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A Dislocation Tale

Author(s): Tod Schimelpfenig
Posted: December 12, 2007

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.  

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