City Slickers 2: The Legend of Cowley's Gold

...or 60 Minutes of Pyrite.

There is no "Golden Hour". There. I said it. Despite the fact that R. Adams Cowley, the BabyDaddy of modern emergent trauma care, made claims to the contrary.

"There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it maybe three days or two weeks later -- but something has happened in your body that is irreparable."[1]

Nosuh.

Realizing this subject has been touched upon many times before, I bring it up anyway. The previous authors are likely more suited, and better versed than I am.

The late, great, Dr. R. Adams Cowley is credited with coming up with the concept of the Golden Hour. Dr. Cowley apparently first discussed this concept as a military surgeon during World War II. After years of research and discussion, the Army awarded Dr. Cowley $100,000 to study shock. Thus, the first clinical shock trauma unit in the Nation was born. The unit consisted of two beds, and then later, four. By 1960, staff was trained and equipment was in place. He then used the idea of the "Golden Hour" to convince other physicians to refer and transfer sick patients to his revolutionary "Death Lab".

The "Death Lab" grew in popularity, and effectiveness. In 1968 an arrangement was made with Maryland State Police to start using military helicopters to get patients to the shock trauma unit more quickly. The first medevac occurred in '69 after the opening of the Center for the Study of Trauma, a 32 bed unit.

There is no denying that Dr. R. Adams Crowley accomplished a LOT for the emergency medical community. Just about everything we know about Shock and Trauma can be directly, or indirectly traced back to the work of Dr. Cowley and his associates. Pre-Hospital care exists largely due to the efforts of this man (Maryland had the first statewide EMS system). No one can take that away from him.

He accomplished so much, based largely on an inaccurate theory, that was back up by outdated data.

The original data set Dr. Cowley used to suport his "Golden Hour" buzz-word was from a 1918 study, observing casualties of World War 1.

"In World War I, there was a real appreciation of the time factor between wounding and adequate shock treatment. If the patient was treated within one hour, the mortality was 10 percent. This increased markedly with time, so that after eight hours, the mortality rate was 75 percent."[2]

The study reported the following mortality percentages:

1 hr 10 %
2 hr 11 %
3 hr 12 %
4 hr 33 %
5 hr 36 %
6 hr 41 %
8 hr 75 %
10 hr 75 %

Even looking at these statistics 90 years later, I don't see a strong case for using them to support a "Golden Hour" Theory. But he did, and it worked. People still continue to talk about "The Golden Hour". The Main Stream Media is convinced THAT is what saves lives in Iraq and Afghanistan.

Strokes and Cardiac Emergencies are Time Sensitive. Everything else is outsides the bounds of a time limit. A casualty can die on impact, bleed out in the first five minutes, or have an obvious injury inconsistent with survival. A casualty can also receive a significant injury/insult, render self aid, and sit-and-wait. There are casualties that occur in austere environments that survive significant Trauma, despite the fact that definitive care is hours away.

There is no research to conclusively support the existence of the Golden Hour. It doesn't exist. The deceitful buzz-phrase served it's purpose, but it's time has passed. Please Stop teaching it. Or don't. Whatever.

1 http://www.umm.edu/shocktrauma/history.htm

2. (Santy, P. Marquis Moulinier, Da Shock Tramatique dans les blessures de Guerre, Analysis d'observations. Bull. Med. Soc. Chir., 1918, 44:205)

The Legend of Combat's Cotton Dutchboy - Debunk'd

...or Pulling the Plug on Tampons in Trauma.

There is a frequently cited story of a package being accidentally sent to some Marines in Iraq back in 2004. This care package was intended for a female service member, but somewhere along the pony express, the shipment was rerouted to a Marine line unit. Contained in this package were some feminine products. Not mud masks and loofahs, but hygiene products, like sanitary napkins and tampons. Lo and behold, while out on a convoy, the Marines were ambushed, and took some casualties. Supposedly, some "quick thinking" Marine used his issued ration of critical thinking and crammed a tampon in the wound, thereby staunching the bleeding, and saving the casualties life.

*ahem* Where to begin?

First, a bit of History. In 1914 Kimberly-Clark developed an absorbent wadding product they called "Cellucotton". Made from processed wood, Cellucotton was five times as absorbent as cotton, and cost half as much to produce. This product was used to bandage wounds during World War 1. In 1919, after the War, Kimberly-Clark had the notion of marketing Cellucotton as disposable sanitary napkins. Their marketing agency suggested changing the name to Kotex®, short for cotton textile. Prior to this, women used washable rags to absorb their menses. This disposable alternative took a while to catch on...but catch on it did. Tampax hit the scene in 1936.

You see, lesson one is that first aid dressings evolved into disposable sanitary napkins, not vice versa.

Next, the prospective use of a tampon as a field-expedient dressing has been around for quite some time. So this talk of using them in 2004 during OIF II isn't the first mention. Veterans of Viet Nam, Panama, Grenada, and the Gulf War mention hearing of it. Back when I was PVT ParaCynic, a veritable sponge for the knowledge imparted by the fine non-Commissioned officers of the United States Army, the life-saving trauma tampon was brought up rather frequently by instructors. "Carry tampons, they're great for plugging bullet holes."

Bullshit.

Herein lies one minor dilemma. The "slick-sleeved" instructors that attempted to pass this information off as reputable had never seen Combat. They lived in a post-Cold War theoretical sand table. They had never seen an actual gunshot wound, let alone effectively treated one. Perhaps that's why they felt a birth canal and a bullet hole were interchangeable.

Does anyone reading this blog need me to draw a picture as to the difference between a high-velocity rifle entry wound and a vagina?

The two most commonplace sizes for high-velocity rifles rounds are 7.62mm and 5.56mm. Now, even when you factor in the tendency of the slug to yaw in flight, the hole created by a 5.56mm round is equivalent to the hole created when you push a Bic ink pen through a piece of paper. Although a 7.62mm is 27% larger than a 5.56mm, it's still not a very big entry hole.

Hardly large enough to push a finger into, without eliciting a painful response, and the associated cursing and threats upon your well-being. *pause*

When the Hell did we start encouraging people to [shove, cram, pack] fingers and foreign objects into open wounds? To all the folks that might say "well, it's ditch medicine", or "it's ghetto medicine": Those are two scenarios where we should discourage such practice even more fervently.

Now, the supposed practice is not to pack the wound with sterile gauze, or iodoform, or some other medically acceptable medium. No, they are talking about cramming a wadded piece of "cellucotton" into a hole that is 1/4 it's size, or smaller.


Next, what's the point? What are you trying to accomplish? Whether the entry wound is in an extremity, the chest, the abdomen, or head, it makes no difference. This is a terrible idea. You're not stopping the bleeding. The tampon will not "expand and exert pressure on the source of any bleeding". You are not "sealing the wound". You have now introduced a fibrous foreign body, into an otherwise "clean" wound tract.

Now, as a component of a dressing, I suppose it's not too terrible of an idea. They're absorbent, and might make a good addition to a pressure dressing, outside of the wound.

Mainstream media isn't helping matters. There was recently a video game trailer released, Army of Two, in which "buddy aid" consists of using a tampon to revive your teammate. ugh.

Satan's Little Cotton Fingers have no business in the management, [field, ditch, ghetto] medicine, or otherwise, of penetrating trauma secondary to high velocity lead poisoning. Much to my chagrin, however, this is another one that is not going to go away any time soon.

Back

I have returned from my brief [vacation, hiatus, escape]. I have a post in the works, but it's another rather long one, and unlike some of the people to the right, I can't do it all in one sitting. That is why they're Better than I...

Overheard

"As you can see from this lengthy, oft-photocopied document from my physician-healer-shaman, Dr. Web, MD, from www..., err, I mean, CANADA, I'll need 125mg of Demerol, 50mg of Phenergan, a turkey sammich, 14 blankets, some extra pillows, and the air conditioning turned up on blast. Also, I'll need access to an AC outlet, so I can plug in my laptop. I must resume flaming ERP, and flooding his Blog with my extensive experience and medical expertise. He just doesn't understand me. I'm in P-A-I-N. Ooooo, Springer's on."

Standing Trendelenburg on it's Head

He didn't work on Shock, and neither does his position, Dammit.

Friedrich Trendelenburg (May 24, 1844 – December 15, 1924) was a German surgeon and son of the philosopher Friedrich Adolf Trendelenburg. A number of medical treatments and terminologies have been named for him. He is perhaps best remembered for the Trendelenburg position in which the patient is placed on a bed which is put into incline such that the patient's head is lower than his feet. Trendelenburg first used this technique in 1881 for an abdominal surgery. (Wiki)

During World War 1, Walter Cannon, an American physiologist, and the same guy that coined "fight-or-flight", as well as developing the theories of homeostasis, popularized the use of Trendelenburg position as a treatment for Shock. 10 years later, he changed his mind.

Ladies and Gentlemen, in case you were absent, sleeping, or ignorant during that block of instruction, the First World War, the Great War, the War to End All Wars took place primarily in Europe from 1914 to 1918. The Treaty of Versailles was signed 28 June 1919.

WW1 ended Ninety years ago. So, at the latest, 80 years ago Dr. Walter Cannon decided he had erred, and rescinded his recommendation for the use of Trendelenburg position in the treatment of Shock. There are 12 listed surviving Veterans of that Conflict. Unlucky Thirteen if you count the Position that inspired this post.

Trendelenburg is still a fixture in initial management of Shock. Despite the fact that it doesn't work, and is potentially more harmful. The theory WAS that by elevating the lower portion of the body, either through Trendelenburg Position or passive elevation of the lower extremities, one could effect a form of autotransfusion, in which blood would be shunted "to the core". In the few studies that support this belief, performed on healthy subjects, these positions increased left ventricular filling, stroke volume and cardiac output, but the effects were transient and returned to baseline within 10 minutes. Conversely, numerous studies show that lung volumes are compromised by the weight of the viscera upon the diaphragm, and increased stress is placed upon the right ventricle. There is also evidence of increased risk of retinal detachment, brachial nerve paralysis, and of course, cerebral edema.

What's even more worrisome than the continued insistence of Trendelenburg, is the lack of elucidation. Individuals are taught to use Trendelenburg for Shock, but never which Type of Shock this nonsense supposedly works on.

Is it intended for Obstructive Shock? No, only relieving the obstruction will help. But you go right ahead, make that PE, tamponade, or pneumothorax dependent. It seems like a good idea to me.

Is it intended for Distributive Shock? As in neurogenic, septic, or anaphylactic shock. Nope, turning a patient upside down doesn't make "the Tank" any smaller. However, every patient with wheezing, urticaria, and profound angioedema LOVES being stood on their head.

Is it intended for Endocrine Shock? Does gravity have any effect on hormones?

Is it intended for Cardiogenic Shock? Like patients who can't breathe, myocardial infarction patients, and CHF-ers LOVE lying down. Even better if you can INCREASE the strain on their heart. Choke yourself.

Trendelenburg Position was intended for use during Hypovolemic Shock. Back in 1917-ish. Then Dr. Cannon changed his mind. Yet just about every where you go, "lay 'em down, raise their feet" is a given when it comes to initial management of a Shock patient. FR, First Aid, BSA, Brady, DOT, AAOS, NR, U.S. Army...

During the second stage of Shock, the Compensatory Stage, the body employs multiple physiological mechanisms in an attempt to reverse the condition. These include neural, hormonal, and bio-chemical mechanisms. I'm not going to get into Acid-Base balances, or renin-angiotensin, etc.

What I will discuss is the action of the carotid baroreceptors. The baroreceptors in the carotid arteries detect hypotension, and signal the release of adrenaline (epinephrine) and noradrenaline (norepinephrine). These are catecholamines with dual roles as hormones and neurotransmitters. Noradrenaline predominately causes vasoconstriction (α1) with a mild increase in heart rate, whereas adrenaline predominately causes an increase in heart rate (β1) with a small effect on the vascular tone; the combined effect results in an increase in blood pressure.

The body is an amazing machine. It manages to compensate, quite well. However, by throwing the legs up, or standing someone on their head, you manage to deceive the carotid baroreceptors into thinking the body has adequate blood volume, and pressure. In turn, they do not trigger the release of catecholamines. The body doesn't get the message to compensate. As soon as that Transient effect of standing them on their head subsides, you succeeded in helping the body skip right through Stage 2 of Shock, and right into Stage 3, the Progressive stage, or more ominously: Decompensation.

There are, however a few appropriate uses for Trendelenburg.

• Abdominal surgery (HOLY SHIT, that's what it was intended for!)
• Central Venous Line Placement in the jugular or subclavian veins. I'll extend that to EJ's for you Paramedics, but the arms of a stethoscope kinda work better.
• Reducing abdominal hernias. For the same reason it's used in abdominal surgery.
• Waterboarding. Yeah. Because of it's negative effects on breathing and airway. Fuckin' Terrorists.
• Various obstetric and gynecological procedures, or practices.

As Usual, Dr. Bledsoe knows what's up.

• Martin JT. The Trendelenburg position: a review of current slants about head down tilt. AANAJ 1995;63:29-36.
• Ostrow CL. Use of the Trendelenburg position by critical care nurses: Trendelenburg survey. Am J Crit Care 1997;6:172-6.
• Taylor J, Weil MH. Failure of the Trendelenburg position to im-prove circulation during clinical shock. Surg Gynecol Obstet 1967;124:1005-10.
• Sing RF, O’Hara D, Sawyer MA, Marino PL. Trendelenburg position and oxygen transport in hypovolemic adults. Ann Emerg Med 1994;23:564-7.
• Terai C, Anada H, Matsushima S, Shimizu S, Okada Y. Effects of mild Trendelenburg on central hemodynamics and internal jugular vein velocity, cross-sectional area, and flow. Am J Emerg Med 1995;13:255-8.
• Bivins HG, Knopp R, dos Santos PA. Blood volume distribution in the Trendelenburg position. Ann Emerg Med 1985;14:641-3.
• Sibbald WJ, Paterson NA, Holliday RL, Baskerville J. The Trendelenburg position: hemodynamic effects in hypotensive and normotensive patients. Crit Care Med 1979;7:218-24.
• Reich DL, Konstadt SN, Hubbard M, Thys DM. Do Trendelenburg and passive leg raising improve cardiac performance? Anesth Analg 1988;67:S184.
  
• Terai C, Anada H, Matsushima S, Kawakami M, Okada Y. Effects of Trendelenburg versus passive leg raising: autotransfusion in humans. Intensive Care Med 1996;22:613-4.

Needless ShoutOut, Rogue

Well, apparently it's going to be necessary to post a bit more often. Rogue Medic not only referenced my most recent entry, but he also placed my name in the subject line. AD read his post, and gave him some "linky-love" which has subsequently caused more than a few extra people to stumble upon my mutterings.

Now, more than 2 people read my writing. Accordingly, I must write more.

And so it begins...

Tourniquets, Trendelenburg, Tampons, Toilet Paper

...or Four Things that Get me fired up. This will likely be a three or four part post...

Certain subjects inevitably come up whilst discussing Trauma management. This is especially true when discussing such things with individuals in the Military. Two of the subjects I'm referring to are controlling bleeding from an extremity, and preventing/controlling shock.

It's common knowledge that exsanguination from extremity wounds in the Number One cause of preventable death on the Battlefield. The Military is finally getting away from it's complete and total fear of effective tourniquets. From the time we take our very first Boy Scouts and Brownies First Aid class, we're taught to apply a dressing, apply direct pressure, utilize pressure dressings, use pressure points, elevate, and as a very, very, OMIGOD Don't Even THINK about it, last resort, tourniquets are mentioned. Can tourniquets cause tissue damage? Yes. I'm not here to deny that. Is there the potential for neuropathies, necroses, and no-mo-hands-and-footsies? Absolutely. Shutting off distal blood supply is no joke. It's a very serious procedure, applied in some of the most dire of circumstances. Some First Aid guides don't even mention Tourniquets. FR, EMT, and even Paramedic courses skim over them. In Paramedic school they'll discuss "back in my day, we used to push enough epinephrine to give a rock a pulse," giving every code bicarb, or in the more recent past, stacked shocks. Science has shown that those practices aren't necessarily effective, and don't save lives. Yet more time is spent mentioning THEM, than the appropriate and effective application of a tourniquet.

Tourniquets Save Lives. You can read whatever studies you want about the harm done by a tourniquet. Paresthesia, amputation, worst case scenarios. People with those outcomes are Alive. It's common knowledge that a properly applied tourniquet can be left in place for greater than 4 hours before irreversible damage occurs. Ask a surgeon. They perform procedures all the time with tourniquets in place.

Properly applied. They save lives. Damage is minimal when properly applied. So why are we so afraid of them? Why don't we embrace the fact that they save lives, and spend time actually LEARNING how to apply them properly? I challenge you to go to your crew room, your next refresher, ask someone at the ER, or your new preceptee what they would use to appropriately apply a tourniquet, and how they would go about doing it.

You'll meet quite a bit of resistance. There will be people that insist that they'll never have to apply a tourniquet, and no one ever should. I mean, 4 liters of NaCl is a good replacement for 4 units of blood, right? Tourniquets are evil, right? They are harmful and too much can go wrong.

Now try to have a conversation with the same people about emergency airways, and worst-case scenarios. Discuss intubation, S.L.A.M., crichothyroidotomy, translaryngeal jets, retrograde intubation, bougies, etc. After all, those can be intense, but we're taught skills to manage the airway.

Painful Truth for all you heroes out there. Patients can often be killed iatrogenically by airway management, mismanagement and overmanagement. The same is not said about bleeding control. You don't kill patients by "overmanaging" their bleeding. This is not to say airways don't save lives. But I think I learned somewhere in Physiology that blood might be important too.

We are taught When, Where, Why, What, Who, and How to Intubate. We know the consequences of a poor intubation, and are taught to recognize when things don't go according to plan.

We are taught that tourniquets are a last ditch effort, and we should exhaust all other methods before resorting to a tourniquet. Well my friend, while you're holding pressure for several minutes to see if it will work, your patient has lost half their blood volume. We should be teaching people how to recognize when a tourniquet is necessary. You can assess bleeding fairly quickly, and figure out what tricks are going to work. If you can't, your training, and/or your experience, has let you down. Time is of the essence. When, Where, Why, What, Who, and How.

The answers are not Never, Nowhere, None, Nothing, No one, and Not. Quit teaching it that way. Common Sense has been discarded for Common Practice for far too long.

Outdated tip of the hat to TOTWTYTR