The Milch Technique for Reducing a Shoulder Dislocation

This post is contributed by Dr. Jeremy Joslin, an avid outdoor enthusiast who is currently training to become an emergency physician.

Here goes:

After a long day trekking through Utah's canyon country, you decide to start heading back to camp. Three days from a car, and an hour away from camp, your hiking partner slips while stepping over a downed tree and catches his arm on the large trunk while falling. As he scrambles back to his feet, he cries out in pain and cannot seem to move his right arm at the shoulder. He knows the feeling, and tells you exactly what's happened: he's dislocated his shoulder again.

Anterior dislocation (where the head [or “ball” of the ball-and-socket joint at the shoulder] of the humerus, which is the large bone of the upper arm, is dislocated forward in relationship to the socket) is the most common type of shoulder dislocation and happens when the arm gets pulled away from the body quickly (abduction), as in the scenario above. Shoulder dislocations are quite painful, and if you are near medical attention, that's where you'll want to head. In the meantime, if you're sure the shoulder is dislocated, waste no time in “reducing” it (putting it back into place). Prompt reduction is beneficial for the joint.

In order to help determine if a shoulder has, indeed, been dislocated, I will reference the Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care (2nd edition) (1), which lists these four features:

• Restriction of motion through the joint's normal range
• Obvious deformity in comparison with the uninvolved side
• Crepitus, or grating, of bone fragments is absent
• Often a typical, identifiable posture of the dislocated joint, which the patient will maintain to minimize pain

Once you've determined that the shoulder has been dislocated, you may want to attempt reduction. There are numerous methods of reduction for an anterior shoulder dislocation. My favorite technique for reduction is the Milch technique. Have the injured person sit, stand, or lie flat on his or her back, and then slowly reach, using the hand of their dislocated shoulder, behind their head and try to touch the opposite shoulder. Somewhere on the very slow, steady reaching, the shoulder will align itself and pop back into place. Another way to describe the positioning is to pantomime a pitcher's "wind up" before a pitch using the affecting side. Have the patient take their time and slowly reach upward and backwards as if they were going to pitch a baseball. If the "wind up" is slow enough, with plenty of rest if needed, you'll get the shoulder to pop back into place. This maneuver can be done solo or with assistance. If you are assisting, cup the victim’s elbow, giving it support and guiding their arm through the maneuver. Your other hand can be placed on their shoulder to apply support to the joint as it goes through the motion.

Why do I appreciate this maneuver so much? Here are my specific reasons:

• Compared with other maneuvers to reduce shoulders, this one seems to be the least painful. (2)
• Some medical providers swear that if the technique is done correctly and slowly, then the patient doesn't even need pain medication. (3)(4)
• It is easily described and easy to remember (the baseball pitch).
• It can be done for self rescue (just take your time and go as slow as possible).
• In my hands, this maneuver has been more successful than other techniques.

I'd like to hear about your favorite technique), or if you've ever needed to reduce a shoulder in the wilderness setting, how you achieved success. Finally, if you're interested in reading more about this very historic subject, begin by following the link to an interesting article.

photo of Jeremy Joslin, M.D.

Tags: shoulder dislocation, Milch technique, Jeremy Joslin, wilderness medicine, outdoor medicine, healthline

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Thank You to Prudence, M.D. for Grand Rounds

Thank you to Prudence, M.D. for including my post about myths to debunk within this week's edition of Grand Rounds. Grand Rounds is a weekly compilation of posts related to health care compiled by a host, who makes a great effort to compile an interesting collection for readers. I also very much appreciate the gracious mention of the upcoming winter meeting of the Wilderness Medical Society.

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Myths to Debunk

There are many myths related to outdoor medicine. These need to be “debunked,” so that people do not fall prey to outdated and useless techniques. Here are some of the most common myths (in italix):

1. Mechanical suction, electric shock, and immersion in ice water are effective first aid (“field”) therapies for snakebite. In truth, these are not only not helpful, they may be quite harmful. Antivenom therapy is the only therapy that has been proven effective, with the possible exception of pressure immobilization for certain elapid (e.g., coral) snake bites.
2. Urinating on a jellyfish sting is an effective method to reduce pain. This is of very limited value. Some persons will cite that it was helpful in their particular case, but at least as many persons will state that it did not diminish the pain. The most effective therapy is decontamination with a specific topical compound, such as vinegar or ammonia. The decontaminant chosen depends upon the species of stinging jellyfish.
3. Applying a cold pack to a jellyfish sting is the most effective method to reduce the pain. Current information indicates that application of warmth (e.g., immersion in non-scalding hot water) may be much more beneficial.
4. Rabies shots are injected into the abdomen and are horribly painful. Not true- post exposure rabies vaccination may include a painful component as rabies immune globulin is injected into the bite site, but the subsequent vaccine, which is administered as part of the post exposure treatment, is given as a series of very tolerable injections into the arm or thigh.
5. In any circumstance of frostbite, rapid rewarming is essential. Actually, this should only be done if the body part can be relatively guaranteed to remain thawed. Otherwise, re-freezing the tissue causes significantly more damage than does the initial episode of freezing.
6. The Heimlich maneuver should be used for any victim of submersion (near-drowning) to remove water from the lungs and improve the chance for survival. The Heimlich maneuver has never been proven to be of use in humans in this situation, and may in fact increase the risk for vomiting and harmful inhalation of gastric contents. There is no evidence that it removes water from the lungs.
7. Drinking large amounts of liquids is harmful during exercise because it promotes stomach cramps. Quite the opposite – so long as the ingested amounts are prudent and don’t promote nausea from a full stomach, it is essential to replace fluids and electrolytes constantly during periods of high exertion, particularly in the heat, to avoid dehydration.
8. A person struck by lightning is “electrically charged” and may not be safely touched. This is not true. It is perfectly safe to touch such a person, and in fact the sooner that breathing can be supported, the more likely that the victim will survive with maximal neurological recovery.
9. In cold water, it is better to remain in the water where one feels warm that to pull oneself onto a rescue vessel or platform and be exposed to wind chill. Absolutely not true – one may lose heat 25 times as fast in the water as in air, so no matter how uncomfortable you feel, if it is possible to get out of the water, do so.
10. Sharks and bears are attracted to menstrual blood, so it is important for women to avoid diving and hiking during menstruation. This is a false concept, and has never been proven to be true, either epidemiologically or scientifically.

photo by Jenny Hargrove

Tags: myths,wilderness medicine, outdoor medicine, healthline

Labels: bear, drowning, Heimlich maneuver, hypothermia, jellyfish, lightning, myths, shark, snakebite, wilderness medicine

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2008 Wilderness & Mountain Medicine Conference

It always gives me great pleasure to announce the continuing medical education (CME) meetings sponsored by the Wilderness Medical Society. The next great event is the 2008 Wilderness & Mountain Medicine Conference, which will be held at The Canyons Resort in Park City, Utah from February 23-27, 2008. Registration for the meeting is available at the WMS website.

Following the theme of last year's successful winter meeting, this event will emphasize issues related to winter environments and activities. There will be a pre-conference Level 1 Avalanche Course, taught by Exum Utah Mountain Adventure guides, Utah Avalanche Center, The Canyons Ski Patrol, and WMS faculty. This is both a didactic and hands-on program designed to allow the participants to learn about safe travel in avalanche terrain, avalanche transceiver use, and snowpack analysis. They will practice efficient rescues with avalanche beacons, and study avalanche victim physiology and medical treatment. This is a certificate program, so that after completion, the participants will be recognized by the American Avalanche Association. There will also be a post-conference Advanced Wilderness Life Support Certification Course.

One of the strongest features of the WMS programs is delivery of optional workshops, which for this meeting will include Introduction to Backcountry Touring, Avalanche Awareness on Snowshoes or Skis, Snowmobile Safety, Ski Patrol Trauma Evaluation, Improvised Splinting, Litters and Packaging, Snowshelters, and Snowshoeing.

The special evening presentations look spectacular. Attendees and guests will be entertained by Andrew McLean on "Extreme Skiing," Dr. Luanne Freer on "What's Your Everest? Combining Your Profession With Your Passion," Dr. Geoff Tabin on "Ophthalmology in Extreme Environment," and Scott McIntosh and Apa Sherpa on "The History and Culture of Sherpas on Mt. Everest: The SuperSherpas Expedition."

The body of the meeting is loaded with lectures related to avalanche, high altitude, cold weather medicine, survival, travel, trauma, and other important topics for medical professionals in wilderness medicine. It will be of great interest to all doctors, nurses, paramedics, EMTs, rescuers, educators, and others who want to be better prepared to operate and assist others in wintry climates. In addition, the meeting is designed to allow ample time for skiing, hopefully in terrific powder, at The Canyons Resort and other fantastic ski areas in Park City. The first 100 registrants who book three nights or more at The Canyons Resort receive a complimentary one-day lift ticket.

Last year's meeting was awesome, and this one is shaping up to be even better. I intend to be there, and look forward to reporting back to you after a great gathering.

Tags: Wilderness Medical Society, WMS, Wilderness & Mountain Medicine Conference, mountain medicine, Park City, avalanche, wilderness medicine, outdoor medicine, healthline

Labels: avalanche, AWLS, CME, continuing medical education, Wilderness Medical Society, winter, WMS

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OTB Footwear

I attended the 2007 Diving Equipment & Marketing Association (DEMA) show recently in Orlando, where I had the good fortune to be presented with a NOGI Award for Science from The Academy of Underwater Arts and Sciences.

It's always fun to stroll through the huge exhibit hall at the DEMA show and check out new equipment, publications, and services for divers. This year was no exception. I was particularly impressed with the boots and shoes on display by the company OTB Footwear, LLC. The footwear was designed for use by the U.S. Navy Seals, to withstand regular use in and around water. In fact, the footwear can be completely immersed in water and still function properly.

OTB Footwear was kind enough to allow me to demo a pair of their Abyss boots, which retail for $115 U.S. The boots are comfortable and provide excellent support for rocky or muddy situations. As is typical for OTB products, the boots utilize materials molded with perforations through the sole, which allow instant water drainage. The boots are shipped with a combination of insoles, including a full length molded shank and perforated ethylene vinyl acetate (EVA) sheet, so that the inside fit can be adjusted for situations ranging from barefoot to a thick pair of socks, neoprene booties or dry suit.

The shoes are really quite comfortable and suitable for dry as well as wet conditions. Thus, they are useful not only for persons in and around the water, but for tactical work, such as special operations associated with search and rescue. I intend to give them a try this winter, to learn if all of the ventilation and drainage features are functional and desirable in colder weather. Proper use of these boots would be in situations where one wishes to achieve prompt drainage when the feet are exposed to extremely wet conditions, including immersion, but the mission must continue. In any circumstance, the wearer would hope that the exposure can be followed soon enough by drying and warming to avoid a cold injury exposure ("immersion foot"). OTB footwear seems to be a great improvement over standard issue leather-type or plastic footwear that become waterlogged and/or retain moisture, without any practical drainage feature, for use in wet or muddy conditions. They can be washed and rinsed easily, and put back into immediate use if necessary.

Tags: OTB footwear, boots, OTB, wilderness medicine, outdoor medicine, healthline

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Let There Be Light

I'm always grateful for high quality equipment that works under adverse circumstances, when I most need it. If you need to practice outdoor medicine in the shadows or at night, on a mountainside, in a cave, or in another low-light situation, you will need artificial light. There are a great many lanterns, flashlights, and headlamps on the market, and numerous features to consider, such as size, weight, durability, power and character of illumination, batteries, expense, ability to withstand the elements, and additional features (e.g., flashing beacon).

When I'm in the wilderness, I favor carrying at least one, and preferably two or more battery-powered sources of light, at least one of which is a headlamp, so that I can have full use of my hands. With the advent of light emitting diode (LED) technology and high-impact plastics, the choices are plentiful and excellent for an outdoorsperson.

I recently procured two excellent headlamps from Petzl: the TACTIKKA XP ADAPT and the e+LITE. The TACTIKKA will now be my primary headlamp, and the e+LITE my backup unit, although I must admit that the e+LITE is a powerful unit for something so small and lightweight.

The TACTIKKA XP ADAPT is rated at 40 lumens for 120 hours powered by 3 AAA batteries. It features a tiltable head, spot beam that can be chosen at 3 different intensities, a flood beam when a sliding filter is (easily) deployed, a flashing setting, three colored (red, green, and blue) sliding filters that are easy to install, and a boost button to increase the intensity and range (up to 50 meters or 164 feet) of a solid beam when the button is held down (this consumes additional energy). The light unit is water resistant (not waterproof), and attaches securely and reversibly to the comfortable elastic headstrap or rigid plastic belt loop. In addition, there is an adhesive plastic mount that can be glued to a helmet in order allow reversible attachment of the light unit. There is an illuminated battery indicator that indicates full charge (green), half charge (orange), and low charge (red). The light unit with batteries weighs 3.84 ounces (109 grams), and comes with a 3-year guarantee.

There is a chart on the back of the package that indicates the decline in power over time for each setting, as the predicted battery life is consumed. For instance, at maximum power (not the "boost" setting), the battery life is 60 hours. When the batteries are new, the unit will project its beam 35 meters (115 feet), after 30 minutes it will project 30 meters (98.4 feet), after 10 hours it will project 20 meters (65.6 feet) and after 30 hours it will project 7 meters (23 feet).


The e+LITE, which comes with a 10-year guarantee against faults in materials or manufacture, is extremely small and powered by two lithium button (CR2032) batteries. It is rated to 16 lumens maximum power, and has settings for high intensity white, low intensity white, flashing white, flashing red, and continuous red light. The battery life is 35 hours of high intensity white and 45 hours of low intensity white light. The light unit has a ball and socket mount that allows 360 degrees of tilt, as well as a small elastic headband and versatile attachment mechanism. It is advertised to withstand a temperature range of minus 22 degrees F (minus 30 degrees C) to 140 degrees F (60 degrees C), so should be able to withstand storage in its accompanying waterproof case when carried in a fanny pack, dive bag, or backpack. Always remember to carry spare batteries in a waterproof container.

I have used Petzl products for many years, and found them to be extremely well designed, comfortable, and reliable. If you intend to be able to function in a medical capacity in dim light or in the dark, you should carry both a primary and a back-up light, and I highly recommend these. The TACTIKKA XP ADAPT is available at Recreational Equipment, Inc. (REI) for $64.95 U.S., and the e+LITE is available at REI for $29.95 U.S.

mountain photo by Mathias Schar

Tags: headlamp, light, Petzl, mountain medicine, wilderness medicine, outdoor medicine, healthline

Labels: headlamp, light

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Cinchona

Gregory Bledsoe, M.D. informs me that he has created a new website, Cinchona, that is intended to allow the wilderness medicine, expedition medicine, travel medicine, and similarly-minded medical communities to exchange information. If the site becomes popular, it has the potential for users to be able to promote their conferences, books, products, blogs, and news stories. Greg intends the site to become a place where people from the far reaches of the diverse field of wilderness medicine can go to view the latest news, updates on current situations, and timely information about a broad range of topics. There is also a job board tab.

Registration is easy and free. Once you register, you are free to post any articles pertinent to Cinchona that you find on the web. According to Greg, the website will thrive only if there is an active community submitting articles and selecting the best ones for mass distribution, through the "stamping" rating procedure that is active at the site. The stamps are basically votes for the articles. If someone posts an article that he or she believes is important and wants the broad community to view it, the goal is to get as many stamps as possible. As viewers read the article and stamp it (e.g., vote for it), the article moves up in priority within the news feed. Ultimately, the most popular articles will be on the opening page of Cinchona, where they will receive the most exposure.

Over time, there will hopefully be enough registered users so that these articles are sifted through and promoted organically. Right not, because the community using the site is small, even 5 votes might put an article on the front page. As more users rate the articles, it will be increasingly difficult to achieve front page status.

Give Cinchona a look, and if it appeals to you, sign up and try it out. The more useful communication that occurs between members of the wilderness medicine community, the better.

photo of Dr. Gregory Bledsoe

Tags: Cinchona, Greg Bledsoe, expedition medicine, wilderness medicine, outdoor medicine, healthline

Labels: Cinchona, expedition medicine, Greg Bledsoe, wilderness medicine

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Mountain & Wilderness Medicine World Congress Abstracts Part 4

As I noted in my first post about the Mountain & Wilderness Medicine World Congress, sponsored by the Wilderness Medical Society and the International Society for Mountain Medicine in Aviemore, Scotland from October 3-7, 2008, there were many excellent abstracts presented. The following is the fourth installment of some of the more interesting of these:

It is axiom in high altitude medicine that altitude-related illnesses do not spare the fit; that is, that fit persons are just as likely to be victims as persons who are out of shape. I have often heard the perhaps counterintuitive observation that perhaps fit persons are more prone to altitude-related illnesses, perhaps because they ascend more rapidly and do not take the proper time to achieve acclimatization. To the best of my knowledge, no one has definitively proved one way or the other either the demographics or causation related to these notions. In “The relationship between a subject’s fitness level and the development of acute mountain sickness,” M. Ranney and colleagues of the TeamEverest Expedition 2007 evaluated fitness in 25 young trekkers using measured maximal oxygen consumption while exercising, and simultaneously recorded AMS symptoms during ascent to Everest Base Camp, which is at an approximate altitude of meters (17,500 feet). Fitter subjects did less well at altitude and had higher daily AMS scores than did their less fit colleagues. The results were more pronounced in males as compared to females. The authors did not propose an explanation for their observations.

Determining predisposition to disease, and then guiding therapy, according to the genetic profile of individuals is in the future of wilderness and mountain medicine. In “Nitric oxide pathway and high altitude pulmonary hypertension,” Almaz Aldashev and colleagues look at nitric oxide synthesis in the lungs, which is related to high-altitude pulmonary hypertension (HAPH, or increased pressure in the circulation of the lungs, which is felt to be a significant cause of high altitude pulmonary edema). They note that a certain genetic profile is associated development of HAPH in resident highlanders of Kyrgyzstan. In “Genetic adaptation to hypobaric hypoxia in sherpas,” Corrado Angelini and colleagues obtained DNA from nine Sherpa porters from different villages in the Solu-Khumbu area of Nepal. They commented that the Himalayan population has a long-standing genetic adaptation to hypoxia and that this contributes to their ability to display a better prolonged maximal physical performance compared to lowlanders.

More abstracts to follow…

photo of the traditional haggis courtesy of www.sausages.co.uk

Tags: Wilderness Medical Society, WMS, International Society for Mountain Medicine, mountain medicine, Aviemore, World Congress, wilderness medicine, outdoor medicine, healthline

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Thank You to Doctor Anonymous for Grand Rounds

Thank you to Doctor Anonymous for including my post about wildfire conflagrations within this week's edition of Grand Rounds. Grand Rounds is a weekly compilation of posts related to health care compiled by a host, who makes a great effort to compile an interesting collection for readers.

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Another Man and a Boy to Admire

I've recently posted twice about the fires in San Diego. As do many natural disasters, they extracted a human toll. I received the following message from my friend Marty Alexander early this week and attempted to put up a post at his request. I thought that the information went out to you on Wednesday, but Google's Blogger service lost everything in the posting process. I apologize to my readers, because I wasn't made aware of this problem until the end of the week. Here is the essence of the lost post, the information for which originated with Richard Halsey of The California Chaparral Institute. I very much hope you will take time to read this now:

"Fifteen year-old Richard Varshock was critically burned during the Harris fire in San Diego County on October 21. He and his father, Tom, were at their home when the fire hit. A California Department of Forestry engine company was on scene when a burnover occurred. Richard’s father died in the flames. Several CDF firefighters were seriously injured. Richard remains in serious condition at the UCSD burn unit in San Diego. His mom, Diane, is by his side everyday.

There are times when it is important to come together as a community to help each other out. This is one of them. The Varshock family did not have fire insurance on their home, which was destroyed by the flames, and their health insurance will not cover much of the costs for Richard’s recovery.

Please consider donating some love. You can do so in a number of ways as described below. I have included two news stories about the incident in addition to attaching a photo of Richard.

This video, created by Richard's friends, will give you some insight into the kind of person Richard is.

Thank you,

Rick (Halsey)"

Per Mr. Halsey, tax-deductible donations can be made to:

Varshock Family Foundation
PO Box 3484
San Diego, CA 92163
Tax ID No. 26-1307576

Schoolmates help out badly burned boy, 15
By Tony Manolatos
UNION-TRIBUNE STAFF WRITER

November 2, 2007

SAN DIEGO – Tributes and support continue to pour in for the family who lost their home and a loved one to last week's wildfires.

Thomas Varshock and his son, Richard, 15, were overrun by flames in the early hours of the Harris fire while trying to save their Potrero home.

The father died and the son is recovering from lung damage and burns to over more than half of his body. He remains in critical condition at UCSD Medical Center in Hillcrest.

Friends and family plan to honor Thomas Varshock, a geological engineer, at a private memorial service today. He was 52, and was one of seven people who lost their lives to the fires, which burned 369,000 acres and destroyed nearly 1,700 homes across San Diego County.

Dr. Raul Coimbra, who oversees trauma, burn and surgical critical care at UCSD, said last week that he expected Richard Varshock and the other burn victims to survive.

“He's doing well,” Coimbra said. “He's a big, strong boy.”

Yesterday, Richard's aunt, Julie Varshock, said he was “improving at a rate greater than what the doctors anticipated.”

Julie Varshock said the family did not have homeowners insurance. The Valhalla High School wrestling team has rented and furnished an apartment near the hospital for Richard's mother, Dianne.

Richard is a sophomore at the high school and a varsity wrestler. A photo of him and two of his buddies is on the team Web site at valhalla-wrestling.cityslide.com/ page/page/177617.htm. A link on the site allows people to make donations.

One of Richard's friends created a video tribute and posted it on YouTube at youtube.com/watch?v= zNscvSBH3Ig.

The 2-minute video, set to a song by Snow Patrol, opens with a grainy black-and-white photo of Richard. More pictures follow, including several that show a smiling Richard goofing around with friends. Others show the flames, and some carry messages.

“Richard is one of the nicest guys you can meet, so please pray for him,” viewers are told.

Burned firefighter anticipated dying
By Tony Manolatos
UNION-TRIBUNE STAFF WRITER

October 27, 2007

Andrew Pikop couldn't outrun the flames that were scorching his back. He heard the helicopter there to rescue him, but he couldn't see it through the blinding smoke and sand. He took cover, first in his fire safety tent and later behind a rock.

As he tried to shield himself, he thought about his family and friends.

“And I thought about how much this is going to hurt – burning to death,” Pikop said yesterday from his hospital bed. “I was absolutely sure I was gonna die.”

Pikop, who turns 24 next month, is one of four Cal Fire firefighters injured while trying to rescue a father and son who fought to save their Potrero home in the early hours of the Harris fire on Sunday morning.

In his first interview, Pikop picked at the white dressings that cover most of his body.

“I'm on a lot of meds, so the pain isn't that bad,” he said. “It hurts when I walk and when I shower. They have to scrape all the dead skin off my back.”

He shares a room in the burn unit at the UCSD Medical Center in Hillcrest with Capt. Raymond “Ray” Rapue, whose face and hands are badly burned.

“When it rains it pours,” Rapue said.

Rapue, 53, was in charge of Pikop and the two other firefighters, whose names have not been released. Both are in critical condition at UCSD.

Information about the firefight has been scarce. Cal Fire has a team of 15 investigating the incident, and everyone involved has been ordered not to discuss the details. But a picture of what happened is beginning to emerge.

Unit Chief Henri Brachais, the lead investigator, said the firefighters were trying to save Thomas and Richard Varshock, whose home is off state Route 94 and Emery Lane in a remote part of San Diego County near the U.S.-Mexico border.

Thomas Varshock died. His 15-year-old son, whose hospital bed is down the hall from Pikop's, has burns to more than 50 percent of his body. On Wednesday, he was covered with a white blanket. His face was bandaged and he was hooked to a ventilator.

Brachais said the fire crew was stopped at the Varshock home when “a burn-over occurred.”

“The fire went up the hill and flames went over the truck,” he said.

Like any other day

For Pikop, the day started like every other Sunday. The crew at the San Marcos station was mowing the lawn and trimming hedges.

Rapue, the captain, was normally based at Cal Fire's Rincon station, one of 18 in the county. He was covering the San Marcos station because the regular captain was off.

The four-member team heard about the fires on the radio, so they weren't surprised when they were dispatched to Potrero, 67 miles away.

The call came in shortly after 9:30 a.m., said Pikop, who started with Cal Fire less than five months ago.

Pikop grew up in the small town of Exeter near Fresno with his parents, Gary and Conselo, and two brothers. An adventure junkie who snowboards and roller blades, he worked as a volunteer firefighter for two years and as an EMS technician for a year.

When Pikop came home from a fire call, his parents sometimes smelled smoke on his clothes, but he always told them he was fine.

“He had a calm attitude,” his mother said. “I think that helped save his life.”

Still, his first call as a volunteer firefighter shook him – he was alone when he arrived at a car wreck that had killed a motorist.

His confidence grew as the calls increased. He sometimes shared his experiences with his 25-year-old brother, Joshua, a U.S. Coast Guardsman.

“I was just amazed at how he handled it all,” Joshua said yesterday. “But he's adventurous. He needs action.”

In May, Pikop finally got the job he'd wanted: a seasonal post with Cal Fire. His contract extended to sometime in November, depending on the severity of the wildfire season.

About two weeks ago Pikop called his brother and told him his first fire season was shaping up to be a bust.

“He thought he was going to get laid off,” Joshua said. “He said, 'There's nothing going on. It's been dead.' ”

Arriving in Potrero

Engine 3387 arrived in Potrero at about 11 a.m. It pulled up to the Varshock residence about an hour later.

What happened next isn't entirely clear, but at some point all four firefighters and the Varshocks took cover in the firetruck.

By then, the fire was raging and Santa Ana winds were knocking down power lines.

“At first I wanted to help my crew get out, but once the fire blew up it disoriented me,” Pikop said.

Somehow he became separated from the firetruck. He heard his colleagues yelling his name, but he was running from flames and couldn't find them.

“I ran through flames. I ran from flames. But the fire caught up to me,” he said.

He figured he was on his own. He assumed the rest of the crew was dead.

Other firefighters working in the Potrero area heard their colleagues radioing for help. They tried desperately to reach the engine, but they couldn't drive through the flames.

A helicopter pilot with the U.S. Forest Service was nearby, dropping water on the fire. The pilot heard the radio calls for help and located the engine from the air.

The pilot, whose name hasn't been released, landed and picked up the three firefighters and the Varshocks from the firetruck. He flew them to a Cal Fire station about a half mile away, then returned to look for Pikop.

About half an hour later, the pilot spotted Pikop and airlifted him to the station. An air ambulance flew everyone to UCSD, where they were admitted at 1:30 p.m.

A few hours later, Conselo and Gary Pikop were making the 6½-hour drive to San Diego. A hospital official was waiting for them in the lobby. It was just after midnight when they saw their son.

“We held his hand, we hugged him and we cried together,” Conselo Pikop said.

Fair condition

Andrew Pikop was listed in fair condition yesterday with first-degree burns to his back, arms and legs. He has second-degree burns on his nose and ears.

When some firefighters came over to his bed to pay their respects, he immediately asked for an update on the wildfires. He is eager to get back to work, he said.

photo of Richard Varshock

Tags: wildfire, fire, Richard Varshock, Andrew Pikop, wilderness medicine, outdoor medicine, healthline

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Can Wildland Conflagrations Be Stopped?

This post is written by Marty Alexander, who is a Senior Fire Behavior Research Officer with the Northern Forestry Centre of the Canadian Forest Service in Edmonton, Alberta, and senior author of the chapter entitled “Wildland Fires: Dangers and Survival” in the 5th edition of the textbook Wilderness Medicine. This post is adapted from an essay he wrote in 2004 - the message still applies.

Can Wildland Conflagrations Be Stopped?

Conflagration – A popular term for a large, fast-moving wildfire exhibiting many or all of the features associated with extreme fire behavior. (Merrill and Alexander 1987)

“Can Southern California Wildland Conflagrations Be Stopped?” (Countryman 1974) is the title of what I feel is one of the more important publications on the subject of fuels management presently available . The publication was written by Clive M. Countryman, a noted wildland fire behavior scientist with the USDA Forest Service based in southern California from 1941 until his retirement in the late 1970s.

Countryman's publication was written following the 1970 fire season in California (and no doubt was prompted by it) in which 16 lives were lost, more than 200,000 hectares of land were burned over, and some 700 homes were destroyed. Countryman’s 11-page publication consists of three major sections involving 17 sub-sections, each of which directly imparts a statement or conclusion worth noting:

The Fire Problem

• Climate, Fuels, Topography, and People Create Fire Problems
• Relatively Few Fires Become Conflagrations
• Conflagrations Are Most Frequent During Santa Ana Winds
• Suppression of Santa Ana Fires is Difficult

Fire Control as a Solution

• Fire Prevention Has Limited Value
• Effect of Organizational Problems on Fire Size is Small
• Firefighting Techniques and Equipment are Not Adequate
• Increased Fire Control Force is Only a Partial Answer

A Solution Through Fuel Modification

• Rotational Burning Creates a Mosaic of Age Classes
• Adverse Effects
• High Costs
• Possible Increased Fire Hazard
• Fuel-Breaks Provide Strips of Modified Fuel
• Fuel-Type Mosaics Can Lower Energy Output
• Fuel-Type Mosaics Can be Created in Many Ways
• Fuel-Type Mosaics Are Not a Quick Cure
• Complete and Coordinated Planning is Essential

The abstract from Countryman’s (1974) publication serves as an excellent summary:

In southern California, many fires start and burn under conditions that permit their control with little burned acreage and fire damage. In contrast, under other conditions of weather and topography, on a small group of fires, control is relatively ineffective; they become large and destructive. A major reason for these "conflagration fires" is the extreme difficulty of stopping the head of a hot, fast-running fire in dry fuels and strong winds. No radically new concept of suppression can be anticipated. The best prospect for alleviation of the problem is modification of the vegetation to reduce fuel energy output. In a fuel-type mosaic containing large areas of light fuels, where conventional suppression will be effective, potential conflagrations could be brought under control while relatively small. Creation of the fuel-type mosaic will require coordinated area-by-area planning and a variety of techniques.

In the concluding section of his publication, entitled “Complete and Coordinated Planning is Essential” Countryman notes:

In essence, the envisioned fuel modification will replace the present wildland vegetation patterns with planned and managed ones. To achieve this, complete and coordinated plans must be developed. As fire does not recognize administrative boundaries, such planning will involve not only fire control agencies, but also local governments, land use planning commissions, and sometimes private interests. Social, economic, land use, and environmental impacts must be determined and evaluated, and the best combinations of fuel modification to achieve adequate fuel-type mosaics for a given area established. Inputs into these plans will be needed from fire control and fire behavior experts, meteorologists, land-use planning specialists, economists, landscape architects, plant ecologists, biologists, recreation planners, and wildland research groups.

Much of the technology needed to create fuel-type mosaics is now available, is being developed, or is susceptible to development through research. Many of the techniques by which type conversion can be done have been demonstrated to be feasible. What is needed now is a comprehensive action plan that will effectively bring this technology to bear on the one factor controlling fire behavior that can successfully be managed and manipulated – the fuel.

To some, the extensive “monkeying with nature” required to replace the present wildland vegetation patterns with planned and managed ones may seen abhorrent. But the impact of man and man-caused fires has already had a massive effect on the natural vegetation, so much so that it is difficult if not impossible to specify what really is a “natural” vegetation pattern in southern California. And this impact will continue as long as conflagrations are a part of the environment. The only alternative to planned and managed vegetation patterns in southern California appears to be acceptance of the great economic damage, threat to human life, and unpleasant aesthetic and environmental effects of unmanageable wildfire.

It’s worth noting Countryman’s emphasis on the importance of “human factors” in reaching solutions to the conflagration management problem. Thirty years later, fire historian Dr. Stephen Pyne (2004) has advocated that “science-based-only solutions” are not enough and that effective wildland fire policy must integrate ethics, economics, aesthetics, and values. Accomplishing this will require consensus among many people; this undoubtedly represents the greatest challenge for wildland fire management in the future.

As Countryman points out in the introduction of his publication, “California does not have an exclusive corner on the large-scale, high-intensity fires often called conflagrations or conflagration fires...Other regions also have large wildland fires from time to time.” In my view, many of the fundamental principles stressed by Countryman can be considered quite applicable to regions of Canada.

The original printed copies of Countryman’s (1974) seminal publication were exhausted many years ago. Fortunately it has recently been made more readily available (at the request of the USDA Forest Service by the author) as a PDF that can be downloaded from:

http://www.treesearch.fs.fed.us/pubs/viewpub.jsp?index=7573

To answer the question posed at the start of this essay: Can Wildland Conflagrations be Stopped? No, not entirely, given the magnitude of the task at the landscape-scale (Amiro et al. 2001; Alexander 2002). One would be a fool to think otherwise. However, there is every reason to believe that through strategic fuel management planning, we could influence the total number and size of the occurrences as well as their geographic distribution and thereby mitigate the impacts of too much of the “wrong kind of fire” (Pyne 2004).

We should take advantage of the lessons of the past (and lessons relearned), like those in southern California, so we don’t have to learn them first hand the hard way. Surely, we have moved on from “it can’t happen here” to the questions of when and where will it happen.

References used in the preparation of this essay:

Alexander, M.E. 2002. An emerging fire management issue in Canada: Forest-fire fuels. Canadian Silviculture 2002(Fall): 14-15.
Alexander, M.E. 2003. Understanding fire behavior -- the key to effective fuels management. Invited Keynote Address at the FERIC Sponsored Fuels Management Workshop, October 6-8, 2003, Hinton, Alberta. 14 pp.
Amiro, B.D.; Stocks, B.J.; Alexander, M.E.; Flannigan, M.D.; Wotton, B.M. 2001. Fire, climate change, carbon and fuel management in the Canadian boreal forest. International Journal of Wildland Fire 10: 405-413.
Bentley, J.R. 1967. Conversion of chaparral areas to grassland: Techniques used in California. U.S. Department of Agriculture, Forest Service, Washington, D.C. Agriculture Handbook No. 328. 35 pp.
Chase, R.A. 1980. FIRESCOPE: A new concept in multiagency fire suppression coordination. U.S. Department of Agriculture, Forest Service, Pacific Southwest Forest and Range Experiment Station, Berkeley, California. General Technical Report PSW-40. 17 pp.
Countryman, C.M. 1974. Can southern California wildland conflagrations be stopped? U.S. Department of Agriculture, Forest Service, Pacific Southwest Forest and Range Experiment Station, Berkeley, California. General Technical Report PSW-7. 11 pp.
Green, L.R. 1977. Fuelbreaks and other fuel modification for wildland fire control. U.S. Department of Agriculture, Forest Service, Washington, D.C. Agriculture Handbook No. 499. 79 pp.
Green, L.R. 1981. Burning by prescription in chaparral. U.S. Department of Agriculture, Forest Service, Pacific Southwest Forest and Range Experiment Station, Berkeley, California. General Technical Report PSW-51. 36 pp.
Green, L.R.; Newell, L.A. 1982. Using goats to control brush regrowth on fuelbreaks. U.S. Department of Agriculture, Forest Service, Pacific Southwest Forest and Range Experiment Station, Berkeley, California. General Technical Report PSW-59. 13 pp.
Merrill, D.F.; Alexander, M.E. (editors). 1987. Glossary of forest fire management terms. Fourth edition. National Research Council of Canada, Canadian Committee on Forest Fire Management, Ottawa, Ontario. Publication 26516. 91 pp.
Moore, H.E. 1981. Protecting residences from wildfires: A guide for homeowners, lawmakers, and planners. U.S. Department of Agriculture, Forest Service, Pacific Southwest Forest and Range Experiment Station, Berkeley, California. General Technical Report PSW-50. 44 pp.
Radtke, K.W.H. 1981 Living more safely in the chaparral-urban interface. U.S. Department of Agriculture, Forest Service, Pacific Southwest Forest and Range Experiment Station, Berkeley, California. General Technical Report PSW-67. 51 pp.
Pyne, S.J. 2004. Tending fire: Coping with America’s wildland fires. Island Press/Shearwater Books, Washington, D.C. 238 pp.
Roby, G.A.; Green, L.R. 1976. Mechanical method of chaparral modification. U.S. Department of Agriculture, Forest Service, Washington, D.C. Agriculture Handbook No. 487. 46 pp.
Rogers, D.H. 1942. Measuring the efficiency of fire control in California chaparral. Journal of Forestry 40: 697-703.
Salazar, L.A.; Gonzalez-Caban, A. 1987. Spatial relationship of a wildfire, fuelbreaks, and recently burned areas. Western Journal of Applied Forestry 2: 55-58.

photo of Marty Alexander

Tags: wildfire, fire, Marty Alexander, wilderness medicine, outdoor medicine, healthline

Labels: fire, Marty Alexander, wildfire

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Thank You to Counting Sheep for Grand Rounds

Thank you to Counting Sheep for including my post about how one amazing man made it through the southern California wildfires within this week's edition of Grand Rounds. Grand Rounds is a weekly compilation of posts related to health care compiled by a host, who makes a great effort to compile an interesting collection for readers.

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A Man to Admire

Because of the recent wildfires in southern California, I wrote a post recently with fire survival advice, based upon the excellent recommendations of my friend Marty Alexander.

I just received a poignant and inspirational reminder from my good friend J.T. Geehr about the human impact of such a cataclysmic event. It is about her father, Bob Hayes, who was forced to evacuate his home just before it burned to the ground. The message is very clear that because of the difficult circumstances we sometimes face in life, there is always need for love and the human spirit. We should never forget the human impact – that wilderness medicine is first and foremost about people - and that each and every person has an important story. Here goes:

“I owe all of you a huge thank you for your touching expressions of sympathy last month after my mother died. I am lucky to have such kind and caring friends. My father misses her very much, and still muses about her great beauty. He recalls the way she looked when she was a 21 year-old bride, and still swoons. We should all be so lucky!

Last Sunday, October 21, I went with my father to mass, and then shared lunch. We talked about a lot of things, in particular his home. I spoke with him about the option of moving to a senior facility, so that if he needed help, it would be available. But he told me he prized his independence and loved his house, and wanted to stay there until it was no longer physically possible to do so. So we began to plan a decorating scheme - he asked me to help make his decor a bit more current. As I left at 3 PM, the smell of smoke permeated the air. I checked on the radio, and discovered that there was a fire in the mountains - Dad said it was far away. The relocation center for the evacuees from that fire was in Poway, close to Dad's house. We didn't feel he was threatened, so I returned home. All evening I checked online for the status of that fire, but all of the coverage that I could find was about Malibu, where another fire raged.

My father was awakened by a phone call at 4:30 AM Monday. One of his friends asked him if he was awake. In typical “Dad” fashion, he answered "Hell, no!" His friend then told him to look outside, because the news was reporting fire in Rancho Bernardo. He looked out his back window and saw that his trees were ablaze, with the wind whipping them wildly. He put on pants, shoes and a shirt, grabbed 2 photo albums and a portrait of my mother, and ran to the garage. When he opened the garage door to leave, he saw flames racing across his driveway. He took off as quickly as his car would allow him, through the flames, in the dark. Confused, he drove to the Rancho Bernardo Inn, parked, and went to the bar. Not surprisingly, there were no other patrons in the bar at 5 AM, so he played a game of pool by himself! A hotel employee came in and told him that they had evacuated a couple of hours ago, and he'd better get out of there ASAP. He went back to his car and tried to drive back home to check on the house. Not an option. He tried to drive to my sister’s house. Not an option – her neighborhood was being evacuated. He then began his drive to my house - ordinarily about an 80 minute drive. He called me at noon from the Border Patrol office on Highway 5; he had stopped there to nap in the car, and when he awoke and tried to drive, his parking brake was stuck. He was there another hour, waiting for assistance from AAA. During that hour, he enjoyed the hospitality of the Border Patrol, while he held them spellbound with his tale of escape. He finally arrived at my house at 2:30 PM, looking like he'd been through hell. But that was just the beginning.

We were unable to get any current information about the status of his neighborhood that entire evening. Every Internet news source sent us to the Google Earth link, which had a lovely aerial picture of my dad's house in perfect condition. For a while, we believed it might possibly have been spared. But it didn't make sense. I checked the posted list of destroyed homes, and looked at the Google image for a "destroyed" neighborhood; it, too, looked perfect. His city councilman's website promised to have an official list of destroyed homes up by 2 PM on Tuesday. We couldn't get through to it until 4 PM, but then it was official - Dad's home was destroyed.

It is hard to understand where this man is getting his strength. He battled cancer two years ago, and buried his wife less than two months ago, but his spirit is truly inspirational. He has shed some tears - mostly from being touched by the kindness he has received. A barber gave him a free haircut, and it brought tears to his eyes. When we went to Nordstrom to get him some clothes, they gave us a free lunch. That brought more tears. When the insurance company told him they were sending him $5,000 to get him through the immediate expenses, he choked up and told the agent, "You people are so wonderful." But other than a few times that he has let down and wept, he has been making the most of what anyone would agree is a devastating circumstance. He says that now he gets to start over, at 87 years old! He has found a residence and will move in next month. He is going to visit my sister in Hawaii in two weeks - we got him new clothes for that journey, and he's so excited about the new sandals.

Rather than dwell on the difficulties ahead, he has been giving thanks for his safety, for his kids, his friends, his relatives, and yes - the kindness of strangers. All of my life, people have told me what a great guy my dad is, and of course, I agreed. But I didn't really understand why he was so great - he was just great. He was 'The Tiger.' This episode has illuminated for me what makes my father the recipient of so much love and admiration. He is upbeat and grateful. Every act of kindness to him is unexpected and appreciated. He has lost every single possession he had, every piece of memorabilia that he has collected over 87 years, and yet, he is trying to make the best of each day. Having tuned 50 last month, I sort of thought that I had life all figured out, that I'd learned all there was to learn. Living through this ordeal with my dad has taught me that I'm just beginning to get the picture.

Thanks for taking the time to read this. Your good thoughts and prayers are appreciated. This is far from over.”

Tags: fire, wildfire, Geehr, Bob Hayes, wilderness medicine, outdoor medicine, healthline

Labels: Bob Hayes, fire, wildfire

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