X-cs: From: Self To: chris@bison.RANGE.ORST.EDU (Chris) Subject: Re: survival food Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Sun, 10 Sep 1995 10:23:42 On 19 Aug 95 at 21:01, Majordomo@list.pitt.edu wrote: > > Thoughts? Sources for pemmican (and I don't mean that fruit and nut > > stuff) other than making it myself? > > I know REI used to keep some of that stuff in stock, but the last time > I ever looked for foods at REI was several years ago. They're too overpriced > nowadays. Another idea would be to check with your local Boy Scout council. > Seems back in my scouting days there were always troops making beef jerkey, > pemmican and other things like that. If REI no longer stocks it, they might > be able to tell you where to find some, perhaps. I can check with the REI > stores here in Atlanta, or get the REI number for you if you like. > > > > Keith Conover, M.D. (NSS 12893, WD4PSY) > > -Chris Kuivenhoven > Thanks, Chris-- I've already called REI and they don't carry meat pemmican any more. With the Boy Scouts found recipies for do-it-yourself but no source of store-bought meat pemmican. But thanks. -- End -- X-cs: From: Self To: JSilver374@aol.com Subject: Re: Wilderness EMS in NY and NJ Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Fri, 22 Sep 1995 07:48:16 On 21 Sep 95 at 23:57, JSilver374@aol.com wrote: > Hi all: > > I'd like to be in touch with anyone with information about the state of > wilderness EMS in NY and NJ, including it's legal status and offical > recognition. > > Thanks... > > Jonathan Silver EMT-D, WEMT > Highland Park, NJ > jsilver374@aol.com > One thing I know; we've been discussing wilderness EMS problems at meetings of the Atlantic EMS Council which includes NJ but not NY. The NJ EMS director has been participating in these discussions with thoughtful commentary and is sympathetic to the needs of wilderness rescuers but at present NJ doesn't have any provisions for WEMS. I suggest you contact NJ EMS and volunteer to help them with working on the problem. Doing some research on the scope of backcountry SAR and wilderness-related EMS calls would be the first place to start and you could maybe work with NJ EMS on this. NY I know nothing about, but I do know that one of WEMSI's Wilderness Command Physicians lives in Glens Falls and is very interested. You might contact him and see what he has found out: Robert Desiderio, M.D. Pilot Knob Rd., P.O. Box 99 Kattskill, NY 12844 Not much, but hope it helps. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: (Fwd) Rib Fractures -- What Can a Caver/Climber Do? Cc: EMED List Reply-to: kconover+@pitt.edu Date: Sat, 23 Sep 1995 18:28:13 ------- Forwarded Messages Follow ------- Date sent: Mon, 18 Sep 1995 20:58:04 -0700 (PDT) From: "Arthur J. Fortini" To: kconover+@pitt.edu Subject: Re: Rib Fractures -- What Can a Caver/Climber Do? On Mon, 18 Sep 1995, Keith Conover, M.D. wrote: > Art-- I'd like to quote your rescue report in the following post to be > sent to the wilderness-emergency-medicine list. May I have your > permission to do so? Feel free to quote the report. I'd interested in hearing any responses you get so that I can share the with the attending physician (she's not on line). > Thank you. Thank *YOU* for asking, Art Fortini -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- Rib Fractures -- What Can a Caver/Climber Do? Here is an interesting rescue report, which I'm cross-posting from the Cavers' Digest mailing list. The emergency physician at the scene had to make a hard decision on the spot, and I'm not trying to second-guess her. But this is a question that has not been prospectively answered in a definitive way: when in the backcountry, how much and what kind of activity is safe with a rib fracture (single rib, no evidence of lung injury, pneumo- or hemo-thorax, or liver/spleen/other abdominal injury)? And should we consider taping the ribs for a self-evacuation, because it decreases pain without the sedation of a large dose of narcotics, even though two studies showed an increased (slightly) incidence of complications with a rib belt? This decision can make a _big_ difference in the risk to the patient, others in the party, and rescuers due to risks from continued exposure/exhaustion, rockfall, and flooding. Here are the references I have handy: 1. Quick G. A randomized clinical trial of rib belts for simple fractures. Am J Emerg Med 1990;8(4):277-81. Shows hemothorax more frequent with displaced rib fx if use rib belt. 2. Lazcano A, Dougherty J, Kruger M. Use of rib belts in acute rib fractures. Am J Emerg Med 1989;7(1):97-100. Shows higher incidence of complications, including atelec- tasis and bloody pleural effusion, with rib belts. My thoughts at this point are that (1) these studies show an increased incidence of hemothorax/bloody pleural effusion, which in these studies was not of the big, hilar-bleed life-threatening type nor is a single rib fracture likely to cause such an injury, (2) these studies didn't show an increase in pneumothorax, which if it turns into a tension variety can be cured by any sharp object (but probably _not_ by a litter tender on a vertical evacuation unless the tender is also a well-trained medic or doctor), and (3) as I remember these studies were small and might lack power to show infrequent complications such as pneumothorax. (Sorry, I don't have them with me and I'm currently taking a break from "hill walking" on the Isle of Arran off the west coast of Scotland - aren't laptops and off-line readers such as Pegasus handy?) At any rate, this report suggests to me that the Wilderness EMS Institute needs a well-thought-out answer to this question for our protocols, even if just some principles for decision-making by those at the scene. Our current protocols are ambiguous on the topic: "If a team member or patient appears to have one or two rib fractures without other injury, do not splint or tape the ribs. Provide pain medication if you are permitted to give it." But this assumes that the person is going to be carried out, and that's not always appropriate. I routinely tell my ED patients with rib fractures not to tape their ribs unless they're playing a very active sport such as basketball or football, but wouldn't climbing a rope out of the cave be similar? I will be interested to hear your replies. Please don't quote this whole article as the report is rather long. -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=- Forwarded by: cavers@CS.YALE.EDU Date sent: Tue, 29 Aug 1995 18:31:07 -0400 Subject: CAVERS-DIGEST digest 5201 Forwarded to: kconover+@pitt.edu To: Multiple recipients of list Send reply to: cavers@CS.YALE.EDU CAVERS-DIGEST Digest 5201 Topics covered in this issue include: [snip] 9) Lech accident by "Arthur J. Fortini" [snip] Topic No. 9 Date: Mon, 14 Aug 1995 21:03:45 -0700 (PDT) From: "Arthur J. Fortini" To: "Cavers' Digest" Cc: dale_pate@nps.gov, jason_richards@nps.gov, caca_cave_resources@nps.gov Subject: Lech accident Message-ID: Congratulations to Peter Jones for making it clear that his info was third hand and should not be considered God's given word. Unfortunately, the media in Canada did not exercise such restraint. Apparenlty, a co-worker of the subject's girlfriend heard that Brad (the victim) had taken a 300 foot fall! Not bad considering there were no reporters to be found during the rescue, and there WAS an official press release made soon after the evacuation was completed. Anyway, here's my two cents worth... I wasn't there when the injury occurred, but it is my understanding that Brad was climbing over some breakdonw in the Yellow Brick Road area when his foot slipped off a hold. His torso then fell a short distance (I'm guessing ~6") landing his ribs on the rock. I'm not sure how long it took him, but he made it to Boulder Falls with only the assistance of his 3 team members. He was just starting to climb up Boulder Falls when I arrived. He was using an ascending system similar to a Mitchell, but not quite; he called it a Yosemite system. He was moving up slowly when the others on his team started expressing concern over his injury. This was the first anyone in my team heard about it. When he was ~60' up the rope, he became exhausted and could climb no further. Fearing inversion or harness induced unconsciousness (a la the French experiments), we decided to take action. Brad was considering doing a change over, but we felt it would be safer if someone were up there with him. Rick, an NCRC instructor, was at the top and sent down the second rope. (A spare rope is kept at the top of BF just in case of something like this.) I went up, did a pick-off, and lowered Brad to the ground. We had an emergency room doctor (Shadi Farbin) in the group at the bottom who examined him and gave us a working diagnosis of a rib fracture with no signs of lung involvement. She said it would be safe to haul him up in a seat/chest harness, but exertion (ie, heavy breathing) would have to be avoided due to the risk of puncturing a lung with a broken bone end. >From my position on the rope, I could easily communicate with both the people at the bottom and Rick at the top. With Brad (the patient) now under a doctors care, Randy Brown (a trip leader) was appointed to start getting people to the top of BF. Rick was to marshall the troops at the top and assume control of the operation. When I arrived at the top, Rick and I looked over potential anchor points and concluded that we would need an additional rope and some additional hardware to do the haul in a safe manner. Since the patient was stable, the cave was warm (68 F), and everyone had bivy bear, we had the luxury of time. I exited the cave to alert the park service and return with the necessary equipment. It was agreed by myself and Rick that if he didn't hear from the surface in 3 hours, he should start sending people out in groups of 2 every hour or so for/with updated information. I found Dale Pate (CCNP Cave Specialist) and informed him of the situation. He alerted the appropriate people, and within ~1 hour, an initial response team of ~5 CCNP personnel and the few cavers on the surface (~5) were heading to the cave. I don't know the details of what happened in the cave during my absence, but everyone except the patient, the doctor, and two other caver, were at the top when we returned. Harry (CCNP) and I went to the bottom of BF, Jason (CCNP) remained on top of BF initially. Some of the others began ferrying loads into the cave, and some remained on the surface. Since I was at the bottom of BF, I'm not sure of these details. When harry and I arrived, things on the bottom were pretty low key; the patient had been given some pain killers, and everyone was trying to get some sleep. In spite of the doc giving the green light for a harness evacuation, Harry elected to do a vertically oriented Sked evac to minimize the size of the target exposed to rock fall danger (BTW this is what Boulder Falls got named for). The Sked, bolting gear, and radio headsets were brought into the cave. The patient was hauled on a 3:1 system using cavers to do the pulling, and the litter attendant (me) climbed a separate rope. Upon reaching the top of BF, the patient was unpackaged and allowd to walk to the entrance pit. The patient was then re-packaged and hauled up the entrance drop using the same technique as at BF. Since the current treatment for broken ribs is to simply wait for them to heal (no casting, taping, binding, etc), the patient decided not to go the hospital. Since there was no indication of lung involvement, this appeared to be a sound decision. Besides, once he returned to Canada, health care would be free. Lessons learned: 1. During Emily's rescue, [a previous rescue in the same cave --KC] it was decided that the natural anchors at Boulder Falls were unsuitable for rescue work. (I wasn't there, so that is second hand information.) As a result, 4 bolts were placed for the current rescue. 2. All of the cavers were taking initiative and getting things done. These included glamorless things like relaying messages, carrying in gear, food, water, ropes, etc. No one was frantic, but everyone was showing enthusiasm. 3. Things were running smoothly before the NPS arrived, so they generally let the cavers continue to do what they were doing. As a result, things continued to run smoothly. It was clear to everyone that Jason and Harry were charge when they arrived, but the roles of the individual cavers changed very little. The cavers in leadership positions continued to provide leadership, and the cavers shuttling gear continued to shuttle gear. 4. In every rescue, there is a need for leaders and worker bees. We had enough leaders and no one complained about being one of the worker bees. No ego rose to the surface in search of a more glamorous role. 5. There was good communication among everyone involved, both within the cave and on the surface. I'm assuming this played a major role in how smoothly things went. The wireless headsets were worth their weight in gypsum at Boulder Falls. A few personal observations: 6. This was one of the smoothest rescues I've seen in a long, long time. There was good communication and a very real atmosphere of teamwork and cooperation. This is significant considering that none of the cavers had ever done any rescue training together. 7. The Park Service provided enough man power to get the job done, but did not let things get out of hand. They had additional resources at their fingertips if the need were to arise (CCNP personnel, the BLM cave rescue team, etc), but elected not to use them. IMHO, this was a good call. I'm sure there are plenty of things that occurred that I did not address because I was not aware of them. What is written above is simply one person's perspective. If anyone who was at the rescue would like to add to this, please feel free. Once again, my thanks to everyone for not letting the rumor mill go wild before the facts were in. And of course Brad sends his thanks to all who helped out. Art Fortini -- 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 (8.6.12/cispop-1.6.1.2) ID for ; Mon, 25 Sep 1995 17:03:06 -0400 Received: from local (daemon@localhost) by post-ofc01.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 25 Sep 1995 17:03:04 -0400 Received: via switchmail for kconover+@pitt.edu; Mon, 25 Sep 1995 17:03:03 -0400 (EDT) Received: from astro.ocis.temple.edu (astro.ocis.temple.edu [155.247.165.100]) by post-ofc01.srv.cis.pitt.edu with ESMTP (8.6.12/cispo-2.0.1.1) ID for ; Mon, 25 Sep 1995 16:57:07 -0400 Received: (from pacer@localhost) by astro.ocis.temple.edu (8.6.12/8.6.12) id QAA20004; Mon, 25 Sep 1995 16:52:43 -0400 Date: Mon, 25 Sep 1995 16:50:27 -0400 (EDT) From: Barry Burton To: kconover+@pitt.edu cc: wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: (Fwd) Rib Fractures -- What Can a Caver/Climber Do? In-Reply-To: <199509242043.QAA15718@post-ofc01.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Keith I've received the post from 18 September relative to "simple" rib fratures. I think I tend to agree with you...the climber/caver is not the 'couch potatoe" we tend to treat in the ED. My understanding of the risks of taping fractured ribs is the resultant atalectasis from failure to breath deeply, etc, following the taping. Let me tell you, from personal experience two years ago: 1. Fractured ribs hurt like a b**** 2. Yes Sam, if I hadn't been so anal and forced myself to breath, the pain probably would have killed me...through complications 3. Though I didn't tape the ribs, I surely splinted them actively with my arms....frequently 4. Still probably got a little hypostatic, until I recognized and initiated self-pulmonary hygeine (ie Cough and deep breath, no matter how m much it hurt) 5. I don't think I could have actively climbed at all during this event. (Especially since I didn't know how, then) With this in mind, I'd suggest a-Temporary splinting (taping) with concomitant pulmonary hygeine (cough/ forced deep breath every 20 minutes, for example) for the short duration of the evacuation (1-2 days) with release of the tape during periods of inactivity, is probably safe, and should be investigated. Especially when "no lung trauma" ie hemoptyiss, open wound, breathlessness, rales, etc. b. Such an individual should honestly evaluate their personal physical capacities at that time. IE: Walk out /crawl out OK, climb out, HIGHLY DUBIOUS. Consider a "haul" Thanks for allowing me to express myself, perhaps not too scientifically, but practically, today. Barry > On Mon, 18 Sep 1995, Keith Conover, M.D. wrote: > > > Art-- I'd like to quote your rescue report in the following post to be > > sent to the wilderness-emergency-medicine list. May I have your > > permission to do so? > -- 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 (8.6.12/cispop-1.6.1.2) ID for ; Mon, 25 Sep 1995 19:48:29 -0400 Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 25 Sep 1995 19:48:28 -0400 Received: via switchmail for kconover+@pitt.edu; Mon, 25 Sep 1995 19:48:28 -0400 (EDT) Received: from JEFLIN.TJU.EDU (jeflin.TJU.EDU [147.140.128.114]) by post-ofc03.srv.cis.pitt.edu with SMTP (8.6.12/cispo-2.0.1.1) ID for ; Mon, 25 Sep 1995 19:47:28 -0400 Received: from JEFLIN.TJU.EDU by JEFLIN.TJU.EDU with SMTP; Mon, 25 Sep 1995 19:46:19 -0400 (EDT) Date: Mon, 25 Sep 1995 19:46:17 +0000 From: "Jack T. Grandey" X-Sender: GRANDEYE@ To: Barry Burton cc: kconover+@pitt.edu, wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: emed-l Re: (Fwd) Rib Fractures -- What Can a Caver/Climber Do? In-Reply-To: Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII On Mon, 25 Sep 1995, Barry Burton wrote: > > With this in mind, I'd suggest > > a-Temporary splinting (taping) with concomitant pulmonary hygeine > (cough/ forced deep breath every 20 minutes, for example) > for the short duration of the evacuation (1-2 days) with > release of the tape during periods of inactivity, is > probably safe, and should be investigated. > > Especially when "no lung trauma" ie hemoptyiss, open > wound, breathlessness, rales, etc. > > b. Such an individual should honestly evaluate their personal > physical capacities at that time. > IE: Walk out /crawl out OK, climb out, HIGHLY DUBIOUS. > Consider a "haul" > > Barry > I think this is an excellent basis for a rib fx protocol for delayed evacuation/extended transport. How about re-formatting it in such a fashion? JTG -- End -- X-cs: From: Self To: Barry Burton ,wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: (Fwd) Rib Fractures -- What Can a Caver/Climber Do? Reply-to: kconover+@pitt.edu Date: Tue, 26 Sep 1995 15:26:31 On 25 Sep 95 at 16:50, Barry Burton wrote: > > My understanding of the risks of taping fractured ribs is the resultant > atalectasis from failure to breath deeply, etc, following the taping. That's the theory -- but the studies, as limited as they are, also suggest that other complitations (e.g., hemothorax) are more common with a rib belt, too. > 2. Yes Sam, if I hadn't been so anal and forced myself to breath, > the pain probably would have killed me...through complications Too bad you were so anal; we might have had a case to go against Sam Chewning's famous and oft-repeated "pain never killed anyone" (P.S. for those who don't know, Sam is a spine surgeon in Charlotte, NC and a Wilderness EMS Institute command physician as well as being the national medical advisor for the National Cave Rescue Commission. And we all _did_ laugh when at a cave rescue he asked if I anyone had an aspirin handy for his headache.) > 4. Still probably got a little hypostatic, until I recognized and > initiated self-pulmonary hygeine > (ie Cough and deep breath, no matter how > m much it hurt) > > 5. I don't think I could have actively climbed at all during > this event. (Especially since I didn't know how, then) But what if you'd had better analgesia, too? You might have had an easier time getting out. -- End -- X-cs: From: Self To: "Jack T. Grandey" ,kconover+@pitt.edu, wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: emed-l Re: (Fwd) Rib Fractures -- What Can a Caver/Clim Reply-to: kconover+@pitt.edu Date: Tue, 26 Sep 1995 15:33:26 On 25 Sep 95 at 19:46, Jack T. Grandey wrote: > > > > > With this in mind, I'd suggest > > > > a-Temporary splinting (taping) with concomitant pulmonary hygeine > > (cough/ forced deep breath every 20 minutes, for example) > > for the short duration of the evacuation (1-2 days) with > > release of the tape during periods of inactivity, is > > probably safe, and should be investigated. > > > > Especially when "no lung trauma" ie hemoptyiss, open > > wound, breathlessness, rales, etc. > > > > b. Such an individual should honestly evaluate their personal > > physical capacities at that time. > > IE: Walk out /crawl out OK, climb out, HIGHLY DUBIOUS. > > Consider a "haul" > > > > Barry > > > > I think this is an excellent basis for a rib fx protocol for delayed > evacuation/extended transport. How about re-formatting it in such a fashion? > But, if you've got adequate analgesia, what's the _risk_ of trying to climb/walk out? Yes, you may need some people along to help and a belay (remember the latter part of the Crossroads rescue? No, I guess not, because you'd rotated out of the cave by that time. Earle had Toradol and quite a bit of morphine in him after we reduced the shoulder; we put him in a seat harness with short belay lines fore and aft, and plugged "holes" in the floor with cavers, and he moved a _lot_ faster than if he'd been in a litter.) I think that if someon _can_ move with taping and analgesia, we should let them; and that probably wouldn't include ascending a fixed line, but could certainly include being hauled up just in a harness with hands and legs free to assist. Don't think it requires a litter evacuation. -- 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 (8.6.12/cispop-1.6.1.2) ID for ; Tue, 26 Sep 1995 18:46:05 -0400 Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Tue, 26 Sep 1995 18:46:05 -0400 Received: via switchmail for kconover+@pitt.edu; Tue, 26 Sep 1995 18:46:05 -0400 (EDT) Received: from astro.ocis.temple.edu (astro.ocis.temple.edu [155.247.165.100]) by post-ofc03.srv.cis.pitt.edu with ESMTP (8.6.12/cispo-2.0.1.1) ID for ; Tue, 26 Sep 1995 18:42:59 -0400 Received: (from pacer@localhost) by astro.ocis.temple.edu (8.6.12/8.6.12) id SAA25350; Tue, 26 Sep 1995 18:39:39 -0400 Date: Tue, 26 Sep 1995 18:38:50 -0400 (EDT) From: Barry Burton To: kconover+@pitt.edu cc: wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: (Fwd) Rib Fractures -- What Can a Caver/Climber Do? In-Reply-To: <199509261927.PAA25278@post-ofc02.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Keith.. On Tue, 26 Sep 1995, Keith Conover, M.D. wrote: > On 25 Sep 95 at 16:50, Barry Burton wrote: > > > > > My understanding of the risks of taping fractured ribs is the resultant > > atalectasis from failure to breath deeply, etc, following the taping. > > That's the theory -- but the studies, as limited as they are, also > suggest that other complitations (e.g., hemothorax) are more common > with a rib belt, too. > References! Please? Do you know the postulated mechanism? > > 4. Still probably got a little hypostatic, until I recognized and > > initiated self-pulmonary hygeine > > (ie Cough and deep breath, no matter how > > m much it hurt) > > > > 5. I don't think I could have actively climbed at all during > > this event. (Especially since I didn't know how, then) > > But what if you'd had better analgesia, too? You might have had an > easier time getting out. This is VERY true. I sort of resisted heavy analgesia (had to drive the family home from the site) and thus "tolerated" the disconfort with self splint (forearm at times of paroxysmanl pain) and APAP Analgesia is the MOST important part, from the patients stand point. And it DEFINATELY would make it easier to comply with the pulmonary regimen (cough, etc) Oft thought (and on trauma, DID PROVIDE) that a IC nerve block would be the best analgesia for a few isolated rib fx, without pulmonary findings. Risk of ptx, in best hands, is real. In the field? Don't think I could routinely justify the risk for the benefit. (On trauma, we loaded the pleura with Marcaine at the time of Chest Tube placement, sort of like a pleural wash. Don't think that would be ideal out back) In case I've been too obtuse, I AGREE with pain control, systemically, for the caver/climber with isolated rib fractures. I don't see OVERWHELMING risk from short term (until 'out' of the risk zone, only) splinting, ie taping, if it significantly facilitates the evacuation phase. BUT, the decision to use this modality goes hand in hand with meticulous pulmonary hygeine. Thanks for forwarding the references on Hemothorax, Keith. 73 Barry N3VOW -- 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 (8.6.12/cispop-1.6.1.2) ID for ; Tue, 26 Sep 1995 18:51:33 -0400 Received: from local (daemon@localhost) by post-ofc02.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Tue, 26 Sep 1995 18:51:32 -0400 Received: via switchmail for kconover+@pitt.edu; Tue, 26 Sep 1995 18:51:31 -0400 (EDT) Received: from astro.ocis.temple.edu (astro.ocis.temple.edu [155.247.165.100]) by post-ofc02.srv.cis.pitt.edu with ESMTP (8.6.12/cispo-2.0.1.1) ID for ; Tue, 26 Sep 1995 18:47:11 -0400 Received: (from pacer@localhost) by astro.ocis.temple.edu (8.6.12/8.6.12) id SAA27831; Tue, 26 Sep 1995 18:44:16 -0400 Date: Tue, 26 Sep 1995 18:43:10 -0400 (EDT) From: Barry Burton To: kconover+@pitt.edu cc: "Jack T. Grandey" , kconover+@pitt.edu, wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: emed-l Re: (Fwd) Rib Fractures -- What Can a Caver/Clim In-Reply-To: <199509261937.PAA16288@post-ofc01.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Keith, and the "group" On Tue, 26 Sep 1995, Keith Conover, M.D. wrote: > On 25 Sep 95 at 19:46, Jack T. Grandey wrote: > > > > > > > > > With this in mind, I'd suggest > > > > > > a-Temporary splinting (taping) with concomitant pulmonary hygeine > > > (cough/ forced deep breath every 20 minutes, for example) > > > for the short duration of the evacuation (1-2 days) with > > > release of the tape during periods of inactivity, is > > > probably safe, and should be investigated. > > > > > > Especially when "no lung trauma" ie hemoptyiss, open > > > wound, breathlessness, rales, etc. > > > > > > b. Such an individual should honestly evaluate their personal > > > physical capacities at that time. > > > IE: Walk out /crawl out OK, climb out, HIGHLY DUBIOUS. > > > Consider a "haul" > > > > > > Barry > > > > > > > I think this is an excellent basis for a rib fx protocol for delayed > > evacuation/extended transport. How about re-formatting it in such a fashion? > > > > But, if you've got adequate analgesia, what's the _risk_ of trying > to climb/walk out? Yes, you may need some people along to help and > a belay (remember the latter part of the Crossroads rescue? No, I > guess not, because you'd rotated out of the cave by that time. > Earle had Toradol and quite a bit of morphine in him after we > reduced the shoulder; we put him in a seat harness with short belay > lines fore and aft, and plugged "holes" in the floor with cavers, > and he moved a _lot_ faster than if he'd been in a litter.) > > I think that if someon _can_ move with taping and analgesia, we > should let them; and that probably wouldn't include ascending a fixed > line, but could certainly include being hauled up just in a harness > with hands and legs free to assist. Don't think it requires a litter > evacuation. > That was my point. Hands and legs for assist, (such a precious notion..letting the conscious defend for themselves) but provide some mechanical power assist ("haul") on the lines. Didn't think the litter was necessary, either, if that is the isolated injury. Sorry if my language skills are a bit sloppy. I'm still learning to crawl with you guys. Barry > -- End -- X-cs: From: Self To: Barry Burton ,wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: (Fwd) Rib Fractures -- What Can a Caver/Climber Do? Reply-to: kconover+@pitt.edu Date: Wed, 27 Sep 1995 11:11:22 On 26 Sep 95 at 18:38, Barry Burton wrote: [snip] > > > My understanding of the risks of taping fractured ribs is the resultant > > > atalectasis from failure to breath deeply, etc, following the taping. > > > > That's the theory -- but the studies, as limited as they are, also > > suggest that other complitations (e.g., hemothorax) are more common > > with a rib belt, too. > > > References! Please? Do you know the postulated mechanism? I put these in the original post, but maybe you missed it when Temple decided that the new undergraduates needed your email address :-) 1. Quick G. A randomized clinical trial of rib belts for simple fractures. Am J Emerg Med 1990;8(4):277-81. Shows hemothorax more frequent with displaced rib fx if use rib belt. 2. Lazcano A, Dougherty J, Kruger M. Use of rib belts in acute rib fractures. Am J Emerg Med 1989;7(1):97-100. Shows higher incidence of complications, including atelec- tasis and bloody pleural effusion, with rib belts. [snip] > > But what if you'd had better analgesia, too? You might have had an > > easier time getting out. > > This is VERY true. I sort of resisted heavy analgesia (had to drive the > family home from the site) and thus "tolerated" the disconfort with self > splint (forearm at times of paroxysmanl pain) and APAP > > Analgesia is the MOST important part, from the patients stand point. And > it DEFINATELY would make it easier to comply with the pulmonary regimen > (cough, etc) Aha. So if you weren't so worried about being able to drive afterwards, you could have been drugged and gotten out relatively safely under your own power? Exactly my point. It's a lot easier to find a ride home for someone than involve 100+ people in a difficult rescue operation. > > Oft thought (and on trauma, DID PROVIDE) that a IC nerve block would be > the best analgesia for a few isolated rib fx, without pulmonary findings. Absolutely. That's why I carry bupivicaine in my "physician extras kit" to supplement my standard WEMSI personal medical kit. (Yes, I finally have an official WEMSI kit just like all our medics, neatly organized, without lots of extra junk in it. It was really hard leaving out all the extra goodies that I want to take and so I put them, things like Fentanyl and Versed and Ketamine and a Gerber camp saw for amputations and a people-sewing kit, in a separate bag.) But, IC nerve blocks are a physician-level, not wilderness-medic level skill. True, the most likely complication is a nontension PTX and the medics are probably better than the docs at recognizing and caring for them, but -- it takes a bit of practice and a fair bit of anatomical knowledge above the EMT-P level to do this. Maybe it's a skill for the special advanced Wilderness EMT module? > > Risk of ptx, in best hands, is real. In the field? Don't think I could > routinely justify the risk for the benefit. (On trauma, we loaded the > pleura with Marcaine at the time of Chest Tube placement, sort of like a > pleural wash. Don't think that would be ideal out back) Yes, but I can see situations where IC block might literally be lifesaving, even if you do have to stick a needle in the chest and have the person keep on going. I've needled the chest in minimally symptomatic patients in the ED who were getting worse after a spontaneous PTX and the surgical resident, to whom I'd promised the procedure of putting in the chest tube, wasn't able to get down to the ED yet. The patient suffered minimal if any pain (used a little lidocaine) and felt a lot better waiting for his chest tube. > > In case I've been too obtuse, I AGREE with pain control, systemically, > for the caver/climber with isolated rib fractures. > > I don't see OVERWHELMING risk from short term (until 'out' of the risk zone, > only) splinting, ie taping, if it significantly facilitates the > evacuation phase. > > BUT, the decision to use this modality goes hand in hand with meticulous > pulmonary hygeine. > Is this a sort of consensus? -- 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 (8.6.12/cispop-1.6.1.2) ID for ; Wed, 27 Sep 1995 17:08:12 -0400 Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Wed, 27 Sep 1995 17:08:12 -0400 Received: via switchmail for kconover+@pitt.edu; Wed, 27 Sep 1995 17:08:12 -0400 (EDT) Received: from astro.ocis.temple.edu (astro.ocis.temple.edu [155.247.165.100]) by post-ofc03.srv.cis.pitt.edu with ESMTP (8.6.12/cispo-2.0.1.1) ID for ; Wed, 27 Sep 1995 17:05:14 -0400 Received: (from pacer@localhost) by astro.ocis.temple.edu (8.6.12/8.6.12) id RAA08543; Wed, 27 Sep 1995 17:02:35 -0400 Date: Wed, 27 Sep 1995 17:01:51 -0400 (EDT) From: Barry Burton To: kconover+@pitt.edu cc: wilderness-emergency-medicine@list.pitt.edu, EMED List Subject: Re: (Fwd) Rib Fractures -- What Can a Caver/Climber Do? In-Reply-To: <199509271518.LAA11279@post-ofc01.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Keith... On Wed, 27 Sep 1995, Keith Conover, M.D. wrote: > On 26 Sep 95 at 18:38, Barry Burton wrote: > [snip] > > [snip] > > > But what if you'd had better analgesia, too? You might have had an > > > easier time getting out. > > > > This is VERY true. I sort of resisted heavy analgesia (had to drive the > > family home from the site) and thus "tolerated" the disconfort with self > > splint (forearm at times of paroxysmanl pain) and APAP > > > > Analgesia is the MOST important part, from the patients stand point. And > > it DEFINATELY would make it easier to comply with the pulmonary regimen > > (cough, etc) > > Aha. So if you weren't so worried about being able to drive > afterwards, you could have been drugged and gotten out relatively > safely under your own power? Exactly my point. It's a lot easier to > find a ride home for someone than involve 100+ people in a difficult > rescue operation. > Yup. I agree...triage rules would suggest not putting the centurians (100 people) at risk if you can facilitate, safely, self assisted evac > > > > Oft thought (and on trauma, DID PROVIDE) that a IC nerve block would be > > the best analgesia for a few isolated rib fx, without pulmonary findings. > > Absolutely. That's why I carry bupivicaine in my "physician extras > kit" to supplement my standard WEMSI personal medical kit. (Yes, I > finally have an official WEMSI kit just like all our medics, neatly > organized, without lots of extra junk in it. It was really hard > leaving out all the extra goodies that I want to take and so I put > them, things like Fentanyl and Versed and Ketamine and a Gerber camp > saw for amputations and a people-sewing kit, in a separate bag.) > I'm jeolous. See, Jack. All you guys have got more toys tahn I. I think I deserve to lose the "geek gadget" moniker NOW! > But, IC nerve blocks are a physician-level, not wilderness-medic > level skill. Yes > True, the most likely complication is a nontension PTX > and the medics are probably better than the docs at recognizing and > caring for them, but -- it takes a bit of practice and a fair bit of > anatomical knowledge above the EMT-P level to do this. Maybe it's a > skill for the special advanced Wilderness EMT module? > Special consideration, special candidate. > > > > Risk of ptx, in best hands, is real. In the field? Don't think I could > > routinely justify the risk for the benefit. (On trauma, we loaded the > > pleura with Marcaine at the time of Chest Tube placement, sort of like a > > pleural wash. Don't think that would be ideal out back) > > Yes, but I can see situations where IC block might literally be > lifesaving, even if you do have to stick a needle in the chest and > have the person keep on going. I've needled the chest in minimally > symptomatic patients in the ED who were getting worse after a > spontaneous PTX and the surgical resident, to whom I'd promised the > procedure of putting in the chest tube, wasn't able to get down to > the ED yet. The patient suffered minimal if any pain (used a little > lidocaine) and felt a lot better waiting for his chest tube. > Done it myself, without lido. He tahnked me for letting him breath. > > > > In case I've been too obtuse, I AGREE with pain control, systemically, > > for the caver/climber with isolated rib fractures. > > > > I don't see OVERWHELMING risk from short term (until 'out' of the risk zone, > > only) splinting, ie taping, if it significantly facilitates the > > evacuation phase. > > > > BUT, the decision to use this modality goes hand in hand with meticulous > > pulmonary hygeine. > > > > Is this a sort of consensus? > I think so, of two. What do the other WCP's and vested parties have to say? Speak (write) up! (Dr) Barry -- End -- X-cs: From: Self To: JSachter@aol.com Subject: Re: Wilderness EM fellowships Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Sat, 30 Sep 1995 11:24:48 On 30 Sep 95 at 3:49, JSachter@aol.com wrote: > Does anyone know of any Wilderness EM fellowships open to graduates of EM > Residency training programs ? One of my residents is interested in pursuing > this upon graduation this spring. > > Many thanks... > > Joseph J Sachter, MD, FACEP (jsachter@aol.com) > Program Director, Emergency Medicine Residency > The Brooklyn Hospital Center There are none. Can't think of anyone who'd be willing to fund a fellowship in a noncertified nonsubspecialty that is for an activity that is essentially completely unfunded. Nobody pays docs to do wilderness medicine, except a little in-kind support like I get here in Pittsburgh. We have a one-month rotation for R-2/3/4 EM residents in wilderness EMS (not EMS and not "wilderness medicine" in general). Had planned to offer it this November but as I'm taking the written boards then have cancelled it; next one will be in March. There is a wilderness medicine elective for FP residents in Boise, ID and at the University of Maine but that's about it. However, encourage your resident to join the Wilderness Medical Society and go to their annual conferences; that's where the real wilderness medicine action is. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu Subject: medical kit packaging Reply-to: kconover+@pitt.edu Date: Sun, 1 Oct 1995 11:08:25 Notes on Packaging of Personal Wilderness Medical Kits Version 0.1, October 1, 1995 This is a preliminary draft, for discussion, to be added to a future version of the WEMSI Personal Wilderness Medical Kit docu- ment. comments to: wilderness-emergency-medicine@list.pitt.edu or, if you don't have electronic mail, to: Keith Conover, M.D., WEMSI Medical Director 36 Robinhood Road Pittsburgh, PA 15220-3014 1. Snap-Off Ampules Many drugs come in these ampules which are opened by snap- ping off the top. They have the advantage of being very compact and light, but the disadvantage that they are fragile and diffi- cult to pack. I've tried many different means of packaging. Most of these have been on small packages I've found in my "junk" box and therefore can't generally be reproduced by others. We're looking for something that is: - cheap - easy to make - provides moderate protection against breakage (note that the outer packaging of one's medical kit should also provide some protection, so this inner packaging need not be "bombproof" or "caveproof") - light - not bulky Most recently, I have made a package using the cardboard "rack" in which ampules are shipped in the box (in this particular case, for 100 microgram Fentanyl ampules). I cut this down to the right size for four ampules (the number I needed, though this will work for any number). I then cut a piece of stiff 3/8" closed-cell foam the same size as the "rack" and used duct tape to tape it on the front of the rack. I also duct-taped the bot- tom, but left the top open. I could then slide the ampules in from the top. They seem to stay in just fine without taping the top. I suppose one could tape some foam or an additional piece of stiff material to the back to provide additional protection, especially from flexing that might break the neck of the ampule. But that would add to the bulk and weight. 2. Inner packaging Prescription medications are in separate blister packaging from the hospital pharmacy, with an expiration date marked on each tablet's packaging. Nonprescription medications are also in blister packaging, except for ibuprofen, which I can't find that way; it's in a small bottle. Most but not all of the blister packs have expira- tion dates on them. I've used a laundry marker to put expiration dates on each individual pill's packaging when not put there by the manufacturer. For generic Pepto-Bismol I also had to put the name on the cellophane inner packaging, too. Acetaminophen (Tylenol) I got in small paper envelopes from the hospital, and each has an expiration date on it. 3. Outer Packaging I've found that for general use, bags from Atwater-Carey (1- 800-359-1646) work nicely for organizing the WEMSI Personal Wilderness Medical Kit. The Minimum and Advanced modules fit nicely in the Trekker II kit bag ($19.95 US). The Search Module fits nicely in the Expedition kit bag ($15.25 US). I've put my extra physician goodies in a Family kit bag ($12.50 US), though it's a bit tight. These bags have the great advantage of keeping things better organized, important if you're using the bag all the time. (I seem to attract medical problems when in the back- country, so this is important to me.) For above-ground rescue, just putting these bags in a plastic bag deep in one's pack should be adequate protection. For caving, I'd dump the contents out into a Pelican case, ammunition box, or Tupperware box that can be sealed with duct tape. Please add your comments and reply to wilderness-emergency- medicine@list.pitt.edu. Thank you. C:\TEXT\WEMS\PACKAGE.DOC -- End -- X-cs: From: Self To: CPT_Kevin_Coonan@ftdetrck-ccmail.army.mil Subject: Re: medical kit packaging Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Sun, 1 Oct 1995 17:37:46 On 1 Oct 95 at 14:23, CPT_Kevin_Coonan@ftdetrck-ccm wrote: > REI carries a variety of zip-out folding cases (you can also get them > pre-packed with a variety of kitchen gadgets) that I have used for two > different medical kits. The smaller one fits nicely in my book > bag/brief case/overnight bag/carry on luggage for not-so-wild trips as > well. They offer little in the way of crush or water protection, but > have performed well under a variety of field conditions (mostly > backpacking and climbing). > > I also have a "micro" kit that fits into my fanny pack w/ my lunch, > water and rain gear for longer climbs, containing epi (1 amp 1:1000 > and a Tb syringe), decadron (2x 4 mg), Tylenol (6), a single ASA, > ibuprofen (four 600mg), superglue, alcohol swabs, tylox (2), > cephadrine (2x500 mg), Steristrips, bandaids, a foil pack of triple > antibiotic goop, a Tegaderm and some 4x4s. It all fits into a heavy > duty zip-lock sandwich bag, stuffed into a very small stuff sack. > > Kevin Coonan, M.D. > There are lots of different bags that work well for medical kits; REI and Adventure Medical are two that I've played with before. But the Atwater-Carey bags seem a little nicer. And I think MRA teams and related wilderness SAR teams can probably get a good deal on them by talking to Phil Carey directly. -- End -- X-cs: From: Self To: Barry Burton ,@ASRC.PML Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: @AMRG.PML,wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Thu, 12 Oct 1995 09:52:51 On 25 Sep 95 at 16:16, Barry Burton wrote: > Keith > > > I'll buy into the low level of need for the actual rescue mission, in > that the people you're looking for are generally in a more fit condition > than the general populace. Well, actually, lots of the people the ASRC looks for are older and have coronary disease. And lots of the loacl volunteer searchers are fat hypertensive volunteer firemen who smoke. > > Agree that the base camp should be set up as medical resource for the > camp, and would propbably be recognized as such by the "unknowing" public. > > My real issue would be at training programs, where 'unknown' individuals > with less than perfect fitnes may attempt to participate while under our > supervision. In fact, didn't the last Camp Soles episode deal with a > student with chest pain? Yes indeedee. We did have a case of cardiac-sounding chest pain on the mountain, and gave him aspirin in the field, and were considering giving heparin. P.S. since we were considering heparin in the field, we also considered that the team medical kit might need to have the following in addition to heparin (we would have give 15,000 units SQ as per the European protocol, and hoped we were out and at the ED, at least, in 6 hours): a tiny monitor that can do a 12-lead, and a way to transmit it over a standard handheld stool guaiac cards and developer (to check for previously-undetected GI bleeding in a patient before starting heparin) Eminase, so we could start thrombolysis in the field > > >From a 'system' perspective, AED's may make sense where risk is high and > resources low. I'm not convinced this would be the BEST utilization at > wilderness base camp. In view of the plethora of medical types (those > damn wilderness docs) and the ALS paramedics from WEMSI that I here tell > show up at all these evolutions, it would make more sense, IMHO, to find > some used/ refurbished LP5's for base ops. (like mine). Just make sure to > get them from the old squads BEFORE the manufacturer rep makes a trade in > deal (FDA regs get in the way). > > This positin is potentially strenghtened by the concept of using the > wilderness teams in the event of civilian catastrophe, interfacing with > local and national Disaster Medical Response systems (PEMA, FEMA, NDMS. > etc) and thus, also opens an avenue for funding. > [snip] > Food for thought, IMHO > > Barry > I'm posting this to the wilderness-emergency-medicine list as well as sending to members of the ASRC. I'd be interested in getting some "outside" perspectives on our discussion about whether wilderness SAR teams need automatic external defibrillators, at least at Base Camp. Thanks. -- End -- X-cs: From: Self To: @AMRG.PML,ralson@isnet.is.wfu.edu (Roy Alson, MD) Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: @ASRC.PML,wemsi-staff@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Thu, 12 Oct 1995 12:21:07 On 12 Oct 95 at 11:55, Roy Alson, MD wrote: [snip] > I would agree that at the base camp, full ALS capability should be > maintained. While the team medical personnel have to be concerned about the > health and well-being of the victim, I still believe their first > responsibility is to the search personnel. > > If you look at a major (or minor) search operation and the numbers of people > involved, with multiple backgrounds and ages, the possibility of serious > illness, including cardiac problems, becomes very real. > > I think being prepared to handle these types of problems is the least we can > do for those involved in the operation > > Roy > Roy L. Alson, PhD, MD, FACEP > "Res-Q-Roy" > Department of Emergency Medicine > Bowman Gray School of Medicine > Winston-Salem, NC 27157 > raslon@isnet.is.wfu.edu > And I guess that the principle that we take care of our search personnel and rescuer first means we should be prepared to deal with a problem that is rare, but lethal, and can sometimes be corrected by a simple though expensive tool (the automated external difibrillator). I'll post your comments to the ASRC maillist and the wilderness-emergency-medicine lists, too, Roy. Thanks. --Keith -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu,@AMRG.PML Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: @ASRC.PML Reply-to: kconover+@pitt.edu Date: Sat, 14 Oct 1995 20:41:28 On 13 Oct 95 at 8:35, Jack T. Grandey wrote: > [snip] > > > > My real issue would be at training programs, where 'unknown' individuals > > > with less than perfect fitnes may attempt to participate while under our > > > supervision. In fact, didn't the last Camp Soles episode deal with a > > > student with chest pain? > > > > Yes indeedee. We did have a case of cardiac-sounding chest pain on > > the mountain, and gave him aspirin in the field, and were considering > > giving heparin. > > > > P.S. since we were considering heparin in the field, we also > > considered that the team medical kit might need to have the following > > in addition to heparin (we would have give 15,000 units SQ as per the > > European protocol, and hoped we were out and at the ED, at least, in > > 6 hours): > > > > a tiny monitor that can do a 12-lead, and a way to transmit it over a > > standard handheld > > > > stool guaiac cards and developer (to check for previously-undetected > > GI bleeding in a patient before starting heparin) > > > > Eminase, so we could start thrombolysis in the field > > > > > [snip, snip, snip] > > Though this event gets referred to frequently, I'm not sure that it > represents a good case in support of "more stuff" since the general > collective opinion of all /p evaluation in the ED is that the patient was > non-cardiac. Having been on scene, I'll support that care @ the time was > correct since MI could neither be confirmed nor RO. That said, I'm not > convinced that more agressive tx would have been appropriate had the toys > been present. Lysing & heparinization (or heparinization & lysing, but I > digress) are not /s risks, particularly when a an evacuation (possibly > extended)over rough terrain is required. Even all that assumes that 12l > MDs worth $13k would survive or that we want to manage a litter patient > /c central line, full monitoring,....etc. > > I'm mindful also of a recent discussion on another list about an acute > HA, LP- patient who was DC'd and died 48 hrs later of a SAH. To quote > the doc from Oz, "some people are just damn unlucky". All HAs should not be > MRI'd (Any extra room in the Range Rover, Keith?) > > /c For Reals, we need to keep yield/weight, factored by risk of procedure > in mind. /c classes, we should consider better medical screening for risks. > > Remember... > > ALL patients eventually die... > all bleeding eventually stops... > if you drop the baby...pick it up. > > AND > > In the wilderness...You carry what you have. > > JTG Cogent observations, Jack. We (SAR teams planning to improve their medical capabilities, I mean) have limitations in terms of weight, expense, and training time. We need to pick and choose what we carry based on: how often will we need it? how much of a difference will it make? will we have enough people with enough training to use it? Splinting limbs makes a fair difference. Giving pain medications makes a fair difference (except for orthopedic surgeons who believe that "pain never killed anyone"). For cardiac chest pain, giving aspirin makes a BIG difference, saving as many lives as thrombolysis in the (big, good) studies. None of these cost much, in terms of weight or expense. And in terms of how often something occurs: we aren't likely to see cardiac chest pain in the backcountry, but if you _do_ see it and don't have an aspirin handy and the person dies, how would you feel? That's probably as important as the other considerations: how bad would you feel if you didn't have it with you and the patient needed it? I wouldn't feel bad if I didn't have an MRI with me in the wilderness. But if I were at a Base Camp and someone coded and I didn't have a defibrillator and the patient died I'd feel pretty bad. Since defibrillators are very expensive, I wouldn't feel as bad as if the patient had chest pain and I didn't have an aspirin, which is cheap. But I'd still feel bad. So we're not likely to see such an event very often? Remember those overweight tobacco-smoking hypertensive firefighters. A save once every 10 years is enough to justify a defibrillator, I think. -- End -- X-cs: From: Self To: wilderness-emergency-medicine@list.pitt.edu,@ASRC.PML Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: @AMRG.PML Reply-to: kconover+@pitt.edu Date: Sun, 15 Oct 1995 10:51:29 On 13 Oct 95 at 9:26, Jack T. Grandey wrote: [snip] > > > I would agree that at the base camp, full ALS capability should be > > > maintained. While the team medical personnel have to be concerned about the > > > health and well-being of the victim, I still believe their first > > > responsibility is to the search personnel. > > > > > > If you look at a major (or minor) search operation and the numbers of people > > > involved, with multiple backgrounds and ages, the possibility of serious > > > illness, including cardiac problems, becomes very real. > > > > > > I think being prepared to handle these types of problems is the least we can > > > do for those involved in the operation > > > > > > Roy > > Agree on all counts. > > > > And I guess that the principle that we take care of our search > > personnel and rescuer first means we should be prepared to deal with > > a problem that is rare, but lethal, and can sometimes be corrected by > > a simple though expensive tool (the automated external > > difibrillator). > > Disagree here. The AED still does not pass the yield/weight+ cost test. > $200 gets a team a handheld GPS that is useful on every mission and > survives just about anything but being run over by a 4x /c deep knobbies > (it gets caught in the tread). $4,500+ (+training, MD dir., etc.) gets a > device that can be used once in a blue and chartreuse striped moon, does > NOT like to be wet & weighs 4-5 KGs. GPS units actually aren't that useful (look at the thread about GPS units currently going on in the Computers in SAR mailing list, especially at Chuck Kollar's and Gene Harrison's tests). And best, they aid in SAR, maybe helping find some lost people a little faster. But an AED could save searchers (even if they could be local firefighters instead of SAR team members). So trying to compare $ amounts for something that can directly save a life with something that helps you navigate in the woods isn't a good comparison. > > Teams should be excellent @ BLS skills, which include recognition of the > infrequent OHSHIT case. They should have reliable comm to a base that is > equipped to handle said cases. Look at the table on page XII-22 of the WEMSI WEMT Curriculum (Wilderness Medical Problems) Lesson Plan. (Call Pam Westfall at the Center for Emergency Medicine at 412-578-3203 if you'd like to order a copy of this, or email her at ) Cardiac Arrest Survival Times: Time to ALS <8 min 8-16 min >16 min Time <4 min 43% 19% 10% to 4-8 min 27% 19% 6% BLS >8 min N/A 7% 0% If you extrapolate this, then if the time to ALS is more than about half an hour, then there's no point in even starting CPR, unless the patient has one of those few causes of cardiac arrest that can be cured by basic CPR (e.g., lightning strike, some cases of near-drowning), or the patient is severely hypothermic. Remember that basic CPR provides 30% of normal cerebral perfusion, but that filling of the coronaries occurs during diastole, and even with perfect basic CPR the diastolic pressure id 0. Which means that with CPR the entire heart is infarcting the whole time you're doing CPR. Which means that if an AED or other ALS is more than half an hour away, forget it. But I think you misunderstood; I never argued for AEDs in the field, just having one at every Base Camp. > > Fall not prey to the "technological imperative" (thanks to Steve Davidson, > MD). > > Restated: "We can, therefore we should." > > Jack T. Grandey, NREMT-P > -- End -- X-cs: From: Self To: WEDOSAR@aol.com Subject: Re: (Fwd) Re: Defibrillators for SAR teams Reply-to: kconover+@pitt.edu Date: Mon, 16 Oct 1995 12:41:26 On 14 Oct 95 at 23:41, WEDOSAR@aol.com wrote: > Keith, > > We can have all the ALS gear we want at base, the local ambulance will > provide it (if not, fire the IC and get somwone who can get resources). In > the field, we cannot afford it ($$$ as patch will confirm), and we really > have very little need for it. > >Mark Jones Ah, but in rural settings, can we depend on having local _ALS_ at base? They may have better things to do, or be out in the field. And it may be a BLS service in the area. --Keith Conover -- End -- X-cs: From: Self To: @AMRG.PML Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: wilderness-emergency-medicine@list.pitt.edu,@ASRC.PML Reply-to: kconover+@pitt.edu Date: Mon, 16 Oct 1995 12:43:44 On 14 Oct 95 at 23:41, WEDOSAR@aol.com wrote: > Keith, > > We can have all the ALS gear we want at base, the local ambulance will > provide it (if not, fire the IC and get somwone who can get resources). In > the field, we cannot afford it ($$$ as patch will confirm), and we really > have very little need for it. > >Mark Jones Ah, but in rural settings, can we depend on having local _ALS_ at base? They may have better things to do, or be out in the field. And it may be a BLS service in the area. Your comment about $$$ for AEDs is quite appropros for almost every SAR team I know (except maybe for BRMRG and the Park Service teams), spending your team's entire budget for five years on an AED may not make sense. -- 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 (8.6.12/cispop-1.6.1.3) ID for ; Mon, 16 Oct 1995 16:43:34 -0400 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 16 Oct 1995 16:43:33 -0400 Received: via switchmail; Mon, 16 Oct 1995 16:43:33 -0400 (EDT) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 16 Oct 1995 16:43:21 -0400 (EDT) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.6.12/cisls-2.4) ID ; Mon, 16 Oct 1995 16:43:04 -0400 Received: from JEFLIN.TJU.EDU (jeflin.TJU.EDU [147.140.128.114]) by list.srv.cis.pitt.edu with SMTP (8.6.12/cisls-2.4) ID for ; Mon, 16 Oct 1995 16:43:01 -0400 Received: from JEFLIN.TJU.EDU by JEFLIN.TJU.EDU with SMTP; Mon, 16 Oct 1995 13:16:40 -0400 (EDT) Date: Mon, 16 Oct 1995 13:16:34 +0000 From: "Jack T. Grandey" X-Sender: GRANDEYE@ To: kconover+@pitt.edu cc: wilderness-emergency-medicine@list.pitt.edu, ASRC.groups.and.members@pitt.edu, AMRG.Members.and.Others@pitt.edu Subject: Re: (Fwd) Re: Defibrillators for SAR teams In-Reply-To: <199510161511.LAA01455@post-ofc02.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 On Mon, 16 Oct 1995, Keith Conover, M.D. wrote: > On 13 Oct 95 at 9:26, Jack T. Grandey wrote: > [snip] > > > > > Disagree here. The AED still does not pass the yield/weight+ cost test. > > $200 gets a team a handheld GPS that is useful on every mission and > > survives just about anything but being run over by a 4x /c deep knobbies > > (it gets caught in the tread). $4,500+ (+training, MD dir., etc.) gets a > > device that can be used once in a blue and chartreuse striped moon, does > > NOT like to be wet & weighs 4-5 KGs. > > GPS units actually aren't that useful (look at the thread about GPS > units currently going on in the Computers in SAR mailing list, > especially at Chuck Kollar's and Gene Harrison's tests). And best, > they aid in SAR, maybe helping find some lost people a little > faster. > > But an AED could save searchers (even if they could be local > firefighters instead of SAR team members). So trying to compare $ > amounts for something that can directly save a life with something > that helps you navigate in the woods isn't a good comparison. > The point is that $200 for useful navigational device is difficult to come up with. Where do you project that teams will get the $4,500+? Also-who will carry it? Who will keep it dry & check its batteries??? I'm a very big proponent of the device, I just don't see it in the woods. > > > > Teams should be excellent @ BLS skills, which include recognition of the > > infrequent OHSHIT case. They should have reliable comm to a base that is > > equipped to handle said cases. > > Look at the table on page XII-22 of the WEMSI WEMT Curriculum > (Wilderness Medical Problems) Lesson Plan. (Call Pam Westfall at the > Center for Emergency Medicine at 412-578-3203 if you'd like to order > a copy of this, or email her at ) Actually, I do have a passing familiarity /c the document. > > Cardiac Arrest Survival Times: > > Time to ALS > <8 min 8-16 min >16 min > Time <4 min 43% 19% 10% > to 4-8 min 27% 19% 6% > BLS >8 min N/A 7% 0% > > If you extrapolate this, then if the time to ALS is more than about > half an hour, then there's no point in even starting CPR, Yup! > unless the > patient has one of those few causes of cardiac arrest that can be > cured by basic CPR (e.g., lightning strike, some cases of > near-drowning), or the patient is severely hypothermic. Remember > that basic CPR provides 30% of normal cerebral perfusion, Beg to differ. I believe the references indicate that it provides 30% of normal CARDIAC OUTPUT. There's been no documentation of how much cerbral perfusion is achieved and there is no reason to assume that the same 30% would apply. > but that > filling of the coronaries occurs during diastole, and even with > perfect basic CPR the diastolic pressure id 0. Which means that with > CPR the entire heart is infarcting the whole time you're doing CPR. It's certainly anoxic and infarction follows ischemia. > > Which means that if an AED or other ALS is more than half an hour > away, forget it. Probably more like 15 min. > > But I think you misunderstood; I never argued for AEDs in the field, > just having one at every Base Camp. Ok. Actually, I think ALS is needed @ base camp. Not just BCLS /c AED. > > > > > Fall not prey to the "technological imperative" (thanks to Steve Davidson, > > MD). > > > > Restated: "We can, therefore we should." > > Jack T. Grandey, NREMT-P -- 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 (8.6.12/cispop-1.6.1.3) ID for ; Mon, 16 Oct 1995 14:56:23 -0400 Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 16 Oct 1995 14:56:22 -0400 Received: via switchmail for kconover+@pitt.edu; Mon, 16 Oct 1995 14:56:22 -0400 (EDT) Received: from JEFLIN.TJU.EDU (jeflin.TJU.EDU [147.140.128.114]) by post-ofc03.srv.cis.pitt.edu with SMTP (8.6.12/cispo-2.0.1.1) ID ; Mon, 16 Oct 1995 14:54:41 -0400 Received: from JEFLIN.TJU.EDU by JEFLIN.TJU.EDU with SMTP; Mon, 16 Oct 1995 13:26:47 -0400 (EDT) Date: Mon, 16 Oct 1995 13:26:41 +0000 From: "Jack T. Grandey" X-Sender: GRANDEYE@ To: kconover+@pitt.edu cc: wilderness-emergency-medicine@list.pitt.edu, AMRG.Members.and.Others@pitt.edu, ASRC.groups.and.members@pitt.edu Subject: Re: (Fwd) Re: Defibrillators for SAR teams In-Reply-To: <199510161510.LAA01381@post-ofc02.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII X-PMFLAGS: 34078848 On Mon, 16 Oct 1995, Keith Conover, M.D. wrote: > On 13 Oct 95 at 8:35, Jack T. Grandey wrote: > > [snip] > > > > > > My real issue would be at training programs, where 'unknown' individuals > > > > In the wilderness...You carry what you have. > > > > JTG > Cogent observations, Jack. We (SAR teams planning to improve their > medical capabilities, I mean) have limitations in terms of weight, > expense, and training time. We need to pick and choose what we carry > based on: > > how often will we need it? > > how much of a difference will it make? > > will we have enough people with enough training to use it? > > Splinting limbs makes a fair difference. Giving pain medications > makes a fair difference (except for orthopedic surgeons who believe > that "pain never killed anyone"). For cardiac chest pain, giving > aspirin makes a BIG difference, saving as many lives as thrombolysis > in the (big, good) studies. None of these cost much, in terms of > weight or expense. Agree /c all except lysing. Lot's of risks are attendant /c that therapy. Careful clinical judgement is needed here. > > And in terms of how often something occurs: we aren't likely to see > cardiac chest pain in the backcountry, but if you _do_ see it and > don't have an aspirin handy and the person dies, how would you feel? > > That's probably as important as the other considerations: how bad > would you feel if you didn't have it with you and the patient needed > it? I wouldn't feel bad if I didn't have an MRI with me in the > wilderness. But if I were at a Base Camp and someone coded and I > didn't have a defibrillator and the patient died I'd feel pretty > bad. Since defibrillators are very expensive, I wouldn't feel as bad > as if the patient had chest pain and I didn't have an aspirin, which > is cheap. I believe in monitor/defribrillators @ base camp. I believe in ASA in personal packs. > But I'd still feel bad. So we're not likely to see such > an event very often? Remember those overweight tobacco-smoking > hypertensive firefighters. A save once every 10 years is enough to > justify a defibrillator, I think. Well, you haven't disqualified frequency as a criteria, just put in $ context. For once every 10 years, it's worth it @ $4,500 (what about the $12,000 for the 12-lead to rule-in lysing?) MRIs are $4,500,000. One bleed every 10 years, same # die, but you "wouldn't feel bad". JTG -- End -- X-cs: From: Self To: Steve Hoffman ,@ASRC.PML Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: @AMRG.PML,wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Mon, 16 Oct 1995 21:45:56 On 16 Oct 95 at 13:35, Steve Hoffman wrote: > > Short (cheap) answer: call the local defib-equipped ambulance for a > standby at the base camp. If the SAR organization has the budget, > training, protocols and medical control supervision, this standard > of care can be improved on in many ways, including a defibrillator > and ACLS skills. > > :> Teams should be excellent @ BLS skills, which include recognition of the > :> infrequent OHSHIT case. They should have reliable comm to a base that is > :> equipped to handle said cases. > > I'd rather spend the $$$ on better gear and better radios and on > repeater and communications systems that will see regular and > potentially immediately life-saving measures. > > :Look at the table on page XII-22 of the WEMSI WEMT Curriculum > :(Wilderness Medical Problems) Lesson Plan. > > :Cardiac Arrest Survival Times: > : > : Time to ALS > : <8 min 8-16 min >16 min > :Time <4 min 43% 19% 10% > :to 4-8 min 27% 19% 6% > :BLS >8 min N/A 7% 0% > : > :If you extrapolate this, then if the time to ALS is more than about [snip] > :CPR the entire heart is infarcting the whole time you're doing CPR. > > CPR isn't particularly effective save as a temporary stabilizing > operation, and -- under the local WEMT protocols -- can be stopped > after 30 minutes for the `degenerative' cases. > > And the survival times shown above indicate that one needs nearly > immediate access to a defibrillator for it to be effective. > > >Which means that if an AED or other ALS is more than half an hour > >away, forget it. > > There is far more to ALS than defibrillation -- I suspect those > `ALS' numbers are actually numbers that reflect time to ACLS. > Without ACLS (`Ninja' or `classic'), the defibrillator enjoys > only limited success. But without the defibrillator (the only really heavy item) all the rest is basically useless. > > quotes from various sources including Barry Burton and Keith Conover. > > :> I'll buy into the low level of need for the actual rescue mission, in > :> that the people you're looking for are generally in a more fit condition > :> than the general populace. > : > :Well, actually, lots of the people the ASRC looks for are older and > :have coronary disease. > : > :And lots of the loacl volunteer searchers are fat hypertensive > :volunteer firemen who smoke. > > > > :> >From a 'system' perspective, AED's may make sense where risk is high and > :> resources low. I'm not convinced this would be the BEST utilization at > :> wilderness base camp. In view of the plethora of medical types (those > :> damn wilderness docs) and the ALS paramedics from WEMSI that I here tell > :> show up at all these evolutions, it would make more sense, IMHO, to find > :> some used/ refurbished LP5's for base ops. (like mine). Just make sure to > :> get them from the old squads BEFORE the manufacturer rep makes a trade in > :> deal (FDA regs get in the way). > :> > :> This positin is potentially strenghtened by the concept of using the > :> wilderness teams in the event of civilian catastrophe, interfacing with > :> local and national Disaster Medical Response systems (PEMA, FEMA, NDMS. > :> etc) and thus, also opens an avenue for funding. > > :I'm posting this to the wilderness-emergency-medicine list as well as > :sending to members of the ASRC. I'd be interested in getting some > :"outside" perspectives on our discussion about whether wilderness SAR > :teams need automatic external defibrillators, at least at Base Camp. > > Having a defibrillator at base camp could be potentially useful, and > having access to one is generally considered necessary, but blindly > carrying one into the woods seems wasteful, save for those cases where > you know (or suspect) you are likely to encounter a cardiac-related > situation. (I can think of better uses for the space in my pack.) Agree. It would be nice to have one to carry in (I mean, have someone _else_ carry in) if you had a known hypothermic patient -- just in case you might be able to get them warm enough to jumpstart if needed. > > Ambulances are trucks, and are designed to haul volumes of seldom-used > and occasionally very necessary equipment around -- and in the EMS > vernacular, this equipment is often called `toys' or `gadgets'. If > you've got a plethoria of help, or you've got pack animals or ATVs, > you've can more reasonably consider carrying a defibrillator. > > In particular, hauling around an LP5 seems wasteful -- they're too > heavy. (No ill will intended here, I've worked with and like using > the LP5. It's just HEAVY.) > > I'd also consider telemetry to be wasteful in the general case -- most > (all?) of what can be done in the field for a cardiac patient can be > done under standing orders and/or on-site rhythm interpretation. > (Telemetry would certainly be a `it would be nice to have' capability, > but its perceived value needs to consider the economics of finance, > use, training and upkeep costs, battery costs, the ever-present > pack mass and pack volume considerations. And when considering > telemetry, one needs to consider the cost of the telemetry equipment > used both in the field and at the medical control base(s).) On-site rhythm interpretation, no problem. On-site 12-lead interpretation for deciding whether to give heparin or not? A bit different. It is potentially possible to have an inexpensive light monitor that will allow you to do 12-leads and transmit them over a 2-meter ham or VHF mountain rescue radio. I'll be we could persuade Gene Harrison or Frank Reid to build one from scratch. Pantridge used such a device (light, cheap monitor) in Northern Ireland in the early days of prehospital care, though docs rode on the flying car (ambulance to us) to interpret. > > At the BLS level, a cardiac rhythm is `shockable' or `not shockable', > and any of the available semi-automatic defibrillators differentiate > the rhythm. At the ALS level, any paramedic or cardiac tech should be > able to operate and should have the protocols to operate fully off-line > -- on-line consultation is often useful, but it is not always available. > Particularly in the backwoods. > > If folks have the training and the dedication to use a defibrillator > and the local service has the budget -- go for it. But without ready > access to ACLS (`Ninja' or classic), a defibrillator may not provide > a particularly large increase in survivability given the expected > and typical duration of these calls. (One recent study showed that > the stacks of shocks followed by a one-drug-at-a-time standard ACLS > regime can lower the potential patient survival rate; that the shocks > can and do damage the patient's cardiac system. See the discussion > of `Ninja' ACLS in a recent JEMS issue.) > > And -- though I'm certain Keith and most (all?) other ALS-level folks > already know this -- those `overweight and oversmoked' degenerative > heart diseases aren't the best situation for cardiac survivability. > The damage has already been done by the time the heart is fibrillating. > The younger folks -- those that suffer from the effects of extreme > hypothermia or a nearby lightening strike -- are better candidates > for successful defibrillation. > > Steve Hoffman > NREMTI, WEMT, BCLSI, N1THN, hauler of LP5 and Heartstart > But some of those overweight hypertensive smoking firefighters are young, and when they knock off a small portion of an obtuse marginal off the LAD and get V Tach -- those are the people who you can save! And scare the s__t out of them and make them change their lifestyles and make longterm survivors out of them. That was the original idea of CPR: "the heart too good to die." -- End -- X-cs: From: Self To: "Robert J. Koester" ,@ASRC.PML Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: @AMRG.PML,wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Mon, 16 Oct 1995 21:45:25 On 16 Oct 95 at 14:11, Robert J. Koester wrote: > Dear Defib types, > What is the bottom line in the autodefib argument? > Do we require the ASRC to purchase an AED? This is > still no guarantee it will make it to that one search every 10 > years where it is needed> > > Do we require every ASRC to own an AED? What if they > can't afford it? Is this the best allocation of resources. > Can every team always send an EMT-B or EMT-D with every > response. > > These are the only two questions that must be answeared > as they relate to the ASRC. Whould an AED be anice thing to > have at base? Of course. But perhaps as technology improves > and the need is seen to be greater pocket AED for personnal use > may become the thing of the future (much like epi kits). Then > the argument for mandating them whould be more clear. Interesting thought. But due to power considerations, even with lithium-ion batteries, a "pocket defib" still will make you lean at 45 degrees. Until we have cold fusion that is. > > The current cost benefit analysis goes something like > this. We have never had someone to my knowledge code at base > in twenty years.--Maybe someone with better access to stats can > figure out the likelyhood of a code at base figuring about 25 > searches a year, lasting on average 24 hours, with 100 people, > with an age breakdown of 50% 16-25, 25% 25-40, 15% 40-50, and > 10% greater than 50. All of these core facts are skewed to > create a greater chance of a heart attack than actual facts. > Considering the AED whould serve little purpose if the patient > coded during a task. For the sake of argument lets say we find > one code every 20 years whould occur in base. How often can we > rely on the local rescue squad? Currently, I would say I have > ALS on scene on about 50% of all searches. I have BLS on the > remaining 40%. With the advent of EMT-B, and priorities of at > least Virginia Rescue squad assisatnace funding, almost all BLS > squads are expected to have AED's in the next two years. > Therefore, I think it is safe to say that in the next two years > I will have an AED present at base 90% of the time based upon > current search practices. If IC's make this more of a priority > I'm almost certain this could be raised to 95%. This means the > oppurtunity for an ASRC owned AED would be about once every 400 > years. This is assuming the ASRC responeded to every search > with an AED. This is true on larger searches. But on fast > local searches, equipment is often left behind due to a lack of > space in vechicles. If an AED was not owned by every ASRC > group the chances of it arriving on scene whould also drop. > Let us also consider an AED does not always "save the person" > (lets define a save as survival after one week). Using the > standard figure we can then calculate the number of saves if we > only get to use our AED every 400 years. For the sake of > argument lets say it saves the person 50% of the time ( I know > thats far to high). This means AED owned by the ASRC whould > save someone about once every 1000 years by my crude > calculations. > > Now ask yourself the only two important questions? > Does the ASRC buy an AED or seven? > Does the ASRC require groups to carry an AED? > > Does the ASRC require members to carry Aspirin? > Can we find a method of spending the same amount of > money that will "save" even more lives (training, methods to > find or evac pts faster, other medical courses or equipment, > etc.) > Bob Koester Since aspirin cost basically nothing, weighs basically nothing, is as effective as coronary thrombolysis in preventing mortality after a MI, is unlikely to cause harm unless someone has a head bleed or ruptured spleen or aspirin allerge (and is also good for eyestrain headaches), and your figures are convincing, I vote we forget about AEDs and all carry an aspirin (or better yet just half an aspirin) in our pockets all the time. We will probably save more lives that way. When and if we become independently wealthy, or someone donates defibrillators, then it makes sense for each ASRC Group to have both manual and automatic defibs at Base, but not plan to carry them in the field. Thanks for all taking part in this discussion. Since the question of whether SAR teams should carry defibrillators has been brought up, I'm glad we discussed it. But in terms of reasonable cost/benefit ratio for leveraging the medical skills of our members and medics, AEDs aren't where it is at. And that seems to be a reasonable consensus and conclusion to this thread unless someone still has violent objections. Again, thanks. -- End -- X-cs: From: Self To: WEDOSAR@aol.com,75714.1425@compuserve.com, rjk5a@avery.med.virginia.edu,dcarter@varic.ang.af.mil Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Tue, 17 Oct 1995 18:59:05 On 17 Oct 95 at 17:27, WEDOSAR@aol.com wrote: > Is Aspirin an authorized med for BLS to be giving to patients without medical > control? > I belive the answer is no because an unresponsive patient cannot tell you if > they are allergic to aspirin (half a tablet or not) No, you can't give ASA (aspirin) without practicing medicine. However, for responsive patients with cardiac-sounding chest pain you can use the "stump" method. Place half an aspirin on the stump. Tell the person with chest pain "It sounds to me like you might be having a heart attack. And we know that this can be very bad. But we also know that taking half an aspirin cuts the risk of death from a heart attack in half. So if _I_ were having chest pain that seemed like it might be a heart attack, and I found half an aspirin on a stump, I would certainly take it, unless I were allergic." This is morally, legally, and ethically appropriate, is not "practicing medicine without a license", and is a good way to get around the restriction that _giving_ medication is practicing a medicine and requires a medical license or a doctor. Letting someone have some of your own over-the-counter medications is entirely legal. _Giving_ it to someone and saying "take this, it'll make you better" is the practice of medicine, and restricted by law. Silly, but it works. -- 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 (8.6.12/cispop-1.6.1.3) ID for ; Fri, 20 Oct 1995 01:38:46 -0400 Received: from local (daemon@localhost) by post-ofc03.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Fri, 20 Oct 1995 01:38:45 -0400 Received: via switchmail for kconover+@pitt.edu; Fri, 20 Oct 1995 01:38:45 -0400 (EDT) Received: from netcom14.netcom.com (pturner@netcom14.netcom.com [192.100.81.126]) by post-ofc03.srv.cis.pitt.edu with ESMTP (8.6.12/cispo-2.0.1.1) ID for ; Fri, 20 Oct 1995 01:37:26 -0400 Received: by netcom14.netcom.com (8.6.12/Netcom) id WAA24656; Thu, 19 Oct 1995 22:36:25 -0700 Date: Thu, 19 Oct 1995 22:36:25 -0700 (PDT) From: Patton M Turner Subject: Re: (Fwd) Re: Defibrillators for SAR teams To: kconover+@pitt.edu In-Reply-To: <199510161511.LAA01455@post-ofc02.srv.cis.pitt.edu> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII X-PMFLAGS: 35127424 On Mon, 16 Oct 1995, Keith Conover, M.D. wrote: > GPS units actually aren't that useful (look at the thread about GPS > units currently going on in the Computers in SAR mailing list, > especially at Chuck Kollar's and Gene Harrison's tests). And best, > they aid in SAR, maybe helping find some lost people a little > faster. Funny, I've reached the same conclusion about GPS. Anyway, do you have an address for the list? About the AEDs: Somebody mentioned how you would feel if you needed one and it wasn't available...My wife and 2 friends were in a biochem class when the prof coded. They started CPR in seconds and told someone to call 911. He told the dispatcher that the prof collapsed and 2 med students were giving CPR. They were 3 mins from the hospital where the EMS is dispatched from. To make a long story short 26 mins a BLS crew arrives and 29 mins later he is pronounced dead at the hospital. My wife and the other 2 guys still second guess the fact that they could have run to the hospital and got a defib, or transported him themselves or ... or... I know when she graduates and we move back out of the city she will buy a defib for the house or car. She'll probally never use it but the $5000 is cheap for avoiding the pain she still feels. Off my soapbox, how about local EMS personal bringing a AED and ambulance to the base camp. Seems a small price for the local comunity to pay in exchange for all of these trained people doing the rescue that would otherwise be their responsability. I am assuming that your area has ACLS units in the communities, this isn't realistic in say Alabama, but in the New England area it seems reasonable. I guess SAR teams may not need the degree of medical control given fire fighters (wildfire and structual) or urban heavy rescue teams but the medics could assume this role as well. Pat -- End -- X-cs: From: Self To: @ASRC.PML,Patton M Turner Subject: Re: (Fwd) Re: Defibrillators for SAR teams Cc: @AMRG.PML,wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu Date: Sat, 21 Oct 1995 18:04:55 On 19 Oct 95 at 22:36, Patton M Turner wrote: > > About the AEDs: Somebody mentioned how you would feel if you needed one > and it wasn't available...My wife and 2 friends were in a biochem class when > the prof coded. They started CPR in seconds and told someone to call > 911. He told the dispatcher that the prof collapsed and 2 med students > were giving CPR. They were 3 mins from the hospital where the EMS is > dispatched from. To make a long story short 26 mins a BLS crew arrives > and 29 mins later he is pronounced dead at the hospital. My wife and the > other 2 guys still second guess the fact that they could have run to the > hospital and got a defib, or transported him themselves or ... or... I > know when she graduates and we move back out of the city she will buy a > defib for the house or car. She'll probally never use it but the $5000 > is cheap for avoiding the pain she still feels. > > Off my soapbox, how about local EMS personal bringing a AED and ambulance > to the base camp. Seems a small price for the local comunity to pay in > exchange for all of these trained people doing the rescue that would > otherwise be their responsability. I am assuming that your area has ACLS > units in the communities, this isn't realistic in say Alabama, but in the > New England area it seems reasonable. I guess SAR teams may not need the > degree of medical control given fire fighters (wildfire and structual) or > urban heavy rescue teams but the medics could assume this role as well. > > Pat > Having AEDs at colleges, fire stations, high schools and the like makes a _lot_ of sense to me, for exactly the reasons your anecdote suggests. I worry about the same thing happening at an ASRC (or any SAR team) Base Camp. But until SAR teams are indepently wealthy (when what freezes over?) it's just not realistic. But maybe having a formal policy in the Operations Manual that, for any operation with "a large number" of people (no sense in putting in a specific number and hamstringing ourselves) the IC should direct Logistics to try to arrange for an ALS standby as for any other mass gathering with a high risk for an ALS need. But if the local squad only has one or two ALS vehicles, this may be a problem. Not much we can do about it, though. -- 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 SMTP (8.7.1/cispop-1.6.1.3) ID for ; Mon, 23 Oct 1995 03:50:08 -0400 Received: from local (daemon@localhost) by post-ofc02.srv.cis.pitt.edu (8.6.12/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Mon, 23 Oct 1995 03:50:08 -0400 Received: via switchmail for kconover+@pitt.edu; Mon, 23 Oct 1995 03:50:07 -0400 (EDT) Received: from pluto.med.pitt.edu (pluto.med.pitt.edu [150.212.2.3]) by post-ofc02.srv.cis.pitt.edu with SMTP (8.6.12/cispo-2.0.1.1) ID for ; Mon, 23 Oct 1995 03:49:29 -0400 Received: from phobos.med.pitt.edu by pluto.med.pitt.edu with smtp (5.1/6.2) id AA01317; Mon, 23 Oct 95 03:49:29 -0400 (EDT) Received: by phobos.med.pitt.edu (5.1/6.2) id AA14884; Mon, 23 Oct 95 03:49:28 -0400 (EDT) Date: Mon, 23 Oct 95 03:49:28 -0400 (EDT) From: Ronald Roth Message-Id: <9510230749.AA14884@phobos.med.pitt.edu> To: kconover+@pitt.edu Subject: AEDs X-PMFLAGS: 33554560 I'm preparing a talk on AEDs for Westmoreland Co. and I've read thru a recent document from . doc. from the AHA. Although they recommend that any one can be trained to use AEDs they doe AEDs, they don't yet recommend that they be placed on street corners, etc. They call it the fire extinguisher theory. At this point the likelyhood of having the right equipment, the right patient, and a trained responder are too low to justify the cost. Having an AED at a base camp would only be cost effective (chance of saving a life.O life) if the population was at risk for cardiac disease and ALS was available ASAP. Ron Roth, MD Liason for the City of PGH Bureau of Fire AED program -- 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 (8.7.1/cispop-1.6.1.3) ID for ; Tue, 31 Oct 1995 11:28:23 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Tue, 31 Oct 1995 11:28:22 -0500 (EST) Received: via switchmail; Tue, 31 Oct 1995 11:28:22 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Tue, 31 Oct 1995 11:27:08 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Tue, 31 Oct 1995 11:26:38 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from vines12.acf.dhhs.gov ([158.71.1.12]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Tue, 31 Oct 1995 11:26:34 -0500 (EST) Received: by vines12.acf.dhhs.gov; Tue, 31 Oct 95 11:26:16 -0500 Date: Tue, 31 Oct 95 11:03:31 -30000 Message-ID: X-Priority: 3 (Normal) To: From: "Dave Matthews" Subject: EMED/ESAR EQUIPMENT Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 ****************************************************************************** ****************************************************************************** Dear Friends, Just a couple of brief questions for any List member(s) that might be interested in commenting: When you walk into the average camping/backpacking outfitter shop, are there any specific items of EMED/ESAR-related equipment that you'd like to find, but which are not usually there ?? What items of EMED/ESAR inventory should such shops be routinely stocking to better support the "front line troops?" Particularly, could somebody enlighten me as to the types of "walkie-talkie" radio equipment that meet applicable specifications and are most preferred by ESAR teams ?? Thanks for any comments or suggestions that you'd care to offer. Best wishes, Dave Matthews Internet: dmatthews@acf.dhhs.gov ****************************************************************************** ****************************************************************************** -- 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 (8.7.1/cispop-1.6.1.3) ID for ; Tue, 31 Oct 1995 18:30:08 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Tue, 31 Oct 1995 15:10:57 -0500 (EST) Received: via switchmail; Tue, 31 Oct 1995 15:10:56 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Tue, 31 Oct 1995 15:07:55 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Tue, 31 Oct 1995 15:07:37 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from ug1.plk.af.mil (UG1.PLK.AF.MIL [129.238.20.32]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Tue, 31 Oct 1995 15:07:33 -0500 (EST) From: PETE_POLLOCK_at_PLE@smtpgw1.plk.af.mil Received: from smtpgw1.plk.af.mil (smtpgw1.plk.af.mil [129.238.32.86]) by ug1.plk.af.mil (8.6.10/8.6.10) with SMTP id NAA29122 for ; Tue, 31 Oct 1995 13:07:30 -0700 Received: from ccMail by smtpgw1.plk.af.mil (SMTPLINK V2.10.05) id AA815173788; Tue, 31 Oct 95 12:09:59 MST Date: Tue, 31 Oct 95 12:09:59 MST Message-Id: <9509318151.AA815173788@smtpgw1.plk.af.mil> To: wilderness-emergency-medicine@list.pitt.edu Subject: Cleaning Wounds in the Wilderness Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 What are the thoughts about cleaning wounds in the wilderness? For example: Suppose the injury involves skin and muscle tissue in an extremity (e.g. an avulsion), and there are clearly foreign objects in the wound (dirt, twigs, leaves). What steps should be taken to clean out this foreign matter? I realize this question may be a little "controversial", in that our medical system prefers to do wound cleaning in the emergency room (of course, this is always desirable where possible). But if the patient is in a remote area, evacuation to the ER may take a long time. Infection is a serious risk then. Are there any thoughts on the cleaning of wounds? Pete Pollock (EMT) -- 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 (8.7.1/cispop-1.6.1.3) ID for ; Wed, 1 Nov 1995 17:00:55 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Wed, 1 Nov 1995 17:00:54 -0500 (EST) Received: via switchmail; Wed, 1 Nov 1995 17:00:54 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Wed, 1 Nov 1995 16:58:52 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Wed, 1 Nov 1995 16:56:25 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from JEFLIN.TJU.EDU (jeflin.TJU.EDU [147.140.128.114]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Wed, 1 Nov 1995 16:56:21 -0500 (EST) Received: from JEFLIN.TJU.EDU by JEFLIN.TJU.EDU with SMTP; Wed, 1 Nov 1995 16:58:10 -0500 (EST) Date: Wed, 1 Nov 1995 16:58:03 +0000 From: "Jack T. Grandey" X-Sender: GRANDEYE@ To: PETE_POLLOCK_at_PLE@smtpgw1.plk.af.mil cc: "Wilderness Emergency Medicine@" Subject: Re: Wound Cleansing in the Wilderness Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 > > What are the thoughts about cleaning wounds in the wilderness? > > For example: Suppose the injury involves skin and muscle tissue in > an extremity (e.g. an avulsion), and there are clearly foreign objects > in the wound (dirt, twigs, leaves). What steps should be taken to clean out > this foreign matter? > > I realize this question may be a little "controversial", in that > our medical system prefers to do wound cleaning in the emergency > room (of course, this is always desirable where possible). But if the > patient is in a remote area, evacuation to the ER may take a long time. > Infection is a serious risk then. > > Are there any thoughts on the cleaning of wounds? > > Pete Pollock (EMT) > > Actually Pete, there is little controversy in the wilderness. Clean the wound! In fact, wound cleansing via copius irrigation is favored over early antibiotic therapy for infection prevention. Good question. JTG Jack T. Grandey, NREMT-P Continuing Education Coordinator Operations Director Albert Einstein Medical Center Wilderness EMS Institute -- 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 (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 19:23:57 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 19:23:56 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 19:23:56 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 19:23:38 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 19:23:19 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from post-ofc01.srv.cis.pitt.edu (root@post-ofc01.srv.cis.pitt.edu [136.142.185.10]) by list.srv.cis.pitt.edu with ESMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 19:23:16 -0500 (EST) Received: from ehdup-a1-8.rmt.net.pitt.edu (ehdup-a1-8.rmt.net.pitt.edu [136.142.20.18]) by post-ofc01.srv.cis.pitt.edu with SMTP (8.7.1/cispo-2.0.1.1) ID ; Thu, 2 Nov 1995 19:15:47 -0500 (EST) Message-Id: <199511030015.TAA08627@post-ofc01.srv.cis.pitt.edu> Comments: Authenticated sender is From: "Keith Conover, M.D." To: PETE_POLLOCK_at_PLE@smtpgw1.plk.af.mil, wilderness-emergency-medicine@list.pitt.edu Date: Thu, 2 Nov 1995 07:14:36 +0000 Subject: Re: More on Wilderness Wound management Reply-to: kconover+@pitt.edu Priority: normal X-mailer: Pegasus Mail for Windows (v2.10) Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk On 2 Nov 95 at 14:44, PETE_POLLOCK_at_PLE@smtpgw1.p wrote: > What I hear people saying is that (correct me if I'm wrong): > > i) It's a good idea to wash out the wound with sterile water. > > ii) Addition of betadine, alcohol etc. is probably NOT beneficial unless > there's a real risk of serious bacterial infections (e.g. rabies bites). > I'd say clean but not necessarily sterile water for irrigation of contaminated wounds. Let me quote from Dr. Richard Edlich, probably the country's leading expert on emergency wound management, writing in Tintinalli JE, Ruiz E, Krome RL. Emergency Medicine: A Comprehensive Study Guide, 4E, Published by the American College of Emergency Physicians. " . . .Two groups of antiseptic agents, containing either an iodophor" [e.g., Betadine(TM) --KC]" or chlorhexidine, exhibit activity against a broad spectrum of organisms and suppress bacterial proliferation. The superiority of one antiseptic agent over another has not been shown. Although these agents can reduce the bacterial contamination on intact skin, they appear to damage the wound defenses and invite the development of infection within the wound itself. Consequently, inadvertent spillage of these agents into the wound should be avoided." And Betadine is a lot better in wounds than mercurochrome, peroxide, alcohol, merthiolate, or other "antiseptics." quoting again from Edlich (one of my old mentors, I might add): "Mechanical forces are employed to rid the wound of bacteria and other particulate matter that are retained on the wound surface by adhesive forces. The two techniques used are irrigation and scrubbing. Low-pressure irrigation can be used for clean owunds, and high pressure irrigation should be reserved for dirty or heavily contaminated wounds. High-pressure irrigation is defined as 7 PSI, and low-pressure as 0.5 PSI" High-pressure irrigation is the force resulting from a 35-cc syringe with a 19-ga needle pushed by an average second-year surgical resident. Or better with one of those little clear plastic splashguards that most EDs have now; they have a needle-sized orifice, and attach to a syringe, but help prevent the bloody fluid from splashing back into your mouth, nose and eyes. You can improvise similar strength irrigation by using a PUR brand iodine-resin filter to filter water, or use iodine tablets (but then you have to wait longer); put the water into a zipper plastic bag, poke a little tiny hole in it, fold the zipper over so it doesn't explode in your face, and direct the stream at the wound. However, for clean wounds (no dirt in them) that are fresh, high-pressure irrigation will actually damage the wound slightly and make infection more likely. But it definitely helps with dirty or old wounds (more than a couple hours without cleansing and dressing). Low-pressure irrigation is basically sloshing some water on the wound, or using a standard irrigation bulb as used in OB kits for neonatal suction. Hope this helps. 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) (for a WEMSI-sponsored list, send "subscribe wilderness-emergency-medicine" to Majordomo@list.pitt.edu) - 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 (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 08:30:58 -0500 From: KevinMTC@aol.com Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 08:30:52 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 08:30:52 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 08:29:14 -0500 (EST) Received: from emout06.mail.aol.com (emout06.mail.aol.com [198.81.10.43]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 08:28:40 -0500 (EST) Received: by emout06.mail.aol.com (8.6.12/8.6.12) id IAA05089; Thu, 2 Nov 1995 08:28:10 -0500 Date: Thu, 2 Nov 1995 08:28:10 -0500 Message-ID: <951102082808_95926803@emout06.mail.aol.com> To: owner-wilderness-emergency-medicine@list.pitt.edu, wilderness-emergency-medicine@list.pitt.edu Subject: Wilderness Wound Management X-PMFLAGS: 34603136 > > What are the thoughts about cleaning wounds in the wilderness? > > For example: Suppose the injury involves skin and muscle tissue in > an extremity (e.g. an avulsion), and there are clearly foreign objects > in the wound (dirt, twigs, leaves). What steps should be taken to clean out > this foreign matter? > > I realize this question may be a little "controversial", in that > our medical system prefers to do wound cleaning in the emergency > room (of course, this is always desirable where possible). But if the > patient is in a remote area, evacuation to the ER may take a long time. > Infection is a serious risk then. > > Are there any thoughts on the cleaning of wounds? > > Pete Pollock (EMT) > > ]Actually Pete, there is little controversy in the wilderness. Clean the wound! In fact, wound cleansing ]via copious irrigation is favored over early antibiotic therapy for infection prevention. A strong argument can be given that such wound should not be closed while in the field unless: 1) they occur on the face 2) they would interfere with evacuation i.e. a laceration in the hand would preclude effective rock/ice climbing. This means butterflies, Steri-Strips as well (although they are easier to remove when the wound becomes infected). These wounds are best managed (wilderness or ER) when packed open with a sterile dressing followed by changes daily or more frequently (depending on tissue exudate). If desired for cosmetic or functional concerns, they can be closed at a later date in a controlled environment. Emphasis should be on copious irrigation. A liter of purified water under pressure (18 ga Angiocath on a 20 cc syringe works well) is a good start. Addition of Betadine, peroxide, alcohol, etc. Probably is not useful and potentially harmful. Kevin Coonan, M.D. Frederick, MD -- 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 (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 18:02:17 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 18:02:16 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 18:02:16 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 18:01:11 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 18:00:34 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from ug1.plk.af.mil (ug1.plk.af.mil [129.238.20.32]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 18:00:30 -0500 (EST) From: PETE_POLLOCK_at_PLE@smtpgw1.plk.af.mil Received: from smtpgw1.plk.af.mil (smtpgw1.plk.af.mil [129.238.32.86]) by ug1.plk.af.mil (8.6.10/8.6.10) with SMTP id QAA22022 for ; Thu, 2 Nov 1995 16:00:27 -0700 Received: from ccMail by smtpgw1.plk.af.mil (SMTPLINK V2.10.05) id AA815356959; Thu, 02 Nov 95 14:44:42 MST Date: Thu, 02 Nov 95 14:44:42 MST Message-Id: <9510028153.AA815356959@smtpgw1.plk.af.mil> To: wilderness-emergency-medicine@list.pitt.edu Subject: More on Wilderness Wound management Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34603136 Thanks for the contributions so far. Very helpful. I'd like to take this discussion one step further now - you'll see what I'm getting at in just a minute. Let me also explain that I'm not trying to "play doctor" here. Wound care is best done in the ER by a trained physician. But very real difficulties do exist for the health care provider in the wilderness. The patient could easily be 4 hrs, 24 hrs (or even 2-3 days away) from hospital care in some circumstances. Making the right decisions could save a limb ... or even a life. So, we are considering a wound involving tissue damage e.g. an avulsion. Furthermore we're assuming no damage to the underlying bone structure or internal organs. What I hear people saying is that (correct me if I'm wrong): i) It's a good idea to wash out the wound with sterile water. ii) Addition of betadine, alcohol etc. is probably NOT beneficial unless there's a real risk of serious bacterial infections (e.g. rabies bites). iii) It's better to apply an open dressing, rather than closing off the wound with butterfly sutures. { I'm not clear on why step iii) may be wrong for injuries to the face } I also assume that no-one has trouble with the idea of picking out foreign matter (dirt, twigs, leaves) from the wound with a pair of tweezers. I expect that this would be done at the same time as washing out the wound. BUT there's one big complication - BLEEDING. Obviously, bleeding is going to obscure the presence of foreign matter. Furthermore, if we apply direct pressure to the wound site, all that foreign matter is going to be compressed into the patient's tissues - doing more damage and increasing the risk of infection. Yes, if the patient's life is in danger (copious bleeding), then there may be no alternative except to apply direct pressure to the wound. However, let's suppose that blood loss isn't quite that critical (e.g. veinous bleeding, but not arterial bleeding). How about if I reduce bleeding by applying a B.P. cuff. Suppose the wound is on an extremity, and I apply the cuff closer to the trunk of the body. By partially inflating the cuff, I should be able to control bleeding for a while (say 15 min.). That should give me enough time to wash out the wound and pick out any foreign matter. Then I can apply a bandage, and release the B.P. cuff. What are the pro's and con's of this procedure? Are there better alternatives? Thanks very much! Pete Pollock Pete_Pollock@ple.af.mil -- 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 (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 10:57:50 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 10:57:49 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 10:57:48 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 10:57:06 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 10:56:31 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from cap1.CapAccess.org (flong@cap1.CapAccess.org [198.69.201.50]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 10:56:27 -0500 (EST) Received: (from flong@localhost) by cap1.CapAccess.org (8.6.12/8.6.10) id KAA26441; Thu, 2 Nov 1995 10:56:43 -0500 Date: Thu, 2 Nov 1995 10:56:40 -0500 (EST) From: "Fred S. Long" To: KevinMTC@aol.com cc: wilderness-emergency-medicine@list.pitt.edu Subject: Re: Wilderness Wound Management In-Reply-To: <951102082808_95926803@emout06.mail.aol.com> Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 On Thu, 2 Nov 1995 KevinMTC@aol.com wrote: [snippage] > A strong argument can be given that such wound should not be closed while in > the field unless: 1) they occur on the face 2) they would interfere with > evacuation i.e. a laceration in the hand would preclude effective rock/ice > climbing. This means butterflies, Steri-Strips as well (although they are > easier to remove when the wound becomes infected). These wounds are best > managed (wilderness or ER) when packed open with a sterile dressing followed > by changes daily or more frequently (depending on tissue exudate). If > desired for cosmetic or functional concerns, they can be closed at a later > date in a controlled environment. Emphasis should be on copious irrigation. > A liter of purified water under pressure (18 ga Angiocath on a 20 cc syringe > works well) is a good start. Addition of Betadine, peroxide, alcohol, etc. > Probably is not useful and potentially harmful. > > Kevin Coonan, M.D. > Frederick, MD > Do you mean addition of Betadine....etc to the water or in addition to the water? "Potentially harmful" in what way and why? Thanks, -- 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 (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 12:34:39 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 12:34:38 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 12:34:38 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 12:33:09 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 12:32:06 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from emout06.mail.aol.com (emout06.mail.aol.com [198.81.10.43]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 12:32:03 -0500 (EST) From: KevinMTC@aol.com Received: by emout06.mail.aol.com (8.6.12/8.6.12) id MAA20090 for wilderness-emergency-medicine@list.pitt.edu; Thu, 2 Nov 1995 12:31:28 -0500 Date: Thu, 2 Nov 1995 12:31:28 -0500 Message-ID: <951102123127_80228548@emout06.mail.aol.com> To: wilderness-emergency-medicine@list.pitt.edu Subject: Wilderness wound management Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 33554560 On Thu, 2 Nov 1995 KevinMTC@aol.com wrote: [snippage] > A strong argument can be given that such wound should not be closed while in > the field unless: 1) they occur on the face 2) they would interfere with > evacuation i.e. a laceration in the hand would preclude effective rock/ice > climbing. This means butterflies, Steri-Strips as well (although they are > easier to remove when the wound becomes infected). These wounds are best > managed (wilderness or ER) when packed open with a sterile dressing followed > by changes daily or more frequently (depending on tissue exudate). If > desired for cosmetic or functional concerns, they can be closed at a later > date in a controlled environment. Emphasis should be on copious irrigation. > A liter of purified water under pressure (18 ga Angiocath on a 20 cc syringe > works well) is a good start. Addition of Betadine, peroxide, alcohol, etc. > Probably is not useful and potentially harmful. > > Kevin Coonan, M.D. > Frederick, MD > >Do you mean addition of Betadine....etc to the water or in addition to the water? >"Potentially harmful" in what way and why? >Thanks, Betadine, in a concentration strong enough to kill most bacteria, is also toxic to fibroblasts, leukocytes, etc. Thus you pay a heavy price for little gain. The goal is NOT to sterilize the wound, but to reduce (i.e. dilute) the bacteria concentration to a level that the local defenses can handle. I suppose you could make an argument that with potentially lethal virus infections, i.e. rabies, the risk of even small number of infectious particles would outweigh the damage done by your local treatment. I will try and check to see if there is anything in the literature that points one way or another. K. Coonan M.D. -- 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 (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 19:58:23 -0500 Received: from local (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1) ID for kconover@pop.pitt.edu; Thu, 2 Nov 1995 19:58:22 -0500 (EST) Received: via switchmail; Thu, 2 Nov 1995 19:58:21 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 2 Nov 1995 19:57:33 -0500 (EST) Received: from local (majordom@localhost) by list.srv.cis.pitt.edu (8.7.1/cisls-2.4) ID ; Thu, 2 Nov 1995 19:57:09 -0500 (EST) X-Authentication-Warning: list.srv.cis.pitt.edu: majordom set sender to owner-wilderness-emergency-medicine using -f Received: from JEFLIN.TJU.EDU (jeflin.TJU.EDU [147.140.128.114]) by list.srv.cis.pitt.edu with SMTP (8.7.1/cisls-2.4) ID for ; Thu, 2 Nov 1995 19:57:05 -0500 (EST) Received: from JEFLIN.TJU.EDU by JEFLIN.TJU.EDU with SMTP; Thu, 2 Nov 1995 19:58:55 -0500 (EST) Date: Thu, 2 Nov 1995 19:58:48 +0000 From: "Jack T. Grandey" X-Sender: GRANDEYE@ To: KevinMTC@aol.com cc: "Wilderness Emergency Medicine@" Subject: Re: Wound Cleansing Message-ID: MIME-Version: 1.0 Content-Type: TEXT/PLAIN; charset=US-ASCII Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk X-PMFLAGS: 34078848 On -1 xxx -1 SMTP%KevinMTC@aol.com@jeflin.tju.edu wrote: > > > > What are the thoughts about cleaning wounds in the wilderness? > > > For example: Suppose the injury involves skin and muscle tissue in > > an extremity (e.g. an avulsion), and there are clearly foreign objects > > in the wound (dirt, twigs, leaves). What steps should be taken to clean out > > this foreign matter? > > > > I realize this question may be a little "controversial", in that > our > medical system prefers to do wound cleaning in the emergency > > room (of course, this is always desirable where possible). But if the > > patient is in a remote area, evacuation to the ER may take a long time. > > Infection is a serious risk then. > > > > Are there any thoughts on the cleaning of wounds? > > > Pete Pollock (EMT) > > > > > ]Actually Pete, there is little controversy in the wilderness. Clean the > wound! In fact, wound cleansing ]via copious irrigation is favored over > early antibiotic therapy for infection prevention. > > A strong argument can be given that such wound should not be closed while in > the field unless: 1) they occur on the face 2) they would interfere with > evacuation i.e. a laceration in the hand would preclude effective rock/ice > climbing. This means butterflies, Steri-Strips as well (although they are > easier to remove when the wound becomes infected). These wounds are best > managed (wilderness or ER) when packed open with a sterile dressing followed > by changes daily or more frequently (depending on tissue exudate). If > desired for cosmetic or functional concerns, they can be closed at a later > date in a controlled environment. Emphasis should be on copious irrigation. > A liter of purified water under pressure (18 ga Angiocath on a 20 cc syringe > works well) is a good start. Addition of Betadine, peroxide, alcohol, etc. > Probably is not useful and potentially harmful. > > Kevin Coonan, M.D. > Frederick, MD > > Agree completely. Wound closure in the wilderness is something that we do selectively, factoring the risk of closed infection vs. additional contamination. For irrigation, we prefer a 60cc syringe /s angio + splash shield for pressure, while minimizing splash contamination of rescuer. In a pinch, use what you have. A zip lock bag /c a pin-hole in the corner works well, if you are cautious re: splash. JTG -- 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 (8.7.1/cispop-1.6.1.3) ID for ; Thu, 2 Nov 1995 17:30:04 -0500 Received: from local (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.7.1/cispo-2.0.1.1)