Monthly Archives: January 2016

Is there anything a SAM splint can’t do?

Deciding what to carry in your medical kit on an expedition is hard. You don’t want to leave anything out, but you can’t carry an entire hospital on your back. I mean, the wheels on the slit lamp really suck at crossing rough terrain. So you have to decide what goes and what doesn’t. Thus the reason for much of the improvisation inherent in wilderness medicine. An item that only does one job had better be the only item that can do that job, or it is extra weight.

C collars are one of those items. Now, ignoring the fact that many of them aren’t good at their job to begin with, they really aren’t good for much else. Sure, you could maybe improvise a pressure dressing out of it, but what else are you going to do? And while some of them do lay flat, they’re still pretty long and take up space that could be used for something else.

Enter the SAM splint®*. Waterproof, moldable, and able to be cut to size, it can be used pretty much anywhere on the body. And everyone has seen the picture of one being used to immobilize the cervical spine. But does it work well in that role?

Improvised C Collar in Auckland

These authors put it to the test against a Philadelphia collar using 13 EM resident “volunteers”. I’m sure they were paid well for their time. Using a goniometer they measured maximal extension, rotation, and lateral flexion. They found that no statistically significant difference in any one measurement, but looking at the results the SAM does appear to allow slightly more rotation and extension, while doing a better job of limiting lateral flexion. This likely is due to the bulkiness of the SAM laterally.

While the method of measuring falls short of a radiographic gold standards, and the number of subjects is low (but powered to an 11° difference per the authors), it looks like the SAM splint, in fact, is just as good as a Philly collar at immobilizing the C spine. I am OK with it in an awake patient, but would add more reinforcement to an unconscious patient.

Comparison of a SAM Splint-Molded Cervical Collar with a Philadelphia Cervical Collar
http://www.ncbi.nlm.nih.gov/pubmed/19594206

*I’m using SAM splint to cover all the moldable splints out there, similar to how Xerox is used to cover all photocopiers. I do not receive any money from SAM Medical Products® for using their name here. You are welcome to use other splints, but this article only used the SAM.

About that New Year’s resolution

Many of us make New Year’s resolutions. And we’ve done it for a long time, with resolutions having been recorded since the time of the Babylonians. And while some of them involve repaying old debts, most are attempts at bettering ourselves (losing weight, blogging more often, quitting smoking, etc).

As medical professionals, we all see the people who set out to become more healthy magically on Jan 1, and often we tell them that moderation is the key. We don’t want people to set goals too lofty that they then cannot meet, causing setbacks or ultimately failures. People shouldn’t expect 1 trip to the gym, or even 1 month to see hugely measurable goals. If you want 1 excursion to make that much of a difference, it has to be of the sort in this case report of a nearly 4 month-long backpacking trip. That is, the nearly ludicrous type.

Of course, the study participant (and investigator, natch) wasn’t a couch potato before his trip. He was an experienced backpacker, at 49. However, he wasn’t an elite athlete either, having a BMI of 29.37 before the trip. He also had Stage I hypertension at 132/98.

True to a resolution, he started out on the Appalachian Trail on Jan 3, finishing on May 1. In total, he hiked from Georgia to New Hampshire, completing 2669km. Anyone who has hiked part or all the AT knows that this is not an insignificant amount of work, even if he wasn’t quite Scott Jurek. In doing so, he lost only 11kg, totaling 13% TBW. However, he went from 25% body fat to 14.3% based on hydrostatic weighing, or 23.8% to 11.6% based on skinfold measuring. These were 43 and 51% changes, respectively. His BMI went down to 25.46, and all of his waist measurements also improved by a fair amount. He even improved his blood pressure to normal (124/78).

This all happened without changing the diet to a large degree. The total amount of calories was remarkably similar at the nearly halfway point as it was pre hike, and at the 100 day mark the hiker was gorging on a resupply visit, consuming nearly 15% more calories. More remarkable was that a diet containing nearly 50% of the calories from fat (at times) still resulted in significant improvement in all lipid levels, including triglycerides, HDL, LDL, and total cholesterol.

So there you have it. All you have to tell your patients (or do yourself), is walk almost 23km per day. In the woods. With snow and rain. Add in another 120km of elevation change (give or take)* over the entirety of the trip and you’ve got a pretty good understanding of the difficulty of pulling this off.

A Long-Duration (118-day) Backpacking Trip (2669 km) Normalizes Lipids Without Medication: A Case Study
http://www.ncbi.nlm.nih.gov/pubmed/20030443

*Based on total distance is 76% of the entire AT, and 120km is 76% of the total elevation change of 156km.