EpiPen Needle

Submitted by:
Greg Friese, MS, NREMT-P, WEMT
President, Emergency Preparedness Systems LLC
Lead Instructor, Wilderness Medical Associates

    Is it long enough to reach lateral thigh muscle?

A common student question during the allergies and anaphylaxis lecture is “how long is an EpiPen needle? (EpiPen Jr. 1/2″ and EpiPen 5/8″).”

I just read the summary of a study that used ultrasound to measure the distance between the skin and lateral thigh muscle in a convenience sample of 248 children ages 1 to 12 years old. The researcher concluded that the depending on the child’s weight the needle would not reach the muscle in 12% of the children that weighed less than 30kg and 30% of children that weighed greater than 30kg.

For the wilderness medicine providers these findings are mostly merely interesting. If you administer epinephrine to treat anaphylaxis and the patient’s symptoms don’t improve it could be for many reasons including slower absorption of the epi by the subcutaneous route instead of the intramuscular route. Remember the WildMed Anaphylaxis protocol includes administration of epinephrine, diphenahydramine, and prednisone, as well as PROP and evacuation. If the patient’s anaphylaxis symptoms persist or return (biphasic reaction) follow the protocol for administration of additional epinephrine. Finally, if time and symptoms allow it may also be prudent to make sure to press the auto-injector against the patient’s bare skin instead of injected through a single layer of clothing.

Wildland Fire Lessons Learned Center

The National Fire Protection Association has released the 2007 Firefighters Fatality Report. The report describes the attributes associated with the on-duty deaths of 102 firefighters in 2007. Only 3 of the firefighters were killed on wildland fires which is the lowest number of wildland fire ground deaths since data collection began in 1977 and well below the 10 year average of 10 wildland fire ground deaths. Another 7 firefighters were killed responding to or training for wildland firefighting.

Wilderness medicine providers should also note that the leading category of firefighter fatalities was from exertion, stress, and other medical issues. Sudden cardiac injury, not burns or trauma, is the leading nature of injury for all firefighters.

The report does not compile statistics for non-fatal injuries, but based on your knowledge or experience with wildland firefighting what are likely or common injuries?

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

Since near misses are the leading predictor for future illness, injury or fatality firefighters can learn from others and apply those lessons to their own prevention efforts. Read more at the Wildland Fire Lessons Learned Center.

How to Lower Risk

Click here for a great article on JEMS.com on how to lower risk incidents.

Written by WMA Instructor:
Greg Friese, MS, NREMT-P
President, Emergency Preparedness Systems LLC

10 People Struck by Lightning- 4 Critical


A group of 10 children and adults were struck by lightning while taking cover under a tree near a soccer field. Regardless of the location there is no safe place outdoors during a thunderstorm. If you hear lightning or see thunder seek shelter immediately in a building with a roof, walls, doors, and windows. If no building is available seek shelter in a vehicle with the doors closed and window rolled up. If no building or vehicle is available move to lower risk areas, spread out, stay low, minimize contact with the ground, and hope for the best.

For more on lightning safety go to http://www.nws.noaa.gov/om/lightning/index.htm

Open Airways Stories from the Back of the Ambulance

Open Airways Stories from the Back of the Ambulance is a collection of first hand accounts by EMTs, paramedics, and EMS instructors. Two Wildmed instructors “ Tim Sheehan and Greg Friese “ each share a memorable case and the lessons they learned.

Visit https://www.fisdap.net/openairways/ to listen to Greg and Tims stories as well as the stories of many other EMS luminaries.

WFR Judi Goes to Camp

WFR Day One: It was a chilly May morning. As I arrived at Chewonki I was pleasantly surprised at the beauty I would surround myself with for 8 days. Our instructors introduced themselves and gave us an overview of how the day would proceed.By 4 pm I had assessed a victim from a fall off the roof, another from an obstructed airway, a painfully gassy victim who had a change of diet, a heart attack victim who died (that was me) and a very angry bicyclist who had a bad fall with trauma to the head.

WOW ALL ON day one!!! Intense is not even the word for this course. The term “it depends” is heard around the clock here at our WFR training. When a question is asked it is almost always followed with “it depends” as the answer.

WFR Day Two: WOW talk about overslept. I awoke at 7:09am – mind you breakfast at 7:15 and class at 8am sharp. The first day was exhausting, overwhelming & intense.. Someone PLEASE tell me what is going on here. I will get through it I am sure.

Day two started with a brief intro to the next few days. Rumor has it Father founder of WMA, Dr. Peter Goth may be here tomorrow for spine lecture and drills. I can see sweat on Eric Duffy’s head, he is pretty nervous.

Today was sooo cool….. I was a freaked out mom that was angry with her husband for bringing us camping, had a daughter that kept fainting, a nephew with a knife, 3 goofballs playing in a tree and a sister high on “something”. I was later a rescuer helping a victim from a bike fall with trauma and then later rescuing a gal that fell off the roof and had TBI.

You will have to experience a WMA WFR course to know more about my stories.. I just had a fantastic dinner but must now study. Read 3 chapters, do two case studies and read the third. No mercy here. WFR Day Three – . This morning we focused on backboarding, Spine Assessments and the Spine protocol. Dr. Peter Goth arrived around 10am and watched Eric Duffy teach his protocol. Dr. Goth had some input and answered questions.

This afternoon we learned how to reduce a shoulder dislocation and restore CSM, how to split arms and legs and determine stable and unstable injuries. I am so looking forward to a night and day off. More studying and case studies this evening.

WFR Day Four: We awoke this morning to rain. Downpours actually. We have been advised rain or shine we will be outside for our first big simulation. We reviewed what we have gone over for the past three days, then dove into more lectures. The rain has let up and the ground is just wet. The patients all got ready for our first big simulation while the primary and secondary rescuers discussed a plan of action for our mass casualty rescue efforts. To know more you will need to take a class and experience it for yourself. I can tell you my gal had a severed limb and was freaking out!!!! I can not even begin to tell you the anxiety’s we felt going into this. Very real feeling is all I can say.

After our simulation we did a litter carry with a patient in the liter for about a 30 minute walk over and between apple trees, under picnic tables and under a cabin that simulated a cave environment. It takes 30 rescuers to evacuate 1 patient when walking out of the wilderness. I now know why!!!

WFR Day Five: Well back at WFR training. Brain is on overload. Totally saturated right now with stuff some important, some merely interesting, and some zebradic. Today we spent the morning doing more lectures and drills. Eric had a gnarly wound on his hand and Gabe simulated the cleaning and caring process for all of us.

Our second major simulation. Today was a bad day for our patients. Elliot and I were selected as Incident Commanders for the simulation. It was hard work – we were in charge of reporting how many critical patients, walking wounded, most critical, evac process and etc. A great deal of pressure. After our simulation we watched the recording and debriefed. I must say the simulations and drills are the best learning environment for me.

WFR Day Six: Today we are doing more lectures and backboarding drills, some carries and more lectures than our final simulation. On today’s simulation I was an assist rescuer. I partner up with a lead and away we go. Half way through the simulation my lead goes down on cardiac arrest and is evacuated immediately. Here I am with my lead rescuer going down and my patient with ASR, two broken bones and attending a drug rehab program where everyones name was PAT. WOW bad day for Judi for sure!!!! More studying tonight.

WFR Day Seven: One more day!! It is a rainy cold morning here at Chewonki. This morning went by fairly quickly with lectures and then out doors for more drills.

We did CPR drill today and my partner and I pretended we had no idea what we were doing. We relied on our lead rescuer to help us from across an imaginary river by shouting the instructions louder than the other rescuers. What a great learning experience.

The class is getting anxious about the final exam tomorrow. We had a great dinner and then on dish duty for me. Once dish duty was complete I proceeded to the classroom to study along with about 10 other students.

WFR Day Eight: DONE today. Wow. We had more lectures this morning and more drills. The drills are definitely a great learning experience. Today we focused on lightning accidents and did three different drills one right after another one. Lunch was great once again! The food here at Chewonki is amazing!! Off to the classroom I went to get in the last 15 minutes of study time and then the final exam!

My experience at Chewonki with Eric Duffy and Gabe Gunning was absolutely amazing! I have always had a great deal of respect for all the instructors but now I walk away as a WMA WFR with more respect than I came in with.Thanks for all your support and words of wisdom.
~ judi

National Estimates of Outdoor Recreational Injuries Treated in Emergency Departments

An Injury Center study published in the most recent issue of Wilderness & Environmental Medicine, found that nearly 213,000 people were treated each year in 2004 and 2005 for outdoor recreational injuries. More than half of these injuries were among young people between the ages of ten and 24. The article, “National estimates of outdoor recreational injuries treated in emergency departments, United States, 2004-2005,” details types of injuries and the sport they are associated with and offers suggestions to help prevent outdoor enthusiasts from becoming injured.Â

Read the complete article here:

Myth: Urticara (aka hives) only occur as a result of an allergic reaction.

Urticaria are those itchy, pink to red, raised skin lesions that are surrounded by a red halo. Although somewhere in the range of 90% of anaphylactic reactions are accompanied by urticaria or some sort of skin reaction, there are many other non-allergic causes. Some of these include physical factors (e.g., pressure, cold), infections (viral, bacterial and parasitic) and systemic illnesses. With all of these possibilities, it is not unusual when no cause is found.

So question (but don’t exclude) the diagnosis of anaphylaxis when there is no sign of skin involvement. Conversely, don’t jump for the epinephrine when an urticarial eruption is the only finding.

Dr. David Johnson

Myth: Once a person has had an anaphylactic reaction to a substance, all subsequent exposures will invariable lead to similar or worse reactions.

There is no question that recurrent reactions can follow re-exposure. As it turns out, however, the probability as reported in the medical literature is considerably less, about 50% for bee stings, for example. These re-exposure reactions can be less severe than the prior reaction.

Taking reasonable steps to avoid re-exposure is as important as being prepared to recognize and treat a reaction should it occur. For some people with recurrent severe reactions, immunotherapy (aka desensitization) can be a very effective deterrent. It is equally important to remember, however, that based on these statistics, not everyone needs to be treated following a re-exposure. Only treat those who develop signs and symptoms consistent with a true anaphylactic reaction.

Dr. David Johnson