Tom De Dorlodot tests some of the FreeFlightPhysiology high altitude equipment in the Karakoram, Pakistan
This is probably the most critical podcast episode we’ve made available to date. As human flight junkies we participate in activities that let’s face it- are dangerous. In this episode we sit down with Matt Wilkes, an anaesthesia and intensive care doctor based in Edinburgh, Scotland who specializes in extreme physiology and remote medicine to walk us through best practices when things go wrong. Matt has practiced in Nepal, Bolivia and New Zealand and honed his remote trauma skills as a Flight Physician for the East African Flying Doctors, picking up casualties from countries including Somalia, South Sudan and the Democratic Republic of Congo. Matt takes us through what we need to be carrying in our first aid kit; how to operate in a wilderness environment; how to assess a casualty and make a scene safe; how to care for a victim including the use of narcotics and pain killers; how having a lack of equipment and difficult access to medicine can be overcome; the affects of cold and altitude on pilots (hypoxia); how an accident scene should be managed; best practices for trauma management (including splinting, binding the pelvis, opening an airway, the lethal triad and keeping people warm, pain relief, head injuries, tourniquets, removing a helmet…); controversies about spinal immobilization and a lot more. This podcast is CRITICAL. Make notes and PLEASE- share this with your fellow pilots! There are links to everything we discuss in the show notes below.
Matt has been a Lead Doctor or Medical Advisor for multiple expeditions, including leading a team on the largest group ever to camp on the summit of Mount Kilimanjaro. Matt is the Director of Adventure Medic magazine, holds a Master’s Degree in Mountain Medicine, is a Fellow of the Academy of Wilderness Medicine and is currently undertaking a PhD studying the interaction of altitude, cold and cognition on paraglider pilots.
PLEASE support Matt’s critical work on extreme physiology and high altitude affects through the http://www.freeflightphysiology.org/
Read a teaser of Matt’s article on high altitude physiology in Cross Country Magazine.
A buck an episode, that’s all we ask.
Matt’s contact details: firstname.lastname@example.org, and The Adventure Medic
Applying a pelvic binder:
Openning an airway:
Removing a full face helmet:
XC magazine articles:
Wilderness Medical Society Guidelines (The current gold standards)
Spinal immobilisation: http://www.wemjournal.org/article/S1080-6032(14)00272-5/fulltext
Basic wound management: http://www.wemjournal.org/article/S1080-6032(14)00278-6/abstract
Altitude Illness: http://www.wemjournal.org/article/S1080-6032(14)00257-9/abstract
First Aid Kit:
Rubber gloves x2
SteriStrip 3mm/6mm x 75mm
Triangular Bandage (Sterile Calico)
Absorbent field dressing (battle field/israeli)
Zinc oxide tape 2.5cm
Ibuprofen 200mg and paracetamol 500mg
Disposable heat pack x 4
Permanent Marker and notepad
Water purification tablets (if water is clean enough to drink, it is clean enough to wash a wound)
Rolltop dry bag
Mentioned in this episode: Tom De Dorlodot, Horacio Llorens, Evan Bouchier, Bill Belcourt, Trey Hackney, Matt Beechinor, Nate Scales, Nick Greece, Cross Country Magazine, USHPA, Isabella Messenger, Jamie Messenger, Ed Ewing, Terry O’Connor, Dr. Lucy Hawkes (https://twitter.com/DrLucyHawkes), Sophia Pinero, Dr. Martin MacGinnis (https://twitter.com/martinmacinnis), Professor Adrian Thomas (https://flight.zoo.ox.ac.uk/people/Thomas), Michael Vergalla (https://michaelvergalla.com/free-flight-research-lab/), Antoine Girard, Alistair Dickie, Reavis Gray, Mike Pfau, Chris Santacroce, Red Bull X-Alps, Caroline Paul
More thoughts on Tourniquets from Matt after the show:
Thank you so much for all the fantastic feedback on the podcast. Given the limited time available to Gavin and I, we couldn’t dwell on every topic in detail, so we have had some brilliant follow up discussions with individual listeners. A particularly interesting exchange has been with Dr Bill Beninati, a paraglider pilot and very experienced trauma doc, currently heading up one of Utah’s helicopter rescue services. We got stuck into the nitty gritty of tourniquets and the evidence behind their use. Bill was concerned that I had been too negative about tourniquets, which we both agree can be lifesaving in the right circumstances. To some extent, that was because I didn’t want to recommend anything on the podcast that didn’t have a solid evidence base, without a chance for a proper discussion about the pros and cons. However, neither Bill nor I would want people to be inhibited from using tourniquets following a paragliding crash. The following is a summary of our thoughts for those interested in delving into the topic in more detail:
1) Prompt tourniquet application is lifesaving.
2) Tourniquets have particular value use in penetrating trauma. This may be particularly important in areas like Utah where broken pine boughs can harden into a blade, injuring blood vessels on contact, less so in areas like Scotland where people tend to suffer more ‘blunt’ trauma.
3) Improvised tourniquets are probably less good than purpose-built ones such as the Combat Action Tourniquet (CAT) but do work.
4) Tourniquets must be correctly applied: too tight increases the risk of tissue/nerve damage, too loose and only the veins will be occluded leading to congestion, swelling and paradoxical bleeding. Apply a tourniquet so you can no longer feel the pulse below the wound, this means that the arterial as well as venous blood flow has been stopped. Better too tight than too loose.
5) Don’t release the tourniquet until medics are present and there is a plan for controlling any subsequent bleeding.
6) The most important thing is to aggressively stop bleeding. Do so in the following sequence until you have control 1) Direct pressure; 2) Haemostatic gauze; 3) Splinting; 4) Tourniquets. It may be that this sequence has to be followed in quick succession. Do not apply tourniquets unnecessarily, but equally don’t be inhibited in doing so by worries about future harm. Tom de Dorlodot’s maxim ‘if there is doubt, there is no doubt’ applies here.
7) Keep the casualty warm and remember that ‘the first clot is the best clot’.
What is the evidence behind our thoughts?
The best evidence from tourniquet use comes from penetrating trauma and blast injuries on the battlefield, where tourniquets have been applied typically for up to two hours (and sometimes up to six hours) and have definitely saved lives. Different studies have shown varying levels of potential harm from tourniquet application (typically nerve injuries) but generally complications have been low and those who have suffered complications have, by definition, survived. How much battlefield lessons can be applied to the civilian wilderness medicine world, and ‘blunt’ rather than ‘penetrating’ trauma is hard to say. There is almost no evidence for tourniquet use in the civilian wilderness medicine setting at the moment, but just because nobody has proven tourniquets help, doesn’t mean that they don’t help. Equally, it doesn’t mean that they don’t have the potential to cause harm if misapplied. Until more evidence emerges, we still have to make a judgement based on the situation in front of us.
The follow is a summary of the evidence for tourniquets from the journal Wilderness and Environmental Medicine’s article ‘Bleeding Control With Limb Tourniquet Use in the Wilderness Setting: Review of Science’ (Wilderness Environ Med. 2017 Jun;28(2S):S25-S32.), which shows what we are up against when trying to make these judgments!
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