Jeremy Joslin

Managing Collapsed or Seriously Ill Participants of Ultra-Endurance Events in Remote Environments

Increasing participation in ultramarathons and other ultra-endurance events amplifies the potential for serious medical issues during and immediately following these competitions. Since these events are often located in remote settings where access may be extremely limited; the diagnostic capabilities, treatment options, and expectations of medical care may differ from those of urban events. This work outlines a process for assessment and treatment of athletes presenting for medical attention in remote environments, with a focus on potentially serious conditions such as major trauma, acute coronary syndrome, exertional heat stroke, hypothermia, hypoglycemia, exercise-associated hyponatremic encephalopathy, severe dehydration, altitude illness, envenomation, anaphylaxis, and bronchospasm. A list of suggested medical supplies is provided and discussed. But, given that diagnostic and treatment options may be extremely limited in remote settings, it is important for medical providers to understand how to assess and manage the most common serious medical issues with limited resources, and to be prepared to make presumptive diagnoses when necessary.

Coca: The History and Medical Significance of an Ancient Andean Tradition

Coca leaf products are an integral part of the lives of the Andean peoples from both a cultural and traditional medicine perspective. Coca is also the whole plant from which cocaine is derived. Coca products are thought to be a panacea for health troubles in regions of South America. This review will examine the toxicology of whole coca and will also look at medicinal applications of this plant, past, present, and future.

Incidence and characteristics of snakebite envenomations in the New York State between 2000 and 2010

OBJECTIVE We sought to evaluate the incidence of reported venomous snakebites in the state of New York between 2000 and 2010. METHODS Data were collected retrospectively from the National Poison Data System (NPDS) and then reviewed for species identification and clinical outcome while using proxy measures to determine incidence of envenomation. RESULTS From 2000 to 2010 there were 473 snakebites reported to the 5 Poison Control Centers in the state of New York. Venomous snakes accounted for 14.2% (67 of 473) of these bites. Only 35 bites (7%) required antivenom. The median age of those bitten by a venomous snake was 33. Most victims were male. CONCLUSIONS Although not rare, venomous snakebites do not occur commonly in New York State, with a mean of just 7 bites per year; fortunately most snakebites reported are from nonvenomous snakes. Yet even nonvenomous bites have the potential to cause moderately severe outcomes. Medical providers in the state should be aware of their management.

Should AED Devices Be Routinely Included in Wilderness Medical Kits

Medical directors of wilderness expeditions and competitive adventure events are often faced with the difficult question of medical necessity for devices such as the automated external defibrillator (AED). Even with increasing availability and portability of the AED, arguments can still be made against the routine inclusion of an AED in expedition or adventure equipment lists. We hope to articulate several of these arguments below.

A prospective evaluation of the contribution of ambient temperatures and transport times on infrared thermometry readings of intravenous fluids utilized in EMS patients

BackgroundDuring cold weather months in much of the country, the temperatures in which prehospital care is delivered creates the potential for inadvertently cool intravenous fluids to be administered to patients during their transport and care by emergency medical services (EMS). There is some potential for patient harm from unintentional infusion of cool intravenous fluids. Prehospital providers in these cold weather environments are likely using fluids that are well below room temperature when prehospital intravenous fluid (IVF) warming techniques are not being employed. It was hypothesized that cold ambient temperatures during winter months in the study location would lead to the inadvertent infusion of cold intravenous fluids during prehospital patient care.MethodsTrained student research assistants obtained three sequential temperature measurements using an infrared thermometer in a convenience sample of intravenous fluid bags connected to patients arriving via EMS during two consecutive winter seasons (2011 to 2013) at our receiving hospital in Syracuse, New York. Intravenous fluids contained in anything other than a standard polyvinyl chloride bag were not measured and were not included in the study. Outdoor temperature was collected by referencing National Weather Service online data at the time of arrival. Official transport times from the scene to the emergency department (ED) and other demographic data was collected from the EMS provider or their patient care record at the time of EMS interaction.ResultsTwenty-three intravenous fluid bag temperatures were collected and analyzed. Outdoor temperature was significantly related to the temperature of the intravenous fluid being administered, b = 0.69, t(21) = 4.3, p < 0.001. Transport time did not predict the measured intravenous fluid temperatures, b = 0.12, t(20) = 0.55, p < 0.6.ConclusionsUse of unwarmed intravenous fluid in the prehospital environment during times of cold ambient temperatures can lead to the infusion of cool intravenous fluid and may result in harm to patients. Short transport times do not limit this risk. Emergency departments should not rely on EMS agencies’ use of intravenous fluid warming techniques and should consider replacing EMS intravenous fluids upon ED arrival to ensure patient safety.

Mandatory Rest Stops Improve Athlete Safety during Event Medical Coverage for Ultramarathons

INTRODUCTION Provisions of medical direction and clinical services for ultramarathons require specific attention to heat illness. Heat stress can affect athlete performance negatively, and heat accumulation without acclimatization is associated with the development of exertional heat stroke (EHS). In order to potentially mitigate the risk of this safety concern, the Jungle Marathon (Para, Brazil) instituted mandatory rest periods during the first two days of this 7-day, staged, Brazilian ultramarathon. METHODS Race records were reviewed retrospectively to determine the number of runners that suffered an emergency medical complication related to heat stress and did not finish (DNF) the race. Review of records included three years before and three years after the institution of these mandatory rest periods. RESULTS A total of 326 runners competed in the Jungle Marathon during the 2008-2013 period of study. During the pre-intervention years, a total of 46 athletes (21%) DNF the full race with 25 (54.3%) cases attributed to heat-related factors. During the post-intervention years, a total of 26 athletes (24.3%) DNF the full race with four (15.4%) cases attributed to heat-related factors. CONCLUSION Mandatory rest stops during extreme running events in hot or tropical environments, like the Jungle Marathon, are likely to improve athlete safety and improve the heat acclimatization process.

Use of the Vocera Communications Badge Improves Public Safety Response Times

Objectives. Violence in the Emergency Department (ED) has been a long-standing issue complicated by deficiencies in staff training, ease of weapons access, and response availability of public safety officers. The Vocera Badge is being used by our staff to request public safety assistance in lieu of a formal phone call to the University Police Communications Center. We sought to learn if use of this technology improved officer response times to the ED. Methods. Mean response times were reviewed and descriptive statistics analyzed to determine if the use of the Vocera Badge improved public safety officer response times to the ED. Results. Average response times improved from an average of 3.2 minutes (SD = 0.456) in the 6 months before the use of the communication badges to an average of 1.02 minutes (SD = 0.319) in the 6 months after use began. Conclusions. The use of the Vocera Badge seemed to decrease response times of public safety officers to our ED compared with the traditional method of calling a dispatch center to request assistance.

Coca: High Altitude Remedy of the Ancient Incas

The use of coca leaf for medicinal purposes is a centuries-old tradition of the native peoples of South America. Coca products are thought by many laypersons to provide risk-free benefits to users participating in strenuous activities at high altitude. Physiologic studies of coca have increased understanding of its possible mechanism of action as well as its potential impact on high altitude activities. This present work explores the role of coca throughout the history of the Andean peoples and explores whether this ancient remedy has a place in modern medicine. A focused summary of research articles with particular relevance to the field of wilderness medicine is also included to better provide the reader with lessons not only from history but also from another culture.

Special Considerations in Medical Screening for Participants in Remote Endurance Events

As participation at remote endurance events increases, so does the need to screen participants for potentially problematic medical conditions, but this process has been ill-defined to date. This article aims to outline a general approach to screening and discusses common or important medical conditions that may need consideration in the screening process. Medical conditions that are considered low risk may translate to high-risk conditions in the setting of a remote and austere location. Medical directors of remote endurance events should have a familiarity with assessing risks and applying informed consent principles to participation. While there are no specific standards on medical disqualification from an event based on medical history alone, several systematic considerations should be made that allow for an assessment of risk to an individual for a specific event. The medical director and event director, in discussion with the athlete and treating clinician when appropriate, should come to a consensus on participation when high-risk medical conditions become apparent during the screening process. Both modifications and accommodations to participation may be used to mitigate both clinical and medicolegal risk and allow for participation.

Do free or low-cost antibiotic promotions alter prescription filling habits?

Objective Because free sample of prescription medications have been shown to influence prescribing habits of physicians, we sought to discern if promotional efforts of a retail pharmacy influenced prescriptions filled in our county after a free antibiotic program was initiated. Methods Retrospective analysis of prescription antibiotics filled throughout the county was performed. Prescriptions filled during the first 6 months of the year before the program was initiated were compared to prescriptions filled during the first 6 months of the year immediately following initiation of the promotion. Results A total of 436,372 antibiotic prescriptions were dispensed during that time. The number of antibiotics filled that were included in the promotion increased by 13.4% while the number of antibiotics filled that were excluded from the promotion decreased by 20.4%. Conclusion These data suggest that the promotional pricing of the antibiotics had a significant impact on the number of prescriptions filled in each category. Because a prescription written does not always equate to a prescription filled, further investigation is needed to confirm the relationship between these promotions and actual prescriber habits.