Outdoor Ed Community

Wilderness First Aid Scope of Practice Update

Tod Schimelpfenig — Fri, 12 Mar 2010 21:08:00 GMT

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Folks

This is an update on the wilderness first aid scope of practice process and documents.

Our group of colleagues have been working steadily on these documents. We have circulated several drafts of the Wilderness First Aid (WFA) Scope of Practice document, considered the feedback we have received and are close to a final draft. We’ve also been working on a Wilderness First Responder Scope (WFR) of Practice document and have a solid working draft which the providers are reviewing. We hope to post this for review later this spring.

One of the challenges we face is balancing the needs of a large spectrum of students, from outdoor trip leaders to camp staff and non-institutional outdoor recreationists, with the length of the course and our ability to deliver the material effectively. A WFA is a basic and introductory course in wilderness medicine, yet we’ve been asked to teach GPS and survival skills, detailed emergency plans, improvised litters, and a wide variety of medical topics. The elder hostel argues for cardiac curriculum, the therapeutic program for mental health curriculum, the ocean based program for marine toxins, the high latitude program for more on cold injury. Folks up north don’t want to hear about heat illness and folks down south don’t want to hear about frostbite.

Choices must be made. As we develop each SOP document, we consider the available medical evidence, input from a variety of sources including practitioners, educators, and consumers, and our collective experience as guides, trip leaders, medical providers and professional medical educators.

We have had many collegial and interesting discussions on what should or should not be included in the scope of practice of a WFA. It is easy to reach consensus on the majority of the content. We spend most of our time on the question of what should be core and what can be an elective skill or topic. There is a need to balance a clear minimum standard for this credential while providing some flexibility to meet individual program needs.

I’m excited that the Wilderness Medical Society (WMS) will consider publishing the scope of practice documents in a consensus position statement on wilderness medicine courses for laypeople. The WMS is writing a series of position statements on important issues in wilderness medicine. The first consensus statement, on altitude illness, will be published in the next edition of the Wilderness and Environmental Medicine Journal. A statement on frostbite treatment is also being developed. Tony Islas MD, incoming WMS President, has offered the WMS as a place to support periodic, perhaps annual or biannual, gatherings of wilderness medicine providers to discuss common issues and revise these documents as needed. I think this is an excellent forum for us to publish our work and continue our conversations. The consensus position statement brings the weight of the society to bear on this question, and it's very appropriate.

A copy of the most current WFA SOP is attached. We are still open to comments.

Take Care

Tod Schimelpfenig

Curriculum Director

Wilderness Medicine Institute of NOLS

Tick-Borne Illness

Paul Auerbach — Sat, 06 Mar 2010 22:02:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

This is the next post based upon a presentation given at the Wilderness Medical Society Annual Meeting held in Snowmass, Colorado from July 24-29, 2009. The presentation was entitled “Lessons Re-learned: The US Army’s Experience with Tick –Borne Illness.” It was delivered by John Westhoff, MD, who is a Fellow of the American College of Emergency Physicians.

Dr. Westhoff made a number of great points, in a session that mentioned Rocky Mountain spotted fever, ehrlichiosis, Lyme disease, tularemia, Q fever, and southern tick-associated rash illness (STARI).

A case presentation format was used to highlight the varied way and severity in which some of these disorders can present to clinicians. For instance, a case was described in which the victim was a 49 year old with a 24 hour history of headache and chills, mildly elevated blood pressure – pulse – respirations – temperature – white blood cell count, and was initially given the diagnosis of sinusitis. One day later, the patient was seen with persistent problems, and informed of a working diagnosis of viral syndrome. Three days later, the patient had developed subjective numbness in the hands and feet, and still had a progressive low grade fever, but the white blood cell count had dropped to normal. The working diagnosis was still viral syndrome. On the fourth visit, the victim underwent a spinal tap (lumbar puncture) and was admitted to the hospital. A skin rash developed and blood testing revealed that the patient suffered from ehrlichiosis, from which there was a full recovery.

Ehrlichiosis can be severe. Dr. Westhoff described another case, in which a young man who initially presented with fever and chills and not much more deteriorated over three days sufficiently to be admitted to the hospital, and died after 8 days in the hospital, again with a diagnosis of ehrlichiosis. During his illness, he suffered from skin rash, muscle pain, high fever, infiltrates (consistent with pneumonia) in his lungs, low blood counts, and severe systemic infection with multi-organ failure. Ticks were found in his groin.

Human ehrlichiosis (there is also a canine form) is present in two forms, one caused by a rickettsial organism known as Ehrlichia chaffeensis, which is spread by Amblyomma americanum tick bites, and the other caused by the rickettsial organisms E. phagocytophila and E. equi, spread by Ixodes tick bites. Infection is usually acquired by a person who inhabits a rural environment. The average incubation period after a bite is approximately 7 to 10 days. The victims, who are more commonly middle-aged adults than children and young adults, complain of a flu-like syndrome with high fever, chills, fatigue, headache, muscle aches, vomiting, and a variety of skin rashes, which can be punctate, bumpy, like tiny bruises, or broad and reddened. A victim often has decreased counts of various types of blood cells, as well as liver dysfunction. The treatment is tetracycline 500 mg four times a day, or doxycycline 100 mg twice a day, for 10 days. The few children who have been diagnosed with ehrlichiosis have been treated with doxycycline 3 mg per kg of body weight in two divided doses per day. Untreated or treated after a delay in diagnosis, up to 15% of victims can develop severe infections, kidney failure, bleeding disorders, seizures, and/or coma.

Human anaplasmosis, which was formerly called human granulocytic ehrlichiosis, is caused by infection of white blood cells by a bacterium named Anaplasma phagocytophilum. Like ehrlichiosis, anaplasmosis is disseminated by bites of Ixodes ticks, the blacklegged tick (I. scapularis) in the Northeast and upper Midwest, and the western blacklegged tick (I. pacificus) on the West Coast. Infected persons have the onset of illness 5 to 21 days after a bite with symptoms of fever, headache, fatigue, and muscle aches, which may progress to more serious illness affecting the kidneys, central nervous system, lungs, and blood system. The treatment is the same as for ehrlichiosis.

We also learned about Rocky Mountain spotted fever (RMSF), which is most commonly seen during the months of April to September, when ticks and humans are most frequently in contact. The disease carries an incubation period of 5 to 10 days, and classically presents with fever (flu-like illness), typical rash 2 to 5 days after the fever, and a history of tick bite. Treatment is usually with doxycycline 100 mg by mouth every 12 hours (4 mg/kg/day for persons under the weight of 45 kg) for 10 days. Chloramphenicol is used for pregnant patients.

After a further discussion of features of ehrlichiosis and Lyme disease and brief discussion of tularemia, Q-fever, and STARI, the bulk of the remainder of the session was devoted to the most important topic – namely, prevention of tick-borne illnesses. The key features noted were personal skin inspection to locate and remove ticks, heightened awareness during tick season, use of appropriate insect repellents, such as DEET (33% controlled release lotion), permethrin treatment of clothing, proper wearing of clothing (long sleeves, tucked in shirts and pants), and so forth. It was emphasized that permethrin treatment of clothing is much more effective than is DEET treatment of clothing.

If you decide to apply permethrin spray to clothing, be certain to do the following:

1) Follow manufacturer’s instructions closely. Do not exceed recommended spraying times.
2) Treat clothing only. Do not apply to skin.
3) Apply the permethrin in a well-ventilated outdoor area, protected from the wind.
4) Only spray the permethrin on the outer surface of clothing and shoes.
5) In a concentration of 0.5%, it can be sprayed on both sides of clothing to lightly moisten the outer surface of the clothing item; it is not necessary to have the clothing soaked through (saturated).
6) Be certain to apply completely cover socks, trouser cuffs and shirt cuffs, where insects may attempt to crawl or fly through openings to your skin.
7) Hang treated clothing outdoors and allow to dry for at least 2 to 4 hours in non-humid conditions and for at least 4 hours in humid conditions.
8) Treat clothing no more often than every 2 weeks.
9) Launder treated clothing separately from other clothing at least once before re-treating.
10) Assume that your treated clothing is effective for repellency for 2 weeks or more. Wear it only when you need to repel insects and arthropods. Store it in a separate impermeable (to permethrin) bag when not in use.

Future Trends in Outdoor Education

Jay Roberts — Fri, 12 Feb 2010 15:16:00 GMT

As we turn the corner away from the 00’s or the “aughts” or whatever historians will choose to call the last decade, it’s worth taking a moment to look ahead toward future trends and issues that will affect things in the outdoor education field for the next ten years or so. Future prognosticating is, of course, a dangerous game and I make no claims that my reading of the tea leaves is any better than anyone else’s guesses. However, I do keep up to date on the goings on in the field as best as I can and spend a good deal of time talking about these issues with colleagues at other programs, institutions, and conferences. So, without further ado, here are my top five trends (in no particular order) in Outdoor Education for the 2010’s...

1. LOCALISM: The impact of the “great recession” is certainly being felt in outdoor education. People are “nesting” more, staying closer to home, and looking for ways to enjoy the outdoors in simpler, more frugal ways. This dovetails nicely to the emerging localism movement connected to broader sustainability and environmental shifts in certain segments of the population. Interest in gardening, local green spaces, and getting kids out in nature is on the rise across the board. How can outdoor education, as a field, tap into this social shift in a way that democratizes nature and challenges some of the elitism and narcissism that has defined outdoor pursuits over the last several decades?

2. SUSTAINABILITY: It’s hip, it’s green, and it’s everywhere. Whether you think this new movement is shallow or deep, it is certainly influential. Equipment manufacturers are going green, ski slopes and other outdoor industries are ramping up sustainability efforts, and even travel and guide purveyors like REI are offering carbon off-sets for eco-tourist travel. Green gear lists for programs are on the rise as are attempts to lower the carbon footprints of everything from college outdoor programs to summer camps to environmental education centers. How can outdoor education act as an example of sustainable operations and education moving forward?

3. ACCESS: Population increases and the impacts of urbanization and suburbanization are placing incremental pressures on our natural recreation and wilderness areas. We are, in many respects, “loving them to death.” Yosemite and Yellowstone have smog alerts and traffic jams. Getting a permit in some places is like winning the lottery. As pressures increase, guided outdoor education groups will be under increasing pressure to find less-crowded and permit-driven recreation areas. Programmers can stay ahead of the curve by looking for less popular climbing areas, rivers, and trails that serve educational purposes without adding to the crowds.

4. NATURAL HISTORY: Knowing how to identify trees, birds, flowers, and the like use to be a stronger part of our national K-12 curriculum as well as the informal curriculum passed down from generation to generation. We have several generations of kids and young adults who cannot identify even the most basic plant and animal species in their own backyards let along the basic geological history or watersheds of their region. As the “no child left inside” movement and the concern for childhood obesity rates grows, re-kindling a love of the more-than-human world through natural history is, well, “natural.” How can outdoor educators leverage this emerging need into programs and new educational opportunities?

5. STANDARDIZATION: Travel to many places in northern Europe or New Zealand and Australia and you will find a professionalization and standardization of outdoor education that we have yet to see here in the States. Ropes courses, climbing walls, and other outdoor education sub-fields are all feeling the pressure toward more national standards. This is both a good and bad thing. With increased standardization comes increased need for certifications and training. This makes access into the field more expensive as a career option. But it also, potentially, increases the quality of the educational product and process. Yet, too much emphasis on “merit badges” can take the flexibility and life out of a field that has long thrived on passion, creativity, and sound judgement over rules, credentials, and bureaucracy. How will the field wrestle with the need for quality control against the strong legacy of individual freedom?

Those are my top five. I would be interested in hearing from others. What with the 2010’s hold for outdoor education?

Pain Management in Children for Broken Bones

Paul Auerbach — Mon, 08 Feb 2010 04:24:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

Pain management is a hot topic in medicine in general and certainly in medicine for the outdoors. Injuries in particular, and many illnesses, cause pain, which in turn causes the victim to suffer. To a great extent, pain is subjective, but regardless of whether your pain is a "1" or a "10," it can be disabling and even dangerous, particularly if it causes you to be distracted in a situation of risk (e.g., climbing, swimming, walking along a ridgeline).

Broken bones usually hurt a great deal. It's commonly believed that the pain is always of a severity to require the administration of "strong" pain medicine, notably, something containing a narcotic compound. This may not be true. In an article (Annals of Emergency Medicine 2009;54:553-560) entitled "A Randomized Clinical Trial of Ibuprofen Versus Acetaminophen With Codeine for Acute Pediatric Arm Fracture Pain," Amy Drendel, MD and colleagues compared the treatment of pain in children with arm fractures by using ibuprofen in a dose of 10 milligrams per kilogram (2.2 pounds) of body weight versus acetaminophen with codeine in a dose of 1 milligram per kilogram (based on the codeine component of the medication). The children were assessed for three days after discharge from an emergency department. Two hundred forty four patients were analyzed in this study.

The authors concluded that ibuprofen was at least as effective as acetaminophen with codeine for children ages 4 to 18 years with arm fractures treated as outpatients. What is also very interesting is that the children receiving ibuprofen had significantly fewer adverse effects, and both the children and their parents were more satisfied with ibuprofen. The proportion of children who had any function (play, sleep, eating, school) affected by pain was significantly lower for the ibuprofen group.

What to make of all this? The known side medication side effects measured were nausea, vomiting, drowsiness, dizziness, and constipation. Ibuprofen appears to be clearly superior in this study population. This is an eye opener for me, because I am a bit surprised (and now enlightened) by the data. I would have expected these broken bones to require more potent pain medication (e.g., a narcotic), but I see that this is not necessarily the case. In the future, I will recommend ibuprofen (if there is no contraindication) as an initial medication for many more types of pain situations, and wait to see if a more potent "rescue drug" is necessary only as needed, rather than as first choice. If remaining alert and fully functional in an outdoor setting is a priority, this makes double sense.

Proper Hydration at High Altitude

Paul Auerbach — Mon, 01 Feb 2010 02:19:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

The standard dictum when advising persons who travel to high altitude, and thus expose themselves to a lower atmospheric oxygen concentration, is to stay "well hydrated," which translates into drinking sufficient liquid that they urinate frequently, with urine color being light (not concentrated). However, this recommendation has heretofore never been based on science, just on presumption and medical common sense. So, it is with great interest that I read an article in the current issue of Wilderness & Environmental Medicine, entitled "Hydration and the Physiological Responses to Acute Normobaric Hypoxia," authored by Alan Richardson, Peter Watt and Neil Maxwell (Wilderness & Environmental Medicine 20, 212-220 (2009).

The objective of the study was to identify how hydration status, above and below normal hydration levels, affects physiological responses and onset of acute mountain sickness (AMS) symptoms during acute normobaric (normal atmospheric pressure - equivalent to that at sea level) hypoxia (lowered concentration of oxygen in the air). In this study, eight males subjects completed intermittent walking tests in the condition noted after controlled normal hydration (euhydration), hyperhydration (too much water) and hypohydration (dehydration - too little water) protocols. During the measurement period of approximately 2 hours' exposure, heart rate, core body temperature, peripheral arterial blood oxygen saturation, urine osmolality (a measure of concentration and thus the state of hydration), and self-reported AMS scores were obtained.

The observations and analysis showed that the different states of hydration had a significant effect on all of these parameters, and that hydration state above (hyper-) and below (hypo-) normal hydration had detrimental consequences on physiological strain and onset of acute mountain sickness symptoms under the conditions studied.

This is very important work, and will undoubtedly spur further investigation. We are fairly familiar with the concept of hypohydration, which leads to dehydration and all of its deleterious effects upon performance and body functions. However, in the setting of high altitude, we are less familiar with hyperhydration (too much water), because we don't encounter it very often, unless it is induced by a doctor- or rescuer-led intervention. We suspect that fluid retention in general, when it occurs for whatever reason, may contribute to the accumulation of fluid in the brain (AMS) or perhaps even the lungs (high altitude pulmonary edema), but this has never been proven. The worsening of headache in this study (as a presumptive symptom of AMS and perhaps harbinger of fluid accumulation in the brain) in the hyperhydration group is a bold word of caution to us to attempt to achieve normal hydration, and nothing more, with our fluid replacement strategies. How best to do this? At the current time, the best we have in the field is maintaining urine color, specific gravity and/or osmolality (signs of urine concentration and thus state of hydration) at preferred values. However, with the advent of technologies such as that offered by Cantimer, we may soon have other methods by which to guide fluid administration, as thirst in and of itself is notoriously not sufficiently precise for this purpose.

SAM Splint versus Philadelphia Collar

Paul Auerbach — Mon, 25 Jan 2010 01:41:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

In an issue of Wilderness and Environmental Medicine (Volume 20, Number 2, 2009), Todd McGrath and Crystal Murphy have written an article entitled “Comparison of a SAM Splint-Molded Cervical Collar with a Philadelphia Collar.” The objective of this study was to compare the effectiveness of a SAM Splint molded into a cervical collar with that of a Philadelphia collar (commonly used by paramedics and others to hold a neck motionless during transport after an accident) at limiting movement of the cervical spine (neck) in a variety of common predicted directions of motion.

Healthy volunteers participated in the study. A goniometer was used to measure degrees of maximal extension (bending the neck backwards) and lateral motion (left and right) with each type of collar. After data analysis, it was concluded that the results of this study suggest that the SAM Splint, when molded into a cervical collar, is as effective as the Philadelphia collar at limiting movement of the cervical spine.

This is good news for rescuers, backpackers, athletic medical responders and others who have occasion to splint an injured or potentially injured neck in the field. I have used SAM Splints to fashion cervical collars for many years, because my observations were that it could be quickly configured into a reliable and functional splint for this purpose, so it is nice to have my suspicions confirmed. There is certainly nothing wrong with using a (preferably, lightweight) Philadelphia collar or other similar pre-molded appliance to maintain a neck motionless when necessary. The general considerations will be space, weight, ease of use, and adaptability to a variety of patient sizes and conditions. Furthermore, it cannot be overemphasized that if you wish to use a SAM Splint or any other rescue product in the outdoors for which operator skill and experience are required, you should take the time to practice beforehand in a controlled and non-frenetic environment.

Legislative Alert: Commercial Drivers Licenses Could be Required for Drivers of 9-15 passenger vehicles under new Senate Bill

Rick Curtis — Mon, 18 Jan 2010 15:40:00 GMT

On December 17, 2009 the Senate Commerce and Transportation Committee passed S. 554: Motorcoach Enhanced Safety Act of 2009. It now is set to go to the full Senate. All outdoor programs should be aware of this bill and its potential impact on your program.

The full language of the bill that is of concern is show below.

SEC. 7 IMPROVED COMMERCIAL DRIVER’S LICENSE TESTING.

(b) Modification of Requirements for Commercial Driver’s License Passenger-Carrying Endorsement- The Secretary shall establish by regulation a requirement that a driver shall have a commercial driver’s license passenger-carrying endorsement in order to operate a commercial motor vehicle and transport not less than 9 and not more than 15 passengers (including a driver) in interstate commerce for compensation.

SEC. 10. COMMERCIAL MOTOR VEHICLE SAFETY INSPECTION PROGRAMS.

(1) PROGRAM REQUIRED- In order to receive a grant pursuant to section 31102 of this title, a State shall conduct an annual safety inspection program for commercial motor vehicles, including motor carriers transporting not fewer than 9 and not more than 15 passengers (including a driver), that receives approval from the Secretary pursuant to paragraph (3).

While much of the legislation is admirably designed to improve safety in commercial buses the proposed requirement in Section 7 that Commercial Driver's Licencense (CDLs) be required for drivers operating 9-15 passenger vehicles across state lines will have significant implications for outdoor programs across the United States. Many outdoor programs have moved away from 15-passenger vans to 10-12 passenger vehicles and up to now have been exempt from CDL requirements since their primary business is not 'transportation for hire.' Should this law pass in its current form many programs would be unable to provide enough CDL-qualified drivers to operate. This is especially true for college and university programs that often utilize student drivers.

The proposed requirements for annual safety inspections outlined in Section 10 of the bill could also have cost and other implications for outdoor programs.

A number of groups including American Camp Association, America Outdoors, the Trade Association of Paddlesports and others have commented on the bill, most taking the stand the the bill is overly broad and that the requirements as stated would have a significant negative impact on outdoor programs around the country.

OutdoorEd.com wants to encourage all outdoor professionals write your congress person now to recommend ammendments to the bill. It's very easy. The first step is to identify your Senators. Go to www.congress.org and find the GET INVOLVED section in the middle of the page. Enter your zip code to find your Senators and how to contact them. You can use the online Web Contact form to contact your Senators directly.

The following language has been suggested. It can be modified to address the specific needs of outdoor programs, outfitters, camps, and college outdoor programs.

The Honorable (insert name)
United States Senate
Washington, DC 20510

Dear Senator ________________

I am writing to express concerns about provisions in S. 554 which require enhanced Commercial Driver's Licenses (CDL) for drivers of 9 to 15 passenger vans operated by small businesses that cross state lines. The proposed legislation requires a CDL and vehicle inspections even if transportation is incidental to the purpose of the business. This new regulatory requirement will make it very difficult for small businesses like mine to find drivers with CDLs. The legislation also requires increased training and testing requirements for CDL drivers. Ironically, a business providing similar services in competition with mine whose vans do not cross state lines will not be required to obtain CDL's for van drivers.

We believe many small businesses such as ours are being caught in a regulatory net cast for other transportation providers, where transportation is the primary purpose of the business. The CDL requirement, with its more stringent testing requirements, may force some outfitters and guides providing recreation services out of business.

Therefore, I am urging you to support provisions that exempt outfitting and guiding businesses from the CDL and inspection requirements where transportation is not the primary purpose of the business. For example, our primary service is providing outfitting and recreation services. We transport our customers to an area where the services are provided and sometimes cross state lines to do so.

Below, please support inclusion of the following modifications to the legislation.

Section 7 B - MODIFICATION OF REQUIREMENTS FOR COMMERCIAL DRIVER'S LICENSE PASSENGER-CARRYING ENDORSEMENT.

At the end of the paragraph insert: In establishing such regulations, the Secretary shall not require a driver to have such an endorsement where the transportation of passengers by motor vehicle for compensation is not the principal line of business of the motor carrier providing the transportation service.

Section 10 - COMMERCIAL MOTOR VEHICLE SAFETY INSPECTION PROGRAMS

(a) (1) at the end of the paragraph insert

(a)(1) Annual Inspection Program please add: In establishing such regulations, the Secretary shall not require a motor carrier to have such an inspection where the transportation of passengers by motor vehicle for compensation is not the principal line of business of the motor carrier.

Thank you for your support for small business. I look forward to hearing from you about this matter.

Sincerely,

Frozen Autoinjectors and Armpits

Tod Schimelpfenig — Sun, 17 Jan 2010 22:05:00 GMT

I recently exchanged emails with a fellow who asked if it was acceptable to freeze the auto-injector in his first aid kit. I told him of course not, you may not have time to thaw the medication. Now curious, I intentionally froze four expired EpiPens® on a minus 22ºF night and timed how long it took to thaw the auto-injectors in my armpit.

The first one mechanically fired with a normal amount of pressure while frozen, the needle extended, but no liquid was ejected. When opened the epinephrine was frozen and there were no obvious cracks in the tubex. I then thawed the remaining three EpiPens® in my left armpit (97ºF via our household mercury thermometer).

At 3 minutes I discharged the second EpiPen®, but only a little bit dribbled out of the needle. I opened this EpiPen® and found the epinephrine still frozen.

At 4 minutes I discharged the third EpiPen® and I saw a stream of liquid, but it seemed less than expected. The epinephrine in this unit was partially thawed.

At 5 minutes I discharged the last EpiPen® and observed a decent steam of liquid and upon opening, found the remaining epinephrine liquid.

Likewise I froze an ampule of epinephrine. This was thawed after 3 minutes under my armpit. The ampule was not cracked. Several years ago we did the same test on one of the older “AnaGuard” syringes and it took 5 minutes to thaw completely.

So there you have it, backyard science to support the common sense practice of keeping a liquid emergency medication thawed and ready to use. It makes no sense to tempt fate and hope you can thaw your medication in time. Keep it close to your body in cold weather.

There is a second question here, will frozen and thawed epinephrine work? If it was frozen and thawed, and I needed it, and it was not discolored with precipitates floating around, I'd use it. According to the UIAA Medical Commission, yes, it will be biologically active. However, freeze-thaw is not the best situation and will accelerate the deterioration of the medication. It can also crack the ampule or syringe and affect sterility of the product.

Take care

Tod

Kupper, Th. Milledge, J. Basnyat, B. Hillebrandt, D. Schoffl, V The Effect of Extremes of Temperature on Drugs. Consensus Statement of the UIAA Medical Commission Vol 10 2008

Posterior Cruciate Ligament Injury

Paul Auerbach — Mon, 11 Jan 2010 04:31:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

We're in ski season and so a few unfortunate individuals will suffer few knee injuries. A while back, a reader asked me to describe an uncommon injury, which is a torn posterior cruciate ligament (PCL).

This injury usually occurs during a fall. As you can see from the drawing, the PCL keeps the lower leg bone (tibia) from moving too far back in relation to the upper leg bone (femur). If a sudden unnatural force is applied, usually a direct blow to the front of the lower leg near the knee while the knee is bent, the tibia is jammed backwards and the PCL may be torn. In the skiing situation, this usually happens during a fall and a tumble, when someone strikes an immovable object, or when the knee is bent or "twisted" and struck forcefully from the side.

The immediate sensation is pain, and there may be a feeling of instability to the knee, particularly when trying to walk or change levels (e.g., walk over the snowpack or on stairs). When the injury occurs, there usually is not the "pop" sensation noted with an anterior cruciate ligament tear. However, the knee will almost always swell, because there is bleeding into the knee joint and/or soft tissue swelling.

The diagnosis may be surmised by taking a good history and understanding the mechanism of injury, performing a physical examination to determine what elicits pain and instability (commonly, the "posterior drawer test"), and these days, most often by magnetic resonance imaging (MRI). Sometimes an x-ray is taken prior to the MRI to determine whether or not there is a broken bone, but the x-ray does not show the structure and integrity of the ligaments and cartilage within the knee.

Until you can see your doctor, you should apply ice packs a few times a day for 15 minutes to help diminish pain and swelling, and avoid weight bearing. Use crutches if you have them. A broadly-applied (mid calf to mid thigh) pressure wrap may help diminish pain and increase stability, but take care to not apply it too tightly. If you decide to take pain medication, avoid aspirin-containing products (to diminish bleeding). If you have a knee brace (usually from a previous injury or as a preventative appliance for certain sports, wear it to provide extra stability.

Whether or not you will need surgery depends on the magnitude of the tear and the degree to which you respond to rehabilitation. Small tears are sometimes treated "conservatively" without surgery and can be rehabilitated under the guidance of an experienced physical therapist. If the knee does not improve or if the tear is sufficiently extensive initially, surgery may be recommended to replace the PCL with a graft.

drawing courtesy of www.zimmer.co.nz

Canadian C-Spine Rule

Paul Auerbach — Sun, 13 Dec 2009 19:18:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

Christian Vaillancourt, MD and his colleagues recently published an article in the journal Annals of Emergency Medicine (2009;54:663-671) entitled "The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics." This rule was originally developed for "clinical clearance" (e.g., without the use of x-rays) of persons with possible cervical spine fracture (broken neck) in alert and stable trauma patients by qualified persons (generally, emergency physicians) in a health care setting (such as an emergency department). This particular study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing important cervical spine injuries.

The Rule, properly applied to an awake and alert injured person for which there is a concern for a cervical spine injury, provides the following direction:

1. If a person has a high-risk factor (age greater than or equal to 65 years; a dangerous mechanism of injury [a fall from an elevation greater than or equal to 3 feet; fall down 5 or more stairs; direct blow to top of head, such as a diving board accident; motor vehicle accident characterized by high speed, rollover or passenger ejection; motorized recreational vehicle accident; bicycle collision]; or numbness/tingling in an arm or leg), then neck immobilization and x-rays are indicated.

2. If the victim is not able to actively rotate his or her neck, under their own power and without assistance, 45 degrees to the left and right without causing pain, then neck immobilization and x-rays are indicated. If the victim is completely without pain at rest and on active range of motion of the neck, then it is unlikely that an unstable fracture is present.

3. Low-risk accident factors that allow safe assessment of range of motion of the neck include simple rear-end motor vehicle collision (excludes being pushed into oncoming traffic, being hit by a bus or large truck, rollover, or hit at high speed by a vehicle); person is capable of a sitting position; person is ambulatory (e.g., walking); delayed onset of neck pain; and absence of posterior or anterior pain on examining (e.g., pressing upon) the neck. If the accident is deemed to be low-risk, then the victim is asked to attempt rotation of his or her neck under their own power and without assistance. See number 2 above.

What does this mean for the layperson who is practicing medicine in the outdoors? It provides a very reasonable approach to deciding who might be safely examined and when to apply a cervical spine immobilization technique. The overall goal is to not move someone's neck if he or she might have an unstable fracture, where movement could jeopardize the integrity of the spinal cord. Clinical judgment and intuition serve important roles, because it truly is best to always err on the side of "better safe than sorry." However, if the victim is low risk from all perspectives, it allows the rescuers more comfort in moving the victim or allowing self-extrication from a difficult situation or hostile environment.

Helmets for Active Sports

Paul Auerbach — Mon, 07 Dec 2009 04:51:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

The National Highway Traffic Safety Administration reported an analysis of motorcycle helmet use in fatal crashes. What was discovered is not surprising - namely, that in states in which there is not a state helmet law, the odds of a rider in a single-vehicle (e.g., the motorcycle) crash wearing a helmet was 72% less than in states with a helmet law. So, absent a law, people are not particularly inclined to wear a helmet.

One needs to couple this information with the facts about the benefits of wearing motorcycle helmets. First, motorcyle fatalities and fatality rates are increasing at a time when motorcycle riding is becoming more popular. Second, the average age of motorcycle fatalities has moved up to 39 years, from 30 years nearly 20 years ago, probably because the age of motorcycle riders has increased. Third, motorcycles expose the drivers more directly to lethal forces than do enclosed vehicles. Helmets are essential to prevent brain injuries and deaths.

What are the arguments against wearing helmets? Some argue that motorcycle helmets are heavy and therefore increase neck and spinal cord injuries. The opposite has been shown to be true. Some opponents claim that motorcycle helmets impair the driver's ability to hear and see. These senses have been studied in the context of motorcycle activity and do not appear to be impaired, and in certain circumstances, may be improved. The argument that motorcycle helmets are only effective up to a speed of 15 miles per hour is not entirely true. Many head injuries follow glancing blows, not high speed direct impacts. It is true that a helmet can not be effective against a tremendous blow, but it is better than nothing.

Many argue that there is a freedom of choice issue at play. If you knew that you were going to be struck on the head during a particular ride, would you choose to wear a helmet? Probably, you would. The problem is that no one is able to predict the day or moment of their accident and head injury. Few people believe that anything bad will ever happen to them.

Motorcycle helmets are a surrogate for helmets in all situations of risk in which there is a reasonable likelihood of being struck on the head and injuring the scalp, skull, and/or brain. What are those situations? In the water, it is the kayaker who is at risk for being flipped onto a rock or getting caught in a strainer. Knocked unconscious in the water, he is drowned. For the rock climber, it is being struck by falling rocks, swinging into a rock face, or suffering a fall. For the horseback rider, it is coming off the horse. For the motorcycle or ATV rider, or bicyclist, it is crashing and striking one's head. For the skier, it is falling, crashing, or being struck by a ski or snowboard.

One gives up very little (nothing, really) and gains everything by wearing a helmet in the appropriate circumstances. Freedom of choice is a selfish concept when one considers that the head-injured victim forces loved ones or society to provide care and the financial resources to manage the injury and rehabilitation, and sadly, support for the disabled person, who might have avoided most of the injury by wearing a helmet.

There is no excuse for not wearing a helmet approved for high risk (for head injury) situations. It is no different than wearing a seat belt in a car or washing your hands before you eat. Prevention is the name of the game. Having cared for many people with devastating head injuries, most of which would have been trivial or absent if a helmet had been worn, I can only hope that we do what it takes to mandate helmet use in every reasonable situation for which they would be of benefit. That is a necessary and appropriate use of the law.

Helmets & Snowsports

In the most recent issue of the journal Wilderness & Environmental Medicine, published by the Wilderness Medical Society, there is an article entitled "Skiing and Snowboarding Head Injuries in 2 Areas of the United States," authored by Mark Greve, MD and colleagues (Wilderness and Environmental Medicine 10:234-238, 2009). The objective of their research was to explore the use of helmets in skiers and snowboarders injured at ski runs and terrain parks in Colorado and the northeast U.S. and to examine differences in head injury severity in terrain parks as compared to ski runs. The study was done by reviewing emergency department records of injured skiers at nine medical facilities in Colorado, New York and Vermont. Eligible patients were skiers and snowboarders who sustained a head injury.

Most of the injuries occurred when the victim hit her or her head on the snow; fewer occurred when the skiers or boarders were involved in collisions with other skiers or fixed objects. Only 37.1% of the victims were wearing helmets. There were significantly fewer instances of loss of consciousness in fall events in the Colorado group; significantly lower incidence of loss of consciousness in fall events in helmet users who struck fixed objects; and a higher incidence of skiers colliding with fixed objects in the Northeast. Even when controlling for helmet use, there were significantly more head injuries in terrain parks.

What does this all mean? Obviously, the study sample is small, but the big takeaway for me is that helmet use makes sense. Why are there more injuries in terrain parks? Perhaps this represents the mechanics of falls when snowboarding, as opposed to skiing, or perhaps it indicates a higher degree of risk (for a head injury) with this sport, either because of the mechanics, degree of risk (e.g., aerial maneuvers, jumps, etc.), speed for the terrain, or propensity to hit a fixed object. It seems like helmet use is a very logical, and perhaps even necessary, way to prevent head injuries, certainly while snowboarding, and probably while skiing.

Wilderness Emergency Medical Services

Paul Auerbach — Sun, 29 Nov 2009 03:40:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

I am frequently asked to write articles for magazines, chapters for textbooks, and commentaries for journals. Almost always, these are published, but sometimes a publishing project will fall through. Such is the case with a book entitled "Prehospital Care - Pearls and Pitfalls," edited by two longstanding emergency physician friends. Since their book is not going to be published, they have given me permission to use my contribution as I see fit in other venues, so please allow me to make the readers of this blog the beneficiaries. With a big thanks to my co-author, Dr. Laurie Kates, here goes:

WILDERNESS EMERGENCY MEDICAL SERVICES

1. What is wilderness medicine?

According to the Wilderness Medical Society (WMS): “Wilderness medicine focuses on medical problems and treatment in remote areas. It includes aspects of physiology, clinical medicine, preventive medicine, and public health.” For the purpose of emergency medical services (EMS) personnel, there are four qualities that define wilderness medicine:

• An austere environment
• Prolonged time to definitive care requiring modifications to traditional pre-hospital protocols
• Integration of rescue and medical skills
• Environmental threats

2. What is the difference between wilderness EMS and urban EMS?

Rapid response, stabilization and transfer to an advanced care facility comprise the focus of traditional urban EMS training systems. The physical remoteness, environmental exposure, challenging geography and often extended periods of time required for a rescue and stabilization require special training and define wilderness EMS. Traditionally, urban EMS is reactive and protocol driven, whereas wilderness EMS requires improvisation, innovation and extended protocols. In urban EMS, patient extrication is typically the responsibility of Fire Department personnel,who hand off patients to EMS providers, who begin providing medical care. In wilderness EMS, patient extrication is often technically difficult and time-intensive, requiring simultaneous administration of medical care by providers skilled in both medical and rescue skills.

3. How are wilderness emergency medical technicians (WEMTs) different from regular EMTs?

The Department of Transportation (DOT) is responsible for creating EMT curricula. The National Registry of Emergency Medical Technicians was inaugurated in 1970 to serve as a national certifying body for EMTs. Standardized tests are used to certify and recertify EMTs at the state level or into the National Registry of EMTs. There is no national standard or formal certification exam for WEMT designation. The WEMT curriculum is based on the DOT EMT curriculum and establishes an approach to emergency care in wilderness settings and is based on the recommendations of the Wilderness Medical Society, the Wilderness EMS Institute (WEMSI), the National Association of Search and Rescue (NASAR), the National Ski Patrol, the National Outdoor Leadership School (NOLS) and several other groups. Typically, a WEMT course includes 45-100 hours of classroom didactic time, 10 hours of emergency department time, and an additional 48 to 80 hours of clinical training as opposed to non-wilderness EMT courses, which require approximately 120 hours of classroom and ambulance ride-along time. WEMT courses include a minimum of 22 hours of training on medical conditions related to environmental conditions. In contrast, the typical EMT course includes only 3-10 hours addressing environmental emergencies. Other unique aspects of the WEMT curriculum include added training on extended patient care, rescue techniques, special equipment, and in providing care for injuries unique to the remote outdoors.

4. What procedures can be performed by WEMTs?

The procedures performed by a WEMT are determined by both the state protocols under which a WEMT practices, as well as his or her level of training. As there is no national standard for WEMT training, different states and health care systems have a variety of policies regarding what health care providers may and may not do given their levels of training. It is the responsibility of all health care providers to know the standard of care for their level of training, what procedures may be performed, and the protocols and policies of their system. Key elements in WEMT training include technical skills and authority, depending on the system in which they are working, to perform the following:

•Airway management, including endotracheal intubation.
•Needle thoracostomy for tension pneumothoraces
•Shock management, including intravenous therapy
•Use of military antishock trousers (MAST), although this is experiencing decreased use and popularity.
•Oxygen administration.
•Medication administration, including epinephrine for allergic reactions; antibiotics for certain circumstances; acetazolamide, nifedipine, and furosemide for altitude sickness; and pain medications for injuries.
•Field rewarming techniques.
•Field reduction and splinting of fractures and dislocations.

5. What employment opportunities and experiences are available for WEMTs?

Wilderness EMT skills are useful for anyone who spends a substantial amount of time in wilderness areas, but can also open new opportunities for employment. Some possibilities include:

• National and state park ranger, such as the ParkMedic program in Yosemite National Park
• Adventure travel
• Search and rescue
• Forest Service worker
• Disaster medicine/relief work
• Work in rural/wilderness areas
• Military

6. Are standards for wilderness (e.g., mountain, water) rescue teams different around the world?

Wilderness rescue teams vary tremendously around the world. In the United States, most teams are volunteer, with a wide range of qualifications and skills from first aid to paramedic, and are under the jurisdication of national parks, state parks, or county sheriffs. In Canada, mountain rescue teams are coordinated by the military. In Europe, most teams are staffed with full-time physicians and paramedics. In many of the most remote areas of the world, there is no organized system of wilderness emergency care, so travelers and expeditions are required to be self-sufficient.

7. What questions must be answered when assembling a team for a rescue?

Wilderness rescue requires coordinated and thorough preparation with consideration to the following:

ENVIRONMENT/GEOGRAPHY

•What time of day is it and will it be? (Are you prepared for a night rescue?)
•What are the anticipated weather (environmental) conditions, and are you prepared for them?
•Is a helicopter, boat, or other specialized rescue vehicle(s) needed or available?
•Is the weather acceptable for air rescue?

VICTIMS

•How long ago did the accident occur?
•What is the number of victims?
•What are their injuries?
•How many people are in the victim’s party?
•How well prepared are they?
•Does anyone in the party have medical experience or training?

RESCUE PERSONNEL

•Do you have a location, or is this a search and rescue?
•Is a “hasty” team (a smaller, less equipped team sent ahead to provide initial care or to search and rescue while the main team prepares and follows) needed? If so, has it been deployed yet?
•Are all team members prepared?

ARE THE RESCUERS AT SIGNIFICANT RISK?

•Are all team members trained for this type of rescue?
•Who is on the medical team?
•Who is on the evacuation team? Is the number of team members adequate? (For instance, 16 to 20 litter carriers are typically necessary for a ground evacuation of 1 to 3 miles over level terrain).
•Is the team equipment organized and divided up adequately?
•How urgent is the situation?
•Will multiple agencies be involved?
•Are communications coordinated between the different agencies?

8. Who is responsible for search and rescue?

•Search and rescue (SAR) is the responsibility of national and state parks, sheriffs, state conservation offices, or other government agencies, depending on the location and jurisdiction. National and state parks do not have a “duty to rescue.” In addition, there is sometimes significant controversy about when rescue missions should be attempted and who should pay for them. The prevailing opinion is that a call for help cannot ethically be dismissed.

•As mentioned in question 4, most rescues are done by volunteer groups.
•90% of mountain rescues are done by foot.
•95% of rescues are performed without physicians present.
•Only Yosemite and Grand Teton National Parks use helicopters extensively.
•Only Denali National Park uses fixed-wing aircraft extensively and helicopters occasionally.
•Only Yosemite, Grand Teton, and Mount Rainier National Parks have rangers specifically trained in technical rescues, advanced medical care, and helicopter operations.
•Many backcountry and climbing areas are outside parks. Rescues in these areas are by local fire and rescue departments, with or without the benefit of special training or technical skills.

9. What special knowledge is needed for searches and rescues (e.g., mountain, high angle, cave, ocean)?

•Understanding equipment (ropes, slings, carabiners, harnesses, helmets, litters, litter harnesses, haul systems, personal flotation devices, throw rings and bags, and litter patient packaging equipment) used in SAR operations, including their maintenance and care.
•Basic radio communication and signaling.
•Basic helicopter and fixed wing operation and procedures.
•Understanding search and rescue procedures.
•Knowledge of the Incident Command System and its use in SAR.
•Basic rope handling and knot tying skills.
•Advanced skills as needed for specific circumstances, including water SAR, white-water rescue, avalanche SAR, technical or vertical (rock) techniques, or cave training.
•Interpersonal skills and the ability to deal with field death and inform family and friends of deaths.

10. What are some examples of scenarios likely to require “extended” rescue and emergency care?

Mountain, wilderness, rural, white-water, air-sea, cave, and avalanche rescue, as well as expedition and disaster medicine and most search and rescue missions. The terms “extended rescue” and “extended emergency care” refer to medical care and rescue efforts beyond the first, or “golden,” hour.

11. What government agencies are responsible for search and rescue?

Federal SAR activities are either under the supervision of the United States Air Force (for inland regions), Aerospace Rescue and Recovery Service (responsible for federal aircraft incidents) or the United States Coast Guard (supervises coastal regions and all maritime and ocean searches). At the state level, there is significant variety in SAR supervision, because it is often under the jurisdiction of law enforcement agencies. All states have legislation that provides support to local governments during emergencies. During a nationally declared disaster, the Federal Emergency Management Agency (FEMA) assumes responsibility for SAR activities. The Department of Health and Human Services runs the National Disaster Management System (NDMS), which develops Disaster Medical Assistance Teams (DMAT) that can be rapidly deployed to nationally declared disaster areas.

12. What are the four phases of SAR?

•Locate.
•Access.
•Stabilize.
•Transport.

13. How many SAR missions occur each year in the United States?

Specific numbers are not reported. It is estimated that more than 100,000 SAR missions occur annually.

14. What are factors that may cause someone to need to be rescued (and therefore, to require the services of a WEMT)?

Any one, or a combination, of the following, may produce a situation that results in the need to be rescued, stabilized, and treated.

•Improper clothing or footgear.
•Fatigue.
•Dehydration.
•Hypo- or hyperthermia.
•Overextension of abilities.
•Lack of physical conditioning.
•Inadequate food.
•Inadequate planning.
•Inadequate leadership.
•Itinerary confusion.
•Inadequate recognition of environmental, physical, or mental factors.
•Inadequate preparation for weather conditions.
•Lack of navigational proficiency (getting lost).
•“Invincible” mind-set.
•Bad luck resulting in injury, illness, or exposure to an adverse environmental condition or event.

15. Is an EMS provider on a trip liable for care rendered during that trip?

The question is, “Is the provider acting as a designated health care provider, or is the provider merely a person on the trip who happens to be an EMS provider?” If the provider is the latter, then he or she is not duty bound to assist others in need. If he chooses to help, he is not invariably protected from liability by a Good Samaritan Law. While a Good Samaritan Law provides protection for medical personnel assisting within the scope of their skills, voluntarily, at an emergency scene, it is important to note that the provider is held to the full capabilities commensurate with his training. If an EMS provider is acting as the trip medical support, then he is liable to provide care at the accepted standard of care. In addition, because EMTs and almost all EMS providers act under a physician’s license, the doctor under whom the EMT is working is also liable for his or her actions.

16. What are some unique ethical dilemmas associated with wilderness EMS?

•How much risk will you accept for yourself and your team when planning SAR (e.g., going out in a snowstorm looking for a child) and treating victims in the wilderness?
•If a rescuer becomes injured, who will you treat first? The original victim or the rescuer?
•If a limited amount of supplies is available, who gets treated?
•How will the care affect others in the group (e.g., leaving scuba divers in the water in order to deliver a diver with decompression sickness to a hyperbaric chamber)?
•In a remote and prolonged care situation, how do the relationships of people in the group affect their choices for care and decisions regarding the group?

More so than in urban situations, a serious emergency in a wilderness area stresses many unique aspects of relationships and decision-making capabilities. From a survivalist point of view, it is necessary to take care of rescuers and teammates before caring for victims. Many potential circumstances can influence this decision. So, one must think about potential circumstances in advance and plan appropriate ways to incorporate a productive reaction to insure the survival and optimal outcome for rescuers, the team, and patients.

17. Where can I get more information about wilderness medicine and wilderness EMS?

WILDERNESS MEDICINE ORGANIZATIONS

•The Wilderness Medical Society, P.O. Box 2463, Indianapolis, IN 46206; (317) 631-1745
•The International Society of Mountain Medicine
•The International Society of Travel Medicine
•The Divers Alert Network

SEARCH AND RESCUE ORGANIZATIONS

•The Mountain Rescue Association
•The National Association for Search and Rescue
•The National Ski Patrol
WILDERNESS EMT TRAINING PROGRAMS

•The Wilderness Emergency Medical Services Institute
•The National Outdoor Leadership School, Wilderness Medicine Institute

There are many companies and colleges that offer WEMT courses. Check in your region for programs near you.

Pearls and Pitfalls

1. Wilderness EMT (WEMT) designation requires specialized training in rescue techniques, use of special equipment, and extended patient care in remote areas.
2. WEMT’s must work very closely with all search and rescue (SAR) personnel to ensure the safety of the patient and all team members.
3. The four phases of SAR are locate, access, stabilize and transport.
4. A unique ethical dilemma for the WEMT is how much personal risk is acceptable to accomplish the rescue.

BIBLIOGRAPHY

1. Auerbach PS (editor). Wilderness Medicine, 5th ed. Philadelphia, Mosby Elsevier, 2007.
1. Cooper DC, LaValla PH, Stoffel RC: Search and rescue. In Auerbach PS (ed): Wilderness Medicine, 5th ed. Philadelphia, Mosby Elsevier 2007, p. 708.
2. Langer CS: Medical liability and wilderness emergencies. In Auerbach PS (ed): Wilderness Medicine5th ed. Philadelphia, Mosby Elsevier 2007, p 2163.
3. Hubbell FR: Wilderness emergency medical and response systems. In Auerbach PS (ed): Wilderness Medicine 5th ed. Philadelphia, Mosby Elsevier 2007, p 694.
4. Iserson KV: Ethics of wilderness medicine. In Auerbach PS (ed): Wilderness Medicine 5th ed. Philadelphia, Mosby Elsevier 2007, p 2170.
5. Johnson, L. An introduction to mountain search and rescue. Emerg Med Clin N Am 22 (2004): p. 511
6. Klainer PH: Prehospital emergency medical services. In Harwood-Nuss AL, Linden CH, Luten RC, et al (eds): The Clinical Practice of Emergency Medicine, 2nd ed. Philadelphia, Lippincott-Raven, 1996, p. 1517
7. Russell, M.F. Wilderness emergency medical services systems. Emerg Med Clin N Am 22 (2004): p. 561
8. Sholl, JM and E.P. Curcio. An Introduction to wilderness medicine. Emerg Med Clin N Am 22 (2004): p. 265

photo courtesy National Outdoor Leadership School (NOLS)

Evidence-Based Management of Wilderness Injuries

Paul Auerbach — Mon, 23 Nov 2009 00:47:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

This is the next post based upon a presentation given at the Wilderness Medical Society Annual Meeting held in Snowmass, Colorado from July 24-29, 2009. The presentation was entitled “Evidence-based Management of Wilderness Trauma with Case Studies from Vermont Search & Rescue.” It was delivered by Tim Burdick, MD, who is a Fellow of the Academy of Wilderness Medicine, Assistant Professor of Family Medicine at the University of Vermont College of Medicine, Medical Officer for Stowe Mountain Rescue, and Medical Team Manager for FEMA Urban Search & Rescue Massachusetts Tasks Force 1.

There are clinical decision rules (or “tools”) used by physicians in order to control the number of tests (such as x-rays) they use to determine whether or not patients have specific injuries. The purpose of such rules is to avoid unnecessary testing, which can add to undesirable consequences, such as additional expense and radiation exposure. In the wilderness, the purpose of decision rules is to determine the likelihood of diagnosis, who might need an evacuation, and when it is advisable to continue or discontinue a trip.

Dr. Burdick noted that there are evidence-based clinical tools for ankle and midfoot fractures, cervical spine (neck) fractures, shoulder dislocations, and detection of fractures (broken bones) using a tuning fork.

The Ottawa ankle decision rules for the use of x-rays to determine the presence or absence of an ankle fracture were determined in patients who had mostly twisted their ankles, rather than fallen. According to these rules, an ankle fracture might exist if (1) the patient complains of pain near either malleolus AND (2) can’t bear weight for a distance of four steps OR suffers bony tenderness (when you press) in either malleolus. As it turns out, the test has a positive predictive value (e.g., when the test is positive the patient has a fracture) of 17% and a negative predictive value (e.g., when the test is negative the patient does not have a fracture) of virtually 100%.

There is something similar for neck fractures. For a blunt injury (e.g., not a stab wound, or “penetrating” injury), here are a set of criteria for which a patient should be evaluated:

1. Patient is alert and reliable
2. Patient is not intoxicated
3. There is no painful, distracting (from the examination) injury (such as a broken leg)
4. There is no focal abnormal neurological finding (such as weakness in the grip strength of a hand, or abnormal deep tendon reflex)
5. There is no midline cervical spine (neck) tenderness when the neck is examined

If all of these conditions were met by a good examination, then according to the medical literature, then only 2 out of 4307 persons initially complaining of neck pain turned out to have a broken neck.

What about dislocated shoulders? The usual admonition against attempting to reduce a shoulder dislocation prior to obtaining x-rays is to avoid tugging on a broken arm, in the event that a fracture-dislocation is present. It appears that there is a greater risk of fracture-dislocation if the victim’s age is less than 40 years and the mechanism involves “substantial force” (e.g., motor vehicle accident, assault, sports injury, or a fall from a distance greater than the victim’s personal height); or in a victim age 40 years or greater, if there is bruising around the humerus (long “upper” bone of the arm) or if the dislocation is the first for the victim. However, given all of this, it is still not clear that attempting the relocation of a dislocated shoulder that happens to be associated with an undetected fracture of the humerus is a big problem, unless one applies extreme force in the attempt and significantly worsens the break. Certainly, putting a shoulder back in place and allowing the victim greater mobility, reducing pain, and perhaps creating a situation that enables self-extrication can be extremely important.

Can someone use a tuning fork to diagnose a longbone fracture? The concept is that sound is conducted through intact bone and joints better than through broken bone. The technique is to place a vibrating tuning fork of a bony prominence beyond (distal to) the suspected fracture and then to listen with a stethoscope over a bony prominence in front of (proximal to) the suspected fracture. Sound conduction is compared between identical exams of the injured and contralateral (uninjured) limb. Decreased conduction (appreciation of sound transmittance) would indicate a possible fracure. One brief analysis of this concept in 1987, utilizing a 128 hertz tuning fork and stethoscope, indicated that it might be useful, improving the detection of fractures by a few percentage points.

The Real Risk of Meds in the Woods

Paula Colman — Thu, 19 Nov 2009 03:28:00 GMT

Many of us have weighed in on the “Meds in the Woods” issue with the competing moral and legal issues keeping the industry from making a uniform statement as to the best practice. With Good Samaritan and epinephrine laws varying from state to state, the discussion becomes even more complicated. At the Wilderness Risk Management Conference recently, people were very passionate about what medications could be acquired, possessed and administered in remote areas during an emergency. Some stated that because the risk of harm is low and the risk of death is high (such as in the case of epinephrine) having the meds is worth the cost if it means saving a life, the moral argument. Others wanted to place the entire burden of medical care squarely on the participant, the inherent risk argument. In certain circumstances, both positions expose organizations and their staff to potential liability.

I suggested to several people at the conference that while organizations may worry this issue will arise when a participant is injured and treated (or not treated), the more likely scenario will have nothing to do with a participant. Instead, a physician or pharmacist will be investigated as part of a civil, criminal or administrative proceeding, and the professional’s prescription drug records will be reviewed. A physician or pharmacist who has prescribed or filled meds to an organization and not an individual patient, for example, will then be investigated and possibly charged. If those meds crossed state lines, Federal agencies will be contacted prompting additional investigations, and soon. They will all follow the chain as far as it goes – directly to the organizations and staff that have the meds in their backpacks or first aid kits. While courts have not yet addressed a “Meds in the Woods” case, they have held physicians, pharmacists and others liable for the misuse, mislabeling, etc. of prescription drugs stemming from an independent investigation. I have seen it in my own practice, and I believe that as agencies become more aggressive and technologies become more sophisticated, it will continue.

In a recent issue of the Wall Street Journal, there was a front-page story about the states’ prescription tracking programs and how they are being used in civil and criminal proceedings against physicians and pharmacists.

Here's the link:

http://www.careerjournal.com/article/SB125668736789811845.html

There is a graphic showing the states that use tracking programs. Ironically, one of the states that doesn't have a tracking program, Missouri, has a very aggressive Board of Pharmacy, in which, one of my former clients spent almost 10 years inlitigation stemming from a physician’s unlawful prescribing of a common prescription pain medicine. The board simply followed the chain. Because of the recordkeeping required by state and Federal laws, finding out where a single drug has travelled is not much more difficult than locating a book ordered from Amazon. The tracking programs discussed in the Journal story show how easy it is for states to conduct broader searches of physicians, pharmacies, patients and pharmaceuticals. While privacy protections imposed by the law still exist to protect against investigative mining of data, once an investigation begins, it will be difficult for agencies to decide whose privacy is entitled to protection, especially if it appears that people down the chain are not acting in a lawful manner.

The Meds in the Woods issue is serious, but not only because of the moral issues the industry faces every time it takes people into remote areas. It is important, because despite an organization's best intentions, it may find itself and its staff with legal issues brought about by physicians, pharmacists and others who had little to do with the program. These are very real risks that, as legal professionals and risk managers working toward a best practice, we should continue to thoughtfully consider and discuss.

-- Paula Colman, Attorney at Law

Wilderness First Aid Scope of Practice

Tod Schimelpfenig — Fri, 30 Oct 2009 19:13:00 GMT

The concept of consistency in the content of Wilderness First Aid (WFA) and Wilderness First Responder (WFR) programs is receiving much attention. Some folks seem to think there is chaos among the various providers with people teaching widely varying practices. I’m not so sure this is the case.

I’ve been talking with David Johnson MD of Wilderness Medical Associates for several years on this question of curriculum consistency. We decided last winter that it was time to move forward on this question and to approach this project by first defining the Scope of Practice (SOP) for WFA and WFR. Scope of Practice is medical jargon for a job description, a statement about what a WFA or WFR should be able to do, and not do. This seems a logical place to start.

We do not feel it is our place to dictate standards to the industry. Rather, we’ve drafted a document with input from peer groups including Aerie, SOLO, Wilderness Medicine Training Center, Wilderness Medicine Outfitters, Landmark Learning and Desert Mountain Medicine. Together we’ve trained over 150,000 WFA students since 2000.

Most of this was straightforward and it was easy to reach agreement. The challenging issues revolve around the total amount of content we think can reasonably fit in a 16 hour program without eroding overall skill retention, and questions on what skills and decisions are appropriate for a WFA.

The attachment below (pdf) is the consensus document, posted to allow a wider audience a chance for input.

Our next step will be to send it to the Wilderness Medical Society’s Education committee for their consideration as part of their charge to develop standard WFA and WFR curriculum.

As you can see, we agree it is time to take another step toward consistency in the WFA and WFR programs, so the consumer, often an outdoor program hiring a trip leader, knows what a credential implies. If you work in outdoor programs and want to participate please send your comments to Dr. Johnson and myself.

Reb Gregg and Jed Williamson Honored at Wilderness Risk Management Conference

Tod Schimelpfenig — Wed, 21 Oct 2009 04:39:00 GMT

Reb Gregg receiving the certificate of the new award in his name.

One of the highlights of last week’s 16th annual Wilderness Risk Management Conference was the inauguration of an annual award recognizing excellence in the practice of wilderness risk management, and extraordinary contributions to the community of outdoor education, adventure and service organizations, and programs and businesses that utilize wild places for their activities.

As the conference co-sponsors - the National Outdoor Leadership School, Outward Bound and the Student Conservation Association - discussed the criteria for the award - integrity, strong ethical underpinnings, curiosity, commitment to continual learning, honesty, innovation and generosity of spirit - one member or another would finish the sentence with a comment of “… you know, like Reb Gregg”.

A recipient of this award has contributed significantly to the practice of wilderness risk management by: raising standards of practice and strategic risk mitigation; providing valued service to the goals, mission and outcomes of an industry that connects people to the wilderness; facilitates individuals to challenge themselves in the outdoors; and supports the stewardship of wilderness. “… you know, like Reb Gregg”.

People, all different types, are drawn to Reb - his charisma and genuine interest in people, in life itself, makes him someone others want to be around. He doesn't look at life in black and white but rather loves engaging in complexity.

It became clear that Reb’s qualities and service models the exceptional leadership, service and innovation this award will honor. Thus, on the opening night of the conference, October 14th, 2009, the co-sponsors announced this award, named:

The Charles (Reb) Gregg Award
For Exceptional Leadership, Service and Innovation
in Wilderness Risk Management

Jed Williamson (the first recipient of the Reb Gregg award) and Reb Gregg

On the closing evening of the conference, October 16th, 2009, I had the privilege of presenting this award to its first recipient, Jed Williamson.

In my remarks I remembered the day, 20 years ago this past July, when David Black was killed by rockfall while on a NOLS course in the Wind River Range. It was NOLS’ first fatality in 10 years, and the first one any of us had managed. Jim Ratz, then NOLS Executive Director, and I talked about who would be best to lead an independent investigation of this incident.

We bantered about some names, then I picked up the phone and did something so many of us have done when we needed help, I called Jed Williamson. I had not met or spoken with Jed before. I knew him only through his work with Accidents in North American Mountaineering and with the American Alpine Club, but when I asked for help, Jed said yes. Jed gave us advice, occasionally pointed feedback, and wise guidance, then, as he does now. This was the beginning of a mentorship in wilderness risk management that has led us to where we are today - that was one very valuable phone call.

Jed has been a college president, bi-athlete, professional ski patroller, mountain guide, camp counselor, safety director, expert witness as well as long stints as staffer, manager, trustee, advisor for the likes of NOLS, Outward Bound, Student Conservation Association, Exum and a host of other schools and colleges.

Jed’s footprint is in every corner of the outdoor education and recreational community and many of his accomplishments are so well known, we forget that Jed was the engine for many of the successful advances in outdoor safety.

Where would we be without Jed? Can we imagine a conference without his accident cause matrix? Some of us occasionally blaspheme the matrix - and this is fun - but we know how important this vocabulary and structure is for our conversations on risk management.
Where would we be without the data and the experience captured in Accidents in North American Mountaineering? This is the template for the incident accounts and case studies so many of us use routinely in training.
Where would we be without the incident review and risk management audit process and the collected wisdom and knowledge many of us may now take for granted? Jed’s hand has molded this process, and guards it’s integrity
Where would we be without the support and hours that Jed has devoted to the Wilderness Risk Management conference?
Is there anyone who has asked for help, information or camaraderie from Jed and not received it?

Dan Garvey, President of Prescott College said, about Jed , “I’ve been blessed to work with Jed throughout my professional career. The world is a better, saner and funnier place because of Jed. When I hear his name I smile and silently nod in gratitude for his impact upon my life.” I couldn’t agree more.

If you see Reb and Jed, extend your congratulations for this richly deserved honor.

Wilderness Risk Management Conference 2009 - Opening address by Janet Zeller

Rick Curtis — Fri, 16 Oct 2009 01:57:00 GMT

Get hundreds of outdoor professionals from field instructors to program managers, add in legal and risk management experts from across North America presenting top notch workshops and you have the annual Wilderness Risk Management Conference sponsored by the National Outdoor Leadership School, Outward Bound, and the Student Conservation Association. If you want to ensure that your program is staying on the cutting edge of managing risk, this is the place to be each year.

This year's Wilderness Risk Management Conference, help in Durham, NC, began with an inspiring opening address by Janet Zeller. Janet is the accessibility program manager for the USDA Forest Service, based in Washington, DC. She has worked in the field of accessibility for two decades and has worked for the Forest Service since 1991. She has helped develop and implement accessibility programs and policies at all levels of the agency. She also teaches accessibility and universal design for programs and facilities at a wide range of training sessions nationally. Janet explored the issues of including people with disabilities in outdoor programs in particular thinking about how risk management impacts inclusive programming. Janet has been quadriplegic since a 1984 accident and has been at the forefront of expanding access to wilderness for individuals with disabilities.

According to statistics there are 54 million people in the U.S. with some form of disability. Fifteen percent of those people have obvious or visible disabilities while 85% are people who have difficulty walking but who don't use a wheelchair, or other mobility device; people who are deaf or hard of hearing; have low vision or are blind; or who have a cognitive impairment or a mental or emotional illness. Of the 178 million recreational visitors to National Forests each year, only 7.7% self-identify as having a disability.

Of the total of 192 million acres of US Forest Service land, 37 million acres are defined as "designated wilderness" which means without motorized or mechanical vehicles or equipment. This was part of the Wilderness Act of 1964. However, that law initially failed to address access by individuals with mobility impairments which 'technically' would have prohibited access by people in wheelchairs. Subsequent modifications and the 1990 Americans with Disabilities Act included a section (Title V Section 508 C) defines the parameters for types of mechanical/assistive equipment that can be used in designated wilderness by individuals that require equipment for their primary mobility .

Janet recounted how returning to the wilderness after her accident reopened a part of her life that had always been incredibly important to her. We all know that exploring the outdoors is a transformative experience, for everyone, so creating opportunities for access is essential. She stressed the idea that including people with disabilities doesn't create greater risk for programs. Access for anyone is defined by the Essential Eligibility Criteria (EEC) which is based on the the individual's ability to perform "the basic skills required for safety for that activity." It is important for programs to carefully evaluate the EEC for your programs which defines who can or cannot participate.

I think Janet opened a window for many of us as to the critical important of designing program activities that extend the power of wilderness to individuals of all abilities.

For more information see the USFS Accessibility Guidelines for Outfitters at www.fs.fed.us/recreation/programs/accessibility

Heat-related Illnesses

Paul Auerbach — Mon, 12 Oct 2009 01:43:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

This is the next post based upon a presentation given at the Wilderness Medical Society Annual Meeting held in Snowmass, Colorado from July 24-29, 2009. The presentation was entitled “Heat Related Illnesses.” It was delivered by Flavio Gaudio, M.D. from Weill Medical College of Cornell University. Dr. Gaudio is a very enthusiastic and articulate physician with great expertise in wilderness medicine.

Dr. Gaudio covered the topics of thermoregulation and heat dissipation, acute heat stress and acclimatization, impaired thermoregulation, and specific heat related illnesses. Thermoregulation for humans is essentially the balance of heat load (generation or external source addition) with heat loss. The act of being alive (basal metabolism) at rest generates about 75 kilocalories of energy per hour, which undissipated would create a human temperature rise of approximately 1 degree Celsius (approximately 9/5 degrees Fahrenheit) per hour. The optimal temperature for human metabolism is between 36 and 37.5 degrees C (96 and 99 degrees F).

Humans shed heat by radiation, evaporation, conduction, convection and respiration. For radiation to be maximally effective, blood flow to the skin must increase. When this occurs, there is a compensatory decrease in blood flow to certain internal organs. Convective heat loss in humans occurs by sweating, which requires evaporation to be effective. Therefore, sweating becomes ineffective with high relative humidity (greater than 75%). The scalp, face and torso have more sweat glands than do the lower limbs. A very important fact is that a limiting factor for evaporation as a cooling mechanism for humans is the gastrointestinal tract, which can only absorb about a liter per hour of liquid. Taking your shirt off to allow sweat to evaporate is generally a good thing, with the following possible exceptions: (1) in strong sunlight, (2) in the absence of any cooling breeze when there is a high solar load (of heat) and (3) if skin is highly pigmented, and would therefore absorb more heat than non-pigmented skin.

Hats should be worn to reduce solar load, but be aware that they may decrease evaporative cooling. So, wear your lightweight hat in the hot sun, but remove it when you are in the shade or if there is a brisk breeze to promote evaporation. And you are sweating.

Acclimatization to heat generally occurs over 1 to 2 weeks, but may take longer, particularly if exposure is intermittent and inadequate for the purpose. Among many changes, it is interesting to note that acclimatized sweat glands have increased sweat capacity and conserve sodium (so the sweat is more dilute).

Pay particular attention to elders and infants, and persons with predisposing medical conditions, such as obesity, kidney disease, diabetes, cystic fibrosis, scleroderma, and Alzheimer’s dementia. Many drugs, both prescription and illicit, may impair heat dissipation.

Fluid replacement strategies for heat cramps, which are generally felt to be caused by water-without-electrolytes replacement, are numerous, but generally center around “sports beverages.” A good natural concoction is ½ liter orange juice combined with ½ liter of water and ½ to 1 teaspoon of table salt. This provides water, fructose, sodium, potassium, chloride, vitamins C and B6, thiamine and folate.

Heat edema (fluid retention and swelling) involves the hands and feet of persons during the first few days of heat exposure. Treatment is rest, elevation of the affected body parts and support hose for the legs and feet. Heat syncope (fainting) is caused by a brief drop in blood pressure associated with some combination of dehydration, dilation of blood vessels in the skin, drug effects, slow heart rate, and pooling of blood in the lower limbs during periods of standing. If there is no other obvious cause of swelling, heat edema may be treated with rest, elevation of the swollen legs and feet and support hose.

Heat syncope is caused by a brief drop in blood pressure and therefore in the pressure of blood delivered to the brain. It may come on quickly, and is usually seen early during an episode of heat exposure. Dehydration is a contributor, as are the effects of certain drugs. The treatment is to replenish fluids.

When someone suffers heat exhaustion, which may lead to full-blown heat stroke, the length of heat exposure has been longer than that which causes heat syncope. Physical findings occur weakness, fatigue, normal to mildly elevated body temperature, rapid heart rate and breathing, thirst, decreased urine output, low blood pressure and altered mental status (listlessness, agitation or confusion). The latter is very important. Anyone who is in the heat and acting abnormally is suffering from heat illness until proven otherwise. Additional physical findings include nausea, vomiting, headache and muscle cramping. Skin signs may be variable and show skin that is sweaty or dry, and hot and flushed or cool and clammy.

Heat stroke is a situation of extreme heat exhaustion with a failure to be able to control body temperature. This is life-threatening and is associated with a body temperature in excess of 40 degrees Centigrade (104 degrees Fahrenheit), severe neurologic signs (delirium, coma, seizures), and injury to many organ systems, such as the liver, gastrointestinal tract, kidneys and heart. It is essential to cool the victim as soon as possible.

Charles Houston MD

Tod Schimelpfenig — Thu, 01 Oct 2009 17:28:00 GMT

Charles S. Houston MD passed away on September 27^that the age of 96. We have lost a great presence in wilderness medicine and mountaineering.

You may recognize Dr. Houston as the author of Going Higher: Oxygen, Man, and Mountains, the wonderful layperson textbook on altitude illness. You may not know of his technical paper in the New England Journal of Medicine that first described High Altitude Pulmonary Edema, his life of research in altitude physiology on Mt Logan in the Yukon, his succession of publications and international forums on hypoxia. Dr. Houston was a mentor to many in the field of wilderness medicine. I loved to listen to him speak about medicine, sharing his thoughtful insights into physiology and treatment, and his compassionate approach to his patients. I’m saddened to know these moments are now in the past.

You might also recognize Dr. Houston's extensive early climbs in Alaska and the Himalayas, including 1st ascents of Mt. Foraker in 1934 and Nanda Devi in 1936 and an exploratory trip to K2 in 1938 where they almost reached the summit. The 1953 K2 expedition is legendary for the heroic descent through storm during which his team would not abandon an ill companion, at great risk to their lives. Reinhold Messner said of this expedition, “I have great respect for the Americans and the way they failed in 1953. They were decent. They were strong. And they failed in the most beautiful way you can imagine.” Read K2 the Savage Mountain, or watch the documentary film "Brotherhood of the Rope" for a tale of a style of expeditioning we can’t help but admire, and should not forget.

Nutrition Needs for Rescuers and the Rescued

Paul Auerbach — Tue, 29 Sep 2009 13:06:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

This is the next post based upon a presentation given at the Wilderness Medical Society Annual Meeting held in Snowmass, Colorado from July 24-29, 2009. The presentation was entitled “Special Nutrition Needs for the Rescued (and the Rescuer!).” It was delivered by Eldon “Wayne” Askew, PhD from the University of Utah. The objectives of the presentation were to emphasize the medical and psychological importance of providing proper nourishment to rescued individuals, highlight some frequently encountered medical situations involving rescue for which clinical nutrition should be considered as part of treatment and stabilization of the rescued individual, and discuss expedition food planning for persons with medical conditions and for rescuers.

Here were some key points:

1. Plan ahead. Everyone is likely to be hungry. This may seem like a simple recommendation, but adequate planning in all aspects of an expedition is often not achieved.
2. Even if persons are not hungry, they will need nourishment of strength.
3. Food and drink can be emotionally reassuring
4. If victims have their energy stores “refueled,” they may be able to participate in their own rescues.
5. Do not count on a few food bars to maintain you. You may be out longer than you anticipate, food and water supply may not be feasible, you may need to share your supplies, and you have an obligation to be adequately fed and hydrated in order to maintain your performance.
6. If a victim is capable of eating and drinking, he or she should consume at least 30 grams of carbohydrate every 30 minutes to put off exhaustion. This is necessary to keep blood glucose sufficiently high to contribute to continued exertion.

By some estimates, 6% of the population suffers from some form of diabetes. If a person is on medication to lower blood sugar, that puts him or her at particular risk for a hypoglycemic (low blood sugar) reaction, so close observation is always necessary. Type I diabetics, who are insulin dependent, are most at risk, so heightened vigilance for this group is important. Trip leaders or other persons responsible for medical care should be informed about who suffers from diabetes, and should carry a glucose meter (“glucometer”). The medically trained person will carry insulin, injectable glucose, and perhaps glucagon for injection. Dr. Askew made the very important point that glucagon should not be expected to work with hypoglycemic persons who are also experiencing starvation, adrenal gland insufficiency or chronic hypoglycemia (low blood sugar), because these conditions are associated with an inability of the liver to produce glucose sufficiently in response to glucagon. These individuals need oral or injected glucose.

Blood sugar levels over 200 milligrams per deciliter (mg/dL) are too high, at 60 to 140 mg/dL are acceptable, and below 60 mg/dL are too low. These are general numbers. Some persons may exhibit signs and symptoms of hypoglycemia at levels above 60 mg/dL. Common symptoms of low blood sugar are shakiness, hunger, sweating, sudden moodiness or behavior changes, confusion, headache, pale skin color, dizziness and fatigue. Common symptoms of high blood sugar are thirst, vomiting, blurred vision , fainting, feeling ill, and fatigue. There is some overlap, but in general low blood sugar is rapid in onset, and high blood sugar develops more gradually.

If someone is suspected or proven to be hypoglycemic, then initially feed them 15 grams of sugar or carbohydrate, followed by small meals or snacks every 3 hours. Food sources that are roughly equivalent to 15 grams of carbohydrate are a slice of bread, a banana, 2 tablespoons of raisins, 1/3 cup of dry milk, 2 small cookies, a small granola bar, 8 ounces of sports beverage, a tablespoon of honey, or 4 restaurant packets of jelly.

Dr. Askew then discussed food allergies. The foods that most commonly cause serious allergic reactions are eggs, milk, fish, shellfish, nuts, soy, and wheat. Manifestations of a serious food allergy are hives, itching, swelling of the lips/face/tongue and throat/elsewhere, wheezing, difficulty breathing, nasal congestion, abdominal pain, diarrhea, nausea/vomiting, and/or dizziness/lightheadedness/fainting. When this occurs, treatment for a severe allergic reaction is necessary. To treat an allergic reaction from any cause, it is optimal to have injectable epinephrine and oral antihistamines.

Other topics covered included dehydration and rehydration, low serum sodium, and the importance of adequate food energy to performance. The last discussion merits more detailed mention, because it is so frequently underestimated.

If a person does not eat adequate food, with the extreme being no food at all, he or she should anticipate being uncomfortable from hunger, and having difficulty concentrating, anxiety, loss of body weight, decreased endurance, weakness, nutritional deficiencies leading to tissue and organ system deterioration, and perhaps collapse and death from starvation.

The situation may occur where a rescuer needs to feed a starving person who has been rescued. The general approach should be to:

1. Resolve any life threatening injuries or medical conditions.
2. Be certain that the person has functioning kidneys. This may be difficult for a layperson to determine, particularly in the field. If the person is still urinating, for the purposes of immediate care, you should proceed to offer food and drink. If the person is so “dry” that he has not urinated for 24 hours or more, then proceed with caution, observing for fluid retention. Approximately 10 milliliters of oral fluid per kilogram of body weight per hour consumed every 2 to 3 hours should initiate urination within 24 hours. An acceptable basic fluid for dehydration is to add the following to each liter: 3 grams potassium chloride, 1 gm sodium chloride, 4 gm calcium gluconate, and 50 gm glucose or sucrose. An alternative is to offer a dilute electrolyte solution (e.g., Gatorade diluted in half).
3. Slowly feed small portions of a food that is relatively high in fat (e.g., bacon, eggs, nuts, banana chips).
4. DO NOT permit the person to gorge on fluid or food. The sudden sensation of profound fullness may cause nausea and vomiting, which are detrimental.

Thanks so much, Dr. Askew, for making the outdoors a safer place!

iPhone Medical Apps: TickDoctor

Paul Auerbach — Mon, 21 Sep 2009 03:21:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

Dr. Jeremy Joslin is a wilderness medicine aficionado and has without question posted the greatest number of intelligent and useful comments to posts at this blog. So, I'm pleased to learn that he has created a very useful iPhone application named TickDoctor.

TickDoctor provides a stunning visual atlas of the most common ticks encountered in North America. Although not yet comprehensive, most common ticks are represented. For each tick species, the user is able to identify males, females, and nymphs. In many instances, there are included images of the engorged female, which often looks very different from its non-fed state.

More than just a beautiful atlas, TickDoctor provides instructions for prevention of tick bites and how to remove them if bites should occur. If a bite has occurred, or if you're just plain curious, Dr. Joslin has included medically relevant data on each species, describing which diseases have been associated with it.

While this application should never substitute for the advice of a physician, it will help guide you to the identification of the tick in question and provide a framework of reference for dealing with "what to do next."

Planning Food for Wilderness Expeditions

Paul Auerbach — Tue, 15 Sep 2009 02:19:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

The Wilderness Medical Society held its Annual Meeting in Snowmass, Colorado from July 24-29, 2009. The meeting was very well attended and once again demonstrated that the Society is the hub organization devoted to advancing the science and clinical practice of wilderness medicine. The format this year was to add a great number of presentations suggested by, and in many cases, delivered by members.

Wayne Askew, Ph.D. and his colleagues taught on the topic of planning and preparing food for wilderness expeditions. Their goals were to allow the participants to develop an appreciation for the role that food and food planning plays in successful and enjoyable backcountry recreation; understand the similarities and differences between small and large group food planning; estimate energy and other nutrient requirements for individuals and groups; review guidelines for planning nutritional support for backcountry expeditions and recreation; and observe demonstration of recipes and preparation techniques for some useful backcountry food items.

A number of terrific observations were made. In no particular order:

1. Food planning is very important in outdoor activities, with emphasis on the word “planning.” One can enhance backcountry travel and survival with good nutrition.
2. Food planning is also important for morale. If people are hungry, malnourished, or unsatisfied, they are not “happy campers.”
3. The food planner for a trip or expedition should be chosen carefully, and should take care to take into account the dietary preferences of the participants.
4. Energy requirements for specific activities related to physical performance and caloric expenditure can be calculated and taken into account for food and meals planning.
5. There are sometimes foods for special needs (e.g., such as allergies, deficiencies, diseases, etc.). While many of the participants can handle their own needs, whomever is managing food should be aware.
6. There are persons who specialize in wilderness nutrition planning. They advise expedition planners on food, water and logistics; plan menu and food supplies for backpackers, wilderness tour groups and expeditions; assist in search and rescue operations; consult with food companies specializing in backpacking foods; and cook food.
7. If a person wants to accomplish nutrition planning, he or she should have a basic knowledge of human nutrition, understand human physiology and the role of food nutrients in extreme environments, know how to utilize food item selections to provide recommended nutrient intakes, and be a good cook in the outdoors.

Food planning by definition means thinking about food in advance. Dr. Askew and his colleagues recommended answering the following questions:

How much room is in your pack?
How much weight can you carry?
How long will you be traveling?
Where are you going?
How much fuel will you need and will you have access to water?
With whom will you be traveling?

Factors that affect food choices in the backcountry are food preferences; weight, perishability, taste and texture of foods; space in the pack; duration of trip; availability of water and fuel for food preparation; environmental conditions; experience with food preparation; special dietary needs; and personal beliefs.

This was a terrific educational experience, with terrific information such as this Planning Guide Nutritional Standards for Backpacking Food for One Person for One Day, based upon U.S. Army AR 40-25 Nutritional Standards for Operational Rations:

http://www.army.mil/usapa/epubs/pdf/r40_25.pdf

Energy (kcal) 3600 (will vary depending upon activity level)
Protein (g) 100
Carbohydrate (g) 440
Fat (g) 160
Vitamin A (RE) 1000
Vitamin C (mg) 60
Vitamin E (mg) 10
Calcium (mg) 800
Iron (mg) 18
Sodium (mg) 5000-7000
Fiber (g) 20-35

Finally, consider the following recipe for energy bars. This is one way to prepare less expensive and more nutritious (than store-bought) bars for personal use. As recommended by Askew and colleagues, you can be creative with this recipe, and use a variety of fruit, nuts, and grains. It is sufficient to make approximately 20 small bars.

Preheat oven to 350°

½ cup brown sugar
1 egg
¼ cup peanut butter
2 tsp vanilla extract
½ cup apple juice (unsweetened)
1 cup whole wheat flour
1 cup quick cooking oats
½ cup wheat germ
½ tsp baking powder
½ tsp baking soda
¼ tsp salt
½ tsp ground cinnamon
½ cup dried fruit (raisins, apricots, dried cranberries, etc.)
½ cup chopped nuts (walnuts, almonds, peanuts, etc.)
½ cup semi-sweet or dark chocolate chips

Mix dry ingredients in one bowl, wet ingredients and added “goodies”
(chocolate chips, raisins, nuts, etc.) in another, then combine. Spread the batter over a lightly greased cookie sheet about ½ -¾ inch thick. Use a spoon dipped in hot water to press the batter into the sheet and shape to the proper thickness. Bake for 10-15 minutes. Allow the pan to cool completely before cutting into bars. The bars can be refrigerated or frozen for longer shelf life.

Nutrition Information: calories 140, protein 5 grams, carbohydrates 20 grams, fiber 2 grams, fat 6 grams (saturated 1 gram) (% of calories from carbohydrates = 52%)

The NOLS Incident Database is 25 years old!

Tod Schimelpfenig — Thu, 10 Sep 2009 22:50:00 GMT

I vividly remember back to 1984 when the late Jim Ratz, then NOLS’ Executive Director, gave his endorsement to the concept of identifying and recording NOLS's risk management incidents. Jim’s support helped us work through our aversion to more paperwork, fear we would open ourselves to litigation and skepticism that we would learn anything useful.

In September 1984 we created a consistent process of gathering the data and defined reportable incidents (we actually have data from the 70’s, but can’t use it due to unclear reporting parameters). This database now has 3.2 million person days of exposure and 12,385 records of wilderness injuries, illnesses, near misses and non-medical incidents. It has generated three papers in peer reviewed medical journals. At the Summer 2009 Annual Meeting of the Wilderness Medical Society, Scott McIntosh, M.D., Director of the Wilderness Medicine Fellowship at the University of Utah, ranked two of these articles within the Top Ten Articles in the Wilderness Medicine literature.

All data has bias, and skeptical eyes are wise eyes, but just having this resource is immensely helpful. Early on it motivated us to reduce our rate of hygiene related illness, athletic injury and wound infections. Now we hope to be able to look at some of our evacuation protocols, such as our decision models for spine clearing and belly pain, and perhaps see if they are indeed valid. The insights gleaned from this view of health and safety on NOLS courses guides our risk management practices, and helps focus the curriculum of the Wilderness Medicine Institute of NOLS on what, of all we could teach, is relevant and practical.

If you want to read the papers:

The first paper

Gentile DA, Morris JA, Schimelpfenig Auerbach PS: Wilderness Injuries and Illness. Ann Emerg Med July 1992;21:853-861

The second paper

Leemon D, Schimelpfenig T: Wilderness Injury, Illness and Evacuation: NOLS Incident Profiles 1999-2002 Wilderness and Environmental Medicine, 14, 174 182 (2003)

http://www.wemjournal.org/wmsonline/?request=get-document&issn=1080-6032&volume=014&issue=03&page=0174

The Third Paper

McIntosh SE, Leemon D, Schimelpfenig T, Visitacion J, ; Fosnocht, D: Medical Incidents and Evacuations on Wilderness Expeditions. Wilderness and Environmental Medicine, 18, 298 304 (2007).

https://rendezvous.nols.edu/content/view/1717/803/

Mechanical Supports for Ankle Sprains

Paul Auerbach — Mon, 07 Sep 2009 20:37:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

Much of how we know to practice medicine for the outdoors, including medicine in remote wilderness environments, comes from what we learn in the urban setting. For instance, I maintain my skills mostly in the Emergency Department at Stanford University. Because Stanford Hospital is a Level 1 trauma center, we care for many victims of all manner of injuries. So, in that practice, I care for persons with afflictions such as broken bones, burns, cuts, amputations, and so forth. What we do for these persons is usually directly applicable to what we might do for someone in an austere setting, with the proviso that we may need to help a victim in the wilderness with less support (equipment, assistance), for a longer time period, and under rugged non-optimal conditions. Adapting to the outdoor setting and learning to improvise when necessary are part of what make wilderness medicine a unique proposition.

One of the most common orthopedic injuries, in a wilderness or urban setting, is an ankle sprain. It ranks right up there with blisters and overuse syndromes and the musculoskeletal disorder that most frequently disables a participant and potentially slows or terminates that person's participation in outdoor and athletic activities. So, the more we can know about how best to manage an ankle sprain (and also how to avoid one), the better.

There is a relatively recent study out of the U.K. that adds to our knowledge base regarding ankle sprain. In a document entitled "Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial," published in the Lancet, Professor SE Lamb D.Phil., JL Marsh Ph.D., JL Hutton Ph.D., R Nakash Ph.D. and MW Cooke Ph.D., on behalf of The Collaborative Ankle Support Trial (CAST Group) offered their observations. This was an emergency department-based study, as they noted that severe ankle sprains are a common presentation in emergency departments in the U.K. In their study, they aimed to assess the effectiveness of three different mechanical supports (Aircast brace, Bledsoe boot ["walking" boot], or 10-day below-the-knee cast) compared to a double-layer tubular compression bandage (similar to an Ace bandage wrapping) in promoting recovery after severe ankle sprains. The study was a multi-center, randomized trial with "blinded" assessment of outcome. Five hundred eighty-four participants suffering from severe ankle sprain were recruited between April, 2003 and July, 2005 from 8 emergency departments across the U.K. Participants were provided with a mechanical ankle support within the first 3 days of attendance by a trained healthcare professional and given advice on reducing swelling and pain. Functional outcomes were measured over 9 months. The primary outcome was quality of ankle function at 3 months. Patients who received the below-knee cast had a more rapid recovery than those given the tubular compression bandage. The investigators noted clinically important benefits at 3 months in quality of ankle function with the cast compared with tubular compression bandage, as well as in pain, symptoms and activity. The mean difference in quality of ankle function between Aircast brace and tubular compression bandage was measurable but less than that with the below-knee cast; there were little differences for pain, symptoms and activity. Bledsoe boots offered no benefit over the tubular compression bandage, which was the least effective treatment throughout the recovery period. There were no significant differences between tubular compression bandage and the other treatments at 9 months. Side-effects were rare with no discernible differences between treatments. In conclusion, for treatment of a severe ankle sprain, a short period of immobilization in a below-knee cast or Aircast results in faster recovery than if the patient is only given a tubular compression bandage. The authors recommended below-knee casts because they show the widest range of benefit.

What does this mean? It means that for a severe ankle sprain, the optimal immediate treatment to hasten short-term recovery and function is complete immobilization (in a position of function) if possible. This is most effectively accomplished with a cast or rigid splint, less effectively accomplished with a walking boot, and barely accomplished (if at all) with an elastic bandage wrap or taping. A sprain involves ligamentous injury, commonly one or more tears, which can heal best if kept immobile and in proper position.

The practicality of the method chosen depends on the setting. In the wilderness, casting or rigid splinting materials may not be available. Furthermore, the victim may need to walk to self-extricate, which requires a minimum amount of mobility and may necessitate the victim needing to fit his foot and ankle into a hiking boot or shoe. There are a number of pre-fashioned splints on the market. I usually carry at least one of these on any hike or trek when I will be a day or more away from a location where I can obtain a splint. The lighter ones provide reasonable rigidity, are lightweight, and do not consume much space in the medical kit or backpack.

Professional Development For Outdoor Educators

Rick Curtis — Mon, 24 Aug 2009 01:40:00 GMT

Fall is coming and for many of us, particularly in college and universities, our busy season is starting. In just a few weeks I'll be sending out almost 1,000 students on 6-day backpacking trips across the east coast. In order to help other people develop their programs I've posted the Outdoor Action Program Leader's Manual for our outdoor orientation program. The complete manual is available for you to adapt to your program and is available at the Outdoor Ed Community at Outdoor Orientation Program Leader's Manual.

Conferences

Fall is also conference time, one of the major ways that outdoor educators expand their skills. I'd like to encourage all of you to take advantage of three of the most valuable conferences this fall.

Wilderness Risk Management Conference: October 14 - 16, Durham, NC - The core objective of the Wilderness Risk Management Conference (WRMC) is to offer an outstanding educational experience to help you mitigate the risks inherent in exploring, working, teaching, and recreating in wild places. The full workshop listing and registration information is avaliable online at WRMC Conference Home Page.

Association for Experiential Education Conference: October 29 - November 1, Montreal, Canada - Each fall, more than 900 attendees come together at the Annual International AEE Conference for professional development and networking. Join us in Montreal if you want to effect change in your work, your life, your community and beyond. You'll leave the conference with the tools, information and inspiration to make a positive impact in the world through the philosophy and principles of experiential education. Visit the AEE International Conference Home Page.

Association of Outdoor Recreation and Education Conference: November 5 - 7, Minneapolis, MN - The AORE annual conference brings outdoor recreation professionals and students together for networking, professional development and information sharing activities and opportunities. The conference includes educational sessions, skill workshops and certifications, keynote addresses and peer networking opportunities at a unique conference site each fall. For more information about 2009 AORE conference workshops, presentations, keynote speakers, social gatherings, lodging, rates, and more, visit the AORE 2009 Conference Home Page.