Reduction of a dislocation is not without controversy. A provider may cause further harm if they act hastily. However, leaving a joint dislocated for many hours will also cause damage. This decision should be influenced by your relationship with the patient, distance from definitive medical care, your comfort with the assessment and the procedure, local regulations, and your institutional protocols, if any. Anyone who informs you that at the introductory wilderness medicine level the assessment of dislocations is straightforward, that the treatment is without risk, or that the skill is easy to retain, is, in our opinion, completely misinformed.
Always have a dislocated joint evaluated by qualified medical personnel upon return to the frontcountry.
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Considerable debate and misinformation surround the administration of epinephrine at the WFR/ WFA level. Some regard adrenalin as the most important item in their first aid kits. Others do not even consider carrying it out of fear of litigation. The DEA is not (yet) hovering above your campsite, waiting for you to give epinephrine to yourself or your family and friends. However, administering your epinephrine to your patient, without lawful protocols signed by an authorized medical provider licensed in your state, is considered by many legal professionals to be an illegal act. This presents an employing agency with a nearly impossible dilemma: can they mandate their employees to break the law? Similarly, it is entirely conceivable that withholding epinephrine or not having epinephrine on an outdoor trip could be considered as acts of omission, which are serious allegations. Many large outdoor organizations, such as the Student Conservation Association, NOLS and Outward Bound have considered the same legal arguments and made very different decisions about whether to carry epinephrine in the field. These are very complex issues. They are debated each year at the Wilderness Risk Management conference. 2009 was no exception. At this year’s conference, outdoor law specialist Frances Turner-Mock stated that she found this to be one of the most complicated legal issues she has ever encountered in law. It is no surprise that so many organizations find it so difficult to make a decision.
Understand that having a certificate that testifies to your competence in the management of anaphylaxis, including the administration of epinephrine, is no substitute for signed physician protocols that are in accordance with local laws and regulations. To date, we know of no lawsuits brought against an individual that administered epinephrine in an outdoor setting.
A number of employing agencies do not have a medical director or the medical director is not licensed in the state that the employee is working; however, many expect their employees to carry and administer adrenalin if needed. This is a potential set-up for litigation. As with so many medical/legal issues, protect yourself by making informed decisions based on thorough assessments; few lawsuits arise from positive patient outcomes.
Further mitigate your risk by considering your relationship to your potential patient and the presence of physician protocols in accordance with the law. Anaphylactic reactions evolve very rapidly, so the best time to weigh the risk is before the trip begins.
It is our hope that adrenaline will be available by auto injector without prescription. At that point, organizations and individuals can make medical decisions based more on medical criteria than legal concerns.