Under the right conditions, we have no particular problem with traction splints for femur fractures.  They can make moving an injured person easier and less painful.  But there are a number of issues related to prolonged application of improvised devices and their infrequent practice and use that concern us.  Let me try to summarize them.

1.  There is no convincing medical evidence that traction splints provide consistent benefit for comfort or long term outcome.  Our instructors, with decades of work experience as paramedics, nurses and physicians confirm this.  Even when properly applied, sometimes traction splints decrease pain, sometimes worsen it and sometimes have no effect at all.

2.   There are claims about the value of a traction splint that have not been demonstrated clinically or in the medical literature.  They do not consistently realign bones.  I believe that the optimal tension (often given as 1 lb /0.45 kg for every10 lbs/4.5 kg body weight or mass  to a maximum of 15 lbs/7 kg) is based on minimizing skin ischemia and not necessarily for the correct amount for bone stability or alignment.  Otherwise, the amount of suggested tension ought to increase as the amount of thigh muscle mass and spasm go up.  Also, the theory that traction decreases the potential space where bleeding can occur seems fanciful at best.

3.  Skilled practitioners have a difficult time gauging the right tension unless a strain gauge is part of the device (e.g., Sager).  Too much increases the risk of ischemia.  Not enough may limit theoretical bone fragment stability, potentially resulting in more pain and more deep tissue and neurovascular injury.

4.   It has been demonstrated that the tension of a properly applied commercial splint decreases significantly within a half hour.  What do you think happens with an improvised splint?  If efficacy is a function of tension and you cannot measure it, how will you know if it has loosened up and by how much?

5.  Traction splints can cause complications and ischemia can occur at the proximal (groin or ischial tuberosity/sitz bone) and distal (ankle) anchor points because of direct and circumferential pressure under tension.  Foot numbness and /or diminished foot pulses frequently develop after commercial traction splints are applied properly in urban EMS.  What do you think would happen after 6, 12 or 24 hours?  Foot ischmia and tissue infarction have been reported after prolonged use.  Other complications like permanent nerve palsies and compartment syndrome have also been documented.

6.  It is difficult to reassess neurovascular function and comfort in patients who are no longer awake and only responding to verbal stimulus or worse.  The issue is compounded with someone with a boot on and/or who is hypothermia packaged.

7.  Even well-trained professional EMS practitioners use commercial traction splints when they are either contraindicated or not needed.

8.  Traction splints can take up a lot of room.  Many airmedical services still use helicopters that cannot transport patients fitted with the most commonly used commercial traction splints.  The same would be true for almost every improvised traction splint that I have ever seen.  Likewise, it can be difficult to fit a tall person with any traction splint into a litter.

9.  Except perhaps for ski patrol, fractured femurs are relatively uncommon injuries.  NOLS has done a good job of monitoring incidents in the field on their programs.  Ask them how many fractured femurs they have had to manage.  Hint: Rarely.

10.  Outside of North America, traction splints are infrequently used because there are better or at least comparable alternatives that are safer and easier to use.   Skiers in W Europe and in an increasing number of places in North America use vacuum mattresses.  These are effective and much more comfortable.  They are also excellent for patient/spine protection.  When a vacuum mattress is not available, we package femurs by incorporating solid, buddy splint padding within the carrying systems.

11.  Under conditions where a traction device may be indicated and acceptable, improvised splints are not a suitable alternative.  They will perform less well than a manufactured variety.  The effectiveness of any is dependent on available materials and creativity.  I suspect there a few students who will do a really fine job.  On the whole, however, most will not be able to make a passable one after less than 6 months from their course.

It was not a simple matter to remove improvised traction splints from our curriculum.  Students had fun and on occasion we were impressed with their ingenuity.  In the end, however, it was hard to justify spending an hour on a skill that would be infrequently used with a device that is of questionable value.  Management of femur injuries are covered during splinting on our courses and we include vacuum mattresses on our specialized courses.  More of our instructors are buying them for use on their courses.

Bottom line: Femur fractures are serious injuries that usually occur as the result of significant forces.  A full assessment, focusing on critical system problems and their stabilization is the crucial first step.

Effective stabilization of femur injuries will help alleviate pain and decrease the possibility of complications.  I believe that either a vacuum splint or good padding in a stable carrying device does a good job of providing both.

Although there is no literature supporting their efficacy in the prehospital setting, a commercial traction splint can be a useful tool when applied by a skilled practitioner who receives periodic training on a particular device and/or uses it during rescues or EMS calls.  They should not be left on for a prolonged period of time (e.g., greater than 2 hours) unless limb neurovascular integrity and splint tension can be monitored properly and regularly.

Regardless, these are painful injuries.  All require the administration of analgesics.

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Q: We are are in the process of training our staff to administer injections and our nurse mentioned administering Benadryl in a vial as an injection. It seems to make perfect sense that you would give someone with a compromised airway an injection if possible rather than a pill to swallow, but I haven’t heard of anyone doing this in a backcountry setting.  I would love to hear any thoughts on this you may have.

Although I would agree that one should not give a pill or liquid to someone with a swollen airway, anaphylaxis can occur without airway involvement. More importantly, however, I don’t believe that training to inject an antihistamine is necessary or worthwhile.  The treatment for anaphylaxis is epinephrine, period.  If you had nothing else, that would be okay.  Except for hives, antihistamines do little for the acute symptoms.  In fact, no one has clearly demonstrated that they are even necessary.  We use them in the hope that they will decrease the likelihood of a biphasic or rebound reaction.

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drawing epinephrineQ: We are moving from epi auto injectors to epi vials and I am working on updating our protocol.  Do you have a protocol for vials?

The protocol for treatment would be the same except for the actual steps of drawing up the medication.  You might want to consider a policy that addresses purchase, storage, disposal, training (I would refresh yearly), monitoring for expiration dates, and usage review (all allergic reactions whether or not meds were used).  With vials, I would suggesting adding that each should be discarded after being used for an episode of anaphylaxis (however many are needed for the episode).  With amps, I would use each for one injection.  In both cases, medication will be wasted but you will decrease the likelihood of contamination.  Given the relative costs compared to autoinjectors, they still remain very cost effective.

, including Protocol 1: Anaphylaxis.

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Pulse oximeters are useful for measuring oxygen saturation in the blood.  They have no capability to measure pH or carbon dioxide.  In fact, that is a potential problem with them.  People can have fairly normal oxygen saturations because of compensatory hyperventilation.  So what looks good could in fact can be bad e.g., oxygen saturation is maintained near-normal at the expensive of hard respiratory work cause by an underlying pulmonary problem.  You would know this by measuring the respiratory rate or, if you could, by measuring pH and/or carbon dioxide levels.  There are other caveats as well e.g.; the interference caused by carbon monoxide.

Assuming that the person has good skin perfusion, a pulse oximeter works the same at altitude as it does at sea level.  As ambient atmospheric pressure decreases, the amount of oxygen in air decreases correspondingly.  Respirations increase to help compensate for this.  In general, however, resting saturations will continue to decrease as one ascents to a higher altitude.

The device itself is not a good tool for diagnosing HAPE/high altitude pulmonary edema.  It could give you the impression that things are better than they really are because of what I mentioned above.  A history of a person’s activity level (decrease in exercise tolerance), vital sign assessment including mental state and lung exam with a stethoscope are in the end cheaper and more accurate.

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If you have heard about the incredible story of the man who survived a cardiac arrest in part by receiving 96 minutes of cardiopulmonary resuscitation (CPR), you might be wondering how I feel now about on termination of resuscitation/stopping CPR after 30 minutes or if I have second thoughts about the comments I made in a   on protocol recognition and  on starting and stopping CPR.

First, if you are unfamiliar with the story, check out some articles online.  from USA Today is pretty good.  If you want more detail and you have the time, check out the unedited interview with Dr Roger White below.  He was the physician who advised the practitioners in the field and also attended to the patient in hospital.  In it he talks in great detail and even shows printouts from the monitors used during the resuscitation.

Essentially, a 54 yo man had a witnessed cardiac arrest in a small town in Minnesota (MN).  CPR was started promptly and was continued by “dozens” of locals, all taking turns in shifts.  They defibrillated him 6 times.  An advanced life support (ALS) team arrived at about 40 minutes into the resuscitation.  They intubated him (placed a breathing tube for ventilations), gave  IV drugs and defibrillated him 6 more times.  Defibrillation established a regular rhythm for very brief periods of time after some of the ALS shocks.  It wasn’t until he was given a large, out of protocol, repeat dose of the anti-dysrhythmic amiodarone that he remained in a rhythm that produced a sustained pulse.  He was then transported the 30+miles to Rochester, MN, for a heart catheterization and other treatment.  He left the hospital after 10 days feeling tired and sore but apparently with his intellect and other body functions intact.

Dr. White admitted that he and the ALS crew questioned the wisdom of continuing in the face of the recalcitrant dysrhythmia.  In the end they chose to continue in large part because they were able to confirm the continuous production of carbon dioxide via one of their monitors.  In essence, this indicated that the CPR was effectively perfusing the lungs, evidenced by the measurable amount of carbon dioxide produced there. This indirect measure of global perfusion gave them hope and thus made it hard to stop.

This gentleman survived because of an extraordinary confluence of circumstances and people, including the online, real-time advice from a “…leading expert in cardiac arrest…”  Take any one or more of those away and the result would have been different.  Most if not all of the capabilities described would be unavailable and/or unrealistic in a wilderness or remote setting in a harsh environment.  This was the quintessential chain of survival.

Bottom line: As amazing as this story is, our CPR protocol still makes sense.

This resuscitation demonstrates that good quality CPR can make a difference.  However, maintaining good quality CPR is not simple.  Fatigue would have set in much more quickly for a significantly smaller crew.  CPR quality and therefore perfusion worsen with rescuer fatigue and maintenance of perfusion is what gave him a chance.  Fatigue in a remote and harsh environment can also put rescuers at risk.  And this success took more than good quality CPR.  Even the AED proved to be of little use without more advanced capabilities.  In the end, the experienced practitioners involved are not sure how or why they succeeded.

Remember too, this was caused by a heart attack with a potentially fixable rhythm and not from trauma or a prolonged submersion.

Q: During my WAFA training, we were told to stop CPR after 30 minutes of cardiac arrest. Are there other agencies/organizations that use this standard of care/treatment? Have there been any conflicts?

If you are in a wilderness or remote setting, the simple answer is yes.

In this setting, we believe that if normothermic (normal body temperature) people in full cardiac arrest do not recover within 30 minutes of continuous CPR, they will not survive.  This, even in the unlikely event of the arrival of advanced life support (ALS)/Emergency Medical Services (EMS) at or near that 30 minute mark.  This number is a conservative estimate derived from the medical literature.  The magic number is probably closer to 20 minutes or less.

Large organizations like the American Heart Association (AHA) and the American Red Cross have focused their attention on settings where automatic external defibrillators and ALS are readily available.  As a result they have not addressed this question of futility, leaving it to medical control.  Some EMS regions have, adopting guidelines similar to ours for use in the urban settings.

The AHA continues to downplay the role of pulse checks for lay providers (which would include WAFA-level training) during assessments of unresponsive people.  While it may make sense to start CPR without assessing pulses in unresponsive, non-breathing patients, we will still use no pulse as one of the criteria for stopping.

Although I am not aware of any problems applying this guideline in the field, I am aware of cases where rescues have continued for 2 hours or more, putting themselves and others at risk.  The outcome have been the same.

Bottom line: In the wilderness or remote setting, stop resuscitation if there is no pulse after performing 30 minutes of continuous CPR.

Q: Can a group of field researchers, certified in basic first aid, be allowed to have an epipen in a first aid kit at the location. There are no individuals with known allergies or prescription for epipen, but they will be in a remote location (2-6 hrs from emergency medical services.

If you are trained to identify anaphylaxis and properly use the device, I would argue, yes.  I have been reviewing the experience of organizations that sponsor our courses.  Even at the first aid level more then a few have used epinephrine accurately and successfully.   Although less frequently, they have administered epinephrine in circumstances where a person with a history did not have the injector and in people who have not had a reaction previously.

I would argue that epinephrine use is first aid for properly trained individuals working in remote environments.  The major problem is state law.  I don’t know the rules, if there are any, in CA.

If you decide to use epinephrine, make sure that you do your due diligence and have a workable and useful risk management process.  Make sure everyone is trained.  You might consider including a yearly review.  Have a good way to store the med, monitor its expiration date and properly dispose of expired and used injectors.  Also, engage whomever writes your prescriptions to review every instance where it is used.

Q:  What do you think about the King Airway and do you think Wilderness First Responders should be certified to use them?

I think it is like any of the supraglottic rescue airways.  It can work effectively much of the time in practiced hands. It has its pluses and minuses; supporters and detractors.

Learning to place a device like this correctly and predictably takes an instructor with experience, adequate class time and equipment.  Most WFR classes don’t have all of these.

This is a piece of equipment rarely necessary for a WFR trained rescuer.  To maintain the skill with competence requires regular, periodic practice.  Placing one incorrectly can be disastrous.  A simpler solution, mouth to mask ventilation, is easier to learn and master and under most circumstances can be at least as effective.

Bottom line: Could be, yes; should be, no.  The limited time available in a WFR course are better spent on more relevant and practical topics and skills.

Q: I am one of four educators within my company and I am looking for suggestions regarding a Wilderness First Responder refresher we are trying to have at our office. We are all certified WFRs and are attempting to create monthly scenarios for our own practice. Do you have suggestions for a good starting point to help keep our knowledge fresh?

You can’t get enough practice.

A good starting point would be to use one of the case studies in the .  Have one person act as the moderator who presents the case and asks questions of the others that leads to the SOAP.  This could also be a homework assignment.  After you are done, you can add in a little critical thinking by changing one or 2 parameters (e.g., location, weather, time of day) to see how that might change the problem and/or plan.

You could also use one of these as the basis for a small simulation or drill

Sometimes we like to do drills using several faces of one problem.  Depending on the group size, make half the group patients and the other half resucuers (or 1/3, 2/3).  Give the patients profiles with varying presentations of a problem.  For example, 1/3 of the patient who are cold, 1/3 with mild hypothermia and 1/3 with severe.  Bring everyone back together and discuss the diagnosis and how each differ.

Q: I take yearly trips into backcountry areas with three other people. I have my certification through WMA. What is the best way to approach my doctor to obtain a prescription for epinephrine to include in our group kit? While none of us has had allergic reactions in the past, assistance is generally hours away.

A:  Be direct and honest.  Outline your training and your intentions.  If your doctor has any questions direct her/him to the resources section our website for the .