Shared Science - Wilderness & Environmental Medicine
WEM and The Journal of Special Operations Medicine (JSOM) participate in a shared science program. This opportunity is made possible through a reciprocal partnership between the journals. Click here to see the JSOM articles selected for WEM readers, please visit:
Helicopter-Based Search and Rescue Operations in the Dutch Caribbean: A Retrospective Analysis
Search and rescue (SAR) operations in the Dutch Caribbean offer basic and advanced prehospital care and transport for definitive care. Helicopter-based SAR in this geographic area has not been previously studied. Data from the Dutch Caribbean Coast Guard were analyzed with the aim of describing the current operational setting and optimizing SAR operations in the future.Evaluation of Escherichia coli Inactivation at High Altitudes Using Solar Water Disinfection
Solar disinfection (SODIS) is an effective method for microbiologic inactivation of contaminated water using ultraviolet rays at low elevations. The aim of this study was to determine the effectiveness of SODIS at higher elevations.Validating the Remote First Aid Self-Efficacy Scale for Use in Evaluation and Training of First Responders in Remote Contexts
The purpose of this study was to investigate the psychometric properties of the remote first aid self-efficacy scale (RFA SES). The RFA SES is a 30-item self-report scale developed in response to emerging evidence showing that self-efficacy is predictive of performance.Therapeutic Plasma Exchange for Venom-Induced Thrombotic Microangiopathy Following Hump-Nosed Pit Viper (Genus: Hypnale) Bites: A Prospective Observational Study
—Thrombotic microangiopathy (TMA), which is the triad of acute kidney injury (AKI), microangiopathic hemolytic anemia (MAHA), and thrombocytopenia, is a rare complication of snakebites, and in Sri Lanka, it is commonly seen with hump-nosed pit viper (HNPV) bites.Perceptions Among Backcountry Skiers During the COVID-19 Pandemic: Avalanche Safety and Backcountry Habits of New and Established Skiers
The coronavirus disease 2019 (COVID-19) pandemic impacted the ski industry worldwide by closing or limiting access to ski resorts. Subsequently, anecdotal reports of increased backcountry use emerged in the press, with concerns of inexperienced skiers causing or having problems in the backcountry. This study attempted to quantify this and identify motivations for new backcountry skiers.Successful Nonextracorporeal Life Support Resuscitation and Rewarming of a Patient with Hypothermia in Cardiac Arrest
We report full recovery of a patient with hypothermia in cardiac arrest following continuous and prolonged cardiopulmonary resuscitation (CPR) and conventional, nonextracorporeal life support (non-ECLS) methods. A 57-y-old man presented with unwitnessed cardiac arrest and a core temperature of 23°C (73°F). The presenting cardiac rhythm was ventricular fibrillation. The team administered epinephrine and performed defibrillation and CPR. Because ECLS was unavailable at the facility, the medical team externally and internally rewarmed the patient using heated blankets, forced warmed air, thoracic lavage, and warmed IV fluids.Intranasal Fentanyl for On-the-Hill Analgesia by Ski Patrol
Intranasal fentanyl offers a means for safe and effective pain management in austere environments. Prehospital analgesia traditionally involves intravenous or intramuscular medication. However, for wilderness rescuers, these methods are often impractical.Point-of-Care Ultrasound Findings in a Case of Botfly Myiasis Contracted in the United States
Botfly infiltration is a rare cause of pediatric skin manifestations in the United States, but should be considered in nonhealing wounds even in nontravelers. We describe the case of a healthy 6-y-old female who had never traveled outside of the southeast United States, presenting with a nonhealing skin lesion. The point-of-care ultrasound (POCUS) findings suggested subcutaneous parasitic infiltration. This case demonstrates the role of POCUS in identification of subcutaneous parasitic infiltration, and differentiation from other, more common skin lesions.Russula subnigricans Poisoning Causes Severe Rhabdomyolysis That Could be Misdiagnosed as Non-ST Segment Elevation Myocardial Infarction
Mushroom poisoning and subsequently the number of patients visiting emergency rooms are increasing, as well as the proportion of fatal mushroom poisonings. Myocytic mushroom poisoning is one of the new clinical classifications. This report documents the course of a family with Russula subnigricans poisoning complicated by severe rhabdomyolysis, including a case that was misdiagnosed as myocardial infarction. A 64-y-old man visited our hospital with symptoms including substernal chest discomfort, nausea, vomiting, and myalgia, lasting for 12 h.Avalanche Preparedness and Accident Analysis Among Backcountry Skier, Sidecountry, and Snowmobile Fatalities in the United States: 2009 to 2019
While avalanche fatalities have remained relatively steady per year, data suggest a possible increase in sidecountry use and snowmobile fatalities. Limited information is known regarding the accident details and preparedness among different groups of backcountry users including snowmobiles, sidecountry, and backcountry skiers, and what specific factors could contribute to their fatalities.Latency of Symptom Progression in Mild Daboia palaestinae Envenomation
Daboia palestinae is the most common venomous snake in Israel. In most cases, snakebite does not develop into a systemic disease. Since the introduction of specific antivenom therapy, the mortality rate has declined sharply. Nevertheless, there is still no uniform therapeutic protocol in Israel for patients who have been envenomated, and there is no current data regarding latency of symptom development. We aimed to evaluate the latency of symptom development after D palaestinae snakebite in patients presenting to the emergency department (ED) with local reaction.Static Rope Rescue Operations in Western Norway: A Retrospective Analysis of 141 Missions
The Norwegian national standard for rescuers describes medical and rescue requirements for helicopter emergency medical services (HEMS) technical crew members, but there is a lack of scientific data supporting these requirements and their safety relevance. The study aims to analyze the rescue profile of Norwegian HEMS static rope human external cargo operations, emphasizing terrain challenges and additional safety measures utilized on-site.Factors Associated with Musculoskeletal Injuries While Hiking with a Backpack at Philmont Scout Ranch
Participants at Philmont Scout Ranch embark on 12-d treks with pre-trek physical conditioning and medical clearance by their primary care physician. In this study, we investigated potential contributing factors to self-reported musculoskeletal injuries during a backpack trek.Cardiovascular and Blood Oxidative Stress Responses to Exercise and Acute Woodsmoke Exposure in Recreationally Active Individuals
Those who work and recreate outdoors experience woodsmoke exposure during fire season. Exercise during woodsmoke exposure harms the cardiovascular system, but the acute physiologic and biochemical responses are understudied. The purpose of this pilot laboratory-based study was to examine the effect of exercise during woodsmoke exposure on acute indicators of cardiovascular function, including heart rate variability (HRV), pulse wave velocity (PWV), blood pressure (BP), augmentation index (AIx), and blood oxidative stress.Arterial Blood Gas and Rotational Thromboelastometry Parameters in Healthy Rescuers Incidentally Exposed to Nitroglycerin, Nitrogen Compounds, and Combustion Products
Acute exposure to nitrogen compounds combined with a massive inhalation of air pollutants can influence respiratory and cardiovascular symptoms and coagulation abnormalities in accidentally exposed healthy adults during cave detonation operations.Nephrotoxic Mushroom Poisoning: Global Epidemiology, Clinical Manifestations, and Management
Because mushroom poisonings are increasing worldwide after ingestions of known, newly described, and formerly considered edible species, the objectives of this review are to describe the global epidemiology of nephrotoxic mushroom poisonings, to identify nephrotoxic mushrooms, to present a toxidromic approach to earlier diagnoses of nephrotoxic mushroom poisonings based on the onset of acute renal failure, and to compare the outcomes of renal replacement management strategies. Internet search engines were queried with the keywords to identify scientific articles on nephrotoxic mushroom poisonings and their management during the period of 1957 to the present.Differential Diagnosis Between Venomous (Bothrops jararaca, Serpentes, Viperidae) and “Nonvenomous” (Philodryas olfersii, Serpentes, Dipsadidae) Snakebites: Is It Always Possible?
Bites of “nonvenomous” snakes can sometimes be mistaken for the bites of venomous snakes. As an example of this confusion, this report describes confirmed bites by Philodryas olfersii and Bothrops jararaca. In the first case, a 55-y-old man with a history of controlled hypertension was bitten on his right forearm by P olfersii. Physical examination revealed extensive edema, erythema, and widespread ecchymoses throughout his right upper limb. Laboratory tests indicated leukocytosis and high D-dimer levels, but normal coagulation, suggestive of a resolved recent coagulopathy.Massive Tick Bites Causing Spotted Fever Rickettsial Infection: A Hazard in a Tea Plantation, Sri Lanka
Tea plantations in Sri Lanka cover the central hills of the island, where spotted fever group (SFG) rickettsial infection is common. In most cases, the history of tick bite is obscure and eschars are not present. A 45-y-old female experienced massive tick bites while working in her tea plantation. She developed fever 2 d after exposure, but the diagnosis of SFG infection was not considered until a skin rash appeared on the eighth day. She had a very high titer of antirickettsial antibodies detected by immunofluorescence assay and responded to doxycycline.Survey of Musculoskeletal Injuries, Prehike Conditioning, and On-Trail Injury Prevention Strategies Self-Reported by Long-Distance Hikers on the Appalachian Trail
Studies show that 40 to 60% of long-distance hikers on the Appalachian Trail experience musculoskeletal (MSK) injuries, but these studies are over a decade old. The increasing popularity of hiking and injury prevention advances warrant re-evaluation of injury patterns. We sought to determine the frequency of self-reported MSK injuries in long-distance hikers on the Appalachian Trail and associations with prehike conditioning and on-trail injury prevention strategies.The Wind-Chill Index
This Lessons from History article about the wind-chill index (WCI) explores the historical polar and meteorologic literature relevant to the topic and presents unpublished work from 1939. Geographer Paul Siple (1908–1968) was a 6-time Antarctic explorer and scientist who invented and named the WCI in his doctoral dissertation at Clark University. Siple and Charles Passel (1915–2002) performed studies in Antarctica in 1940 that led to publication in 1945. This paper is often credited as the beginning of the WCI.Urological Emergencies and Diseases in Wilderness Expeditions
When considering medical emergencies that might affect an expedition, urologic emergencies are typically not included. However, the reality is that manageable and prevalent urologic disease processes can pose significant challenges for the wilderness medicine physician and warrant consideration. The purpose of this review is to identify and discuss the most commonly encountered urologic emergencies and diseases in the wilderness setting and to prepare the expedition medicine physician for management of these urgent conditions.Prehospital Cross-Sectional Study of Drowning Patients Across the United States
Every year drowning is responsible for 7% of injury-related deaths worldwide, making it the third leading cause of unintentional injury-related death. However, in the United States, little is known regarding the prehospital presentation and management of these patients. The purpose of this study was to describe the drowning population in the United States, with a focus on prehospital time intervals, transport, and cardiac arrest frequency.Rhabdomyolysis and Multisystem Organ Failure Due to Fulminant Ehrlichiosis Infection
A previously healthy 51-y-old male presented to his local emergency department with subjective fevers, myalgias, dyspnea, and generalized weakness that had been progressive for several weeks. He was initially diagnosed with bilateral pneumonia, septic shock, and rhabdomyolysis requiring transfer to a tertiary care facility. He was treated for sepsis with broad-spectrum antibiotics, steroids, and a fluid bolus before transfer. Once he arrived at the tertiary care facility, he developed respiratory failure requiring intubation and ventilatory support.Fatal Events Related to Running Competitions in the Mountains
The few epidemiologic studies published previously about different forms of mountain running (ie, fell running, sky running, and ultratrail running) have not reported on fatal events. This report aims to contribute to the literature on mountain running fatalities, recording and classifying fatal events related to mountain running competitions found in online literature searches over a 12-y period.Point-of-Care Ultrasound Diagnosis of Acute High Altitude Illness: A Case Report
With the advent of high-quality portable ultrasound machines, point-of-care ultrasound (POCUS) has gained interest as a promising diagnostic tool for patients with high altitude illness. Although POCUS is used successfully in hospital environments to detect interstitial pulmonary edema and increased intracranial pressure, the relationship between specific sonographic criteria and high altitude illness is still unclear. We report the case of a healthy 32-y-old male who developed acute respiratory distress and neurologic impairment at 4321 m while participating in a high altitude medical research expedition.Influence of Fluid Delivery Schedule and Composition on Fluid Balance, Physiologic Strain, and Substrate Use in the Heat
Wildfire suppression is characterized by high total energy expenditure and water turnover rates. Hydration position stands outline hourly fluid intake rates. However, dose interval remains ambiguous. We aimed to determine the effects of microdosing and bolus-dosing water and microdosing and bolus-dosing carbohydrate-electrolyte solutions on fluid balance, heat stress (physiologic strain index [PSI]), and carbohydrate oxidation during extended thermal exercise.Altitude-Related Disorders on Mount Kilimanjaro, Tanzania: Two-Year Survey in a Local Referral Center
A significant number of climbers on Mount Kilimanjaro are affected by altitude-related disorders. The aim of this study was to determine the main causes of morbidity and mortality in a representative cohort of climbers based on local hospital records.Gas in Joints After Diving: Computed Tomography May Be Useful for Diagnosing Decompression Sickness
A 26-y-old experienced scotoma scintillans after 59 min of scuba diving at a maximum depth of 26 m. After the patient smoked a cigarette, the scotoma scintillans ceased. However, he then developed a headache, general fatigue, and shoulder and elbow pain. He therefore called an ambulance. Based on the rules of the medical cooperative system for decompression sickness in Izu Peninsula, the fire department called a physician-staffed helicopter. After a physician checked the patient, his complaints remained aside from a low-grade fever.Acute Hamstring Muscle Tears in Climbers—Current Rehabilitation Concepts
Acute hamstring injuries are often caused by the heel hook technique. This technique is unique to climbing and causes injury to muscular and inert tissues of the posterior thigh. The heel hook is used by climbers during strenuous ascent on overhanging walls and when crossing difficult terrain. The technique reduces the amount of upper body strength required during strenuous climbing because the climber’s center of mass is retained within the base of support. The heel hook is stressful collectively for the hamstring muscle group and musculotendinous junction.Athlete’s Heart in Elite Sport Climbers: Cardiac Adaptations Determined Using ECG and Echocardiography Data
Sudden cardiac death in a young athlete is the leading cause of mortality in athletes during sport. Specific knowledge about cardiac adaptations are necessary for a better understanding of the underlying causes of such events.Prehospital Use of Ketamine in Mountain Rescue: A Survey of Emergency Physicians of a Single-Center Alpine Helicopter-Based Emergency Service
Although ketamine use in emergency medicine is widespread, studies investigating prehospital use are scarce. Our goal was to assess the self-reported modalities of ketamine use, knowledge of contraindications, and occurrence of adverse events associated with its use by physicians through a prospective online survey.Developing Cricothyroidotomy Skills Using a Biomaterial-Covered Model
Cricothyroidotomy is an advanced and life-saving technique, but it is also a rare and a difficult procedure. The purpose of the present study was to produce a low-cost simulation model with realistic anatomic features to investigate its effectiveness in developing cricothyroidotomy skills.Envenomation by Trachinus draco and Pain Management
We report a case of a 42-y-old female patient who sustained a sting to the neck from a Trachinus draco fish. She subsequently developed complications including arytenoid membrane edema secondary to either the local anesthetic agent administered to the wound or the dracotoxin itself. The patient was examined in the emergency department after the sting. Local anesthesia with lidocaine was administered to the areas of injury at another hospital before presenting to our hospital emergency department.Evaluation of Three Field Rewarming Techniques During Cold Weather Military Training
The purpose of this work was to evaluate the effectiveness of 3 rewarming techniques to determine how warfighters, and perhaps other populations in wilderness environments, should prioritize field rewarming options after a brief accidental immersion in cold water.Bothrops atrox Snakebite: How a Bad Decision May Lead to a Chronic Disability: A Case Report
Snakebites are a neglected and underestimated global health hazard. In the Brazilian Amazon, Bothrops snakebites are the most prevalent and may lead to severe complications. Here we describe a severe case of Bothrops atrox snakebite that, owing to delayed medical assistance, presented with renal and respiratory failure, compartment syndrome, and tissue necrosis. After several fasciotomy surgeries, the patient survived; however, he showed significant functional disability. Prompt management of snake envenomation would aid in the early diagnosis of local and systemic complications and, consequently, would result in a better functional outcome with improved quality of life.Venom-Induced Consumption Coagulopathy Following Hump-Nosed Pit Viper (Genus: Hypnale) Envenoming in Sri Lanka: Uncertain Efficacy of Fresh Frozen Plasma
Hump-nosed pit vipers (Hypnale spp) cause the highest number of venomous snakebites in Sri Lanka. Bites commonly cause local envenoming leading to local pain, swelling, and necrosis of the site of the bite. Acute kidney injury is the most common systemic manifestation, and some patients develop venom-induced consumption coagulopathy (VICC). Genus Hypnale comprises 3 species. Of them, H hypnale is found in Sri Lanka and the Western Ghats region of India. The other 2 (H nepa and H zara) are endemic species in Sri Lanka.Successful Defibrillation at a Core Temperature of 18.2 Degrees Celsius
Both the temperature at which defibrillation can be effectively used and how often it should be repeated in severe accidental hypothermia have not been definitely established. Current recommendations are based mainly on expert opinion and suggest withholding defibrillation after 3 shocks when the core temperature is below 30°C (86°F). However, growing evidence supports the effectiveness of defibrillation in patients with a core temperature below 30°C (86°F). We present a case of successful defibrillation of a 54-y-old, severely hypothermic patient with a core temperature of 18.2°C (64.8°F).Review of Scorpion Stings and Snakebites Treated by the French Military Health Service During Overseas Operations Between 2015 and 2017
Depending on their theatre of operation, French soldiers may potentially be exposed to scorpion stings and snakebites. Following the recommendations of a French military health service (FMHS) technical committee for envenomation, the FMHS provides antivenoms appropriate to each deployment. This work aimed to evaluate this risk of envenomation and to assess the antivenoms used by the FMHS in operational theatres since the creation of this committee in 2015.Trends in Snakebites Related to Texas Tropical Storms and Hurricanes, 2000–2017
Anecdotal media reports suggest an increase in snakebites after hurricanes. After Hurricane Harvey, several households called Texas poison control centers to report snakebites that occurred when rising water flooded homes. Patterns of snakebite before and after hurricane landfalls have not been well studied.Emergency Medical Services and Remote Medical Oversight in Sequoia and Kings Canyon National Parks, 2011–2013
The University of California San Francisco Fresno Department of Emergency Medicine provides base hospital support for the Sequoia and Kings Canyon National Parks (SEKI) emergency medical services (EMS) system. This descriptive epidemiologic study reports reasons the park EMS system is used and interventions provided, detailing the nature of patient encounters, type and frequency of injuries and interventions, reasons for base hospital contact, and patient dispositions.Venomous Snakebites in Canada: A National Review of Patient Epidemiology and Antivenom Usage
There are 3 pit viper species in Canada. Limited Canadian literature exists on the epidemiology of venomous snakebites and the treatment patterns with antivenom. This study described the epidemiology, the utilization of antivenom, and estimated expenditures due to forfeited antivenom for pit viper envenomations in Canada.Climbing-Related Injury Among Adults in the United States: 5-Year Analysis of the National Emergency Department Sample
Rock climbing and mountaineering are popular outdoor recreational activities. More recently, indoor climbing has become popular, which has increased the number of persons at risk for climbing-related injuries. The purpose of this study was to assess the morbidity, mortality, and healthcare cost due to climbing-related injury among persons presenting to US emergency departments (ED).An Experience of Improvised Laryngoscopy
Airway management in the wilderness runs the gamut from basic airway support to endotracheal intubation. Fortunately, direct laryngoscopy is a seldom called upon skill in expedition medicine. However, the medical skills required during a mission or expedition are never truly known in advance. Improvisation during evolving medical events is a mainstay of expedition medicine education and practice. It is unlikely, given constraints of weight and size of expedition medical kits, that a conventional laryngoscope would find its way into a standard “go bag.” Faced with the real but rare event of needing to intubate a patient in an austere environment, how can improvisation be used? Multiple ideas for improvised laryngoscopes can be found in the wilderness medicine literature, but which, if any, of these devices have true clinical utility? To this end, participants of a recent Wilderness Medical Society preconference in medical elements of light search and rescue were given the opportunity to devise and construct their own improvised laryngoscopes and attempt intubation of a training mannequin.Wilderness Mass Casualty Incident (MCI): Rescue Chain After Avalanche at Everest Base Camp (EBC) In 2015
The Nepal Earthquake of 2015 killed over 8000 people and injured over 20,000 in Nepal. Moments after the earthquake, an avalanche of falling ice came down from above Everest Base Camp (EBC). The air blast created by the avalanche flattened the middle part of EBC, killing 15 people and injuring at least 70. The casualties were initially triaged and treated at EBC and then evacuated by air to Kathmandu for definitive care. There were intermediate stops at the villages of Pheriche and Lukla during which the casualties were offloaded, retriaged, treated, and loaded again for further transport.Research Gaps in Wilderness Medicine
Wilderness medicine involves the treatment of individuals in remote, austere environments. Given the high potential for injuries as well as the unique treatment modalities required in wilderness medicine, evidence-based clinical practice guidelines are necessary to provide optimal care. In this study, we identify evidence gaps from low-quality recommendations in wilderness medicine clinical practice guidelines and identify new/ongoing research addressing them.Update on the Epidemiology of Scorpion Envenomation in the South of Tunisia
Scorpion envenomation is still a frequent occurance in tropical and subtropical regions. In Tunisia, multiple studies on scorpion envenoming have contributed to an improved understanding of cardiac dysfunction and factors predictive of poor prognosis. These previous studies have contributed to the current standardized management of envenomed patients. However, the epidemiology of scorpion envenoming in Tunisia has not been updated for more than 10 years. The aim of this study was to report an update of the epidemiological features of scorpion envenomation in the southern region of Tunisia.Common Bite—Bizarre Rash
A 21-year-old man with no significant medical history presented to a travel medicine clinic with an itchy rash. Both anterior thighs were itchy, red, warm, and swollen. There was a large bulla on the anterior aspect of the left thigh. He had been bitten by mosquitoes on both thighs less than 24 h previously. What is your diagnosis?Prevention of Friction Blisters in Outdoor Pursuits: A Systematic Review
The purpose of this systematic review was to determine if sock, antiperspirant, or barrier strategies were effective in prevention of friction blisters in wilderness and outdoor pursuits. A search of PubMed and EMBASE was conducted. Title, abstract, and full text articles were screened by 2 authors using predetermined inclusion and exclusion criteria to identify prospective controlled trials investigating prevention methods for friction blisters involving the foot. Only blisters associated with wilderness and outdoor pursuits (running, hiking, marching, etc.) were considered.A Novel Cooling Method and Comparison of Active Rewarming of Mildly Hypothermic Subjects
To compare the effectiveness of arteriovenous anastomosis (AVA) vs heated intravenous fluid (IVF) rewarming in hypothermic subjects. Additionally, we sought to develop a novel method of hypothermia induction.
