Wilderness & Environmental Medicine最新文献

Introduction: Providers can evaluate patients who sustain trauma during outdoor activities by using the extended focused assessment with sonography for trauma (FAST) and the limited knee ultrasound. Remote tele-mentored ultrasound (RTMUS) can help minimally trained providers in the wilderness if they have difficulty obtaining a view or have questions about the interpretation of an image. The goal of our study was to determine the feasibility of using RTMUS to teach the FAST exam and knee ultrasound exam to ultrasound-naive medical students during a wilderness medicine outdoor activity.

Methods: Medical students from two large academic institutions were randomized to receive either in-person or RTMUS education during a wilderness activity 1 d before completion of FAST and knee ultrasound exams. All students received limited ultrasound instruction before the event. The images obtained by the students were compared. Two ultrasound-trained emergency physicians evaluated the images for their ability to identify structures and support a diagnosis from the images. Simple descriptive statistics were performed.

Results: There was a statistically significant difference between the RTMUS group and the in-person group. The images captured by the in-person group were more likely to identify structures and support a diagnosis than those captured by the RTMUS group.

Conclusions: In this study, ultrasound-naive medical students who received in-person education on conducting the knee exam and FAST exam obtained higher-quality images than students who received RTMUS education. This study suggests that if RTMUS is used for medical purposes, increased ultrasound training may be needed prior to initiation of RTMUS.

The impact and severity of natural disasters and hazards have been increasing in the United States and throughout the world. With our mounting reliance and dependence on technology in our industrialized society, technological disasters also have become more commonplace. Although disasters may occur with little to no warning, these risks are felt to be acceptable despite their ability to impact large populations. Natural and technological disasters disproportionately affect vulnerable populations, including those with end-stage kidney disease (ESKD). The impact of natural and technological disasters on the ESKD community has been closely examined via numerous case studies and through the lens of particular disasters, but there is a paucity of data exploring the impacts of natural and technological disasters on the ESKD community by disaster type. A comprehensive literature search was performed using PubMed and Google Scholar, and relevant articles pertaining to the impacts of natural and technological disasters on the ESKD community were reviewed. More than 50 studies were reviewed in total. This review aimed to identify common patterns and trends observed in the impacts of different disaster types on the ESKD community to better prepare patients and their providers before the next disaster strikes.

Management of the airway in austere environments can differ substantially from standard in-hospital airway management. Devices such as nasopharyngeal airways, oropharyngeal airways, endotracheal tubes, extraglottic airways, ventilators, and sedative and paralytic medications may not be available. Weather, scene hazards, difficulties of extrication, transport times, skill sets of rescuers, and availability of advanced equipment are highly variable. Standard decision-making processes and guidelines, such as intubation for Glasgow Coma Scale score ≤ 8, are not always optimal in austere settings. Airway management in austere settings involves many variables leading to complex decision-making. We present 2 cases in which airway management likely would have been similar in hospital settings but differed in austere environments based on the available resources. We discuss current concepts and methods for airway management in austere environments with a review of the pertinent literature.

Cough persisting for 5 wk, low-grade fever, and thick, pinkish to reddish, foul-tasting sputum made the doctors seeing this patient think of tuberculosis at first. However, a history of aspirating seawater during recreational free diving gave a clearer picture of how this patient got sick. Investigations later revealed a cavitary lesion in the right lung, and sputum culture grew Klebsiella pneumoniae, resulting in a diagnosis of lung abscess. This case is being reported to show this peculiar way that a bacterial pathogen entered the respiratory tree and that recreational free diving poses a health risk if done in a marine environment where this "survivor bacteria" thrives.

Introduction: Long QTc syndrome can predispose patients to fatal ventricular arrhythmias. We studied the effects of a rapid ascent and a multiday stay at high altitude on QTc interval.

Methods: We recorded electrocardiograms (ECGs) on study subjects at sea level and then again after a 1-d ascent to 3800 m. Two sea-level ECGs were recorded at the initial screening visit (SL1) and 14 days later (SL2). Altitude ECGs were recorded at approximately 16 and 86 h after arrival. SpO₂ was recorded prior to each ECG measurement. We defined prolonged QTc as a QTc interval >450 ms for men and >470 ms for women. We used multivariate analysis to analyze the QTc interval for the effect of drugs, altitude, and changes in electrolytes.

Results: We enrolled 107 subjects: 61 males and 46 females between the ages of 19 and 54 y, with a median age of 34 y. QTcF (QT interval for varying heart rates using Fridericia's formula) at SL1 was 405±17 ms; at SL2, 404±17 ms; at 16 h, 411±18 ms; and at 86 h, 427±24 ms. After 86 h at altitude, 12 participants met the criteria for prolonged QT syndrome, and 61% of subjects had QTc prolongation of >20 ms from sea-level values. This was independent of changes in serum electrolyte levels, (i.e., sodium, potassium, and calcium), bicarbonate levels, and SpO₂.

Conclusion: High altitude exposure can lengthen a healthy adult's QTc interval by more than 20 ms. It remains unknown whether this increase might raise the risk of torsades de pointes in people with long QT intervals at baseline.

Wilderness medicine elective rotations for graduate medical students are gaining popularity. The number of electives continues to grow, each with varying curriculum, format, and means of assessment. Previous curriculum guidelines attempted to standardize the knowledge-based competency for medical students in this field. Concurrently, medical education has evolved, emphasizing learner-centric and outcome-based observable competencies. Competencies based on individual qualities have since been complemented by practice-specific activities called entrustable professional activities (EPAs), which may consist of smaller observable practice activities (OPAs). This has allowed educators to use a holistic approach to determine that an individual can be fully entrusted to carry out an unsupervised activity. We surveyed current graduate-level wilderness medicine elective directors to determine expert panel recommendations for the EPAs of wilderness medicine for graduate medical students. The aim was to create EPAs and OPAs that experts deem fundamental for a wilderness medicine elective rotation and align them under the framework of entrustable practice in medical education. By mapping wilderness medicine EPAs and OPAs to competencies, we can better measure developmental progression and degree of entrustment in graduate wilderness medicine electives.