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.

Q: We are moving from epi auto injectors to epi vials and I am working on updating our protocol.  Do you have a protocol for vials?

The protocol for treatment would be the same except for the actual steps of drawing up the medication.  You might want to consider a policy that addresses purchase, storage, disposal, training (I would refresh yearly), monitoring for expiration dates, and usage review (all allergic reactions whether or not meds were used).  With vials, I would suggesting adding that each should be discarded after being used for an episode of anaphylaxis (however many are needed for the episode).  With amps, I would use each for one injection.  In both cases, medication will be wasted but you will decrease the likelihood of contamination.  Given the relative costs compared to autoinjectors, they still remain very cost effective.

Click here to access the Wilderness Medical Associates’ Field Protocols, including Protocol 1: Anaphylaxis.

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.

Please consider helping AORE make a difference by reviewing this document if you have ever sponsored a WFR course, attended at WFR course, or instructed a WFR course. Does this document include the topics that you want your staff to know? As a participants of a Wilderness First Responder course, is this training enough to prepare you for backcountry medical emergencies? Are the elective topics sufficient? Please be clear, professional, and thorough.

Click here for the Wilderness First Responder Scope of Practice.

Please send your comments to Tim Mertz (mertzt@uwstout.edu). Comments received will be consolidated and then presented to the wilderness medical providers for consideration in the final document.

Starting in May of 2010, Wilderness Medical Associates, the industry leader in wilderness medicine will begin offering the WEMT-Intermediate course.  This course is designed to expand the knowledge base and scope of currently certified Wilderness EMTs or EMTs.

Wilderness EMT Course Content

This course meets all requirements of the Department of Transportation (DOT) Emergency Medical Technician-Intermediate/85 (EMT-I/85) curriculum and the Wilderness Medical Associates WEMT-I curriculum. Topics include patient assessment, body systems, equipment improvisation, trauma, oxygen administration, automatic defibrillation, ECG interpretation, IV therapy, pharmacology, overview of primary care medicine, advanced assessment, endotracheal intubation, environmental medicine, toxins, backcountry medicine, wilderness protocols, and wilderness rescue.

Wilderness specific subject topics include:

Logistics and Introduction, General Concepts in Wilderness Medicine, Roles and Responsibilities, Patient Assessment, Critical System Problem Recognition Drill, Critical System Summary, Spine Musculoskeletal, Limb Splinting, Dislocation Reduction Demo and Practice, Skin, Soft Tissues and Burns, SAR/Organization, Small Group BLS Simulations Thermoregulation, Cold Injuries, Altitude, ALS Treatments and Meds, Appropriate Technology, ALS Tools and Medications, Night Simulation, Expedition Practitioner/Backcountry medicine, Toxins, Bites and Stings, Lightning, Submersion injuries, Diving, Improvised carries, low angle litter evacuation, hypothermia wraps, antibiotic usage, pain management, common problems associated with the EENT.

Wilderness EMT Class Format

This course is 75 hours classroom and 36 hours clinical time over 16 days. On most days class will run from 8:00 a.m. to 6:00 p.m. Mornings will begin with quizzes and case presentations from students who had hospital rotations on the previous day. The rest of the morning will be devoted to lectures.

Afternoons are devoted to practical hands-on sessions and video taped simulations. Expect 2-3 emergency rescue simulations with made-up victims and stage blood that will be videotaped for enhanced learning. Evenings are reserved for case studies, clinical rotations, and assignments.

Need more information or want to enroll?

Contact us at:

office@wildmed.com

1-888-WILDMED

Click here for the list of upcoming Wilderness EMT-I courses.

Click here for more information about the Wilderness EMT-I course.

http://www.ems1.com/ems-products/cpr/articles/605748-Texas-youths-set-record-for-worlds-largest-CPR-training-class/

No it was not a pie eating contest or sporting event.  Apparently they were certified by the Guinness folks for holding the world’s largest CPR class – 4626 students.

“As expected with thousands of junior high students, there was plenty of goofing around during the lesson. Giggling was common when they first gave their inflatable mannequins mouth-to-mouth resuscitation, and more than a few decided to head butt or slap their Mini Anne CPR dummies. But most appeared to take the lesson seriously.

Cluck (the mayor who helped organize the CPaRlington program)walked several laps around the field during the lesson, and he said most participants understood the techniques and could resuscitate someone if needed. Each student is now required to take the dummies home and teach four other people.”

Although not specifically mentioned, 30 minutes and inflatable CPR dummies sound a lot like the American Heart Association’s (AHA) CPR Anytime. Regardless of whose curriculum, I am assuming that this was not a certifying course.

The CPR Anytimeis a real departure from where the AHA was even 5 years ago.  There was a time when everyone taking one of their courses was hovered over by a hypervigilant instructor making sure that each student’s compressions and ventilations were within an upper and lower limit.  Skill testing success or failure was determined by lines on a piece of graph paper spit out from the side of the testing dummy.  Everyone knew that you had to modify your technique for the testing mannequin used, in order to pass.

Most instructors led their students to believe that if their technique varied in anyway from the norm, those efforts would hasten a patient’s demise.  Everyone assumed that the AHA knew what it was doing and as a result no one else (other than the American Red Cross and a few others) could be trusted to teach CPR.  Now these courses are more user friendly and accessible, engineered to train the masses.  These self-directed offerings are a convenient way for people to learn a skill that could enhance survivability following a cardiac arrest without having to take a course.  No one knows whether or not this new approach will make a difference.  Others of us have been allowed to use our own curricula and ideas to teach this once sacred procedure.  It seems that AHA mantra has become, do something.  Over the years, anecdotal stories suggest that an untrained person doing something is potentially beneficial and not harmful.  Science shows us that early intervention does make a difference.  I agree

Still, this rock concert-like event makes me cringe.  Why not do it right?  Is the time spent in school classrooms so valuable that they don’t have time for this or practical First Aid?   The AHA hopes people taking self-directed courses will in turn teach someone else.  Would these kids do a better job teaching their parents after a course like the one noted above or after a proper course, esepically one that utilized a variety of teaching methodolgies (e.g., fun) and was integrated in with what they are leaning in school?

This is not a criticism of these kids.  This is what they know.  Kudos to them not for the record but for the initiative and sense of civic concern.  But with a little guidance and effort, think about how much more could be done.

Authors of an editorial and article that appeared in the Wilderness and Environmental Medicine Journal earlier this year (Vol 20, 106 and 113-117) argued that there is no standard in wilderness medicine training for outdoor educators. In addition, they suggested that organizations offering this training have curricula that are not evidenced-based and are quite possibly irrelevant to the true needs of their intended audiences. They characterized these training organizations as fractious and secretive (my selection of words). These suggestions and characterizations are misleading and inaccurate. I personally have an open and collegial relationship with the principles of a number of these organizations. We attend and present at some of the same conferences and regularly meet to discuss what we are doing and why. Anyone can see what we teach by buying our texts, reading our blog, listening to our conference presentations, and freely downloading articles and protocols from our web site. Over the years, these interactions have resulted in changes and upgrades for all of us. The competitive atmosphere of excellence has forced each of us to look carefully at what we teach and how we teach it. Being wrong and inept would result in marginalization as well as loss of business. Over the last several years these conversations have become more focused. The participants are highly experienced outdoor and educational professionals, some with long careers as outdoors medical practitioners. They work or manage training organizations who have taught over 150,000 WFA students since 2000. Through a collaborative effort with these peers, we hope to write Scope of Practice (SOP) documents to define the intended audience and what a person at different levels of training should be able to do and should not do in the field. Ultimately the signatories will publish them for public information and scrutiny. The first of these is a SOP for Wilderness First Aid (WFA). It will be discussed at this year’s American Outdoor Recreation and Education (AORE) conference in Minneapolis and presented to the Wilderness Medical Society.

Click here for the Wilderness First Aid (WFA) Scope of Practice.