Category Archives: injury

Necessity is the mother of tourniquet invention

A lot of wilderness medicine teaching is geared towards bringing the right tools for the circumstances, but sometimes you end up in a situation where you don’t have the best tool for the job. Thus,  quite a bit of preparing for austere environments is making improvised devices out of whatever is lying around.

This article discusses one of those macgyvered lifesaving tools. While there are many commercially available tourniquets out there, there are still times when you have to create one out of something else. As the article points out, you might simply run out of tourniquets at a mass casualty incident. When the situation arises that you have to create a tourniquet, what items should you use to make one?

The authors chose to test the band and windlass design. They mention that this was based on a paucity of non-military literature about various improvised tourniquets. The band was always cotton cloth folded into shape, and they tested 3 items common to the urban environment as windlasses. While pencils, chopsticks, and popsicle sticks might not exist in the wilderness, they’re a reasonable idea for testing. It’s not like you can ensure quality control with broken twigs.

Using a computerized above-the-knee amputation simulator, they then attempted to stop bleeding using the improvised tourniquet and one of the potential windlasses. If 1 pencil, popsicle stick, or chopstick was insufficient to stop bleeding (or broke), the test would be repeated with 2, 3, or 4 until 100% effectiveness was reached.

Granted, this study only looked at occluding arterial flow instead of venous, and had a very narrow scope of windlasses. In the end, the take-home message is as follows:

  • Popsicle sticks suck as windlasses, and you shouldn’t use them. They often broke on the first turn.
  • Pencils are better, but still pretty terrible.
  • Strangely enough, chopsticks work best of those tested.
  • 2, or better yet 3, is always better than 1 when it comes to windlasses
  • Maybe use something other than flimsy wood objects when you make an improvised windlass, such as plastic or metal
  • Use a commercial device if you can find one

Which Improvised Tourniquet Windlasses Work Well and Which Ones Won’t?
http://www.ncbi.nlm.nih.gov/pubmed/25771027

Use hematoma blocks for wilderness anesthesia

You’re on a simple hiking expedition and suddenly a member of the group takes a wrong step on the trail and collapses in pain. You examine them carefully and discover a gnarly ankle fracture-dislocation. It’s a bit of a walk back to camp, and you’re worried about the foot’s neurovascular status during the return. What do you do?

Well, if you were in the ED, you’d likely hook the patient up to every single monitor in the room, get 7 providers in the room, fill out the mandatory checklist, and perform procedural sedation. However, you’re out in the woods, and the pine trees don’t have etCO2 monitors built into them. You could give a hefty dose of pain medicine and try to yank the foot back into place, but prior experiences trying to reduce limbs without adequate analgesia or sedation lead you to decline that option. Unfortunately, now you’re out of options.

Or so you thought. It turns out that there’s a surprisingly effective option promoted by our orthopedic colleagues (or at least one of them). Enter the intra-articular hematoma block of the ankle. You may have done intra-articular anesthesia with a dislocated shoulder before, and you’ve probably done hematoma blocks for wrist fractures. It works for those, so use it here as well. The author of the paper is even nice enough to give a figure demonstrating exactly where one should put the block, assuming the anatomic landmarks aren’t obliterated by the fracture-dislocation.

From the original article

Insert the needle in a lateral and cephalad direction. If you hit the talus, pull out and aim higher. Aspirate blood, and inject your lidocaine. Done correctly, the patient will have complete anesthesia to the joint, allowing you to perform a successful reduction. The article has a nice technique for accomplishing reduction if your usual brute force doesn’t work. It’s similar to the finger trap technique taught to reduce a Colles’. Basically, you place the leg into tubular fabric and suspend the affected extremity in the air. Gravity and rotational forces then gradually pull the ankle joint back into place. If you don’t happen to pack stockinette in your first aid kit, you can use socks, thermal underwear, long shirt-sleeves, or even tight-fitting pants instead.

Just make sure and immobilize the joint afterwards, and remind the patient that just because their ankle is numb doesn’t mean it’s a good idea to stand on it. And while this article only discusses ankle injuries, other fractures are amenable to hematoma blocks as well. Yet another arrow to add to your wilderness medicine quiver.

Field Management of Displaced Ankle Fractures:Techniques for Successful Reduction
http://www.ncbi.nlm.nih.gov/pubmed/19364168

Femoral traction splints, helpful or not?

It’s been awhile since the FOAM twitter community got together and discussed the utility of femoral traction splints. Thus, forgive me for not remembering all the finer details of everyone’s points of view. The gist of that discussion was similar to many other twitter-based medical discussion. Many anecdotal accounts of benefits of an intervention (in this case, traction splints), vs the utter lack of data showing benefit. Knowing that absence of data does not equal absence of benefit, we all left likely doing the same thing we were doing before. And that discussion was mostly directed at commercial devices used in inter-facility transport or in-hospital use.

In wilderness medicine, the situation is even worse. Poor or completely nonexistent data, and even fewer premanufactured devices are available. Therefore, many “traction” splints are make-shift devices that are macgyvered out of available materials. After all, make-shift devices are the essence of austere medicine.

But do we need to be doing them at all, and more importantly, should we be teaching the next generation of wilderness medical professionals to do it ad infinitum? Let’s face it, the devices we concoct out of ski poles, webbing, carabiners, and the like, often aren’t very good at providing traction to begin with. They simply aren’t robust enough compared to commercial products. Not only that, but the usually involve some poor soul being left without a shirt, poles, a jacket, and maybe their backpack. If there’s real benefit to doing it, that’s a reasonable sacrifice. But if there isn’t, is it time to stop?

This article investigated the use of femoral traction splints by Mountain Rescue England and Wales, as well as did a literature review to see if there is any definitive data for or against the use of traction splints. The authors also surveyed rescue teams to assess their use and opinions of traction splints.

They found that suspected femur fractures were fairly uncommon in their cohort, occurring at a rate of less than 10 per year. This likely overestimates actual fractures by a decent margin as well. Of these, only 13% were treated with traction splints, 17% with non-traction splints, and a whopping 70%(!) without any splinting at all. This data flies in the face of what was reported by the responding rescuers. Fully 68% reported that they used a traction splint for every suspected femur fracture, and the other 32% said they selectively used them. Generally they felt the devices to be useful and not problematic in the survey as well. Then why aren’t they using them? This isn’t answered by this survey, but I bet a few medical directors out there would like to know why their medics are saying one thing, and doing another.

What did the literature say about traction splinting? Of the 141 they found using Boolean operators, only 5 were ultimately included in the review. The rest were historical, single case reports, too low level of evidence, or not pertaining to the issue at hand. And of those 5 (see references below), all were level of evidence 4. Shockingly, there aren’t a lot of double blinded RCTs on this topic.

Of those articles, they also found that splints were often applied to patients with contraindications, are rarely used, take up space, and don’t have much evidence for their benefit. Specifically, the often theorized benefits of pain reduction, bleeding, and nerve injury are not shown in any recent literature. There is a book from 1919 (Gray, H. The Early Treatment of War Wounds. H Frowde, Hodder and Stoughton, London; 1919) that argues a reduction of death from 80% to 15% for femoral gunshot injuries, but this can’t be used realistically today as evidence.There is a teaser at the end of the article though. Susanne Spano at UCSF-Fresno presented a poster at SAEM with some good data that showed no statistical difference in mortality or complications of actual femur fractures treated with either traction splinting or no traction splinting.

The main problem in prehospital or wilderness care is that the person with the femur fracture also needs extraction. Traction splints interfere with many litters, are by design only useable for 1 type of injury, and require a significant amount of highly specific training. In the end, I’m not saying that traction splinting isn’t without benefits. In the pre-hospital or austere setting, these benefits are much smaller and have a higher risk associated as well. And certainly I don’t advocate not immobilizing the limb, as this clearly has benefit. But creating a make-shift splint needs to stop being taught as the best or only way to treat femur injuries. And simple splinting should be used until we have clear data showing a benefit to traction splinting.

Femoral Traction Splints in Mountain Rescue Prehospital Care: To Use or Not to Use? That Is the Question
http://www.wemjournal.org/article/S1080-6032(15)00075-7/abstract

Referenced Articles

Agrawal, Y., Karwa, J., Shah, N., and Clayson, A. Traction splint: to use or not to use. J Perioper Pract. 2009; 19: 295–298
Wood, S.P., Vrahas, M., and Wedel, S.K. Femur fracture immobilization with traction splints in multisystem trauma patients. Prehosp Emerg Care. 2003; 7: 241–243
Abarbanell, N.R. Prehospital midthigh trauma and traction splint use: recommendations for treatment protocols. Am J Emerg Med. 2001; 19: 137–140
Bledsoe, B. and Barnes, D. Traction splints: an EMS relic?. JEMS. 2004; 29: 64–69
Ellerton, J., Tomazin, I., Brugger, H., and Paal, P. International Commission for Mountain Emergency Medicine. Immobilization and splinting in mountain rescue. High Alt Med Biol. 2009; 10: 337–342

Sailing expeditions gone wrong

Ah, sailing. The joy that can be had utilizing just the wind to move effortlessly across the water. At least, that’s what it looks like to the untrained observer. Even casual sailing requires a bit of effort, and if there’s a race involved, the work can be quite strenuous. Combine this with the boat changing direction frequently, often while the rigging is also moving about, and you end up with injuries.

But how do you figure out the common injuries to better prepare for them, or better yet, prevent them altogether? The authors of this paper chose the time-honored method of the internet survey. Ignoring what I said last week about the internet, it certainly allows for greater numbers than you would expect to get in a single site clinical survey. This likely results in reporting bias, as does the fact that in this survey, the average time spent sailing was 65 days per year. Certainly not a beginner group, which would reduce the number of injuries. Also, no fatal injuries were reported by third parties using the surveys, so at the extreme end of injury (death and serious disability) there would be an absence of data as well.

With that out-of-the-way, what were the injuries self-reported by this grizzled group of sailors? Mostly extremity injuries, including contusions and lacerations. Upper and lower extremities were both nearly equal at around 40% of the injuries. Head injuries represent around 10% of the total, and are almost always from the boom or spinnaker pole coming across during a jibe or tack. All of these injuries are broken down into finer detail in the paper, in case you want to know the exact percentages of knee contusions versus leg contusions.

An interesting finding was that fractures are more common in larger keel boats than in smaller dinghies. This is straightforward, as not only are all the things that can break you larger on a keel boat, there often aren’t as many open hatches to fall into on a dinghy. Nearly half of the injuries were minor enough to not need treatment, and only 4% required “evacuation” or “hospitalization”, which sounds like an interesting composite end point. However, there were still a fair amount of injuries that did need treatment, some quite serious.

From these data, certain events that lead to injury can be identified. Jibes in high wind (whether planned or not), falls through hatches or companionways, rig failures, and collisions all have high injury rates. Heavy weather, fatigue, poor communication, and inexperience all contribute to injuries as well. Most injuries occur in the cockpit, but most time is spent there as well.

A smaller part of the paper is devoted to maritime illnesses. Unsurprisingly, more than half were sunburns. Seasickness was next in frequency at nearly a third, and then you get into the single digit rates for hypothermia and dehydration. Prevention is key for these, because if you’re down a crew member, the rest have to work harder to make up the difference, increasing their risk of injury.

An important thing to note from this survey is the self-reported poor use of lifejackets. Only 30% reported using them. Allow me to be clear, the lifejacket isn’t there because you can swim, it’s there for the times you can’t. 2/3 of deaths on the water are caused by drowning, and the majority of those occur while not wearing lifejackets. Other concerning safety behaviors include alcohol use prior to injury (clearly underreported), as well as poor compliance with sunscreen recommendations.

A final point is that their injury rate of 4.6 per 1000 days of sailing is markedly different from earlier studies that had rates of 0.29 and 2.2 injuries per 1000 hours. Thus, while nobody can clearly pin down the injury rate, the ballpark number shows it isn’t the most dangerous recreational activity out there.

Sailing Injury and Illness: Results of an Online Survey
http://www.ncbi.nlm.nih.gov/pubmed/21168780