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Risk Management & First Aid

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  • 07/19/12--08:09: When to Use Tourniquets
  • Re-posted with permission from Wilderness Medical Associates International.

    I am not sure that there is a consensus about their use but here is my opinion about tourniquets in remote and hostile environments.

    In brief:

    1.  Learn how to use one and practice with it.

    2.  Apply to stop bleeding not controlled by well-aimed direct pressure.

    3.  Use something wide and firm (but not hard) that can apply circumferential pressure.  The pressure should be sufficient to stop bleeding.  Make sure that it is in good shape and not a knock-off.

    4.  Place proximally (upstream) and as close to the wound as possible.

    5.  Don’t release in the field if the patient is in shock, has an an amputated limb, or has a wound site that cannot be monitored for re-bleeding.

    6.  For a long evacuation, wait an hour before trying to release it.  If bleeding starts again, re-secure.  Note the time and leave it in place until definitive care is reached or arrives.

    7.  Under dangerous circumstances, one may be applied before a thorough evaluation is possible.  These should be applied to the proximal thigh or arm if there is any question about the location and/or number of wounds.  Carefully check the wound when it is safe and feasible. As indicated, leave, reposition, or release it or add a second one proximally.

    The following is an explanation of my above opinion.  None of this should be misconstrued as a blanket endorsement to buy and carry one on all trips.

    Tourniquets have a checkered history and hyperbolic claims continue to muddy the water.  Past and current combat experience in the SW Asian theaters has drawn renewed attention to them because injuries to limbs have been a major source of life-threatening bleeding. There, they are being used successfully to control obvious and potentially serious bleeding.  In the later case, they are applied before a proper assessment is possible e.g., multiple casualties, continued live fire.  The tourniquets used are relatively cheap and can be lifesaving if used properly.  As with anything in medicine, nothing works 100% of the time.

    In civilian practice, it is relatively rare for death from limb bleeding to occur because properly applied, well-aimed direct pressure failed. Still, tourniquets have their use outside of theater (e.g., mass casualty), so knowing how to use one is important. The relevant questions include what, where and for how long.

    What:
    A good tourniquet
    ought to be soft (but not mushy) and wide.  Within limits, wider is better. To be effective, the circumferential pressure needs to be sufficient to stop bleeding. A sphygmomanometer (BP cuff) might be ideal except that they usually will not maintain adequate pressure for a long enough period of time. They and similarly designed devices are also bulky and fragile. The gauges break easily and the fabric, bladder and tubes are vulnerable to sharp objects. Cordage, like a rope or 550 cord (parachute), is not a good choice either because of the potential for direct skin and neurovascular injury.

    There are a variety of more serviceable versions. Two of them, the CAT (combat application tourniquet) and SOFTT (special operations forces tactical tourniquet), have worked reasonably well in combat. They are compact, inexpensive and easily applied, even by the patient.  Their advantages are a tradeoff for effectiveness.

    Where:
    One needs to have enough remaining limb to hold the tourniquet. I have heard intelligent people argue that they should never be applied to forearms and legs (lower).  Generally, I disagree and experience would seem to bear that opinion out.  They should be applied as close to the wound as possible.  When circumstances prevent a proper assessment for location and number of wounds, some recommend using only the proximal arm (upper) and/or  thigh as default positions.

    If limb bleeding will not stop, especially with a thighanother applied in parallel, proximally, may help. Stay off joints.  Controlling junctional (e.g., in the groin) bleeding remains problematic.

    How long:
    People fear tourniquets because prolonged use can lead to neurovascular damage and tissue death. We know that tissue death from impaired circulation can occur in as little as two hours. We also know that tourniquets have been left on for over 16 hours without any notable harm.

    Releasing a tourniquet has its own risks and there are circumstances where removal never makes sense.  These later would include limb amputation, shock, the inability to monitor the wound or continued bleeding.  Intermittently releasing them to temporarily restore circulation has been reported to lead to unrecognized, ongoing blood loss and patient death.   On a long evacuation, if the conditions seem otherwise safe, waiting 1 hour before attempting a removal seems like a reasonable time interval.  If bleeding starts again, resecure,  note the time and leave it in place.

    Improper application is an important cause of failure.  They can also fail when they breakdown from environmental exposure or from poor construction (e.g., older version knockoff).  Always check your equipment before heading out and replace anything questionable.  Practice with any tool before you need it for a real emergency.

    There are plenty of good resources online that cover step-by-step application and the identification of knockoffs (e.g., date printed on webbing, red tip on the end of webbing).


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    Re-posted with permission from Wilderness Medical Associates International.

    Walking through the first aid aisle at your local outfitter store can be overwhelming. While there are many excellent prepared kits on the market, often enthusiasts choose to create and specialize their own.  Your kit will be different based on where you are camping and hiking. Trips at altitude, near marine environments or canyoning, and desert trekking each have unique needs that would require you augment your kit accordingly.

    Below is a “basic kit list,” to which you can add on as your number of adventurers, length of trip, level of training, or destination dictate. An asterisk marks items that you might include for your week-long trip. For your overnight, you can feel comfortable paring down the quantities.

    Personal Protection:

    • Gloves (Nitrile) – Vinyl is too porous, and latex is a common allergen.  Bring a few more pair than you think you need. You use one pair of gloves each time you clean a wound, and gloves aren’t designed to be re-used. If your gloves have been in your kit for a long time, check them to make sure they didn’t degrade in heat or cold. Have these easily accessible so that you are inclined to use them when needed.
    • CPR mask and airway management- you can get a quality mask with a filter for around $12. “Keychain” masks are better than nothing, but have a short life span when put to use. If you have been trained to use airway adjuncts, include some—they are a little bit of weight for a lot of good.
    • Wound care (probably the most common supplies I use on trips):
    • 1” athletic tape- one roll per person per week for hiking/skiing/climbing trips (really). It’s good for blister prevention, blister covering, ankle taping, and much more.
    • Gauze/ dressings (4-6) – different sizes and a few nonadherent (great for burns or abrasions).
    • Adhesive bandages (8)- various styles.
    • Roller gauze or vet wrap (2)- something to keep the gauze next to the wound that won’t cut off circulation. Vet wrap lasts longer than roller gauze.
    • Waterproof/ breathable (occlusive) wound dressings (2-3)*- an invaluable addition to wound care if you will be out for a few days. On a clean wound, this can create an environment conducive to healing that lasts a couple days. These are generally 2” x 3” or larger.
    • Tweezers- invest in a good pair (sharp and pointy), which will only cost a couple dollars more than a cheap pair.
    • Small magnifier- for wound cleaning. Be sure you have a reliably bright light source for wound exploration.
    • Wound cleaning*- a 60cc syringe (check the local feed store) with an irrigation tip is cheap and lightweight and gives better pressure than anything we could improvise.
    • Trauma shears (1)- there are some cool tiny ones (4”) on the market that only cost a few dollars and work great.
    • Blister care- Moleskin, foam, gel pads, or whatever your flavor. Duct tape should not be used on open blisters.

    Musculoskeletal injuries:

    • Compression wrap(s)- 3” works great for supporting ankles or knees.
    • Aluminum foam splint (1)
    • Triangular bandages (2)- these are multi-functional.

     

    Over the counter medications:

    • Pain management- ibuprofen and acetaminophen work in different ways. Bring what you prefer, and pack a few grains of rice if you have bottles of tablets. It keeps the tablets from becoming a paste in moist conditions.
    • Gastrointestinal meds*- antacids such as calcium carbonate, anti-diarrheal such as loperamide, or whatever works for you.
    • Antihistamines- diphenhydramine for allergic reactions. Epinephrine injectors are prescription only and should be carried by those who require them.
    • Topical antibiotic cream*- good for small, shallow wounds. No need to get a huge tube, and beware of antibiotic allergies among your group.

    Random other things and debatable items:

    • Your Field Guide of Wilderness & Rescue Medicine
    • Timepiece
    • Extra waterproof zip bags- these can be packaged with your SOAP note, pencil, and local emergency numbers.
    • Stethoscope*- If you are comfortable listening to lung sounds, I would recommend this for aquatic or altitude trips.
    • Oral glucose gel*- If you have honey in your camp kitchen, it will suffice. Many coffee shops have honey packets available as condiments- perhaps pick up a few with your purchase.
    • Temporary dental filling*- maybe not for a week-long trip, but it’s small, cheap, easy to find in the store, and can turn a trip around to the good easily.
    • Antifungal cream*- miconazole or clotrimazole would be good for a longer trip.

     Comfort care to be carried by individuals, depending on the environment:

    • Aloe*
    • Throat lozenges*
    • Lip balm
    • Sunscreen
    • Insect repellant
    • Contact care
    • Personal medications- asthma inhalers, etc.

    Much of this can be bought at local pharmacies, “feed and seed” stores, grocery stores, or through online retailers.

    Pick your vessel. You might be inclined to choose a zippered nylon clamshell with organizer pouches or see-through dividers. Or, if you are an ultralight hiker, you may choose waterproof zip-top bags. For paddling trips, dry bags or dry cases may be preferred if you can keep the inside dry (but I wouldn’t want to haul a dry box on a mountaineering trip!) Regardless of your outside package, it is worth the extra few minutes to compartmentalize your contents by thought- something that makes sense to you, like: big wounds; little wounds and blisters; common pills (like ibuprofen); uncommon pills (like GI meds); etc. I use a vacuum sealer when I am more worried about water seepage or risk management (this makes it inevitable to see if something’s been used, and then program managers know to seek out an incident report or replace stock).

    Have a great trip!

    *This assumes your survival gear (the rest of the ten essentials) is packaged elsewhere.


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    Wilderness First Aid (WFA) courses are taught by multiple individuals and programs.  They have become a standard for people working and recreating in the outdoors.  Are they effective?  Can the participants remember the information?  Can they perform the skills?

    To investigate these questions NOLS Wilderness Medicine Institute (WMI) conducted a research project to measure retention of WFA skills and knowledge.  There is literature on skill and knowledge retention in CPR and first aid, but nothing we could find on WFA courses.

    The research was conducted with our colleagues at the University of Utah; Scott Schumann PhD, Jim Sibthorp PhD and Rachel Collins MS.  At the conclusion of an open enrollment WFA course the study participants were given a written exam and an assessment of their confidence in their ability to perform their WFA skills.  At either 4, 8 or 12 months post course they returned to complete a scored skills-based scenario, familiar to anyone who has taken a WMI WFA course.  They also repeated the WFA knowledge and self-efficacy measures they took at the original training.   You can read the detailed study methodology, results and limitations at the Journal of Wilderness and Environmental Medicine http://wemjournal.org/.  

     

    Our findings are not surprising. 

    • We quickly forget what we do not practice. The longer the time from training, the more we forget. 

    • Written tests do not correlate with performance on practical tests.

    • Our opinions on our competence may not correlate with our practical performance. 

    The study participants demonstrated poor skill proficiency when taking vital signs, obtaining a medical history, and conducting the focused spine assessment (a selective spine immobilization protocol).  These results are consistent with studies that show first aid knowledge and skills, or any skills or knowledge for that matter,  deteriorate in the absence of repeated practice. 

    The poor skill retention seen in this study brings an interesting perspective to the complaints we hear about the burden of biannual recertification of WFA/WFR.  The American Heart Association suggests practicing medical professionals refresh their BLS skills more frequently than every 2 years.  We cannot assume that laypeople will retain their skills any better than practicing professionals.  Bravo to those organizations with ongoing training for their staff.

    The study did not look at teaching competency, but it does beg these questions.  The content may be basic first aid, but in our (albeit biased) opinion the volume of stuff in a WFA requires a skilled educator to have any chance for competent graduates.  WFA courses are taught by skilled educators and outdoor medicine practitioners, and they are taught by people who obtain a WFA instructional credential online with no verification they can teach effectively, have ever touched a patient or spent a night outdoors.  Buyer beware.   

    These results raise the question of the appropriate role for this certification.  The WFA course was designed as an introductory layperson first aid course for those close to help or assisting a more highly trained provider and is described in this context in the Scope of Practice document.  It has unfortunately evolved into a wilderness trip leader credential.

    We must also pause and ponder all the content people want crammed into this course.  Of everything we could teach, what needs to be learned by a layperson to practice wilderness first aid?  We have grown to expect more from this course than we can deliver in 16 hours of instruction.

    WMI doesn't find these results discouraging, nor did we choose, as can happen in product research, to bury the negative results.  We empirically assessed and now report our outcomes.  We have already revised our WFA curriculum.  We cut unnecessary content detail, including the focused spine assessment.  We found more practice time in a busy agenda.  We are developing other educational tools to increase retention.  We're excited to continue to evolve an important curriculum that is accurate, realistic and practical.

    Cordially

    Tod Schimelpfenig

    Curriculum Director

    NOLS Wilderness Medicine Institute

    Reference: Schumann SA , Schimelpfenig T , Sibthorp J , Collins RH. An examination of wilderness first aid knowledge, self-efficacy, and skill retention . Wilderness Environ Med. 2012;23:281–287

    September 2012


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    by Paul Auerbach

    Our National Parks are a treasured heritage, and one of the ways in which we appreciate the outdoors. Millions of visitors flock to the parks in order to camp, hike, climb, swim and most of all, appreciate the wonder and natural beauty of America. As with any other outdoor setting, there are risks of injuries and illnesses. A recent cluster of cases of hantavirus pulmonary syndrome apparently originating from Curry Village in Yosemite National Park this summer points this out.

    Hantaviruses (such as the sin nombre virus) cause a syndrome characterized by a combination of fever, lung failure, kidney failure, shock, and bleeding. The viruses are spread in the excreta of rodents; in the United States, hantavirus pulmonary syndrome (HPS) has been linked to the deer mouse (Peromyscus maniculatus) and white-footed mouse (P. leucopus), as well as to the cotton rat (Sigmodon hispidus) and rice rat (Oryzomys palustris). The animals shed the virus in saliva, urine, and feces. Aerosols are the most likely route of transmission from rodents to humans. Insect bites have not yet been implicated in transmission. The virus found in the U.S. is not known to cause human-to-human transmission.

    The deer mouse is a creature that is adept at squeezing through very small openings. In the case of Curry Village at Yosemite, mouse nests have been found in the wall spaces of tent cabins, and mice have tested positive for the virus from around the park.

    HPS  has been reported in most states west of the Mississippi River, as well as in a few eastern states. In Louisiana and Florida, two hantavirus species, bayou virus and Black Creek virus, have been identified. A person infected by the virus has an incubation period of 1 to 6  weeks after exposure, and then suffers from fever, muscle aches, headache, cough, dizziness, abdominal pain, nausea and vomiting, and diarrhea for a few days; this is followed by difficulty breathing, mottled skin on the limbs, shock, and, sometimes, bleeding. In the U.S., approximately a third of victims die.

    Most victims have had an interaction with rodents, such as when cleaning a barn or capturing the animals. Unfortunately, there is not yet any specific therapy beyond supportive care. Because a person with hantavirus infection may become seriously ill at a rapid rate, it is important to promptly bring any suspected victim to medical care.

    To avoid unnecessary exposure to hantavirus, it is recommended that wilderness enthusiasts observe the following precautions:

    • keep food and water covered and stored in rodent-proof containers
    • dispose of food clutter
    • spray dead rodents, nests, and droppings with disinfectant before handling (wear gloves)
    • clean and disinfect cabins and other shelters thoroughly before using
    • don’t make camp near rodent sites
    • don’t sleep on bare ground 
    • burn or bury garbage promptly 
    • discard food that looks like it may have been chewed upon by rodents
    • use only bottled or disinfected water for campsite purposes.

     

    Reprinted with permission from Healthline.com


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    The Wilderness First Aid (WFA) course, widely taught by numerous providers, can be burdened with unrealistic expectations of the topics and skills that can be taught in a basic layperson first aid program.

    In 2010, sensing a need to clarify what first aid skills and knowledge are realistic and practical for a WFA provider representatives from the major wilderness medicine educators created a WFA Scope of Practice (SOP) document.  The SOP is in essence a job description of what a WFA provider should know and what skills they should and should not be able to perform. 

    The original writing group convened this fall to review and update the WFA SOP.  Two years have passed since the original document and with the publication of the WFA Skills Retention Study a review was timely.  The latest version articulates the minimum skills and knowledge base for a WFA provider.

    Another ongoing project is a review of the medical evidence supporting WFA practices.  Several representatives of wilderness medicine schools are on this Wilderness Medical Society working group.  We hope to see publication of this work in 2013. 

    This SOP document is not binding on anyone.  It is not crafted as a curriculum.   It reflects the consensus of a group of providers who created and have taught this course to tens of thousands of students over three decades and who are actively engaged in the practice of wilderness first aid.  It is our hope that it provides some guidance to those who teach WFA and guidance for the outdoor program manager deciding on the appropriate certification for their staff and for the consumer who is choosing between different certifications.  

    We invite observations and comments, which can be submitted to any member of the working/writing group, and for organizations/individuals to indicate their support for this work by adding their signatures.

    Cordially

    Tod Schimelpfenig

    Curriculum Director

    NOLS Wilderness Medicine

    December 2012


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