December 2007 - Posts

• NOLS Incident Database Paper Published

  A new paper based on the National Outdoor Leadership School's Incident database has been published in the Journal of Wilderness and Environmental Medicine (18, 298-304(2007). It gives a perspective on injury and illness rates at NOLS from 2002-2005.   You can access it at: http://www.nols.edu/resources/research/abstracts.shtml.  The title is Medical Incidents and Evacuations on Wilderness Expeditions.   In 1984 NOLS created a comprehensive safety database to record incident data; all injuries, illnesses, near-miss incidents, and evacuations that occur on courses.  At 23 years and counting we believe it’s the longest running dataset in the industry, with more than 3 million person days of experience and 13,000 records. These data are used to guide the development of WMI’s curriculum and the wilderness medicine and risk management practices of NOLS.  This is the latest of three peer reviewed journal papers generated from this database.   Posted Dec 19 2007, 03:42 PM by Tod Schimelpfenig with no comments

• A Dislocation Tale

  One of the illusions about wilderness medicine is that we teach our students techniques which are beyond our skill or experience,  that really are the province of a physician.    Some of the blame for this miss-perception  lies in wilderness medicine  instructors, who in their enthusiasm,  distort the differences between first aid in the city, and in the wild.  In reality, most of the content of wilderness medicine courses for laypeople, as I teach them, are comprised of well-established first aid practices.  The differences lie in the context in which we prepare our students to practice.  We don’t train them to wait for the ambulance.  We teach them to deal with challenging environmental conditions, to improvise, to be skilled with environmental illnesses and injuries, to focus on prevention, and to make decisions on if, and how urgently, a patient needs to see the doctor.  One of the few unique techniques in wilderness medicine is the concept of laypeople reducing dislocations. Early reduction often results in dramatic pain relief, reduces circulatory and neurological risks to the extremity, can allow for better immobilization and ease of transport.   It’s supported by the practice guidelines of the Wilderness Medical Society and many other wilderness medical experts and protocols.  And as this real tale describes, can be very helpful to patient and rescuers. One day last summer a participant on a NOLS wilderness trip slipped on an alpine snowfield and when self arresting with her ice axe suffered an apparent anterior dislocation of her shoulder, complicated by obvious diminished circulation to the extremity (no radial pulse) and a pale and tingling hand. The course leader attempted to reduce the dislocation, however initial attempts with traction on the humerus were unsuccessful.  He used a satellite phone to call his base, inform them of the situation and initiate an air evacuation.  Complicating this situation was poor weather in this alpine cirque, including very high winds.   It was also evening, with only a couple of hours of daylight left.   The closest helicopter was approximately a 2 hour flight from the scene. The air ambulance folks were in a difficult situation of appreciating the urgency of the medical situation, and knowing the weather conditions were marginal at best. This was a very real risk versus benefit decision. While it was being debated, the base heard from the course leader that the shoulder was still dislocated and circulation to the extremity was still compromised.  The course leader tried a different technique, lying the patient on a boulder and dangling her arm off the side with a bit of weight to fatigue the tight shoulder muscles.   After an hour, when the school's evacuation coordinators were approaching a deadline to make a go – no go decision, the phone rang.  The trip leader was able to relay that the shoulder had relocated and circulation had returned to the arm.  The local weather was still poor.  He cancelled the request for the air evacuation.  The patient was walked to the trailhead the next morning and has recovered nicely. Herein lies the value of reducing a dislocation in remote circumstances.  Without this tool the patient may have suffered a serious injury to her arm, and rescuers may have been put in harms way.  The field of wilderness medicine needs to continue to be thoughtful and wise about what we teach laypeople. We need to weight the risks of harm with the potential benefits and seek data to support what we do rather than relying on anecdotal experience.  There are things we don’t want a WFR with an 80-hour training course and limited to no clinical experience to do in the field (e.g. suturing a wound), but the advice of experts, available data, and our experience (just ask any river professional), tells us that reducing a shoulder can be helpful if done carefully by a well trained wilderness medicine provider.     Posted Dec 12 2007, 08:29 PM by Tod Schimelpfenig with no comments

• Defining Hypothermia

  Why is it taught  that hypothermia occurs whenever someone is shivering or their temperature drops by a degree or two?    I’ve read in several medical texts that the definition of hypothermia is a core body temperature below 95F(35C). (A question from a student in a course I'm teaching) Yes, if you read the medical literature on hypothermia it’s common to see a threshold for hypothermia at 95F (35C).   As a medical geek I like to probe the origins of stuff like this.  The best I can figure this norm was described by British researchers in the 1960’s and has become a commonly shared criteria.   It’s fine and dandy for researchers or medical personnel with access to advanced life support to anchor their work at this point, but it’s not the world in which we manage hypothermia.  We don’t work in rescue helicopters or emergency rooms with physicians, nurses and the benefits of medical technology, or inside a controlled physiology laboratory.  We have to manage cold people in the wilderness.   We teach people to recognize hypothermia from subtle and early clues such as impaired ability to perform complex tasks, fine motor shivering, apathy, confused and sluggish thinking, slurred speech, stumbling, and "the umbles."   We do this because we know it’s much easier to stay warm than to warm a cold person. Compared to the scientist our definition of hypothermia is loose.  We call  people hypothermic who are probably only stressed by the cold, or are cold and unhappy, or who are simply having trouble coping with the environmental conditions.    I’d imagine if we could measure the temperature of our “hypothermic” students we would find it only decreased a degree or two, if at all.    It doesn’t matter that our patient’s temperature may be higher than a clinical definition.  It’s not important in the field to know the patient’s temperature.  What’s important is to be self-aware of your physical state and vigilant of how your companions are faring in the cold.  What’s important is acting early and aggressively to stay warm, rather than needing to rewarm to cold person.  We can treat this early stage of hypothermia, these cold stressed people in the wilderness.  A hypothermia wrap, a good meal and some warm fluids often are just what the doctor ordered.  What we can’t afford to miss, because it’s much harder to manage in the field, is real hypothermia  Posted Dec 12 2007, 09:09 AM by Tod Schimelpfenig with no comments

• The Milch Technique for Reducing a Shoulder Dislocation

  Medicine for the Outdoors Blog by Paul Auerbach, M.D. reposted with permission    This post is contributed by Dr. Jeremy Joslin, an avid outdoor enthusiast who is currently training to become an emergency physician. Here goes: After a long day trekking through Utah's canyon country, you decide to start heading back to camp. Three days from a car, and an hour away from camp, your hiking partner slips while stepping over a downed tree and catches his arm on the large trunk while falling. As he scrambles back to his feet, he cries out in pain and cannot seem to move his right arm at the shoulder. He knows the feeling, and tells you exactly what's happened: he's dislocated his shoulder again. Anterior dislocation (where the head [or “ball” of the ball-and-socket joint at the shoulder] of the humerus, which is the large bone of the upper arm, is dislocated forward in relationship to the socket) is the most common type of shoulder dislocation and happens when the arm gets pulled away from the body quickly (abduction), as in the scenario above. Shoulder dislocations are quite painful, and if you are near medical attention, that's where you'll want to head. In the meantime, if you're sure the shoulder is dislocated, waste no time in “reducing” it (putting it back into place). Prompt reduction is beneficial for the joint. In order to help determine if a shoulder has, indeed, been dislocated, I will reference the Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care (2nd edition) (1), which lists these four features: • Restriction of motion through the joint's normal range • Obvious deformity in comparison with the uninvolved side • Crepitus, or grating, of bone fragments is absent • Often a typical, identifiable posture of the dislocated joint, which the patient will maintain to minimize pain Once you've determined that the shoulder has been dislocated, you may want to attempt reduction. There are numerous methods of reduction for an anterior shoulder dislocation. My favorite technique for reduction is the Milch technique. Have the injured person sit, stand, or lie flat on his or her back, and then slowly reach, using the hand of their dislocated shoulder, behind their head and try to touch the opposite shoulder. Somewhere on the very slow, steady reaching, the shoulder will align itself and pop back into place. Another way to describe the positioning is to pantomime a pitcher's "wind up" before a pitch using the affecting side. Have the patient take their time and slowly reach upward and backwards as if they were going to pitch a baseball. If the "wind up" is slow enough, with plenty of rest if needed, you'll get the shoulder to pop back into place. This maneuver can be done solo or with assistance. If you are assisting, cup the victim’s elbow, giving it support and guiding their arm through the maneuver. Your other hand can be placed on their shoulder to apply support to the joint as it goes through the motion. Why do I appreciate this maneuver so much? Here are my specific reasons: • Compared with other maneuvers to reduce shoulders, this one seems to be the least painful. (2) • Some medical providers swear that if the technique is done correctly and slowly, then the patient doesn't even need pain medication. (3)(4) • It is easily described and easy to remember (the baseball pitch). • It can be done for self rescue (just take your time and go as slow as possible). • In my hands, this maneuver has been more successful than other techniques. I'd like to hear about your favorite technique), or if you've ever needed to reduce a shoulder in the wilderness setting, how you achieved success. Finally, if you're interested in reading more about this very historic subject, begin by following the link to an interesting article. Posted Dec 11 2007, 11:41 PM by Outdoor Ed with no comments