Wilderness & Environmental Medicine最新文献

A 64-y-old male went caving and packrafting in Chiapas, Mexico. On return, he developed fever, headaches, and nausea and was treated empirically for leptospirosis with ceftriaxone and doxycycline. Convalescent IgM titers returned positive for leptospirosis. Other work-up was negative. As the symptoms of leptospirosis abated, the patient developed an areflexic quadriparesis. Nerve conduction velocities confirmed acute motor axonal neuropathy consistent with Guillain-Barré syndrome. Serologic work-up disclosed anti-GD1a antibodies. He was treated with intravenous immune globulin for 5 d and then did extensive rehabilitation. Three years after diagnosis, he is once again exploring caves.

IntroductionWilderness medicine (WM) is the study of medicine in austere environments. There are several US multidisciplinary courses that teach WM to people from varying medical backgrounds. However, WM topics are covered to different extents. This study's purpose was to compare WM components among US multidisciplinary training courses.MethodsThe American College of Emergency Physicians WM fellowship curriculum's 19 components and the Fellowship of the Academy of Wilderness Medicine's 12 core and 16 elective competencies and their credits were used as two control lists. Curricula from 10 US multidisciplinary courses were analyzed for WM components. Using descriptive analysis, each course curriculum was compared with the controls.ResultsThis study examines WM components in 10 courses. The greatest number of American College of Emergency Physicians WM fellowship topics (14 of 19) was covered by the Paramedic course and the fewest number (4 of 19) by the Tactical Combat Casualty Care-Combat Lifesaver course. The greatest number of Fellowship of the Academy of Wilderness Medicine core credits (56) was offered by the Paramedic course and the fewest number (24) by the Tactical Combat Casualty Care-Medical Personnel course. The greatest number of Fellowship of the Academy of Wilderness Medicine elective credits (83) was offered by the Paramedic course and the fewest number (25) by the Tactical Combat Casualty Care-Combat Lifesaver course.ConclusionThis research analyzed WM components in US multidisciplinary courses and demonstrated that each covers WM topics to varying extents. This shows an opportunity for these courses to expand their WM education within their scope. It also demonstrates competencies offered by different courses for interested trainees.

Introduction-Decision-making in clinical environments is often impacted by cognitive biases and exacerbated by high stakes, time pressures, and unreliable feedback-characteristics of a "wicked learning environment," as defined by Robin Hogarth.^1,2 Traditional medical education inadequately addresses these biases, relying primarily on passive, lecture-based instruction. Objective-To bridge this gap, we designed and piloted an experiential learning workshop for first-year medical students, integrating backcountry skiing as a parallel wicked learning environment to teach decision-making biases, fallacies, and heuristics. Methods-The study employed a qualitative questionnaire to better understand student experience and measured learning outcomes. Results-Twenty-six students participated in the classroom-based components, and of those 26, 8 participated in the experiential learning component. Qualitative questionnaire responses suggest an elevated understanding of how backcountry decision-making informs clinical decision-making and the importance of decision-making within patient care. Discussion-There is clear potential for the programming to be expanded and applied to other forms of the outdoor recreation experience. Results suggest that applying the experiential learning model provides an additional and broader understanding of how decision-making biases may intersect with practical applications in medical settings. Despite limitations, including a low response rate, the results suggest that this novel approach enhances the understanding of cognitive biases and decision-making in clinical settings. Future iterations will aim to scale participation, include quantitative assessments, and explore alternative wicked learning environments. Conclusion-This pilot program demonstrates the potential of combining outdoor experiential learning with medical education to address critical gaps in teaching decision-making biases and improve clinical practice.

IntroductionHemorrhage control in austere environments is challenging, particularly for wounds that are not amenable to tourniquets. Hemostatic gauzes are crucial in such settings, but their efficacy may be compromised by suboptimal storage conditions, including extreme temperatures, where discoloration has been observed. This study evaluated the impact of extreme temperature exposure on the efficacy of hemostatic gauze using thromboelastography.MethodsBlood from 30 healthy adults was diluted by 30% with hetastarch to mimic trauma-induced coagulopathy. Kerlix and QuikClot Combat Gauze stored for 3 weeks in cold (-10°C), hot (70°C), and room-temperature (22°C) environments were compared in the thromboelastography parameters of R (time to initiation of clot formation), K (clot amplification), α angle (clot formation rate), and MA (maximum amplitude of clot).ResultsCompared with whole blood, diluted blood had weaker clots with slower clot-formation kinetics (MA=58  vs 43 mm, P<0.0001; K=2.6 vs 4.0 min, P<0.0001; α angle=55 vs 47 degrees, P<0.0003) but faster clot initiation times (R=8.7 vs 7.1 min, P<0.0001). Addition of either gauze shortened clot initiation times (Kerlix: 7.1 vs 5.0 min, P<0.0001; QuikClot Combat Gauze: 7.1 vs 2.7 min, P<0.0001), with QuikClot Combat Gauze significantly shortening R compared with Kerlix. Reductions in R values were consistent across temperature extremes (P<0.05). The other parameters were consistently unaffected (P>0.05).ConclusionsThis in vitro laboratory study demonstrated that hemostatic gauze retained its ability to initiate clotting in vitro even after prolonged exposure to temperature extremes.

IntroductionThe Boundary Waters Canoe Area (BWCA) is a backcountry recreation area. This study aimed to characterize injuries sustained in the BWCA.MethodsA single reviewer completed a retrospective chart review of trauma admissions to Essentia Health from January 1, 2014 to February 25, 2023. Patients were included if their injury was documented to have occurred in the BWCA and they had not opted out of research.ResultsEighteen patients were found to have sustained injury in the BWCA. Most were adult males (78%), White (89%), and nonsmokers (94%). Most patients had no alcohol (83.3%) or drug (94.4%) use related to the injury. Seven patients self-extricated out to the BWCA, 6 were transported by ground Emergency Medical Services, and 5 required flight extrication. Median time from notification of injury to Emergency Medical Services arrival was 64 min. Time from notification of injury to hospital arrival was a median of 131 min. Falls were the main mechanism of injury (61%), followed by strike injury (22%) and water injury (17%). A few patients required lifesaving interventions (eg, prehospital intubations, needle thoracostomy, and blood transfusion). Twelve patients required a procedure (eg, <5 chest tubes and 10 surgeries). All 18 patients were alive at discharge.ConclusionThe most common injuries sustained in the BWCA were from falls, strikes, and water injuries. In collaboration with forest ranger stations, we plan to provide this information to backpackers to assist in their preparation for backcountry emergencies.

IntroductionThe COVID-19 pandemic affected the ski industry globally, including limiting access to ski resorts and prompting more skiers and snowboarders to explore the backcountry. In this study, we quantified the willingness to take risks (risk propensity) and self-perceived ability to assess hazards in the backcountry and to explore correlations between these factors.MethodsWe based our study on a previously reported data set gathered under the supervision of our senior author, who collected anonymous responses to a 29-question online survey completed by 4792 self-identified backcountry skiers and snowboarders (aged ≥18 yr) in the United States and Canada. The survey was distributed primarily through regional avalanche centers, education providers, and skiing organizations. Pearson correlation coefficients and multivariable linear regression models were used to analyze associations among variables. More specifically, we examined the relationships among confidence in assessing avalanche terrain and willingness to take risks, level of avalanche training, years of experience, and days per season of backcountry skiing.ResultsWe identified a positive correlation between confidence in assessing avalanche terrain and willingness to take risks, level of avalanche training, years of experience, and days per season of backcountry skiing. Female respondents demonstrated lower risk willingness and self-reported ability to assess avalanche risk compared to males. Over 30% of individuals lacking level 1 avalanche training expressed confidence in appraising complex terrain. Our findings demonstrated a positive correlation between greater risk propensity, formal avalanche education, and increasing confidence in assessing avalanche terrain. However, we also observed concerningly high confidence levels among skiers with minimal or no training.ConclusionsAvalanche education should focus on aligning skiers' confidence with their actual abilities to reduce overconfidence and enhance safety. We recommend that future research aim to include a more diverse sample, especially those less engaged in formal avalanche education.

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.

Introduction-Wilderness medicine (WM) is a growing field offering advanced training and recognition through graduate medical education (GME) WM fellowships and the Fellow of the Academy of Wilderness Medicine (FAWM) professional designation. GME fellowships, introduced in 2004, provide immersive, structured training and experiential learning opportunities. The FAWM designation, established in 2005, is earned through approved educational activities. This study compared alumni outcomes between these pathways.Methods-A cross-sectional survey was conducted among GME fellowship graduates and FAWM recipients. Inclusion criteria were GME fellowship alumni or individuals with FAWM recognition. Exclusion criteria included incomplete surveys. Respondents were surveyed on demographics, academic output, and satisfaction with their training. Data analysis included χ² tests for categorical data, analysis of variance for publication comparisons, and ordinal Likert scales for satisfaction.Results-Of 321 responses, 281 were included. GME alumni expressed greater satisfaction with mentorship and research opportunities; 95% of FAWM-only respondents reported exposure to career opportunities unknown prior to fellowship. There was no detectable difference (P=0.523) between FAWM-only respondents' number of WM-related publications. Overall, 93% of FAWM-only respondents and 76% of GME alumni would repeat their fellowship. Both groups demonstrated high proficiency in WM, with 89% feeling proficient.Conclusion-Both GME and FAWM pathways support WM education and career development. However, GME fellowships provide enhanced academic involvement, mentorship, and performance of relevant clinical skills. FAWM introduced new wilderness careers and had higher alumni satisfaction. These findings highlight the complementary roles of GME fellowships and FAWM recognition in advancing proficiency and professional growth.