“Disrupting Natural Selection in Southern Appalachia”®
Vol X, No. 1• January 2017
Updates and Committee Reports:
We held an Advanced Wilderness Life Support (AWLS) Course on September 30 - October 2, 2016, at an outstanding facility called "Wilderness Adventure at Eagle Landing" just outside of Roanoke, VA. We had 27 students attend the course, including two students who certified in Wilderness First Aid, and two physicians from Nepal who audited the course. A total of 23 students successfully obtained AWLS certification. In addition to the course content, participants enjoyed the opportunity to select one of several outdoor activities offered during a scheduled break in the program. These included local mountain biking, hiking a popular scenic trail, learning about water rescue techniques, and open leisure time. Our colleagues from Nepal provided an after dinner presentation on hiking in the Himalayas at our annual ACWM Banquet.
Linda Laskowski-Jones, MS, APRN, ACNS-BC, CEN, FAWM, FAAN
Winter Focus: Frostbite in Roanoke, Virginia
Frostbite can occur in Roanoke. Especially in the cold winter months in our high risk populations. Some high-risk features for urban frostbite are alcohol use, poor protective clothing, homelessness, elderly and psych illness. Of course the other population at risk is outdoor enthusiasts who get stuck out in the elements unprepared.
Prevention is key for frostbite. However typically when we become involved it is too late for that. The most important aspect of field treatment is get the patient to an area where they can stay warm and not re-freeze. You should not attempt to rewarm a frostbitten body part unless you can ensure it stays warm. This is especially important in expedition medicine. Frostbite should be warmed in a warm water bath. It should not be rubbed (friction causes for damage) or placed near a fire (or heater) as with diminished sensation patients can be burned. Hypothermia should be addressed before or while addressing frostbite.
Once in the emergency department re-warm frost bite in a warm water bath of approximately 37-39 C. Rapid re-warming is key, overheating should be avoided and re-warming should not be stopped due to pain (give pain meds). Patients should be given fluid to remain euvolemic to help with tissue perfusion. (Remember cold diuresis – so many cold patients are somewhat dehydrated).
Once warm the area should be bandaged sterilely and splinted. Cold exposure should be avoided. Hemorrhagic blisters should not be debrided. Some controversy exists over clear blisters; it is reasonable to also leave these intact.
Ibuprofen should be started in the field at a dose of 12 mg/kg per day divided twice daily (minimum to inhibit harmful prostaglandins) to a maximum of 2400 mg/day divided four times daily.
There is evidence for tPA to improve re-perfusion in severe cases . This decision should be made in consultation with the frostbite telemedicine line. Empiric antibiotics are not indicated. Tetanus should be updated.
Surgical debridement should not be performed until skin perfusion is clearly demarcated. This can take 2 – 6 weeks. Studies have shown early surgical treatment leads to more tissue loss than late treatment. There will be exceptions to this if wet gangrene occurs.
Consultation with wound care, podiatry, orthopedics or plastics may be considered. Vascular surgery or IR may be helpful if catheter directed TPA is considered. Transfer to a burn center may also be reasonable, however in this region there is a lot less frostbite experience than in other regions.
As a physician there is a great resource for severe frostbite cases through the University of Utah. http://healthcare.utah.edu/burncenter/frostbite.php
Dr. Stephanie Lareau (and the wilderness medicine fellowship)
Beginning in 2008, we began presenting the Mountain Laurel Award, awarded each year to an individual or group who has made extraordinary, lasting and substantial contributions to wilderness medicine in the southern Appalachians. It is intended to be a lifetime achievement award, and is the highest honor we can bestow. The 2016 Award was given to Fred Baty. In 2012, Fred retired as Assistant Chief of the Knoxville Fire Department after 39 years of service. He is adjunct faculty and lead Wilderness Medicine faculty at Roane State Community College, and since 1995 has written and taught WM courses. Fred was one of the original leaders of the Wilderness Medical Society's annual Student elective, having authored the prehospital portion of this course. He remains a leader in Wilderness Medicine in our region.
Since 2007, we annually present the Founder's Award to an individual who has provided extraordinary service to the Center. This year's award was presented to Richard Salkowe. Richard is a podiatrist who also has a PhD in Spatial Epidemiology and Environmental Science & Policy. He is a Research Associate at the University of South Florida and a Master Instructor at the FEMA Center for Domestic Preparedness in Anniston, Alabama where he provides education in the medical management of disasters and highly infectious diseases. He is an avid outdoorsman. Richard has been personally responsible for the production of our newsletter, and his service and efforts in this endeavor have been truly extraordinary. He lives in Florida, outside our official region, but spends the summer season exploring the backwoods in West Virginia and North Carolina.
Named in honor if the original recipients, the Carleton-Stranahan Award was created to recognize Outstanding Volunteer Service. The 2016 award was presented to an individual who has volunteered both behind the scenes doing administrative tasks, creating t-shirt designs, and many other things, as well as volunteering at practically every event the ACWM has been involved in: Daniel Culpepper. Thank you Daniel for everything you do!
Michael J. Caudell, MD, FACEP, FAWM, DiMM
Southern Appalachian Publications
We continue to look to publicize those in the Southern Appalachians publishing on wilderness medicine topics. Please send us information on publications for inclusion here!
Urquhart,C., Paulsen, D., Moncayo, A. and R. T. Trout Fryxell . 2016 Evaluating Surveillance Methods for Arboviral Vectors of La Crosse Virus and West Nile Virus of Southern Appalachia.
Journal of the American Mosquito Control Association. 32(1):24-33.
Staudt A , Leidner AK , Howard J , et al. 2013. The added complications of climate change: understanding and managing biodiversity and ecosystems. Frontiers in Ecology and the Environment 11: 494–501.
Advisory Council Engagement
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