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Amylopectin Powder’s Amazing Ability Top Stop Hemorrhaging Fast

Michael Kilbourne and colleagues recently published an article entitled “Hemostatic Efficacy of Modified Amylopectin Powder in a Lethal Porcine Model of Extremity Arterial Injury”( Annals of Emergency Medicine 2009;53:804-810). The purpose of the study described in this article was to investigate the blood-stopping ability of a modified amylopectin powder in an animal (pig) model of severe limb bleeding created by an injury to the femoral artery.

Following creation of the injury, animals were treated either with regular gauze with manual compression or with specially modified amylopectin powder and manual compression. Some of the endpoints measured in the study were total blood loss, survival, and time to bleeding cessation.

Post-treatment blood loss in the amylopectin powder-treated group was much less (approximately 0.275 liter) than in the gauze group (approximately 1.3 liters). Bleeding was stopped in approximately 9 minutes in the amylopectin group, and never stopped in the gauze group. 100% of the amylopectin animals survived, and none of the gauze animals survived.

While this study was directed to improve care for victims of major trauma (including wartime situations), the applicability to situations in the outdoors is direct. Many blood-stopping bandages have come to the civilian market, and they are quite useful. I carry them with me whenever I’m going into the wilderness, and often when I cover athletic events as the team doctor. They’re useful for nosebleeds and cuts, not just for severe injuries. Some of the product names include HemCon Bandage, QuickClot, BleedArrest, QR, Celox, and BloodStop. There will undoubtedly be improvements in these products, in particular the delivery systems, be they bandages or powders.

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This post, Amylopectin Powder’s Amazing Ability Top Stop Hemorrhaging Fast, was originally published on by Paul Auerbach, M.D..

How To Survive A Wildfire: Lessons From Australia

We are still in fire season in the U.S., and with persistent hot, dry and windy conditions, may see quite a few more conflagrations this summer and into the autumn. The fires that can be attributed to human behavior occur for the same reasons year in and year out, whether they are accidental or intentional. So, we will face them, and knowing what to do before they happen can be a prerequisite for survival.

Of course, fires occur worldwide, and there is much to learn from the experience of others. Some months back, there was an interesting commentary in the news during fire season in Australia that pondered the question, “Why did so many die in Australian bushfires?” Here is a paraphrasing of the response:

“Yes this is awful – devastating to the psyche. For Australia, this is bigger than the twin towers and we cannot blame an external agency. Much of it we did ourselves. All over central Victoria, it was the worst fire weather by far that has ever been experienced. Temperatures were above 40 degrees centigrade (105 degrees fahrenheit) for days, there was no significant rain for months, and there were strong to gale force winds straight out of the central desert for days.

It seems that most people who died actually did so trying to flee at the last moment. They died on the open or in cars, especially in crashes along the roads or running into fallen trees. Even before the fires hit, it was so hot that eucalyptus trees were dropping large branches everywhere.

Many who survived in the fire storm did so in prepared or ad hoc refuges and bunkers or inside their houses, leaving their homes only when the houses were burning but the main fire had passed.

The problem was that in some areas the winds were so strong that houses were torn apart by the wind, leaving no option but to be in the open. As usual, many of the injured did not have suitable clothing. For some, the attire of shorts and thongs may have been fatal. The fires were so hot that they melted alloy wheels on cars. Many, if not most, people living in the area at least evacuated their children, and the elderly and sick. Most houses were relatively well prepared for ‘normal’ fires. This is a semi-rural area, so people had water, pumps, mobile and fixed sprays, and plans. The problem was that they had no chance to use them, because everything happened so fast and was so intense.

The area was beautiful-the sort of dangerous beauty that comes from houses situated amongst trees. The area is a mountain ash forest. Many of the trees around the houses are stringy barks and cyprus pines, all of which become explosive in fires. There was ember spotting as many as five miles ahead of the main fire front. The actual fire winds were over 100 kilometers per hour. At times, the main fire front moved at 30 to 40 kilometers per hour.

Some persons commented that one of the most bewildering aspects of ‘Black Saturday’ was the disconnect between the general and, ultimately, prophetic warnings issued by authorities beforehand and the absence of specific information when the fires overwhelmed communities. But really! There is not some celestial fire watcher able to communicate with everyone and tell them what to do! Phones were out, the emergency call (000) was overwhelmed (1800% over normal call volume) and the operators were actually listening to people die without being able to help.

There have been so many extraordinary stories of bravery and good luck, but it is really difficult to put it all into perspective. People everywhere seem to be really quiet and depressed. There is a constant barrage of awful vision on the TV that keeps on reinforcing the horror. Really well known people are dead. So many kids and complete families.”

Key points for those who will one day face the prospect of encountering a wildland fire:

1. The thermal intensity of a wildland fire is beyond imagination. It is far better to be away from the heat than to try to shelter within it and try to survive. Escape routes should not be left to serendipity or improvisation. Anyone who lives in an area that is vulnerable to wildfire should have a plan for when and how to escape.

2. One needs to understand fire behavior, and how to avoid panic. Last minute attempts at self rescue are often marked by tragedy.

3. The wildland-urban interface is growing. The minority of homeowners subject to wildland fire risk have properly cleared their property of remediable fire hazards, and likely are not completely prepared to protect their lives and dwellings.

4. Warning systems are not infallible, and resources are easily overwhelmed. Everyone needs to take personal responsibility for being on the lookout for wildfire, and for his or her response to an encroaching blaze.

5. The aftermath of most natural catastrophes can be as devastating as the event. Entire communities and populations are affected, so we share the responsibility to prevent fires, report them promptly, protect our family and friends, and assist response teams in doing their jobs to suppress fires.

This post, How To Survive A Wildfire: Lessons From Australia, was originally published on by Paul Auerbach, M.D..

Spit Test To Determine Hydration Status

I’m often asked about technologies that are amenable to research applied in outdoor or wilderness settings. A company called Cantimer has developed and made available one of these technologies.

Cantimer is a privately–held, development–stage company commercializing a patented, proprietary, sensor technology platform based on a convergence of micro electromechanical systems (MEMS) technology and advanced polymer science. According to the website, the Company’s first commercial product will be an innovative, hand–held device for non-invasive measurement and monitoring of human hydration status from the osmolality of saliva.

This past October (2008), there was a press release issued by the Company. To paraphrase:

“Cantimer, Inc. Delivers First Alpha Instruments for Real-Time, Non-Invasive, Incident-Scene Assessment of Dehydration in Firefighters

Devices to be used for field testing in structural fire environments and search and rescue operations.

Cantimer, Inc. announced that it has shipped ten alpha instruments for real-time, non-invasive assessment of human hydration to the U.S. Government’s Technical Support Working Group (TSWG). The units will be used for incident-scene assessment of dehydration in firefighters. Dr. Christina Baxter, from TSWG, commented, ‘The focus over the last several months has been on laboratory work that adds to the body of knowledge regarding salivary osmolality as a useful measure of human hydration or dehydration status. That work has gone very well. We are now looking forward to using these new devices for actual field testing in structural firefighting or search and rescue operations – with more of an emphasis on implementation, ergonomics and the user experience.’

Maintaining an optimal level of hydration is a major health concern for firefighters and other emergency scene first responders. Progressive acute dehydration associated with physical exertion in heat-stressed environments significantly increases the risks of temperature-related health problems, with resulting losses of productivity and, in some cases, death. It has been shown that fluid losses of as little as 2% of total body weight (3.5 pounds in a normally 175 pound individual) can lead to noticeable compromises in physical and cognitive performance.

Dehydration and resulting temperature-related health problems among firefighters are preventable through adequate on-scene hydration management. Cantimer’s devices, incorporating the Company’s proprietary sensing technology, enable convenient, field-deployable, real-time measurement, and therefore management, of hydration status from an easily-obtained sample of saliva.

Although easy to treat if identified early, dehydration is a pervasive condition that contributes to a large number of preventable hospitalizations in the U.S. every year. Cantimer believes that the availability of a hand-held device that aims to make it as easy to determine a person’s state of hydration as it is to take their body temperature will have significant benefits, not only for the health and safety of firefighters and other first-responders, but for military personnel, athletes at all levels, the elderly, the very young and those suffering from a wide range of medical conditions.”

The wilderness and outdoor medicine literature is replete with opinions and arguments about conditions predisposing to dehydration and the determination of hydration status. We presume dehydration in the field by clinical diagnosis (e.g., signs and symptoms), but do not generally deploy an actual quantifiable measurement to determine its presence. So, with the advent of the technology espoused by Cantimer, we may finally have a convenient tool with which to begin to diagnose, as opposed to predict, dehydration, during virtually any activity for which the physical environment will allow its use. This will hopefully also allow us to test different hydration/rehydration strategies, including various fluids, electrolyte concentrations, and so forth.

This post, Spit Test To Determine Hydration Status, was originally published on by Paul Auerbach, M.D..

Hot Water for Jellyfish Stings

There are multiple therapies recommended for field therapy (first aid) for jellyfish stings. These include topical decontaminants, such as vinegar (acetic acid), rubbing alcohol, papain, citrus juice, ammonia, and others; rapid decontamination combined with removal of nematocysts (by scraping, shaving, or abrasion); application of ice or cold packs; and application of heat. In addition, there is the consideration of therapy for an allergic reaction to jellyfish venom(s).

Application of heat, in the form of hot water “to tolerance” (non-scalding) is a relatively new therapy, in comparison to others that have been recommended for years in one form or another. The major proponents for this therapy are Australians, who have observed and evaluated this therapy clinically, predominately in victims of the Australian species of man-of-war jellyfishes. Their observations have been that this therapy is very helpful, as the victims improve clinically, particularly in showing relief from pain.

I am encouraged by this finding, and hope that it proves to be true over the long haul, and not just until it falls out of favor based upon some new recommendation. So, until further notice, here is general advice about how to manage a jellyfish sting:

The following is recommended for all unidentified jellyfish and other creatures with stinging cells, including the box jellyfish, Portuguese man-of-war (“bluebottle”), Irukandji, fire coral, stinging hydroid, sea nettle, and sea anemone:

1. If the sting is felt to be from the box jellyfish (Chironex fleckeri), immediately flood the wound with vinegar (5% acetic acid). Keep the victim as still as possible. Continually apply the vinegar until the victim can be brought to medical attention. If you are out at sea or on an isolated beach, allow the vinegar to soak the tentacles or stung skin for 10 minutes before you attempt to remove adherent tentacles or further treat the wound. In Australia, surf lifesavers (lifeguards) may carry antivenom, which is given as an intramuscular injection at the first-aid scene. There is recent discussion in the medical literature about whether or not antivenom against box jellyfish as currently administered to humans is beneficial. Until further notice, it is likely to be used by clinicians. Notably, the pressure immobilization technique is no longer recommended as a therapy for jellyfish stings.

2. For all other stings, if a topical decontaminant (vinegar or isopropyl [rubbing] alcohol) is available, pour it liberally over the skin or apply a soaked compress. Some authorities advise against the use of rubbing alcohol on the theoretical grounds that it has not been proven beyond a doubt to help. However, many clinical observations support its use. Since not all jellyfish are identical, it is extremely helpful to know ahead of time what works against the stinging creatures in your specific geographic location. For instance, vinegar may not work as well to treat sea bather’s eruption, which is commonly seen in certain Mexican coastal waters; a better agent (also subject to some differing opinions) may be a solution of papain (such as unseasoned meat tenderizer). For a fire coral sting, citrus (e.g., fresh lime) juice that contains citric, malic, or tartaric acid may be effective, with emphasis on the word “may.”

Until the decontaminant is available, you can rinse the skin with seawater. Do not rinse the skin gently with fresh water or apply ice directly to the skin, as these may worsen the envenomation. A brisk freshwater stream (forceful shower) may have sufficient force to physically remove the microscopic stinging cells, but nonforceful application is more likely to cause the stinging cells to discharge, increasing the envenomation. A nonmoist ice or cold pack may be useful to diminish pain, but take care to wipe away any surface moisture (condensation) prior to its application.

As I mentioned above, observations from Australia suggest that hot (nonscalding) water application or immersion may diminish the sting of the Portuguese man-of-war from that part of the world. The generalization of this observation to treatment of other jellyfishes, particularly in North America, should not automatically be assumed, because of the fact that application of fresh water worsens certain envenomations. However, the concept is intriguing, and I intend to try it the next time I am stung if hot water is available. (How hot is hot? The upper limit of temperature should be 113 degrees Fahrenheit or 45 degrees Centigrade.) Otherwise, I will continue to use vinegar (e.g., StingMate) or another of the useful topicals.

3. Apply soaks of vinegar or rubbing alcohol for 30 minutes or until pain is relieved. Baking soda powder or paste is recommended to detoxify the sting of certain sea nettles, such as the Chesapeake Bay sea nettle. If these decontaminants are not available, apply soaks of dilute (quarter-strength) household ammonia. A paste made from unseasoned meat tenderizer (do not exceed 15 minutes of application time, particularly not upon the sensitive skin of small children) or papaya fruit may be helpful. These contain papain, which may also be quite useful to alleviate the sting from the thimble jellyfish that cause sea bather’s eruption. Do not apply any organic solvent, such as kerosene, turpentine, or gasoline. While likely not harmful, urinating on a jellyfish, or any other marine, sting has never been proven to be effective.

4. After decontamination, apply a lather of shaving cream or soap and shave the affected area with a razor. In a pinch, you can use a paste of sand or mud in seawater and a clamshell.

5. Reapply the vinegar or rubbing alcohol soak for 15 minutes.

6. Apply a thin coating of hydrocortisone lotion (0.5 to 1%) twice a day. Anesthetic ointment (such as lidocaine hydrochloride 2.5% or a benzocaine-containing spray) may provide short-term pain relief.

7. If the victim has a large area involved (an entire arm or leg, face, or genitals), is very young or very old, or shows signs of generalized illness (nausea, vomiting, weakness, shortness of breath, chest pain, and the like), seek help from a doctor. If a child has placed tentacle fragments in his mouth, have him swish and spit whatever potable liquid is available. If there is already swelling in the mouth (muffled voice, difficulty swallowing, enlarged tongue and lips), do not give anything by mouth, protect the airway, and rapidly transport the victim to a hospital.

To prevent jellyfish stings, an ocean bather or diver should wear, at a minimum, a synthetic nylon-rubber (Lycra [DuPont]) dive skin. Safe Sea® Sunblock with Jellyfish Sting Protective Lotion, which is both a sunscreen and jellyfish sting inhibitor, has been shown to be effective in preventing stings from many jellyfish species.

This post, Hot Water for Jellyfish Stings, was originally published on by Paul Auerbach, M.D..

Dropping The Ball In Patient Care: Provider Handoffs

One of the most dangerous times for a patient is during the transition, or “handoff,” between providers. This is due to a number of reasons. First, the original provider(s) may not relay all the information he or she knows about the patient to the next provider(s). Second, the accepting team may take it for granted that everything is known about the patient, and therefore not take a complete history or perform an adequate physical examination. Third, if the patient initially looks good, the accepting providers may be lulled into a false sense of security, and not anticipate a deterioration in the patient’s condition.

We know this problem to exist in the hospital setting. Survey of doctors-in-training suggests that handoffs may commonly lead to patient harm. Last year (2008) in September, there was a blog written by Elizabeth Cooney in the Boston Globe that stated, “a 2006 survey of resident physicians at Massachusetts General Hospital found that handoffs commonly lead to patient harm, according to an article in The Joint Commission Journal on Quality and Patient Safety.” More than 50 percent “of the 161 medical or surgical residents who responded to the anonymous survey said they recalled at least one occasion in their last month-long rotation when a patient suffered from flawed handoffs.” Approximately “one in nine said the harm that resulted was significant.” The respondents said that “if the patient was coming from the emergency department or from another hospital, problematic handoffs were more likely.”

This holds true in the field. Unless the new treatment team makes the assumption that they need to begin their assessment of the patient’s condition from scratch, they are more likely to make a mistake. Obviously, such caution depends on the possible severity of the patient’s condition and the rescue/environmental situation. If I can get a decent handle on a patient’s condition, and there is little or no risk of me missing something, I will tailor my questioning and examination to suit the circumstances. However, I always start from the position that something has been hidden from me, of course not intentionally, and that the patient’s initial assessment has underestimated the problem(s).

I cannot begin to tell you how many times I have found something that was missed, or have accepted the care of a patient just as he or she began to “crash.” This is in no way a criticism of others, just a common fact of medical care. Previous rescuers may have been tired, the conditions may not have been conducive to a full examination, the patient may have been withholding information, or the situation may have just taken its natural course and worsened. Regardless, it’s my responsibility to learn what I can as quickly as I can about my patient, so that nothing slips through the cracks.

Here are some simple rules to follow:

1. If the situation permits, ask your new patient to repeat his or her history. If they are reticent to engage in a long conversation, at least try to get them to relate current relevant events.
2. Repeat as much of the physical examination as you can. Explain to the patient that you have assumed their care, and that in order to do the best that you can on their behalf, it’s important for you to understand their issues and to be able to monitor their progress based up the exam.
3. Assume that until you have talked to the patient or otherwise obtained a comprehensive history, and performed a physical examination with your own hands, eyes, and ears, that you do not know as much about your patient as you could.
4. If a patient is under your care for a prolonged time, or if you are managing a situation prone to rapid or undetected deterioration, interview and examine your patient as often as is necessary and practical. If you must be absent from a patient for a longer period than is prudent between examinations, delegate the responsibility to someone else.

image of leg splinting courtesy of

This post, Dropping The Ball In Patient Care: Provider Handoffs, was originally published on by Paul Auerbach, M.D..

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