Received: from bci.batcon.org (bci.batcon.org [204.157.161.3]) by shadow-blue.cis.pitt.edu with SMTP (8.7.2/cispop-1.6.1.3) ID for ; Mon, 4 Dec 1995 09:40:25 -0500 Received: from Mitch ([204.157.161.102]) by bci.batcon.org (8.6.9/8.6.9) with SMTP id PAA28775 for ; Wed, 21 Sep 1988 15:47:48 -0500 Date: Wed, 21 Sep 1988 15:47:48 -0500 Message-Id: <198809212047.PAA28775@bci.batcon.org> X-Sender: jkennedy@batcon.org X-Mailer: Windows Eudora Version 1.4.3 Mime-Version: 1.0 Content-Type: text/plain; charset="us-ascii" To: kconover@pop.pitt.edu From: jkennedy@batcon.org (Jim Kennedy) Subject: Re: Permission to Quote X-PMFLAGS: 34078848 0 >I'd like to quote your posting about the Laurel Caverns rescue in a >reply to post both to the Cavers Digest and >wilderness-emergency-medicine lists. I'd also like to refer the case >to Paul Paris, M.D., the regional EMS medical director, for >discussion, using your and others' posts as part of the reference >material. > >Maybe this will help put some pressure on the local rescue/EMS types >from the top. > >OK with you? Keith, Use whatever you want from my short article. Feel free to intersperse with comments. I realize that there are several people more qualified than me to discuss the rescue, but nobody did. After all, I'm 1500 miles away! By the way, Dale left the hospital yesterday for Harrisburg (and home). He is getting about pretty well with the walker, and is recovering _much_ faster than I did with a similar (but apparently more severe) injury. - Jim -- End -- X-cs: From: Self To: EMERG-L@VM.MARIST.EDU Subject: Re: snakebite Reply-to: kconover+@pitt.edu Date: Fri, 14 Jul 1995 15:09:46 On 14 Jul 95 at 12:56, Wayne Redmond wrote: > According to the Fourth edition "Emergency Care In the Streets", by > Nancy Caroline: > > "It was previously recommended to apply ice or other cooling measures > to a snakebite, in an attempt to retard absorption of the venom. That > technique , however, was found simply to increase local tissue > destruction" > > > keep pt. immobilized, splint limb in dependent position below the > level of the heart, remove jewelry, O2, I.V., transport. > My $.02 worth: This problem with cold is relatively specific to North American pit vipers: rattlesnakes, copperheads, and water moccasins (cottonmouths) (oh, yes, for the herpetologists out there, the Massasauga, too). However, ice can cause frostbite even for harmless snakebites (I've seen this in years past). However, the advice to immobilize the patient and splint the limb are based on no evidence whatsoever. Well, there was one study in which they forced half of the small furry animals (gerbils or rabbits, as I remember) with massive envenomation to run on one of those little exercise wheels in the cage. A few more of them died. If it were in a backcountry situation, and someone had an obviously envenomated bite, and they could walk, I'd walk them out rather than waiting hours for a litter to arrive. It's unlikely to do anything bad, as there is only that one animal study to suggest increasing risk, and generalizing from that animal study to humans, and from severe envenomation (animals given the LD50=50% expected mortality) and generalizing from strenuous forced exercise to walking is taking things too far. Splinting makes sense because it makes the bitten limb hurt less. Splinting below, above, or at the level of the heart probably makes no difference, and I challenge anyone who says differently to cite evidence. -- End -- X-cs: From: Self To: EMERG-L@VM.MARIST.EDU Subject: Re: Snakebite Protocols Reply-to: kconover+@pitt.edu Date: Fri, 14 Jul 1995 15:15:45 On 14 Jul 95 at 4:27, Richard Penny wrote: > I'm working on updating the snakebite FAQ for rec.backcountry. > > The protocols I learned as an EMT in California and in my W-EMT course > both indicated that icing a snakebite is contraindicated. > > However, the opposite advice (ice the bite) must have at one > time been prevalent. I have seen a number of posts by amateur > first-aiders recommending that ice be applied to snakebites. > > So, I would like to have a strong justification to explain why modern > protocols state that snake bites should not be iced. Anyone know? > A) cold causes increased local tissue destruction when applied to North American pit viper bites. See the following references: Sullivan JB Jr, Wingert WA. Reptile Bites. in Auerbach PS, Geehr EC, Ed Management of wilderness and environmental emergencies. 2nd ed. St. Louis: C.V. Mosby Co., 1989:479-511. Gill KA Jr. The evaluation of cryotherapy in the treatment of snake envenomation. So Med J 1968;63:552-6. Durand LS, Rodeheaver GT, Edlich RF. Poisoning by pit vipers. W Va Med J 1982;78(7):162-7. B) There has never been any scientific evidence to show that cold is good for pit viper bites (though it is for brown recluse bites). I know of plenty of toxicologists who will serve (and have served) as expert witnesses against people who use cryotherapy for pit viper bites. -- End -- X-cs: From: Self To: sysop@emergency.com Subject: Re: Heat Illness news release Reply-to: kconover+@pitt.edu Date: Tue, 18 Jul 1995 17:15:50 On 16 Jul 95 at 23:00, sysop@emergency.com wrote: > > Doc: > > No personal offense taken on your criticism of our work (if that is > disasters, and timely features like the one you commented on. > > Unfortunately, on the misc.emergency services list, if a doctor > criticizes a paramedic...it is taken as gospel and that the paramedic > MUST BE WRONG or the physician wouldn't have taken the time to write. > While I understand your criticism and depth of your knowledge, to > others it may have appeared to be a "flame". While you told me > personally that the article was generally "excellent", others have Gak. We need to get away from this in EMS in general. The medics I work with don't hesitate to tell me when I have my head in the incorrect orifice, nor to debate medical issues. It should be the same everywhere. > Lastly, there is no difference in the pre-hospital phase of care for > heat exhaustion or heat stroke...they need to be cooled and taken to a > nice cool emergency room...Agreed? While physologically they may > present with cool, clammy skin, hot clammy skin, or dry hot skin...and > are taken from a hot environment...they need to be treated for heat > injury. Right? I understand your differentiation and acknowledge it, > but am not sure how it is going to change what emt's/medics do in the > field. My only worry is that an EMT or medic might decide someone might not have heatstroke because he or she is still sweaty. Actually, the prehospital treatment is about the same, but by telling the ED that you've got someone with suspected heatstroke they will be triaged to be seen sooner. (Not that patients every wait in EDs after being brought in Code 3 . . . ) > learning. As I said, unfortunately, your comments were construed by > some as discrediting our submission. OK, do me a favor. Quote some of the email that was just between your organization and me, particularly where I was complimentary, and post it to the emerg-l list. That should take care of the unwarranted assumption of some people. Or would you like me to post something? I figure you could probably pick and choose a better quote since you understand the problem better. > > I would welcome any/all information on this or other emergency medicine > topics and look forward to publishing them in our EmergencyNet NEWS, if > you were interested. Please feel free to contact us, if we may ever be > of any service. Thanks very much, and again my apologies for an inadvertent flame (I guess if maybe I said I was just a medic like I used to be, things would have been better?) -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: "EMS Agenda for the Future" Cc: @AMRG.PML,@ASRC.PML,@WEMSI.PML Reply-to: kconover+@pitt.edu Date: Sat, 5 Aug 1995 15:08:17 WEMSI just recently received a letter from the National Association of EMS Physcicians about the "EMS Agenda for the Future." I'll try to get an electronic version to post. The most important points: 1. the "EMS Agenda for the Future" will be a consensus process. "The straw man document will be created by a task force of EMS experts across the country. ... Once written, the document will be distributed to the widest possible cross section of EMS organizations for their peer review." 2. "Solicit participation from your membership by having them contact the NAEMSP Office at 1-800-228-3677 and ask to become a "Peer Reviewer" for the document." 3. "Solicit participation ... in the Blue Ribbon Conference Dec 1-2, 1995 at the McLean Hilton, Tyson's Corner, VA. Participation will be limited to the first 150 registrants. Registration materials will be forwarded to you directly during the month of September." I'll be climbing and hiking on the Isle of Arran off the west coast of Scotland the first couple of weeks of September, so I'd suggest you call NAEMSP if you want to receive registration materials for the conference directly. I'd like to see WEMSI there strongly representing the interests of the Wilderness EMS community. Thanks. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: survival food Reply-to: kconover+@pitt.edu Date: Wed, 16 Aug 1995 16:29:55 Can anyone on this list help? I was repacking my survival kit for wilderness SAR, and I've been carrying a small alcohol stove (weighs just a few ounces), and to prepare on it, some Quinoa, a South American grain that cooks in just 10 minutes, and a few boullion cubes for salt and taste, and a small Richmoor meat bar (basically Cherokee-style meat pemmican). The advantage of these foods is that they will stay edible for years in a pack, yet will provid a hot and filling survival meal for two, with lots of fat and protein; exactly what you need for a forced bivouac. And when you're starving, such a meal is exactly what you crave. Yes, I do carry some high-carbo muchies all the time; but those are recycled regularly. The problem is that Richmoor quit making meat bars. In the past I'd also used Amundsen meat pemmican that I got from Canada somewhere, but haven't seen that for about 20 years, so I can't replace my 10-year-old meat bar. I guess with health-conscious backpackers going for vegetarian freeze-dried meals (I like them myself, I have to admit) meat bars have gone the way of the dodo. Does anyone know any supplier who sells meat pemmican (dried pounded meat and rendered fat, sometimes with some spices or some pea flour)? Or something similar? Does the miltary have anything similar? Or should I just give up and pack a compressed lurp (military Mountain House freeze-dried food that is compressed)? The military rations are low-fat compared to my survival ration, so a less efficient source of energy per unit weight. Also, it will probably spoil easily if the metal foil develops a hole. My previous survival rations basically are imperishable for years, and I'm not sure about the long-term survival of military rations because of the packaging. Thoughts? Sources for pemmican (and I don't mean that fruit and nut stuff) other than making it myself? -- End -- X-cs: From: Self To: broche@titan.tcn.net (Bernie Roche) Subject: Re: survival food Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Thu, 17 Aug 1995 20:11:25 On 17 Aug 95 at 4:55, Bernie Roche wrote: > [Much deleted] > > >Thoughts? Sources for pemmican (and I don't mean that fruit and nut > >stuff) other than making it myself? > > > >Keith Conover, M.D. (NSS 12893, WD4PSY) > > Hi, Keith: > > I once found myself having to use my survival food "for real" > during the fall hunt. I opened the kit, only to find that some of the > food had deteriorated and spoiled all the rest, with the exception of > some coffee in a foil pack. It was a long, cold, HUNGRY night. I wasn't > lost, just too far back in the bush to walk out in the dark...the > area is heavy bush, with few landmarks. The risk of becoming lost > was too great. I got out without any problem in the morning, and > now have a different attitude toward survival gear. > > I recommend developing the attitude that one spends quite a bit > of money every year on non-essentials...movies, magazines, computer > games, whatever. It's better to blow a few dollars by eating last > year's survival food and replacing it once a year. This way, one > can have a broad range of goodies, as there are MANY things which > will keep well for a year. For example, I think ALL of today's > tinned goods will keep at least a year, if not subjected to rust. > (Dipping canned goods in melted parrafin will prevent rusting, if > they are packed in such a way as to protect the wax coating.) > > If you elect to use canned goods, it's best to use several small > tins rather than one big one, as this will reduce spoiling if you > use your kit in hot weather (I'm talking about spoilage after you open > a tin). Servings suitable for one, or at the most two, meals are best. > > Last time I was at Camp Soles, I let the students trying firing > some signal flares from my pack which were outdated. If memory serves, > only one or two out of six or eight worked! These danged things go > bad even faster than food. The expiry date is there for a reason. > Expired chemical signalling devices should be used (wasted) in classes > or exercises. Only fresh-dated signals should be in your pack. > > I strongly recommend going over one's survival kit at least once > a year. It's fun, it only takes a few minutes, and you can keep your > supplies fresh and ensure a less unpleasant wilderness experience > should you have reason to see if the kit works. > > Best Wishes, > > Bernie > Since you didn't post this reply to the list as far as I can tell, I'll ignore your advice to Dr. Barry about excessive quoting and quote your whole email note; your observations are, in my opinion, worthy of reading by all on the net. Yes, I agree that checking one's survival rations yearly is appropriate. However, I want survival rations that require water to cook -- I carry canned supplies in the vehicle but don't want to carry them with me all the time. I can carry a "little demon" stove modified to burn alcohol in a Nalgene bottle rather than Sterno that leaks all over the place, a half a meat bar (2 oz of meat pemmican) and some quinoa and I'm set for a hearty meal for two; it will last for several years, and weighs very, very little. But you're right, I should replace the quinoa and the meat pemmican and the bouillion cubes every year or so. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: Re: survival food -Reply Reply-to: kconover+@pitt.edu Date: Thu, 17 Aug 1995 22:06:20 On 17 Aug 95 at 7:35, Wayne Gagnon wrote: > I'm neither a survivalist nor a nutritionalist (plus, I'm just browsing this > list), BUT, I'd like to know if a PowerBar or (a few) would be a good > compliment to survival food pack? > I think power bars are great, and they last a long time in my pack; they are just as appetizing after a year or so (mildly only, that is) and I think they keep better than Clif bars. But they are primarily carbohydrate, and not satisfying or high-protein or high-fat enough for a survival dinner. Having bivvyed many times in the past, I want a solid, meat-and-potatoes dinner when in a survival situation (well, meat and quinoa; potatoes don't travel well.) -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.10/cispop $Revision: 1.6 $) ID for ; Thu, 17 Aug 1995 22:52:47 -0400 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.6.10/cispo-2.0) ID for kconover@pop.pitt.edu; Thu, 17 Aug 1995 22:52:46 -0400 Received: via switchmail; Thu, 17 Aug 1995 22:52:45 -0400 (EDT) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 17 Aug 1995 22:52:00 -0400 (EDT) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.6.10/cisls-2.4) ID ; Thu, 17 Aug 1995 22:51:57 -0400 Date: Thu, 17 Aug 1995 22:51:57 -0400 Message-Id: <199508180251.WAA13970@list.srv.cis.pitt.edu> To: kconover+@pitt.edu From: Majordomo@list.pitt.edu Subject: Majordomo results: who Reply-To: Majordomo@list.pitt.edu X-PMFLAGS: 33554560 -- >>>> who wilderness-emergency-medicine Members of list 'wilderness-emergency-medicine': kollar+@pitt.edu kconover+@pitt.edu bernie@interlog.com GRANDEYE@jeflin.tju.edu pacer@astro.ocis.temple.edu das@fore.com harrison@mitre.org broche@titan.tcn.net peter_mccabe@ed.gov msattler@jungle.com MHMILLER@aol.com BigGreen@aol.com JSachter@aol.com holtschn@bbt.com rhpope1@eos.ncsu.edu dscuteri@apollo.hp.com jrr@apollo.hp.com ALAURENT@npr.org ucr@saccw.cc.ar.us mcmullen@u.washington.edu grow@SCFF.CHINALAKE.NAVY.MIL whitedl@ix.netcom.com hoffman@xdelta.ENET.dec.com IDWAYNE@OFFSMTP.hboc.com hans@CAM.ORG JSilver374@aol.com rcries@teleport.com TJMcGuire@aol.com BRITTONDL@k1023.a1.ornl.gov djoyce@pipeline.com rfh@hogpa.ho.att.com MikelMD@aol.com vinhan@pipeline.com BUTLER@mee.tcd.ie mlevyppp@corcomsv.corcom.com donmarr@harborside.com tdmeyer@terminus.intermind.net reburr@aol.com dtc9c@faraday.clas.virginia.edu pturner@netcom.com KentJB@aol.com MACKANIC@PICARD.EVMS.EDU tsmith@amauta checker+@pitt.edu briroy@freenet.columbus.oh.us boruchse@UMDNJ.EDU davis@realtime.ab.ca Terrence.Jones@ncal.kaiperm.org thompsonke@merlin.aa.edu Ed.Pezalla@ncal.kaiperm.org Rafael.Gray@ncal.kaiperm.org mortimer@medisun.UCSFresno.EDU rbrown@hippocrates.family.med.ualberta.ca chris@bison.RANGE.ORST.EDU Wb7qni@aol.com frederic.de.thysebaert@infoboard.be DRMOON@aol.com >>>> >>>> Keith Conover, M.D. (NSS 12893, WD4PSY) **** Command 'keith' not recognized. >>>> - Information Systems Coordinator, Dept. of EM, Mercy Hospital END OF COMMANDS **** Help for Majordomo@list.pitt.edu: This is Brent Chapman's "Majordomo" mailing list manager, version 1.93. 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If you have any questions or problems, please contact "Majordomo-Owner@list.pitt.edu". -- End -- Received: from news.hboc.com (splat.hboc.com [199.250.128.36]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.10/cispop $Revision: 1.6 $) ID for ; Fri, 18 Aug 1995 06:21:56 -0400 Received: from OFFSMTP.hboc.com (offsmtp.hboc.com [139.177.1.146]) by news.hboc.com (8.6.11/8.6.9) with SMTP id GAA26632 for ; Fri, 18 Aug 1995 06:27:00 -0400 Received: from HBOC_DOMAIN_#h#1-Message_Server by OFFSMTP.hboc.com with Novell_GroupWise; Fri, 18 Aug 1995 06:26:53 -0400 Message-Id: X-Mailer: Novell GroupWise 4.1 Date: Fri, 18 Aug 1995 06:20:07 -0400 From: Wayne Gagnon To: kconover+@pitt.edu, kconover@pop.pitt.edu, broche@titan.tcn.net Cc: wilderness-emergency-medicine@list.pitt.edu Subject: Re: survival food -Reply X-PMFLAGS: 34603136 What exactly is meat pemmican and quinoa? This is kind of on the same line as survival food: I'm an on-call firefighter and a vegetarian. Wayne's rule No. 3: Always carry food. I need something to keep in a pack in my car in case I get "stranded" at a fire for a long time when all that's being served is doughnuts and meat-based food. I currently carry granola bars which I rotate about every 3 months. Is there anything else out there that will satisfy my no-meat, low-fat, low-sugar, low-salt diet. (Granted, if It come to "real" survival, I'll eat anything BUT my companions.) ...wayne Wayne A. Gagnon Firefighter/Illustrator/Programmer wayne.gagnon@hboc.com -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: Re: survival food -Reply Reply-to: kconover+@pitt.edu Date: Fri, 18 Aug 1995 07:43:53 On 18 Aug 95 at 6:20, Wayne Gagnon wrote: > What exactly is meat pemmican and quinoa? Meat pemmican is a traditional Indian/native American food; the recipe I head was I believe from a Cherokee friend. Take meat and trim off the fat. Render the fat by heating gently over a small fire until it melts; drain off the melted fat and save. Smoke and air-dry the lean meat; maybe marinate in spices first. After dry, pound into a powder. Mix the lean meat powder, rendered fat, and pea or arrrowroot flour (some recipes call for pounded nuts, too) and maybe some more spices. Form into a bar and wrap in waxed paper. Will keep indefinitely and can be eaten as is in small amounts, and can be dropped into boiling water with local vegetables to make a meat soup. A standard survival food from the sixteenth century in North America. Quinoa is a South American grain that provides complete protein. It cooks in about 10 minutes. If dry, it'll keep for a long time. > > This is kind of on the same line as survival food: > > I'm an on-call firefighter and a vegetarian. Wayne's rule No. 3: Always > carry food. I need something to keep in a pack in my car in case I get > "stranded" at a fire for a long time when all that's being served is > doughnuts and meat-based food. > > I currently carry granola bars which I rotate about every 3 months. Is > there anything else out there that will satisfy my no-meat, low-fat, > low-sugar, low-salt diet. (Granted, if It come to "real" survival, I'll eat > anything BUT my companions.) > Well, Quinoa and a vegetarian boullion cube makes a good combination; I eat vegetarian meals by preference, but for survival situations I prefer to take some meat pemmican because of the extra energy boost it gives -- End -- X-cs: From: Self To: Mark Pearson ,wilderness-emergency-medicine@list.pitt.edu Subject: Re: Wilderness Medical Society Question Reply-to: kconover+@pitt.edu Date: Mon, 21 Aug 1995 17:57:18 On 21 Aug 95 at 13:48, Mark Pearson wrote: > To whom it may concern, > > I am looking for a contact to the Wilderness Medical Society. > A phone number, email, or web site will do. > > Specifically, I am looking for information regarding the > Wilderness Medicine Conference which is usually held in > September at Squaw Valley, CA. > > Sincerely, The University of San Diego runs a series of wilderness medicine conferences; theirs are, I believe, often at Squaw Valley (but so are others sometimes); don't have the address handy. However, the premier wilderness medicine conferences are those run by the Wilderness Medical Society: Wilderness Medical Society P.O. Box 2463 Indianapolis, IN 46206 1-317-631-1745 Upcoming WMS Conferences: Sixth Annual Winter Wilderness Medicine 2/10-16/1996 Travel and Environmental Medicine Santa Fe, NM 4/24-28/1996 -- End -- X-cs: From: Self To: wemsi-staff@list.pitt.edu Subject: avalanche information from WMS Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Tue, 22 Aug 1995 18:25:49 I just emailed this to Mike Yee for possible inclusion in the Trauma section of the WEMSI Wilderness EMT Curriculum, based on what Bruno Durrer presented at the Aspen conference (Wilderness Medical Society/Second World Congress on Wilderness Medicine). Thought you all might find it interesting. The GIF file that is attached is of the flowsheet that I made up from Bruno's description of the algorithm (Figure Y). The other diagrams didn't scan well so I'm going to see if I can get originals from Bruno. (the following preliminary draft material is copyright (c) 1995 by the Wilderness EMS Institute and permission is hereby granted for electronic dissemination within the wilderness emergency medicine community; may be reproduced for other purposes with written permission, just ask. --Keith Conover, M.D., WEMSI Medical Director) =-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-= Avalanches In addition to broken bones and internal injuries, avalanches can present unique problems to a Wilderness EMT. Most critical is deciding whether apparently dead avalanche victims are dead of asphyxia (suffocation), or "cold but not yet dead" from hypothermia. The major cause of death from avalanche burial is asphyxia, not hypothermia. Statistics gathered in Switzerland over many years show that about 80% of deaths from avalanches are caused by asphyxia, injuries in about 10-15%, and accidental hypothermia in 5% or less.[1] These statistics also show how likelihood of sur- vival decreases rapidly over time (Figure X; Graph 2 from Dur- rer's paper). This information was gathered in a search and res- cue system in which the average time for a mountain rescue medi- cal team to reach the site is less than twenty minutes; Swiss mountain rescue teams are usually alerted directly by radio from the party in distress, and respond directly to the scene with a doctor. An avalanche victim may be trapped with snow occluding the nose and mouth, in which case the victim will die of asphyxia in about fifteen minutes, after which the body will begin to cool. If the victim has a "closed" air pocket around the nose and mouth, he or she may survive for up to about two hours, dying of a combination of slow asphyxia and gradual hypothermia. If the air pocket has a connection with the outside air (an "open" pocket) longer survival is possible. However, based on the Swiss data cited above, those buried in an avalanche cool at an average of about 3 degrees C per hour, and severe hypothermia may result. This emphasizes the need in more remote areas for parties to carry and be prepared to use self-rescue equipment (e.g., avalan- che locator transceivers, avalanche poles, and shovels). It also emphasizes the importance of self-rescue rather than waiting for an organized avalanche search party. It also emphasized the importance of teaching travelers in avalanche-prone areas to, when caught in an avalanche, to cup their hands around their faces to provide an air pocket. When faced with several unresponsive victims of an avalanche, one might be tempted to treat them all with cardio-pulmonary resus- citation, assuming that they all have severe hypothermia. However, you would like to direct limited on-scene resources to those most likely to benefit. There are two other important reasons to establish more specific triage criteria. First, bet- ter triage will eliminate rescuers resuscitating those who are beyond hope while staying in the avalanche path and maybe becom- ing victims themselves. Second, triage will allow better use of limited cardiopulmonary bypass facilities at receiving hospitals. However, even with immediate CPR and air transport for heart bypass rewarming, survival from such avalanche burial remains poor, due to the high incidence of death from asphyxia rather than hypothermia. The problem at the scene is to determine whether asystolic patients are dead from asphyxia and should be pronounced dead at the scene, or severely hypothermic and should receive vigorous resuscitation. Based on the information pre- sented above, Durrer and Brugger have developed a triage system for avalanche victims. The key criteria for this triage system are (1) having rescuers detect whether there was an air pocket, (2) attaching an electrocardiographic monitor to look for an electrical heart rhythm, and (3) obtaining a tympanic, esophageal, or rectal "core" temperature taken at the time of rescue. (Additional cooling may occur after rescue.) This triage procedure is shown as a flowsheet in Figure Y. References 1. Durrer B, Brugger H. Recent advances in avalanche survival. Paper Presented at Second World Congress on Wild. Med. Second World Congress on Wilderness Medicine, August 8-12, 1995, Aspen, Colorado. Indianapolis, IN: Wilderness Medical Society, 1995:180-7. Attachments: C:\upload\avalanch.gif -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.10/cispop $Revision: 1.6 $) ID for ; Tue, 22 Aug 1995 23:30:11 -0400 Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.6.10/cispo-2.0) ID for kconover@pop.pitt.edu; Tue, 22 Aug 1995 23:30:10 -0400 Received: via switchmail for kconover+@pitt.edu; Tue, 22 Aug 1995 23:30:08 -0400 (EDT) Received: from netcom10.netcom.com (pturner@netcom10.netcom.com [192.100.81.120]) by post-ofc03.srv.cis.pitt.edu with ESMTP (8.6.10/cispo-2.0) ID for ; Tue, 22 Aug 1995 23:29:41 -0400 Received: by netcom10.netcom.com (8.6.12/Netcom) id UAA11641; Tue, 22 Aug 1995 20:27:25 -0700 Date: Tue, 22 Aug 1995 20:27:24 -0700 (PDT) From: Patton M Turner Subject: Re: survival food To: kconover+@pitt.edu cc: wilderness-emergency-medicine@list.pitt.edu In-Reply-To: <199508162032.QAA01042@post-ofc01.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII X-PMFLAGS: 35127296 Not to offend anyone, but wouldn't it be as easy to make your own as post the request and then order it? You can buy the jerky already dried anyway, and just add fat. Does your training as an MD make the idea of pouring fat over red meat a little offensive :-). BTW, another advantage of your rations is that every body else will be carying sugar (candy bars bought at last minute, hard candy, drink mix (for flavor or to kill the taste of Iodine), Power Bars, MRE's, etc) and the taste will get old quick. Pat -- End -- X-cs: From: Self To: Patton M Turner Subject: Re: survival food Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Wed, 23 Aug 1995 08:17:33 On 22 Aug 95 at 20:27, Patton M Turner wrote: > Not to offend anyone, but wouldn't it be as easy to make your own as > post the request and then order it? You can buy the jerky already dried > anyway, and just add fat. The advantage of the prepacked meat pemmican is that it's prepared under cleaner conditions than I can approach at home, and sealed in foil, so it's less likely to get moldy. One can scape off the mold and use the interior of an old chunk of pemmican but unless you're a fan of Gorgonzola cheese this probably isn't appetizing . And pounding the jerky into powder takes a _long_ time! -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.10/cispop $Revision: 1.6 $) ID for ; Wed, 23 Aug 1995 08:28:24 -0400 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.6.10/cispo-2.0) ID for kconover@pop.pitt.edu; Wed, 23 Aug 1995 08:28:23 -0400 Received: via switchmail; Wed, 23 Aug 1995 08:28:22 -0400 (EDT) Received: from list.srv.cis.pitt.edu via qmail ID ; Wed, 23 Aug 1995 08:27:15 -0400 (EDT) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.6.10/cisls-2.4) ID ; Wed, 23 Aug 1995 08:27:11 -0400 Date: Wed, 23 Aug 1995 08:27:11 -0400 Message-Id: <199508231227.IAA03002@list.srv.cis.pitt.edu> To: kconover+@pitt.edu From: Majordomo@list.pitt.edu Subject: Majordomo results: who Reply-To: Majordomo@list.pitt.edu Status: U X-PMFLAGS: 33554560 -- >>>> who wilderness-emergency-medicine Members of list 'wilderness-emergency-medicine': kollar+@pitt.edu kconover+@pitt.edu bernie@interlog.com GRANDEYE@jeflin.tju.edu pacer@astro.ocis.temple.edu das@fore.com harrison@mitre.org broche@titan.tcn.net peter_mccabe@ed.gov msattler@jungle.com MHMILLER@aol.com BigGreen@aol.com JSachter@aol.com holtschn@bbt.com rhpope1@eos.ncsu.edu dscuteri@apollo.hp.com jrr@apollo.hp.com ALAURENT@npr.org ucr@saccw.cc.ar.us mcmullen@u.washington.edu grow@SCFF.CHINALAKE.NAVY.MIL whitedl@ix.netcom.com hoffman@xdelta.ENET.dec.com IDWAYNE@OFFSMTP.hboc.com hans@CAM.ORG JSilver374@aol.com rcries@teleport.com TJMcGuire@aol.com BRITTONDL@k1023.a1.ornl.gov djoyce@pipeline.com rfh@hogpa.ho.att.com MikelMD@aol.com vinhan@pipeline.com BUTLER@mee.tcd.ie mlevyppp@corcomsv.corcom.com donmarr@harborside.com tdmeyer@terminus.intermind.net reburr@aol.com dtc9c@faraday.clas.virginia.edu pturner@netcom.com KentJB@aol.com MACKANIC@PICARD.EVMS.EDU checker+@pitt.edu briroy@freenet.columbus.oh.us davis@realtime.ab.ca Terrence.Jones@ncal.kaiperm.org thompsonke@merlin.aa.edu Ed.Pezalla@ncal.kaiperm.org Rafael.Gray@ncal.kaiperm.org mortimer@medisun.UCSFresno.EDU rbrown@hippocrates.family.med.ualberta.ca chris@bison.RANGE.ORST.EDU Wb7qni@aol.com frederic.de.thysebaert@infoboard.be DRMOON@aol.com katyhein@u.washington.edu gluecker@warp6.cs.misu.NoDak.edu pbu-medical_pa@akm0044.anc.xwh.bp.com rnr@med.pitt.edu ish@rhi.hi.is llampe@linknet.kitsap.lib.wa.us schroeder@i-link.net carol@aemrc.arizona.edu >>>> >>>> Keith Conover, M.D. (NSS 12893, WD4PSY) **** Command 'keith' not recognized. >>>> - Information Systems Coordinator, Dept. of EM, Mercy Hospital END OF COMMANDS **** Help for Majordomo@list.pitt.edu: This is Brent Chapman's "Majordomo" mailing list manager, version 1.93. 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If you have any questions or problems, please contact "Majordomo-Owner@list.pitt.edu". -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.10/cispop $Revision: 1.6 $) ID for ; Wed, 23 Aug 1995 13:12:46 -0400 Received: from local (daemon@localhost) by post-ofc02.srv.cis.pitt.edu (8.6.10/cispo-2.0) ID for kconover@pop.pitt.edu; Wed, 23 Aug 1995 13:12:44 -0400 Received: via switchmail for kconover+@pitt.edu; Wed, 23 Aug 1995 13:12:43 -0400 (EDT) Received: from netcom14.netcom.com (pturner@netcom14.netcom.com [192.100.81.126]) by post-ofc02.srv.cis.pitt.edu with ESMTP (8.6.10/cispo-2.0) ID for ; Wed, 23 Aug 1995 13:10:21 -0400 Received: by netcom14.netcom.com (8.6.12/Netcom) id KAA03752; Wed, 23 Aug 1995 10:08:03 -0700 Date: Wed, 23 Aug 1995 10:08:02 -0700 (PDT) From: Patton M Turner Subject: Re: survival food To: kconover+@pitt.edu In-Reply-To: <199508231225.IAA13991@post-ofc02.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII X-PMFLAGS: 34078848 I kind of doubt it about the cleaner conditions unless they irridate the food. Foil packaging is nice (no O2/H2O permability as with plastic), but IMHO I have found plastic more durable (using a commerical quality sealer, not a seal a meal. Pounding the jerkey isn't too bad if it is very dry to begin n with. I have used dried jerkey and then dried it more with silica jel. Pat On Wed, 23 Aug 1995, Keith Conover, M.D. wrote: > On 22 Aug 95 at 20:27, Patton M Turner wrote: > > > Not to offend anyone, but wouldn't it be as easy to make your own as > > post the request and then order it? You can buy the jerky already dried > > anyway, and just add fat. > > The advantage of the prepacked meat pemmican is that it's prepared > under cleaner conditions than I can approach at home, and sealed in > foil, so it's less likely to get moldy. One can scape off the mold > and use the interior of an old chunk of pemmican but unless you're a > fan of Gorgonzola cheese this probably isn't appetizing . And > pounding the jerky into powder takes a _long_ time! > > > Keith Conover, M.D. (NSS 12893, WD4PSY) > - Information Systems Coordinator, Dept. of EM, Mercy Hospital > - Clinical Assistant Professor, Dept. of Emergency Medicine, > Univ. of Pittsburgh (EM Residency and Center for Emergency Medicine) > - Medical Director, Wilderness EMS Institute > (http://www.pitt.edu/DOC/95/30/32686/Wemsi.html) > - Eastern Region, Natl. Cave Rescue Comm./Appalachian SAR Conf. > -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.10/cispop $Revision: 1.6 $) ID for ; Wed, 23 Aug 1995 13:11:21 -0400 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.6.10/cispo-2.0) ID for kconover@pop.pitt.edu; Wed, 23 Aug 1995 13:11:19 -0400 Received: via switchmail; Wed, 23 Aug 1995 13:11:19 -0400 (EDT) Received: from list.srv.cis.pitt.edu via qmail ID ; Wed, 23 Aug 1995 13:10:45 -0400 (EDT) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.6.10/cisls-2.4) ID ; Wed, 23 Aug 1995 13:10:34 -0400 Received: from merlin ([198.59.159.4]) by list.srv.cis.pitt.edu with SMTP (8.6.10/cisls-2.4) ID for ; Wed, 23 Aug 1995 13:10:30 -0400 From: thompsonke@merlin.aa.edu Date: Wed, 23 Aug 1995 11:10:32 -0600 Message-Id: <95082311103200@merlin.aa.edu> To: wilderness-emergency-medicine@list.pitt.edu Subject: a response to PA Wilderness EMT Part 4 X-VMS-To: SMTP%"wilderness-emergency-medicine@list.pitt.edu" Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34603136 A L B U Q U E R Q U E A C A D E M Y I N T E R O F F I C E M E M O R A N D U M Date: 23-Aug-1995 10:16am MDT From: Ken Thompson THOMPSONKE Dept: Tel No: 828-3143 TO: Remote Addressee ( wilderness-emergency-medicine@list.pitt.edu ) Subject: a response to PA Wilderness EMT Part 4 Folks, this is the first time I've written to the "list", and, so, think I should introduce myself. I've been working in the field of outdoor education since 1982 and have been a SOLO Wilderness-EMT for about 8 years and have taught part-time for both SOLO and WMI for 6 years. I'm currently the department chair of Experiential Education (essentially outdoor adventure trips) at Albuquerque Academy. I've also got MRA experience and have spent several years volunteering on an ambulance at the EMT-I level. I've also edited a Wilderness Medicine Newsletter (not the WMS's) for a number of years and so have kept abreast of research, general practice, and legal issues pertinent to those of us who are primarily wilderness trip leaders and secondarily lay-providers of wilderness first aid and medicine. I'd like to express my opinion about the tiers articulated in Keith's plan and see what rises to the surface among those of you who are out there reading: 1) My experiences in outdoor programming indicate that among most, if not all, the major outdoor schools and university programs, the Wilderness First Responder, as taught by SOLO, WMI, and WMA, has become the standard acceptable level of training. 2) Even with the development of radio and phone technology those of us who lead trips into wilderness areas may find ourselves dealing with injuries and illnesses for 12 hours to 2 days. The nature of our jobs often makes it impractical for us to belong to a state's EMS agency (we're rarely in town). So we fall outside the purview of state EMS regulations, often to the frustration of those state agencies. 3) The best outdoor schools are rigorous about maintaining training levels and standards among their respective staffs. The alternative, in our litigious society, is to go out of business. 4) I think we in the outdoor community have acquired a fair bit of experience with Wilderness First Responders and that they do quite well performing the following skills appropriately: 1. wilderness CPR guidelines 2. the reduction of selected dislocations 3. clinically "clearing" a c-spine 4. irrigating wounds for extended care These are skills that are found variously in other guidelines at the EMT level and above. 5) Some programs also carry injectable epinephrine, diphenhydramine, acetaminophen, aspirin, ibuprofen, albuterol inhalers, dexamethasone, acetaminophen and other meds appropriate for where and with whom we are traveling. The reality is that we are often called upon to function in more of an expedition medical role than a rescuer role. For that matter I've also provided emergency dental care, nursing care, and psychological care including the application of physical restraints. And, I'm the first to say that even with solid training and very specific treatment guidelines this can be scary business (my academic background is in literature and writing). However, the alternative is to provide sub-standard care, or no care at all, to conditions that are, in my opinion, treatable by lay-providers. 6) Therefore it is my opinion that the outdoor trip leader needs a few advanced skills, perhaps even more so than the professional or volunteer EMT rescuer (who has access to higher levels of training in a "system"). I also believe these can be adequately taught in an 80-hour WFR curriculum. 7) We also frequently operate in two or three states on any given trip and the legal issues have been confusing and confounding. 8) HELP? ADVICE? INFORMATION? COMMISERATION? Most sincerely, Ken -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.10/cispop $Revision: 1.6 $) ID for ; Wed, 23 Aug 1995 12:41:36 -0400 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.6.10/cispo-2.0) ID for kconover@pop.pitt.edu; Wed, 23 Aug 1995 12:41:35 -0400 Received: via switchmail; Wed, 23 Aug 1995 12:41:35 -0400 (EDT) Received: from list.srv.cis.pitt.edu via qmail ID ; Wed, 23 Aug 1995 12:40:01 -0400 (EDT) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.6.10/cisls-2.4) ID ; Wed, 23 Aug 1995 12:39:54 -0400 Received: from mail2.digital.com (mail2.digital.com [204.123.2.56]) by list.srv.cis.pitt.edu with SMTP (8.6.10/cisls-2.4) ID for ; Wed, 23 Aug 1995 12:39:50 -0400 Received: from us2rmc.zko.dec.com by mail2.digital.com; (5.65 EXP 4/12/95 for V3.2/1.0/WV) id AA04901; Wed, 23 Aug 1995 09:33:31 -0700 Received: from xdelta.enet by us2rmc.zko.dec.com (5.65/rmc-22feb94) id AA03038; Wed, 23 Aug 95 12:08:30 -0400 Message-Id: <9508231608.AA03038@us2rmc.zko.dec.com> Received: from xdelta.enet; by us2rmc.enet; Wed, 23 Aug 95 12:31:19 EDT Date: Wed, 23 Aug 95 12:31:19 EDT From: Steve Hoffman To: wilderness-emergency-medicine@list.pitt.edu Cc: hoffman@xdelta.ENET.dec.com Apparently-To: wilderness-emergency-medicine@list.pitt.edu Subject: Backboarding Protocols Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34603136 The Solo WEMT program includes protocols for determining if c-spine immobilization is necessary for a particular patient, and these protocols are beyond the protocols used by most (all?) non-wilderness EMTs. Is anyone aware of any state or local c-spine immobilization protocols similar to WEMT protocols used in long-transport or other `non-traditional-WEMT' situations? I am WEMT-rated and regularly responding to calls in a relatively rural area, where incident-to-hospital transport times are regularly over a half an hour under normal weather and traffic conditions. I fully expect to be presented with a situation where WEMT protocols would be valid and available, and I fully expect my local (non-WEMT) medical control physician to, uh, have kittens, were I to switch over to WEMT protocols around immobilization or dislocation reduction, etc. I'd rather be proactive about this situation, and I'd like to provide medical control with materials and information that will help both of us provide better care. Can anyone provide information or suggestions? Steve Hoffman WEMT, NR EMT-Intermediate -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.10/cispop $Revision: 1.6 $) ID for ; Wed, 23 Aug 1995 16:31:26 -0400 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.6.10/cispo-2.0) ID for kconover@pop.pitt.edu; Wed, 23 Aug 1995 16:31:25 -0400 Received: via switchmail; Wed, 23 Aug 1995 16:31:17 -0400 (EDT) Received: from list.srv.cis.pitt.edu via qmail ID ; Wed, 23 Aug 1995 16:30:47 -0400 (EDT) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.6.10/cisls-2.4) ID ; Wed, 23 Aug 1995 16:30:29 -0400 Received: from named.caps.maine.edu (named.caps.maine.edu [130.111.32.11]) by list.srv.cis.pitt.edu with SMTP (8.6.10/cisls-2.4) ID for ; Wed, 23 Aug 1995 16:30:26 -0400 Received: from orion.bdc.bethel.me.us by named.caps.maine.edu (AIX 3.2/UCB 5.64/4.03) id AA13894; Wed, 23 Aug 1995 16:30:25 -0400 Date: Wed, 23 Aug 1995 16:30:25 -0400 Received: from async10.ts-bethel.bdc.bethel.me.us by orion.bdc.bethel.me.us id aa19693; 23 Aug 95 16:26 EDT Mime-Version: 1.0 Content-Type: text/plain; charset="us-ascii" To: wilderness-emergency-medicine@list.pitt.edu From: Phil Gormley Subject: Wilderness Medical Associates Message-Id: <9508231626.aa19693@orion.bdc.bethel.me.us> Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 35127424 Dear Dr. Conover Recently I received from a friend in New Hampshire a hard copy of some information that you placed on your list. As Executive Director of Wilderness Medical Associates, I found it interesting and amusing to learn that we are dying. Particularly when you suggest that it was because "NASAR has dumped its contract" with us. To suggest that NASAR has dumped us, and that because of this we are in trouble is absurd (nice shot, though). I wish that you had taken the time to contact us to understand what Wilderness Medical Associates has been accomplishing over the past few years. You have chosen to listen to only part of the story. We underwent an organizational behavior change in 1991. The path I chose to take for the company was to extricate us from all of the politics and battles of the past, reorganize and quietly move the company forward. For your information here are some of our highlights: * Since 1991 our business has increased sevenfold. * Last year we had just over 500 students attend our programs (this in a year when we committed to a zero percent growth allow systems to catch up>) * The schedule for 1996 is already ahead of 1995. * This year we entered into an agreement with Outward Bound USA to provide the Medical Screening Program that we have published to all Outward Bound Schools in the U.S. We are currently negotiating the same with Canadian Outward Bound Wilderness School. * We have three new publications to support our courses. * We are negotiating a new textbook. * We have expanded our international business and the Fall have programs contracted in Wales, Belgium and Australia (all three courses running with maximum student numbers). * We are using new National Standardized Curriculum as a core and have developed our own overheads and support materials which blend urban and extended care. * We are running an eight day staff training/meeting in September. * Our long contracts are up 80 percent. It's too bad you haven't taken the time to know us. We are not the same company you knew when the old management team was here. I think you would agree that we do not sound like a dying company. Also, as point of information, we have seven courses listed on our current schedule in California and Oregon. I look forward to hearing from you. Paul Marcolini WEMT-P Executive Director Wilderness Medical Associates -- End -- X-cs: From: Self To: thompsonke@merlin.aa.edu Subject: Re: a response to PA Wilderness EMT Part 4 Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Wed, 23 Aug 1995 19:20:40 Ken-- Thanks very much for your comments. The more I think about it, the more I come to believe that you are right in that: WFR (as currently being standardized) is the standard for trip leaders, camp leaders, and guides. AND, since those people are for the most part NOT part of the EMS system, the EMS system should not regulate them in general. EXCEPT that WFR is also becoming the standard for rangers and others who DO interface or become part of the EMS system. So that the WFR standard, even if it comes from primarily outside the EMS system (though that depends on the medical practice and EMS laws of each state) should be recognized by the state EMS systems. In other words, the standard for state park rangers should not be DOT or NSC First Responder but ASTM/WMS WFR, and this should be recognized in EMS regulations. But the regulations shouldn't seek to control everyone who is a WFR, because some are in the EMS system but most not. As far as legal issues: best for trip leaders and other WFRs who are not in government or a recognized SAR team to try to operate under the medical practice act as a medical agent of a doctor (GET a medical director!) but not as part of the EMS system. The trick is to make sure that the WFR stuff that gets written in for the EMS WFRs makes sense in terms of the non-EMS WFRs, too. -- End -- X-cs: From: Self To: hoffman@xdelta.ENET.dec.com Subject: Re: Backboarding Protocols Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Wed, 23 Aug 1995 21:04:11 Steve- I agree with your concernes, both for people on boards for a long time, and for worries bout your medical director havng kittens if you started doing WEMT things on the street. Three things to consider: The NAEMSP Clinical Guidelines are for _Delayed Transport_ which includes the wilderness but also the rural setting. (See the recent post on this list with the references.) My editorial and review of the literature might be of some use to you in approaching your medical director, as might be the references in this document that I'll post for your review. I can't post the entire refernced editorial due to copyright but if you want I can email a single reprint to you personally. Let me know. Wilderness EMS Institute unofficial occasional publication #1 Cervical Spine Clearing by Wilderness EMTs ------------------------------------------ Notes of a Wilderness EMS Institute telephone conference held February 1995 Keith Conover, M.D. (emergency physician), Medical Director Sam Chewning, M.D. (spine surgeon), Medical Command Officer Jack Grandey, EMT-P, (paramedic supervisor) Operations Director Copyright 1995 by the Wilderness EMS Institute. This document may be reproduced by any means, without written permission, _if_ it is reproduced in whole, including this copyright notice. It may be us ed by any person for any use, public, private, or commercial. Excerpts and quotes must include this following disclaimer: the participants in this conference have attempted to assure that all materia l herein is accurate, but can accept no responsibility for its use. It is offered to the public solely for general background information and as a guide to the more formal medical literature, and sho uld not be referenced as a justification for any policy or protocol. All care rendered by WEMTs must be at the direction of a licensed physician and accord- ing to applicable laws and regulations. This telephone conference was held to discuss the specifics of how WEMSI teaches WEMTs to "clear the cervical spine" and how WEMSI protocols specify this for personnel under WEMSI medical direction. The specific issue was the role of distracting injuries, and in particular the impact of a case presented in the _Journal of Wilderness Medicine_. The goal was to develop a formal recommendation for the Medical Advisory Board to review. An ad-hoc committee of three, including an emergency physician, spine surgeon, and paramedic, and also the WEMSI Medical Director, Medical Command Officer, an d Operations Director, seemed ideal for expeditiously developing a workable consensus. ================================================================= 1. A "Distracting Injury" List? ------------------------------- We observed that, as described in Dr. Conover's editorial and other similar reviews, there is truly no such thing as an "occult cervical spine fracture." In all such reported cases, the patient's sen sorium was clouded by drugs, head injury, or other massive traumatic injury. The idea of the "distracting injury" is that painful injuries can distract one from a significant cervical spine injury. We discussed the possibility of establishing a "list" of injuries or illnesses that should be considered to be "distracting." However, the list is so broad, including both traumatic and nontraumatic conditions (e.g., testicular torsion, appendicitis, impacted renal stones) that we felt any attempt at a definitive list cou ld be misleading. We also felt that "clearing the c-spine" in the wilderness requires clinical judgment, including a careful assessment of the risk/benefit ratio of clearing the cer- vical spine in each particular judgment. Therefore, we felt that the protocols should have a few footnoted examples, such as those above plus the traumatic injuries noted in Dr. Conover's editorial and letter, to provide a general guide to the WEMT. The footnote should make clear that these are merely examples. 2. The _Journal of Wilderness Medicine_ case. --------------------------------------------- A case recently published in the _Journal of Wilderness Medicine_1 suggested that it is possible for an alert, awake patient who does not appear to be in distress to have a significant cervical spine injury without detectable signs or symptoms. Those interested should read the case. In short, the patient was in a very remote area; took a long sliding fall, resulting in an evident forearm fract ure as well as other less significant injuries; cracked his hel- met and had a loss of consciousness; but walked back to a tent, where he seemed not to be in significant distress, and was awake and a lert. Dr. Conover noted, in a letter to be published in the _Journal of Wilderness Medicine_ "As I wrote in a previous editorial2, a long bone fracture should be considered a distracting injury. The patie nt described by Levitan would not be "cleared," but would be immobilized, if following the protocol proposed in the editorial. . . . Pain perception and clinical evidence of distress are conditio ned by many factors: cultural expectations and upbringing, individual constitution, and the psychosocial surroundings of an injury. However, the _relative_ painfulness of major injuries should not be affected by such fac- tors. . . . WEMTs should also be well-trained in evaluating musculoskeletal injuries, so they will recognize potential long-bone fractures, and immobilize such patients whe n the mechanism of injury suggests possible spinal injury." We noted that a long fall, a cracked helmet, and a loss of consciousness, all were indications of a significant mechanism of injury, and should lead one to suspect a cervical spine injury. _However_ , the whole point of the idea of "clearing the cervical spine in the wilderness" is to _ignore_ a significant mechanism of injury, and for selected patients to go entirely on history and physical to "clear" the cervical spine. One question about this case: was the patient truly totally awake and oriented, or did he have some residual clouding of sensorium from the head injury and concussion? This is not 100% clear from t he case report, at least in the minds of some. Certainly, any patient who has sustained a loss of con- sciousness should have a careful evaluation of the patient's mental status and cognition before any attempt to clear the cervical spine. 3. "Unstable" Cervical Spine Injury? ------------------------------------ Dr. Chewning, a recogized authority on the topic of cervical spine injury, noted that the concept of "unstable cervical spine injury" is now being re-evaluated by spine surgeons. Spine surgeons are beginning to think that those with a neurological deficit from a cervical spine fracture are not at risk for additional neurological damage unless there is another significant injury to the cervical spine. Minor movement of the neck is thought unlikely to cause additional neurological damage, though major flexion or extension (e.g., drag- ging an unconscious patient out of a car with his neck flexed so his chin is on his chest) might cause some damage in some cases. There is also a growing impression that alert patients, even with "unstable" cervical spine injuries, will have enough spas m and pain not to allow any additional neurological damage. Certainly the JWM patient mentioned above did enough walking and climbing before immobilization to argue strongly for this. 4. Backboard Dangers -------------------- The dangers of hypothermia and worsening clinical status when a wilderness patient has to wait for spinal immobilization, and the increased difficulty of evacuation, are well-known to SAR personnel. However, there is also a growing realization within the orthopedic, neurosurgical, rehabilitation and emergency medicine fields that being on an unpadded backboard can cause severe pain and even sev ere injury. One study with volunteers showed they could only stay on the board for less than 30 minutes without moderate to severe pain.3 Other studies suggest that being on an unpadded backboard f or 1-2 hours causes damage to the skin that can lead to necrosis and the need for skin grafts or other heroic measures.4,5 The upshot of all of this, at least among spine surgeons, is to emphasize the need to get people off back-boards quickly, and to minimize the need for rigid immobilization for a ll but a few patients. Even with _well-padded_ backboards, some National Cave Rescue Commission mock patients have required intramuscular injections for the pain associated with being immobilized. References 1. Levitan RM. Occult cervical spine fracture in a wilderness setting. J Wild Med 1994;4:182-6. 2. Conover K. EMTs should be able to clear the cervical spine in the wilderness [editorial]. J Wild Med 1992;3(4):339-43. 3. Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med 1994;23(1):48-51. 4. Linares HA, Mawson AR, Suarez E. Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics 1987;10:571-3. 5. Mawson AR, Bundo JJ, Neville P. Risk factors for early occuring pressure ulcers following spinal cord injury. Am J Phys Med Rehab 1988;67:123-7. C:\TEXT\WEMS\CSPINE.DOC -- End -- X-cs: From: Self To: hoffman@xdelta.ENET.dec.com Subject: Re: Backboarding Protocols Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Wed, 23 Aug 1995 21:09:24 Steve- I agree with your concernes, both for people on boards for a long time, and for worries bout your medical director havng kittens if you started doing WEMT things on the street. Three things to consider: The NAEMSP Clinical Guidelines are for _Delayed Transport_ which includes the wilderness but also the rural setting. (See the recent post on this list with the references.) Maine has started an experimental protocol to clear cervical spines "on the street" (from the emed-l emergency medicine mailing list): From: RWHartung@aol.com Date sent: Tue, 1 Aug 1995 13:28:35 -0400 To: emed-l@itssrv1.ucsf.edu Subject: Re: emed-l Fixed and dilated... On 8/1/95, Mikel Rothenberg, MD wrote: I was involved in some of the discussion of clearing C-spines in the field in Maine while I was on the regional EMS board there. This originally was brought up by one of our ED MDs who is a well known wilderness medicine expert. The concern in the wilderness setting is in unnecessarily immobilizing patients who may then have a more difficult, long wilderness "extrication". The concern in the more traditional EMS arena was whether pts in an MVA (for example) might not have much pain immediately after the injury because of a "stress response" (for lack of a better term). We did, however, end up adopting criteria for clearing pts in the field. We felt these criteria were necessary from both a "positive" and a "negative" side. That is, many patients were being unnecessarily immobilized but we also found several cases of patients not being immobilized when they should have been. So polishing up our field criteria was a two-edged sword. Maine, by the way, is currently in the midst of a liability demonstration project regarding clearing patients in the ED without x-rays. If the patient meets the following criteria (and this is documented), there is felt to be no risk of significant c-spine injury and you will be backed up on this in court. ("By participating in the project, you receive the benefit of being permitted to use the parameters and protocols as an affirmative defense in a lawsuit against you...") "Criteria for not obtaining cervical spine x-rays (significant cervical spine injury is assumed not to be present and cervical spine x-rays are not mandatory for trauma patients who meet all of the following criteria); 1. No complaint of cervical spine pain 2. No localized cervical spine tenderness by palpation 3. No subjective or objective findings of spinal cord or nerve root injury a. subjective: weakness or paresthesia b. objective: motor or sensory deficit and 4. Have a reliable history and physical exam and aprropriate response (not intoxicated or otherwise impaired)." Note that these criteria apply only to patients who do not have other distracting injuries (that is, painful injuries elsewhere that might make it hard to realize that you also have a broken neck). Russ Hartung, MD EMS Director CVPH Medical Center Plattsburgh, NY My editorial and review of the literature might be of some use to you in approaching your medical director, as might be the references in this document that I'll post below for your review. I can't post the entire refernced editorial due to copyright but if you want I can email a single reprint to you personally. Let me know. Wilderness EMS Institute unofficial occasional publication #1 Cervical Spine Clearing by Wilderness EMTs ------------------------------------------ Notes of a Wilderness EMS Institute telephone conference held February 1995 Keith Conover, M.D. (emergency physician), Medical Director Sam Chewning, M.D. (spine surgeon), Medical Command Officer Jack Grandey, EMT-P, (paramedic supervisor) Operations Director Copyright 1995 by the Wilderness EMS Institute. This document may be reproduced by any means, without written permission, _if_ it is reproduced in whole, including this copyright notice. It may be us ed by any person for any use, public, private, or commercial. Excerpts and quotes must include this following disclaimer: the participants in this conference have attempted to assure that all materia l herein is accurate, but can accept no responsibility for its use. It is offered to the public solely for general background information and as a guide to the more formal medical literature, and sho uld not be referenced as a justification for any policy or protocol. All care rendered by WEMTs must be at the direction of a licensed physician and accord- ing to applicable laws and regulations. This telephone conference was held to discuss the specifics of how WEMSI teaches WEMTs to "clear the cervical spine" and how WEMSI protocols specify this for personnel under WEMSI medical direction. The specific issue was the role of distracting injuries, and in particular the impact of a case presented in the _Journal of Wilderness Medicine_. The goal was to develop a formal recommendation for the Medical Advisory Board to review. An ad-hoc committee of three, including an emergency physician, spine surgeon, and paramedic, and also the WEMSI Medical Director, Medical Command Officer, an d Operations Director, seemed ideal for expeditiously developing a workable consensus. ================================================================= 1. A "Distracting Injury" List? ------------------------------- We observed that, as described in Dr. Conover's editorial and other similar reviews, there is truly no such thing as an "occult cervical spine fracture." In all such reported cases, the patient's sen sorium was clouded by drugs, head injury, or other massive traumatic injury. The idea of the "distracting injury" is that painful injuries can distract one from a significant cervical spine injury. We discussed the possibility of establishing a "list" of injuries or illnesses that should be considered to be "distracting." However, the list is so broad, including both traumatic and nontraumatic conditions (e.g., testicular torsion, appendicitis, impacted renal stones) that we felt any attempt at a definitive list cou ld be misleading. We also felt that "clearing the c-spine" in the wilderness requires clinical judgment, including a careful assessment of the risk/benefit ratio of clearing the cer- vical spine in each particular judgment. Therefore, we felt that the protocols should have a few footnoted examples, such as those above plus the traumatic injuries noted in Dr. Conover's editorial and letter, to provide a general guide to the WEMT. The footnote should make clear that these are merely examples. 2. The _Journal of Wilderness Medicine_ case. --------------------------------------------- A case recently published in the _Journal of Wilderness Medicine_1 suggested that it is possible for an alert, awake patient who does not appear to be in distress to have a significant cervical spine injury without detectable signs or symptoms. Those interested should read the case. In short, the patient was in a very remote area; took a long sliding fall, resulting in an evident forearm fract ure as well as other less significant injuries; cracked his hel- met and had a loss of consciousness; but walked back to a tent, where he seemed not to be in significant distress, and was awake and a lert. Dr. Conover noted, in a letter to be published in the _Journal of Wilderness Medicine_ "As I wrote in a previous editorial2, a long bone fracture should be considered a distracting injury. The patie nt described by Levitan would not be "cleared," but would be immobilized, if following the protocol proposed in the editorial. . . . Pain perception and clinical evidence of distress are conditio ned by many factors: cultural expectations and upbringing, individual constitution, and the psychosocial surroundings of an injury. However, the _relative_ painfulness of major injuries should not be affected by such fac- tors. . . . WEMTs should also be well-trained in evaluating musculoskeletal injuries, so they will recognize potential long-bone fractures, and immobilize such patients whe n the mechanism of injury suggests possible spinal injury." We noted that a long fall, a cracked helmet, and a loss of consciousness, all were indications of a significant mechanism of injury, and should lead one to suspect a cervical spine injury. _However_ , the whole point of the idea of "clearing the cervical spine in the wilderness" is to _ignore_ a significant mechanism of injury, and for selected patients to go entirely on history and physical to "clear" the cervical spine. One question about this case: was the patient truly totally awake and oriented, or did he have some residual clouding of sensorium from the head injury and concussion? This is not 100% clear from t he case report, at least in the minds of some. Certainly, any patient who has sustained a loss of con- sciousness should have a careful evaluation of the patient's mental status and cognition before any attempt to clear the cervical spine. 3. "Unstable" Cervical Spine Injury? ------------------------------------ Dr. Chewning, a recogized authority on the topic of cervical spine injury, noted that the concept of "unstable cervical spine injury" is now being re-evaluated by spine surgeons. Spine surgeons are beginning to think that those with a neurological deficit from a cervical spine fracture are not at risk for additional neurological damage unless there is another significant injury to the cervical spine. Minor movement of the neck is thought unlikely to cause additional neurological damage, though major flexion or extension (e.g., drag- ging an unconscious patient out of a car with his neck flexed so his chin is on his chest) might cause some damage in some cases. There is also a growing impression that alert patients, even with "unstable" cervical spine injuries, will have enough spas m and pain not to allow any additional neurological damage. Certainly the JWM patient mentioned above did enough walking and climbing before immobilization to argue strongly for this. 4. Backboard Dangers -------------------- The dangers of hypothermia and worsening clinical status when a wilderness patient has to wait for spinal immobilization, and the increased difficulty of evacuation, are well-known to SAR personnel. However, there is also a growing realization within the orthopedic, neurosurgical, rehabilitation and emergency medicine fields that being on an unpadded backboard can cause severe pain and even sev ere injury. One study with volunteers showed they could only stay on the board for less than 30 minutes without moderate to severe pain.3 Other studies suggest that being on an unpadded backboard f or 1-2 hours causes damage to the skin that can lead to necrosis and the need for skin grafts or other heroic measures.4,5 The upshot of all of this, at least among spine surgeons, is to emphasize the need to get people off back-boards quickly, and to minimize the need for rigid immobilization for a ll but a few patients. Even with _well-padded_ backboards, some National Cave Rescue Commission mock patients have required intramuscular injections for the pain associated with being immobilized. References 1. Levitan RM. Occult cervical spine fracture in a wilderness setting. J Wild Med 1994;4:182-6. 2. Conover K. EMTs should be able to clear the cervical spine in the wilderness [editorial]. J Wild Med 1992;3(4):339-43. 3. Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med 1994;23(1):48-51. 4. Linares HA, Mawson AR, Suarez E. Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics 1987;10:571-3. 5. Mawson AR, Bundo JJ, Neville P. Risk factors for early occuring pressure ulcers following spinal cord injury. Am J Phys Med Rehab 1988;67:123-7. C:\TEXT\WEMS\CSPINE.DOC -- End -- X-cs: From: Self To: Phil Gormley Subject: Re: Wilderness Medical Associates Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Wed, 23 Aug 1995 21:31:49 I'm glad to hear that reports of WMA's death are greatly exaggerated! I heard the ugly rumors in my past message at the Second World Congress on Wilderness Medicine in Aspen, and couldn't find anyone there who said otherwise. I was surprised that nobody from WMA was at the PETSAC meeting, and counted this as additional evidence in favor of the rumors I'd heard. My apologies, and glad to see you still as an active force in wilderness medicine. P.S. maybe I should have told you this was just a ploy to get you on the wilderness-emergency-medicine list. Glad it worked that way, anyway; welcome, and I wish you and WMA long life. P.S. What is going on with Peter these days? -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.10/cispop $Revision: 1.6 $) ID for ; Thu, 24 Aug 1995 04:39:05 -0400 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.6.10/cispo-2.0) ID for kconover@pop.pitt.edu; Thu, 24 Aug 1995 04:39:05 -0400 Received: via switchmail; Thu, 24 Aug 1995 04:39:05 -0400 (EDT) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 24 Aug 1995 04:38:17 -0400 (EDT) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.6.10/cisls-2.4) ID ; Thu, 24 Aug 1995 04:37:57 -0400 Received: from mwunix.mitre.org (mwunix.mitre.org [128.29.154.1]) by list.srv.cis.pitt.edu with ESMTP (8.6.10/cisls-2.4) ID for ; Thu, 24 Aug 1995 04:37:54 -0400 Received: from mwmgate2.mitre.org (mwmgate2.mitre.org [128.29.155.13]) by mwunix.mitre.org (8.6.10/8.6.4) with SMTP id EAA29229; Thu, 24 Aug 1995 04:37:50 -0400 Message-Id: <199508240837.EAA29229@mwunix.mitre.org> Date: Thu, 24 Aug 95 04:37:37 EDT From: G_HARRISON%w035_nw@MWMGATE1.mitre.org To: wilderness-emergency-medicine@list.pitt.edu, kconover+@pitt.edu Subject: Re: survival food Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 Dump the "tinker-toy" (build it yourself) food - get some MREs!! And you _do_not_ have to heat them. And if you don't want to carry the whole thing (in their _nice_tough_ packs), you can extract the miscellaneous stuff and reseal the thing. Have you ever tried eating your rice raw and uncooked?? I thought your English crackers were better.....! 73 & QSL! Gene :) ______________________________ Reply Separator _________________________________ Subject: survival food Author: kconover+@pitt.edu at -smtp- Date: 8/16/95 16:32 Can anyone on this list help? I was repacking my survival kit for wilderness SAR, and I've been carrying a small alcohol stove (weighs just a few ounces), and to prepare on it, some Quinoa, a South American grain that cooks in just 10 minutes, and a few boullion cubes for salt and taste, and a small Richmoor meat bar (basically Cherokee-style meat pemmican). The advantage of these foods is that they will stay edible for years in a pack, yet will provid a hot and filling survival meal for two, with lots of fat and protein; exactly what you need for a forced bivouac. And when you're starving, such a meal is exactly what you crave. Yes, I do carry some high-carbo muchies all the time; but those are recycled regularly. The problem is that Richmoor quit making meat bars. In the past I'd also used Amundsen meat pemmican that I got from Canada somewhere, but haven't seen that for about 20 years, so I can't replace my 10-year-old meat bar. I guess with health-conscious backpackers going for vegetarian freeze-dried meals (I like them myself, I have to admit) meat bars have gone the way of the dodo. Does anyone know any supplier who sells meat pemmican (dried pounded meat and rendered fat, sometimes with some spices or some pea flour)? Or something similar? Does the miltary have anything similar? Or should I just give up and pack a compressed lurp (military Mountain House freeze-dried food that is compressed)? The military rations are low-fat compared to my survival ration, so a less efficient source of energy per unit weight. Also, it will probably spoil easily if the metal foil develops a hole. My previous survival rations basically are imperishable for years, and I'm not sure about the long-term survival of military rations because of the packaging. Thoughts? Sources for pemmican (and I don't mean that fruit and nut stuff) other than making it myself? Keith Conover, M.D. (NSS 12893, WD4PSY) - Information Systems Coordinator, Dept. of EM, Mercy Hospital - Clinical Assistant Professor, Dept. of Emergency Medicine, Univ. of Pittsburgh (EM Residency and Center for Emergency Medicine) - Medical Director, Wilderness EMS Institute (http://www.pitt.edu/DOC/95/30/32686/Wemsi.html) - Eastern Region, Natl. Cave Rescue Comm./Appalachian SAR Conf. -- End -- Received: from post-ofc03.srv.cis.pitt.edu (post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.10/cispop $Revision: 1.6 $) ID for ; Thu, 24 Aug 1995 07:59:10 -0400 From: ChasEMTP@aol.com Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.6.10/cispo-2.0) ID for kconover@pop.pitt.edu; Thu, 24 Aug 1995 07:59:10 -0400 Received: via switchmail for kconover+@pitt.edu; Thu, 24 Aug 1995 07:59:09 -0400 (EDT) Received: from mail04.mail.aol.com (mail04.mail.aol.com [152.163.172.53]) by post-ofc03.srv.cis.pitt.edu with ESMTP (8.6.10/cispo-2.0) ID for ; Thu, 24 Aug 1995 07:56:23 -0400 Received: by mail04.mail.aol.com (8.6.12/8.6.12) id HAA28769 for kconover+@pitt.edu; Thu, 24 Aug 1995 07:55:53 -0400 Date: Thu, 24 Aug 1995 07:55:53 -0400 Message-ID: <950824075550_82122050@mail04.mail.aol.com> To: kconover+@pitt.edu Subject: Re: emed-l PA Wilderness EMS Plan, Part 1 (QI/Standards) Dear Sir, Please keep in touch with me, as of now I have no time to review your plan but I would like to next week (hopefully!!!!) I am a WEMT-P from maine and have worked closely with WMA and other NASAR Wilderness instructors.. Just keep reminding me if you would like me to take a look in the future or whatever... Have a great day. Chuck McMahan -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.10/cispop $Revision: 1.6 $) ID for ; Thu, 24 Aug 1995 14:19:53 -0400 Received: from local (daemon@localhost) by post-ofc02.srv.cis.pitt.edu (8.6.10/cispo-2.0) ID for kconover@pop.pitt.edu; Thu, 24 Aug 1995 14:19:52 -0400 Received: via switchmail for kconover+@pitt.edu; Thu, 24 Aug 1995 14:19:51 -0400 (EDT) Received: from igate1.hac.com (igate1.hac.com [192.48.33.10]) by post-ofc02.srv.cis.pitt.edu with SMTP (8.6.10/cispo-2.0) ID for ; Thu, 24 Aug 1995 14:16:27 -0400 Received: from msmail3.hac.com ([147.17.106.41]) by igate1.hac.com (4.1/SMI-4.1) id AA00480; Thu, 24 Aug 95 11:13:55 PDT Message-Id: Date: 24 Aug 1995 11:24:08 -0800 From: "Greenbaum, Hugh D" Subject: RE: emed-l PA Wilderness EMS Plan, Part 1 (QI/Standards) To: kconover+@pitt.edu Cc: "EMED-L" , "Schuster, Steven K" X-Mailer: Mail*Link SMTP-MS 3.0.2 Keith, just a few commments: [snip] >Wilderness/Backcountry Context: >The specialized prehospital situations of wilderness, back- >country, and other delayed and prolonged transport contexts such >as catastrophic disasters, in which EMS delivery is complicated >by one or more of the following four factors: > remoteness as far as logistics and access; > a significant delay in the delivery of care to the patient; > an environment that is stressful to both patients and rescuers; > or > lack of equipment and supplies. The criteria above are too loose, in that many urban EMS situations will meet these criteria. I (humbly) suggest the following revision: The specialized prehospital situations of wilderness, back- country, and other delayed and prolonged transport contexts such as catastrophic disasters, in which EMS delivery is complicated by one or more of the following four factors: * remoteness resulting in significant delays (greater than one hour) in patient access or delivery of care by EMS crews. (This eliminates nearly all urban rescue situations, with the possible exception of building collapses and confined space rescues). * locations requiring specilized equipment or training in order to access or extricate the patient, and where the time to access such personnel and equipment is significant (greater than one hour). (This should eliminate most of the urban incidents not eliminated under the first criterion.) * environmental conditions that are likely to complicate the patient's condition due to delays in access and/or treatment (e.g., rain, heat). * environmental conditions that are likely to put rescuer safety at abnormally risk (all EMS personnel live with certain risks, but technical resuce in gale-force winds seems to fit this criterion). Other than that.... Thanx for asking!...HDG ------------------------------------------------------------------------------- Hugh D. Greenbaum, BS, EMT-1 voice: (714)732-2581 Systems Engineer FAX: (714)732-4522 Hughes Aircraft Company e-mail: hgreenbaum@msmail3.hac.com P.O. Box 3310 MS 676/E239 compuserve: 71544,2070 Fullerton, CA 92634-3310 "I save lives, and so what if it's fun." ------------------------------------------------------------------------------- -- End -- Received: from post-ofc02.srv.cis.pitt.edu (post-ofc02.srv.cis.pitt.edu [136.142.185.11]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.10/cispop $Revision: 1.6 $) ID for ; Thu, 24 Aug 1995 16:43:44 -0400 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.6.10/cispo-2.0) ID for kconover@pop.pitt.edu; Thu, 24 Aug 1995 16:43:44 -0400 Received: via switchmail; Thu, 24 Aug 1995 16:43:44 -0400 (EDT) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 24 Aug 1995 16:43:24 -0400 (EDT) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.6.10/cisls-2.4) ID ; Thu, 24 Aug 1995 16:41:28 -0400 Received: from mail1.digital.com (mail1.digital.com [204.123.2.50]) by list.srv.cis.pitt.edu with SMTP (8.6.10/cisls-2.4) ID for ; Thu, 24 Aug 1995 16:41:24 -0400 Received: from us2rmc.zko.dec.com by mail1.digital.com; (5.65 EXP 4/12/95 for V3.2/1.0/WV) id AA24197; Thu, 24 Aug 1995 13:27:29 -0700 Received: from xdelta.enet by us2rmc.zko.dec.com (5.65/rmc-22feb94) id AA06234; Thu, 24 Aug 95 14:18:00 -0400 Message-Id: <9508241818.AA06234@us2rmc.zko.dec.com> Received: from xdelta.enet; by us2rmc.enet; Thu, 24 Aug 95 16:25:11 EDT Date: Thu, 24 Aug 95 16:25:11 EDT From: Steve Hoffman To: wilderness-emergency-medicine@list.pitt.edu Cc: mail11:; (us2rmc::"kconover+@pitt.edu"), hoffman@xdelta.ENET.dec.com Apparently-To: kconover+@pitt.edu, wilderness-emergency-medicine@list.pitt.edu Subject: field c-spine clearance Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 In some private e-mail with Doctor Keith Conover (kconover+@pitt.edu) concerning field c-spine clearance, I cited a passage I believe was originally from the Wilderness EMS Institute "unofficial occasional publication #1" and made a few comments on it, and Dr Conover thought that the comments might be of general interest to this list. ". . . Pain perception and clinical evidence of distress are conditio ned by many factors: cultural expectations and upbringing, individual constitution, and the psychosocial surroundings of an injury..." I've encountered a number of adolescent patients involved in and injured in various team- or group-oriented athletic or automotive endeavors in my tenure in non-wilderness EMS, and I have noted that the answers to pain- or injury-oriented questions provided by these adolescent patients to be incorrect at worst, and suspect at best. I've encountered specific cases where adolescent patients neglected to mention various immediately-prior injuries -- injuries from event(s) that the patient apparently viewed as unrelated to the current injury. I've also seen information on relevent medical conditions omitted. A solid series of recent-past medical history questions should pick up most relevent prior medical history, but that these mis-answers and omissions even occur is rather disturbing. And my experience with adolescent patients has taught me to direct specific, pointed, and repeated questions to any adolescent patient, and to direct similar questions to the available parental units or post-adolescent bystanders. I've learned to ask questions about the adolescent's level of participation and level of performance in the current activity, and to ask about any falls or trauma in the current activity and any falls or trauma within the last week -- Mom seems to remember Junior's `ringing his bell' yesterday better than Junior does. Parental or bystander comparisions of the patient's recent and previous performance and comparisions of relative mental status can be of obvious value -- Mom also seems to notice when Junior's mentation is altered. Few of the adolescent patients in my experience have had drugs or alcohol onboard, though this is individual and obviously a concern. (And substance and medication questions are ones I tend ask together, that I ask in private, and that I ask only after explaining to the patient why I want to know and how far the answers will get without a subpeona.) Based on field experience, I much prefer clearing the c-spine on post-adolescent patients. Steve Hoffman Solo WEMT, NR EMT-Intermediate -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: helicopters for SAR Reply-to: kconover+@pitt.edu Date: Thu, 24 Aug 1995 11:34:38 This is a copy of a letter I recently wrote, and I think it's a concern to all in the wilderness rescue and EMS communities -- I think the greatest potential for SAR helicopter disasters comes when aeromedical helicopter services get a call for a backcountry patient. The helicopter services that do SAR on a regular basis know what the problems are, but the great many more who don't do SAR on a regular basis are at risk, sometimes for patients who really should be carried out by ground. I've asked Karl Neumann, editor of the Wilderness Medicine Letter, for permission to post the Wilderness EMS Cases on a WorldWide Web page along with information on subscriptions, but have yet to hear back. [Wilderness EMS Institute letterhead] Reply to: Keith Conover, M.D. 36 Robinhood Road Pittsburgh, PA 15220-3014 412-561-3413 Internet: kconover+@pitt.edu August 17, 1995 Ted Delbridge, M.D. Standards Coordinator, National Association of EMS Physicians 230 McKee Place, Suite 500 Pittsburgh, PA 15213-4904 Dear Dr. Delbridge: SUBJECT: Medical Helicopters for Backcountry Rescue I am writing to suggest that NAEMSP develop a standard for the use of medical helicopters for back- country rescue. My concerns are sparked by a con- junction of three things: 1. Last week I was at the Second World Congress on Wilderness Medicine in Aspen, Colorado. I attended a session given by one of my colleages, Dr. Bill Clem, on the use of helicopters in wilderness search and rescue. He presented several helicopter crashes with multiple deaths when helicopters were used for backcountry rescue, even for as trivial an injury as a fractured ankle without other injuries. (Evacuating a patient with such an injury is not a difficult wilderness rescue task.) Also at this conference we had several discus- sions about the use of cellular phones in the back- country, and how hikers are now calling for rescues in situations where they are often not truly needed. 2. Dr. Ron Roth just sent me short excerpt from "9-1-1" which states: "Cellular telephones were designed for ground level and short distances. What happens when you call from 12,700 feet, say from Lizard Head Peak in the San Juan mountains in southwestern Colorado? It works fine. Hikers used a cellular telephone to call for help when a companion broke an ankle. Presumably after quite a few explanations ("you're where?"), the San Miguel County sheriff flew a helicopter and transported the injured hiker to a hospital." 3. Today at the Center for Emergency Medicine's Grand Rounds, I am presenting a case where an aeromedical helicop- ter was used for a backcountry rescue, but in retrospect was probably not medically indicated. The upshot of all this convinces me that, in general: (a) Most wilderness search and rescue teams know when to call a helicopter for a backcountry rescue, and most helicopter services that routinely do backcountry rescue know when a helicopter rescue is indicated, and when not. (b) Many EMTs and paramedics, and many aeromedical helicopter service providers, do not know when a backcountry helicopter rescue is indicated and when it is not, because they don't appreciate the capabilities of wilderness search and rescue teams, nor the dangers of backcountry helicopter rescue. What this suggests is that aeromedical helicopter serv- ices, as well as search and rescue helicopter services, should adopt standard guidelines for the use of helicopters in backcountry rescue. As the Wilderness Medical Society has already developed such standards (see enclosed Practice Guidelines), I suggest that NAEMSP use these as a starting point to develop its own standards on this subject. Thank you very much. Yours truly, Keith Conover, M.D., Medical Director encl: Wilderness Medicine Letter WEMS Case #3, Wilderness Medical Society Practice Guidelines cc: Dr. Roth [The WMS Practice Guidelines are available from: Wilderness Medical Society P.O. Box 2463 Indianapolis, IN 46206 1-317-631-1745] -- End -- Received: from post-ofc01.srv.cis.pitt.edu (post-ofc01.srv.cis.pitt.edu [136.142.185.10]) by shadow-blue.cis.pitt.edu with ESMTP (8.6.10/cispop $Revision: 1.6 $) ID for ; Thu, 24 Aug 1995 12:07:25 -0400 Received: from local (daemon@localhost) by post-ofc01.srv.cis.pitt.edu (8.6.10/cispo-2.0) ID for kconover@pop.pitt.edu; Thu, 24 Aug 1995 12:07:25 -0400 Received: via switchmail for kconover+@pitt.edu; Thu, 24 Aug 1995 12:07:25 -0400 (EDT) Received: from mail1.digital.com (mail1.digital.com [204.123.2.50]) by post-ofc01.srv.cis.pitt.edu with SMTP (8.6.10/cispo-2.0) ID for ; Thu, 24 Aug 1995 12:06:04 -0400 Received: from us2rmc.zko.dec.com by mail1.digital.com; (5.65 EXP 4/12/95 for V3.2/1.0/WV) id AA24805; Thu, 24 Aug 1995 08:53:24 -0700 Received: from xdelta.enet by us2rmc.zko.dec.com (5.65/rmc-22feb94) id AA23520; Thu, 24 Aug 95 11:22:06 -0400 Message-Id: <9508241522.AA23520@us2rmc.zko.dec.com> Received: from xdelta.enet; by us2rmc.enet; Thu, 24 Aug 95 11:51:03 EDT Date: Thu, 24 Aug 95 11:51:03 EDT From: Steve Hoffman To: mail11:; (us2rmc::"kconover+@pitt.edu") Cc: hoffman@xdelta.ENET.dec.com Apparently-To: kconover+@pitt.edu Subject: field c-spine clearance X-PMFLAGS: 34603136 Hello Doctor, Yes, I would be interested in the reprint -- if nothing else, it will help me establish baseline c-spine should-be immobilization guidelines, and (as you mention) it might help convince my medical control physician of the usefulness of need-not immbolization guidelines. Address below. The need-not guidelines may require approval and/or discussion at the regional and/or state level, but I expect the should-be guidelines are well within the current local c-spine immobilization guidelines. Local medical control reasonably prefers c-spine immobilization to non-immobilization, but I'm not sure folks realize just how painful that half-hour (or more) ride in the back of the truck really is. re: ". . . Pain perception and clinical evidence of distress are conditio ned by many factors: cultural expectations and upbringing, individual constitution, and the psychosocial surroundings of an injury..." I've encountered a number of young males involved in various team- or group-oriented athletic endeavors over the years, and have found various patient answers to pain- or injury-oriented questions to be incorrect at worst, and highly suspect at best. I've encountered cases where the patients neglected to mention various immediately-prior injuries -- injuries from event(s) that the patient apparently viewed as unrelated to the current injury -- when questioned. (A good series of recent-past medical history questions should pick this up, but it is a disturbing trend among these patients, and something I have learned to direct specific questions toward.) None of these patients had drugs or alcohol on-board. Having no basis in experience, I cannot say if this holds for various back-country activities among a similar population, but I suspect it holds for any similar group activities. And -- based on experience and training -- juvenile males are a common population found in the back-country. Thanks, Steve Hoffman WEMT, NR EMT-Intermediate PO Box 1175, Wilton NH, 03086-1175 -- End --