Received: from gate1.health.state.ny.us (gate.health.state.ny.us [192.135.176.62]) by pop.srv.cis.pitt.edu with SMTP (8.7.5/cispop-1.6.1.4) ID for ; Wed, 2 Oct 1996 08:57:37 -0400 (EDT) Received: by gate1.health.state.ny.us id AA27507 (InterLock SMTP Gateway 3.0 for kconover@pop.pitt.edu); Wed, 2 Oct 1996 08:57:36 -0400 Received: by gate1.health.state.ny.us (Internal Mail Agent-2); Wed, 2 Oct 1996 08:57:36 -0400 Received: by gate1.health.state.ny.us (Internal Mail Agent-1); Wed, 2 Oct 1996 08:57:36 -0400 Resent-From: rrt01@health.state.ny.us Resent-Message-Id: <199610021257.IAA09813@pop.srv.cis.pitt.edu> Message-Id: <199610021257.AA27507@gate1.health.state.ny.us> Comments: Converted from PROFS to RFC822 format by PUMP V2.2X Resent-Date: Wed, 2 Oct 96 08:55:27 EDT From: Subject: disaster plan To: "Keith Conover, M.D." Date: 2 Oct 96 07:35 EDT Content-Type: text X-UIDL: f78f71bf3cc95f2d0c4ad40d4cd0aa5b X-PMFLAGS: 33554560 0 The basic objectives of Incident Command Mgt (ICM) will still apply; you just need to figure out what resources are available to meet those objectives. For example, in NYC city transit buses are routinely used as mobile Tx areas and can easily transport large #'s of "walking wounded" to hospitals, leaving ambulances available to transport the more seriously injured & sick. (BTW, EMT's are onboard the bus & 1-2 ambulances escort it, just in case someone deteriorates enroute.) This same resource can be used in even the most rural setting. Just substitute "school bus" for "transit bus". The trick is knowing who to call & what his/her phone # is at 2am on Sunday morning! I will post your orig msg on the MCI-TALK list (MCI-TALK@medicom.norden1.com). This is an international list of MCI & disaster mgrs. It's been quiet lately so this may give them something to yak about. I believe to subscribe all you need to do is send the usual msg to LISTSERV@... I'll check w/ the list moderator to make sure. If you'd like to talk about your situation in more detail, all my contact info is below. Later... (The above opinions are my own and not...) * Raymond R. Thielke, EMT/P, Sr EMS Rep * NYS Dept Of Health, Bureau of Emerg Med Svcs * 217 S. Salina St. E-mail: RRT01@health.state.ny.us * Syracuse, NY 13202 Phone# (315)426-7711 ----------------------------Original message---------------------------- Date: Tue, 01 Oct 1996 05:06:06 -0700 From: "William W. Wheeler" Organization: San Luis Valley Med Clinics To: wilderness-emergency-medicine@list.pitt.edu Subject: disaster plan Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Has anyone ever written a disaster plan for a remote area? We have a small ski area in southern Colorado (Wolf Creek) that is about 45 minutes to 1 hour away from ambulance support, and about 1.5 hours away from a 60 bed hospital. Any suggestions would be helpful! Thanks. Bill Wheeler, M.D. Alamosa. CO wwwmd@rmii.com -- End -- X-cs: From: Self To: wemsi-staff@list.pitt.edu Subject: Brainstorming Sessions Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover@pitt.edu Date: Mon, 7 Oct 1996 17:31:31 WEMSI will be conducting two brainstorming sessions to accept input to be used in final revisions of the WEMSI WEMT curriculum prior to formal publication (yes, we're getting very close). We welcome anyone who is interested to attend and voice their suggestions. We also will take input by email, mail, smoke signals, whatever. These sessions are primarily for general concerns -- the Task Groups worry about specific medical details of content. First will be: Sunday, 3 November 1400-1700 hours Camp Soles, near Seven Springs Resort, which itself is in the Laurel Mountains about an hour drive east of Pittsburgh. Second will be: Tuesday, 3 December 2045-2200 hours Room 2126 Mercy Hospital (this is right after the Allegheny Mountain Rescue Group meeting in that same room). All general comments should be in by the end of 1996 to be reflected in the formal combined first edition of the Lesson Plans, Textbook, and Course Guide. Thanks for your interest. -- End -- X-cs: From: Self To: Harold Jaynes Subject: Re: Hello!! Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover@pitt.edu Date: Tue, 8 Oct 1996 17:40:51 [background for the wilderness-emergency-medicine list: Keith and Harold have been talking about the new chemical oxygen generation system that EmOx is just starting to market in the U.S.; I also showed it to some rescue teams and vendors when I was at the Ireland/UK Mountain Rescue Conference in Dublin a couple of weeks ago. The system with 3 charges retails for about $200 [not sure what the refills cost, maybe Harold can provide input on this] and a single charge of chemicals plus 500 cc water in the lightweight unit provide about 15 minutes of warm, humidified oxygen at 2-15 LPM. It weighs, less the water, only about 5 lbs.] On 8 Oct 96 at 8:47, Harold Jaynes wrote: > Hello Keith: > > I just wanted to drop a quick note and see if you had had a chance > to test out the emOx unit and what your impressions were... We've all been playing with it but haven't had a real or mock rescue to try it out on yet - probably soon. > He also incidated that medical oxygen supplies there are black with > a white top and not green....it that pretty much in the UK or > overall?? We certainly don't have a problem changing or modifying > the colors so long as the demand warrants it. I think that's throughout the entire UK -- they were surprised that ours were green. > The manufacturer also indicated that it shouldn't be a problem to > retrofit the unit so it can stay in a reasonably upright > position...it doesn't have to be totally upright, just so long as it > is not horizontal. I do not see this as a big problem though. > Harold Jaynes > MedTrak International, Inc. > 410.381.6488 Voice > 410.381.7670 Fax > 1.888.TRY.EMOX Toll free > http://www.emox.com Several people were also interested in ganging two of them together with a T-piece and filling and emptying them alternately to provide a continuous source of oxygen. Have you thought about this at all? Thanks. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: WMS PETSAC, part 1 Cc: Lee Frizzell/Frank Hubbell Reply-to: kconover@pitt.edu Date: Wed, 9 Oct 1996 11:41:04 WMS = Wilderness Medical Society PETSAC = Prehospital Emergency Training, Standards and Accreditation Committee. Wilderness Medical Society P.O. Box 2463 Indianapolis, IN 46206 1-317-631-1745 Holly Weber was kind enough to extend permission for me to OCR the minutes and her cover letter and distribute to the list. This and the next couple of messages explain what's going on in this regard. ------------------------------------------------- September 30, 1996 Dear Wilderness Medicine Educator, At long last...an update! I just received minutes from the two Wilderness Medical Society PETSAC Meetings which are enclosed for your review. As you can see when reading the minutes, I have been asked to fill a liaison role between PETSAC and the Wild Med Ed Community. I am already receiving letters, calls, and questions about the whole process. PLEASE, continue to express your concerns I am compiling a file of comments, concerns and questions about where the project is going for the Society. It is hard to talk esoterically about what people think, but when I have their thoughts in writing the concerns can be seen from the wide range of perspectives When speaking with folks over the phone, I am asking them to send a letter as well as to document the conversation. While the WFR curriculum revisions are under way, the Society will be looking to all of us for recommendations on what to do with it; how it will be used, how access will be granted, etc. They will also want feedback on the next step. Will the WFR project end with a complete. consensus curriculum? Or is there still a desire for an accreditation process with q/a, exams, etc. Is the WEMT the logical next step, or is there something more pressing? I will continue to gather comments on these questions. so please take some time to write them down and send them along. When I have amassed a significant quantity, I will see that they get circulated to all involved The plan from here as detailed in the minutes is to have a final draft nailed down by December 31, 1996. This draft will hopefully parallel the re-writing of The Practice Guidelines. As a committee, PETSAC believes our next step should be the WEMT curriculum. Most likely there will be another meeting scheduled for Steamboat Springs in February. I will keep you informed. I hope the minutes fill in the gap for you Again, please do not hesitate to call. Respectfully yours Holly A. Weber You can reach Holly through SOLO's email: Lee Frizzell/Frank Hubbell ---------------------------------------------------- Minutes from the PETSAC Committee Meeting 1996 Winter Meeting Big Sky Montana February 1996 In attendance: Eric A. Weiss, MD Chair, William W. Forgey, MD, Anne Dickison, MD, Warren Bowman, MD, Bruce Paton, MD, Pam Foyster, Holly Weber, Paul Thomas, Buck Tilton, Frank Hubbell, DO, Tod Schimelpfenig, Steve Lyons Dr. Weiss provided reviewed the mission of the PETSAC committee, and the progress to date. Ms. Weber noted that in reviewing the Wilderness First Responder programs currently offered, there seems to be a real difference in the way courses are marketed and the potential audiences. It may be wise to look at separate target areas, Wildemess First-Aid Advance Wilderness First-Aid and WFR, recognizing the separate areas will meet the needs of different groups and organizations of all types including the Canadian groups who interface with US groups. Mr. Schimelpfenig noted that in the survey he just did for associate members, one of the messages that came out in the comments was that a lot of the associate members in the Society consider themselves wilderness medical educators, and provide public first-aid programs. He suggested that people are asking the Society for more involvement in what should be in the curriculum, how to present it, because of the numbers of people recreationing in the outdoors certainly pushes us toward paying a little more attention to Wilderness First-Aid. Dr. Hubbell described a project of the American Alpine Club for the British Hungarian Counsel. They offer a basic 16 hour course for kids and outdoor enthusiasts providing minimum standards to make them safer, a very commonsense approach. The Alpine Club has been working on the same concept and it is certainly something WMS could do in conjunction with the Alpine Club. The emphasis is on preventive medicine. Dr. Paton described the WMS lay meetings winch use the Practice Guidelines as a basis for their programming and are designed to provide the non-physician with guidelines for safer outdoor experiences. Dr. Hubbell suggested a poster for schools to put up in their outdoor centers describing what belongs in your backpack. Dr. Weiss recommended that the curriculum developed follow the national standards for EMT and augment the wilderness module or wilderness component He described wilderness first-aid as a huge topic that the committee will need to review. Dr. Paton suggested completing the WFR curriculum review and evaluating that process and then determining the next project. Dr. Weiss asked for additional curriculum submission. He acknowledged the recommendation of adding a participant to the process who is familiar with wilderness first responses. The committee will develop a curriculum which will be distributed to participants for comment. He encouraged anybody with any feedback to submit that to Holly Weber or him and that will disseminate that as well Dr. Weiss thanked the participants for attending and their continued dedication to the project. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: WMS PETSAC, part 2 of 3 Reply-to: kconover@pitt.edu Date: Wed, 9 Oct 1996 11:42:24 ---------------------------------------------------- Minutes from the PETSAC Committee 1996 WMS Annual Meeting Kananaskis, Alberta Monday, August 5,1996 Notes taken by Dian Simpkins and Chris Brokaw Committee members present: Eric A. Weiss, MD, Chair; Holly Weber; Warren Bowman, MD, William W. Forgey, MD, Anne Dickison, MD, ex offlcio. Also present: Dian Simpkins and Chris Brokaw. Not present: Pam Foyster; John Clair, Bruce Paton, MD and Tad Schimelpfenig. I. Review of the mission of PETSAC and support of other organizations. II. Definition of the committee. III. Time Grid: Bruce Paton worked on a breakdown of time for topics, and this grid was provided to the committee. IV. Communication: Holly Weber is serving as liaison to the teaching industry. She said that the industry understands that the curriculum will take some time to design, but that groups would like to be informed by WMS on the progress of the development. Dr. Weiss agreed that groups should be informed as to our progress, even when there may not be much to report. Holly Weber agreed to serve as a working member of the Committee. V. Curriculum Discussion: Dr. Weiss asked the group to determined how detailed the cur riculum should be. Do we want to tell people precisely what to teach, or should we simply tell them what topics should be covered? Comments from the committee: Ms. Weber feels that in order to become standardized, we need to be specific on what to teach. Dr. Forgey would like to see us use the WMS Practice Guidelines in writing the curriculum. He feds we must provide clear-cut instruction. Dr. Forgey suggested that since he is currently working on revising and updating the practice guidelines, he could take on the task of plugging in guideline fulfillment into the curriculum. He suggested that he and Ms. Weber work together to determine realistic and appropriate teaching goals and timelines for each topic. Dr. Weiss was originally planning on splitting up the topics among the committee members and expressed concern about overburdening Dr. Forgey and Ms. Weber; but they agreed that the project is manageable for them. It was agreed that the topics would be split between Drs. Weiss and Forgey and Ms. Weber. Ms. Weber feels that she could feedback on specific topics others in the teaching industry. Dr. Forgey agreed that this is the point at winch we should solicit opinions and methods from the industry. Dr. Forgey thinks this is a good opportunity to implement the WMS Practice Guidelines and to work on revising them at the same time. Dr. Weiss would like to see this project come to fruition. Dr. Forgey and Ms. Weber will work together to determine what is practical for teaching protocol. Then, they'll take the project back to the committee for modification. Vl. Definitions It was pointed out that the curriculum is not for teaching search and rescue, but is wilderness medical training. Dr. Weiss cited the ASTM's definitions of Wilderness First Responder. We need to clearly define what will be included or not included. The committee determined that evacuation is a separate course. Dr. Dickison noted that she thinks we should use the same terminology in WEMT that is used in standard EMT training. Dr. Forgey suggested that this sort of thing should be noted after he and Ms. Weber have prepared the first draft. VII. Time Frame There will be a general PETSAC information meeting tomorrow, 8/6 at noon. The first draft of the curriculum is scheduled for completion by 12/31/96. Dr. Forgey suggested that as segments are completed they be sent to Dr. Weiss for distribution to the committee. VIII. Other Discussions Dr. Weiss provided the time grid to Ms. Weber. It was agreed that it is desirable for Ms. Weber to contact provider schools when something deviates drastically from her experience. Dr. Dickison suggested that & time Omit be set for the basic WFR level as a guideline The program will begin with an 80-hour Omit as a guideline. Expansion will be considered pending review of the supporting notes. Provider schools will be sent a copy of the first draft of the curriculum. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: WMS PETSAC, part 3 or 3 Reply-to: kconover@pitt.edu Date: Wed, 9 Oct 1996 11:43:14 Minutes from the PETSAC Committee Meeting 1996 WMS Annual Meeting Kananaskis, Alberta Tuesday, August 6.1996 Notes taken by Dian Simpkins In attendance Eric A. Weiss, MD Committee chair, Holly Weber, Bill Forgey MD, Anne Diskison, MD Linnea Renner, Don Vardell, Karl Neumann, MD, and Kelly Turner. I. Dr. Weiss gave background information on the formation of the PETSAC committee, identifying it as a sub-committee of the Board. The sub-committee met on Monday, August 5 to review the progress on the curriculum project and as a group renewed their commitment to the work of the committee. Holly Weber will be joining the PETSAC committee. II. Dr. Weiss described the process whereby Pam Foyster had received the curricula from the educational providers. From those curricula, a listing of topics for the WFR course has been assembled. The sub-committee has agreed on the actual format of the curriculum. The design will be more inclusive and comprehensive than earlier anticipated Dr. Forgey Dr. Weiss and Ms. Weber will be coordinating the production of the curriculum. The resulting document will be distributed to selected experts for review. The final draft of the curriculum is scheduled for December 31 1996. III. The Board will be asked to fund the cost of the curriculum project IV. The following points were discussed related to the curriculum: - a timetable should be included for the allotment of hours - the final document should have a copyright, allowing use with permission. - the curriculum will follow the Practice Guidelines (the NSC First Aid text will also be reviewed for compliance with the Practice Guidelines) V. There was discussion of a potential problem if there is not consensus among the training providers, but agreement is anticipated because minimum standards are what is under consideration. The next project of the PETSAC Committee will be Wilderness EMT. [end] -- End -- X-cs: From: Self To: Frank Ouimette Subject: Re: wire saw for amputations Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover@pitt.edu Date: Tue, 15 Oct 1996 11:37:34 On 15 Oct 96 at 9:17, Frank Ouimette wrote: > you might want to include the wire saw in the baic pac for the > reason of a basic EMT may need the ability to saw down small trees > to build an improvised litter, plus there are many other uses That is certainly a good reason to carry a wire saw -- but that's more of a rescue kit reason than a medical kit reason, i.e., we don't include headlights or food in the kit, though they are clearly needed for wilderness rescue. However, for cave rescue, or rescue in barren areas, a wire saw would be basically useless, so I think I would leave it up to the discretion of the SAR team or individual SAR person to decide on appropriate rescue gear to take. This also make the job of deciding on the medical kit a lot easier, by restricting its focus. Thanks for your comment. I'll share it with the rest of the wilderness-emergency-medicine list for list subscribers' edification. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: EMOX oxygen system Cc: Harold Jaynes Reply-to: kconover+@pitt.edu Date: Sun, 3 Nov 1996 18:49:03 Just had a chance to try out the EMOX-911 oxygen system in a near-real-life (simulated) wilderness rescue last night. It was at a WEMSI Wilderness EMT class put on by the Center for Emergency Medicine of Western Pennsylvania at a camp near the Seven Springs resort in the Laurel Mountains of SW PA. The students had to take care of two patients who had fallen off a trail and gotten hurt impacting into trees. Once just had a concussion and woke up and was fine, the other had multiple injuries and significant hypothermia. A cold front was just coming through, the air temperature dropped from 45 F to 35 F in about an hour, there was a nice gusty wind up to about 20 knots, and just a bit of snow. And of course the rescue happened just about dusk. The students had some trouble reading the instructions by headlight so I helped by starting up the system and giving them some pointers. One problem was apparent at once -- the oxygen tubing was so stiff from the cold it took two students to stretch it out. Got the stuff mixed in the green canister and the humidifier filled without difficulty. It started putting out oxygen OK. We were hoping that the oxygen would be warm but it wasn't at all. (Needs to have insulation around the canister and O2 tubing, which won't be difficult to do, and maybe we don't want to pour cold water into the humidifier, just do with whatever humidity comes from the reaction mixture.) It smelled "nasty" according to the victim and some of the students, but if the patient really needed it I'm sure it would be bearable. Seemed to work OK until, at the chaotic scene, the oxygen canister got tipped over, the humidifier filled with the reaction mixture and the victim got a faceful of the slurry. At that point the system was abandoned. So, looks promising but like we need to still do some work. -- End -- X-cs: From: Self To: EMED List ,cclau@HA.ORG.HK Subject: Re: Field Amputation Cc: Sam Chewning <75537.2201@compuserve.com>,wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Mon, 4 Nov 1996 08:56:53 On 4 Nov 96 at 12:47, A&E Dept, PYNEH, Hong Kong wrote: > Dear all, > > We have a recent case of a man whose lower limbs were entrapped in a > tractor with rotating blade. The small tractor was used for cutting > grass and could be pushed around by one person. The lower limbs were > entangled within the blade and the patient was transferred to us > with the machine still attached. It was very difficult for the > fireman and ambulance staff to move the patient to the back of the > ambulance and stabilise the machine via en route. Amputation was > performed in the ED to remove the patient from the machine. The > question: should we amputate at the scene. Does anybody has a > protocol on when and how to perform a field amputation. Thanks. > > Wong Tai-wai > Accident & Emergency Dept. > Eastern Hospital > Hong Kong We don't have a protocol, but for wilderness rescue we have thought about it a lot and done some "practice" amputations. We realized that standard techniques would not work well in many of our situations (e.g., trapped under a rock deep within a cave). So we tried several methods, using lightweight equipment, on a "practice" limb made as follows (Sam will correct me if I've got it a bit wrong, he's the one who made it): tree limb about 3-4" in diameter pieces of polypropylene twine taped to limb with duct tape plastic sheet duct-taped around this towel duct-taped around this plastic sheet duct-taped around this. We then had some of the students at our Wilderness EMT/Wilderness Command Physician class in Dublin try different methods: 1. hand axe (hatchet): very difficult to do, had trouble with the plastic and twine and towel. 2. wire "camp" saw (piece of twisted wire about 20" long with teeth along its length, and small keyrings at either end for finger grips): worked well but the person sawing was very strong and had to have plenty of room to move his hands. Sam, an orthopedic surgeon, notes that his orthopedic group has switched to buying these saws from a local camp supply store and sterilizing them as they're much cheaper than the medical versions and work just as well. 3. using a Gerber folding camp saw (looks like a folding "buck" knife but with large teeth, blade is about 6-7" long and folds into a plastic handle). This worked very well, provided one first used a serrated-edge pocket knife to cut through the superficial "muscle" and "skin" and "fascia" to prevent the saw's teeth from catching on them. I saw something interesting at a hardware store: a tiny battery-operated chainsaw that is on the end of a pole, designed for tree trimming. It might be very handy for doing an amputation, but I haven't been able to get one to try yet. I did find the name of the device and the name and city of the manufacturer: it's a WoodZig, and it's made by Blount of Portland, Oregon, USA. If I can get one and it looks like it will work, I'll post the message to the lists. My current amputation hardware is a SOG serrated-edge knife (3" blade) plus the Gerber folding camp saw. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu,Patton M Turner Subject: Re: Field Amputation Cc: EMED List ,cclau@HA.ORG.HK Reply-to: kconover+@pitt.edu Date: Mon, 4 Nov 1996 21:19:31 On 4 Nov 96 at 12:43, Patton M Turner wrote: > > tree limb about 3-4" in diameter > > Is this a realistic simulation of bone? Having buchered animals > before, I have found a 8 tooth per inch (tpi) crosscut handsaw is > the maximum pitch I have had luck with. A 18 tpi hacksaw works > better. True, the Gerber saw has only 3 teeth per inch. And it only weighs 3 ounces on my postal scale. A hacksaw blade doesn't have the rigidity to be held by one end in a confined space. > Do you know what a recipro saw (aka Sawsall) is? It is a > reciprocating blade supported on one end. Commonly used in > demolition, rough construction, rescue, etc. Anyway, blades are > available in various lengths, pitches, and tooth styles. One of the > manufacturers (Lenox) makes a folding handle for the blade to allow > the blades to be used as a handheld saw. This would allow blade > selection and replacement. > > The saw handles are available from most any electrical supply. > Blades are available from most any hardware store, though they will > only carry a few of the hundreds available. I'll have to take a look at one of these. But I bet they weigh more than 3 ounces. > Makita makes a battery powered recipro saw also. Assuming this is > to be kept in a truck, the blades could be packaged and autoclaved > ahead of time. Kind of hard to maintain aseptic technique with a > chain saw. I'll have to take a look at these. My particular interest is in situations where every ounce of gear's weight is scrutinized closely (wilderness rescue). The problem with the chainsaw and the Makita saw you mention is the weight and having batteries charged when you need them. If one of these is light enough (and I was interested in the pruning mini-chainisaw because it looked very light) I would make up a battery pack that used disposable AA lithium cells because they are very light, have an indefinite shelf life, perform quite well in the cold, are readily available and have multiple uses. I use them for: cell phone 2M/VHF handheld headlamp flashlight otoscope/ophthalmoscope laryngoscope meaning that a few lightweight lithium cells can have a multiplicity of uses. I suspect the Makita saw requires one of the _heavy_ 7.2 or higher voltage Ni-Cad batteries just like my regular drill and hammer drill at home. Your mileage may vary -- not every rescue team needs to be so fanatical about weight. In wilderness rescue, for instance, sterility of the blade takes second place to having something light enough so that your pack doesn't prevent you from getting there in the first place. -- End -- Received: from post-ofc02.srv.cis.pitt.edu (daemon@post-ofc02.srv.cis.pitt.edu [136.142.185.24]) by pop.srv.cis.pitt.edu with ESMTP (8.8.2/cispop-1.6.1.4) ID for ; Mon, 4 Nov 1996 22:00:03 -0500 (EST) Received: from local (daemon@localhost) by post-ofc02.srv.cis.pitt.edu (8.8.2/cispo-2.0.1.7) ID for kconover@pop.pitt.edu; Mon, 4 Nov 1996 22:00:02 -0500 (EST) Received: via switchmail for kconover+@pitt.edu; Mon, 4 Nov 1996 22:00:02 -0500 (EST) Received: from isnet.is.bgsm.edu (root@isnet2.is.bgsm.edu [152.11.200.253]) by post-ofc02.srv.cis.pitt.edu with ESMTP (8.8.2/cispo-2.0.1.7) ID for ; Mon, 4 Nov 1996 21:57:19 -0500 (EST) Received: from 206.27.1.1.ols.net (deanm.ols.net [205.139.152.205]) by isnet.is.bgsm.edu (8.7.1/8.7.1) with SMTP id VAA14440 for ; Mon, 4 Nov 1996 21:54:41 -0500 (EST) Date: Mon, 4 Nov 1996 21:54:41 -0500 (EST) Message-Id: <199611050254.VAA14440@isnet.is.bgsm.edu> X-Sender: ralson@bgsm.edu X-Mailer: Windows Eudora Light Version 1.5.2 Mime-Version: 1.0 To: kconover+@pitt.edu From: "Roy L. Alson, PhD, MD" Subject: Re: Field Amputation Content-Type: text/plain; charset="us-ascii" X-UIDL: 52a9c172e4c63126f5f514976c793a02 X-PMFLAGS: 36176000 0 Kieth, I carry one of the Lennox saws in my bunker gear for rescue. Using a 12 tpi blade for windows instead of a glass master. It costs only $20.00 instead of the $200.00 for the glass master. With a 18 tpi blade, it will cut sheet metal, without problems. It should work as a bone saw and I will get a hold of a pig leg or something and try it. The saw ways about 10 oz. Roy ++++++++++++++++++++++++++++++++++++++++++ Roy L. Alson, PhD, MD, FACEP Assistant Professor of Emergency Medicine Bowman Gray School of Medicine Medical Director-EMS NC Baptist AirCare ralson@bgsm.edu 910-716-2193 Fax: 910-716-5438 ..All opinions expressed here are my own.. "Opinions are like rectal sphincters... Everyone has at least one!"... -- End -- X-cs: From: Self To: Sam Chewning <75537.2201@compuserve.com>,pirie1@server.uwindsor.ca (Steven D. Pirie) Subject: Re: Field Amputation Cc: wilderness-emergency-medicine@list.pitt.edu,EMED List Reply-to: kconover+@pitt.edu Date: Tue, 5 Nov 1996 19:14:36 On 4 Nov 96 at 23:57, Steven D. Pirie wrote: > Dr. Conover > > >tree limb about 3-4" in diameter > >pieces of polypropylene twine taped to limb with duct tape > >plastic sheet duct-taped around this > >towel duct-taped around this > >plastic sheet duct-taped around this. > > This is a great idea... I will have to try it out. Have you ever > contemplated using a leg from a larger animal such as a cow or horse > that has been destroyed due to illness? I think that if you found a > limb that was the approximate size of the human limb that was in > question for the amputation it would simulate it quite well. Reasonable, but messy, and not as easy to improvise on the spot (as happened this time). > >2. wire "camp" saw (piece of twisted wire about 20" long with teeth > >along its length, and small keyrings at either end for finger > >grips): > > worked well but the person sawing was very strong and had to have > >plenty of room to move his hands. Sam, an orthopedic surgeon, > >notes that his orthopedic group has switched to buying these saws > >from a local camp supply store and sterilizing them as they're much > >cheaper than the medical versions and work just as well. > > Some of the people that I work with (including me) carry this in > case we HAVE to preform an amputation when it is infeasible to > evacuate the casualty. (ie: behind enemy lines with no medical evac > or trapped in a confined space.) Never had to do it though. I would > be nice to simulate. I only know of one person that has used this > method. He was a Medic (British) in Iraq when one of the members of > his patrol (which was behind enemy lines) stepped on a "toe popper" > land mine. He stated it worked well... In fact he stated it worked > very well. I was not aware that a medical version of the saw was > available. > > Since the Army here does not teach this procedure (the wire saw > method) I was wondering if you have a procedure in print or know of > one that has been published? Everyone I tell about the wire saw > method asks me. Do you think that you might need two saws as the > first one will become dull while cutting or may break? (that would > be a real problem only being half way through when you loose your > saw). Well, the orthopods use it just for cutting the bone. I'll cc: Sam Chewning and see if he or his partners ever have to use more than one for an amputation. > Currently there are two methods taught by the military on the first > line (or recce) field courses. Both involve a knife and a hacksaw > blade. I used to carry two hacksaw blades until I saw the pocket > camp saw idea in the WEMSI medical kit. Many recce medics, Nursing > Officers and Medical Officers carry hacksaw blades if they are in an > area where it is possible that an amputation may have to be > preformed and there is no intermediate surgical kit. (There are two > more procedures taught as second and third line procedures but both > involve the use of a intermediate field / advanced surgical centre > surgical kit.) As I tell them about the wire saw method they love > ther idea. If you are interested in the procedures that we have > developed for field amputations just let me know and I can send them > via email to you. > > >My current amputation hardware is a SOG serrated-edge knife (3" > >blade) plus the Gerber folding camp saw. > > Humm... Should I sell my wire camp saw? I do carry a Gerber LSW saw > in my rucksack.... From my observations the camp saw was at least as good as the wire saw, and could be used in more confined spaces. > Nice chatting with you, > > Steven > pirie1@server.uwindsor.ca > > -------------------------------------------------------------------- > ----------- OCdt Steven D. Pirie Nursing Officer BScN Plan I / Year > III University of Windsor Canadian Forces Medical Service P.S. I'm sending this back to both lists because your observations are probably of interest to others. -- End -- X-cs: From: Self To: Patton M Turner Subject: Re: Field Amputation Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Tue, 5 Nov 1996 19:19:58 On 4 Nov 96 at 21:49, Patton M Turner wrote: > On Mon, 4 Nov 1996, Keith Conover, M.D. wrote: > > > True, the Gerber saw has only 3 teeth per inch. And it only > > weighs 3 ounces on my postal scale. A hacksaw blade doesn't have > > the rigidity to be held by one end in a confined space. > > A recipro saw blade does have this rigidity due to it's intended > use. Biggest problem I see is that the Lenox frame is heavy (say 12 > oz vs 3 oz) as it is made of die cast aluminum. It wouldn't take > much to make a light weight rigid handle for just the blade. > > > > > > Do you know what a recipro saw (aka Sawsall) is? It is a > > > reciprocating blade supported on one end. Commonly used in > > > demolition, rough construction, rescue, etc. Anyway, blades are > > > available in various lengths, pitches, and tooth styles. One of > > > the manufacturers (Lenox) makes a folding handle for the blade > > > to allow the blades to be used as a handheld saw. This would > > > allow blade selection and replacement. > > > > > > The saw handles are available from most any electrical supply. > > > Blades are available from most any hardware store, though they > > > will only carry a few of the hundreds available. > > > > I'll have to take a look at one of these. But I bet they weigh > > more than 3 ounces. > > > > > Makita makes a battery powered recipro saw also. Assuming this > > > is to be kept in a truck, the blades could be packaged and > > > autoclaved ahead of time. Kind of hard to maintain aseptic > > > technique with a chain saw. > > > > I'll have to take a look at these. > > > > My particular interest is in situations where every ounce of > > gear's weight is scrutinized closely (wilderness rescue). The > > problem with the chainsaw and the Makita saw you mention is the > > weight and having batteries charged when you need them. If one of > > these is light enough (and I was interested in the pruning > > mini-chainisaw because it looked very light) I would make up a > > battery pack that used disposable AA lithium cells because they > > are very light, have an indefinite shelf life, perform quite well > > in the cold, are readily available and have multiple uses. I use > > them for: > > > > cell phone > > 2M/VHF handheld > > headlamp > > flashlight > > otoscope/ophthalmoscope > > laryngoscope > > > > meaning that a few lightweight lithium cells can have a > > multiplicity of uses. I suspect the Makita saw requires one of > > the _heavy_ 7.2 or higher voltage Ni-Cad batteries just like my > > regular drill and hammer drill at home. > > > > Your mileage may vary -- not every rescue team needs to be so > > fanatical about weight. In wilderness rescue, for instance, > > sterility of the blade takes second place to having something > > light enough so that your pack doesn't prevent you from getting > > there in the first place. > > I don't think either product is particularly sutiable for wilderness > rescue, but all things being equal, a reciprocating saw will be > lighter in weight and consume less power than a chain saw. > > And yes, I like AA bats also. I don't cary anywhere near the > medical gear you do, but I also use them in a ACR rescue strobe, and > ICOM battery packs for both my VHF, UHF, and VHF aircraft HTs. > Since my pager eats them (works off FM radio stations for improved > rural coverage), I usually by them by the box of 48, and keep them > in the truck. > > I haven't seen a AA battery pack for my cell phone, but I usually > leave it off, and get people to call my pager, saving the battery. > > Pat > -- End -- Received: from post-ofc03.srv.cis.pitt.edu (daemon@post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by pop.srv.cis.pitt.edu with ESMTP (8.8.2/cispop-1.6.1.4) ID for ; Wed, 6 Nov 1996 01:31:57 -0500 (EST) Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.8.2/cispo-2.0.1.7) ID for kconover@pop.pitt.edu; Wed, 6 Nov 1996 01:31:57 -0500 (EST) Received: via switchmail for kconover+@pitt.edu; Wed, 6 Nov 1996 01:31:57 -0500 (EST) Received: from naps.uwindsor.ca (dns.uwindsor.ca [137.207.232.1]) by post-ofc03.srv.cis.pitt.edu with SMTP (8.8.2/cispo-2.0.1.7) ID for ; Wed, 6 Nov 1996 01:30:50 -0500 (EST) Received: by naps.uwindsor.ca (SMI-8.6/SMI-SVR4) id BAA28042; Wed, 6 Nov 1996 01:32:11 -0500 Received: from server.campus.uwindsor.ca(137.207.92.12) by dns.uwindsor.ca via smap (V2.0beta) id xma027921; Wed, 6 Nov 96 01:28:01 -0500 Received: from [137.207.226.23] by server.uwindsor.ca via SMTP (951211.SGI.8.6.12.PATCH1042/951211.SGI.AUTO) id BAA12566; Wed, 6 Nov 1996 01:27:58 -0500 Message-Id: Mime-Version: 1.0 Date: Wed, 6 Nov 1996 01:26:04 -0500 To: JRPierceJr@aol.com From: pirie1@server.uwindsor.ca (Steven D. Pirie) Subject: Re: Field Amputation Cc: kconover+@pitt.edu Content-Type: text/plain; charset="us-ascii" X-UIDL: 41693761d2e5dcd126a53b93d478eab6 X-PMFLAGS: 34078848 0 Dr. Pierce, >For those of us less expereineced in such situations, what do you use for >anesthesia in the field and how do you control bleeding of the stump? The techniques that I was instructed in the Army was to use: The advanced method: 1) The ketamine and fentanyl patches that Dr. Conover uses. We also have versed and morphine as an option though. The basic method for medics that don't have / can't use some of the more advanced medications: 2) a) 1 hour prep - 125mg Demerol and 10 mg Valium IM (separate injections) b) 75-90cc of 1% Xylocaine infiltrated into tissue at cutting site from skin to bone. c) 10cc of 1% Xylocaine into the periosteum when you get there. d) post op (if evac is a few days out) 75-100mg Demerol IM q 3-4h prn. until Acetaminophen with hydrocodone will suffice. For bleeding control we use an improvised tourniquet.(1" tubular webbing would work but not everyone has it... I do carry some though so I can make a swiss seat if I am not carrying my sash cord.) Also a B/P cuff will also work as a tourniquet it will fit around the limb. Also lots of surgical sponges (4x4's etc) with direct pressure. Some of the guys that are in heavily landmine contaminated areas also carry some bone wax for the drainage from the femur and a amputation shield (I don't bother just opt to use the sponges if I have to). Ligation of the major vessels and, if required the nerve stumps are done as soon as possible to control bleeding. All lesser vessels that cannot be sewn shut have muscle bundles sewn over them. This should control most of the bleeding when the tourniquet is released. Hope that helps give you a better picture. Steven pirie1@server.uwindsor.ca ------------------------------------------------------------------------------- OCdt Steven D. Pirie Nursing Officer BScN Plan I / Year III University of Windsor Canadian Forces Medical Service -------------------------------------------------------------------------------- Sent via server server from the University of Windsor in Canada. -------------------------------------------------------------------------------- -- End -- X-cs: From: Self To: pirie1@server.uwindsor.ca (Steven D. Pirie) Subject: Re: Field Amputation Reply-to: kconover+@pitt.edu Date: Wed, 6 Nov 1996 07:42:15 On 6 Nov 96 at 1:26, Steven D. Pirie wrote: > Dr Conover, > > I was just thinking... > > With the use of the electric (battery) saw, don't you have to be > more worried about the heat generated and passed through the femur? > How do you control this abundance of heat? Will just irrigating with > an IV set up or a large syringe do it? > > Steven Usually we're in cold enough environments where I haven't thought this would be a problem. Your suggestions would be fine in a hot environment, I think. -- End -- Received: from post-ofc01.srv.cis.pitt.edu (daemon@post-ofc01.srv.cis.pitt.edu [136.142.185.10]) by pop.srv.cis.pitt.edu with ESMTP (8.8.2/cispop-1.6.1.4) ID for ; Wed, 6 Nov 1996 09:23:28 -0500 (EST) Received: from local (daemon@localhost) by post-ofc01.srv.cis.pitt.edu (8.8.2/cispo-2.0.1.7) ID for kconover@pop.pitt.edu; Wed, 6 Nov 1996 09:23:27 -0500 (EST) Received: via switchmail for kconover+@pitt.edu; Wed, 6 Nov 1996 09:23:26 -0500 (EST) Received: from smtp.acf.dhhs.gov (srvr10.acf.dhhs.gov [158.71.1.10]) by post-ofc01.srv.cis.pitt.edu with SMTP (8.8.2/cispo-2.0.1.7) ID for ; Wed, 6 Nov 1996 09:16:59 -0500 (EST) Received: by smtp.acf.dhhs.gov; Wed, 6 Nov 96 9:16:33 -0500 Date: Wed, 6 Nov 96 8:54:09 -30000 Message-ID: X-Priority: 3 (Normal) To: From: "Dave Matthews" Subject: Re: Field Amputation MIME-Version: 1.0 Content-Type: text/plain; charset=US-ASCII X-UIDL: 68ef8a42055a626dde4032c8e9020503 X-PMFLAGS: 34078848 0 *************************************************************************** *************************************************************************** Dr. Conover -- A follow-up to yesterday's note. Although the Kit Carson story is almost certainly a "tall tale from around the campfire," for anybody who's interested the account will be found in the Kit Carson biography published by the University of Nebraska Press. Exact title escapes me at the moment. A couple of notes on wire cable saws: The NATO MILSPEC version is most commonly supplied to the U.S. market by Coghlan's. It can be identified by the fact that it's connected to the finger rings by swivels. Another supplier of this item is BCB Outdoor Equipment. Beware of a cheapo Taiwan look-alike, which has no swivels and is of inferior quality. One other version used to be available and may still be encountered from time to time. It was marketed under the name VARCO, and looks somewhat like a twisted piece of razor wire. It is quite "stickery" and must be carried in a round tobacco tin unless you want it to tear up your other equipment. Its reputed to cut well and to be of good quality, if you can tolerate its "rough edges." One last thought -- the saw found in the handle of the Glock entrenching tool deserves being looked at, if one is going to carry an entrenching tool for any reason. The Glock is lightest of any "diggers" of this type that I've seen, durable, and expensive. The saw looks like it would do the job. Best wishes, Dave Matthews Internet address: dmatthews@acf.dhhs.gov **************************************************************************** **************************************************************************** -- End -- X-cs: From: Self To: Woolfbob@aol.com, wilderness-emergency-medicine@list.pitt.edu Subject: Re: Field amputations. Cc: EMED List ,cclau@HA.ORG.HK Reply-to: kconover+@pitt.edu Date: Thu, 7 Nov 1996 17:02:17 On 6 Nov 96 at 10:23, Bob Woolf wrote: > Derek, > > I don't think anyone is proposing that chain saw amputation be > included in the daily activities of Paramedics by any means. Well, I just got through to Oregon Cutting Systems who made the WoodZig (battery powered chainsaw) and they've just quit making them, nor do they make anything similar that might be useful for field amputations. Sigh. I had high hopes for this device. Because I can easily see situations where there is not enough room to swing a cat, er, move a saw back and forth to cut off an arm or leg. If anyone sees a tiny chainsaw anywhere, please note the manufacturer and let me know. Thanks! -- End -- X-cs: From: Self To: ERSwanson1@aol.com Subject: Re: Field Amputation Cc: EMED List ,wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Thu, 7 Nov 1996 21:16:27 On 7 Nov 96 at 19:04, ERSwanson1@aol.com wrote: > Kieth, > Why Ketamine and Fentanyl together? > Ketamine is a dissociative anesthetic and analgesic. You probably > don't need to use Fentanyl with it. Be careful who you give > ketamine to because of its adrenergic response (not a good idea for > folks with coronary artery disease). I would use the Fentanyl as opposed to Ketamine on initial approach to the patient for immediate pain relief. I'd use Ketamine when I got to the point of actually deciding to do the amputation. I'd also use Bupivicaine (not lidocaine) locally for anaesthesia. > Fentanyl would also be a good agent on its own or with a sedative. > Remember > Fentanyl has very little sedative properties until you use very high > doses. I'd prefer not to use the Fentanyl as an anaesthetic because in most wilderness situations it would be hard to protect the airway. For this same reason I think I would use atropine along with the Ketamine even though it seems that atropine isn't necessary for routine use in the ED. Having lots of upper airway secretions in the ED is bad, but having it where I can't control the airway under a rock deep in a cave would be _very_ bad. Not as bad as if they stop breathing from Fentanyl and I can't reach the airway because that is down at my left ankle as I'm getting ready to do an amputation. > You could even use morphine which is probably more universally > available > than the above agents. Watch for repiratory depression with the > opiods. Absolutely. And not discounting Narcan, and being a big proponent of morphine relative to Demerol (yech), I still would rather have the shorter-acting Fentanyl. It's not a substitute for morphine but an addition to it for certain situations where you want to have the narcotic wear off quickly, as in this case where the ketamine will wear off, or for a shoulder dislocation where you want the person to get up and walk/climb afterwards. (Though I do remember one shoulder dislocation who got about 20 mg MS before I reduced it and he was still able to walk/climb out with assistance. I think in retrospect if I had been at his side, rather than giving orders to wilderness medics over the field phone, I would have used a mixture of fentanyl and MS, so some of the effect would have worn off more quickly after the reduction.) > Eric R Swanson, MD > Attending Physician, Dept. of Emergency Medicine, Mercy Hospital of > Pittsburgh Clinical Instructor, Dept. of Emergency Medicine, > University of Pittsburgh School of Medicine Clinical Instructor, > Dept. of Surgery, University of Utah School of Medicine > I hope you don't mind my forwarding this to the EMED and wilderness-emergency-medicine lists, it's a good discussion. -- End -- X-cs: From: Self To: Woolfbob@aol.com Subject: Re: Field amputations. Cc: Multiple recipients of list EMED-L ,wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Fri, 8 Nov 1996 00:37:14 On 7 Nov 96 at 23:35, Woolfbob@aol.com wrote: > Kieth, > > I just recieve a Danmark catalog today which has what I think is the > saw you are talking about. It is a yellow, short of zig-zag shaped > tool. They give a number for it in the catalog of B-8860-509813 and > list a reduced price of $49.99 for with the extended service plan > coming in at 12.99. This appears to be their holiday catalog and > since it only came in the mail about 6 hours ago, I would expect > that the item is still available. You might want to call them back > with the new catalog number and see if you can get it. The claim it > is "lightweight" and uses a 9.6 volt fast charge battery. Is that > the one? The picture is a bit small to be sure (and my bifocals are > in need upgrade!) but it appears that the name on it is WoodZig. > Let me know. I see what you're talking about -- a cordless tree trimmer. But this isn't quite what I had in mind. The discontinued WoodZig had a tiny chainsaw blade about 6-8" long, and looked like it would reach deep enough into the tissue to get a femur. The yellow thing that is in the current catalog is more of a portable sabre saw, and would be hard to get in deep enough to do a femur. (BTW I'm very nearsighted and just took out my contacts and switched to my glasses preparatory to going to bed; so I just took off my glasses to in effect "put on my loupes" and get wonderful magnification and it says "LumberJack" on the label." Thanks for the help, though. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: kidneys, dehydration, and NSAIDs Reply-to: kconover+@pitt.edu Date: Mon, 11 Nov 1996 15:54:43 Back a while ago, a question about the role of NSAIDs in causing kidney failure at altitude and when dehydrated. I still don't have a precise answer, but the following is of interest: An article from January 1996 about analgesics and kidney failure provides several quotes that may be of some interest to those who take NSAIDs, tylenol or ASA when in the backcountry (and when exercising heavily and getting dehydrated. ... "In patients with normal renal function, aspirin should not be taken within 48 hours of ingestion of any nonnarotic NSAID, and vice versa." ... "In patients with impaired renal fuction, acute glomerulonephritis, _sodium_depletion_ [emphasis addded], cirrhosis with ascites, and in children with congestive heart failure, aspirin should be avoided. If its use is necessary, careful monitoring of renal function should be undertaken. This would consist, at the least, of following the serum creatinine concentration at baseline and regular intervals." [N.B. most of us who exercise in the heat will get sodium depleted, also known as dehydrated. This talks mostly about the continued use of aspirin, not one or two, but still there is some worry when one is significantly dehdrated about taking even two aspirin. --KC] "Acetaminophen remains the nonnarcotic analgesic of choice in patients with underlying renal disease. The habitual consumption of acetaminophen should be discouraged. If indicated medically, the long-term use of acetaminophen should be supervised by a physician." ,,, "Combinations of Aspirin/Acetaminophen: The experimental data provide a biochemical and pathological basis for the enhanced renal toxicity of analgesic mixtures compared with that of single agents." "Nonsteroidal Aniinflammatory Drugs: The use of NSAIDs is safew when the drugs are taken in therapeutic doses for a limited period. Patients with preexisting risk factors, including underlying renal disease and _volume_depletion_ [emphasis added], are susceptible to potentially life-threatening nephrotoxicity, including acute renal failure and serious fluid and electorlyte disorders. NSAID-related acute renal failure is usually, but not inevitably, reversible. ... [Henrich WL et al. National Kidney Foundation position paper: Analgesics and the kidney: Summary and recommendations to the Scientific Advisory Board of the National Kidney Foundation from an ad hoc committee ofthe National Kidney Foundation. Am J Kidney Dis 1996;27(1):162-165.] Bottom line: the decision is yours. I won't take NSAIDs such as ibuprofen until I'm well-hydrated. And if I have to take a NSAID and then go to altitude or exercise a lot in the heat, I'll take special care to stay hydrated, including hourly pee stops to check the color and amount of urine. Your mileage may vary. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: altitude and asthma medication? Reply-to: kconover+@pitt.edu Date: Mon, 11 Nov 1996 17:38:43 On 9 Nov 96 at 8:53, parada@hsmdla.sspn.sld.ar wrote: > I've got a > tecnical question: There are some climbers here that are going to > try to climb Aconcagua (6993 mts , about 23000 ft). One of them has > mild asthma so uses salbutamol+corticosteroid (together) by puff > only when he's got wheezzing (infrequently). My concern is about > using B2 bronchodilators at high altitude due to heart rate increase > by hypoxia and the drug. Is there anything that should be changed > before going to altitude ,they will be climbing by the end of > november. Is Cromoglicate a better option for this particular case > or he should not worry and use salbutamol+corticosteroids as always. > Thanks Marcelo ARGENTINA Well, continuing the steroids makes great sense. Cromoglicate sounds like what I know as cromolyn sodium, which is a cell membrane stabilizer for asthma prevention, and theoretically should be better in the sense that you suggest, i.e., less tachycardia, and more importantly, less cardiac irritability! Only question is whether the cromolyn will be as effective as the salbutamol -- I have some doubts on this. The other problem to consider is the bad effects of dry air on mucus clearance from the asthmatic lungs -- not sure if there's any good solution for this. (Having mild asthma I've become convinced that saline nasal spray helps at altitude -- but maybe that's just because I can breathe through my nose better!) With your permission I'd like to post your question and my reply to the wilderness-emergency-medicine list and see what others think. -- End -- Received: from post-ofc03.srv.cis.pitt.edu (daemon@post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by pop.srv.cis.pitt.edu with ESMTP (8.8.2/cispop-1.6.1.4) ID for ; Mon, 11 Nov 1996 22:14:02 -0500 (EST) Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.8.2/cispo-2.0.1.7) ID for kconover@pop.pitt.edu; Mon, 11 Nov 1996 22:14:01 -0500 (EST) Received: via switchmail for kconover+@pitt.edu; Mon, 11 Nov 1996 22:14:01 -0500 (EST) Received: from gabriel.cc.emory.edu (gabriel.cc.emory.edu [170.140.30.75]) by post-ofc03.srv.cis.pitt.edu with ESMTP (8.8.2/cispo-2.0.1.7) ID for ; Mon, 11 Nov 1996 22:12:03 -0500 (EST) Received: from 170.140.250.214 (anx54-214.dialup.emory.edu [170.140.250.214]) by gabriel.cc.emory.edu (8.7.3/8.6.9-950630.01osg-itd.null) with SMTP id WAA29987; Mon, 11 Nov 1996 22:12:28 -0500 (EST) Message-ID: <3287EC17.4EBB@emory.edu> Date: Mon, 11 Nov 1996 22:16:48 -0500 From: Ron Brown X-Mailer: Mozilla 3.0 (Macintosh; I; PPC) MIME-Version: 1.0 To: kconover+@pitt.edu CC: wilderness-emergency-medicine@list.pitt.edu Subject: Re: altitude and asthma medication? References: <199611112239.RAA14775@post-ofc01.srv.cis.pitt.edu> Content-Transfer-Encoding: 7bit Content-Type: text/plain; charset=us-ascii X-UIDL: 6e35767dbf87e0d8b0a127f1902aa231 X-PMFLAGS: 34078848 0 The only point I would make is to emphasize that inhaled steroids are efficacious oly if they are used regularly, not just during infrequent wheezing. And in the thin, dry, cold air, a higher dose (say Azmacort four puffs qid) might be better. Ron Brown, MD -- End -- Received: from post-ofc01.srv.cis.pitt.edu (daemon@post-ofc01.srv.cis.pitt.edu [136.142.185.10]) by pop.srv.cis.pitt.edu with ESMTP (8.8.2/cispop-1.6.1.4) ID for ; Tue, 12 Nov 1996 06:48:18 -0500 (EST) Received: from local (daemon@localhost) by post-ofc01.srv.cis.pitt.edu (8.8.2/cispo-2.0.1.7) ID for kconover@pop.pitt.edu; Tue, 12 Nov 1996 06:48:17 -0500 (EST) Received: via switchmail for kconover+@pitt.edu; Tue, 12 Nov 1996 06:48:17 -0500 (EST) Received: from mamc.e-mail.amedd.army.mil (MAMC.E-MAIL.AMEDD.ARMY.MIL [192.138.33.1]) by post-ofc01.srv.cis.pitt.edu with SMTP (8.8.2/cispo-2.0.1.7) ID for ; Tue, 12 Nov 1996 06:43:00 -0500 (EST) Received: from SMTPLINK.MAMC.AMEDD.ARMY.MIL by host.mamc.e-mail.amedd.army.mil id aa16991; 12 Nov 96 3:23 PST Received: from ccMail by MAMC.SMTPLINK.AMEDD.ARMY.MIL (SMTPLINK V2.11) id AA847798265; Tue, 12 Nov 96 05:31:36 PST Date: Tue, 12 Nov 96 05:31:36 PST From: MAJ Ian Wedmore Message-Id: <9610128477.AA847798265@MAMC.SMTPLINK.AMEDD.ARMY.MIL> To: kconover+@pitt.edu Subject: Re: altitude and asthma medication? Content-Type: text X-UIDL: 7ebe220959b93c528da4dda2b5d67699 X-PMFLAGS: 33554560 0 The salbuterol prn with the azmacort daily as it should be perscribed is the way to go, climbing above Berlin at 21000ft the heart rate would be maxed with exercise and the salbuterol would probably have minimal further effect. The azmacort daily would be good not only for the cold air induced bronchospasm and high altitude pharyngitis but also the approach to all the routes on aconcagua is very dry and dusty and just as likely to induce broncospasm, but if the person in question is not using azmacort daily he should be. I have used B-agonists at altitude without any problems, particuarly in a young healthy population - Ian ______________________________ Reply Separator _________________________________ Subject: altitude and asthma medication? Author: kconover+@pitt.edu at Internet-Mail Date: 11/11/96 3:37 PM On 9 Nov 96 at 8:53, parada@hsmdla.sspn.sld.ar wrote: > I've got a > tecnical question: There are some climbers here that are going to > try to climb Aconcagua (6993 mts , about 23000 ft). One of them has > mild asthma so uses salbutamol+corticosteroid (together) by puff > only when he's got wheezzing (infrequently). My concern is about > using B2 bronchodilators at high altitude due to heart rate increase > by hypoxia and the drug. Is there anything that should be changed > before going to altitude ,they will be climbing by the end of > november. Is Cromoglicate a better option for this particular case > or he should not worry and use salbutamol+corticosteroids as always. > Thanks Marcelo ARGENTINA Well, continuing the steroids makes great sense. Cromoglicate sounds like what I know as cromolyn sodium, which is a cell membrane stabilizer for asthma prevention, and theoretically should be better in the sense that you suggest, i.e., less tachycardia, and more importantly, less cardiac irritability! Only question is whether the cromolyn will be as effective as the salbutamol -- I have some doubts on this. The other problem to consider is the bad effects of dry air on mucus clearance from the asthmatic lungs -- not sure if there's any good solution for this. (Having mild asthma I've become convinced that saline nasal spray helps at altitude -- but maybe that's just because I can breathe through my nose better!) With your permission I'd like to post your question and my reply to the wilderness-emergency-medicine list and see what others think. --Keith Conover, M.D., FACEP http://www.pitt.edu/~kconover -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: (Fwd) Re: altitude and asthma medication? Reply-to: kconover+@pitt.edu Date: Mon, 18 Nov 1996 22:59:15 ------- Forwarded Message Follows ------- Date: 13 Nov 96 16:43:16 EST From: Matthew.F.Russell@Dartmouth.EDU (Matthew F Russell) Subject: Re: altitude and asthma medication? To: kconover@pop.pitt.edu --- Forwarded Message from Reed.Brozen@Hitchcock.ORG (Reed Brozen) --- >Date: 13 Nov 96 15:36:58 EST >From: Reed.Brozen@Hitchcock.ORG (Reed Brozen) >Subject: Re: altitude and asthma medication? >To: Matthew.F.Russell@Dartmouth.EDU (Matthew F Russell) You can post my response if you wish. I have no personal experience at altitude so take what I say with a grain of salt. Beta agonists seldome are limited by their tachycardia. The trend is more and more to use continuous nebs until the asthma improves even if the patients heart rate is topping 140. The main endpoints are improvement or emesis as a side effect. A young healthy and tachycardic person (from hypoxia) should have no contraindication to beta agonists. They work better than cromolyn. And if salbutamol is seravent then it has fewer of the cardiac chronotropic side effects than albuterol. I do suggest that albuterol be available as well. Asthma seems likely to act up in the face of altitude pharyngitis, altitude bronchitis, and altitude bronchorrhea. Other than this I agree with everything that Dr. Conover stated and I personally use saline nasal spray in dry environments as well. Does my point of view help? See ya. Reed Brozen, MD DHMC Lebanon, NH. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: smoke inhalation + backcountry intubation Reply-to: kconover+@pitt.edu Date: Sat, 23 Nov 1996 04:00:55 Ron Walls (an emergency physician from Harvard well-known as an expert on airway management) and I were both lecturing in Taipei this weekend. We were discussing a situation that all wilderness EMTs and WEMT physician medical directors should think about: Inhalation burns from a crowning flashover accident during forest fire suppression. Let's say a fire crew digs in and dives under their space blankets during a flashover, and survive. The fire crowned but then a thunderstorm came along and damped down the fire so all survived with nothing more than minor burns. But one of the crew members complains of a cough and is coughing up small amounts of black stuff (carbonaceous sputum, if you will). And one member of the team is a Wilderness EMT-Paramedic. The questions are: 1. Is it OK to intubate the crew member and then have him walk out? I have always said the answer is clearly "yes," and Ron agrees. To discuss the next questions, I need to note that the WEMSI personal wilderness medical kit includes morphine and a single 6.5mm endotracheal tube and gloves for digital intubation, but not diazepam (e.g., Valium) or midazolam (e.g., Versed) or succinyl choline or a lidocaine or a laryngoscope or any IV fluids (though it does include 2 18 ga IV catheters and a saline lock). And that these things were not left out for any reason except that we want to keep this kit _light_. Indeed, it's already too heavy and big to carry in your pack all day without making you want to go through and throw out things before the next operation. 2. Should the WEMT-P use: - blind nasotracheal intubation? Ron says no, because blind probing could make the edema worse and precipitate laryngeal occlusion. - awake oral intubation, using morphine, midazolam (e.g., Versed) and some local lidocaine squirted into the larynx while gently advancing a laryngoscope into the pharynx? This would be Ron's choice. - or, start an IV, give 100 mg lidocaine, then 5 mg MSO4, then 2 mg midazolam (e.g., Versed) for official rapid sequence intubation? Ron argues against this because it might not be possible to ventilate the patient with mouth-to-mouth if the intubation fails (due to laryngeal edema), precipitating need for a cricothyrotomy. And, figured into your calculations is the likelihood of a WEMT-P actually needing to do this, and the importance of a WEMT-P doing this. The rule is to intubate anyone with inhalation burns if they show signs of sooty or carbonaceous sputum, shortness of breath, or hoarseness. Before their larynx swells and they arrest, that is. But only a fraction of those even with these symptoms will actually swell, obstruct and arrest. On the other hand, even if rare, this is a situation where a WEMT-P is likely to be able to save someone's life with a (relatively) simple maneuver. Regarding lightweight laryngoscopes, let me quote from a previous message on this list: > But I guess I should also point out that there are very > lightweight disposable plastic laryngoscope blades that will fit on > a standard Welch-Allyn pediatric handle. I got my set of three > different sized blades from: > > Parr Emergency Product Sales > P.O. Box 76 > Galloway, OH 43119 > > And putting two 1.6 V Eveready lithium "photographic" cells in this > handle makes a very light-weight combination. As a good example, I > try to keep my Personal Wilderness Medical Kit just exactly the same > as listed on the Web page. But I've got a laryngoscope in a > "physician addendum" bag that I carry when I'm willing to carry the > extra weight. I will be very interested in your replies. They will fit in well with our upcoming revision of the WEMSI Personal Wilderess Medical Kit list. Thank. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: (Fwd) Re: Cave Rescue Preplan / Prevention Reply-to: kconover+@pitt.edu Date: Thu, 28 Nov 1996 22:34:37 Thought those on the list might have some suggestions to add. ------- Forwarded Message Follows ------- From: Self To: ncrc@ontos.usa.com (NCRC Discussion List) Subject: Re: Cave Rescue Preplan / Prevention Reply-to: kconover@pitt.edu Date: Wed, 18 Sep 1996 19:33:30 On 3 Sep 96 at 19:22, Doug Moore wrote: > > **************************************************************** > *** * NOTICE! > * * The following information cannot be published without > the * * expressed consent of the author. > * > **************************************************************** > *** > > > > On 3 Sep 1996 at 19:22, Douglas Moore > (mail@ih{douglas.moore@svis.org}) wrote: > > > Got a couple quick questions that I'd like a quick answer to from > some of the people here. All questions are in regard to a couple of > caves that we have been working on surveying. A quick overview of > the caves are as follows since they all appear to be the same. The > entrances are near sump belly crawls with approximately six inches > of air space during low flow. The belly crawls extend for between > 100 and 200 feet into the cave with several 90 degree twists. The > following questions are based on the possibility that a survey crew > could become trapped in the cave for an extended period of time of > up to four days. It is assumed that blasting or other means would > probably be taken after this time period. > > 1. We have at are disposal several surplus plastic ammo cans > and > would like to or are currently placing them in the caves as > flood packs. What the question is what would be the best > contents to place inside? The assumption would be that the > surveyers do not have adequate supplies in there personal > cave packs for a stay beyond the intended survey period of > up to 12 hours. Currently the surveyers are going slightly > hypothermic after 6 hours in cave. The size of the ammo > cans are approximately 4.5 x 12 x 12 inches internally. > > 2. I am willing to lay communication wire to the nearest point > in > the cave that can be used for waiting out a flood. What is > the cheapest method to obtain communication out of the cave? > It is assumed that the phone, etc. will be left in the cave > during the life of the survey and may become flooded during > the winter months. > > Thanks alot, Doug! > > -------------------------------------------------------------------- > ------- | /\+/\ Douglas L Moore II /\+/\ > | | NSS 33064SU - NASAR 102903 > | | UTM Zone 17 Coordinates 562,160 > East 4,363,370 North | | Staff - Eastern Region - NCRC > (http://svis.org/erncrc/erncrc.htm) | | Owner - Karst Sports > (Caving, Climbing, & Rescue equipment) 304.592.2600 | | On > the World Wide Web at http://svis.org/msc/karst.htm | | > Catalog available upon request > | > -------------------------------------------------------------------- > ------- > > > -------------------------------------------------------------------- > -------- Internet: douglas.moore@svis.org (Douglas Moore) This > message was processed by Software Valley Information System > -------------------------------------------------------------------- > -------- If space and long survivability of the rations are the main considerations: 1. include a tiny stove (e.g., alcohol stove, fuel tabs, etc.) and assume there's plenty of water to boil. 2. pack the ammo boxes with military MR8 rations. When pulverized and mixed with boiling water it makes cream of wheat with (whole) milk -- warm, filling, though somewhat monotnous. 3. Throw in some almonds (keep well) and raisins and other dried fruit to throw in the above. 4. Seal up some Quinoa (South American grain that cooks in 10 minutes and provides complete protein with all essential amino acids, unlike other grains). 5. Throw in some different flavor boullion cubes for the above. This will make a compact nourishing ration pack that requires some time to prepare (good when you've got little else to do) and requires a lot of water to fix (not a problem if the reason you're there is flooding). Just brining the water to a boil will eliminate any significant chance of contracting "bad germs" by drinking the stream water -- however it won't protect against heavy metals or pesticides (better check the hydrology of the cave). An alternative would be to include a PUR or similar iodine-resin pump filter with a charcoal postfilter which should provide drinkable water from any cave water. And remember to add in a couple military style collapsible canteens. For a little variety, throw in some meat pemmican if you can find it -- pounded (powdered) jerky, pea flour, and rendered fat in equal proportions. It provides complete protein and more energy per pound than just about anything else. I used to get Amundsen Brand pemmican from Canada's Hudson Bay Company but not sure if they still offer it. Eaten as is it is moderately disgusting. Small bits dropped into Quinoa or to flesh out boullion into a nourishing stew. With your permission, I'd like to cross-post this to the wilderness-emergency-medicine list to see if there are other good thoughts for you there. --Keith Conover, M.D., FACEP -- End -- Received: from post-ofc02.srv.cis.pitt.edu (root@post-ofc02.srv.cis.pitt.edu [136.142.185.24]) by pop.srv.cis.pitt.edu with ESMTP (8.8.3/cispop-1.6.1.4) ID ; Tue, 17 Dec 1996 18:03:58 -0500 (EST) Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.8.3/cispo-2.0.1.7) ID ; Tue, 17 Dec 1996 18:02:39 -0500 (EST) Received: via switchmail; Tue, 17 Dec 1996 18:02:39 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Tue, 17 Dec 1996 18:00:52 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.8.3/cisls-2.4) ID ; Tue, 17 Dec 1996 17:59:37 -0500 (EST) Received: from emout11.mail.aol.com (emout11.mx.aol.com [198.81.11.26]) by list.srv.cis.pitt.edu with SMTP (8.8.3/cisls-2.4) ID for ; Tue, 17 Dec 1996 17:59:28 -0500 (EST) Received: by emout11.mail.aol.com (8.6.12/8.6.12) id RAA10496 for wilderness-emergency-medicine@list.pitt.edu; Tue, 17 Dec 1996 17:58:52 -0500 X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f From: JSilver374@aol.com Date: Tue, 17 Dec 1996 17:58:52 -0500 Message-ID: <961217175252_776664565@emout11.mail.aol.com> To: wilderness-emergency-medicine@list.pitt.edu Subject: W-EMED Tourniquets; Wilderness guidlines Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu Content-Type: text X-UIDL: 4feee01d6c86a4d0bd6f142af216fc4a Status: U X-PMFLAGS: 33554560 0 Hi all, In reading through the WMS practice guidelines (1995) on tourniquets, the recommendation is to release the tourniquet every 5 minutes while maintaining direct pressure to assess it's continued need. (p 11) This makes sense to me since you want to minimize tissue necrosis if at all possible. My EMT book (Hafen & Karren, 3rd ed.), on the other hand, states that the tourniquet should not be removed at all (except on physician's orders). This seems appropriate in an urban setting. But it goes on to say there is a danger of blood clots entering the circulatory system if the tourniquet is released. This would be a problem no matter where the patient is and maybe a greater problem in a wilderness setting. What is the current thought on the issue? Thanks and Happy Holidays Jonathan Silver, EMT-D, WEMT Highland Park, NJ Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc02.srv.cis.pitt.edu (root@post-ofc02.srv.cis.pitt.edu [136.142.185.24]) by pop.srv.cis.pitt.edu with ESMTP (8.8.3/cispop-1.6.1.4) ID ; Wed, 18 Dec 1996 10:53:55 -0500 (EST) Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.8.3/cispo-2.0.1.7) ID ; Wed, 18 Dec 1996 10:53:49 -0500 (EST) Received: via switchmail; Wed, 18 Dec 1996 10:53:49 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Wed, 18 Dec 1996 10:52:16 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.8.3/cisls-2.4) ID ; Wed, 18 Dec 1996 10:51:33 -0500 (EST) Received: from gabriel.cc.emory.edu (gabriel.cc.emory.edu [170.140.30.75]) by list.srv.cis.pitt.edu with ESMTP (8.8.3/cisls-2.4) ID for ; Wed, 18 Dec 1996 10:51:29 -0500 (EST) Received: from 170.140.250.108 (anx52-108.dialup.emory.edu [170.140.250.108]) by gabriel.cc.emory.edu (8.7.3/8.6.9-950630.01osg-itd.null) with SMTP id KAA23566 for ; Wed, 18 Dec 1996 10:52:09 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Message-ID: <32B7CDF7.4526@emory.edu> Date: Wed, 18 Dec 1996 10:57:00 +0000 From: Ron Brown X-Mailer: Mozilla 3.0 (Macintosh; I; PPC) MIME-Version: 1.0 To: wilderness-emergency-medicine@list.pitt.edu Subject: Re: W-EMED Tourniquets; Wilderness guidlines References: <961217175252_776664565@emout11.mail.aol.com> Content-Transfer-Encoding: 7bit Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu Content-Type: text/plain; charset=us-ascii X-UIDL: d28cb92cb8be96b425d5c055de2d41f0 X-PMFLAGS: 35127424 0 I would think in a wilderness setting involving WEMT response there should exist protocols allowing some tourniquet use, with periodic release, without constant physician input. This would of course be situation-dependent, as there is some controversy concerning the use of tourniquets in snakebites--the release of accumulated toxins, lactic acid and other substances (thromboxanes?) with the loosening of the tourniquet for the sake of perfusion perhaps causing some degree of shock. Is the release of blood clots--in essence a DVT--really a concern with the use of tourniqets, or is this anecdotal? Is there another indication for tourniquets outside of envenomnation in the wilderness setting? I have done direct pressure for venous bleeds, been trained in pressure points for arterial bleeds, but only heard of the controversy over tourniquets with regard to poisoning. Ron Brown, MD Emory University Atlanta Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- X-cs: From: Self To: Ron Brown ,wilderness-emergency-medicine@list.pitt.edu Subject: Re: W-EMED Tourniquets; Wilderness guidlines Reply-to: kconover+@pitt.edu Date: Wed, 18 Dec 1996 18:03:31 On 18 Dec 96 at 10:57, Ron Brown wrote: > I would think in a wilderness setting involving WEMT response there > should exist protocols allowing some tourniquet use, with periodic > release, without constant physician input. This would of course be > situation-dependent, as there is some controversy concerning the use > of tourniquets in snakebites--the release of accumulated toxins, > lactic acid and other substances (thromboxanes?) with the loosening > of the tourniquet for the sake of perfusion perhaps causing some > degree of shock. If you're talking about using tourniquets for North American pit viper bites -- I don't think there's any controversy. Current recommendations (Auerbach and Geehr, for example, or the WMS Practice Guidelines) are flatly against tourniquets of any sort for snakebite. > Is the release of blood clots--in essence a > DVT--really a concern with the use of tourniqets, or is this > anecdotal? Purely anecdotal -- unless someone can provide a reference that I haven't seen. > Is there another indication for tourniquets outside of > envenomnation in the wilderness setting? I have done direct > pressure for venous bleeds, been trained in pressure points for > arterial bleeds, but only heard of the controversy over tourniquets > with regard to poisoning. Ron Brown, MD Emory University Atlanta Here is an excerpt from the current Wilderness EMS Institute protocols: Primary Survey, Bleeding Control: Applying a tourniquet on the street is deciding to sacrifice a limb to save a life. EMTs rarely, if ever, need to use a tourniquet, because direct pressure and elevation almost always stop bleeding. Continued slow bleeding is not a major problem for most EMTs. The patient will be in the Emergency Department before the continued blood loss will be a problem. With long evacuation and transport times, though, even slow external bleeding can cause shock. Usually, if you can slow the bleeding down, the body's own clotting mechanisms will stop the bleeding. However, these clotting mechanisms may not work properly under certain conditions, e.g., hypothermia, extensive crush injury, or snakebite. The key to control bleeding to use firm localized pressure directly over the bleeding vessels. Your gloved finger, covered with a single gauze pad to make it less slippery, is ideal. You should apply pressure for a full ten minutes, then release pressure and see if it bleeds again. (Use your watch to time yourself) If it starts bleeding again, apply pressure, this time for fifteen minutes. If you release pressure or slip off the blood vessel and it starts again, start holding again for another full count by the clock. (When the bleeding starts again, the clot that had been building is pushed off by the bleeding.) Once the bleeding is controlled, you can apply a pressure dressing with a wad of small gauze pads under it to replace your finger's pressure to prevent it from bleeding again. The standard rule on the street is not to remove blood soaked dressings, but to place new dressings on top. This is not appropriate for the wilderness. In the wilderness, you should remove blood-soaked dressings, identify the bleeding vessels, and apply pressure to them as described above. On occasion, you may find it difficult to adequately stop bleeding, because you can't precisely identify the bleeding vessels. In such a situation, you may be able to use a temporary tourniquet as a tool to identify the bleeding sites. Surgeons and emergency physicians routinely use tourniquets for up to thirty minutes to allow "bloodless field" surgical repairs. Having details not obscured by bleeding makes the surgical repair much easier. Similarly, you can use a tourniquet to locate the bleeding vessels; you then apply direct pressure, and release the tourniquet. If you put a tourniquet on someone's limb, the limb won't become severely painful for about half an hour, and you won't start having irreversible damage to the limb for another fifteen minutes. However, you shouldn't need a tourniquet for more than a few minutes. (You should only apply a tourniquet by a specific doctor's order or standing orders from your medical director.) Whenever you apply a tourniquet, it must be wide, to prevent damage to soft tissues, and tight, to prevent any leakage. A blood pressure cuff makes an ideal tourniquet, provided you can ensure that it doesn't deflate. A clamp on the BP cuff tubes will work, provided you watch the cuff to make sure it doesn't leak. Various materials can be placed into or onto wounds to help staunch bleeding. Thrombin powder works well. However, only one particular brand and type is stable for more than thirty days at room temperature. (Thrombin 5,000, 10,000, and 20,000 units (topical powder), Johnson & Johnson, is stable for three years at room temperature.) Other common materials include GelFoam and oxidized regenerated cellulose (Surgicel), both of which are stable at room temperature. These are light and may be carried and used, but are so seldom useful that their inclusion in a personal wilderness medical kit is questionable. -- End -- Received: from post-ofc03.srv.cis.pitt.edu (root@post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by pop.srv.cis.pitt.edu with ESMTP (8.8.3/cispop-1.6.1.4) ID ; Fri, 20 Dec 1996 20:21:45 -0500 (EST) Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.8.3/cispo-2.0.1.7) ID ; Fri, 20 Dec 1996 20:21:37 -0500 (EST) Received: via switchmail; Fri, 20 Dec 1996 20:21:37 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Fri, 20 Dec 1996 20:21:16 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.8.3/cisls-2.4) ID ; Fri, 20 Dec 1996 20:20:12 -0500 (EST) Received: from netcom12.netcom.com (pturner@netcom12.netcom.com [192.100.81.124]) by list.srv.cis.pitt.edu with SMTP (8.8.3/cisls-2.4) ID for ; Fri, 20 Dec 1996 20:20:07 -0500 (EST) Received: (from pturner@localhost) by netcom12.netcom.com (8.6.13/Netcom) id RAA08973; Fri, 20 Dec 1996 17:20:07 -0800 X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Date: Fri, 20 Dec 1996 17:20:06 -0800 (PST) From: Patton M Turner Subject: Re: W-EMED Tourniquets; Wilderness guidlines To: wilderness-emergency-medicine@list.pitt.edu cc: wilderness-emergency-medicine@list.pitt.edu In-Reply-To: <32B7CDF7.4526@emory.edu> Message-ID: MIME-Version: 1.0 Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu Content-Type: TEXT/PLAIN; charset=US-ASCII X-UIDL: c4ba79ae1ef94af9e30602c33540e102 X-PMFLAGS: 34078848 0 Dr Brown, I am not aware of the suggestion of using tourniquets for North American snake bites. I have seen recomendations of using a constricting band for lympth, but this advice is usually tempered with a warning to only stop lympth flow, not blood flow. In fact Sawyer pulled the lympth constrictor out of their snakebite first aid kit. Now if we were talking about other snakes with neurotoxic venom, reducing bloodflow by any means might be an advantage, but with North American pit vipers, reducing blook flow is going to greatly increase the local damage. Pat On Wed, 18 Dec 1996, Ron Brown wrote: > I would think in a wilderness setting involving WEMT response there > should exist protocols allowing some tourniquet use, with periodic > release, without constant physician input. This would of course be > situation-dependent, as there is some controversy concerning the use of > tourniquets in snakebites--the release of accumulated toxins, lactic > acid and other substances (thromboxanes?) with the loosening of the > tourniquet for the sake of perfusion perhaps causing some degree of > shock. > Is the release of blood clots--in essence a DVT--really a concern with > the use of tourniqets, or is this anecdotal? > Is there another indication for tourniquets outside of envenomnation in > the wilderness setting? I have done direct pressure for venous bleeds, > been trained in pressure points for arterial bleeds, but only heard of > the controversy over tourniquets with regard to poisoning. > Ron Brown, MD > Emory University > Atlanta > Do not reproduce without author's express permission. > To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" > as the body of a message (no subject) To: Majordomo@list.pitt.edu > Submissions To: wilderness-emergency-medicine@list.pitt.edu > Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- X-cs: From: Self To: "DAVID L DILLINGHAM" Subject: re: Re: W-EMED Tourniquets; Wilderness guidlines Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Sun, 29 Dec 1996 08:43:04 On 20 Dec 96 at 7:41, DAVID L DILLINGHAM wrote: > Dr. Conover, > > In 18 years working emergency medicine i have had one uncontrolled > bleeding > incident. The time from the accident to the hospital was 25 > minutes. In a true wilderness setting the time may far exceed one > hour. The case for releasing the tourniquet may have valid > applications. Persons found in wilderness areas are usually younger > and in good health. Is there any case studies available to determin > the effects of the release of toxins in the blood stream? The only things of relevance are: 1. crush syndrome case reports. Crush injuries with entrapment are so different from a simple tourniquet that I believe there is no point in trying to generalize from one to the other. 2. hand surgery practice. Hand surgeons and emergency physicians routinely use tourniquets for a bloodless field. And we leave them on for up to an hour and release them. And there are no case reports I am aware of where this caused a thromboembolism, or of the "toxins" causing death of a patient. > If faced > with a situation where the limb was mostly intact and still > salvageable i may attempt to release the tourniquet. My only > question would be what may happen to my patients condition? If > toxins are released into the return blood flow how detrimental would > the results be as opposed to the loss of the limb? > > David Dillingham EMT-1A > I'd use the tourniquet, and release it after applying better direct pressure or a good pressure bandage. -- End --