The latest news, views and opportunities from EWM Towers
|
||||||||||||
|
||||||||||||
|
|
||||||||||||
|
||||||||||||
|
![]() |
|
|||||||
|
|
|
|
|||||||||||||
|
|||||||||||||
|
|
|||||||||||
|
|||||||||||
|
|
|||||||||||
|
|||||||||||
|
Not many things you can say that change your life! Attending the Wild Medicine course was one of those events.
Amazing set of people and a fantastic opportunity to learn about conservation and desert medicine.
The kind of odd things we learnt…
– Take blood from a cheetah,
– Learn about (and touch – optional) many poisonous snakes,
– Sleep in a desert, walk 14km through a dry river canyon,
– What are the problem animals with Rabies? (A: Kudu),
– How can carnivores live outside conservation areas & not get killed by farmers &
villagers?
– How to build a vineyard in a desert … what?!..And the thing that changed our lives? Meet the Bushmen and see their need for healthcare! My wife and I are volunteering at Naankuse to run the Bushmen medical services. The real thing we learned? There are many people out there that can benefit from our skills …
Oh and by the way Namibia is amazing you get to see loads … but you can also get a 4×4 and do a week or so trip before the course.
Not many things you can say that change your life! Attending the Wild Medicine course was one of those events.
Amazing set of people and a fantastic opportunity to learn about conservation and desert medicine.
The kind of odd things we learnt…
– Take blood from a cheetah,
– Learn about (and touch – optional) many poisonous snakes,
– Sleep in a desert, walk 14km through a dry river canyon,
– What are the problem animals with Rabies? (A: Kudu),
– How can carnivores live outside conservation areas & not get killed by farmers &
villagers?
– How to build a vineyard in a desert … what?!..And the thing that changed our lives? Meet the Bushmen and see their need for healthcare! My wife and I are volunteering at Naankuse to run the Bushmen medical services. The real thing we learned? There are many people out there that can benefit from our skills …
Oh and by the way Namibia is amazing you get to see loads … but you can also get a 4×4 and do a week or so trip before the course.
Our speakers will be sharing their state-of-the-art operational best practices and experience, and are ideally placed to provide expert knowledge to delegates within the areas of:
Expedition and Wilderness Medicine | Pre-Hospital Medicine | Disaster and Relief Medicine | Pre-Hospital and Disaster Medicine
It is a unique opportunity to gain knowledge from the world’s most experienced and senior extreme medicine professionals, and will also give many valuable practical learnings:
The speaker line up includes:
Located at the stunning N/a’ankuse Lodge and Wildlife Sanctuary only 42kms east of Windhoek is Expedition & Wilderness Medicine’s new Conservation Medicine Course. This truly unique lodge is set amidst a natural savannah, with riverine vegetation, lush grass plains and magnificent mountain views, and offers a malaria free Wild Medicine course.
The main objective of the course is to educate attendees as to how we can integrate the diagnostic and problem solving skills of both human and animal health professionals with the knowledge of conservation professionals. Ultimately this should help all concerned to better manage the environment and biodiversity to the benefit of all the inhabitants of our beautiful planet.
The emerging interdisciplinary field of conservation medicine, which integrates human and veterinary medicine and environmental sciences, is largely concerned with zoonose. At the present time there is very little sharing knowledge in both an academic and practical session and this course serves to address this significant gap.
Dr Roger Alcock, lead medic on this Septembers Keswick based Expedition & Wilderness Medicine course talk about the high calibre of medics on the search & rescue scenerio run on the hills about the EWM training base
The aim of the Expedition & Wilderness Medicine Course is to provide aspiring and experienced expedition doctors, nurses, paramedics and advanced medics with the skills and practical knowledge to become valuable members of an expedition medical team.
The gold standard and highly acclaimed course based in Keswick and Plas y Brenin in Wales
Of interest
Expedition | Desert | Diving | Mountain | Polar | Jungle | Jobs |
![]() |
![]() |
![]() |
![]() |
![]() |
![]() |
![]() |
|
||||||
![]() |
||||||
![]() |
![]() |
|
||||
![]() |
![]() |
Mountain Medicine Course Leader Dr Luanne Freer reports from EverestMOUNTAIN MEDICINE 22.5 CME
|
||||
![]() |
||||||
![]() |
Leader of this years Mountain Medicine Course in Nepal Dr Luanne Freer head of the EverestER clinic providing medical cover for Everest climbers & Sherpas alike makes her initial report from Base Camp.Luanne reports; ‘Each year we are amongst the first to arrive at Everest Base Camp for the spring season and we are amongst the last to leave. As we work to set up the EverestER clinic, workers from climbing teams level ground and set up tents in anticipation of the later arrival of the climbers and guides. One of the most important tasks taking place during this time is the planning and setting of the route up the treacherous Khumbu Ice Fall.An elite group of Sherpa climbers, known as the Icefall Doctors, bear the difficult and dangerous task of setting ropes and ladders across the numerous crevasses that make up the ice fall.
Ang Gyeltzen Sherpa is a member of the Icefall Doctors and an electronics wizard. Each year he provides assistance to the clinic. This year, bored because snowfall has delayed work on the icefall route, Ang Gyeltzen helps us set up our new solar charging system. Spaces on the Mountain Medicine course are extremely limited secure your place now 24 October 2011 to 08 November 2011 |
![]() ![]() |
||||
![]() |
![]() |
|
||||
![]() |
![]() |
Desert Medicine Course prepares to gather in Namibia
|
||||
![]() |
||||||
![]() |
Our Desert Medicine course departs for Namibia at the end of this month led by Dr Amy Hughes and Dr Christoffer van Tulleken of Channel 4’s ‘Medicine Men Go Wild’ fame.Chris is currently an academic registrar at University College London Hospital in Infectious Disease & Tropical Medicine & has extensive experience of remote medicine. Chris has been the medical consultant and location medic for more than 12 documentary series including BBC’s Tribe, Amazon & Human Planet. He has also presented several documentaries about humanitarianism, science & remote indigenous societies.
The course, set in the shadow of Namibia’s highest peak in a stunningly remote area of Damaraland, covers a whole gamut of desert related subjects including envenomation, desert navigation, tropical medicine & looking for water. The meeting place is in Windhoek on the morning of the 1st May & to secure your place email us now 01 May 2011 to 07 May 2011 |
![]() ![]() |
||||
![]() |
![]() |
|
||||
![]() |
![]() |
Dr Nick Knight reflects on the recent Keswick course
|
||||
![]() |
||||||
![]() |
With the sunshine out and the rasping sounds of the Search and Rescue Teams over the two-way radios out on the Cumbria hills, you would have been easily mistaken in thinking you were in the middle of a real emergency. In fact, it was the final Search and Rescue exercise (with CASEVAC) of a fantastic 4 day Expedition Medicine Course in Keswick in Cumbria.As the University Liaison for Expedition Medicine, it was the first course that I attended as a new member of the ‘EM faculty’ – and what a fantastic experience it was. Not only did I get to absorb the electric atmosphere of the 60+ delegates there alongside the seasoned expedition medics leading the course but it gave me ample opportunity to see how such courses can align themselves with my role as University Liaison and to stimulate a few more ideas. Spaces on this course are limited secure your place now 16 May 2011 to 19 May 2011 – Plas Y Brenin, Wales |
![]() ![]() |
||||
![]() |
![]() |
|
||||
![]() |
![]() |
International ‘World Extreme Medicine’ Conference & EXPO – ‘Taking Medicine to the Extremes’.
|
||||
![]() |
||||||
![]() |
We are very close now to confirming the content, which will be modular in nature & CME certified, the location & the dates. We are able to offer a great discount rate for nurses, paramedics & students & we are hoping to get all this information out to you over the next couple of weeks.Pre register your interest by emailing here
London late April 2012
Salt Lake City September 2012
|
![]() |
||||
![]() |
![]() |
|
||||
![]() |
![]() |
INTERVIEW WITH MEDICAL DIRECTOR DR AMY HUGHEFACE 2 FACE |
||||
![]() |
||||||
![]() |
Dr Amy Hughes talks to the camera about Expedition Medicine.As Expedition Medicine’s new medical director Dr Amy Hughes, Pre-hospital Care Registrar with the Kent HEMS Team, speaks about the growing opportunities for medics as Expedition Medicine, a medical sub speciality, continues to grow & develop.This article is in video format & can be watched by following this link | ![]() |
||||
![]() |
|
|||||
![]() |
||||||
![]() |
![]() |
|||||
![]() |
![]() |
JOBS
|
||||
![]() |
||||||
![]() |
If you want to ensure that you hear about the job opportunities as soon as we receive them then we recommend that you ’like’ our Facebook group. *URGENT: Doctor required for charity expedition with the Ultimate Travel Company.
Outline duties/responsibilities: You will be trekking with the group and will have your own porter to carry the medical kit. You will be expected to provide medical advice, dispense medication and services as appropriate and within your capability to the trek participants and other expedition staff. This may involve triage, stabilization, initial treatment and transfer of anyone suffering a serious illness or injury. You would be expected to have very good communication skills, be an excellent team player and work at all times with the GMC guidelines of Good Medical Practice and the Duties of a Doctor.If you are interested in this post please contact Jennie or Stef at the Ultimate Travel Company with a short resume of your relevant experience email Jennie or Stephanie here or telephone 020 7386 4673. The Khomas Medical Centre in Windhoek, Namibia, a private multidisciplinary group practice, is looking for qualified doctors to work in their busy practice. Successful applicants will get a lot of hands on experience & encounter a wide variety of infectious diseases such as HIV & TB as well as ample chance to explore this amazing country Interested doctors should contact Karen Trümper. |
![]() |
||||
![]() |
||||||
![]() |
||||||
Finally…….
|
||||||
![]() |
Expedition Medicine’s UK Course Welcomes their University Liaison
With the sunshine out and the rasping sounds of the Search and Rescue Teams over the two-way radios out on the Cumbria hills – you would have been easily mistaken in thinking you were in the middle of a real emergency. In fact, it was the final Search and Rescue exercise (with CASEVAC) of a fantastic 4 day Expedition Medicine Course in Keswick in Cumbria.
As the University Liaison for Expedition Medicine, it was the first course that I attended as a new member of the ‘EM faculty’ – and what a fantastic experience it was. Not only did I get to absorb the electric atmosphere of the 60+ delegates there alongside the seasoned expedition medics leading the course but it gave me ample opportunity to see how such courses can align themselves with my role as University Liaison and to stimulate a few more ideas.
International Extreme Medicine EXPO- Expedition & Wilderness | Tactical | Disaster Medicine
‘Taking Medicine To The Extremes’
A major new International ‘World Extreme Medicine conference and EXPO’ series with the first inaugural event in London April 2012 followed by Salt Lake City in September 2012 with the very best speakers from around the world, leading figures from the world of expedition and wilderness travel, displays from focused industry leaders and also awards. All CME accredited on a modular basis to allow you select just a day or to attend the entire medical expo.
Over the last ten years the care of casualties in a remote environment has come a long way. This has been driven by conflict, the apparent exponential rise in natural disasters and our capacity to respond on an international scale and not least by the evolving interest in the field of expedition and wilderness medicine. The conference concept was generated out of a desire to amalgamate the associated specialties in this field and to share the skills and knowledge we have acquired. It will run over 4 days and involve some of the major specialists in their field of remote and austure medicine.
Developed specifically with medical professionals in mind the International ‘World Extreme Medicine EXPO’ will also be of interest to other medical specialists and students for which there will be a discounted rate.
To pre-register your interest for ‘Extreme Medicine’ email us here.
International Extreme Medicine EXPO- Expedition & Wilderness | Tactical | Disaster Medicine
‘Taking Medicine To The Extremes’
A major new International ‘World Extreme Medicine conference and EXPO’ series with the first inaugural event in London April 2012 followed by Salt Lake City in September 2012 with the very best speakers from around the world, leading figures from the world of expedition and wilderness travel, displays from focused industry leaders and also awards. All CME accredited on a modular basis to allow you select just a day or to attend the entire medical expo.
Over the last ten years the care of casualties in a remote environment has come a long way. This has been driven by conflict, the apparent exponential rise in natural disasters and our capacity to respond on an international scale and not least by the evolving interest in the field of expedition and wilderness medicine. The conference concept was generated out of a desire to amalgamate the associated specialties in this field and to share the skills and knowledge we have acquired. It will run over 4 days and involve some of the major specialists in their field of remote and austure medicine.
Developed specifically with medical professionals in mind the International ‘World Extreme Medicine EXPO’ will also be of interest to other medical specialists and students for which there will be a discounted rate.
To pre-register your interest for ‘Extreme Medicine’ email us here.
The treatment of cholera in an active malaria zone is a difficult matter. This is especially true with lessons being learned in Haiti and their recent cholera outbreak. I am specifically referring to the combination of Chloroquine (antimalarial) and the antibiotic class Macrolides (used in treatment of cholera). A post that I made back in 2009 has new recent relevance and I wanted to repost that here:
Azithromycin, Chloroquine and Arrythmias:
Travel medicine frequently uses medicines that are taken under special circumstances and for short periods of time, like a trip. Many travelers carry an antidiarrheal antibiotic on their trip and a common choice is azithromycin. This can potentially be a problem when they are also traveling in a malaria area and using chloroquine for prevention. Two very commonly used medicines chloroquine (antimalarial) and azithromycin(macrolide antibiotic used for respiratory infections and diarrhea) both have wonderful safety profiles, individually. However when taken together, there is discussion of the chance of a heart arrhythmia, specifically prolonging the QT interval. In fact, my software I use for prescribing cites this as a combination to avoid.
There are several important articles that can be used to look at this problem and evaluate the risks. One very good paper looks at medications that prolong this QT interval:
These authors list azithromycin as a “very improbable” medication, although other macrolides are listed as higher risk. Chloroquine is listed as an “Unknown” medication, with respect to prolongation of QT interval. This article was based on expert opinions.
This study looked directly at this problem, in animal models. Their research showed no increase in arrhythmia risk.
A wonderful article that is actually helping to look at using this drug combination to treat resistant forms of malaria. More about this combination and treating malaria here. Their study did show an increase in the QT interval in both groups of those who received chloroquine alone and those who received the combination of chloroquine and azithromycin. This QT interval increase was maximum on day number three and returned to baseline by the end of the study.
Most of the information I am finding looks reassuring for safely using this combination, in healthy individuals. Those with a history of arrhythmia should use this combination with caution and discuss this problem with their doctor, before they take these two medicines within a close amount of time.
Contributer: Dr Erik McLaughlin | www.adventuredoc.net
Pre-hospital Expedition Medicine Series
Dr Amy Hughes, Medical Director of Expedition Medicine and Pre-Hospital Emergency Medicine Registrar and HEMS paramedic Dave Marshall, both part of the Kent Helicopter Emergency Medical Team, continue their series examining pre-hospital expedition trauma care and associated kit.
In the second article in the series, Dave Marshall gives an overview of managing pelvic fractures pre-hospitally and in an expedition environment, and introduces the use of the pelvic splint.
Edited by Dr Amy Hughes.
Pre hospital and Expedition management of pelvic trauma and use of the pelvic splint
Expeditions have become more and more adventurous over the past years, both in destination and the participants involved. As a result, the frequency and pattern of injury is changing and the demand on the medical team thus increased. Having a broad knowledge of fracture management, including mechanism of injury, clinical findings, reduction techniques and splinting is essential. Although one of the most enjoyable challenges of being a medic on an expedition team is improvisation regarding kit used to manage various ailments and injuries, practice and competence in the use of non-improvised kit such as the Pelvic Sam Splint is essential.
Mechanism of Injury
Pelvic fractures often result in extensive disruption of the bony structures and associated ligaments of the pelvis and are potentially life-threatening injuries. The fractures associated with the greatest morbidity and mortality involve significant forces such as motor vehicle crashes, motorcyclist crash, pedestrian versus car, falls from height and crush injuries. Early suspicion, identification and management of a pelvic fracture at the prehospital stage is essential to reduce the risk of death as a result of hypovolaemia, (1). It is especially important to be able to identify, treat and minimize risk of further damage when in a remote area miles from the nearest medical facility.
Understanding the mechanism of injury is vital in being able to predict the potential for significant injury to the pelvis and its underlying structures, even in the absence of clinical signs. It is, therefore, essential that time is taken to evaluate the mechanisms involved in any accident resulting from significant force or where there is pain or injury to the spine, abdomen, pelvis or femurs.
In motor vehicle accidents – a not uncommon event on expeditions – learning how to ‘read’ the wreckage to help identify possible pelvic injury, in conjunction with clinical suspicion, can significantly aid diagnoses.
The intrusion into the passenger and drivers door is likely to result in massive lateral injury to the pelvis.
The intrusion into fuel tank shows the imprint of the riders pelvis. This would often result in significant fracture to the pelvis – often multiple, often ‘’open book’’ pelvis.
Anatomical structure of the pelvis
The pelvic ring is often likened to a polo mint in that it is almost impossible to have a significant break in one place and not another. The most common area to be damaged in trauma is the pubic rami, acetabulum and the sacroiliac joint. There is extensive vasculature through and around the pelvic ring, most notably the iliac vessels. For imagery see > http://visualsunlimited.photoshelter.com/image/I0000kUOn3NJHcZU.
The greatest risk of a pelvic fracture is catastrophic haemorrhage and gentle handling of the patient in the initial and subsequent stages could literally be the difference between life and death. Whole blood clotting time is approximately 10 minutes, (depending on the environment). Expedition medics should be familiar with the ‘first clot best clot’ theory. In other words, a patient sustaining a traumatic injury resulting in haemorrhage will begin to form a clot using their own clotting factors. If this clot is disrupted they could easily bleed to death. A full fluid resuscitation will not be practical in the field as most expeditions carry a maximum of 2 litres of crystaloid. However it should be noted that overloading the patient with fluid can be equally harmful, and small boluses should be given to maintain a central pulse and cerebral perfusion. This is known as permissive hypotension and will be discussed in more detail in a future article. Disruption of this first clot in the prehospital setting could be fatal, and without access to blood and clotting agents the patient may die. Trauma will result in the patient becoming acidotic, hypothermic, and coagulopathic. (3)
This coagulopathy cannot be easily reversed pre-hospitally, each factor contributes to the decline in the others. (see above diagram). Any disruption to the first clot will have devastating consequences. Ultimately, the patient requires definitive haemorrhage control, (surgery, angiography and embolisation), and replacement of blood and clotting agents.
The glass pelvis: Think of the pelvis as being made of very fragile glass, and you can see the clot in the form of a cartoon jelly inside. The jelly is very delicate and unless movement is gentle and kept to a minimum, it will ‘wobble’ to the point of destruction very easily. The same applies to the blood clot! Early recognition of the potential for a pelvic injury, gentle handling and prompt stabilisation is vital to improve the outcome of a patient injured on an expedition.
Clinical Features of a pelvic injury:
As we have already discussed, a patient with a suspected pelvic fracture must be handled very carefully. Whether in a medical facility or the most extreme expedition environment, the same principles apply to prevent worsening the injury and preserving the clot.
Log rolling the patient should be avoided at all costs!
The medical kit available on expeditions will be minimal. Stretchers may have to be improvised and transportation limited. However, all medical kits should have some sort of pelvic binder which should be applied carefully and correctly at the earliest opportunity,
Application of the pelvic SAM splint.
The casualty will inevitably have to be placed in the supine position, to evacuate them on whichever device is available. This can be achieved by a coordinated team approach utilising other members of the expedition.
One person should be at the head end of the patient maintaining in manual inline immobilisation, (MILS), and they will give clear commands to the team when moving the casualty, (“ready, brace, roll”). A pelvic binder such as the one shown can be applied using a minimal 10-15% roll, (enough to get a bum cheek off the ground!)
Once in position the device can be tightened just enough to maintain anatomical alignment. Do not over tighten as this could cause significant further damage!
Log rolling patients.
Whilst sometimes useful in a controlled hospital environment following appropriate imaging, should be avoided in the pre hospital field. In simple risk versus benefit terms it could have catastrophic consequences. By using the hands available and correctly briefing the team about the amount of movement required (one cheek off!), it should be possible to optimise the care of the casualty prior to evacuating them to definitive care.
Improvised methods of pelvic splinting on expeditions
Much of the challenge of expedition medicine is improvisation. The medical kit you take out with you may not have SAM splints in them. Providing a support can be placed across the greater trochanter, then any sort of material could be used – for example clothing, a sheet, or a canvass of some kind.
Fluids
The approach to fluid management in trauma has changed. Two litres of fluid is not necessarily required for management of pelvic injury. Titrate fluid according to the presence of pulses or cerebration (alertness). The presence of a radial pulse, and even in certain circumstances (without associated head injury) presence of a femoral pulse signifies the blood pressure is sufficient to perfuse the necessary organs and promote clot preservation. Further details of permissive hypotension will follow in another article.
Analgesia
Essential – this depends on what is available. Intravenous opiates or a fentanyl lolly is ideal for analgesia, after the use of paracetamol or a NSAID.
Other injuries
Pelvic injuries are often present in conjunction with other significant injuries – spinal, femur, urological or abdominal as examples. Whether or not other injuries have been excluded, spinal precautions are essential in conjunction with good management of the pelvis.
References
MDDUS (Medical and Dental Defence Union of Scotland) took the oppurtunity in one of the quiter periods in Expedition and Wilderness Medicines Medical Director Amy Hughes hectic schedule to interview her about her career in expedition medicine.
Dr Hughes co-leads the Mountain Medicine course in Nepal with Everest ER founder Dr Luanne Freer in October
MDDUS (Medical and Dental Defence Union of Scotland) is an independent mutual organisation offering expert medico-legal advice, dento-legal advice and professional indemnity for doctors, dentists and other healthcare professionals throughout the UK.
Feedback on our recent Polar Medicine training course in Norway has clearly affected some of the course delegates by creating a need for ‘biggles-speak’…
PapaFoxtrot calling Red Leaders AlphaHotel, AlphaCharlie, DeltaBravo, Bravo and Delta
Congrats on recent Operation Polar Bear
Wizard week
No prangs
Best ever
Location stunning
Bunks and chow excellent
Red Leaders all SPLENDID
Hope all returned to base safely
Please pass on to all members of Polar Bear as don’t have call signs
Do you read me ?
Over
Dr Amy Hughes medical career has been far from ordinary and she talks about how she has ended up as medical lead at EWM.
Dr Hughes co-leads with Dr Luanne Freer our CME accredited Mountain Medicine course on the Everest Base Camp trail in Nepal.
Dr Amy Hughes, Medical Director of Expedition Medicine and Pre-Hospital Emergency Medicine Registrar with Kent Helicopter Emergency Medical Team gives a brief overview of managing femur fractures in an expedition environment, in the first article in a series examining pre-hospital expedition trauma care and associated kit..
Management of a mid-shaft fractured femur in the field and use of the Kendrick Traction Device
Expeditions have become more and more adventurous over the past years, both in destination and the participants involved. As a result, the frequency and pattern of injury is changing and the demand on the medical team thus increased. Having a broad knowledge of fracture management, including mechanism of injury, clinical findings, reduction techniques and splinting is essential. Although one of the most enjoyable challenges of being a medic on an expedition team is improvisation regarding kit used to manage various ailments and injuries, practice and competence in the use of non-improvised kit such as the Kendrick Traction Device is vital.
Mechanism of injury
Fractured femurs form only a small percentage of common injuries on expeditions but can be associated with significant morbidity and mortality. Early effective management is vital in view of the risk of significant blood loss, pain, long term complications and compartment syndrome. In assessing and managing femur injuries, it is also very important to exclude associated injuries such as chest, axial skeleton, pelvis and head. This article will focus only on mid shaft femur injuries, further discussion on management of multi-trauma will be examined in another article.
A high energy force is often needed to fracture the femur in a young, fit individual unless they have a pre- existing medical condition predisposing them to reduced bone density (osteoporosis, malignancy, malnutrition, muscle atrophy, previous fracture). Road Traffic Collision are the one of the most common risks to participants on an expedition and a common mechanism for high energy transfer resulting in fractures of the femur – especially dashboard injuries. Other mechanisms of injury include falls from height, pedestrian versus vehicle and direct trauma to the leg. As mentioned above, associated injury need to be considered and managed appropriately, especially pelvic injuries.
Mid shaft femur fractures
These fractures are almost always the result of high energy trauma, the mechanisms of which have been mentioned above. As the femur is very vascular, injury can result in significant blood lost and a requirement for haemorrhage control and clot preservation pre-hospitally until definitive care can be reached is paramount. The pattern of femur injury often results from the direction of force applied. For example, a perpendicular force results in a transverse fracture pattern, an axial force may damage the knee or hip and rotational forces may cause spiral or oblique fracture patterns (1) . Again, understanding the mechanism of the injury is fundamental in determining the resultant pathology. Further complications from mid-shaft femur fractures include deep vein thrombosis, fat emboli, nerve palsies and rarely compartment syndrome.
Clinical Features
Pain is the initial most significant feature. The leg may be shortened and rotated and/or visually deformed with swelling and fullness to the thigh. If the injury is compound (or open) then there will be a wound over the fracture site communicating with the bone / bony fragments. The person will be unable to weight bear. A neurovascular assessment should always be done, with distal pulses felt (often worth marking the pulse with an ink cross) and distal perfusion monitored both after the initial injury, following any intervention and throughout the course of the casevac.
Management
It is vitally important to ensure there are no other traumatic injuries, and an ATLS management approach to the patient should be made.
The ultimate aim of management of a femur fracture is to return the limb to its normal anatomical position. This not only helps reduce pain by bringing the bony fragments into alignment and reducing muscle spasm and soft tissue involvement, it also reduces bleeding, improves clot preservation and helps improve distal perfusion. In the pre-hospital expedition environment resources are limited but if there are no formal traction devices available, improvised devices can easily be used.
Traction is needed on the limb to help bring the proximal and distal ends of the fracture back into alignment, reduce bleeding and pain.
Steps to management of mid shaft femur fractures on an expedition
ANALGESIA – depending on what you have available:
IRRIGATION
TRACTION
The Kendrick Traction Device (KTD). Lightweight and very effective. Approx weight 0.5kgThere is also a boot hitch strap (see final images)
Step 1:
Place upper thigh strap high into groin with the pole holes on the outside of the leg. This strap must sit as high as possible. Measure out the length of the pole against the leg. The bottom of the pole should extend approximately one section length below the foot. The pole can be shortened and lengthened in a similar manner to a tent pole.NOTE : Manual inline traction of the limb should be undertaken as soon as possible and throughout the KTD application
Step 2:
Example of manual in-line traction of the limb.Prior to the ankle strap being positioned, the yellow Velcro strap can be applied just above the knee. This may need tightening after traction has been applied.
Step 3:
Apply ankle strap. The padded part of the strap sits behind the ankle. Tighten using the green strap. The yellow strap fits over the pole end (black part) and traction can be applied gently by tightening the red strap. Traction should be applied until the leg is comfortably under traction and in anatomical alignment. Check distal perfusion.
Step 4:
Step 5:
Apply the two other Velcro straps…..the red strap at the top of the thigh, the green on the lower leg. Manual in-line traction can now be released.
Step 6: Boot hitch
The KTD comes with the option of a boot hitch which can sit over a walking boot if the decision is made not to remove the shoe. The boot hitch strap is laid under the ankle, the white label on the inside of the strap lying closest to the boot.
Step 7: Boot Hitch
Step 8: Boot hitch
The same process as per the ankle strap can then occur, although there are only two straps – the yellow attaches over the end of the pole, the red strap is used for tractioning the splint with a small amount of counter-traction.
Other splints:
i. Sager traction splint – this is bulkier to carry as part of an expedition medical kit but is effective and allows traction of both femurs simultaneously.
ii. Improvised splints
Walking pole or sturdy wooden stick braced and secured to either side of fractured limb (the outside length up to the pelvis, the inside length up to groin) and extending a good 15cm below the ankle. A cross pole positioned across distal end of the poles below the ankle and tied into place. A figure of eight strapping around the ankle, extending down over the cross pole and tightened on itself thus pulling traction down the length of the leg. Alternatively, the figure of eight strapping can be tied to the cross bar and a small piece of wood or metal can be used on the length of strapping between the foot and the cross bar to twist the strapping and tighten the traction on the limb. Important to ensure traction is comfortable and foot remains perfused with a good distal pulse.
The injured leg splinted against the non-injured leg using a walking pole or sturdy stick and strapping (crepe bandage, clothing, rope). This doesn’t allow for traction but may be the only option available to provide some comfort to the patient prior to evacuation.
IV FLUIDS
Providing the patient is cerebrating and has a good radial pulse, intravenous fluids are not required unless there are significant signs of haemorrhagic shock. Permissive hypotension is not discussed in this article and further reading is advised regarding the changes and advances in fluid management in trauma. Do not run 2 litres of fluid into the patient!!
IV Antibiotics for compound (open) fracture and Tetanus prophylaxis
Open fractures are tetanus prone wounds, and most participants on expeditions should be up to date with there tetanus vaccinations. However, it is vital to check with the participant when their last booster was and documenting it for handover when definitive care is reached. If a patient is not vaccinated, of if they are unsure, the vaccine should be administered. The current UK guidelines state that a patient is considered Tetanus immune if they have received five doses of vaccine in their lifetime (3).
Intravenous antibiotics should certainly be considered in the expedition environment. A Cochrane systematic review of the use of antibiotics in open fractures as an adjunct to irrigation and further care found that administering antibiotics did reduce the incidence of early wound infections (3, 4) . Depending on what you carry, a first generation cephalosporin can be used.
References