Outdoor Ed Community

Wilderness Medical Society Meeting WFA Discussion

Tod Schimelpfenig — Mon, 26 Jul 2010 16:54:00 GMT

On Sunday evening July 25^th Tony Islas MD, president of the Wilderness Medical Society (WMS) hosted a meeting of wilderness medicine providers at the summer meeting of the WMS. All of the major providers were represented, including the Red Cross and members of ski patrol, representatives from AORE and WEA, Todd Minor from Cornell, the military and people just interested in local wilderness medicine education and a lively discussion. It was a great turnout of people and a pivotal evening for wilderness medicine.

Tony spoke of the role of the WMS in wilderness medicine education, and his desire that the society serve as a forum for discussion and a source of expertise for the industry. I’m excited about this agenda. We are the educators of the lay public and outdoor professionals. An active line of communication between the wilderness medicine instructor and the society will be a good thing–enhancing consistency and quality. He stated that the society is not interested in developing or endorsing a specific curriculum, in program accreditation or instructor credentialing. They do want to take the Scope of Practice documents our working group has developed and publish these as consensus position statements in the Journal of Wilderness and Environmental Medicine. It’s a sound endorsement of our work and will make the document available in the medical literature.

We have some more work to do incorporating feedback we have received, especially some thoughtful comments from AORE. We’ll have one more chance for anyone interested to comment in the months ahead. We’ll then craft the SOP’s into publishable form.

We’ve been asked about program accreditation, instructor credentialing, consistent certification lengths and quality assurance. These may be issues we want to address down the line, but first things first. Let’s get these SOP’s done.

Tod Schimelpfenig
Curriculum Director
WMI of NOLS

New Zealand Coroner's Report has Lessons for all of us

Rick Curtis — Mon, 19 Jul 2010 00:47:00 GMT

The New Zealand Mountain Safety Council (MSC) has issued a press release regarding the New Zealand Coroner's Report on the deaths of six high school students and a teacher on April 15, 2008 in a canyoning accident on a program run by the Sir Edmund Hillary Outdoor Pursuits Centre (OPC). I blogged about the original incident back in April 2008. Having been to OPC and knowing some of the staff I understand how devastating death on a program can be.

In the two years since the tragedy the families have struggled to understand what happened as has the lone instructor who was leading the trip. No criminal charges were filed, but OPC was charged under the Health and Safety in Employment Act that included:

The Centre's obligation to ensure the safety of other people in the place of work.
The Centre's obligation to ensure that its employees' actions didn't expose others to avoidable risks.
The Centre's obligation to protect the instructor who went into the gorge with the school party.

In March 2009 OPC was fined $40,000 and ordered to make $440,000 in reparations to the families of those involved in the accident under the Health and Safety in Employment Act. Since the accident a number of administrative staff working at the Centre have resigned, many of them understandably coping with the tragedy.

The Coroner's Report is a factual and often chilling account of what transpired. It paints a detailed picture of an accident taking place, a series of events that cascaded into tragedy and points out weaknesses within operating and program structures that are not unique to OPC. The Coroner's Report is something that every outdoor program should read. The thirty-nine page report describes in detail the incident itself and the other events and structures at OPC. Numerous contributing factors were identified by the Coroner:

Risk Analysis
Required Assessments of weather impact on activity
Instructor qualifications for a Gorge trip
Historical knowledge of past flooding events
Swimming ability and connecting swimmers
Escape routes and refuges
Radio reception
Rescue plan
Throwbagging
Staff to student ratio
Monitoring the environment
Non compliance with policies
Audit/Accreditation
Independent Review

In his summary the Coroner is quite clear on the major factors that lead to this accident:

"Regrettably, lack of environmental awareness, lack of instructional use of historical information, instructor inexperience, lack of proper assessment before the gorge was entered to ensure there was no significant chance of water levels rising above a safe level during the trip, lack of or inadequate communication when in the gorge between the instructor and the Field Manager or OPC base staff, failure to implement a crisis plan and dispatch response teams in a timely manner, under-estimation of risks, and complacency contributed to the tragic deaths of six students and one teacher."

This was a tragedy for all of New Zealand and for outdoor programs around the world. I post this blog in part to respond to the call from the MSC for people to learn from the tragedy. Like other significant tragedies in outdoor education that have been extensively written about (ex. Lessons Learned by Deb Ajango), the Coroner's Report is a reminder, and a wake-up call for all outdoor programs. I strongly encourage all of you to read the report in detail, share it with your staff, and carefully review the contributing factors in this incident. I think every program will find at least one familiar thread that applies to your operation. I know I did.

'There, but for the grace of God, go all of us.'

Download the Coroner's Report

Children & Nature Network releases Natural Leaders Network Toolkit

Outdoor Ed — Mon, 05 Jul 2010 23:48:00 GMT

The Children & Nature Network (C&NN) was created to encourage and support the people and organizations working nationally and internationally to reconnect children with nature. The network provides a critical link between researchers and individuals, educators and organizations dedicated to children's health and well-being.

C&NN has just annnounced the release of the Natural Leaders Network Toolkit. This tool kit is a guide for all youth around the world who want to start Natural Leaders action groups or networks. It’s like a road map to figure out how to get started and where to go with your work. It offers some cool ideas and gives examples of how you might build your own Network. You will find stories of current Natural Leaders and the work they are doing, as well as the history of the Natural Leaders Network and how Natural Leaders fit into the greater movement to reconnect kids to nature. Go ahead, download it now and start reading.

The Children & Nature Network launched the Natural Leaders Network in 2008 to encourage young leaders to take decisive action against nature-deficit disorder. With founding support from the Sierra Club’s Building Bridges to the Outdoors, and the corporate support of The North Face, we are ready to take on this challenge.

Reports from the Children & Nature Network

June is the nation’s Great Outdoors month, proclaimed by the President of the United States and all 50 state governors. The Children & Nature Network (C&NN) is among those organizations celebrating and supporting Great Outdoors month. C&NN has chosen the occasion to announce the release of two major studies it commissioned with funding support from the W.K. Kellogg Foundation.

The “American Beliefs Associated with Children’s Nature Experience Opportunities: Development and Application of the EC-NES Scale,” was conducted by the Maryland-based independent non-profit learning research Institute for Learning Innovation (ILI) at the request of the Children & Nature Network. Authors are John Fraser, Ph.D.; Joe E. Heimlich, Ph.D.; and Victor Yocco. This is the first study to establish a baseline measure of the attitudes of the American public concerning the importance of direct experiences in nature for children’s healthy development. Among its findings, the survey indicates that parents and others in the public see the benefits to children’s physical development and their love of nature from nature-based experiences, but do not tend to see the cognitive, emotional and social benefits from those experiences. The study also revealed a wide age differentiation—the younger the adult participating in the survey, the less likely he or she is to see the benefits for children’s healthy development from these experiences in nature.

While the public reports positive attitudes about children playing outdoors in nature, the respondents also reported barriers. The most dominant was concern about safety. Respondents reported significant differences between locations where they played as children, such as woods, and where they let children play today, such as indoors. They identified “wilder” places like woods, streams and ponds as the riskiest locations.

To C&NN, this discrepancy strongly suggests that the movement must develop new ways for parents to feel safer introducing their children to nature, such as Family Nature Clubs (http://www.childrenandnature.org/movement/natureclubs/).

“We believe this landmark study is the first but not the last of its kind,” said Cheryl Charles, Ph.D., President and CEO of the Children & Nature Network. “During the next five years, we hope to see the children and nature movement reach more people, of all income and cultural groups, and that, in the next survey, they report an even stronger appreciation for the importance of children’s direct experiences with nature for their healthy development —along with a greater willingness to make those opportunities possible for every child, every day.”

The second study, C&NN’s Grassroots Survey, developed by the Children & Nature Network’s national Grassroots Leadership Team with independent analysis of the results by professional evaluator, M. Lynette Fleming, Ph.D., provides a baseline measure of the growth of the “children and nature movement” as reported by grassroots leaders and representatives of the more than 70 campaigns working to reconnect children and nature. These campaigns are registered on the Children & Nature Network’s map of the movement (www.childrenandnature.org), located in more than 40 states—spanning cities, states and regions. These campaigns, in total, report between 900,000 to 1.5 million participants during 2009.

Among other findings, reported as changes since their children and nature campaigns started:
• 74% of the campaigns report an increase in community support;
• 71% report increased awareness of the importance of nature for children’s healthy development;
• 71% report increased media attention; and
• More than half report an increased number of people participating in events and programs.

In addition, Fleming reports a trend toward collaborative efforts to support the growth of the children and nature movement, rather than individual efforts by individual organizations and agencies—locally, regionally and nationally.

“This report is the first to quantify the numbers of people reached as well as the value of the resources that the Children & Nature Network provides in the effort to nourish and support this movement,” said Betsy Townsend, Founding Chair of C&NN’s national Grassroots Leadership Team and a member of the C&NN Board of Directors. “I am inspired by these indicators of progress—and compelled by how much work we all still need to do to reverse the trend that Richard Louv, co-founder and Chairman of C&NN, has called nature-deficit disorder.”

“I am heartened by the rapid growth of the children and nature movement, evidenced in part by these studies,” said Richard Louv, C&NN co-founder, Chairman, and author of Last Child in the Woods: Saving Our Children from Nature-Deficit Disorder. “However, more research is needed on a number of fronts. And we are a long way from reaching our goal of every child experiencing their birthright of experience in the natural world, which we believe offers better health, improved learning abilities, and a sense of wonder.”

2009 Independant Baseline Study
The “American Beliefs Associated with Children’s Nature Experience Opportunities: Development and Application of the EC-NES Scale,” is the first study to establish a baseline measure of the attitudes of the American public concerning the importance of direct experiences in nature for children’s healthy development.Download PDf

2009 Grassroots Survey
The second study, C&NN’s Grassroots Survey, developed by the Children & Nature Network’s national Grassroots Leadership Team with independent analysis of the results by professional evaluator, M. Lynette Fleming, Ph.D., provides a baseline measure of the growth of the “children and nature movement” as reported by grassroots leaders and representatives of the more than 70 campaigns working to reconnect children and nature. Download PDF

Health Benefits to Children from Contact with the Outdoors & Nature
The following is a synthesis of selected research and studies on health benefits. These studies, along with others, were originally published as part of C&NN's four volumes of annotated bibliographies of research and studies listed below. Download PDF

Children's Contact with the Outdoors & Nature: A Focus on Educators and Educational Settings
The following is a synthesis of selected research and studies that focus on education and educational settings. These studies, along with others, were originally published as part of C&NN's four volumes of annotated bibliographies of research and studies listed below. Download PDF

Children and Nature 2009: A Report on the Movement to Reconnect Children to the Natural World
Download PDF [1.1MB]

C&NN Community Action Guide: Building the Children & Nature Movement from the Ground Up
Download PDF [1.4MB]

Consensus Altitude Guidelines

Tod Schimelpfenig — Sun, 27 Jun 2010 01:31:00 GMT

Folks

The Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for prevention and treatment of acute mountain sickness, high altitude cerebral edema and high altitude pulmonary edema. These recommendations are published in the current edition of the Wilderness and Environmental Medicine Journal (Vol 21 (2), 146-155, 2010). This is the first in what I expect will be a series of consensus statements addressing wilderness medicine practices. While written for physicians and including prescription medication advice that is beyond the scope of practice of lay first aid providers, there are some sound evidence based recommendations supporting the common practices for prevention through gradual ascent and treatment with descent. I don’t read any significant changes from current recommendations or from what is commonly taught in reputable wilderness medicine courses.

You can access the article here: wemjournal.org/.

Take care

Tod Schimelpfenig
Curriculum Director
Wilderness Medicine Institute of NOLS

WFR Scope of Practice Draft

Tod Schimelpfenig — Fri, 21 May 2010 15:26:00 GMT

The group of wilderness medicine providers working on scope of practice documents have completed a draft of a Wilderness First Responder (WFR) Scope of Practice (SOP) Guideline to accompany the Wilderness First Aid (WFA) SOP published last fall. We’re circulating the WFR SOP draft to provide an opportunity for public comment

In 1999 a number of prominent wilderness medicine course providers made copies of their curriculum available and participated in a discussion that resulted in the Wilderness Medical Society Wilderness First Responder Recommended Minimum Topic List. ¹ This has remained the most prominent published document defining the WFR. David Johnson MD of Wilderness Medical Associates and I have been talking for several years about curriculum consistency in wilderness medicine. We decided in the winter of 2009 that it was time to move forward on this question and to approach this project by first defining what a WFA and WFR should know and what they should be able to do, their “scope of practice.”

It’s not a curriculum, set of lesson plans or supporting text. There are plenty of these available to those who wish to teach. We have no enforcement ability or agenda and our work is non-binding. We do hope it sets some boundaries and clarifies these credentials.

The process of circulating and discussing drafts among the working group has been educational and collegial. We don’t all agree on every detail of the document - we’re a bunch of opinionated medical geeks - but we have been able to achieve a consensus.

The field of wilderness medicine has been accused of designing courses without any basis in medical evidence. I disagree. There is evidence, and we use it.² Granted, much of it is tradition, expert opinion or educated guess, but this “level of evidence” abounds in first aid. Good science on whether a technique actually changes the outcome is often lacking, especially in a wilderness context. We have to extrapolate an urban study to the wilderness. We have to use our experience, as biased as it may be. We’re well aware of the ongoing arguments over the effectiveness of various first aid skills. The SOP reflects our distillation of this material into a set of practical and relevant skills that we can reasonably expect a lay medical provider to perform in the field and that will help, and not harm the patient.

One of the challenges of wilderness medicine is the many different contexts of practice. Hikers and paddlers will have different injury/illness profiles, as will adventure racers, outdoor programs and rock climbers. There are consistent themes; soft tissue and athletic injury, flu-like and GI illness are common. We also know we carry our medical history with us, and that people can have cardiac, respiratory and other medical events in the wilderness. The SAR reports show us the rare severe injury events. Those who argue that wilderness leaders need only rudimentary medical skills don’t appreciate this breath of need.

Our focus is on the first aid. Of greater importance are the fundamental outdoor skills, leadership and judgment that are the foundation of prevention and ultimately more powerful medicine that the first aid we can practice in the wilderness.

We’ll gather input through the summer and meet at the Wilderness Medical Society meeting in Snowmass in July to discuss next steps. I’m asked whether a standard curriculum or wilderness medicine program and instructor accreditation are next. I don’t know. I do know, as Steve Donelan wrote recently in the WEM Journal, “Even an evidence based, standardized curriculum cannot guarantee that students will learn. Whether our classes are effective in preparing students for real emergencies still depends more on how we teach than on what we teach.”³

Wilderness Medical Society Curriculum Committee. Wilderness First Responder: Recommended Minimum Course Topics. Wilderness & Environmental Medicine, 10, 13-19.1999.
Islas T. What kills us in the woods. Syllabus, 25th Annual Meeting of the Wilderness Medical Society. Snowmass, CO.; July 2008,
Donelan S. Classroom and Reality: What Should We Teach in Wilderness First Aid Courses? Wilderness & Environmental Medicine, 21, 64–66 (2010)

Outdoor Nation: Empowering the nation's youth outdoors

Outdoor Ed — Mon, 10 May 2010 03:06:00 GMT

Outdoor Nation is a growing community of young Outsiders -- artists, athletes, advocates and ambassadors -- who have joined together to champion the outdoors. This new youth-led movement will reclaim, redefine and rediscover the outdoors - building an Outdoor Nation for this and future generations.

How to Get Involved!

Share this application http://www.outdoornation.org/summit with your networks: Facebook, Twitter, emails, friends and colleagues and encourage them to apply.

Outdoor Nation will:

Mobilize a movement by empowering young people across the country to champion the outdoors and outdoor issues
Influence federal, state and local outdoor policies and programs
Provide advice and a youthful perspective to outdoor companies and organizations
Create a community that shares outdoor passions and organizes outdoor outings
Host events that bring the Outdoor Nation together - providing networking and training opportunities

Outdoor Youth Summit and Festival

On June 19 and 20, thousands of Outsiders from Outdoor Nation will join together for the world's first two-day Outdoor Youth Summit and Festival in New York City's famed Central Park. This event will unite young people from across the country with a common mission: to champion the outdoors and advance a youth-driven movement.

Outdoor Nation Festival

On June 19th, thousands of young people of all ages will join together to celebrate the active, outdoor lifestyle. This multi-faceted event will turn the world's iconic urban park into an adventure playground and festival - fusing pop culture with an outdoor ethic and lifestyle. All activities will be inclusive, open to the public and free of charge.

Outdoor Nation Summit

On June 20th, Outdoor Nation will bring together young people from all 50 states to take part in an Outdoor Youth Summit to develop a national agenda, set priorities and outline strategies to champion the outdoors. The Summit will enable young leaders to craft and deliver their message of change to the country as well as exchange ideas, skills and connections -- building a strong Outdoor Nation for all.

Coalition

Supported by a coalition of more than 40 organizations - including The Outdoor Foundation, The North Face, REI, National Park Service and the Recreational Boating and Fishing Foundation -- Outsiders will receive the tools, training and social support they need to spur a cultural revolution that leads to a strong Outdoor Nation.

Bacterial Diarrhea

Paul Auerbach — Mon, 03 May 2010 01:04:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

Foodborne bacterial diarrhea is a common problem of backpackers, kayakers, divers - of anyone who ventures into the outdoors and is therefore associated with ingestion of fresh fruits and vegetables, travels to developing countries, practices inadequate hygiene, or even dines in public restaurants. Diagnosis and treatment of infectious diarrhea (bacterial, protozoal, viral, and other causes) is an essential skill for the wilderness medicine practitioner.

In an article (New England Journal of Medicine 2009;361:1560-1569) entitled "Bacterial Diarrhea," my good friend Dr. Herbert DuPont of the University of Texas School of Public Health and the Baylor College of Medicine provided a phenomenal update on the topic. There is a wealth of information in the article, so I will hit a few of the facts and figures that should be of greatest interest to this particular readership.

Campylobacter, nontyphoid Salmonella, Shiga toxin-producing E. coli, and Shigella bacteria are common causal agents of bacteria-induced diarrhea in the U.S. Other bacteria are more frequently associated with particular environments, such as Aeromonas in tropical regions. Plesiomonas shigelloides is associated with seafood ingestion and international travel.

The article was U.S.-focused. Acute watery diarrhea should bring to mind E. coli, Salmonella and Campylobacter. Bloody diarrhea ("dysentery") is suggestive of colitis. The four major U.S. causes, in descending order, are Shigella, Campylobacter, nontyphoid Salmonella and Shiga toxin-producing E. coli.

Food poisoning is the term used when a preformed toxin in good is eaten, which causes intoxication rather than an infection. A common culprit is Staphylococcus aureus. Others are Clostridium perfringens and Bacillus cereus.

Traveler's diarrhea can be caused by many different bacteria, but the most common is E. coli. Persons with traveler's diarrhea may be treated empirically with antibiotics without having their stool examined under the microscope or by stool culture. To prevent the disease, rifaximin in a dose of 200 mg once or twice a day taken with major meals while in the affected area appears to be effective. Indications for prophylaxis include an important trip, underlying illness that might be worsened by the disease, condition in which someone might be more prone to diarrhea, or suggestion that a person has increased susceptibility for some other reason.

Treatment recommendations are discussed. For all cases of diarrhea, attention to fluid and electrolyte replacement is essential. A diet of easily digestible food or a diet of bananas, rice, applesauce and toast is often recommended, but there is no evidence that such diets hasten recovery. It is important to keep the victim hydrated and nourished as best possible, which supports the concept of oral feeding. Drugs that diminish the number of bowel movements, such as loperamide, may be helpful. If the victim suffers from fever or dysentery, then antimotility drugs should only be used in combination with antibiotics.

This is an important and comprehensive review article for anyone interested in bacterial diarrhea. There are complete antibiotic recommendations, lists of complications, and discussion of areas of uncertainty. While the article is written for doctors, it has much information that can be understood and used effectively by laypersons.

Evolving Snake Venom

Tod Schimelpfenig — Mon, 19 Apr 2010 02:56:00 GMT

Have you heard the story of evolving snake venom? Apparently snake venom in general is becoming more potent and, gasp, snakes have been interbreeding and sharing potent neurotoxins. Alas, while this is good stuff for horror movies, it’s not yet been scientifically demonstrated and probably isn’t true.

There were several media articles in 2009 describing the increasingly potent snake venom. Since then I've been asked a number of times about this concept, and have listened to people state this as a fact. There is an article in the most recent Wilderness and Environmental Medicine (WEM) Journal that discusses this question in depth.

According to the authors, both very reputable snakebite researchers, it's only speculation that snake venoms are quickly evolving, or becoming more toxic.

The concept that snakebites are becoming worse has not been demonstrated in the medical literature. The perception that they are worse can be influenced by media drama, especially 'real-life' television drama or the dramatic images of a few isolated bites that circulate on the internet. The WEM paper describes how an isolated case report became media drama when opinions of experts who questioned the hypothesis of rapidly evolving venom were not included in the lay press articles.

Venom composition and toxicity varies within populations of the same species of snake, which may account for the different s/s and an illusion of evolution. If the average envenomation is indeed becoming more severe, the paper offers several other possible explanations including larger snakes, more provoked bites, and the difficulty of comparing severity in the face of changing snakebite treatment protocols over the years.

I've heard that the Mojave rattlesnake is interbreeding with other populations and spreading it's neurotoxin around. This has not been demonstrated. The "Mojave neurotoxin" has been identified in some isolated Southern Pacific rattlesnake populations, but these are not near populations of Mojave rattlesnakes. It may well be that we are simply getting better at identifying the many toxins in snake venom.

The article also discussed the pace of evolution, which doesn't match the rapid changes supposedly happening.

So, we don't know if venom is rapidly evolving or becoming more potent. We do know we are always vulnerable to the dramatic story, especially if in involves snakes, spiders or other creepy crawlers.

Take care

Tod

Hayes W and Mackessy S. Sensationalistic Journalism and Tales of Snakebite: Are Rattlesnakes Rapidly Evolving More Toxic Venom? Wilderness and Environmental Medicine, 21, 35-45 (2010)

Raynaud's Phenomenon and Altitude

Paul Auerbach — Mon, 22 Mar 2010 03:22:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

In a past issue of Wilderness and Environmental Medicine (Volume 20, Number 2, 2009), Andrew Luks and colleagues published an article entitled “Can People with Raynaud’s phenomenon Travel to High Altitude?” The purpose of their inquiry was to determine whether high altitude travel adversely affects mountain enthusiasts with Raynaud’s phenomenon (RP).

RP is constriction of tiny blood vessels in the fingers and/or toes after exposure to cold or an emotionally stressful situation. The initial appearance is one of severely blanched (whitened) or bluish skin, often with a sharp “cut-off” margin in the midportion of the digit(s). This is caused by decreased circulation. The episode ends with vigorous reflow of blood into the digit, which causes it to become warm and reddened. This phenomenon is different and much more pronounced than the normal mottling or diffuse and persistent discoloration sometimes seen in hands and feet exposed to cold. RP is usually symmetrical, involving both hands or both feet, and is usually apparent in sufferers by the age of 40 years. Because RP can be associated with a number of underlying diseases or anatomic abnormalities, a first-time sufferer should seek medical evaluation. Prevention in the outdoors involves primarily protecting the hands and feet and keeping them warm, avoiding drugs that cause blood vessel constriction, and prohibiting tobacco use. Many drugs have been recommended at one time or another to treat RP, but at the currrent time the calcium-channel blockers (such as nifedipine) and drugs that block the sympathetic nervous system (which causes blood vessels to constrict) are most in favor as therapies for use outside of the hospital. Blood vessel dilators, such as nitroglycerin or niacin, have not been proven effective.

Volunteers with RP were recruited to complete an online anonymous survey, which addressed aspects of their RP and mountaineering activities. Eighty-nine percent of respondents engaged in winter sports, but only 22% reported changing their mountain activities because of Raynaud’s phenomenon. Only 12% used prophylactic medications to attempt to prevent or mitigate their RP. Fifteen percent of respondents reported an episode of frostbite following a RP attack at high altitude.

The conclusions were that motivated individuals with primary RP, employing various prevention and treatment strategies, can engage in different activities, including winter sports, at altitudes above 2440 meters. Frostbite may be common in this population at high altitude, and care must be taken to prevent its recurrence.

image courtesy of www.clevelandclinic.org

Wilderness First Aid Scope of Practice Update

Tod Schimelpfenig — Fri, 12 Mar 2010 21:08:00 GMT

Folks

This is an update on the wilderness first aid scope of practice process and documents.

Our group of colleagues have been working steadily on these documents.We have circulated several drafts of the Wilderness First Aid (WFA) Scope of Practice document, considered the feedback we have received and are close to a final draft. We’ve also been working on a Wilderness First Responder Scope (WFR) of Practice document and have a solid working draft which the providers are reviewing.We hope to post this for review later this spring.

One of the challenges we face is balancing the needs of a large spectrum of students, from outdoor trip leaders to camp staff and non-institutional outdoor recreationists, with the length of the course and our ability to deliver the material effectively. A WFA is a basic and introductory course in wilderness medicine, yet we’ve been asked to teach GPS and survival skills, detailed emergency plans, improvised litters, and a wide variety of medical topics. The elder hostel argues for cardiac curriculum, the therapeutic program for mental health curriculum, the ocean-based program for marine toxins, the high latitude program for more on cold injury. Folks up north don’t want to hear about heat illness and folks down south don’t want to hear about frostbite.

Choices must be made. As we develop each SOP document, we consider the available medical evidence, input from a variety of sources including practitioners, educators, and consumers, and our collective experience as guides, trip leaders, medical providers and professional medical educators.

We have had many collegial and interesting discussions on what should or should not be included in the scope of practice of a WFA .It is easy to reach consensus on the majority of the content. We spend most of our time on the question of what should be core and what can be an elective skill or topic. There is a need to balance a clear minimum standard for this credential while providing some flexibility to meet individual program needs.

I’m excited that the Wilderness Medical Society (WMS) will consider publishing the scope of practice documents in a consensus position statement on wilderness medicine courses for laypeople. The WMS is writing a series of position statements on important issues in wilderness medicine. The first consensus statement, on altitude illness, will be published in the next edition of the Wilderness and Environmental Medicine Journal. A statement on frostbite treatment is also being developed. Tony Islas MD, incoming WMS President, has offered the WMS as a place to support periodic, perhaps annual or biannual, gatherings of wilderness medicine providers to discuss common issues and revise these documents as needed. I think this is an excellent forum for us to publish our work and continue our conversations. The consensus position statement brings the weight of the society to bear on this question, and it's very appropriate.

A copy of the most current WFA SOP is attached (see the attachment link below). We are still open to comments.

Take Care,

Tod Schimelpfenig
Curriculum Director
Wilderness Medicine Institute of NOLS

Tick-Borne Illness

Paul Auerbach — Sat, 06 Mar 2010 22:02:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

This is the next post based upon a presentation given at the Wilderness Medical Society Annual Meeting held in Snowmass, Colorado from July 24-29, 2009. The presentation was entitled “Lessons Re-learned: The US Army’s Experience with Tick –Borne Illness.” It was delivered by John Westhoff, MD, who is a Fellow of the American College of Emergency Physicians.

Dr. Westhoff made a number of great points, in a session that mentioned Rocky Mountain spotted fever, ehrlichiosis, Lyme disease, tularemia, Q fever, and southern tick-associated rash illness (STARI).

A case presentation format was used to highlight the varied way and severity in which some of these disorders can present to clinicians. For instance, a case was described in which the victim was a 49 year old with a 24 hour history of headache and chills, mildly elevated blood pressure – pulse – respirations – temperature – white blood cell count, and was initially given the diagnosis of sinusitis. One day later, the patient was seen with persistent problems, and informed of a working diagnosis of viral syndrome. Three days later, the patient had developed subjective numbness in the hands and feet, and still had a progressive low grade fever, but the white blood cell count had dropped to normal. The working diagnosis was still viral syndrome. On the fourth visit, the victim underwent a spinal tap (lumbar puncture) and was admitted to the hospital. A skin rash developed and blood testing revealed that the patient suffered from ehrlichiosis, from which there was a full recovery.

Ehrlichiosis can be severe. Dr. Westhoff described another case, in which a young man who initially presented with fever and chills and not much more deteriorated over three days sufficiently to be admitted to the hospital, and died after 8 days in the hospital, again with a diagnosis of ehrlichiosis. During his illness, he suffered from skin rash, muscle pain, high fever, infiltrates (consistent with pneumonia) in his lungs, low blood counts, and severe systemic infection with multi-organ failure. Ticks were found in his groin.

Human ehrlichiosis (there is also a canine form) is present in two forms, one caused by a rickettsial organism known as Ehrlichia chaffeensis, which is spread by Amblyomma americanum tick bites, and the other caused by the rickettsial organisms E. phagocytophila and E. equi, spread by Ixodes tick bites. Infection is usually acquired by a person who inhabits a rural environment. The average incubation period after a bite is approximately 7 to 10 days. The victims, who are more commonly middle-aged adults than children and young adults, complain of a flu-like syndrome with high fever, chills, fatigue, headache, muscle aches, vomiting, and a variety of skin rashes, which can be punctate, bumpy, like tiny bruises, or broad and reddened. A victim often has decreased counts of various types of blood cells, as well as liver dysfunction. The treatment is tetracycline 500 mg four times a day, or doxycycline 100 mg twice a day, for 10 days. The few children who have been diagnosed with ehrlichiosis have been treated with doxycycline 3 mg per kg of body weight in two divided doses per day. Untreated or treated after a delay in diagnosis, up to 15% of victims can develop severe infections, kidney failure, bleeding disorders, seizures, and/or coma.

Human anaplasmosis, which was formerly called human granulocytic ehrlichiosis, is caused by infection of white blood cells by a bacterium named Anaplasma phagocytophilum. Like ehrlichiosis, anaplasmosis is disseminated by bites of Ixodes ticks, the blacklegged tick (I. scapularis) in the Northeast and upper Midwest, and the western blacklegged tick (I. pacificus) on the West Coast. Infected persons have the onset of illness 5 to 21 days after a bite with symptoms of fever, headache, fatigue, and muscle aches, which may progress to more serious illness affecting the kidneys, central nervous system, lungs, and blood system. The treatment is the same as for ehrlichiosis.

We also learned about Rocky Mountain spotted fever (RMSF), which is most commonly seen during the months of April to September, when ticks and humans are most frequently in contact. The disease carries an incubation period of 5 to 10 days, and classically presents with fever (flu-like illness), typical rash 2 to 5 days after the fever, and a history of tick bite. Treatment is usually with doxycycline 100 mg by mouth every 12 hours (4 mg/kg/day for persons under the weight of 45 kg) for 10 days. Chloramphenicol is used for pregnant patients.

After a further discussion of features of ehrlichiosis and Lyme disease and brief discussion of tularemia, Q-fever, and STARI, the bulk of the remainder of the session was devoted to the most important topic – namely, prevention of tick-borne illnesses. The key features noted were personal skin inspection to locate and remove ticks, heightened awareness during tick season, use of appropriate insect repellents, such as DEET (33% controlled release lotion), permethrin treatment of clothing, proper wearing of clothing (long sleeves, tucked in shirts and pants), and so forth. It was emphasized that permethrin treatment of clothing is much more effective than is DEET treatment of clothing.

If you decide to apply permethrin spray to clothing, be certain to do the following:

1) Follow manufacturer’s instructions closely. Do not exceed recommended spraying times.
2) Treat clothing only. Do not apply to skin.
3) Apply the permethrin in a well-ventilated outdoor area, protected from the wind.
4) Only spray the permethrin on the outer surface of clothing and shoes.
5) In a concentration of 0.5%, it can be sprayed on both sides of clothing to lightly moisten the outer surface of the clothing item; it is not necessary to have the clothing soaked through (saturated).
6) Be certain to apply completely cover socks, trouser cuffs and shirt cuffs, where insects may attempt to crawl or fly through openings to your skin.
7) Hang treated clothing outdoors and allow to dry for at least 2 to 4 hours in non-humid conditions and for at least 4 hours in humid conditions.
8) Treat clothing no more often than every 2 weeks.
9) Launder treated clothing separately from other clothing at least once before re-treating.
10) Assume that your treated clothing is effective for repellency for 2 weeks or more. Wear it only when you need to repel insects and arthropods. Store it in a separate impermeable (to permethrin) bag when not in use.

Future Trends in Outdoor Education

Jay Roberts — Fri, 12 Feb 2010 15:16:00 GMT

As we turn the corner away from the 00’s or the “aughts” or whatever historians will choose to call the last decade, it’s worth taking a moment to look ahead toward future trends and issues that will affect things in the outdoor education field for the next ten years or so. Future prognosticating is, of course, a dangerous game and I make no claims that my reading of the tea leaves is any better than anyone else’s guesses. However, I do keep up to date on the goings on in the field as best as I can and spend a good deal of time talking about these issues with colleagues at other programs, institutions, and conferences. So, without further ado, here are my top five trends (in no particular order) in Outdoor Education for the 2010’s...

1. LOCALISM: The impact of the “great recession” is certainly being felt in outdoor education. People are “nesting” more, staying closer to home, and looking for ways to enjoy the outdoors in simpler, more frugal ways. This dovetails nicely to the emerging localism movement connected to broader sustainability and environmental shifts in certain segments of the population. Interest in gardening, local green spaces, and getting kids out in nature is on the rise across the board. How can outdoor education, as a field, tap into this social shift in a way that democratizes nature and challenges some of the elitism and narcissism that has defined outdoor pursuits over the last several decades?

2. SUSTAINABILITY: It’s hip, it’s green, and it’s everywhere. Whether you think this new movement is shallow or deep, it is certainly influential. Equipment manufacturers are going green, ski slopes and other outdoor industries are ramping up sustainability efforts, and even travel and guide purveyors like REI are offering carbon off-sets for eco-tourist travel. Green gear lists for programs are on the rise as are attempts to lower the carbon footprints of everything from college outdoor programs to summer camps to environmental education centers. How can outdoor education act as an example of sustainable operations and education moving forward?

3. ACCESS: Population increases and the impacts of urbanization and suburbanization are placing incremental pressures on our natural recreation and wilderness areas. We are, in many respects, “loving them to death.” Yosemite and Yellowstone have smog alerts and traffic jams. Getting a permit in some places is like winning the lottery. As pressures increase, guided outdoor education groups will be under increasing pressure to find less-crowded and permit-driven recreation areas. Programmers can stay ahead of the curve by looking for less popular climbing areas, rivers, and trails that serve educational purposes without adding to the crowds.

4. NATURAL HISTORY: Knowing how to identify trees, birds, flowers, and the like use to be a stronger part of our national K-12 curriculum as well as the informal curriculum passed down from generation to generation. We have several generations of kids and young adults who cannot identify even the most basic plant and animal species in their own backyards let along the basic geological history or watersheds of their region. As the “no child left inside” movement and the concern for childhood obesity rates grows, re-kindling a love of the more-than-human world through natural history is, well, “natural.” How can outdoor educators leverage this emerging need into programs and new educational opportunities?

5. STANDARDIZATION: Travel to many places in northern Europe or New Zealand and Australia and you will find a professionalization and standardization of outdoor education that we have yet to see here in the States. Ropes courses, climbing walls, and other outdoor education sub-fields are all feeling the pressure toward more national standards. This is both a good and bad thing. With increased standardization comes increased need for certifications and training. This makes access into the field more expensive as a career option. But it also, potentially, increases the quality of the educational product and process. Yet, too much emphasis on “merit badges” can take the flexibility and life out of a field that has long thrived on passion, creativity, and sound judgement over rules, credentials, and bureaucracy. How will the field wrestle with the need for quality control against the strong legacy of individual freedom?

Those are my top five. I would be interested in hearing from others. What with the 2010’s hold for outdoor education?

Pain Management in Children for Broken Bones

Paul Auerbach — Mon, 08 Feb 2010 04:24:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

Pain management is a hot topic in medicine in general and certainly in medicine for the outdoors. Injuries in particular, and many illnesses, cause pain, which in turn causes the victim to suffer. To a great extent, pain is subjective, but regardless of whether your pain is a "1" or a "10," it can be disabling and even dangerous, particularly if it causes you to be distracted in a situation of risk (e.g., climbing, swimming, walking along a ridgeline).

Broken bones usually hurt a great deal. It's commonly believed that the pain is always of a severity to require the administration of "strong" pain medicine, notably, something containing a narcotic compound. This may not be true. In an article (Annals of Emergency Medicine 2009;54:553-560) entitled "A Randomized Clinical Trial of Ibuprofen Versus Acetaminophen With Codeine for Acute Pediatric Arm Fracture Pain," Amy Drendel, MD and colleagues compared the treatment of pain in children with arm fractures by using ibuprofen in a dose of 10 milligrams per kilogram (2.2 pounds) of body weight versus acetaminophen with codeine in a dose of 1 milligram per kilogram (based on the codeine component of the medication). The children were assessed for three days after discharge from an emergency department. Two hundred forty four patients were analyzed in this study.

The authors concluded that ibuprofen was at least as effective as acetaminophen with codeine for children ages 4 to 18 years with arm fractures treated as outpatients. What is also very interesting is that the children receiving ibuprofen had significantly fewer adverse effects, and both the children and their parents were more satisfied with ibuprofen. The proportion of children who had any function (play, sleep, eating, school) affected by pain was significantly lower for the ibuprofen group.

What to make of all this? The known side medication side effects measured were nausea, vomiting, drowsiness, dizziness, and constipation. Ibuprofen appears to be clearly superior in this study population. This is an eye opener for me, because I am a bit surprised (and now enlightened) by the data. I would have expected these broken bones to require more potent pain medication (e.g., a narcotic), but I see that this is not necessarily the case. In the future, I will recommend ibuprofen (if there is no contraindication) as an initial medication for many more types of pain situations, and wait to see if a more potent "rescue drug" is necessary only as needed, rather than as first choice. If remaining alert and fully functional in an outdoor setting is a priority, this makes double sense.

Proper Hydration at High Altitude

Paul Auerbach — Mon, 01 Feb 2010 02:19:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

The standard dictum when advising persons who travel to high altitude, and thus expose themselves to a lower atmospheric oxygen concentration, is to stay "well hydrated," which translates into drinking sufficient liquid that they urinate frequently, with urine color being light (not concentrated). However, this recommendation has heretofore never been based on science, just on presumption and medical common sense. So, it is with great interest that I read an article in the current issue of Wilderness & Environmental Medicine, entitled "Hydration and the Physiological Responses to Acute Normobaric Hypoxia," authored by Alan Richardson, Peter Watt and Neil Maxwell (Wilderness & Environmental Medicine 20, 212-220 (2009).

The objective of the study was to identify how hydration status, above and below normal hydration levels, affects physiological responses and onset of acute mountain sickness (AMS) symptoms during acute normobaric (normal atmospheric pressure - equivalent to that at sea level) hypoxia (lowered concentration of oxygen in the air). In this study, eight males subjects completed intermittent walking tests in the condition noted after controlled normal hydration (euhydration), hyperhydration (too much water) and hypohydration (dehydration - too little water) protocols. During the measurement period of approximately 2 hours' exposure, heart rate, core body temperature, peripheral arterial blood oxygen saturation, urine osmolality (a measure of concentration and thus the state of hydration), and self-reported AMS scores were obtained.

The observations and analysis showed that the different states of hydration had a significant effect on all of these parameters, and that hydration state above (hyper-) and below (hypo-) normal hydration had detrimental consequences on physiological strain and onset of acute mountain sickness symptoms under the conditions studied.

This is very important work, and will undoubtedly spur further investigation. We are fairly familiar with the concept of hypohydration, which leads to dehydration and all of its deleterious effects upon performance and body functions. However, in the setting of high altitude, we are less familiar with hyperhydration (too much water), because we don't encounter it very often, unless it is induced by a doctor- or rescuer-led intervention. We suspect that fluid retention in general, when it occurs for whatever reason, may contribute to the accumulation of fluid in the brain (AMS) or perhaps even the lungs (high altitude pulmonary edema), but this has never been proven. The worsening of headache in this study (as a presumptive symptom of AMS and perhaps harbinger of fluid accumulation in the brain) in the hyperhydration group is a bold word of caution to us to attempt to achieve normal hydration, and nothing more, with our fluid replacement strategies. How best to do this? At the current time, the best we have in the field is maintaining urine color, specific gravity and/or osmolality (signs of urine concentration and thus state of hydration) at preferred values. However, with the advent of technologies such as that offered by Cantimer, we may soon have other methods by which to guide fluid administration, as thirst in and of itself is notoriously not sufficiently precise for this purpose.

SAM Splint versus Philadelphia Collar

Paul Auerbach — Mon, 25 Jan 2010 01:41:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

In an issue of Wilderness and Environmental Medicine (Volume 20, Number 2, 2009), Todd McGrath and Crystal Murphy have written an article entitled “Comparison of a SAM Splint-Molded Cervical Collar with a Philadelphia Collar.” The objective of this study was to compare the effectiveness of a SAM Splint molded into a cervical collar with that of a Philadelphia collar (commonly used by paramedics and others to hold a neck motionless during transport after an accident) at limiting movement of the cervical spine (neck) in a variety of common predicted directions of motion.

Healthy volunteers participated in the study. A goniometer was used to measure degrees of maximal extension (bending the neck backwards) and lateral motion (left and right) with each type of collar. After data analysis, it was concluded that the results of this study suggest that the SAM Splint, when molded into a cervical collar, is as effective as the Philadelphia collar at limiting movement of the cervical spine.

This is good news for rescuers, backpackers, athletic medical responders and others who have occasion to splint an injured or potentially injured neck in the field. I have used SAM Splints to fashion cervical collars for many years, because my observations were that it could be quickly configured into a reliable and functional splint for this purpose, so it is nice to have my suspicions confirmed. There is certainly nothing wrong with using a (preferably, lightweight) Philadelphia collar or other similar pre-molded appliance to maintain a neck motionless when necessary. The general considerations will be space, weight, ease of use, and adaptability to a variety of patient sizes and conditions. Furthermore, it cannot be overemphasized that if you wish to use a SAM Splint or any other rescue product in the outdoors for which operator skill and experience are required, you should take the time to practice beforehand in a controlled and non-frenetic environment.

Legislative Alert: Commercial Drivers Licenses Could be Required for Drivers of 9-15 passenger vehicles under new Senate Bill

Rick Curtis — Mon, 18 Jan 2010 15:40:00 GMT

On December 17, 2009 the Senate Commerce and Transportation Committee passed S. 554: Motorcoach Enhanced Safety Act of 2009. It now is set to go to the full Senate. All outdoor programs should be aware of this bill and its potential impact on your program.

The full language of the bill that is of concern is show below.

SEC. 7 IMPROVED COMMERCIAL DRIVER’S LICENSE TESTING.

(b) Modification of Requirements for Commercial Driver’s License Passenger-Carrying Endorsement- The Secretary shall establish by regulation a requirement that a driver shall have a commercial driver’s license passenger-carrying endorsement in order to operate a commercial motor vehicle and transport not less than 9 and not more than 15 passengers (including a driver) in interstate commerce for compensation.

SEC. 10. COMMERCIAL MOTOR VEHICLE SAFETY INSPECTION PROGRAMS.

(1) PROGRAM REQUIRED- In order to receive a grant pursuant to section 31102 of this title, a State shall conduct an annual safety inspection program for commercial motor vehicles, including motor carriers transporting not fewer than 9 and not more than 15 passengers (including a driver), that receives approval from the Secretary pursuant to paragraph (3).

While much of the legislation is admirably designed to improve safety in commercial buses the proposed requirement in Section 7 that Commercial Driver's Licencense (CDLs) be required for drivers operating 9-15 passenger vehicles across state lines will have significant implications for outdoor programs across the United States. Many outdoor programs have moved away from 15-passenger vans to 10-12 passenger vehicles and up to now have been exempt from CDL requirements since their primary business is not 'transportation for hire.' Should this law pass in its current form many programs would be unable to provide enough CDL-qualified drivers to operate. This is especially true for college and university programs that often utilize student drivers.

The proposed requirements for annual safety inspections outlined in Section 10 of the bill could also have cost and other implications for outdoor programs.

A number of groups including American Camp Association, America Outdoors, the Trade Association of Paddlesports and others have commented on the bill, most taking the stand the the bill is overly broad and that the requirements as stated would have a significant negative impact on outdoor programs around the country.

OutdoorEd.com wants to encourage all outdoor professionals write your congress person now to recommend ammendments to the bill. It's very easy. The first step is to identify your Senators. Go to www.congress.org and find the GET INVOLVED section in the middle of the page. Enter your zip code to find your Senators and how to contact them. You can use the online Web Contact form to contact your Senators directly.

The following language has been suggested. It can be modified to address the specific needs of outdoor programs, outfitters, camps, and college outdoor programs.

The Honorable (insert name)
United States Senate
Washington, DC 20510

Dear Senator ________________

I am writing to express concerns about provisions in S. 554 which require enhanced Commercial Driver's Licenses (CDL) for drivers of 9 to 15 passenger vans operated by small businesses that cross state lines. The proposed legislation requires a CDL and vehicle inspections even if transportation is incidental to the purpose of the business. This new regulatory requirement will make it very difficult for small businesses like mine to find drivers with CDLs. The legislation also requires increased training and testing requirements for CDL drivers. Ironically, a business providing similar services in competition with mine whose vans do not cross state lines will not be required to obtain CDL's for van drivers.

We believe many small businesses such as ours are being caught in a regulatory net cast for other transportation providers, where transportation is the primary purpose of the business. The CDL requirement, with its more stringent testing requirements, may force some outfitters and guides providing recreation services out of business.

Therefore, I am urging you to support provisions that exempt outfitting and guiding businesses from the CDL and inspection requirements where transportation is not the primary purpose of the business. For example, our primary service is providing outfitting and recreation services. We transport our customers to an area where the services are provided and sometimes cross state lines to do so.

Below, please support inclusion of the following modifications to the legislation.

Section 7 B - MODIFICATION OF REQUIREMENTS FOR COMMERCIAL DRIVER'S LICENSE PASSENGER-CARRYING ENDORSEMENT.

At the end of the paragraph insert: In establishing such regulations, the Secretary shall not require a driver to have such an endorsement where the transportation of passengers by motor vehicle for compensation is not the principal line of business of the motor carrier providing the transportation service.

Section 10 - COMMERCIAL MOTOR VEHICLE SAFETY INSPECTION PROGRAMS

(a) (1) at the end of the paragraph insert

(a)(1) Annual Inspection Program please add: In establishing such regulations, the Secretary shall not require a motor carrier to have such an inspection where the transportation of passengers by motor vehicle for compensation is not the principal line of business of the motor carrier.

Thank you for your support for small business. I look forward to hearing from you about this matter.

Sincerely,

Frozen Autoinjectors and Armpits

Tod Schimelpfenig — Sun, 17 Jan 2010 22:05:00 GMT

I recently exchanged emails with a fellow who asked if it was acceptable to freeze the auto-injector in his first aid kit. I told him of course not, you may not have time to thaw the medication. Now curious, I intentionally froze four expired EpiPens® on a minus 22ºF night and timed how long it took to thaw the auto-injectors in my armpit.

The first one mechanically fired with a normal amount of pressure while frozen, the needle extended, but no liquid was ejected. When opened the epinephrine was frozen and there were no obvious cracks in the tubex. I then thawed the remaining three EpiPens® in my left armpit (97ºF via our household mercury thermometer).

At 3 minutes I discharged the second EpiPen®, but only a little bit dribbled out of the needle. I opened this EpiPen® and found the epinephrine still frozen.

At 4 minutes I discharged the third EpiPen® and I saw a stream of liquid, but it seemed less than expected. The epinephrine in this unit was partially thawed.

At 5 minutes I discharged the last EpiPen® and observed a decent steam of liquid and upon opening, found the remaining epinephrine liquid.

Likewise I froze an ampule of epinephrine. This was thawed after 3 minutes under my armpit. The ampule was not cracked. Several years ago we did the same test on one of the older “AnaGuard” syringes and it took 5 minutes to thaw completely.

So there you have it, backyard science to support the common sense practice of keeping a liquid emergency medication thawed and ready to use. It makes no sense to tempt fate and hope you can thaw your medication in time. Keep it close to your body in cold weather.

There is a second question here, will frozen and thawed epinephrine work? If it was frozen and thawed, and I needed it, and it was not discolored with precipitates floating around, I'd use it. According to the UIAA Medical Commission, yes, it will be biologically active. However, freeze-thaw is not the best situation and will accelerate the deterioration of the medication. It can also crack the ampule or syringe and affect sterility of the product.

Take care

Tod

Kupper, Th. Milledge, J. Basnyat, B. Hillebrandt, D. Schoffl, V The Effect of Extremes of Temperature on Drugs. Consensus Statement of the UIAA Medical Commission Vol 10 2008

Posterior Cruciate Ligament Injury

Paul Auerbach — Mon, 11 Jan 2010 04:31:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

We're in ski season and so a few unfortunate individuals will suffer few knee injuries. A while back, a reader asked me to describe an uncommon injury, which is a torn posterior cruciate ligament (PCL).

This injury usually occurs during a fall. As you can see from the drawing, the PCL keeps the lower leg bone (tibia) from moving too far back in relation to the upper leg bone (femur). If a sudden unnatural force is applied, usually a direct blow to the front of the lower leg near the knee while the knee is bent, the tibia is jammed backwards and the PCL may be torn. In the skiing situation, this usually happens during a fall and a tumble, when someone strikes an immovable object, or when the knee is bent or "twisted" and struck forcefully from the side.

The immediate sensation is pain, and there may be a feeling of instability to the knee, particularly when trying to walk or change levels (e.g., walk over the snowpack or on stairs). When the injury occurs, there usually is not the "pop" sensation noted with an anterior cruciate ligament tear. However, the knee will almost always swell, because there is bleeding into the knee joint and/or soft tissue swelling.

The diagnosis may be surmised by taking a good history and understanding the mechanism of injury, performing a physical examination to determine what elicits pain and instability (commonly, the "posterior drawer test"), and these days, most often by magnetic resonance imaging (MRI). Sometimes an x-ray is taken prior to the MRI to determine whether or not there is a broken bone, but the x-ray does not show the structure and integrity of the ligaments and cartilage within the knee.

Until you can see your doctor, you should apply ice packs a few times a day for 15 minutes to help diminish pain and swelling, and avoid weight bearing. Use crutches if you have them. A broadly-applied (mid calf to mid thigh) pressure wrap may help diminish pain and increase stability, but take care to not apply it too tightly. If you decide to take pain medication, avoid aspirin-containing products (to diminish bleeding). If you have a knee brace (usually from a previous injury or as a preventative appliance for certain sports, wear it to provide extra stability.

Whether or not you will need surgery depends on the magnitude of the tear and the degree to which you respond to rehabilitation. Small tears are sometimes treated "conservatively" without surgery and can be rehabilitated under the guidance of an experienced physical therapist. If the knee does not improve or if the tear is sufficiently extensive initially, surgery may be recommended to replace the PCL with a graft.

drawing courtesy of www.zimmer.co.nz

Canadian C-Spine Rule

Paul Auerbach — Sun, 13 Dec 2009 19:18:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

Christian Vaillancourt, MD and his colleagues recently published an article in the journal Annals of Emergency Medicine (2009;54:663-671) entitled "The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics." This rule was originally developed for "clinical clearance" (e.g., without the use of x-rays) of persons with possible cervical spine fracture (broken neck) in alert and stable trauma patients by qualified persons (generally, emergency physicians) in a health care setting (such as an emergency department). This particular study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing important cervical spine injuries.

The Rule, properly applied to an awake and alert injured person for which there is a concern for a cervical spine injury, provides the following direction:

1. If a person has a high-risk factor (age greater than or equal to 65 years; a dangerous mechanism of injury [a fall from an elevation greater than or equal to 3 feet; fall down 5 or more stairs; direct blow to top of head, such as a diving board accident; motor vehicle accident characterized by high speed, rollover or passenger ejection; motorized recreational vehicle accident; bicycle collision]; or numbness/tingling in an arm or leg), then neck immobilization and x-rays are indicated.

2. If the victim is not able to actively rotate his or her neck, under their own power and without assistance, 45 degrees to the left and right without causing pain, then neck immobilization and x-rays are indicated. If the victim is completely without pain at rest and on active range of motion of the neck, then it is unlikely that an unstable fracture is present.

3. Low-risk accident factors that allow safe assessment of range of motion of the neck include simple rear-end motor vehicle collision (excludes being pushed into oncoming traffic, being hit by a bus or large truck, rollover, or hit at high speed by a vehicle); person is capable of a sitting position; person is ambulatory (e.g., walking); delayed onset of neck pain; and absence of posterior or anterior pain on examining (e.g., pressing upon) the neck. If the accident is deemed to be low-risk, then the victim is asked to attempt rotation of his or her neck under their own power and without assistance. See number 2 above.

What does this mean for the layperson who is practicing medicine in the outdoors? It provides a very reasonable approach to deciding who might be safely examined and when to apply a cervical spine immobilization technique. The overall goal is to not move someone's neck if he or she might have an unstable fracture, where movement could jeopardize the integrity of the spinal cord. Clinical judgment and intuition serve important roles, because it truly is best to always err on the side of "better safe than sorry." However, if the victim is low risk from all perspectives, it allows the rescuers more comfort in moving the victim or allowing self-extrication from a difficult situation or hostile environment.

Helmets for Active Sports

Paul Auerbach — Mon, 07 Dec 2009 04:51:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

The National Highway Traffic Safety Administration reported an analysis of motorcycle helmet use in fatal crashes. What was discovered is not surprising - namely, that in states in which there is not a state helmet law, the odds of a rider in a single-vehicle (e.g., the motorcycle) crash wearing a helmet was 72% less than in states with a helmet law. So, absent a law, people are not particularly inclined to wear a helmet.

One needs to couple this information with the facts about the benefits of wearing motorcycle helmets. First, motorcyle fatalities and fatality rates are increasing at a time when motorcycle riding is becoming more popular. Second, the average age of motorcycle fatalities has moved up to 39 years, from 30 years nearly 20 years ago, probably because the age of motorcycle riders has increased. Third, motorcycles expose the drivers more directly to lethal forces than do enclosed vehicles. Helmets are essential to prevent brain injuries and deaths.

What are the arguments against wearing helmets? Some argue that motorcycle helmets are heavy and therefore increase neck and spinal cord injuries. The opposite has been shown to be true. Some opponents claim that motorcycle helmets impair the driver's ability to hear and see. These senses have been studied in the context of motorcycle activity and do not appear to be impaired, and in certain circumstances, may be improved. The argument that motorcycle helmets are only effective up to a speed of 15 miles per hour is not entirely true. Many head injuries follow glancing blows, not high speed direct impacts. It is true that a helmet can not be effective against a tremendous blow, but it is better than nothing.

Many argue that there is a freedom of choice issue at play. If you knew that you were going to be struck on the head during a particular ride, would you choose to wear a helmet? Probably, you would. The problem is that no one is able to predict the day or moment of their accident and head injury. Few people believe that anything bad will ever happen to them.

Motorcycle helmets are a surrogate for helmets in all situations of risk in which there is a reasonable likelihood of being struck on the head and injuring the scalp, skull, and/or brain. What are those situations? In the water, it is the kayaker who is at risk for being flipped onto a rock or getting caught in a strainer. Knocked unconscious in the water, he is drowned. For the rock climber, it is being struck by falling rocks, swinging into a rock face, or suffering a fall. For the horseback rider, it is coming off the horse. For the motorcycle or ATV rider, or bicyclist, it is crashing and striking one's head. For the skier, it is falling, crashing, or being struck by a ski or snowboard.

One gives up very little (nothing, really) and gains everything by wearing a helmet in the appropriate circumstances. Freedom of choice is a selfish concept when one considers that the head-injured victim forces loved ones or society to provide care and the financial resources to manage the injury and rehabilitation, and sadly, support for the disabled person, who might have avoided most of the injury by wearing a helmet.

There is no excuse for not wearing a helmet approved for high risk (for head injury) situations. It is no different than wearing a seat belt in a car or washing your hands before you eat. Prevention is the name of the game. Having cared for many people with devastating head injuries, most of which would have been trivial or absent if a helmet had been worn, I can only hope that we do what it takes to mandate helmet use in every reasonable situation for which they would be of benefit. That is a necessary and appropriate use of the law.

Helmets & Snowsports

In the most recent issue of the journal Wilderness & Environmental Medicine, published by the Wilderness Medical Society, there is an article entitled "Skiing and Snowboarding Head Injuries in 2 Areas of the United States," authored by Mark Greve, MD and colleagues (Wilderness and Environmental Medicine 10:234-238, 2009). The objective of their research was to explore the use of helmets in skiers and snowboarders injured at ski runs and terrain parks in Colorado and the northeast U.S. and to examine differences in head injury severity in terrain parks as compared to ski runs. The study was done by reviewing emergency department records of injured skiers at nine medical facilities in Colorado, New York and Vermont. Eligible patients were skiers and snowboarders who sustained a head injury.

Most of the injuries occurred when the victim hit her or her head on the snow; fewer occurred when the skiers or boarders were involved in collisions with other skiers or fixed objects. Only 37.1% of the victims were wearing helmets. There were significantly fewer instances of loss of consciousness in fall events in the Colorado group; significantly lower incidence of loss of consciousness in fall events in helmet users who struck fixed objects; and a higher incidence of skiers colliding with fixed objects in the Northeast. Even when controlling for helmet use, there were significantly more head injuries in terrain parks.

What does this all mean? Obviously, the study sample is small, but the big takeaway for me is that helmet use makes sense. Why are there more injuries in terrain parks? Perhaps this represents the mechanics of falls when snowboarding, as opposed to skiing, or perhaps it indicates a higher degree of risk (for a head injury) with this sport, either because of the mechanics, degree of risk (e.g., aerial maneuvers, jumps, etc.), speed for the terrain, or propensity to hit a fixed object. It seems like helmet use is a very logical, and perhaps even necessary, way to prevent head injuries, certainly while snowboarding, and probably while skiing.

Wilderness Emergency Medical Services

Paul Auerbach — Sun, 29 Nov 2009 03:40:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

I am frequently asked to write articles for magazines, chapters for textbooks, and commentaries for journals. Almost always, these are published, but sometimes a publishing project will fall through. Such is the case with a book entitled "Prehospital Care - Pearls and Pitfalls," edited by two longstanding emergency physician friends. Since their book is not going to be published, they have given me permission to use my contribution as I see fit in other venues, so please allow me to make the readers of this blog the beneficiaries. With a big thanks to my co-author, Dr. Laurie Kates, here goes:

WILDERNESS EMERGENCY MEDICAL SERVICES

1. What is wilderness medicine?

According to the Wilderness Medical Society (WMS): “Wilderness medicine focuses on medical problems and treatment in remote areas. It includes aspects of physiology, clinical medicine, preventive medicine, and public health.” For the purpose of emergency medical services (EMS) personnel, there are four qualities that define wilderness medicine:

• An austere environment
• Prolonged time to definitive care requiring modifications to traditional pre-hospital protocols
• Integration of rescue and medical skills
• Environmental threats

2. What is the difference between wilderness EMS and urban EMS?

Rapid response, stabilization and transfer to an advanced care facility comprise the focus of traditional urban EMS training systems. The physical remoteness, environmental exposure, challenging geography and often extended periods of time required for a rescue and stabilization require special training and define wilderness EMS. Traditionally, urban EMS is reactive and protocol driven, whereas wilderness EMS requires improvisation, innovation and extended protocols. In urban EMS, patient extrication is typically the responsibility of Fire Department personnel,who hand off patients to EMS providers, who begin providing medical care. In wilderness EMS, patient extrication is often technically difficult and time-intensive, requiring simultaneous administration of medical care by providers skilled in both medical and rescue skills.

3. How are wilderness emergency medical technicians (WEMTs) different from regular EMTs?

The Department of Transportation (DOT) is responsible for creating EMT curricula. The National Registry of Emergency Medical Technicians was inaugurated in 1970 to serve as a national certifying body for EMTs. Standardized tests are used to certify and recertify EMTs at the state level or into the National Registry of EMTs. There is no national standard or formal certification exam for WEMT designation. The WEMT curriculum is based on the DOT EMT curriculum and establishes an approach to emergency care in wilderness settings and is based on the recommendations of the Wilderness Medical Society, the Wilderness EMS Institute (WEMSI), the National Association of Search and Rescue (NASAR), the National Ski Patrol, the National Outdoor Leadership School (NOLS) and several other groups. Typically, a WEMT course includes 45-100 hours of classroom didactic time, 10 hours of emergency department time, and an additional 48 to 80 hours of clinical training as opposed to non-wilderness EMT courses, which require approximately 120 hours of classroom and ambulance ride-along time. WEMT courses include a minimum of 22 hours of training on medical conditions related to environmental conditions. In contrast, the typical EMT course includes only 3-10 hours addressing environmental emergencies. Other unique aspects of the WEMT curriculum include added training on extended patient care, rescue techniques, special equipment, and in providing care for injuries unique to the remote outdoors.

4. What procedures can be performed by WEMTs?

The procedures performed by a WEMT are determined by both the state protocols under which a WEMT practices, as well as his or her level of training. As there is no national standard for WEMT training, different states and health care systems have a variety of policies regarding what health care providers may and may not do given their levels of training. It is the responsibility of all health care providers to know the standard of care for their level of training, what procedures may be performed, and the protocols and policies of their system. Key elements in WEMT training include technical skills and authority, depending on the system in which they are working, to perform the following:

•Airway management, including endotracheal intubation.
•Needle thoracostomy for tension pneumothoraces
•Shock management, including intravenous therapy
•Use of military antishock trousers (MAST), although this is experiencing decreased use and popularity.
•Oxygen administration.
•Medication administration, including epinephrine for allergic reactions; antibiotics for certain circumstances; acetazolamide, nifedipine, and furosemide for altitude sickness; and pain medications for injuries.
•Field rewarming techniques.
•Field reduction and splinting of fractures and dislocations.

5. What employment opportunities and experiences are available for WEMTs?

Wilderness EMT skills are useful for anyone who spends a substantial amount of time in wilderness areas, but can also open new opportunities for employment. Some possibilities include:

• National and state park ranger, such as the ParkMedic program in Yosemite National Park
• Adventure travel
• Search and rescue
• Forest Service worker
• Disaster medicine/relief work
• Work in rural/wilderness areas
• Military

6. Are standards for wilderness (e.g., mountain, water) rescue teams different around the world?

Wilderness rescue teams vary tremendously around the world. In the United States, most teams are volunteer, with a wide range of qualifications and skills from first aid to paramedic, and are under the jurisdication of national parks, state parks, or county sheriffs. In Canada, mountain rescue teams are coordinated by the military. In Europe, most teams are staffed with full-time physicians and paramedics. In many of the most remote areas of the world, there is no organized system of wilderness emergency care, so travelers and expeditions are required to be self-sufficient.

7. What questions must be answered when assembling a team for a rescue?

Wilderness rescue requires coordinated and thorough preparation with consideration to the following:

ENVIRONMENT/GEOGRAPHY

•What time of day is it and will it be? (Are you prepared for a night rescue?)
•What are the anticipated weather (environmental) conditions, and are you prepared for them?
•Is a helicopter, boat, or other specialized rescue vehicle(s) needed or available?
•Is the weather acceptable for air rescue?

VICTIMS

•How long ago did the accident occur?
•What is the number of victims?
•What are their injuries?
•How many people are in the victim’s party?
•How well prepared are they?
•Does anyone in the party have medical experience or training?

RESCUE PERSONNEL

•Do you have a location, or is this a search and rescue?
•Is a “hasty” team (a smaller, less equipped team sent ahead to provide initial care or to search and rescue while the main team prepares and follows) needed? If so, has it been deployed yet?
•Are all team members prepared?

ARE THE RESCUERS AT SIGNIFICANT RISK?

•Are all team members trained for this type of rescue?
•Who is on the medical team?
•Who is on the evacuation team? Is the number of team members adequate? (For instance, 16 to 20 litter carriers are typically necessary for a ground evacuation of 1 to 3 miles over level terrain).
•Is the team equipment organized and divided up adequately?
•How urgent is the situation?
•Will multiple agencies be involved?
•Are communications coordinated between the different agencies?

8. Who is responsible for search and rescue?

•Search and rescue (SAR) is the responsibility of national and state parks, sheriffs, state conservation offices, or other government agencies, depending on the location and jurisdiction. National and state parks do not have a “duty to rescue.” In addition, there is sometimes significant controversy about when rescue missions should be attempted and who should pay for them. The prevailing opinion is that a call for help cannot ethically be dismissed.

•As mentioned in question 4, most rescues are done by volunteer groups.
•90% of mountain rescues are done by foot.
•95% of rescues are performed without physicians present.
•Only Yosemite and Grand Teton National Parks use helicopters extensively.
•Only Denali National Park uses fixed-wing aircraft extensively and helicopters occasionally.
•Only Yosemite, Grand Teton, and Mount Rainier National Parks have rangers specifically trained in technical rescues, advanced medical care, and helicopter operations.
•Many backcountry and climbing areas are outside parks. Rescues in these areas are by local fire and rescue departments, with or without the benefit of special training or technical skills.

9. What special knowledge is needed for searches and rescues (e.g., mountain, high angle, cave, ocean)?

•Understanding equipment (ropes, slings, carabiners, harnesses, helmets, litters, litter harnesses, haul systems, personal flotation devices, throw rings and bags, and litter patient packaging equipment) used in SAR operations, including their maintenance and care.
•Basic radio communication and signaling.
•Basic helicopter and fixed wing operation and procedures.
•Understanding search and rescue procedures.
•Knowledge of the Incident Command System and its use in SAR.
•Basic rope handling and knot tying skills.
•Advanced skills as needed for specific circumstances, including water SAR, white-water rescue, avalanche SAR, technical or vertical (rock) techniques, or cave training.
•Interpersonal skills and the ability to deal with field death and inform family and friends of deaths.

10. What are some examples of scenarios likely to require “extended” rescue and emergency care?

Mountain, wilderness, rural, white-water, air-sea, cave, and avalanche rescue, as well as expedition and disaster medicine and most search and rescue missions. The terms “extended rescue” and “extended emergency care” refer to medical care and rescue efforts beyond the first, or “golden,” hour.

11. What government agencies are responsible for search and rescue?

Federal SAR activities are either under the supervision of the United States Air Force (for inland regions), Aerospace Rescue and Recovery Service (responsible for federal aircraft incidents) or the United States Coast Guard (supervises coastal regions and all maritime and ocean searches). At the state level, there is significant variety in SAR supervision, because it is often under the jurisdiction of law enforcement agencies. All states have legislation that provides support to local governments during emergencies. During a nationally declared disaster, the Federal Emergency Management Agency (FEMA) assumes responsibility for SAR activities. The Department of Health and Human Services runs the National Disaster Management System (NDMS), which develops Disaster Medical Assistance Teams (DMAT) that can be rapidly deployed to nationally declared disaster areas.

12. What are the four phases of SAR?

•Locate.
•Access.
•Stabilize.
•Transport.

13. How many SAR missions occur each year in the United States?

Specific numbers are not reported. It is estimated that more than 100,000 SAR missions occur annually.

14. What are factors that may cause someone to need to be rescued (and therefore, to require the services of a WEMT)?

Any one, or a combination, of the following, may produce a situation that results in the need to be rescued, stabilized, and treated.

•Improper clothing or footgear.
•Fatigue.
•Dehydration.
•Hypo- or hyperthermia.
•Overextension of abilities.
•Lack of physical conditioning.
•Inadequate food.
•Inadequate planning.
•Inadequate leadership.
•Itinerary confusion.
•Inadequate recognition of environmental, physical, or mental factors.
•Inadequate preparation for weather conditions.
•Lack of navigational proficiency (getting lost).
•“Invincible” mind-set.
•Bad luck resulting in injury, illness, or exposure to an adverse environmental condition or event.

15. Is an EMS provider on a trip liable for care rendered during that trip?

The question is, “Is the provider acting as a designated health care provider, or is the provider merely a person on the trip who happens to be an EMS provider?” If the provider is the latter, then he or she is not duty bound to assist others in need. If he chooses to help, he is not invariably protected from liability by a Good Samaritan Law. While a Good Samaritan Law provides protection for medical personnel assisting within the scope of their skills, voluntarily, at an emergency scene, it is important to note that the provider is held to the full capabilities commensurate with his training. If an EMS provider is acting as the trip medical support, then he is liable to provide care at the accepted standard of care. In addition, because EMTs and almost all EMS providers act under a physician’s license, the doctor under whom the EMT is working is also liable for his or her actions.

16. What are some unique ethical dilemmas associated with wilderness EMS?

•How much risk will you accept for yourself and your team when planning SAR (e.g., going out in a snowstorm looking for a child) and treating victims in the wilderness?
•If a rescuer becomes injured, who will you treat first? The original victim or the rescuer?
•If a limited amount of supplies is available, who gets treated?
•How will the care affect others in the group (e.g., leaving scuba divers in the water in order to deliver a diver with decompression sickness to a hyperbaric chamber)?
•In a remote and prolonged care situation, how do the relationships of people in the group affect their choices for care and decisions regarding the group?

More so than in urban situations, a serious emergency in a wilderness area stresses many unique aspects of relationships and decision-making capabilities. From a survivalist point of view, it is necessary to take care of rescuers and teammates before caring for victims. Many potential circumstances can influence this decision. So, one must think about potential circumstances in advance and plan appropriate ways to incorporate a productive reaction to insure the survival and optimal outcome for rescuers, the team, and patients.

17. Where can I get more information about wilderness medicine and wilderness EMS?

WILDERNESS MEDICINE ORGANIZATIONS

•The Wilderness Medical Society, P.O. Box 2463, Indianapolis, IN 46206; (317) 631-1745
•The International Society of Mountain Medicine
•The International Society of Travel Medicine
•The Divers Alert Network

SEARCH AND RESCUE ORGANIZATIONS

•The Mountain Rescue Association
•The National Association for Search and Rescue
•The National Ski Patrol
WILDERNESS EMT TRAINING PROGRAMS

•The Wilderness Emergency Medical Services Institute
•The National Outdoor Leadership School, Wilderness Medicine Institute

There are many companies and colleges that offer WEMT courses. Check in your region for programs near you.

Pearls and Pitfalls

1. Wilderness EMT (WEMT) designation requires specialized training in rescue techniques, use of special equipment, and extended patient care in remote areas.
2. WEMT’s must work very closely with all search and rescue (SAR) personnel to ensure the safety of the patient and all team members.
3. The four phases of SAR are locate, access, stabilize and transport.
4. A unique ethical dilemma for the WEMT is how much personal risk is acceptable to accomplish the rescue.

BIBLIOGRAPHY

1. Auerbach PS (editor). Wilderness Medicine, 5th ed. Philadelphia, Mosby Elsevier, 2007.
1. Cooper DC, LaValla PH, Stoffel RC: Search and rescue. In Auerbach PS (ed): Wilderness Medicine, 5th ed. Philadelphia, Mosby Elsevier 2007, p. 708.
2. Langer CS: Medical liability and wilderness emergencies. In Auerbach PS (ed): Wilderness Medicine5th ed. Philadelphia, Mosby Elsevier 2007, p 2163.
3. Hubbell FR: Wilderness emergency medical and response systems. In Auerbach PS (ed): Wilderness Medicine 5th ed. Philadelphia, Mosby Elsevier 2007, p 694.
4. Iserson KV: Ethics of wilderness medicine. In Auerbach PS (ed): Wilderness Medicine 5th ed. Philadelphia, Mosby Elsevier 2007, p 2170.
5. Johnson, L. An introduction to mountain search and rescue. Emerg Med Clin N Am 22 (2004): p. 511
6. Klainer PH: Prehospital emergency medical services. In Harwood-Nuss AL, Linden CH, Luten RC, et al (eds): The Clinical Practice of Emergency Medicine, 2nd ed. Philadelphia, Lippincott-Raven, 1996, p. 1517
7. Russell, M.F. Wilderness emergency medical services systems. Emerg Med Clin N Am 22 (2004): p. 561
8. Sholl, JM and E.P. Curcio. An Introduction to wilderness medicine. Emerg Med Clin N Am 22 (2004): p. 265

photo courtesy National Outdoor Leadership School (NOLS)

Evidence-Based Management of Wilderness Injuries

Paul Auerbach — Mon, 23 Nov 2009 00:47:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

This is the next post based upon a presentation given at the Wilderness Medical Society Annual Meeting held in Snowmass, Colorado from July 24-29, 2009. The presentation was entitled “Evidence-based Management of Wilderness Trauma with Case Studies from Vermont Search & Rescue.” It was delivered by Tim Burdick, MD, who is a Fellow of the Academy of Wilderness Medicine, Assistant Professor of Family Medicine at the University of Vermont College of Medicine, Medical Officer for Stowe Mountain Rescue, and Medical Team Manager for FEMA Urban Search & Rescue Massachusetts Tasks Force 1.

There are clinical decision rules (or “tools”) used by physicians in order to control the number of tests (such as x-rays) they use to determine whether or not patients have specific injuries. The purpose of such rules is to avoid unnecessary testing, which can add to undesirable consequences, such as additional expense and radiation exposure. In the wilderness, the purpose of decision rules is to determine the likelihood of diagnosis, who might need an evacuation, and when it is advisable to continue or discontinue a trip.

Dr. Burdick noted that there are evidence-based clinical tools for ankle and midfoot fractures, cervical spine (neck) fractures, shoulder dislocations, and detection of fractures (broken bones) using a tuning fork.

The Ottawa ankle decision rules for the use of x-rays to determine the presence or absence of an ankle fracture were determined in patients who had mostly twisted their ankles, rather than fallen. According to these rules, an ankle fracture might exist if (1) the patient complains of pain near either malleolus AND (2) can’t bear weight for a distance of four steps OR suffers bony tenderness (when you press) in either malleolus. As it turns out, the test has a positive predictive value (e.g., when the test is positive the patient has a fracture) of 17% and a negative predictive value (e.g., when the test is negative the patient does not have a fracture) of virtually 100%.

There is something similar for neck fractures. For a blunt injury (e.g., not a stab wound, or “penetrating” injury), here are a set of criteria for which a patient should be evaluated:

1. Patient is alert and reliable
2. Patient is not intoxicated
3. There is no painful, distracting (from the examination) injury (such as a broken leg)
4. There is no focal abnormal neurological finding (such as weakness in the grip strength of a hand, or abnormal deep tendon reflex)
5. There is no midline cervical spine (neck) tenderness when the neck is examined

If all of these conditions were met by a good examination, then according to the medical literature, then only 2 out of 4307 persons initially complaining of neck pain turned out to have a broken neck.

What about dislocated shoulders? The usual admonition against attempting to reduce a shoulder dislocation prior to obtaining x-rays is to avoid tugging on a broken arm, in the event that a fracture-dislocation is present. It appears that there is a greater risk of fracture-dislocation if the victim’s age is less than 40 years and the mechanism involves “substantial force” (e.g., motor vehicle accident, assault, sports injury, or a fall from a distance greater than the victim’s personal height); or in a victim age 40 years or greater, if there is bruising around the humerus (long “upper” bone of the arm) or if the dislocation is the first for the victim. However, given all of this, it is still not clear that attempting the relocation of a dislocated shoulder that happens to be associated with an undetected fracture of the humerus is a big problem, unless one applies extreme force in the attempt and significantly worsens the break. Certainly, putting a shoulder back in place and allowing the victim greater mobility, reducing pain, and perhaps creating a situation that enables self-extrication can be extremely important.

Can someone use a tuning fork to diagnose a longbone fracture? The concept is that sound is conducted through intact bone and joints better than through broken bone. The technique is to place a vibrating tuning fork of a bony prominence beyond (distal to) the suspected fracture and then to listen with a stethoscope over a bony prominence in front of (proximal to) the suspected fracture. Sound conduction is compared between identical exams of the injured and contralateral (uninjured) limb. Decreased conduction (appreciation of sound transmittance) would indicate a possible fracure. One brief analysis of this concept in 1987, utilizing a 128 hertz tuning fork and stethoscope, indicated that it might be useful, improving the detection of fractures by a few percentage points.

The Real Risk of Meds in the Woods

Paula Colman — Thu, 19 Nov 2009 03:28:00 GMT

Many of us have weighed in on the “Meds in the Woods” issue with the competing moral and legal issues keeping the industry from making a uniform statement as to the best practice. With Good Samaritan and epinephrine laws varying from state to state, the discussion becomes even more complicated. At the Wilderness Risk Management Conference recently, people were very passionate about what medications could be acquired, possessed and administered in remote areas during an emergency. Some stated that because the risk of harm is low and the risk of death is high (such as in the case of epinephrine) having the meds is worth the cost if it means saving a life, the moral argument. Others wanted to place the entire burden of medical care squarely on the participant, the inherent risk argument. In certain circumstances, both positions expose organizations and their staff to potential liability.

I suggested to several people at the conference that while organizations may worry this issue will arise when a participant is injured and treated (or not treated), the more likely scenario will have nothing to do with a participant. Instead, a physician or pharmacist will be investigated as part of a civil, criminal or administrative proceeding, and the professional’s prescription drug records will be reviewed. A physician or pharmacist who has prescribed or filled meds to an organization and not an individual patient, for example, will then be investigated and possibly charged. If those meds crossed state lines, Federal agencies will be contacted prompting additional investigations, and soon. They will all follow the chain as far as it goes – directly to the organizations and staff that have the meds in their backpacks or first aid kits. While courts have not yet addressed a “Meds in the Woods” case, they have held physicians, pharmacists and others liable for the misuse, mislabeling, etc. of prescription drugs stemming from an independent investigation. I have seen it in my own practice, and I believe that as agencies become more aggressive and technologies become more sophisticated, it will continue.

In a recent issue of the Wall Street Journal, there was a front-page story about the states’ prescription tracking programs and how they are being used in civil and criminal proceedings against physicians and pharmacists.

Here's the link:

http://www.careerjournal.com/article/SB125668736789811845.html

There is a graphic showing the states that use tracking programs. Ironically, one of the states that doesn't have a tracking program, Missouri, has a very aggressive Board of Pharmacy, in which, one of my former clients spent almost 10 years inlitigation stemming from a physician’s unlawful prescribing of a common prescription pain medicine. The board simply followed the chain. Because of the recordkeeping required by state and Federal laws, finding out where a single drug has travelled is not much more difficult than locating a book ordered from Amazon. The tracking programs discussed in the Journal story show how easy it is for states to conduct broader searches of physicians, pharmacies, patients and pharmaceuticals. While privacy protections imposed by the law still exist to protect against investigative mining of data, once an investigation begins, it will be difficult for agencies to decide whose privacy is entitled to protection, especially if it appears that people down the chain are not acting in a lawful manner.

The Meds in the Woods issue is serious, but not only because of the moral issues the industry faces every time it takes people into remote areas. It is important, because despite an organization's best intentions, it may find itself and its staff with legal issues brought about by physicians, pharmacists and others who had little to do with the program. These are very real risks that, as legal professionals and risk managers working toward a best practice, we should continue to thoughtfully consider and discuss.

-- Paula Colman, Attorney at Law

Wilderness First Aid Scope of Practice

Tod Schimelpfenig — Fri, 30 Oct 2009 19:13:00 GMT

The concept of consistency in the content of Wilderness First Aid (WFA) and Wilderness First Responder (WFR) programs is receiving much attention. Some folks seem to think there is chaos among the various providers with people teaching widely varying practices. I’m not so sure this is the case.

I’ve been talking with David Johnson MD of Wilderness Medical Associates for several years on this question of curriculum consistency. We decided last winter that it was time to move forward on this question and to approach this project by first defining the Scope of Practice (SOP) for WFA and WFR. Scope of Practice is medical jargon for a job description, a statement about what a WFA or WFR should be able to do, and not do. This seems a logical place to start.

We do not feel it is our place to dictate standards to the industry. Rather, we’ve drafted a document with input from peer groups including Aerie, SOLO, Wilderness Medicine Training Center, Wilderness Medicine Outfitters, Landmark Learning and Desert Mountain Medicine. Together we’ve trained over 150,000 WFA students since 2000.

Most of this was straightforward and it was easy to reach agreement. The challenging issues revolve around the total amount of content we think can reasonably fit in a 16 hour program without eroding overall skill retention, and questions on what skills and decisions are appropriate for a WFA.

The attachment below (pdf) is the consensus document, posted to allow a wider audience a chance for input.

Our next step will be to send it to the Wilderness Medical Society’s Education committee for their consideration as part of their charge to develop standard WFA and WFR curriculum.

As you can see, we agree it is time to take another step toward consistency in the WFA and WFR programs, so the consumer, often an outdoor program hiring a trip leader, knows what a credential implies. If you work in outdoor programs and want to participate please send your comments to Dr. Johnson and myself.

Reb Gregg and Jed Williamson Honored at Wilderness Risk Management Conference

Tod Schimelpfenig — Wed, 21 Oct 2009 04:39:00 GMT

Reb Gregg receiving the certificate of the new award in his name.

One of the highlights of last week’s 16th annual Wilderness Risk Management Conference was the inauguration of an annual award recognizing excellence in the practice of wilderness risk management, and extraordinary contributions to the community of outdoor education, adventure and service organizations, and programs and businesses that utilize wild places for their activities.

As the conference co-sponsors - the National Outdoor Leadership School, Outward Bound and the Student Conservation Association - discussed the criteria for the award - integrity, strong ethical underpinnings, curiosity, commitment to continual learning, honesty, innovation and generosity of spirit - one member or another would finish the sentence with a comment of “… you know, like Reb Gregg”.

A recipient of this award has contributed significantly to the practice of wilderness risk management by: raising standards of practice and strategic risk mitigation; providing valued service to the goals, mission and outcomes of an industry that connects people to the wilderness; facilitates individuals to challenge themselves in the outdoors; and supports the stewardship of wilderness. “… you know, like Reb Gregg”.

People, all different types, are drawn to Reb - his charisma and genuine interest in people, in life itself, makes him someone others want to be around. He doesn't look at life in black and white but rather loves engaging in complexity.

It became clear that Reb’s qualities and service models the exceptional leadership, service and innovation this award will honor. Thus, on the opening night of the conference, October 14th, 2009, the co-sponsors announced this award, named:

The Charles (Reb) Gregg Award
For Exceptional Leadership, Service and Innovation
in Wilderness Risk Management

Jed Williamson (the first recipient of the Reb Gregg award) and Reb Gregg

On the closing evening of the conference, October 16th, 2009, I had the privilege of presenting this award to its first recipient, Jed Williamson.

In my remarks I remembered the day, 20 years ago this past July, when David Black was killed by rockfall while on a NOLS course in the Wind River Range. It was NOLS’ first fatality in 10 years, and the first one any of us had managed. Jim Ratz, then NOLS Executive Director, and I talked about who would be best to lead an independent investigation of this incident.

We bantered about some names, then I picked up the phone and did something so many of us have done when we needed help, I called Jed Williamson. I had not met or spoken with Jed before. I knew him only through his work with Accidents in North American Mountaineering and with the American Alpine Club, but when I asked for help, Jed said yes. Jed gave us advice, occasionally pointed feedback, and wise guidance, then, as he does now. This was the beginning of a mentorship in wilderness risk management that has led us to where we are today - that was one very valuable phone call.

Jed has been a college president, bi-athlete, professional ski patroller, mountain guide, camp counselor, safety director, expert witness as well as long stints as staffer, manager, trustee, advisor for the likes of NOLS, Outward Bound, Student Conservation Association, Exum and a host of other schools and colleges.

Jed’s footprint is in every corner of the outdoor education and recreational community and many of his accomplishments are so well known, we forget that Jed was the engine for many of the successful advances in outdoor safety.

Where would we be without Jed? Can we imagine a conference without his accident cause matrix? Some of us occasionally blaspheme the matrix - and this is fun - but we know how important this vocabulary and structure is for our conversations on risk management.
Where would we be without the data and the experience captured in Accidents in North American Mountaineering? This is the template for the incident accounts and case studies so many of us use routinely in training.
Where would we be without the incident review and risk management audit process and the collected wisdom and knowledge many of us may now take for granted? Jed’s hand has molded this process, and guards it’s integrity
Where would we be without the support and hours that Jed has devoted to the Wilderness Risk Management conference?
Is there anyone who has asked for help, information or camaraderie from Jed and not received it?

Dan Garvey, President of Prescott College said, about Jed , “I’ve been blessed to work with Jed throughout my professional career. The world is a better, saner and funnier place because of Jed. When I hear his name I smile and silently nod in gratitude for his impact upon my life.” I couldn’t agree more.

If you see Reb and Jed, extend your congratulations for this richly deserved honor.

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Reb Gregg and Jed Williamson Honored at Wilderness Risk Management Conference