Wilderness Doc: New Guidelines for Spinal Protection

In Spinal Protection in the Wilderness: What We’ve Been Doing Wrong for Decades the Wilderness Doc talks about the new (Dec. 2019) Wilderness Medical Society Guidelines for spinal cord protection and what it means for wilderness/remote care. Reprinted below is an excerpt, be sure to go and read the whole article so that you aren’t misled into doing something dangerous by the sample.

…If you have been a victim of a traumatic injury over the past 50 years, you have been quickly placed in a cervical collar and strapped to a backboard to “protect your spine”. Countless patients have been tortured (ok, maybe a little overly dramatic but…) for hours on end as they waited for their spines to be “cleared”.

This practice guideline simplifies the use of rigid cervical collars and immobilization all the way down to–don’t use them

You and a friend find yourselves in the mountains of Georgia hiking along a moderate to difficult trail with some steep terrain. Your friend turns to look at an interesting bird flying through the forest canopy and loses his footing sliding off and down the steep embankment. You rush to the edge of the trail to watch as he turns over and over, falling head over heels down the 100-foot slope. Quickly, you slide down the embankment and find yourself at your partner’s side. He is awake and alert, cursing vigorously at his misstep.

You ask, “Are you alright?”

Sitting up, he replies, “Yes.” As he carefully bends his neck to the left, right, back, and front with no indication of pain of any type.

Throughout the last half-century, any physician or provider with the slightest knowledge of emergency medicine would have fainted at the thought of letting a patient go through the maneuvers described above. If asked about what should have taken place, they would tell you the patient had to be immobilized. Immediately upon arriving on the scene, the uninjured party should have counseled their companion to remain still, lie completely flat on the ground, and not move their neck.

After all, there could be an unnoticed and unidentified spinal cord injury.

We must protect the spinal cord. 

Given the guidelines as presented in this paper, the patient above has cleared himself. Being alert and able to safely and without pain mobilize the neck in a full range of motion (without distracting injury) rules out a spinal cord injury. In some instances, it may be desired to provide some form of non-rigid cervical spine motion restriction. However, the rigid cervical collar has been shown to cause more harm than good…

Click here to read the entire article at Wilderness Doc.

Wilderness Doc: Hydration and Rehydration

While hydration may seem more like a summer topic, cold, dry weather can cause a decrease in thirst, making it easier to become dehydrated. Here’s an article from Wilderness Doc on Hydration and Rehydration, including using a nasogastric tube for severely dehydrated patients. While Doc doesn’t discuss it in this article, there is also the option of emergency rectal hydration for patients who are unconscious, suffering nausea, or in shock.

Hydration aka water…essential for life. We take for granted this vital substance which we cannot live without. In much of the world, however, clean drinking water is a luxury. In a previous post, I have discussed how to make this water safe to drink. In this post, I want to examine what you might be able to do for yourself or a companion should you become dehydrated.

Oral rehydration is the standard way to rehydrate. This can be accomplished with small sips of water, Gatorade or, in dire circumstances, whatever you have at hand. If you have more resources, making an oral rehydration solution is even better. There are several options to make this. The two most common start with a quart of clean water to which the following is added:

Option 1: One teaspoon of salt, 8 teaspoons of sugar. Mix, then add 0.5 cup orange juice or half a banana (mashed).

Option 2: One-fourth teaspoon of baking soda, 1/4 teaspoon salt. Mix. Add 2 tablespoons of sugar or honey. Mix again. Add 0.5 cup orange juice or half a banana (mashed).

Ideally, the dehydrated patient will drink at least 3 quarts of this solution daily until the diarrhea or other source of dehydration ceases.

Unfortunately, the severely dehydrated patient may refuse or be physically unable to drink the solution. In those cases, consider a nasogastric tube feeding for these patients. Most people are able to easily place such a tube with some lubrication either through KY or other water soluble lubricants applied either to a standard NG tube or to IV tubing or any relatively clean piece of small caliber, flexible tubing. Be sure to test placement by listening over the stomach while blowing into the mouth end (proximal end) of the tube and hearing bubbles in the stomach. You should also start out with a very small (less than 5 ml) test infusion. If coughing occurs, check placement again as you do not want to introduce the solution into the lungs and potentially produce a pneumonitis. The amount of fluid to administer for adults is calculated by adding the patient’s weight in kg’s to 40. An 80 kg patient would need 80+40=120 ml/hr of the oral rehydration fluid. This would be continued until the patient is able to drink the solution on their own, without aid of the tubing.

While there are examples of WWII POW’s utilizing sharpened bamboo sticks and rubber tubing to fashion IV’s, the risk of infection from this would be very high. Further, the art of finding a vein in such a severely dehydrated patient is one most, even with modern and sterile equipment do not possess. If things are so bad as to even consider such a situation, it is likely natural processes will not be stopped. So, while an interesting thought experiment, I would recommend you think more about and ensure adequate knowledge of the above skills instead…

Wilderness Doc: Pre-Hospital Care in Mass Casualty Shootings

This article from Wilderness Doc discusses a key difference in civilian vs military shooting injuries and how, because of the difference, the first aid focus for civilians may be better served with blod clotting bandages than tourniquets — Pre-Hospital Care in Mass Casualty Shootings.

 

You will likely recognize the above picture as a CAT tourniquet. As programs such as Stop The Bleed and others have focused on the use of tourniquets in the field, these have become a popular item for most to carry in our kits. This is for good reason too. Studies and data coming from military experience in Afghanistan and Iraq have shown, these devices are no longer to be considered the “last ditch” efforts we once thought. That being said, what does the data show about efficacy or applicability of this data in civilian shootings as we have recently seen in El Paso and Dayton?

This very question was addressed in the May/June 2019 edition of the Air Medical Journal. Three studies by Smith, Butler and de Jager were used to discuss differences between the battlefield and civilian injuries. Interestingly, military injuries tend to be to extremities. This is due to several reasons. First, many soldiers are injured by high explosive devices and the fragments coming off of them. Secondly, the battlefield and the highly armed nature of the two sides on the battlefield, tends to separate the combatants much further than what is seen in the civil setting. This separation makes shots to vital areas such as the torso, head and neck less likely. Finally, soldiers tend to wear body armor that covers vital areas. While not fool proof, especially against higher caliber and more powerful rounds, it can protect against many rounds, especially if shot from a distance.

What does this difference mean for civilian first responders in such scenarios? It means that chest, back and head shots are much more likely. These areas are, obviously, not amenable to tourniquet placement. So, while still important, we need to adjust training and prepare our first responders for what they are more likely to see. In particular, the authors advise focusing on chest wounds. While there are many who have survived head shots, the chest can be far more survivable. Focusing on pressure and hemostatic impregnated gauze as well as chest seals and decompression may be the next line in pre-Hospital treatment. Also, ensuring such first responders are well versed in all forms of artificial airways can be lifesaving…

Click here to read the rest of the article at Wilderness Doc.