Joseph H. Kahn

The Impact of Footwear and Packweight on Injury and Illness Among Long-Distance Hikers

Abstract Objective.—To determine the prevalence and predictors of injury and illness among long-distance hikers. Methods.—This was a cross-sectional study of long-distance hikers (>500 miles [805 km]) along the Appalachian Trail and Pacific Crest Trails between August and October of 2006. An 8-page survey instrument was made available to hikers at a designated station near the northern terminus of the respective trails. The survey questions were yes/no or multiple choice. Independent variables included packweight, footwear, and type and frequency of water purification. χ2 tests to compare categorical data and the Cochran-Armitage test for trend were used (P < .05 significant). We used logistic regression to compare the variables concurrently, and significance was determined using likelihood ratio tests. Profile likelihood confidence intervals for the odds ratios are reported. Results.—Of the 128 hikers completing surveys that met inclusion criteria, the mean age was 33 years (range  =  18–65 years), 94% walked >1500 miles (2400 km), and 70% were male. Using univariate analysis, trends were noted in the proportion of hikers reporting paresthesias and increasing packweight (35% with 10–20 pound [4.5–9 kg] packs, 50% with 21–30 pound [9.5–13.5 kg] packs, and 69% with >31 pound [14 kg] packs [P < .002]), as well as in the proportion of hikers reporting paresthesias and increasing footwear rigidity (29% sandals, 36% running shoes, 42% hiking shoes, and 68% hiking boots [P < .001]). In multivariate analysis compared to sandals, the odds ratio of suffering from paresthesias with running shoes was 1.57 (95% CI 0.3, 12.2), hiking shoes 1.73 (95% CI 0.3, 13.9), and hiking boots 3.9 (95% CI 0.7, 32.1) (P  =  .16). Compared to 10 to 20 pound (4.5–9 kg) packs, the odds ratios of suffering from paresthesias with 21 to 30 pound (9.5–13.5 kg) packs was 1.5 (95% CI 0.6, 3.9), and for >31 pounds (14 kg) was 2.2 (CI 0.7, 7.1) (P  =  .03). Adjusting for footwear and pack weight, only pack weight was significantly associated with paresthesias. Packweight and footwear were not significantly associated with other musculoskeletal injuries, such as joint sprains or chronic pain, and muscle injuries. Conclusions.—There is an association between packweight and the prevalence of paresthesias among long-distance hikers. The association between type of footwear and the prevalence of paresthesias is significant when analyzed independently, but loses its significance when the variables are examined together. This suggests that there is confounding between footwear and packweight.

The Physical Examination of the Eye

This article is a review of the anatomy of the eye and its surrounding tissues. A working knowledge of the functional anatomy of the eye will aid the emergency physician in performing a thorough yet efficient physical examination of the eye. A goal-directed physical examination of the eye will allow the emergency physician to attempt to identify (or exclude) visionthreatening disease processes and facilitate communication with the ophthalmologist.

The management of stab wounds to the back

The management of stab wounds to the back is controversial. There are certain clear indications for exploratory laparotomy, but most cases require a diagnostic workup and a period of observation. In this article, different diagnostic modalities are presented, including local wound exploration, diagnostic peritoneal lavage, abdominal computed tomography (CT) scan, triple-contrast abdominal CT scan, and intravenous pyelography (IVP). Recommendations for management are given, with emphasis on abdominal CT scan and observation.

Basic neuroanatomy and stroke syndromes.

Stroke should not solely be considered a disease of the elderly, and racial disparities are most evident among young adults. Acute stroke can present at any age and it is important to be familiar with the evaluation and treatment of stroke to provide timely care. The National Institute of Health Stroke Scale helps physicians objectively evaluate stroke patients. This article presents an overview of basic information on neuroanatomy, pathophysiology, and stroke syndromes.

Geriatric Emergency Medicine: Principles and Practice

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Current Trends in Geriatric Emergency Medicine

The number of geriatric visits to United States emergency departments continues to rise. This article reviews demographics, statistics, and future projections in geriatric emergency medicine. Included are discussions of US health care spending, geriatric emergency departments, prehospital care, frailty of geriatric patients, delirium, geriatric trauma, geriatric screening and prediction tools, medication safety, long-term care, and palliative care.

Professional Liability Insurance

This article introduces the emergency physician to professional liability insurance: the type of insurance, whether it is the only type available in the region, and, if claims-made insurance, whether the tail coverage rate is reasonable; the limits of liability and whether these are appropriate for emergency medicine in the region; the policy exclusions and restrictions; the insurance companys financial strength; whether an attorney is provided for a claim, whether fees are covered by the policy, whether they are subtracted from the policy limit, whether the physician can choose a defense attorney, and whether the physicians consent is required for the insurance company to settle a case.

Risk management. Preface.

The vast majority of emergency physicians are well trained, highly skilled, competent, and compassionate. Nevertheless, litigation is a constant threat to the practicing emergency physician. The very nature of the practice of emergency medicine makes adverse outcomes unavoidable. We often have no knowledge of the preexisting medical conditions of the patients we treat. Many of our patients have no access to essential medical care, causing them to present late in the course of disease. Further complicating the picture is the high number of repeat emergency department patients who often lull us into a false sense of security because of absence of serious medical conditions on prior visits. Lack of an ongoing relationship with the patient and family makes litigation more likely when adverse outcomes occur. In this issue, we have attempted to provide some principles of emergency medical practice that may help avoid litigation. The article on clinical practice guidelines provides a framework for when guidelines should be followed and when it is acceptable to deviate from them. The article on professional liability insurance discusses what types of malpractice insurance is available to emergency practitioners, and reviews the amount of settlements and judgments issued in recent years. The article on the legal process describes in detail the process of being a defendant or an expert witness in a malpractice action. The article on emergency department overcrowding describes perhaps the most pervasive problem in emergency medicine today, with strategies for lowering risk. The article on informed consent provides insights into dealing with patients who refuse treatment and for determining whether these patients have the capacity to refuse treatment. The article also touches on alternative care plans and implied consent. Physician review will soon become a required component of board certification and hospital credentialing in emergency medicine, and the article on this important topic describes the latest state and federal agency requirements. The article on the Emergency Medical Treatment and Active Labor Act (EMTALA) gives a current description of what emergency physicians should do to remain in compliance of this federal ‘‘anti-dumping law.’’ The article on documentation and communication covers the key issues of how to minimize risk and bad outcomes during change of shift, admission, and discharge of patients. It also focuses on the importance of thorough, concise, and clear charting, which is too often ignored in the practice of emergency medicine.

Afterword: High Success Approach

Emergency physicians care for a high volume of critically ill and injured patients, generally with no prior knowledge of patients’ histories and, usually, with little or no warning of patients’ arrival. Despite the careful, knowledgeable, compassionate practice of most emergency physicians, bad outcomes will occur. There is no way to completely avoid being named in a malpractice suit because a patient, patient’s family, or patient’s estate may sue despite the emergency physician’s best efforts. However, there are some principles that may help minimize adverse outcomes and avoid litigation.