters were there? Or perhaps none were in leadership positions so as to manage the operation better? > In an emergency (and IMNSHO), SAR and cave-rescue teams can and should > be treated the same as a HazMat specialist or team -- SAR teams are > the experts in their area(s) of knowledge and are correctly equipped > to deal with the situation, and are and should be called in to "assist" > the local emergency services teams. Not to run the scene. The minute > an unfamiliar and/or untrusted SAR, caver, or HazMat team even tries > to "run the scene", they run the risk of being ignored and/or removed > from the scene. And this situation will have unfortunate implications > to all parties -- to any ill-trained and ill-equipped rescuers, and to > the victim(s) alike. The only problem with this idea is that often the specialty team is the only one with the expertise to run the operation. Lost person serch is an excellent and critical example. Those with the most training and expertise in lost person search should _run_ the operation at the highest level (even higher than ICS Operations Chief) to provide the best outcome. And only in highly-frequented areas such as the National Parks are the local rescue people expert at running such operations. Many emergency service providers in areas with lots of lost people have arrangements with nearby search teams to run the operations for them. The same applies to cave search and cave rescue. A large part of NCRC training, at Level II and above, is MANAGEMENT and not tactics. [snip] > And keep after the > various organization(s) -- personnel turnover can be quite common, > and having a "familiar face" is important. This is probably why past training sessions for the Hopwood Fire Department and nearby EMS agencies haven't had as salutary effect as one would desire. -- End -- X-cs: From: Self To: Jose Salazar Subject: Re: WMS Wilderness First Aid Course -Reply Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Mon, 18 Dec 1995 10:53:46 On 5 Dec 95 at 8:03, Jose Salazar wrote: > Keith, > > It was good seeing you this weekend. Unfortunatly business > commitments kept me away part of the weekend. Thank you for > the information regarding discussions about wilderness FA. > I will speak with Al Thygerson. I will also keep you informed of > where we are heading. > For your information, in March we will be releasing the 2nd edition > of our Responding to Emergencies book. It will have a chapter on > "When Help is Delayed" It provides and introduction to rural and > wilderness settings. We are also looking at releasing this as a > module. In that case it would probably be a good add on for > minimum training for FTMs. I saw in the e-mails that standard first > aid was being considered as a minimum this module would be > beneficial. Sounds interesting. But the Responding to Emergencies book/course is the equivalent of the old Advanced course, right? Which means a bit more than the old standard first aid. But I'll be very interested to see that chapter in the book and the lesson plan for that portion of the course. Since ARC first aid courses are generally available cheap, this may be a more reasonable alternative for poor outdoor clubs and SAR teams compared to the planned NAS/WMS Wilderness First Aid course. -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.3/cispop-1.6.1.3) ID for ; Fri, 22 Dec 1995 14:26:10 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.3/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Fri, 22 Dec 1995 14:26:09 -0500 (EST) Received: via switchmail; Fri, 22 Dec 1995 14:26:09 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Fri, 22 Dec 1995 14:24:59 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.3/cisls-2.4) ID ; Fri, 22 Dec 1995 14:23:20 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from emout04.mail.aol.com (emout04.mail.aol.com [198.81.10.12]) by list.srv.cis.pitt.edu with SMTP (8.7.3/cisls-2.4) ID for ; Fri, 22 Dec 1995 14:23:17 -0500 (EST) From: Wb7qni@aol.com Received: by emout04.mail.aol.com (8.6.12/8.6.12) id OAA05434 for wilderness-emergency-medicine@list.pitt.edu; Fri, 22 Dec 1995 14:22:45 -0500 Date: Fri, 22 Dec 1995 14:22:45 -0500 Message-ID: <951222142245_97221309@emout04.mail.aol.com> To: wilderness-emergency-medicine@list.pitt.edu Subject: Litter system... Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 0 For those who asked, I'm still waiting for details on the Stokes/packframe litter system. We know it is called the Aeroluen (no one knows the exact spelling), but are trying to find a manufacturer and price. Apparently, the Mountain Rescue Council (MRC) in Seattle has one they're not using which is up for sale. I'll try to get more info as soon as I can, but it may be a month or so. Let me know directly if you need more information. James Li, MD -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.3/cispop-1.6.1.3) ID for ; Wed, 27 Dec 1995 13:42:49 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.3/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Wed, 27 Dec 1995 13:42:47 -0500 (EST) Received: via switchmail; Wed, 27 Dec 1995 13:42:47 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Wed, 27 Dec 1995 13:41:25 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.3/cisls-2.4) ID ; Wed, 27 Dec 1995 13:40:16 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from sol.racsa.co.cr (sol.racsa.co.cr [200.9.56.10]) by list.srv.cis.pitt.edu with SMTP (8.7.3/cisls-2.4) ID for ; Wed, 27 Dec 1995 13:40:11 -0500 (EST) Received: by sol.racsa.co.cr (5.0/SMI-SVR4) id AA22619; Wed, 27 Dec 1995 12:40:06 +0600 Date: Wed, 27 Dec 1995 12:40:05 +0600 (GMT) From: "Gaia S.A" To: kconover+@pitt.edu Cc: Jose Salazar , wilderness-emergency-medicine@list.pitt.edu Subject: Re: WMS Wilderness First Aid Course -Reply In-Reply-To: <199512271627.LAA00938@post-ofc01.srv.cis.pitt.edu> Message-Id: Mime-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 35127424 0 Hi! This is Dario Castelfranco - Jardin Gaia - Costa Rica Widlife Rescue Center. Ph-Fax (506) 7770535 gaiamrsa@sol.racsa.co.cr Do you know if a Spanish translation exist or is planned in the next future ? Sincerly Dario Castelfranco On Wed, 27 Dec 1995, Keith Conover, M.D. wrote: > On 5 Dec 95 at 8:03, Jose Salazar wrote: > > > Keith, > > > > It was good seeing you this weekend. Unfortunatly business > > commitments kept me away part of the weekend. Thank you for > > the information regarding discussions about wilderness FA. > > I will speak with Al Thygerson. I will also keep you informed of > > where we are heading. > > For your information, in March we will be releasing the 2nd edition > > of our Responding to Emergencies book. It will have a chapter on > > "When Help is Delayed" It provides and introduction to rural and > > wilderness settings. We are also looking at releasing this as a > > module. In that case it would probably be a good add on for > > minimum training for FTMs. I saw in the e-mails that standard first > > aid was being considered as a minimum this module would be > > beneficial. > > Sounds interesting. But the Responding to Emergencies book/course is > the equivalent of the old Advanced course, right? Which means a bit > more than the old standard first aid. But I'll be very interested to > see that chapter in the book and the lesson plan for that portion of > the course. Since ARC first aid courses are generally available > cheap, this may be a more reasonable alternative for poor outdoor > clubs and SAR teams compared to the planned NAS/WMS Wilderness First > Aid course. > > Keith Conover, M.D. (NSS 12893, WD4PSY) > - Information Systems Coordinator, Dept. of EM, Mercy Hospital > - Clinical Assistant Professor, Dept. of Emergency Medicine, > Univ. of Pittsburgh (EM Residency and Center for Emergency Medicine) > - Medical Director, Wilderness EMS Institute > (http://www.pitt.edu/DOC/95/30/32686/Wemsi.html) > (for a WEMSI-sponsored list, send "subscribe > wilderness-emergency-medicine" to Majordomo@list.pitt.edu) > - Eastern Region, Natl. Cave Rescue Comm./Appalachian SAR Conf. > -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: Re: WMS Wilderness First Aid Course -Reply Reply-to: kconover@pitt.edu Date: Wed, 27 Dec 1995 14:43:17 On 27 Dec 95 at 12:40, Gaia S.A wrote: > Hi! This is Dario Castelfranco - Jardin Gaia - Costa Rica Widlife Rescue > Center. Ph-Fax (506) 7770535 gaiamrsa@sol.racsa.co.cr > > Do you know if a Spanish translation exist or is planned in the next > future ? > > Sincerly > Dario Castelfranco Don't know personally, but maybe Jose can tell us of any plans for a Spanish version of the Red Cross book. I don't know of anyone on-line to ask about the National Safety Council/Wilderness Medical Society book and course. If you're interested, or wish to express your interest in a Spanish translation of the NSC/WMS book, I suggest you write: Alton Thygerson Dept. of Health Sciences Brigham Young University Provo, UT 84602 USA -- End -- X-cs: From: Self To: Jose Salazar , wilderness-emergency-medicine@list.pitt.edu Subject: Re: WMS Wilderness First Aid Course -Reply -Reply Reply-to: kconover@pitt.edu Date: Wed, 27 Dec 1995 14:52:11 On 27 Dec 95 at 13:32, Jose Salazar [American Red Cross --KC] wrote: [snip] >> > For your information, in March we will be releasing the 2nd >> edition >> > of our Responding to Emergencies book. It will have a chapter >> on >> > "When Help is Delayed" It provides and introduction to rural >> and >> > wilderness settings. We are also looking at releasing this as a >> > module. In that case it would probably be a good add on for >> > minimum training for FTMs. I saw in the e-mails that standard >> first >> > aid was being considered as a minimum this module would be >> > beneficial. >> >> Sounds interesting. But the Responding to Emergencies >> book/course is the equivalent of the old Advanced course, right? >> Which means a bit more than the old standard first aid. But I'll be >> very interested to see that chapter in the book and the lesson >> plan for that portion of the course. Since ARC first aid courses >> are generally available cheap, this may be a more reasonable >> alternative for poor outdoor clubs and SAR teams compared to >> the planned NAS/WMS Wilderness First Aid course. > > Keith: > > The Responding to Emregencies course did not replace the old > Advanced First Aid course. It is a standard first aid level course > with additional information to fill H.S. and college curriculums. > Skill wise it's at the strandard level. The book is schedululed for > March 1996 release. > > Jose Salazar Thanks, Jose. I don't know if you are subscribed to the wilderness-emergency-medicine list, but I thought this was of general interest so I've posted it to that list. There was also a message on that list from Costa Rica, asking if there are plans to release the ARC first aid books in Spanish. I think was about both the Responding to Emergencies and the planned wilderness first aid course. Thanks. -- End -- X-cs: From: Self To: "parada@hsmdla.sspn.sld.ar" Subject: Re: Spine Board Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover@pitt.edu Date: Wed, 27 Dec 1995 15:08:18 On 27 Dec 95 at 10:51, parada@hsmdla.sspn.sld.ar wrote: > Keith > I received your message and I thank you very much for the information. > I was on a short christmas trip and just arrived yesterday so I'm answering > all my mail today. I am not sure what the "Stokes" is but I figure it is > like a "Basket" litter. "Navy Wire Basket Litter" is one of the terms also used: it's a steel or aluminum basket with steel chicken-wire inside it, though the more modern ones are high-impact plastic (e.g., Ferno-Washington, Junkin are US manufacturers). > I will be writing to CMC to get more Information. > The other question is about the vacuum splint which we frequently use in our > ski resort but we have some tecnical problems to get the injured properly > on it ,that means it is almost impossible to logroll someone on the > vacsplint even if you previously turn it into a longboard by pumping the air > out before putting the person on the splint ,then starting all the procedure > from the begining. Well, the solution to _that_ is simple, if I understand correctly. Log-roll the patient onto the arms of some people on one side, have them roll the patient up against their chests, which gets the patient up off the ground. Then lay the vacuum splint in front of them, and have them gently lower the patient into/onto the vacuum splint. It's still possible to have excellent spinal immobilization during this manuver. In cave rescue, we sometimes use slings passed under the patient, which allows lifting despite not being able to be exactly beside the patient. > Anyway I got a message from James Li that tells me about > a webbing system that apparently is better than the wheel so I will be > emailing him. There was a long discussion about webbing vs. wheels for wilderness rescue on the misc.emergency_services discusssion group about 6-12 months ago. Basically some like wheels, some like webbing. In our area (central Appalachians) wheels aren't used much, as our trails are rough. The only exception is places like popular national parks where some of the more popular trails are even paved with asphalt (macadam). Many of us (Appalachian Search and Rescue Conference) carry lengths of 2" (5 cm) wide automotive seatbelt webbing as "load straps" to attach to the litter rail, throw over the opposite shoulder, and bring down to the opposite hand. This webbing can also make a dandy piggy-back carry for a small and relatively uninjured patient. We find the idea of attaching the webbing to pack frames problematic due to the heavy brush in this area. We don't use packframes at all for rescue -- rescuers tend to end up hanging from their packframes in a rhododendron or mountain laurel bush. > Thanks again and hope to you a Merry Christmas and Happy New Year. > I will probably be in touch in the near future. > > Marcelo Parada MD > ARGENTINA Best wishes for happy holidays. I'll also post this to the wilderenss-emergency-medicine list. -- End -- X-cs: From: Self To: Bernie Roche ,marc@proxy.com (Marc Colbeck) Subject: Re: Wilderness EMS Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover@pitt.edu Date: Wed, 27 Dec 1995 16:28:38 On 27 Dec 95 at 15:05, Marc Colbeck wrote: > I've another question for you. Is there any article, or national clearing > house that can give me the broad picture of SAR/Wilderness/Disaster > medicine in North America? I've seen the WEMSI web page and have spoken at > length with Bernie Roche (nice fellow) and have learned a lot about WEMSI, > but I want to get a broad picture of the entire industry as well. Who > should I contact about that? I'd hesitate to call it an "industry" as that implies someone's paying for the product, which is not really the case for WEMS. It's nearly 100% volunteer. Even those who get paid for doing emergency work (me, and probably you, for example) end up doing wilderness EMS as "extra credit." But the current touchstone for the "industry" of providing WFR/WEMT training (which is, however, an industry, even if a cottage one) is the Prehospital Emergency Training, Standards and Accreditation Committee of the Wilderness Medical Society, and Eric Weiss Eric A. Weiss is the Chair of this committee. The WMS PETSAC is now working on developing a standardized curriculum for Wilderness First Responder and soon after for Wilderness EMT. ASTM, the standards organization, is working on standards for performance and training for these levels (WFR and WEMT), and John Clair John Clair is chairing these efforts. BTW, ASTM Committee F-30 on EMS may have a web page in the near future. It'll be announced on the wilderness-emergency-medicine list when it's open. Since this is of interest to many, I think, I'll take the liberty of (1) posting this message to the wilderness-emergency-medicine list, and (2) asking Bernie to post this information on the WEMSI web page. Thanks for your interest! -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.3/cispop-1.6.1.3) ID for ; Wed, 27 Dec 1995 14:52:04 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.3/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Wed, 27 Dec 1995 14:52:03 -0500 (EST) Received: via switchmail; Wed, 27 Dec 1995 14:52:03 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Wed, 27 Dec 1995 14:50:07 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.3/cisls-2.4) ID ; Wed, 27 Dec 1995 14:50:04 -0500 (EST) Date: Wed, 27 Dec 1995 14:50:04 -0500 (EST) Message-Id: <199512271950.OAA15620@list.srv.cis.pitt.edu> X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to Majordomo-Owner@list.pitt.edu using -f To: kconover+@pitt.edu From: Majordomo@list.pitt.edu Subject: Majordomo results: who Reply-To: Majordomo@list.pitt.edu X-PMFLAGS: 33554560 0 -- >>>> who wilderness-emergency-medicine Members of list 'wilderness-emergency-medicine': kollar+@pitt.edu kconover+@pitt.edu GRANDEYE@jeflin.tju.edu pacer@astro.ocis.temple.edu das@fore.com harrison@mitre.org broche@titan.tcn.net peter_mccabe@ed.gov MHMILLER@aol.com JSachter@aol.com holtschn@bbt.com rhpope1@eos.ncsu.edu dscuteri@apollo.hp.com jrr@apollo.hp.com ALAURENT@npr.org ucr@saccw.cc.ar.us mcmullen@u.washington.edu grow@SCFF.CHINALAKE.NAVY.MIL whitedl@ix.netcom.com hoffman@xdelta.ENET.dec.com IDWAYNE@OFFSMTP.hboc.com hans@CAM.ORG JSilver374@aol.com rcries@teleport.com TJMcGuire@aol.com BRITTONDL@k1023.a1.ornl.gov djoyce@pipeline.com rfh@hogpa.ho.att.com MikelMD@aol.com vinhan@pipeline.com BUTLER@mee.tcd.ie mlevyppp@corcomsv.corcom.com tdmeyer@terminus.intermind.net reburr@aol.com dtc9c@faraday.clas.virginia.edu pturner@netcom.com KentJB@aol.com MACKANIC@PICARD.EVMS.EDU checker+@pitt.edu briroy@freenet.columbus.oh.us davis@realtime.ab.ca Terrence.Jones@ncal.kaiperm.org thompsonke@merlin.aa.edu Ed.Pezalla@ncal.kaiperm.org Rafael.Gray@ncal.kaiperm.org rbrown@hippocrates.family.med.ualberta.ca chris@bison.RANGE.ORST.EDU Wb7qni@aol.com frederic.de.thysebaert@infoboard.be katyhein@u.washington.edu gluecker@warp6.cs.misu.NoDak.edu pbu-medical_pa@akm0044.anc.xwh.bp.com rnr@med.pitt.edu ish@rhi.hi.is llampe@linknet.kitsap.lib.wa.us schroeder@i-link.net carol@aemrc.arizona.edu fourrm.ednet@mmc.org pgormley@bdc.bethel.me.us mschoen@netcom.com Drbob2b@aol.com lindelld@medcolpa.edu JMPARNELL@aol.com Bob.Norris@Forsythe.Stanford.EDU jisutter@ix.netcom.com dkupas@shrsys.hslc.org medman@locke.ccil.org WolfT@dbisna.com RWayneND@aol.com Smwb@aol.com CPT_Kevin_Coonan@ftdetrck-ccmail.army.mil bcs@neosoft.com ralson@isnet.is.wfu.edu sweiss@mailhost.tcs.tulane.edu NKKS30F@prodigy.com prk5@cornell.edu David.Copeland@cor.dowjones.com shawn.herron@louky.iglou.com assistek@nicoh.com nitinn@acsu.buffalo.edu mconnolly@eckert.acadcomp.monroecc.edu dpeakmd@aol.com dudtej@hutchcc.edu sean@puma.cyberport.com EMSINST@aol.com kerok@yrkpa.kias.com uslander@uog9.uog.edu rrt01@health.state.ny.us jmbst85+@pitt.edu mat@robwales.demon.co.uk minifie@warp6.cs.misu.NoDak.edu stewa@etek.chalmers.se ngibson@qualcomm.com celms@ix.netcom.com rmw@netcom.com flong@CapAccess.org dmatthews@acf.dhhs.gov gatsby@i-2000.com reply@medconnect.com Robert.Peck@ncal.kaiperm.org ROBERTD@WESTMEAD.wh.su.edu.au khkh@slip.net tsmith@amauta.rcp.net.pe ellinwood@ACAVAX.LYNCHBURG.EDU Steven_Stephanides@qmlink.draper.com LMW8522@aol.com axc135@psu.edu st36@cornell.edu ecrabtre@INDYVAX.IUPUI.EDU durkintj@vuse.vanderbilt.edu btilton200@aol.com. dfcarter@facstaff.wisc.edu dean@ice.net.au cshaffer@falcon.lhup.edu g9ucwm@fnma.com MDNMSS@aol.com al443190@academ01.mty.itesm.mx RSSHANDLER@aol.com dsm@dcg.fe.defence.gov.au EMSIMAGES@aol.com 13460DJ@MSU.EDU DOUGHERTY@a1.kids.wustl.edu pirie1@server.uwindsor.ca parada@hsmdla.sspn.sld.ar SCHWARTZ@VMS.OCOM.OKSTATE.EDU JRPierceJr@aol.com Pierre_malfait@unicall.be mmintz@com-tec.com dburnet@cello.gina.calstate.edu MEFranklin@aol.com melb0012@gold.tc.umn.edu mkragnes@acr.acfac.rpslmc.edu toadster@mindspring.com BMannix@aol.com pdriscol@moose.uvm.edu thierbac@goofy.zdv.Uni-Mainz.DE lacey@access.mountain.net Paul.S.Spivack@Hitchcock.ORG grenard@herpmed.com RJustl@aol.com sanchez@elnorte.com.mx fletcja9@wfu.edu evds@ruca.ua.ac.be sissy@yfs.yfs.emory.edu boehm@primate.wisc.edu enramir@usp.br bonobo@uia.ua.ac.be antony_davidge@Merck.Com BugNut8833@aol.com rkyes@u.washington.edu glander@acpub.duke.edu SKAGGS@TWSUVM.UC.TWSU.EDU dzb@acpub.duke.edu cmzoo@zoo.cmzoo.org dboone@epix.net kimberly@access.mountain.net rge3@cornell.edu shermfw9@wfu.edu maxs@vision.eri.harvard.edu gaiamrsa@sol.racsa.co.cr meduca@igr.nl millsaps@interpath.com Dave.Du.Toit@enviro.iafrica.com 73710.2030@compuserve.com yorns@typhoon.coedu.usf.edu ANJRQ@acad2.alaska.edu pford@geron.com jgreen@tpoint.net Martinc@eden.com goose@esu.edu rosss@nevada.edu mjewell@vt.edu cpt_ian_wedmore@MAMC.SMTPLINK.AMEDD.ARMY.mil mikel@intercon.com fortujl9@wfu.edu Gavin.Lowe@comlab.ox.ac.uk MOSER.J.E%wec@dialcom.Tymnet.COM Gnanagas@aol.com bill_grimes@tikal.biosci.arizona.edu bmwiard@rmii.com lgentling@mayo.edu johnraj@pl.jaring.my tod_schimelpfenig@nols.edu -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.3/cispop-1.6.1.3) ID for ; Thu, 28 Dec 1995 02:36:16 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.3/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 28 Dec 1995 02:36:16 -0500 (EST) Received: via switchmail; Thu, 28 Dec 1995 02:36:16 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 28 Dec 1995 02:35:49 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.3/cisls-2.4) ID ; Thu, 28 Dec 1995 02:35:27 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from shrsys.hslc.org (SHRSYS.HSLC.ORG [192.100.94.3]) by list.srv.cis.pitt.edu with ESMTP (8.7.3/cisls-2.4) ID for ; Thu, 28 Dec 1995 02:35:25 -0500 (EST) Received: from SHRSYS.HSLC.ORG by SHRSYS.HSLC.ORG (PMDF V5.0-4 #15223) id <01HZBOR068TC90N6ZL@SHRSYS.HSLC.ORG> for WILDERNESS-EMERGENCY-MEDICINE@LIST.PITT.EDU; Thu, 28 Dec 1995 02:35:28 -0500 (EST) Date: Thu, 28 Dec 1995 02:35:28 -0500 (EST) From: "Douglas F. Kupas, MD" Subject: ED hypothermia protocol To: WILDERNESS-EMERGENCY-MEDICINE@list.pitt.edu Message-id: <01HZBOR08V0290N6ZL@SHRSYS.HSLC.ORG> X-VMS-To: WILDERNESS-EMERGENCY-MEDICINE@LIST.PITT.EDU MIME-version: 1.0 Content-type: TEXT/PLAIN; CHARSET=US-ASCII Content-transfer-encoding: 7BIT Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 35127424 0 A recent hypothermic patient has prompted some interesting discussions at my institution, and I would appreciate the group's input. The patient had been wet and cold for more than an hour and was responsive only to pain when our helicopter's medical crew arrived. Enroute to our institu- tion, the perfusionist and cardiothoracic surgeon were called into the hospital. This dramatically reduced the time to fem-fem bypass rewarming . The patient arrived with a bladder temp of 28.2 C. Just before completing vascular access for bypass the patient experienced a v. fib. arrest. He was rapidly warmed and was discharged neurologically intact. I am interested in any formal or informal criteria/protocols for mobilizing a bypass team prior to a patient's arrival. The pre-mobilization of the team in this case proved to be very beneficial. Thanks for your thoughts and have a Happy New Year! Doug Douglas F. Kupas, MD EMS Medical Director Geisinger Medical Center dkupas@geisinger.edu -- End -- X-cs: From: Self To: "Douglas F. Kupas, MD" Subject: Re: ED hypothermia protocol Reply-to: kconover@pitt.edu Date: Thu, 28 Dec 1995 11:50:47 On 28 Dec 95 at 2:35, Douglas F. Kupas, MD wrote: > A recent hypothermic patient has prompted some interesting discussions at > my institution, and I would appreciate the group's input. The patient > had been wet and cold for more than an hour and was responsive only to > pain when our helicopter's medical crew arrived. Enroute to our institu- > tion, the perfusionist and cardiothoracic surgeon were called into the > hospital. This dramatically reduced the time to fem-fem bypass rewarming > . The patient arrived with a bladder temp of 28.2 C. Just before > completing vascular access for bypass the patient experienced a v. fib. > arrest. He was rapidly warmed and was discharged neurologically intact. > I am interested in any formal or informal criteria/protocols for > mobilizing a bypass team prior to a patient's arrival. The pre-mobilization > of the team in this case proved to be very beneficial. Thanks for your > thoughts and have a Happy New Year! Doug -- a couple of thoughts. 1. the criteria ought to apply both to mobilizing the bypass team at your institution, AND to deciding whether to transport the patient to your institution vs. going to a facility without bypass capabilities. 2. my initial thoughts on who needs bypass: a. you can rewarm _anyone_ with bypass; but the question is who really _needs_ it. Your patient certainly did. b. the main need for bypass is someone in v.fib. c. a secondary need for bypass is for those who are so cold that they are very likely to go into v.fib spontaneously (we know that v.fib is probably a function of the "area under the curve" of temperature vs. time, with the horizontal line indicating the critical temperature differing slightly for different people) d. since we know you can't defibrillate people colder than about 30-32 degrees C, I'd vote for one of these two temps as the triage criteria for bypass. However, a caveat: this should be a reliable tympanic, deep rectal, or esophageal temp to be considered "real." (view with nonproportional font) T|\ e| \ / m| \ / p|...\.............../...critical temp (pt dependent) | \*************/ | \***********/ <- v.fib danger proportional | \*********/ to area under curve | --------- +-------------------------------------------------- rescue+ hospital time --> field rewarming rewarming -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: Schedule, WEMSI-Recognized WEMT classes Reply-to: kconover@pitt.edu Date: Sun, 31 Dec 1995 22:31:37 Schedule of WEMSI-Recognized Wilderness EMT and Wilderness Command Physician Classes Revised 12/31/95 Prerequisites: - for WEMT classes: + EMT training or better + outdoor equipment and condition to participate fully in field exercises + basic wilderness SAR certification or equivalent (N.B. some providers offer SAR training prior to the WEMT class that will meet this requirement for those lacking SAR training.) - for WCP classes: + licensed physician + qualified to provide medical direction to EMS personnel, or wilderness rescue medical personnel, in home jurisdiction + experience at providing medical direction to prehospital personnel + outdoor equipment and condition to participate fully in field exercises -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- WHO: - Center for Emergency Medicine of Western PA WHERE: - at Camp Soles (near Seven Springs in SW PA mountains) WHEN: - Basic Wilderness Rescue (MEETS SAR PREREQUISITE): + will be held on a weekend prior to each class (exact date TBA) + not needed for ASRC or VA GSAR FTMs or higher, or equivalent) - WEMT: two days one weekend, three days another weekend + April 21 & 22 and May 3, 4 & 5. + WEMT: October 19 & 20 and Nov 1,2 & 3. - Wilderness Command Physician (two days): + November 1-2 (Friday-Saturday COST: - TBA CONTACT: - Pam Westfall, Administrative Asst. Center for Emergency Medicine 230 McKee Place, Suite 500 Pittsburgh, PA 15213-4904 412-578-3203 email: Pam Westfall -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- WHO: - QUEST and Bloomsburg State University and Geisenger Medical Center WHERE: - Bloomsburg State University, Northcentral PA WHEN: - June 5-9 COST: - $110 (text+class fee) - plus food and lodging. The food/lodging costs will be approx. $15.00/day/pers. for lodging and approx. $16.00/day/pers. for food. Lodging will be in campus dorms and the food will be at the cafe. Students will be allowed to make other arrangements if they wish but will be very strongly advised to stay and eat on campus. CONTACT: - Tom Burkiewicz (QUEST) 717-389-4342 or Bradford Bason 307 E. Market St. Danville, PA 17821 717-271-1314 (H) 717-326-8185 (W) 717-271-1339 (Bason Rescue Equipment Voicemail) email: Brad Bason -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- WHO: - Maryland Institute for Emergency Medical Services System, Region I WHERE: - Western Maryland WHEN: - in the spring COST: - TBA CONTACT: - Steve Meyer HCR 1, Box 177-A Barton, MD 21521 301-463-5881 (H/W) email: MIEMSS Region I--David Ramsey -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- WHO: - National Cave Rescue Commission, Eastern Region WHERE: - Near Elkins, WV WHEN: - June (22-30), as part of the East Region National Cave Rescue Commission weeklong training college (MAY ATTEND FIRST WEEKEND AND OBTAIN NCRC BASIC CAVE RESCUE ORIENTATION CARD WHICH WILL MEET SAR PREREQUISITE) COST: - TBA CONTACT: - John Appleby, ER-NCRC Regional Coordinator 899 Kulp Rd. Perkiomenville, PA 18074 1-215-541-4994 (H) email: John B. Appleby -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- WHO: - Irish Mountain Rescue Association WHERE: - Dublin, Ireland WHEN: - in September, before the UK/Irish National Mountain Rescue Conference COST: - TBA CONTACT: - Joe O'Gorman, Training Officer Irish Mountain Rescue Association 9 Kingston Heights Ballinteer Rd. Dublin 16 Ireland 00353 1-298-9719 email: Gerard Butler -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- There is also talk about a WEMSI WEMT course in Virginia but nothing more definite at present. CONTACT: - Rob Christie, Medical Officer Appalachian Search and Rescue Conference 1604 Trap Road Vienna, VA 22812 703-319-1479 (H) 703-370-4101 (W) email: Rob Christie <75714.1425@compuserve.com> -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- N.B.: the class, previously announced to tentatively be held in the Philadelphia area will not be held in 1996, and probably not in 1997, but may be held at some later date. -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.7.3/cispop-1.6.1.3) ID for ; Tue, 2 Jan 1996 19:27:22 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.3/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Tue, 2 Jan 1996 19:27:21 -0500 (EST) Received: via switchmail; Tue, 2 Jan 1996 19:27:20 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Tue, 2 Jan 1996 19:26:30 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.3/cisls-2.4) ID ; Tue, 2 Jan 1996 19:24:10 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from JEFLIN.TJU.EDU (jeflin.TJU.EDU [147.140.128.114]) by list.srv.cis.pitt.edu with SMTP (8.7.3/cisls-2.4) ID for ; Tue, 2 Jan 1996 19:24:08 -0500 (EST) Received: from JEFLIN.TJU.EDU by JEFLIN.TJU.EDU with SMTP; Tue, 2 Jan 1996 19:23:04 -0500 (EST) Date: Tue, 2 Jan 1996 19:23:02 +0000 From: "Jack T. Grandey" X-Sender: GRANDEYE@ To: "Wilderness Emergency Medicine@" cc: Walt Stoy Subject: Paramedic Curriculum Revision Project Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 0 As most of you know, The Center for Emergency Medicine of Western Pennsylvania is embarking on a complete revision of the the National Standard Curriculum for EMT-Ps. I am presently looking for upto 4 qualified & interested individuals to serve on the writing team for the Environmental Conditions section. The structure of our writing team as well as the process for completion of our assignment is still under development, but it will be our goal to complete a comprehensive yet relevant treatment of environmentally induced/aggravated conditions by June of 1996. If you have interest in serving on this team, please email or fax me a letter along /c a brief CV, detailing previous writing & outdoors experience, ASAP. JTG Jack T. Grandey, NREMT-P Continuing Education Coordinator Operations Director Albert Einstein Medical Center Wilderness EMS Institute -- End --