# What's the best way to do a BP on a snowsuited patient in extreme cold?



## mycrofft (Dec 27, 2008)

Yes, yes, I know, but besides taking him/her to the ski chalet first!

I used to rapidly snake the stethoscope head up the sleeve (or, if needed, tetrasnip my way to the antecubital fossa) then use a big cuff around the entire suit sleeve if it wasn't ridiculously puffy. PSI (or mmHg) are PSI (or mmHg), it took longer to inflate it but my readings in the situation seemed to be pretty close to what we would get once we could shuck the pt out of the suit.

(Actually, after my chem warfare training, I changed my attitude to first ascertaining if the pt could be/needed to be moved to a safe and warmer situation first; a hotile environment greatly limits what you can safely do while it still is impacting the pt. "Care on the spot" was then the second consideration, _after_ what you could call "environmental scene safety" I guess).
Thoughts?  Policies?


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## mycrofft (Dec 27, 2008)

*OOps I buried my own post!*

Any comments?:blush:


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## traumateam1 (Dec 28, 2008)

mycrofft said:


> I used to rapidly snake the stethoscope head up the sleeve (or, if needed, tetrasnip my way to the antecubital fossa) then use a big cuff around the entire suit sleeve if it wasn't ridiculously puffy. PSI (or mmHg) are PSI (or mmHg), it took longer to inflate it but my readings in the situation seemed to be pretty close to what we would get once we could shuck the pt out of the suit.



And this didn't work this time? 

Can we get them OUT of the extreme cold, then take some layers off to do the BP?


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## akflightmedic (Dec 28, 2008)

What is your transport time to definitive care or a warmer location?

Is a BP absolutely necessary prior to moving locations?

This kind of question all comes down to the actual details of the event.

Does the nature of their injury demand knowing a BP instantly? If not, transport to warmer location and then assess. 

If they have a strong radial pulse, then you know their systolic is at least 80, odds are if its strong and its a minor injury it is even better...right? So what is the hurry to get a BP?

From someone who worked in the Arctic for several years, I think there are many times you can forgo a BP or an intervention until you arrive a warmer location or circumstances change.


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## mycrofft (Dec 28, 2008)

*Thanks! Have a good one!*

mycrofft.....


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## yowzer (Dec 28, 2008)

Take the BP around  their neck. 

Seriously... unless you can easily get them out of the bulky warm stuff and into something else that'll keep them warm and yet give access (Say a sleeping bag)... BP can be done via palpation (Which isn't going to be incredibly accurate, but is better than nothing and will give a rough idea of if they're high or low).  Get what vitals you can, but not at the cost of increasing their chance of becoming hypothermic.  If you need to remove clothing anyways, might as well get one, but I wouldn't do it just for the sake of am ausculated blood pressure.


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## mycrofft (Dec 28, 2008)

*The method I used worked OK, I was asking if there was a better one.*

Of course, the answer is "Get them where it's warmer"! I was target-fixated upon better ways to do something the hard way. Triage is probably the only imperative dictating BP like that, and even then getting warm and accessible-er is needed quickly.


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## BossyCow (Dec 29, 2008)

I've snaked a cuff around an arm inside a snowsuit/parka leaving the majority of the pt covered I would think that would be more accurate than the bigger cuff over the sleeve.


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## Veneficus (Dec 29, 2008)

Why not just look for clinical signs of perfusion until you get somewhere warm? 

If you get a BP of 280/160 what are you going to do out in the cold?
If you get a BP of 50/p what then? 

(aside from maybe questioning that number if the person is talking coherently to you) But you get my point.

What good are these numbers without a proper physical exam anyway?


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## BossyCow (Dec 29, 2008)

Veneficus said:


> Why not just look for clinical signs of perfusion until you get somewhere warm?



It totally depends on the circumstances. How close to the rig is the pt? How long before they are able to transport. Is this a packout of an hour plus? What symptoms was the pt experiencing. Are they down from a possible cardiac event? Are they a trauma pt and bleeding out into their belly? A set of baseline vitals is important.. probably why they call them vital.

The OP was asking a question on technique, not on whether or not to do it.


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## Veneficus (Dec 29, 2008)

BossyCow said:


> It totally depends on the circumstances. How close to the rig is the pt? How long before they are able to transport. Is this a packout of an hour plus? What symptoms was the pt experiencing. Are they down from a possible cardiac event? Are they a trauma pt and bleeding out into their belly? A set of baseline vitals is important.. probably why they call them vital.
> 
> The OP was asking a question on technique, not on whether or not to do it.




I wasn't/still not trying to be accusatory, just putting out some food for thought.

What if the rig is far away? How much does it change?

Isn’t time of transport as soon as possible? 5 minutes, an hour, 10 hours, 72 hours, you will do what you can with what you have based on the patients clinical issues.

You will need more info than a BP to treat a cardiac event. Though I admit hypotension would be an indicator of right sided insult or infarction. A weak pulse, altered LOC, could probably give that away as well. But to treat it, you are going to have to ditch the snow suit anyway.

In a trauma patient with intraperitoneal bleeding, time to transport will be a much more critical factor than anything that can be done for him in the field, no matter what his pressure. You would probably have to take off the suit to assess that anyway. So if suit is off, why not take the BP then?

Please entertain my thoughts:
Patient A: BP: 120/70 pulse: 86 resps: 10
Patient B: BP: 90/70 pulse: 70 resps: 12
 Patient C: BP:140/82 pulse: 110 resps 16
Who is sicker? 

I was trying to illustrate a set of vital signs is not enough to make treatment decisions on. I realized he was asking the best way and I wanted to offer food for thought before he decided on technique, that it may alter the one he chooses.


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## Jon (Dec 29, 2008)

Wow. Any ski patrollers out there? What do you do "on the mountain" for first aid?

My gut instinct would be that I'm doing nothing more than a "rapid assessment"... +radial pulses=moderately adequate perfusion, and leave it at that until I can get the patient out of the elements.

No sense killing him faster because he's hypothermic.


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## BossyCow (Dec 29, 2008)

Jon said:


> Wow. Any ski patrollers out there? What do you do "on the mountain" for first aid?
> 
> My gut instinct would be that I'm doing nothing more than a "rapid assessment"... +radial pulses=moderately adequate perfusion, and leave it at that until I can get the patient out of the elements.
> 
> No sense killing him faster because he's hypothermic.



Absolutely Jon.... when the temp is in the low teens, our treatment of the pt is going to be much different. The old strip and flip just isn't an option. 

and as to:


> In a trauma patient with intraperitoneal bleeding, time to transport will be a much more critical factor than anything that can be done for him in the field, no matter what his pressure. You would probably have to take off the suit to assess that anyway. So if suit is off, why not take the BP then?



If its possible to get a quick and nasty assessment of early BP to compare without exposing the pt to the extreme temps.. its a good thing. We don't necessarily have to take the suit completely off, instead we can do a piecemeal peek a boo of areas followed by quickly covering the pt back up. 

It's important to know these types of things becaues a stable pt is more likely to get a safer, gentler transport while an unstable pt is going to be looking at an airlift or another less safe, faster extrication.

Since many of our pack outs can be several days, that's time for a slow spleen rupture to show up, or other slower developing issues. Having a nice set of baselines gives us a starting point. If its possible to get that baseline without exposing the pt to the elements.. don't you think it might be nice to do that?


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## Veneficus (Dec 29, 2008)

BossyCow said:


> Since many of our pack outs can be several days, that's time for a slow spleen rupture to show up, or other slower developing issues. Having a nice set of baselines gives us a starting point. If its possible to get that baseline without exposing the pt to the elements.. don't you think it might be nice to do that?



Without disrespect,
I am highly suspect of the effectiveness of “spot checking” for occult injuries such as liver or splenic lacs, especially in the early stages where clinical signs such as Cullen’s or Grey Turner’s may not have manifested yet. For me personally, if I suspect I cannot do a thorough assessment or that there may be a serious injury, we are getting out of the elements if it means a lean to, and then anything that interferes is coming off. My opinion on this matter like others is not gospel; it is what I would do based on my knowledge and ability. (If I ever become all knowing or all powerful I will start charging a lot more for my service)

I understand low grades can be managed without surgical intervention, but I wouldn’t want to try that out in the wilderness unless I had no other option, and only until help could come. 

Since I know in trauma that SBP does not correlate to CVP and therefore end tissue perfusion, I find limited diagnostic use with it. Pulse pressure is much more useful. So the BPs would need to be accurate, a quick and dirty one would not due. I heard a quote that I think are words to live by.

“Critical care is a mindset, not a place.”

I have seen “stable patients” crash suddenly more times than I can even remember. Anyone can read vital signs, I prefer to focus on finding the injuries, especially the occult ones, and then preserving or resuscitating organism function.  I would rather have an exam without a set of numbers than a set of numbers without a good exam, ideally it would be both. It’s just my way. Not the only way. But I am glad to be able to discuss all the different opinions.


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## Luno (Dec 30, 2008)

Jon said:


> Wow. Any ski patrollers out there? What do you do "on the mountain" for first aid?
> 
> My gut instinct would be that I'm doing nothing more than a "rapid assessment"... +radial pulses=moderately adequate perfusion, and leave it at that until I can get the patient out of the elements.
> 
> No sense killing him faster because he's hypothermic.



BP Cuff over the jacket, palpate, it's not important in most outdoor/extreme weather circumstances to be 100 percent accurate,  but it's important to establish a baseline to watch for changes.  If you're in a situation where it's critical to be 100 percent accurate, then you should PUHA.


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## mycrofft (Dec 30, 2008)

*In twenty-below Farenheit, quick and dirty had better do.*

Happily, I'm away from those temps now but when I was in 'em, it was suburban and urban, mostly hips and showshovel MI's, no more than ten miles to nearest hospital...although sometimes that meant  forty minutes due to ice and accidents blocking the way.

If you think snow suits in deep cold are tough, try "ground crew ensembles" (chem warfare defense suits) wearing M-17 masks in a chemical-laced environment?


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## FF894 (Dec 30, 2008)

About 8 years ago we were at a MVC-guy entrapped but not severly injured.  Guys awake, talking, and complaining of pain - all good signs in my book.  My junior partner procedes to whip out the shears and cut up the sleeve of his goose-feather down jacket while I was going around the other side.  Next thing I know we are all in white-out conditions, and its not snow.  I could have killed him.  Weeks later I still had feathers on me and in our bags.


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## medicdan (Dec 30, 2008)

mycrofft said:


> Happily, I'm away from those temps now but when I was in 'em, it was suburban and urban, mostly hips and showshovel MI's, no more than ten miles to nearest hospital...although sometimes that meant  forty minutes due to ice and accidents blocking the way.
> 
> If you think snow suits in deep cold are tough, try "ground crew ensembles" (chem warfare defense suits) wearing M-17 masks in a chemical-laced environment?



Can you feel a pulse to palp through those suits? Assuming you havent deconed, how do you get inside to feel the pulse?


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## BossyCow (Dec 30, 2008)

If I find a pt lying in a snowbank or in below freezing temps.. I'm going to do an initial assessment based on the most information I can get in the fastest way possible without increasing the danger to the pt. Now, does this mean that I expose a pt to the elements in order to get a BP or does it mean that I don't bother with a BP at all.. because these are two of the suggestions made. My answer was neither.. I will attempt to get a BP as part of my initial rapid trauma assessment. If what I see there, or what is evident by the mechanism of injury shows a high likelihood of internal trauma, then I have a number of decisions to make.  First.. how fast and by what method can I get this patient out of the wilderness and to a trauma center.. second.. what do I do in the meantime to improve the pts chances of survival? 

Yes a lean to is an option.. but if making a lean to and starting a fire takes more time than tranporting the pt to an LZ for airlift, I'm opting for the transport. Wilderness EMS is about weighing options and picking the best one for that patient in that situation. For an *initial *assessment and taking an *initial*B/P I'm going with my original post. Care doesn't stop there and its not the complete description of total pt care.. but its where I'm going to start.


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## frogtat2 (Dec 30, 2008)

*bp*

I was fascinated as I read this thread.  Its interesting how different people look at things in different ways. 

I live in an area where we treat hypothermia year round.  In listening to the comments and suggestions made previously, I can only speak to what I would do.

After assessing the mechanism of injury and noted the time frame to when you can get this person some place warm leaves you with a tough decision to make.

Rule number one we teach all our emt students is you NEVER cut a down coat in an enclosed enviornment.  That being said, if it were me, I would go ahead and cut the sleeve to access the arm and obtain an accurate bp.  Afterwards, I would then close the sleeve back up using duct tape.  It would hold the sleeve together and keep the pts arm warm and dry, while giving us the ability to reassess the bp in the future.

We rednecks love duct tape!!!


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## Veneficus (Dec 30, 2008)

frogtat2 said:


> I was fascinated as I read this thread.  Its interesting how different people look at things in different ways.
> 
> I live in an area where we treat hypothermia year round.  In listening to the comments and suggestions made previously, I can only speak to what I would do.
> 
> ...




I think we all agree that how far off your transport is makes the decision what to do. If you are out in the wild, you might have to do more before you can move or make decisions than if you can pull your truck up curbside and toss the snow shoveler (is that even a word/) in the back. But the scenario keeps morphing, so of course the decisions and priorities do as well.


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## FF894 (Dec 30, 2008)

frogtat2 said:


> That being said, if it were me, I would go ahead and cut the sleeve to access the arm and obtain an accurate bp.  Afterwards, I would then close the sleeve back up using duct tape.  It would hold the sleeve together and keep the pts arm warm and dry, while giving us the ability to reassess the bp in the future.



When my boy cut a down sleeve with sheers, it exploded in a flood of feathers.  There is no holding those suckers back once seal has been ruptured.


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## marineman (Dec 30, 2008)

We don't do SAR and I've never been on a call that we couldn't get the ambulance within 100 yards of the patient but we have a company policy that anything outdoors when the temp is below 40* is an emergency response regardless of dispatch code and all patients require urgent moves to a climate controlled environment. Therefore we wouldn't take a BP in the field for this type of emergency, it's a snatch and run.

My thought for anyone that would have to do this would be rather than cutting all the way up the sleeve why not start at the elbow and go up a few inches and just cut yourself a window big enough to get the BP cuff in on the arm, then you can either palp the pressure or send the steth just below your "window" to auscultate it.


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## Lin57EMT (Dec 30, 2008)

*BPs*

After reading all the posts, I think there may be two scenarios that are the crux of the differing answers.  

In prehospital ambulance situations, assessing ABCs (where a pulse is only palpated, not counted) is enough to get you to the next step, which is your transport decision.  Stay and play, or load and go?  After that we can fiddle all we like with actual vitals.  We don't have to expose a patient to extreme weather to get the BP, unless you're administering nitro or something similar.

In the wilderness situation, there is no real "load and go", because getting a patient to definitive care can take hours, even days.  In that situation a responder MUST have vitals to formulate a treatment plan.  

Nobody wants to trade hypothermia for a systolic and diastolic IF THEY DON'T HAVE TO.  But in the wilderness situation, where time moves ten times slower than our usual prehospital setting, obtaining and monitoring vitals is an essential part of the treatment plan and must be addressed.  

I, too, live in hypothermia land.  Truthfully, there are very few scenarios where exposing an arm or leg for the short length of time it takes to obtain a BP will put the patient in any real jeopardy, but still we would hesitate to do it.  Take a quick feel at the pulse, do a good "look test", use other methods to check perfusion, and get your patient into a forgiving environment. 

Wilderness people, as always it's a judgement call and each injury and each patient will require that you evaluate on an individual basis.  

No pat answers for this one, I think.


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## rjz (Jan 9, 2009)

My 10 years of ski patroling says to take a radial pulse and get them to "base". If they don't have a radial pulse get them to base faster and call a helicopter. Nothing I can do on the hill but transport, and nothing I can do ALS in "base" as I am only a BLS ski patroller. So a good dose of ski wax is the best thing I would say.


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## EMT-P633 (Jan 10, 2009)

Open parka, move 1 arm out of the sleeve, apply cuff. close parka. (assuming your cuff has the trigger mech. with the gauge on the trigger) route trigger/guage through either the neck or wrist opening. and use XXX/P. toss a couple hot packs in the arm pits for good measure on rewarming after exposing....


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## LucidResq (Jan 12, 2009)

rjz said:


> My 10 years of ski patroling says to take a radial pulse and get them to "base". If they don't have a radial pulse get them to base faster and call a helicopter. Nothing I can do on the hill but transport, and nothing I can do ALS in "base" as I am only a BLS ski patroller. So a good dose of ski wax is the best thing I would say.



Hallelujah. 

If you suspect shock, get them the hell out of there and focus on monitoring other indicators like their mental status and HR. BP is obviously an important assessment. However, patient care is more important than having that number to write down. Sure, most of the time they're not going to die of hypothermia or suffer frostbite because you exposed their arm, but they're going to be uncomfortable. I can think of few situations where getting a BP is so urgently important that I would want to make my patient uncomfortable. 

They say in SAR that 98% of our patients will be stable. Meaning, they will either be dead by the time we get there or they are not going to die anytime in the near future. So yes, in an extended carry-out situation, I'd probably feel alright with exposing a bit to take a BP unless they're so critical I am entirely focused on getting that person to definitive care and little else. We're not going to be rewarming them actively at all anyways. 

It's killing me because I don't remember the name of it - but another local SAR team has a big snowsuit for patients they rescue in winter operations that provides easy access to important sites like the AC but is easily closed back up to minimize heat loss. If I remember it I'll repost.


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## crotchitymedic1986 (Jan 12, 2009)

Any condition that is serious enough to mandate an immediate B/P in the outdoor setting, will also require the removal of the coat.  If you are just doing it for your report because you are not transporting, a B/P can be taken at the wrist, by sliding the jacket up a few inches.


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## BossyCow (Jan 12, 2009)

crotchitymedic1986 said:


> Any condition that is serious enough to mandate an immediate B/P in the outdoor setting, will also require the removal of the coat.  If you are just doing it for your report because you are not transporting, a B/P can be taken at the wrist, by sliding the jacket up a few inches.



No it doesn't


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## crotchitymedic1986 (Jan 12, 2009)

Sure it does, if you can not wait to get them to a warmer setting, then they must have an emergent condition.  Any emergent condition, will require access to the patients arms and torso (whether medical or trauma).  If it is not emergent enough that you feel the need to undress them in the bitter cold, then they can wait until you get to a warmer area.  

But please give me an example.


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## BossyCow (Jan 12, 2009)

crotchitymedic1986 said:


> Sure it does, if you can not wait to get them to a warmer setting, then they must have an emergent condition.  Any emergent condition, will require access to the patients arms and torso (whether medical or trauma).  If it is not emergent enough that you feel the need to undress them in the bitter cold, then they can wait until you get to a warmer area.
> 
> But please give me an example.



Taking a BP is part of a set of baseline vitals. There are issues that can show up in a wilderness situation that would not be obvious on initial assessment, even if we did  open them up and expose them to the elements. For example, a ruptured spleen, sepsis, if its possible.. and it is, to get the BP without exposing uneccessary parts to the cold.. seems to me it makes sense to do it that way. Why compound the initial issue with hypothermia if its not necessary?


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## rjz (Jan 13, 2009)

I agree that a BP is part of a baseline set of vitals (here it goes) BUT....in my experence the majority of things that I see on a ski run a BP is not needed. If I do need to know about their circulation status I can check a radial pulse, check their LOC, look in their eyes, and look at their skin and get a good feel for what their blood is doing. This is just like being able to look at a pt. from across the room and decide if they are sick or not. If they are sick you know they are sick, please don't waste scene time trying to remove clothing to get a BP that won't change your treatment. If they do have splene injury, closed head, etc. that BP's would be nice for; you will catch it w/o having to worry about a BP. ( with proper assessment techniques.)   Yesterday I took care of a busted sternum and a dislocated shoulder neither of which needed a BP. A simple pulse check surficed until I got into base. The sternum had every botton, velco strap, metal clip in use to close himself up against the elements that trying to get it all off was a NIGHTMARE. however a simple move of the glove cuff and I was able to assess his ciculation, the wrist is usually well protected from the elements and so skin signs can also be checked there.

So my two cents...BP are not needed on a ski hill they can wait.


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## BossyCow (Jan 14, 2009)

rjz said:


> I agree that a BP is part of a baseline set of vitals (here it goes) BUT....in my experence the majority of things that I see on a ski run a BP is not needed. If I do need to know about their circulation status I can check a radial pulse, check their LOC, look in their eyes, and look at their skin and get a good feel for what their blood is doing. This is just like being able to look at a pt. from across the room and decide if they are sick or not. If they are sick you know they are sick, please don't waste scene time trying to remove clothing to get a BP that won't change your treatment. If they do have splene injury, closed head, etc. that BP's would be nice for; you will catch it w/o having to worry about a BP. ( with proper assessment techniques.)   Yesterday I took care of a busted sternum and a dislocated shoulder neither of which needed a BP. A simple pulse check surficed until I got into base. The sternum had every botton, velco strap, metal clip in use to close himself up against the elements that trying to get it all off was a NIGHTMARE. however a simple move of the glove cuff and I was able to assess his ciculation, the wrist is usually well protected from the elements and so skin signs can also be checked there.
> 
> So my two cents...BP are not needed on a ski hill they can wait.



Not on a ski hill maybe, but in the backcountry yes. Totally depends on your packout time.


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## Summit (Jan 29, 2009)

Since the question is what is the BEST way... not should you...

Four ways:
1. Do they have big pit zips? They do? Life is so easy!
2. Unzip coat front, stuff BP cuff down coat arm (works sometimes).
3. Remove one arm from coat, put on cuff, replace sleeve with pump/guage coming out at the neck.
4. Radial pulse means systolic is prolly above 80... unless they are hypothermic... or my fingers are numb...


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## rjz (Feb 16, 2009)

BHey Summit,

I like it I had never thought of using the pit zips before. Thanks!!B)


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