Deer hunting season is upon us again, so it’s time for emergency departments to start seeing an increase in hunting injuries. Although you would think this would mean accidental gunshot wounds, that is not the case. The most common hunting injury in deer season is a fall from a tree stand.
Tree stands typically allow a hunter to perch 10 to 30 feet above the ground and wait for game to wander by. They are more frequently used in the South and Midwest, usually for deer hunting. A recent descriptive study by the Ohio State University Medical Center looked at hunting related injury patterns at two trauma centers.
Half of the patients with hunting-related injuries fell, and 92% of these were tree stand falls. 29% were gunshots. The authors found only 3% were related to alcohol, although this seem very low compared to our experience in Minnesota.
Most newer commercial tree stands are equipped with a safety harness. The problem is that many hunters do not use it. And don’t look for comparative statistics anytime soon. There are no national reporting standards.
The image on the left is a commercial tree stand. The image on the right is a do-it-yourself tree stand (not recommended). Remember: gravity always wins!
The October Trauma MedEd Newsletter will be released to subscribers over this Wednesday. I’ll be covering Inside Stuff. Articles include:
- Managing foreign bodies
- Orthopedic implants and the TSA
- Gunshots and lead poisoning
- And more!
Anyone on the subscriber list as of 8PM Tuesday (CST) will receive it on Wednesday, November 5. I’ll release it to everyone on Friday via the blog. So sign up for early delivery now by clicking here!
Pick up back issues here!
Everywhere you turn in the trauma and EMS world, you run into the concept of the “golden hour.” Basically, it refers to the idea that it’s important to get an injured patient to definitive care promptly, or mortality begins to rise. It has been used to justify a lot of what we do in trauma care and trauma systems. But where did this come from? And is it true?
The BTLS course attributes the term to R Adams Cowley from the ShockTrauma Center in Baltimore. Unfortunately, no references are given. A biography of Cowley entitled Shock-Trauma names him the author of the term, basing it on dog research. No references were given.
A review of Cowley’s research reveals a few tidbits. A case series of patients implies that speed is good, but does not analyze time to definitive care. It does reference older work by other authors, but once again, no relationship between timing and outcome is evaluated.
A textbook edited by Cowley contains a reference to an article about “Cowley’s golden hour.” This article contains a statement that “patients are assumed to be dying and much of the golden hour has passed.” It goes on to state that the first 60 minutes after injury determines the patient’s mortality. It, in turn, refers to another of his earlier articles. This one states that “the first hour after injury will largely determine a critically injured person’s chance for survival." No data or reference is given.
Bottom line: The concept of the "golden hour” has taken on a life of its own. Yes, it’s a good idea. And yes, there is some actual data to support it, although the quality is somewhat lacking. But this does point out the need to question everything, even some of our most deeply held beliefs. They are not always what they seem to be.
Reference: The Golden Hour: scientific fact or medical urban legend? Acad Emerg Med 8(7):758-760, 2001.
More dogma, or is it actually useful? Any time a chest tube (tube thoracostomy) is inserted, we automatically order a chest x-ray. Even the ATLS course recommends obtaining an image after placement. But anything we do “automatically” is grounds for critical analysis to see if there is a valid reason for doing it.
A South African group looked at the utility of this practice retrospectively in 1004 of their patients. They place 1042 tubes. Here are the factoids:
- Patients were included if they had at least one chest x-ray obtained after insertion
- Patients were grouped as follows: Group A (10%) had the tube inserted on clinical grounds with no pre-insertion x-ray (e.g. tension pneumothorax). Group B (19%) had a chest x-ray before and had ongoing clinical concerns after insertion. Group C (71%) had a chest-xray before and no ongoing concerns.
- 75% of injuries were penetrating (75% stab, 25% GSW), 25% were blunt
- Group A (insertion with pre-x-ray): 9% had post-insertion findings that prompted a management change (kinked, not inserted far enough)
- Group B (ongoing clinical concerns): 58% required a management change based on the post-x-ray. 33% were subcutaneous or not inserted far enough (!!)
- Group C (no ongoing clinical concerns): 32 of 710 (5%) required a management change, usually because the tube was too deep
The authors concluded that if there are no clinical concerns (tube functioning, no clinical symptoms) after insertion, then a chest x-ray is not necessary.
Bottom line: But I disagree with the authors! Even with no obvious clinical concerns, the tube may not be functioning for a variety of reasons. Hopefully, this fact would then be discovered the next day when another x-ray is obtained. But this delays the usual progression toward removing the tube promptly by at least one day. It increases hospital stay, as well as the likelihood of infection or other hospital-associated complication. A chest x-ray is cheap compared to a day in the hospital, which would potentially happen in 5% of these patients. I recommend that we continue to obtain a simple one-view chest x-ray after tube insertion.
One of the cornerstones of allopathic medicine is the use of drugs to treat disease conditions. And unfortunately, one of the side effects of using drugs to treat problems is the production of side effects(!).
In trauma care, even something as simple as treating pain from an injury can create major problems. Give a narcotic pain medication. The patient gets nauseated and vomits. Try a different narcotic. The patient develops constipation. Give stool softeners and cathartics. Diarrhea. Then pseudo-obstruction develops. Give neostigmine. The patient becomes bradycardic. Give… well, you get the picture.
How common are side effects? Very! Did anyone see the first TV commercials for Chantix, the smoking cessation drug? It was about 3 minutes long because of the long list of side effects that were described. I’m surprised anyone was willing to risk them just to stop smoking cigarettes.
A recent study looked at the number of side effects listed on the labels of 5,602 medications approved by the FDA. There were a grand total of 534,125 adverse drug effects described in the packaging. Some interesting statistics:
- The number of adverse effects for ranged from 0 to 525(!) for a single drug
- The median number of adverse effects was 49, the average was 70
- Drugs with the most side effects are used in neurology, psychiatry and rheumatology
- Newer drugs had significantly more adverse effects than older ones
It’s certainly easy to bash pharmaceutical companies on their products. But some of these findings may be due to more rigorous testing and monitoring, as well as nuances in the populations in which these drugs are used.
Bottom line: Drugs are chemicals! Each chemical has a number of effects, some of which are desirable, and some of which are not. The drug companies choose to market a drug based on one desired effect (e.g. control of nausea). Just remember, when you give that medication, you will probably get the desired effect, but you will just as likely also get some of the other 69 possible side effects. Be prepared, and prescribe sensibly.
Reference: A quantitative analysis of adverse events and “overwarning” in drug labeling. Arch Int Med 171(10):944-946, 2011.