When Would a Loss of Consciousness be a Survival Mechanism?

One of our WAFAs was in a first year lecture to 150 students at med school. The professor
asked, “When would a loss of consciousness be a survival mechanism?” The students were
silent for a minute, then the WAFA raised his hand.

When the professor called on him, he explained the preservation of the basic “reptilian”
functions and the concept of peeling the onion.

The professor was amazed. He said that this was an excellent explanation, one that he had
not run into, and that he had never run into a first year student who understood it.

A Close Encounter: Patient Evacuation by WMA WFR

Kudos to Mike T., a 2006 WFR grad, for his tact and sharing his story:

“I am a 2006 WFR Grad and I wanted to tell you about a recent backpacking trip in the Sierra Nevada Mountains. Just as we reached camp at our most remote location, 8000 feet on top of a mountain, one of our group members fell on some rocks. We eventually learned that the patient had lacerated his spleen and bruised some ribs. Thanks to the WFR training we were able to evacuate the patient safely without causing further injury. The rescue involved a CDF firefigher crew, a Sherrif’s Office search and rescue team, and a total of three helicopters over a 12 hour period.”

How to Prepare for the Outdoors in the Bitter Cold

Bitter cold is descending across the northern tier of the continental United States. Forecasted highs are for single digits above 0 Fahrenheit. As a wilderness medicine provider you know that heat is lost by several mechanisms.

Convection heat loss increases as wind speed increases.

Wind chill is a function of air temperature and wind speed at 5 feet above the ground. A wind chill chart is available at http://www.wrh.noaa.gov/lkn/windchill.php.

If you must be or choose to be outdoors during bitter cold temperatures do these things:

1. Dress in layers
2. Minimize any exposed skin
3. Use clothing, natural features, or structures to minimize wind exposure
4. Maintain a warm core by staying well fed and well hydrated
5. Watch for signs of cold challenge and mild hypothermia and intervene early
6. Watch for signs of superficial frostbite in yourself and your companions and intervene early

Submitted by:
Greg Friese, MS, NREMT-P, WEMT

Congratulations Ben

I know I should wait until we can do an official WMA news release but I could not restrain myself. This week, Ben Woodard has been named Chief Ranger for Maine’s Baxter State Park. This is especially wonderful because the park is one of the jewels of the State and, in my humble opinion, the entire US. Ben is a square peg for a square hole. I could not be more pleased and pround. More to follow.
DJ
WMA
www.wildmed.com

9 Dec 2008

I read medical articles and feeds fairly regularly. They give me ideas for future articles and commentary but in the end they pile up, collect dust and never see the light of day. Starting today, I am going to try to communicate about what is on my mind more regularly. Please let me know what you think.

If you are not familiar with Dr Bryan Bledsoe, you might consider checking out some of his columns at the Journal of Emergency Medical Services web site (www.jems.com). I don’t know him personally so I cannot describe his personality but he does seem to have a penchant for skepticism and he calls out nonsense when he sees it. His column last week was particularly good. In it he lists the 10 articles about EMS/emergency medicine that he finds most interesting.

Number one on his list is the Hauswald et al article that calls into question the universal utility of spine packaging(1). It is an article that we have referred to regularly as we have evolved our philosophy around spine management in the field. It is a good reminder that there is no good scientific evidence that shows that spine immobilization does anything to prevent spinal cord injury following a column injury. In fact, claims to the contrary (10% or more), cord injuries caused by movement after the initial injury are rare. If this procedure is of questionable value and potentially dangerous, why do we keep putting so many people on boards and in litters? When do the benefits of technical rescue because of a perceived need for full spine stabilization (e.g., mechanism of injury, unable to clear the spine) outweigh the inherent risks involved in many of these efforts?

An article by Lerner and Moscati was new to me (2). In it they looked at how the concept of the “Golden Hour” for trauma management was conceived by its original advocate, Dr. R. Adams Cowley. You guessed it, they could find no scientific basis.

He also includes two tongue and cheek articles (3,4). Each year around Christmas/New Year, the British Medical Journal (www.bmj.com). publishes a couple of funny, off-beat, wickedly insightful articles. The two on his list were among my favourites.

I think that this list of 10 is a good idea. Maybe I will try too. This is not just about debunking, it is about finding out what is factual, reasonable or fanciful.

DJ
WMA
www.wildmed.com

1. Hauswald M, Ong G, Tandberg D, et al: “Out-of-hospital spinal immobilization: Its effect on neurologic injury.” Academic Emergency Medicine. 5(3):214–219, 1998
2. Lerner EB, Moscati RM: “The golden hour: Scientific fact or medical ‘urban legend’?” Academic Emergency Medicine. 8(7):758–760, 2001.
3. Smith GC, Pell JP: “Parachute use to prevent death and major trauma related to gravitational challenge: Systematic review of randomised controlled trials.” British Medical Journal. 327(7429):1459–1461, 2003.
4. Green RJ, Pierce JM: “The ideal tool for decorators: A novel use for disposable laryngoscope blades.” British Medical Journal. 333(7582):1297–1298, 2006.

Legality in Administering Epinephrine

Ask Dr. Johnson
Click on the link above to go to www.wildmed.com and ask Dr. Johnson a question!

Q: What is the legality in administering epinephrine to someone? Are WFA certified individuals allowed to carry epi-pens to have someone use if in an emergency situation or can epi-pens only be used if they are prescribed to someone?

Like many questions, the answers depends. States vary in what they consider to be legal. Some have specific provisions for lay providers. Others strictly forbid administering medication to non-family members. Most are not clear. I believe that this is a first aid skill. So do the American Heart Association and the American Academy of Allergy, Asthma and Immunology. In Ontario, an Epi Pen can be purchased without a prescription. So where is the problem? It lies with the concept of the administration of a prescription medication by a non-licensed provider. Tens of thousands of people have been trained. I know that some of our graduates administer epinephrine each year. I am not aware of any bad outcomes, including adverse reactions or legal issues arising from administration of epinephrine by lay providers. Although many of us have written in defense of this procedure and organizations have lobbied on behalf of the training, a gray area still exists.

The most prudent approach when you are working for someone else would include the following:

1. Training – Keep your certification current.
2. Authorization – Make sure that your employer knows about your level of training and has authorized you to administer the medication for any client should the need arise. Get your patient’s permission.
3. Medication – Make sure that you have unexpired medication that is the correct concentration (if you are not using an autoinjector). It should be clear, colorless and free of any particulates. Your organization should supply the medication.
4. Protocol/SOP – If you are using an organizational protocol (you should), make sure that it is current and approved. Review this at least yearly. In addition, there should be a regular accounting for the medication including the expiration date and disposal.
5. Review – Anytime epinephrine is used (or should have been used), your employer should do a comprehensive review of the event, report back to the principles involved with the findings, and modify policy as needed based on this review.

If you administer epinephrine outside of a work setting, you still have the same responsibility to practice competently – current certification, unexpired medication, familiarity with your training protocol and patient permission.

In the relatively unusual likelihood it is medically necessary, epinephrine injection has proven to be an extremely low risk procedure for a significant benefit. I personally believe that the appropriate use of epinephrine for anaphylaxis is ethical and medically appropriate even where the legality might be questionable. Your employer should seek a legal opinion for your state. For more information on our view of the legal implications including the Good Samaritan legislation, a sample protocol or other articles on this or other topics, go to www.wildmed.com and click on ‘Resources’.

Increase in Food Allergies

This article (http://www.msnbc.msn.com/id/27725975/) discusses the dramatic rise in pediatric food allergies diagnoses and the corresponding increase in the number of children carrying EpiPens.

Remember the definitive treatment for anaphylaxis is specific medications of epinephrine, anti-histamine, and corticosteroids. Outdoor adventure program leaders that are responsible for first aid should rely on specific training, certification, and medical director authorization to recognize and treat anaphylaxis.

Based on recent on-course conversations students have reported to me increasing legal anxiety and hesitation for outdoor adventure programs to carry EpiPens that are not prescribed to a specific individual. This issue is likely to gain more attention if the occurrence of food allergies is increasing as programs carrying EpiPens is decreasing. Does your program carry EpiPens? Has your program recently stopped carrying EpiPens? Do you have a medical director authorized protocol for anaphylaxis assessment and treatment?

Share your thoughts in the comments section.

Submitted by:
Greg Friese, MS, NREMT-P, WEMT
President, Emergency Preparedness Systems LLC

Discussion on Epi-Pen Prescription Increase

Hey everybody,

Below is an CNBC news blog link to an article on the increase in epi pen demand and use, given the proliferation of peanut and other allergen based responses. DJ and Dr. Peter et.al. were saying this year’s back, confirming they were forward leaning ‘ahead of their time’, despite being viewed as heretics when they proposed that doing things like reducing dislocations, discontinuing CPR, and treating severe allergic reactions were reasonable and prudent things to be doing.

My rhetorical question would be, with this increase in
prescriptions being written for epi pens (thus profits), why hasn’t some other medical company resurrected the patent on the old user – friendly, cost – efficient “Anaguard” syringe system?
Pharmaceutical collusion, perhaps?

http://www.msnbc.msn.com/id/27725975/

–Dennis Kerrigan, WMA Lead Instructor

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I know it was rhetorical but…….

http://www.twinject.com/patients/learn_more.html


–Cabot Stone, WMA Lead Instructor

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“Hollister-stier drug company, the original developer of the Anakit and Anaguard injectable 1:1000 epinephrine solution has recieved FDA approval for a replacement epinephrine product to be called Twinject (for the two doses in the syringe). Many outdoor programs used the Anakit or Anaguard product for treating anaphyllaxis or severe asthma. The company discontinued the product in 2001 after their supplier of epinephrine (Wyeth Pharmaceuticals) ran into financial problems and stopped producing the epinephrine solution. Since Hollister-stier did not make the drug (only packaged it in the Anaguard syringe) they did not have FDA approval to produce the actual drug, only to produce the syringe.

The company submitted an application for their own production version of the epinephrine solution. FDA approval was granted in July and the company plans to begin production of the Twinject unit in the spring of 2004.”

The Twinject and Anakit rights were bought and obtained by Versus Pharmaceuticals in 2006 in the US and produced in Canada by Paladin Labs. Since they own both patents, it may be hard to get them to produce Anakits again.

–Mike Webster, Executive Director of WMA Canada Ltd.

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…at Verus sold Twinject earleier this year.

http://www.bizjournals.com/atlanta/stories/2008/03/10/daily37.html?ana=from_rss

–Dr. David Johnson, President & Medical Director of WMA and WMA Canada Ltd.