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  Subjects -> ENVIRONMENTAL STUDIES (Total: 755 journals)
    - ENVIRONMENTAL STUDIES (690 journals)
    - POLLUTION (22 journals)
    - TOXICOLOGY AND ENVIRONMENTAL SAFETY (34 journals)
    - WASTE MANAGEMENT (9 journals)

ENVIRONMENTAL STUDIES (690 journals)            First | 1 2 3 4 5 6 7     

Membranes     Open Access   (4 followers)
Midwest Studies In Philosophy     Hybrid Journal   (11 followers)
Mine Water and the Environment     Hybrid Journal   (6 followers)
Mitigation and Adaptation Strategies for Global Change     Hybrid Journal   (12 followers)
Modern Asian Studies     Hybrid Journal   (4 followers)
Modern Cartography Series     Full-text available via subscription   (6 followers)
Mountain Research and Development     Open Access   (3 followers)
Multequina     Open Access  
Mutation Research/Fundamental and Molecular Mechanisms of Mutagenesis     Hybrid Journal   (2 followers)
Mutation Research/Genetic Toxicology and Environmental Mutagenesis     Hybrid Journal   (7 followers)
Natur und Recht     Hybrid Journal   (5 followers)
Natural Areas Journal     Full-text available via subscription   (7 followers)
Natural Hazards     Hybrid Journal   (99 followers)
Natural Resources     Open Access  
Natural Resources and Environmental Issues     Open Access   (5 followers)
Nature and Culture     Full-text available via subscription   (9 followers)
NeuroToxicology     Hybrid Journal   (1 follower)
Neurotoxicology and Teratology     Hybrid Journal   (2 followers)
NEW SOLUTIONS: A Journal of Environmental and Occupational Health Policy     Full-text available via subscription   (6 followers)
New Zealand Journal of Environmental Law     Full-text available via subscription   (2 followers)
NJAS - Wageningen Journal of Life Sciences     Full-text available via subscription   (1 follower)
Noise Notes     Full-text available via subscription   (3 followers)
Observatorio Medioambiental     Open Access  
Occupational and Environmental Medicine     Full-text available via subscription   (8 followers)
Ocean Acidification     Open Access  
Oecologia     Hybrid Journal   (24 followers)
Oikos     Hybrid Journal   (26 followers)
Open Journal of Ecology     Open Access   (10 followers)
Open Journal of Marine Science     Open Access   (6 followers)
Open Journal of Modern Hydrology     Open Access   (1 follower)
Our Nature     Open Access   (2 followers)
Oxford Journal of Legal Studies     Hybrid Journal   (14 followers)
Pace Environmental Law Review     Open Access   (4 followers)
Packaging, Transport, Storage and Security of Radioactive Material     Hybrid Journal   (2 followers)
Palaeobiodiversity and Palaeoenvironments     Hybrid Journal   (3 followers)
Papers on Global Change IGBP     Open Access   (1 follower)
Particle and Fibre Toxicology     Open Access   (3 followers)
Pastos y Forrajes     Open Access  
Pesquisa em Educação Ambiental     Open Access  
Pharmacology & Therapeutics     Hybrid Journal   (5 followers)
Pharmacology Biochemistry and Behavior     Hybrid Journal   (1 follower)
Philosophical Studies     Hybrid Journal   (6 followers)
Physio-Géo     Open Access   (2 followers)
Pittsburgh Journal of Environmental and Public Health Law     Open Access   (1 follower)
Planet     Open Access  
Planning & Environmental Law: Issues and decisions that impact the built and natural environments     Hybrid Journal   (5 followers)
Plant Ecology & Diversity     Partially Free   (9 followers)
Plant Knowledge Journal     Open Access   (2 followers)
Plant, Cell & Environment     Hybrid Journal   (4 followers)
Polar Journal     Hybrid Journal   (1 follower)
Policy Studies     Hybrid Journal   (6 followers)
Policy Studies Journal     Hybrid Journal   (5 followers)
Polish Polar Research     Open Access   (4 followers)
Political Studies     Hybrid Journal   (21 followers)
Political Studies Review     Hybrid Journal   (14 followers)
Population and Environment     Hybrid Journal   (6 followers)
Population Ecology     Hybrid Journal   (9 followers)
Population Studies: A Journal of Demography     Hybrid Journal   (4 followers)
Postcolonial Studies     Hybrid Journal   (5 followers)
Practice Periodical of Hazardous, Toxic, and Radioactive Waste Management     Full-text available via subscription   (3 followers)
Presence Teleoperators & Virtual Environments     Hybrid Journal   (1 follower)
Presidential Studies Quarterly     Hybrid Journal   (3 followers)
Procedia Environmental Sciences     Open Access   (2 followers)
Proceedings of ICE, Waste and Resource Management     Hybrid Journal   (3 followers)
Proceedings of the Institution of Mechanical Engineers Part M: Journal of Engineering for the Maritime Environment     Hybrid Journal   (1 follower)
Proceedings of the International Academy of Ecology and Environmental Sciences     Open Access   (4 followers)
Process Safety and Environmental Protection     Hybrid Journal   (3 followers)
Progress in Industrial Ecology, An International Journal     Hybrid Journal   (4 followers)
Psychological Assessment     Full-text available via subscription   (5 followers)
Public Money & Management     Hybrid Journal   (4 followers)
Public Works Management & Policy     Hybrid Journal   (5 followers)
Qatar Foundation Annual Research Forum Proceedings     Open Access   (3 followers)
Radioactivity in the Environment     Full-text available via subscription   (4 followers)
Regional Environmental Change     Hybrid Journal   (3 followers)
Regional Studies     Hybrid Journal   (6 followers)
Religious Studies     Hybrid Journal   (9 followers)
RELP - Renewable Energy Law and Policy     Full-text available via subscription   (4 followers)
Remediation Journal     Hybrid Journal   (5 followers)
Remote Sensing Letters     Hybrid Journal   (8 followers)
Renaissance Studies     Hybrid Journal   (11 followers)
Rendiconti Lincei     Hybrid Journal  
Renewable Energy Focus     Full-text available via subscription   (7 followers)
Research and Practice for Persons with Severe Disabilities     Full-text available via subscription   (3 followers)
Research Journal of Environmental Sciences     Open Access   (1 follower)
Research Journal of Environmental Toxicology     Open Access   (2 followers)
ReSource     Full-text available via subscription  
Resources     Open Access  
Resources, Conservation and Recycling     Hybrid Journal   (9 followers)
Reuse/Recycle Newsletter     Hybrid Journal   (2 followers)
Review of English Studies     Hybrid Journal   (7 followers)
Review of Environmental Economics and Policy     Hybrid Journal   (7 followers)
Revista AIDIS de Ingeniería y Ciencias Ambientales. Investigación, desarrollo y práctica     Open Access   (2 followers)
Revista Brasileira de Engenharia Agrícola e Ambiental     Open Access   (1 follower)
Revista Capital Científico     Open Access  
Revista Chapingo. Serie Ciencias Forestales y del Ambiente     Open Access   (2 followers)
Revista de Ciências Ambientais     Open Access  
Revista de Gestão Ambiental e Sustentabilidade - GeAS     Open Access  
Revista de Salud Ambiental     Open Access  
Revista Eletrônica em Gestão, Educação e Tecnologia Ambiental     Open Access   (1 follower)
Revista Hábitat Sustenable     Open Access   (3 followers)

  First | 1 2 3 4 5 6 7     

Wilderness & Environmental Medicine    [5 followers]  Follow    
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
     ISSN (Print) 1080-6032
     Published by Elsevier Homepage  [2556 journals]
  • Wilderness Medical Society Practice Guidelines for the Treatment of Acute
           Pain in Remote Environments
    • Abstract: Publication date: Available online 21 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Katie W. Russell , Courtney L. Scaife , David C. Weber , Jeremy S. Windsor , Albert R. Wheeler , William Smith , Ian Wedmore , Scott E. McIntosh , James R. Lieberman
      The Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians.


      PubDate: 2014-01-24T16:32:16Z
       
  • How To Teach Emergency Procedural Skills in an Outdoor Environment Using
           Low-Fidelity Simulation
    • Abstract: Publication date: Available online 21 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Kathleen D. Saxon , Alison P.R. Kapadia , Nadia S. Juneja , Benjamin S. Bassin
      Teaching emergency procedural skills in a wilderness setting can be logistically challenging. To teach these skills as part of a wilderness medicine elective for medical students, we designed an outdoor simulation session with low-fidelity models. The session involved 6 stations in which procedural skills were taught using homemade low-fidelity simulators. At each station, the students encountered a “victim,” who required an emergency procedure that was performed using the low-fidelity model. The models are easy and inexpensive to construct, and their design and implementation in the session is described here. Using low-fidelity simulation models in an outdoor setting is an effective teaching tool for emergency wilderness medicine procedures and can easily be reproduced in future wilderness medicine courses.


      PubDate: 2014-01-24T16:32:16Z
       
  • Migraine Headache Confounding the Diagnosis of Acute Mountain Sickness
    • Abstract: Publication date: Available online 24 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Francis J. Karle III , Paul S. Auerbach
      A 36-year-old man with a history of migraine headache attempted to hike from Lukla, Nepal, to Mount Everest Base Camp. On the sixth day of hiking, he had a migraine headache. After achieving resolution with typical therapies and rest, he ascended higher. Another headache developed that was interpreted to be a migraine. The headache was treated, and he ascended higher, after which severe symptoms of acute mountain sickness developed, necessitating his evacuation by helicopter. Persons with headaches in daily life may present challenges to diagnosis when traveling to high altitude. Careful evaluation and decision making are needed to achieve proper diagnosis and treatment of acute mountain sickness.


      PubDate: 2014-01-24T16:32:16Z
       
  • Erratum
    • Abstract: Publication date: Available online 23 January 2014
      Source:Wilderness & Environmental Medicine




      PubDate: 2014-01-24T16:32:16Z
       
  • Use of the Visual Range of Detection to Estimate Effective Sweep Width for
           
    • Abstract: Publication date: Available online 22 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Robert J. Koester , Kenneth B. Chiacchia , Charles R. Twardy , Donald C. Cooper , John R. Frost , R. Quincy Robe
      Objective Standard-of-practice search management requires that the probability of detection (POD) be determined for each search resource after a task. To calculate the POD, a detection index (W) is obtained by field experiments. Because of the complexities of the land environment, search planners need a way to estimate the value of W without conducting formal experiments. We demonstrate a robust empirical correlation between detection range (Rd) and W, and argue that Rd may reliably be used as a quick field estimate for W. Methods We obtained the average maximum detection range (AMDR), Rd, and W values from 10 detection experiments conducted throughout North America. We measured the correlation between Rd and W, and tested whether the apparent relationship between W and Rd was statistically significant. Results On average we found W ≈ 1.645 × Rd with a strong correlation (R 2 = .827). The high-visibility class had W ≈ 1.773 × Rd (also R 2 = .867), the medium-visibility class had W ≈ 1.556 × Rd (R 2 = .560), and the low-visibility had a correction factor of 1.135 (R 2 = .319) for Rd to W. Using analysis of variance and post hoc testing, only the high- and low-visibility classes were significantly different from each other (P < .01). We also found a high correlation between the AMDR and Rd (R 2 = .9974). Conclusions Although additional experiments are required for the medium- and low-visibility search objects and in the dry-domain ecoregion, we suggest search planners use the following correction factors to convert field-measured Rd to an estimate of the effective sweep width (W): high-visibility W = 1.8 × Rd; medium-visibility W = 1.6 × Rd; and low-visibility W = 1.1 × Rd.


      PubDate: 2014-01-24T16:32:16Z
       
  • Remember Empathy
    • Abstract: Publication date: Available online 17 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Scott E. McIntosh , Tracy Cushing , Linda E. Keyes



      PubDate: 2014-01-20T17:02:57Z
       
  • Appalachian Trail Hikers’ Ability to Recognize Lyme Disease by
           Visual Stimulus Photographs
    • Abstract: Publication date: Available online 13 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Judith M. Knoll , Andrea C. Ridgeway , Christine M. Boogaerts , Glenn A. Burket III
      Background Lyme disease is the most common vector-borne infectious disease in North America. With nearly 2,500 Appalachian Trail (AT) hikers entering the endemic area for as long as 6 months, exposure to the disease is likely. The characteristic exanthem of erythema migrans (EM) should be a trigger for seeking medical treatment, and its recognition in this relatively isolated environment is important. Objective The purpose of this study was to determine the ability of AT hikers to identify EM, the exanthem of Lyme disease. Methods Hikers were administered a photographic stimulus in this Internal Review Board–approved pilot study. Historical hiking data, basic demographics, and self-reported treatment and diagnosis were collected. Results In all, 379 responses were collected by 4 researchers at 3 geographically separate locations at or proximate to the AT from June 2011 to May 2012. Fifty-four percent of respondents (206 of 379) were able to recognize the photographs of EM/Lyme disease; 46% could not. Of those who did recognize EM, 23 (6%) had seen it either on themselves or on another hiker while on the AT. A total of 37 hikers stated that they had been diagnosed with Lyme disease while hiking, and of these, 89% were treated with antibiotics. Thirteen of these 37 hikers (35%) diagnosed with Lyme disease had visualized an embedded tick. Nine percent of all respondents reported they had been diagnosed with Lyme disease by a healthcare practitioner, whether from EM, symptomatology, or by titer. Conclusions This study suggests that hikers are poorly able to recognize the characteristic exanthem of Lyme disease but have a high exposure risk.


      PubDate: 2014-01-16T15:06:14Z
       
  • National Estimates of Noncanine Bite and Sting injuries Treated in US
           Hospital Emergency Departments, 2001–2010
    • Abstract: Publication date: Available online 13 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Ricky Langley , Karin Mack , Tadesse Haileyesus , Scott Proescholdbell , Joseph L. Annest
      Objective Injuries resulting from contact with animals and insects are a significant public health concern. This study quantifies nonfatal bite and sting injuries by noncanine sources using data from the National Electronic Injury Surveillance System–All Injury Program (NEISS-AIP). Methods The NEISS-AIP is an ongoing nationally representative surveillance system used to monitor all types and causes of injuries treated in US hospital emergency departments (EDs). Cases were coded by trained hospital coders using information from medical records on animal and insect sources of bite and sting injuries being treated. Data were weighted to produce national annualized estimates, percentages, and rates based on the US population. Results From 2001 to 2010 an estimated 10.1 million people visited EDs for noncanine bite and sting injuries, based on an unweighted case count of 169,010. This translates to a rate of 340.1 per 100,000 people (95% CI, 232.9–447.3). Insects accounted for 67.5% (95% CI, 45.8–89.2) of bite and sting injuries, followed by arachnids 20.8% (95% CI, 13.8–27.9). The estimated number of ED visits for bedbug bite injuries increased more than 7-fold—from 2156 visits in 2007 to 15,945 visits in 2010. Conclusions This study provides an update of national estimates of noncanine bite and sting injuries and describes the diversity of animal exposures based on a national sample of EDs. Treatment of nonfatal bite and sting injuries are costly to society. Direct medical and work time lost translates to an estimated $7.5 billion annually.


      PubDate: 2014-01-16T15:06:14Z
       
  • Impact of a Student-Organized Conference on Wilderness Medicine Education
    • Abstract: Publication date: Available online 8 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Stephanie A. Lareau , Patrick E. Robinson , Sean S. Wentworth , Henderson D. McGinnis



      PubDate: 2014-01-12T16:31:01Z
       
  • Hornet Stings Presenting to a Primary Care Hospital in Anuradhapura
           District, Sri Lanka
    • Abstract: Publication date: Available online 8 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Buddhika T.B. Wijerathne , Geetha K. Rathnayake , Suneth B. Agampodi



      PubDate: 2014-01-12T16:31:01Z
       
  • Symptomatic Hypotonic Hyponatremia Presenting at High Altitude
    • Abstract: Publication date: Available online 8 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Susanne J. Spano , Zacharia Reagle , Timothy Evans
      We present a case of altered mental status and seizure that occurred at an altitude known to cause high altitude-related illnesses. Based on the presenting symptoms, the patient was initially transferred to the hospital with a presumptive diagnosis of high altitude cerebral edema. On review of imaging and laboratory data, she was found to be experiencing symptomatic hypotonic hyponatremia. This case presented an interesting diagnostic challenge and underscores the importance of maintaining a broad differential diagnosis when evaluating a patient with altered mental status from an alpine setting.


      PubDate: 2014-01-12T16:31:01Z
       
  • Comparison of Heat Donation Through the Head or Torso on Mild Hypothermia
           Rewarming
    • Abstract: Publication date: Available online 9 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Bhupinder Jit K. Sran , Gerren K. McDonald , Alan M. Steinman , Phillip F. Gardiner , Gordon G. Giesbrecht
      Objective The purpose of the study was to compare the effectiveness of head vs torso warming in rewarming mildly hypothermic, vigorously shivering subjects using a similar source of heat donation. Methods Six subjects (1 female) were cooled on 3 occasions in 8ºC water for 60 minutes or to a core temperature of 35ºC. They were then dried, insulated, and rewarmed by 1) shivering only; 2) charcoal heater applied to the head; or 3) charcoal heater applied to the torso. The order of rewarming methods followed a balanced design. Esophageal temperature, skin temperature, heart rate, oxygen consumption, and heat flux were measured. Results There were no significant differences in rewarming rate among the 3 conditions. Torso warming increased skin temperature and inhibited shivering heat production, thus providing similar net heat gain (268 ± 66 W) as did shivering only (355 ± 105 W). Head warming did not inhibit average shivering heat production (290 ± 72 W); it thus provided a greater net heat gain during 35 to 60 minutes of rewarming than did shivering only. Conclusions Head warming is as effective as torso warming for rewarming mildly hypothermic victims. Head warming may be the preferred method of rewarming in the field management of hypothermic patients if: 1) extreme conditions in which removal of the insulation and exposure of the torso to the cold is contraindicated; 2) excessive movement is contraindicated (eg, potential spinal injury or severe hypothermia that has a risk of ventricular fibrillation); or 3) if emergency personnel are working on the torso.


      PubDate: 2014-01-12T16:31:01Z
       
  • The Use of Ivermectin to Kill Ixodes Scapularis Ticks Feeding on Humans
    • Abstract: Publication date: Available online 9 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Johnathan M. Sheele , Lucie R. Ford , Adele Tse , Benjamin Chidester , Peter A. Byers , Daniel E. Sonenshine
      Objective The purpose of this study was to determine whether 400 µg/kg oral ivermectin is able to kill Ixodes scapularis nymphs and adult female ticks feeding on humans. Methods Ten study subjects each wore 2 ostomy bags, the one containing 24 I scapularis nymphs, and the other containing 24 I scapularis adult females. Twenty-four hours after the ostomy bags were attached, study subjects received either 400 µg/kg ivermectin or placebo. Thirty hours after the ivermectin or placebo was consumed, the ticks were removed, and mortality determined in a double-blinded manner. Results Eleven percent of the I scapularis nymphs attached in the ivermectin group compared with 17% in the placebo. Mortality for the I scapularis nymphs that attached at the time of removal was 55% in the ivermectin group and 47% in the placebo group. Mortality for the I scapularis nymphs 5 days after removal was 92% in the ivermectin group and 88% for the placebo. Three percent of the I scapularis adults attached in the ivermectin group compared with 9% in the placebo group. Mortality for I scapularis adults was 0% on day 3 and 33% on day 8 for both the ivermectin and placebo groups. There were statistically insignificant differences in the mortality rates between I scapularis nymphs and adults exposed to ivermectin or placebo. Conclusions There were a high number of ticks that died in both groups but the data do not support our hypothesis that ivermectin can kill I scapularis. The study was not designed to determine whether it could prevent the transmission of tick-borne illness.


      PubDate: 2014-01-12T16:31:01Z
       
  • Priapism after western black widow spider (Latrodectus hesperus)
           envenomation
    • Abstract: Publication date: Available online 9 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Sean Bush , Rohn McCune , Tammy Phan
      Priapism in children after a black widow spider bite is a rare phenomenon with only a few case reports noted in the literature. Black widow bites are commonly associated with pain, muscle cramping, hypertension, and tachycardia. Initial treatment includes pain control with opiate or opioid medications and benzodiazepines, with antivenom reserved for severe cases of envenomation manifested by uncontrolled pain or hypertension. Treatment with antivenom for priapism is not well described; however, it has been noted to resolve priapism in the few cases that have been reported. We present a case of a 3-year-old boy who was bitten by a black widow and presented with abdominal cramping and priapism.


      PubDate: 2014-01-12T16:31:01Z
       
  • A Dangerous Cup of Tea
    • Abstract: Publication date: Available online 9 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Caleb P. Canders , Steve R. Stanford , Alan T. Chiem



      PubDate: 2014-01-12T16:31:01Z
       
  • Catfish Noodling Forearm Injury Requiring Urgent Surgical Treatment: A
           Case Report and Review of the Literature
    • Abstract: Publication date: Available online 9 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Courtney R.J. Kaar , Christina Plikaitis , Kevin W. Germino , Albert K. Nakanishi
      “Noodling” is an ancient form of hand fishing recently gaining in popularity as a hobby and sport. We present one of the first case reports of a noodling injury in an adolescent male seeking to land a large catfish, and also review the literature on catfish-related injuries.


      PubDate: 2014-01-12T16:31:01Z
       
  • Victims’ Response to Snakebite and Socio-epidemiological Factors of
           1018 Snakebites in a Tertiary Care Hospital in Sri Lanka
    • Abstract: Publication date: Available online 9 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Abeysinghe M. Kularatne , Anjana Silva , Kalana Maduwage , Ishani Ratnayake , Chmara Walathara , Chanka Ratnayake , Suresh Mendis , Ranjith Parangama
      Background Although snake bite remains a major health problem in Sri Lanka, there is a dearth of baseline information that would be useful in education about and prevention of snakebite. Objectives The purpose of this study was to describe the socio-demographic characteristics, behavioral responses, treatment seeking, and prehospital interventions of snakebite victims in an area with high snakebite burden. Methods This prospective study was based on a cohort of snakebite victims presented to the Anuradhapura Teaching Hospital over a 1-year period from January 2010. Results Of the total of 1018 snakebite admissions, 69% were male and 65.8% were aged 21 to 50 years. Most of the victims were farmers (40%). The offending snakes were seen by 549 victims (54%); of these, only 46% (255) presented with a dead snake specimen. Only 38 of 1018 (4%) had first sought some form of indigenous treatment such as locally applied medications, herbal decoctions, nasal insufflations (“Nasna”), or applying snake stone over the bitten site. Some form of first aid had been adopted by 681 victims (67%), of whom all had washed the bitten site, and 18 victims (2%) and 4 (0.4%) had applied a dressing or incised the bitten site, respectively. A tourniquet had been applied by 353 victims (35%) for mean duration of 26 minutes (range, 5 to 120 minutes). None of the patients had immobilized the bitten limb by splinting. Oral medications had been used for pain relief in 74 cases (7%), paracetamol by all. Conclusions A proportion of patients still seek native remedies and use inappropriate first aid after snakebite in Sri Lanka.


      PubDate: 2014-01-12T16:31:01Z
       
  • They Had Me in Stitches: A Grand Canyon River Guide’s Case Report
           and a Review of Wilderness Wound Management Literature
    • Abstract: Publication date: Available online 11 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Susanne J. Spano , Brad Dimock
      We present a case of failed conservative management of a traumatic wound sustained in a wilderness setting. The patient was initially treated with a povidone-iodine scrub, suture closure, and expectant management by 2 physicians who were paying clients on a multiday river rafting expedition. Empiric antibiotic coverage and irrigation of the dehisced wound were initiated several days after initial treatment. The patient arranged his own evacuation 8 days after injury. Hospitalization, intravenous (IV) antibiotics, and surgical debridement with wound vacuum placement led to a full recovery. This case presents several common wound care pitfalls. The sequelae to these pitfalls are more dramatic in a wilderness setting and underscore the importance of early aggressive management and considering prompt evacuation when treating wounds sustained in the wilderness.


      PubDate: 2014-01-12T16:31:01Z
       
  • Wound Care in the Wilderness: Is There Evidence for Honey?
    • Abstract: Publication date: Available online 3 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): James Austin Stewart , Owen Lane McGrane , Ian S. Wedmore
      Honey is one of the most ancient remedies for wound care. Current research has shown promising results for its use in wound care. This review is intended to inform readers of the physiological properties of honey and the evidence that exists to support its clinical use. When compared with evidence for current wound treatment, honey has proven to be a safe, effective, and sometimes superior treatment for various wounds. There are currently US Food and Drug Administration–approved medical-grade honey products available in the United States. Although there have been no clinical trials exploring the use of honey in wilderness environments, it may be a safe, improvisational wound treatment. More robust studies are needed for definitive conclusions of its efficacy and safety.


      PubDate: 2014-01-07T17:33:41Z
       
  • Wilderness and Adventure Travel With Underlying Asthma
    • Abstract: Publication date: Available online 3 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Daniel Doan , Andrew M. Luks
      Given the high prevalence of asthma, it is likely that providers working in a pretravel setting will be asked to provide guidance for asthma patients about how to manage their disease before and during wilderness or adventure travel, while providers working in the field setting may need to address asthma-related issues that arise during such excursions. This review aims to provide information to assist providers facing these issues. Relevant literature was identified through the MEDLINE database using a key word search of the English-language literature from 1980 to 2013 using the term “asthma” cross-referenced with “adventure travel,” “trekking,” “exercise,” “exercise-induced bronchoconstriction,” “high-altitude,” “scuba,” and “diving.” We review data on the frequency of worsening asthma control during wilderness or adventure travel and discuss the unique aspects of wilderness travel that may affect asthma patients in the field. We then provide a general approach to evaluation and management of asthma before and during a planned sojourn and address 2 particular situations, activities at high altitude and scuba diving, which pose unique risks to asthma patients and warrant additional attention. Although wilderness and adventure travel should be avoided in individuals with poorly controlled disease or worsening control at the time of a planned trip, individuals with well-controlled asthma who undergo appropriate pretravel assessment and planning can safely engage in a wide range of wilderness and adventure-related activities.


      PubDate: 2014-01-07T17:33:41Z
       
  • Marooned
    • Abstract: Publication date: Available online 3 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Tom Edward Mallinson



      PubDate: 2014-01-07T17:33:41Z
       
  • Novel Approach to the Diagnosis of Fractures in an Austere Environment
           Using a Stethoscope and a Cellular Phone
    • Abstract: Publication date: Available online 3 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Brett A. Matzek , Phillip T. Fivecoat , Reis B. Ritz
      Background Fracture diagnosis in the austere environment where radiographic tests are not available can be a challenge. In the past, a diagnostic technique has been described using a tuning fork and stethoscope to assess decreased sound conduction in the fractured extremity. In this study, we evaluate the use of a cellular phone’s vibrate function and a stethoscope to limit equipment carried by expeditionary practitioners. Objective The purpose of this study was to evaluate the accuracy of fracture diagnosis using a cellular phone and stethoscope. Methods This is a pilot study to assess the usefulness of the above technique before clinical implementation. In 3 cadavers, we created fractures of the humerus and femur. Twenty-seven emergency medicine residents and an attending physician performed the diagnostic technique. Results Overall, the use of the cellular phone and stethoscope resulted in a sensitivity of 73% (95% confidence interval [CI]: 0.64 to 0.81) and a specificity of 83% (95% CI: 0.77 to 0.88), with a positive predicted value of 68% (95% CI: 0.59 to 0.77) and a negative predicted value of 86% (95% CI: 0.81 to 0.90). Positive likelihood ratio was 4.3, and negative likelihood ratio was 0.32. Conclusions The use of a cellular phone and stethoscope may be a useful tool for the diagnosis of fractures in the austere environment. However, further study is needed to validate these findings in the clinical environment.


      PubDate: 2014-01-07T17:33:41Z
       
  • Out of Body Experiences
    • Abstract: Publication date: Available online 3 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Harvey V. Lankford



      PubDate: 2014-01-07T17:33:41Z
       
  • Traumatic Injury Patterns Associated With Static Line Parachuting
    • Abstract: Publication date: Available online 2 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Vincent L. Ball , Jared A. Sutton , Aicha Hull , Bridget A. Sinnott
      Objective We investigated the incidence and injury patterns of acute parachuting injuries evaluated at a level II military facility during a 5-year period to compile medical information that may assist in improving the safety of parachuting. Methods A retrospective chart review of all parachuting injuries that presented to the Madigan Army Medical Center emergency department in Tacoma, Washington, during a 5-year period from February 2005 to June 2011. Results A total 110 patient charts met inclusion criteria. Lower extremity injuries made up 65% of total injuries, followed by 22% head injuries, 22% neck or back injuries, and 19% upper extremity injuries. One patient died in the emergency department of head injuries, and 1 patient was transferred for an open-book pelvic fracture. The most common phase of the jump in which to sustain injury was at landing. A total of 15 patients were admitted to the hospital. It is of note that some patients had combined injuries. The mechanism of injury documented in 96 of 110 (87%) patients and 10 of 15 (66%) admitted patients was a difficult landing. Conclusions The rate of injury for each area of the body is within previously reported rates, with lower extremity injuries making up the largest category and leading to the majority of admissions. The most common time to sustain an injury was during landing, which represented a majority of both emergency room visits and hospitalizations.


      PubDate: 2014-01-03T17:20:07Z
       
  • Hydration in Female Drivers in a 1044 km Dog Sled Race in Finnmark
    • Abstract: Publication date: Available online 2 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Andi Weydahl , Giovanna Calogiuri
      Objective Drinking strategies during long dog sled competitions are important to avoid dehydration. Most of the studies involving dog sled racers (mushers) refer to male subjects. The purpose of this study was to study female mushers participating in a dog sled race of 1044 km, with a focus on hydration and drinking behavior. Methods Two female mushers (aged 50 and 23 years), of the 6 who signed up for participation in the dog sled 1044 km race, volunteered for the study. Before the race, maximum oxygen uptake and maximum heart rate (HR) were determined. Body compositions was measured before and shortly after the race. Heart rate was continuously measured by a HR monitor in the first 2 legs of the race, and urine samples were collected during the race. Urine osmolality and urine specific gravity were determined using freezing point depression and handheld refractometer. Values of urine osmolality greater than 900 mOsm·L−1 and specific gravity greater than 1.030 were used as signs of dehydration. Results The older musher had a mean HR of 65%, and the younger musher had a mean HR of 57% of the predicted maximum HR. The mushers reached a peak HR of 91% of their predicted maximum; they worked at an average HR of 55% (average of all legs). The younger woman had urine osmolality values above the dehydration limits in most of the samples. Only small changes in the before and after race anthropometric measurements were found. Conclusions Dog sled racing is a strenuous activity and drinking strategies are important to avoid dehydration. It seems that the drinking strategy of our subjects was adequate to supplement the hydration loss; yet, emotional arousals occurring during the race may affect drinking behavior. The attentive assistance of the mushers’ handlers is therefore important.


      PubDate: 2014-01-03T17:20:07Z
       
  • Comparing Student Outcomes of Hybrid and Conventional Wilderness Emergency
           Medical Technician Programs
    • Abstract: Publication date: Available online 2 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Joshua D. Martin



      PubDate: 2014-01-03T17:20:07Z
       
  • The tropical frangipani caterpillar, Pseudosphinx tetrio, can grow up to 6
           inches in length
    • Abstract: Publication date: Available online 2 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Sara Squyres



      PubDate: 2014-01-03T17:20:07Z
       
  • Where Wilderness, Medicine, Technology, and Religion Collide
    • Abstract: Publication date: Available online 2 January 2014
      Source:Wilderness & Environmental Medicine
      Author(s): Lori Weichenthal , Sameir Alhadi
      We report a case of a man injured in Yosemite National Park (YNP) whose use of technology and refusal of medical care, based on his Christian Science religious beliefs, created multiple challenges to the providers working to rescue and care for him. This case illustrates how our increasingly diverse and complex world requires flexibility and openness to provide the optimal care, both in the wilderness and in the front country.


      PubDate: 2014-01-03T17:20:07Z
       
  • Causes of Accidents in Terrain Parks: An Exploratory Factor Analysis of
           Recreational Freestylers’ Views
    • Abstract: Publication date: Available online 2 December 2013
      Source:Wilderness & Environmental Medicine
      Author(s): Luis Carús
      Objective This study examines ski and snowboard terrain park users’ views on aspects associated with accidents by identifying and assessing variables that may influence the occurrence of accidents and the resulting injuries. Methods The research was conducted in a major resort in the Spanish Pyrenees, using information gathered from freestyle skiers and snowboarders aged 6 or older. To identify interrelationships among variables and to group the variables belonging to unified concepts, an exploratory factor analysis was performed using varimax rotation. Results The results revealed 5 factors that grouped the measured variables that may influence the occurrence of accidents while freestyling in terrain parks. The park features, conditions of the activity, and the user’s personal conditions were found to have the most substantial influence on the freestylers’ perceptions. Conclusions Variables identified as components of the main factors of accident risk in terrain parks should be incorporated into resort management communication and policies.


      PubDate: 2013-12-02T05:49:35Z
       
  • Fatalities in Wingsuit BASE Jumping
    • Abstract: Publication date: December 2013
      Source:Wilderness & Environmental Medicine, Volume 24, Issue 4
      Author(s): Omer Mei-Dan , Erik Monasterio , Michael Carmont , Anton Westman
      Objective To analyze fatality data associated with wingsuit use in an international case series of fixed-object sport parachuting (BASE jumping) to identify incident and injury mechanisms and to form a basis for potential prevention measures and future safety recommendations. Methods A descriptive epidemiological study was performed of fatal injury events occurring in wingsuit BASE jumping. Fatalities (n = 180) were sequentially analyzed assessing human, equipment, and environmental factors from 1981 to 2011. Main outcome measures included descriptions of typical fatal incident and injury mechanisms. Results Of the 180 fatal events, 39 (22%) were related to use of wingsuits; 38 (97%) launched from cliffs and 1 (3%) from a building. Of the 39 fatalities, 19 (49%) were caused from cliff strikes, 18 (46%) from ground impact, and 1 (3%) from a building strike. Thirty-eight (97%) of the fatalities were male. During 2002 to 2007 there was a total of 61 BASE jumping deaths, 10 (16%) of which were related to the use of wingsuits, whereas during 2008 to 2011 there was a total 59 fatal events, of which 29 (49%) were related to the use of wingsuits. Seventeen fatalities (39%) were attributed to wingsuit path miscalculation. In the first 8 months of 2013, 17 of 19 (90%) fatalities were wingsuit related. Most fatalities occurred between April and October, reflecting a seasonal increase in activity in the northern hemisphere summer. Conclusions Wingsuit-related BASE jump fatalities appear to be increasing as wingsuit BASE jumping increases in popularity. Most fatalities are attributed to cliff or ground impact, and are mostly the result of flying path miscalculation.


      PubDate: 2013-11-16T11:09:47Z
       
  • Injuries in Commercial Whitewater Rafting on the New and Gauley Rivers of
           West Virginia
    • Abstract: Publication date: December 2013
      Source:Wilderness & Environmental Medicine, Volume 24, Issue 4
      Author(s): Aram Attarian , Christos Siderelis
      Objective To describe the rates, patterns, and likelihood of injuries in commercial whitewater rafting on the New and Gauley rivers, West Virginia. Methods Standardized injury report forms developed by the West Virginia Whitewater Commission were reviewed for years 2005–2010 to provide a statistical account of injuries reported by licensed commercial rafting outfitters operating on the New and Gauley rivers. Results Overall, musculoskeletal injuries (sprains/strains, 21.1%; dislocations, 13.8%; fractures, 12.2%) comprised the majority (47.4%) of incidents followed by injuries to soft tissue (lacerations, 29.0%; abrasions, 13.3%; contusions, 2.3%). Almost one half (44.3%) of injuries were to the head, neck, and shoulders followed by the lower extremities (foot/ankle/leg/knee/hip, 33.9%) and upper extremities (hand/wrist/arm, 14.3%). Data analyzed using the Somers’ D statistic revealed the likelihood of an injury occurring inside the raft is P = .55, and P = .39 when passengers are ejected from the raft into the river. The most likely injuries to occur to passengers are a laceration (P = .51) or a sprain (P = .20). The main probabilities for the risks of injuries were found to be to the head (P = .24), shoulder (P = .16), and face (P = .13) of the passenger. Conclusions By knowing what injuries are common, their likelihood of occurrence, and the settings in which they happen, commercial outfitters can initiate practices to reduce injury rates.


      PubDate: 2013-11-16T11:09:47Z
       
  • Clinical Effects and Antivenom Use for Snake Bite Victims Treated at Three
           US Hospitals in Afghanistan
    • Abstract: Publication date: December 2013
      Source:Wilderness & Environmental Medicine, Volume 24, Issue 4
      Author(s): Jason D. Heiner , Vikhyat S. Bebarta , Shawn M. Varney , Jason D. Bothwell , Aaron J. Cronin
      Objective Annually, more than 100,000 US and international military and civilian personnel work in Afghanistan within terrain harboring venomous snakes. Current literature insufficiently supports Afghan antivenom treatment and stocking guidelines. We report the clinical course and treatments for snakebite victims presenting to US military hospitals in Afghanistan. Methods All snakebite victims presenting to 3 US military emergency departments between July 2010 and August 2011 in northern and southern Afghanistan were examined via chart review. Case information included patient demographics, snake description, bite details and complications, laboratory results, antivenom use and adverse effects, procedures performed, and hospital course. Results Of 17 cases, median patient age was 20 years (interquartile range [IQR], 12–30), 16 were male, and 82% were Afghans. All bites were to an extremity, and median time to care was 2.8 hours (IQR, 2–5.8). On arrival, 8 had tachycardia and none had hypotension or hypoxia. A viper was implicated in 5 cases. Ten cases received at least 1 dose of polyvalent antivenom, most commonly for coagulopathy, without adverse effects. Six received additional antivenom, 6 had an international normalized ratio (INR) > 10, and none developed delayed coagulopathy. Three received blood transfusions. Hospital stay ranged from 1 to 4 days. None required vasopressors, fasciotomy, or other surgery, and none died. All had resolution of marked coagulopathies and improved swelling and pain on discharge. Conclusions We report the largest series of snake envenomations treated by US physicians in Afghanistan. Antivenom was tolerated well with improvement of coagulopathy and symptoms. All patients survived with minimal advanced interventions other than blood transfusion.


      PubDate: 2013-11-16T11:09:47Z
       
  • Employee Perception of a Mandated Helmet Policy at Vail Resorts
    • Abstract: Publication date: December 2013
      Source:Wilderness & Environmental Medicine, Volume 24, Issue 4
      Author(s): Christopher B. Davis , Mark R. Brownson , Brent J. Levy , Morgan A. Valley , Bruce Evans , Steven R. Lowenstein
      Objective The purpose of this study was to measure support for a mandated helmet policy among resort employees along with the impact of such a policy on job satisfaction, and additionally, to measure the prevalence of barriers to helmet use among this population. Methods In all, 728 Vail Resort employees were surveyed regarding their opinions on the helmet policy and on general helmet use. Results The majority of the 728 employees surveyed (66.5%; 95% CI: 63% to 70%) agreed with the helmet policy. Only 18% (95% CI: 16% to 21%) reported a negative effect on job satisfaction. Older employees (>25 years old) were more likely to disagree with the policy (odds ratio [OR] 3.1; 95% CI: 2.2 to 4.3) and report a negative effect on job satisfaction (OR 4.8; 95% CI: 3.0 to 7.6). Skiers were much more likely than snowboarders to report a negative effect on job satisfaction (OR 9.8; 95% CI: 5.2 to 18.1). Among resort employees, ski patrollers were more likely to disagree with the mandate (OR 9.8; 95% CI: 6.8 to 13.9) and report a negative effect on job satisfaction (OR 13.2; 95% CI: 8.3 to 21.). Forty-three percent of participants (95% CI: 39% to 46%) agreed with the statement that wearing a helmet encourages reckless behavior whereas 51.0% (95% CI: 47% to 54%) believed that wearing a helmet limits sensory perception. Conclusions A mandatory helmet use policy was supported by most resort employees. However, ski patrollers and older, more experienced employees were more likely to report a negative effect on job satisfaction. Barriers to helmet use continue to persist in the ski industry and represent a target for further educational efforts.


      PubDate: 2013-11-16T11:09:47Z
       
  • Heat Stroke Risk for Open-Water Swimmers During Long-Distance Events
    • Abstract: Publication date: December 2013
      Source:Wilderness & Environmental Medicine, Volume 24, Issue 4
      Author(s): Filippo Macaluso , Rosario Barone , Ashwin W. Isaacs , Felicia Farina , Giuseppe Morici , Valentina Di Felice
      Open-water swimming is a rapidly growing sport discipline worldwide, and clinical problems associated with long-distance swimming are now better recognized and managed more effectively. The most prevalent medical risk associated with an open-water swimming event is hypothermia; therefore, the Federation Internationale De Natation (FINA) has instituted 2 rules to reduce this occurrence related to the minimum water temperature and the time taken to complete the race. Another medical risk that is relevant to open-water swimmers is heat stroke, a condition that can easily go unnoticed. The purpose of this review is to shed light on this physiological phenomenon by examining the physiological response of swimmers during long-distance events, to define a maximum water temperature limit for competitions. We conclude that competing in water temperatures exceeding 33°C should be avoided.


      PubDate: 2013-11-16T11:09:47Z
       
  • Medical Planning for Extended Remote Expeditions
    • Abstract: Publication date: December 2013
      Source:Wilderness & Environmental Medicine, Volume 24, Issue 4
      Author(s): Kenneth V. Iserson
      Remote extended expeditions often support scientific research and commercial resource exploration or extraction in hostile environments. Medical support for these expeditions is inherently complex and requires in-depth planning. To be successful, this planning must include substantial input from clinicians with experience in remote, emergency, and prehospital medicine and from personnel familiar with the proposed working environment. Using the guidelines discussed in this paper will help ensure that planners consider all necessary, medically relevant elements before launching an extended remote expedition. The 10 key elements of a workable remote healthcare system are to: 1. Optimize workers’ fitness 2. Anticipate treatable problems 3. Stock appropriate medications 4. Provide appropriate equipment 5. Provide adequate logistical support 6. Provide adequate medical communications 7. Know the environmental limitations on patient access and evacuation 8. Use qualified providers 9. Arrange for knowledgeable and timely consultations 10. Establish and distribute rational administrative rules Planners using these guidelines may better be able to generate a strategy that optimizes the participants’ health benefits, the expedition’s productivity, and the expedition sponsor’s cost savings.


      PubDate: 2013-11-16T11:09:47Z
       
  • Effect of Caffeine Intake on Finger Cold-Induced Vasodilation
    • Abstract: Publication date: December 2013
      Source:Wilderness & Environmental Medicine, Volume 24, Issue 4
      Author(s): Byeong Jo Kim , Yongsuk Seo , Jung-Hyun Kim , Dae Taek Lee
      Objective The purpose of the study was to investigate the effect of caffeine intake on finger cold-induced vasodilation (CIVD). Methods Ten healthy men underwent 6 experimental trials characterized by control (NCAFF) or caffeine intake (CAFF) via chewing gum (300 mg of caffeine) while resting on a chair or performing submaximal (70% maximal oxygen consumption) or maximal (100% maximal oxygen consumption) treadmill exercise (Bruce protocol) followed by immersion of the middle finger in a water bath (5°C) for 20 minutes. Finger temperature (Tf ) and time parameters of the first CIVD cycle and post-test norepinephrine were measured. Results Exercise duration for submaximal and maximal exercise was 8.9 ± 0.9 and 12.4 ± 0.8 minutes, respectively. CAFF had no effect on Tf, but exercise increased minimal Tf in NCAFF (9.08 ± 1.27°C, 13.02 ± 2.13°C, and 13.25 ± 1.63°C in rest, submaximal, and maximal exercise, respectively) and CAFF (8.76 ± 1.39°C, 12.50 ± 1.91°C, and 12.79 ± 1.20°C). Maximal Tf was significantly higher in NCAFF (15.98 ± 1.04°C, 16.18 ± 1.56°C, and 15.14 ± 1.52°C) than in CAFF (13.56 ± 1.19°C, 15.52 ± 1.31°C, and 14.39 ± 1.43°C), resulting in a significant difference between minimal and maximal Tf in rest (NCAFF, 6.89 ± 1.56°C and CAFF, 4.79 ± 1.23°C), but not in exercise conditions. CAFF had no effect on CIVD time responses, but exercise significantly shortened CIVD onset and peak time compared with rest in both NCAFF and CAFF. Norepinephrine concentration was significantly greater in CAFF (290.6 ± 113.0 pg/mL, 278.1 ± 91.4 pg/mL, and 399.8 ± 125.5 pg/mL) than NCAFF (105.6 ± 29.5 pg/mL, 199.6 ± 89.6 pg/mL, and 361.5 ± 171.3 pg/mL). Conclusions Caffeine intake before finger immersion in cold water does not result in a thermogenic effect and adversely affects CIVD responses, whereas exercise modifies CIVD temperature and time responses.


      PubDate: 2013-11-16T11:09:47Z
       
  • WMS Practice Guidelines Development: Commentary from the Co-Chairs of the
           WMS Practice Guidelines Committee
    • Abstract: Publication date: Available online 15 October 2013
      Source:Wilderness & Environmental Medicine
      Author(s): Tracy Cushing , Robert Quinn



      PubDate: 2013-10-19T14:01:12Z
       
  • Injury Patterns in Recreational Alpine Skiing and Snowboarding at a
           Mountainside Clinic
    • Abstract: Publication date: Available online 15 October 2013
      Source:Wilderness & Environmental Medicine
      Author(s): Tim Coury , Anthony M. Napoli , Matthew Wilson , Jeff Daniels , Ryan Murray , Dave Milzman
      Objective The purpose of this study was to examine the demographic and injury characteristics of skiing and snowboarding at a mountainside clinic. Methods Prospectively collected data of all acutely injured patients at the Big Sky Medical Clinic at the base of Big Sky Ski Area in the Northern Rocky Mountains were reviewed. A total of 1593 patients filled out the study questionnaire during the 1995–2000 and 2009–2010 ski seasons. Injury patterns by sport, demographics, and skill level were analyzed and compared over time. Results The mean overall age was 32.9 ± 14.9 years, 35.4 ± 15.2 for skiers and 23.6 ± 9.5 for snowboarders (P < .01). The knee accounted for 43% of all skiing injuries, the shoulder 12%, and the thumb 8%. The wrist accounted for 18% of all snowboarding injuries, the shoulders 14%, and the ankle and knee each 13%. Beginner snowboarders were more likely to present with wrist injuries compared with intermediate (P = .04) and advanced snowboarders (P < .01). Demographic and injury patterns did not significantly change over time. Conclusions At this mountainside clinic, the most frequent ski injuries are to the knee and shoulder, regardless of skill level. Beginning snowboarders most frequently injure their wrists whereas shoulder injuries remain frequent at all skill levels. Knowledge of these injury patterns may help manage patients who present for medical care in the prehospital setting as well as help in designing targeted educational tools for injury prevention.


      PubDate: 2013-10-19T14:01:12Z
       
  • Wilderness Medical Society Practice Guidelines for the Prevention and
           Treatment of Heat-Related Illness
    • Abstract: Publication date: Available online 16 October 2013
      Source:Wilderness & Environmental Medicine
      Author(s): Grant S. Lipman , Kurt P. Eifling , Mark A. Ellis , Flavio G. Gaudio , Edward M. Otten , Colin K. Grissom
      The Wilderness Medical Society (WMS) convened an expert panel to develop a set of evidence-based guidelines for the recognition, prevention, and treatment of heat-related illness. We present a review of the classifications, pathophysiology, and evidence-based guidelines for planning and preventive measures as well as best-practice recommendations for both field- and hospital-based therapeutic management of heat-related illness. These recommendations are graded based on the quality of supporting evidence and the balance between the benefits and risks or burdens for each modality.


      PubDate: 2013-10-19T14:01:12Z
       
  • Management of snakebite and systemic envenomation in rural Ecuador using
           the 20-minute whole blood clotting test
    • Abstract: Publication date: Available online 9 October 2013
      Source:Wilderness & Environmental Medicine
      Author(s): David P. Gaus , Diego F. Herrera , Carlos J. Troya , Alicia H. Guevara
      Objectives In low-income countries, snakebites are frequently managed in rural areas in health centers with severely constrained resources. Many healthcare providers in these settings have limited access to the numerous and relatively expensive laboratory studies used to diagnose envenomation. The relatively simple and inexpensive 20-minute whole blood clotting test (WBCT) has been recommended by several international organizations for the diagnosis of certain venomous snakebites. This study proposes to confirm the utility of the WBCT as the sole laboratory diagnostic tool to determine systemic envenomation in hematotoxic snakebite management in severely resource-constrained areas of the world. Methods The authors reviewed all 110 cases of snakebite during a 6-year period in a small hospital in rural Ecuador using the WBCT. Results All cases presented within 24 hours of snakebite. Twenty cases revealed normal coagulation with no clinical evidence of systemic envenomation. Ninety cases had no evidence of clot formation (positive WBCT) at 20 minutes, suggesting systemic envenomation. Of these 90 cases, according to a classification scale, 54 were mild, 26 were moderate, and 10 were severe envenomations requiring transfer to tertiary care. All mild and moderate systemic envenomations were successfully treated at the rural hospital. All severe envenomations were treated initially with antivenom before transfer to tertiary care. One patient with severe envenomation died in tertiary care. Conclusions The WBCT was predictive of the presence or absence of systemic envenomation from snakebite in our region. The WBCT guided the successful management of mild and moderate systemic envenomation, and spared patients with no evidence of systemic envenomation from potential side effects of antivenom.


      PubDate: 2013-10-11T14:18:01Z
       
  • Exertional Heat-Related Illnesses at the Grand Canyon National Park,
           2004–2009
    • Abstract: Publication date: Available online 9 October 2013
      Source:Wilderness & Environmental Medicine
      Author(s): CDR Rebecca S. Noe , Ekta Choudhary , LCDR Jennifer Cheng-Dobson , Amy F. Wolkin , CDR Sara B. Newman
      Background The Grand Canyon National Park has approximately 4 million visitors between April and September each year. During this period, outdoor activity such as hiking is potentially hazardous owing to extreme heat, limited shade, and steep, long ascents. Given the high visitation and the public health interest in the effects of extreme heat, this study calculated morbidity rates and described heat-related illness (HRI) among visitors. Methods We conducted a retrospective cross-sectional study from April 1 through September 30, during 2004–2009. From a review of Ranger Emergency Medical Services (EMS) incident report files, we extracted information on those that met the case definition of greater than 1 hour of outdoor heat exposure with an HRI assessment or diagnosis, HRI self-report, or signs or symptoms of HRI without another etiology noted. Visitor and temperature data were obtained from respective official sources. Results Grand Canyon EMS responded to 474 nonfatal and 6 fatal HRI cases, with the majority (84%) being US residents, 29% from Western states. Of the nonfatal cases, 51% were women, the median age was 43 years (range, 11–83 years), and 18% reported a cardiovascular condition. Clinical HRI assessments included dehydration (25%), heat exhaustion (23%), and suspected hyponatremia (19%). Almost all (90%) were hiking; 40% required helicopter evacuation. The highest HRI rates were seen in May. Conclusions HRI remains a public health concern at the Grand Canyon. High-risk evacuations and life-threatening conditions were found. Majority were hikers, middle-aged adults, and US residents. These findings support the park’s hiker HRI prevention efforts and use of park EMS data to measure HRI.


      PubDate: 2013-10-11T14:18:01Z
       
  • Search and Rescue in the Intermountain West States
    • Abstract: Publication date: Available online 3 October 2013
      Source:Wilderness & Environmental Medicine
      Author(s): Katie W. Russell , David C. Weber , Brian M. Scheele , Ryan P. Ernst , Nicholas C. Kanaan , William R. Smith , Scott E. McIntosh , Albert R. Wheeler III
      Background Minimal data exist regarding the activity, membership, training, and medical oversight of search and rescue (SAR) teams. Objective Our objective was to describe these characteristics in the Intermountain West SAR organizations. Methods A contact list was generated and electronic surveys were sent to SAR officials in each Intermountain West county. Results were descriptively analyzed. Results Of the contacted jurisdictions, 56% (156) responded to the survey. The annual average call volume was 29 missions (range, 5 to 152). Multiple levels of medical training were represented on SAR teams, ranging from first aid/cardiopulmonary resuscitation providers to the physician level, and 79% of teams provided some medical training to their membership. Of the SAR medical professionals, 23% had formal wilderness medical training. Local emergency medical services provided 60% of the medical care on SAR missions rather than SAR personnel. Formal physician medical oversight was present in 41% of the SAR teams. These physicians participated in a range of SAR activities including medical protocol drafting (including expanded scope of practice), medical trainings, mission participation, medical consultation, and prescribing medications for field use. The majority (69%) of those physicians were trained in emergency medicine, and 45% of the active medical directors had protocols allowing for an expanded scope of practice due to the remote nature of SAR medical care. Conclusions Intermountain West SAR teams vary in their activity, composition, training, and level of medical oversight. This study confirms that opportunities exist for physician integration with SAR teams in the studied states and likely throughout the United States.


      PubDate: 2013-10-03T14:01:10Z
       
  • Dental Extractions Using Improvised Equipment
    • Abstract: Publication date: Available online 26 September 2013
      Source:Wilderness & Environmental Medicine
      Author(s): Kenneth V. Iserson
      Extracting a tooth is the final treatment for multiple dental problems. Persons who are not dentists, however, have little experience with tooth extractions. When a remote setting makes it impossible to send a patient for optimal dental treatment, the clinician may need to extract teeth, sometimes using improvised equipment. The following cases of two patients with three carious, painful molars describe such a situation. The non-dental clinicians had to improvise not only appropriate dental tools, but also personal protective equipment, a functional suction machine, medications for a dental block, a dental chair, and dental consent forms and follow-up instructions in the patients’ language. In these cases, they also communicated with their patients through a translator. To prepare to do tooth extractions in remote settings, clinicians should learn and practice dental blocks and review extraction techniques before they deploy. If they must do an extraction, clinicians should use the closest approximation available to the appropriate dental tools. When done correctly, a dental extraction can take some time and should not be rushed.


      PubDate: 2013-09-29T11:12:13Z
       
  • Further Clinical Evidence for the Existence of Neurotoxicity in a
           Population of the European Adder (Vipera berus berus) in Eastern Hungary:
           Second Authenticated Case
    • Abstract: Publication date: Available online 26 September 2013
      Source:Wilderness & Environmental Medicine
      Author(s): Tamás Malina , Gergely Babocsay , László Krecsák , Csaba Erdész
      We report a recent case of common adder (Vipera berus) envenoming causing paralytic signs and symptoms. A 12-year-old girl was bitten by the nominate subspecies of the common adder (V. berus berus) in eastern Hungary on May 2, 2012, 22 km away from where the first neurotoxic V. berus berus envenoming was reported in 2008. The patient developed unambiguous cranial nerve disturbances, manifested in bilateral impairment characterized by oculomotor paralysis with partial ptosis, gaze paresis, and diplopia. Drowsiness and photophobia were her additional symptoms; both occurred only during the first day of envenoming. Until now among viper envenomings in Europe, photophobia has only been documented by victims of Vipera aspis. Supportive and symptomatic treatments were administered during 3 days of hospitalization. Although case reports of V. berus berus envenomings are often published, clinical experience with neurotoxicity by this subspecies still remains rare. Population-based and geographic variation of venom composition in V. berus berus seems to include neurotoxic envenomings in certain populations. This second authenticated case provides new clinical evidence for the existence of a possible neurotoxic V. berus berus population in a restricted geographical area in eastern Hungary.


      PubDate: 2013-09-29T11:12:13Z
       
  • Effect of Advanced Trauma Life Support (ATLS) on the Time Needed for
           Treatment in Simulated Mountain Medicine Emergencies
    • Abstract: Publication date: Available online 25 September 2013
      Source:Wilderness & Environmental Medicine
      Author(s): Franck G Billmann , Claude Burnett , Stefanie Welke , Therezia Bokor-Billmann
      Objective The number of tourists exploring mountainous areas continues to increase. As a consequence, rescue operations are increasing, especially for trauma and polytrauma victims. The outcome of such patients depends greatly on the duration of the prehospital stabilization. Limited medical training of mountain rescuers may adversely affect the outcome of patients. There is no study investigating high altitude trauma treatment. The aim of this study is to analyze the impact of advanced trauma life support (ATLS) principles in mountain trauma, and to discuss a possible role of ATLS in mountain medicine education programs. Methods We designed 5 tasks representing life-threatening trauma problems encountered in mountain rescue. They were used to evaluate the physician’s ability to adequately diagnose and react to trauma situations. We created 2 groups: 1) the ATLS group, consisting of physicians who passed the ATLS course and the mountain medicine course, and 2) the non-ATLS group, consisting of physicians who did not obtain the ATLS training but who did pass the mountain medicine course. We compared the time spent to complete the tasks in both groups. Results In 4 of the 5 tasks (airway, breathing, circulation, and combination), the ATLS group completed the task significantly faster. In the environment task, however, the ATLS group was slower. This was the only not significant result. Conclusions ATLS principles adapted and implemented for high altitude medicine education may have a positive impact on high altitude trauma treatment and outcomes.


      PubDate: 2013-09-25T14:44:41Z
       
  • Patterns of Outdoor Recreational Injury in Northern British Columbia
    • Abstract: Publication date: Available online 25 September 2013
      Source:Wilderness & Environmental Medicine
      Author(s): Floyd A. Besserer , Nadine R. Caron
      Objective The objective of this study was to examine the patterns of severe injury documented at a northern British Columbia regional trauma center based on age, sex, month of year, activity type, injury type, and injury severity as they relate to participation in outdoor recreational activities. Methods A retrospective analysis of data abstracted from the British Columbia Trauma Registry for patients sustaining injuries between April 1, 2004, and March 31, 2007, while engaged in outdoor recreational activities in the Northern Health Authority. The British Columbia Trauma Registry inclusion criteria are as follows: 1) admitted for treatment of injuries sustained from the transfer of external energy or force; 2) admitted to the facility within 7 days of injury; and 3) length of stay more than 2 days or in-hospital mortality. Results In all, 159 patients met study criteria. August and September were peak injury months (mean 7.3 and 7.0 per month, respectively). The highest injury patterns involved cycling (n = 31), all-terrain vehicle operation (n = 30), horseback riding (n = 22), and snowmobiling (n = 22). Of the 159 patients, 76.1% were male, with a peak age distribution between 10 years and 19 years (22%). Males were more commonly injured than females among cycling (83.9%), all-terrain vehicle (86.7%), and snowmobile (100%) traumas. Females were more commonly injured from horseback riding events (42.1%). Conclusions This study emphasizes the need for rapid translation of research findings into injury prevention awareness and programming in northern British Columbia, particularly relating to cycling, horseback riding, snowmobiling, and all-terrain vehicle operation. Further investigation is required to analyze long-term outcomes for this common injury population.


      PubDate: 2013-09-25T14:44:41Z
       
  • An Observational Study of Personal Ultraviolet Dosimetry and Acute Diffuse
           Reflectance Skin Changes at Extreme Altitude
    • Abstract: Publication date: Available online 25 September 2013
      Source:Wilderness & Environmental Medicine
      Author(s): Ivy Cheng , Alex Kiss , Lothar Lilge
      Objective To determine the level of UV radiation at extreme altitude and to assess the effect it has on the skin. Methods Fifteen expeditioners and 10 Sherpas were assessed during a climbing expedition on the north side of Mt Everest (8848 m). UV exposure measurement and diffuse skin reflectance spectrophotometry were performed at the beginning and end of the expedition. Results Over the course of the expedition, the expeditioners and Sherpas received a median dose of 93.6 (interquartile range [IQR], 61.0–102.8) and 102.5 (IQR, 72.2–117.8) minimal erythemal doses (MEDs) of UV radiation. The maximum dosage exceeded 106 ± 1.4 MEDs. Using reflectance spectrophotometry, expeditioner and Sherpa melanin-hemoglobin increased by 83.6% (IQR, –1.5 to 89.8%) and 24.7% (IQR, –22.4 to 61.5%) for exposed skin, respectively. The amount of subcutaneous lipid-water decreased by a factor of 196.6 (IQR, 52.1–308.4) and 46.7 (IQR, 1.8–1156.5), for expeditioners and Sherpas, respectively. Conclusions This expedition’s participants received massive doses of UV radiation during their time at high altitude. In many individuals this was similar to the annual exposure of northern European office-workers (100 MEDs). Diffuse skin reflectance spectroscopy revealed considerable subcutaneous lipid loss, skin dehydration, and increased melanin in keeping with these levels of exposure.


      PubDate: 2013-09-25T14:44:41Z
       
  • Retrieval of Additional Epinephrine From Auto-injectors
    • Abstract: Publication date: Available online 14 September 2013
      Source:Wilderness & Environmental Medicine
      Author(s): Seth C. Hawkins , Carl Weil , Fred Baty , David Fitzpatrick , Bryan Rowell
      Anaphylaxis is a challenging condition for any austere environment. It is unpredictable, has sudden onset and a high fatality rate, and is responsive only to epinephrine, a prescription medication. The Wilderness Medical Society has formally recommended that non-medical providers working in austere environments be trained to administer epinephrine. Medical providers frequently prescribe auto-injectors for this purpose due to their ease of use by nonmedical providers. However, auto-injectors have limitations in the wilderness environment, particularly due to their single-dose (or at most 2-dose) design. This paper describes an austere environment technique for obtaining multiple additional doses of epinephrine from auto-injectors that have already been used as designed.


      PubDate: 2013-09-15T02:42:01Z
       
  • Energy Expenditure and Intensity Levels During a 6170-m Summit in the
           Karakoram Mountains
    • Abstract: Publication date: Available online 13 September 2013
      Source:Wilderness & Environmental Medicine
      Author(s): Andrew D. Miller , Bryan J. Taylor , Bruce D. Johnson
      Objective Although the majority of high altitude studies have used doubly labeled water to assess energy expenditure (EE), minimal research has examined variation in intensity levels while participating in such an expedition. The purpose of this study was to use ambulatory monitoring technology to assess EE and time spent in moderate (3.0–6.0 METS), vigorous (6.0–9.0 METS), and very vigorous (>9.0 METS) intensities during an expedition to summit a 6170-m peak in Northern Pakistan. Methods Twelve men and 2 women were studied. Their EE was determined from galvanic skin response, heat flux, and biaxial accelerometry using a multisensor armband. Lake Louise Scores for altitude illness assessment were obtained each morning. Results Average daily total EE and number of steps taken was 4173 ± 848 kcal/d (range, 3332 to 4838 kcal/d) and 26,232 ± 7210 steps/d (range, 11,788 to 34,979 steps/d), respectively. On average, subjects spent approximately 7.7 h/d performing physical activity (>3.0 METS). Of this, subjects spent 399 ± 107, 61 ± 77, and 3 ± 10 min/d at moderate, vigorous, and very vigorous intensity levels, respectively, corresponding to 88%, 11%, and 1% of total physical activity time. During summit day, subjects climbed at an intensity equivalent to approximately 42% of their high altitude predicted maximal oxygen consumption at 5100 m). Conclusions During a high altitude expedition, subjects predominantly exercise at a moderate intensity, with limited time spent at higher intensity levels. Use of accelerometer-based technology may provide more cost-effective and logistically easier means of assessing EE in extreme environments.


      PubDate: 2013-09-15T02:42:01Z
       
  • Endothelial PAS Domain Protein 1 Chr2:46441523(hg18) Polymorphism Is
           Associated With Susceptibility to High Altitude Pulmonary Edema in Han
           Chinese
    • Abstract: Publication date: Available online 13 September 2013
      Source:Wilderness & Environmental Medicine
      Author(s): Ying-zhong Yang , Ya-ping Wang , Yu-juan Qi , Yang Du , Lan Ma , Qin Ga , Ri-li Ge
      Objective The purpose of this study was to test the hypothesis that polymorphisms in the endothelial PAS domain protein 1 (EPAS1) gene are associated with the susceptibility to high altitude pulmonary edema (HAPE) in Han Chinese. Methods This study enrolled 153 HAPE patients (HAPE-p), matched with Han Chinese resistant to HAPE (HAPE-r) and local highland Tibetans from Yushu earthquake construction population in Qinghai where the altitude is more than 3500 m above sea level. The polymorphism of EPAS1 chr2:46441523(hg18) was genotyped by polymerase chain reaction restriction fragment length polymorphism and confirmed by DNA sequencing. Results The frequencies of EPAS1 chr2:46441523(hg18) polymorphism C allele were significantly higher in the HAPE-p group than in the HAPE-r group (P < .001), but the frequencies of heterozygous C/G were significantly higher in the HAPE-r group than in the HAPE-p group (P < .001). Moreover, the frequencies of the EPAS1 chr2:46441523(hg18) polymorphism G allele were significantly higher in the highland Tibetan group than in the HAPE-p and HAPE-r groups. Conclusions The EPAS1 chr2:46441523(hg18) polymorphism C is strongly associated with susceptibility to HAPE in Han Chinese, and the EPAS1 chr2:46441523(hg18) polymorphism G is present at high frequency and may be associated with high altitude adaptation in the Tibetans.


      PubDate: 2013-09-15T02:42:01Z
       
 
 
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