1.  There is no convincing medical evidence that traction splints provide consistent benefit for comfort or long term outcome.  Our instructors, with decades of work experience as paramedics, nurses and physicians confirm this.  Even when properly applied, sometimes traction splints decrease pain, sometimes worsen it and sometimes have no effect at all.

2.   There are claims about the value of a traction splint that have not been demonstrated clinically or in the medical literature.  They do not consistently realign bones.  I believe that the optimal tension (often given as 1 lb /0.45 kg for every10 lbs/4.5 kg body weight or mass  to a maximum of 15 lbs/7 kg) is based on minimizing skin ischemia and not necessarily for the correct amount for bone stability or alignment.  Otherwise, the amount of suggested tension ought to increase as the amount of thigh muscle mass and spasm go up.  Also, the theory that traction decreases the potential space where bleeding can occur seems fanciful at best.

3.  Skilled practitioners have a difficult time gauging the right tension unless a strain gauge is part of the device (e.g., Sager).  Too much increases the risk of ischemia.  Not enough may limit theoretical bone fragment stability, potentially resulting in more pain and more deep tissue and neurovascular injury.

4.   It has been demonstrated that the tension of a properly applied commercial splint decreases significantly within a half hour.  What do you think happens with an improvised splint?  If efficacy is a function of tension and you cannot measure it, how will you know if it has loosened up and by how much?

5.  Traction splints can cause complications and ischemia can occur at the proximal (groin or ischial tuberosity/sitz bone) and distal (ankle) anchor points because of direct and circumferential pressure under tension.  Foot numbness and /or diminished foot pulses frequently develop after commercial traction splints are applied properly in urban EMS.  What do you think would happen after 6, 12 or 24 hours?  Foot ischmia and tissue infarction have been reported after prolonged use.  Other complications like permanent nerve palsies and compartment syndrome have also been documented.

6.  It is difficult to reassess neurovascular function and comfort in patients who are no longer awake and only responding to verbal stimulus or worse.  The issue is compounded with someone with a boot on and/or who is hypothermia packaged.

7.  Even well-trained professional EMS practitioners use commercial traction splints when they are either contraindicated or not needed.

8.  Traction splints can take up a lot of room.  Many airmedical services still use helicopters that cannot transport patients fitted with the most commonly used commercial traction splints.  The same would be true for almost every improvised traction splint that I have ever seen.  Likewise, it can be difficult to fit a tall person with any traction splint into a litter.

9.  Except perhaps for ski patrol, fractured femurs are relatively uncommon injuries.  NOLS has done a good job of monitoring incidents in the field on their programs.  Ask them how many fractured femurs they have had to manage.  Hint: Rarely.

10.  Outside of North America, traction splints are infrequently used because there are better or at least comparable alternatives that are safer and easier to use.   Skiers in W Europe and in an increasing number of places in North America use vacuum mattresses.  These are effective and much more comfortable.  They are also excellent for patient/spine protection.  When a vacuum mattress is not available, we package femurs by incorporating solid, buddy splint padding within the carrying systems.

11.  Under conditions where a traction device may be indicated and acceptable, improvised splints are not a suitable alternative.  They will perform less well than a manufactured variety.  The effectiveness of any is dependent on available materials and creativity.  I suspect there a few Wilderness First Responder students who will do a really fine job.  On the whole, however, most will not be able to make a passable one after less than 6 months from their course.

It was not a simple matter to remove improvised traction splints from our curriculum.  Students had fun and on occasion we were impressed with their ingenuity.  In the end, however, it was hard to justify spending an hour on a skill that would be infrequently used with a device that is of questionable value.  Management of femur injuries are covered during splinting on our courses and we include vacuum mattresses on our specialized courses.  More of our instructors are buying them for use on their courses.

Bottom line: Femur fractures are serious injuries that usually occur as the result of significant forces.  A full assessment, focusing on critical system problems and their stabilization is the crucial first step.

Effective stabilization of femur injuries will help alleviate pain and decrease the possibility of complications.  I believe that either a vacuum splint or good padding in a stable carrying device does a good job of providing both.

Although there is no literature supporting their efficacy in the prehospital setting, a commercial traction splint can be a useful tool when applied by a skilled practitioner who receives periodic training on a particular device and/or uses it during rescues or EMS calls.  They should not be left on for a prolonged period of time (e.g., greater than 2 hours) unless limb neurovascular integrity and splint tension can be monitored properly and regularly.

Regardless, these are painful injuries.  All require the administration of analgesics.

First, if you are unfamiliar with the story, check out some articles online.  This one from USA Today is pretty good.  If you want more detail and you have the time, check out the unedited interview with Dr Roger White below.  He was the physician who advised the practitioners in the field and also attended to the patient in hospital.  In it he talks in great detail and even shows printouts from the monitors used during the resuscitation.

Essentially, a 54 yo man had a witnessed cardiac arrest in a small town in Minnesota (MN).  CPR was started promptly and was continued by “dozens” of locals, all taking turns in shifts.  They defibrillated him 6 times.  An advanced life support (ALS) team arrived at about 40 minutes into the resuscitation.  They intubated him (placed a breathing tube for ventilations), gave  IV drugs and defibrillated him 6 more times.  Defibrillation established a regular rhythm for very brief periods of time after some of the ALS shocks.  It wasn’t until he was given a large, out of protocol, repeat dose of the anti-dysrhythmic amiodarone that he remained in a rhythm that produced a sustained pulse.  He was then transported the 30+miles to Rochester, MN, for a heart catheterization and other treatment.  He left the hospital after 10 days feeling tired and sore but apparently with his intellect and other body functions intact.

Dr. White admitted that he and the ALS crew questioned the wisdom of continuing in the face of the recalcitrant dysrhythmia.  In the end they chose to continue in large part because they were able to confirm the continuous production of carbon dioxide via one of their monitors.  In essence, this indicated that the CPR was effectively perfusing the lungs, evidenced by the measurable amount of carbon dioxide produced there. This indirect measure of global perfusion gave them hope and thus made it hard to stop.

This gentleman survived because of an extraordinary confluence of circumstances and people, including the online, real-time advice from a “…leading expert in cardiac arrest…”  Take any one or more of those away and the result would have been different.  Most if not all of the capabilities described would be unavailable and/or unrealistic in a wilderness or remote setting in a harsh environment.  This was the quintessential chain of survival.

Bottom line: As amazing as this story is, our CPR protocol still makes sense.

This resuscitation demonstrates that good quality CPR can make a difference.  However, maintaining good quality CPR is not simple.  Fatigue would have set in much more quickly for a significantly smaller crew.  CPR quality and therefore perfusion worsen with rescuer fatigue and maintenance of perfusion is what gave him a chance.  Fatigue in a remote and harsh environment can also put rescuers at risk.  And this success took more than good quality CPR.  Even the AED proved to be of little use without more advanced capabilities.  In the end, the experienced practitioners involved are not sure how or why they succeeded.

Remember too, this was caused by a heart attack with a potentially fixable rhythm and not from trauma or a prolonged submersion.

A:   We have steered away from silver sulfadiazine (e.g., Silvadene) at work for years.  We have found that products like a vasoline-type gauze, e.g., Xeroform, is more comfortable and easier to maintain requiring fewer banadage changes.  In a 2008, a Cochrane review of dressings for superficial and partial thickness burns noted that silver sulfadiazine delayed healing and that moist dressings seem to decrease the pain and decrease healing times.

Bottomline: Fewer, less vigorous washings with less frequent bandage changes adds up to important practical advantages.

“…the stuff works..”  or “…they make a difference…”, those are the suppositions that get to the heart of the matter.  I have written previously about clot enhancers and have expressed my unabashed skepticism.

In the last few years, the original QuikClot that was supposed to stop all bleeding without any harmful effects has been reformulated to be cooler because of concerns about burns.  Reengineered again, it is available, impregnated in gauze.  But do any of these really work?  There are anecdotal reports and animal studies.  The claims made by Z-Medica that their products have saved hundreds of lives seem hyperbolic and unsubstantiated by anything more than individual or pooled testimonials.  Each new animal trial shows the new product to be better than the prior one, the one that was supposed to stop all bleeding.( http://www.z-medica.com)  This is not science, this is marketing.  I am not aware of any clinical trials that look at important human outcome in any meaningful way.  The fact that someone, like the army, is using something does not make it efficacious or safe.  And in addition to burns, there have been other problems reported with the older formulations.  I don’t believe that the science with the other leading products (chitosan-based: e.g., http://www.celoxmedical.com) is any better.

I completely understand why the military wants a product that will stop bleeding easily.  Think about it.  As with all combat, bleeding is the major pathway to death.  Field treatment has improved significantly but who wouldn’t want to do better for otherwise healthy young women and men?  What could be better than being able to pour something into an exsanguinating wound and have the bleeding stop, especially where a tourniquet cannot be applied?  It does not work that way with any product on the market.  It does seem that the gauze formulations of each have some promise.  They can be wrapped around a wound or tightly stuffed into deeper ones and then secured by a tight pressure wrap.  Assuming that the product added is safe and effective, it could enhance what already works.

What should you do?  We know that bandaging that is visually directed toward the bleeding site (well-aimed), stuffed in for deeper wounds, and then secured by a pressure wrap have a good track record.  This is certainly true for the vast majority of wounds we are likely to see in non-combat, civilian events.  There are no confounding substances and anyone can buy these materials easily and inexpensively.  On the other hand, the least expensive of either of the major clot enhancing products retail for about 10$ US and many are 25$ US and more.  But wouldn’t it be worth it to decrease exposure to potential m thinking FG and OHbloodborne pathogens?  If there is bleeding, there is blood around.  Whether you use the sachet containing QuikClot or either gauze impregnated product, you still have to apply it manually and hold it in place like plain gauze until secured.  Gloves, eye protection, and clothing are still your best protection.  And what are you going to use if you haven’t got a clot enhancer with you?

Based on research, plain surgical masks were felt to afford insufficient protection compared to the more expensive, fitted, N95 mask.  This week, the result of an important N95 vs plain mask study is being questioned because of the methodology used.  Still, this is a big deal, especially for at risk populations like young kids, pregnant women and people over 65.  Underlying conditions like asthma and other chronic illnesses can increase a person’s risk for a more severe illness.

Influenza virus can be broadcast about 3 feet from droplets generated by coughing and sneezing.    The virus laden droplets gain access and infect through eye and nose mucous membranes.  This initial contact is either direct or indirect.  The later occurs when the droplets land on a surface and then are spread to the mucous membranes by hand contact.  It is often difficult to get more 3 feet away from someone in a tent, on-board ship or in a classroom.  Keeping surfaces clean under these kinds of circumstances can be a challenge.

Here is what I think:

1. Most people with influenza are sick.  Cough, sore throat, headache or muscle aches with a fever should get your attention.
2. Hand washing regularly both before but particularly after contact is very important.
3. Coughing into a disposable tissue that is immediately thrown out or, lacking one, into one’s elbow crease will minimize spread potential.
4. If you are running a program, isolating people with some symptoms will help.  In the middle of the ocean you cannot send the person home but you can use a mask and good hygiene.  If conditions permit, on deck, some distance from others would be better than being trapped below deck.   Think of this principle for other settings.
5. Some kind of a mask is better than none and one mask for someone ill is cheaper and easier than one mask for everyone else.  It is hard to believe, if lacking a mask, that even a bandana wouldn’t offer at least some protection.
6. Canceling or postponing a trip for the person with symptoms makes sense.
7. When you think about hygiene don’t forget about things that you touch – e.g., flash lights, binoculars, GPS.  An outbreak of conjunctivitis at a college, reported in the NEJM in 2003, was felt to be related to ubiquitous public computer terminals.  Placing hand cleaner near them accompanied by instructions to use before and after was credited in part for getting things under control.
8. Most of these steps make some sense to help minimize or contain many infectious illnesses.

The vast majority of people who contract H1N1 will survive just fine.  But, when you are not at home, little problems have a way of getting worse (magnifier effect), ultimately affecting everyone’s health and safety.  Expeditions or other remote missions are always easier and more fun when people are well.