Lori Weichenthal

Altitude-related illness in two California national parks

High-altitude illness encompasses a spectrum of disorders related to the hypoxia experienced by individuals at elevation. Altitude-related illness has been well described in the United States, but there are no studies published in the medical literature looking at the occurrence of high-altitude illness within the US National Parks system. The purpose of this study is to describe the incidence, treatment, and outcomes of visitors to Sequoia and Kings Canyon National Parks who presented to emergency medical services (EMS) personnel with signs and symptoms consistent with high-altitude illness. We conducted a retrospective review of all EMS patient care records (PCRs) from Sequoia and Kings Canyon National Parks during the study period of June 1992 to August 1995. There were 23 cases of altitude-related illness identified by EMS personnel in the parks during the 38-month study period, including five cases of high-altitude pulmonary edema and 19 cases of acute mountain sickness. One patient died, nine patients were transported to local hospitals, nine patients were assisted in their descent and then released from medical care, and four patients were treated and then allowed to continue their travels. There was an average of 5.9 cases per year of high-altitude illness and an incidence of one case per 27 EMS contacts. We conclude that altitude-related illness does occur in Sequoia and Kings Canyon National Parks and, although high-altitude illness accounts for only 4% of EMS contacts, caring for these patients uses a significant amount of national park resources. We suggest continued training of emergency medical technicians and park medics in the recognition and treatment of these disorders. We also support education of hikers to reduce or prevent the morbidity associated with altitude-related illness.

Core content for wilderness medicine fellowship training of emergency medicine graduates

Wilderness medicine is the practice of resource-limited medicine under austere conditions. In 2003, the first wilderness medicine fellowship was established, and as of March 2013, a total of 12 wilderness medicine fellowships exist. In 2009 the American College of Emergency Physicians Wilderness Medicine Section created a Fellowship Subcommittee and Taskforce to bring together fellowship directors, associate directors, and other interested stakeholders to research and develop a standardized curriculum and core content for emergency medicine (EM)-based wilderness medicine fellowships. This paper describes the process and results of what became a 4-year project to articulate a standardized curriculum for wilderness medicine fellowships. The final product specifies the minimum core content that should be covered during a 1-year wilderness medicine fellowship. It also describes the structure, length, site, and program requirements for a wilderness medicine fellowship.

The effect of mandatory nurse ratios on patient care in an emergency department.

BACKGROUND In 2004, California enacted mandatory nurse-to-patient ratios in an effort to improve patient care. OBJECTIVES The aim of the study was to look at the association between nursing ratios and quality of care in an urban teaching Emergency Department (ED). METHODS This was an observational study, looking at indicators of quality care before and after the introduction of nursing ratios in an urban California ED serving a mainly indigent population. Indicators examined included wait times; patients who left without being seen (LWBS); medication errors; acute coronary syndrome (ACS) patients receiving aspirin; and time to antibiotics in pneumonia patients. Means and proportions were analyzed using t-tests and chi-squared, as appropriate. RESULTS All measured wait times increased significantly in 2004 compared to 2003, including room time (from 79 to 123 min, p = 0.0001), throughput time (from 365 to 397 min, p = 0.001), and admission time (from 447 to 552 min, p = 0.0001). Patients who LWBS decreased (from 11.9 % to 11.2%, p = 0.0002). Time to antibiotics in pneumonia patients decreased (from 103 to 62 min, p = 0.002). There were no statistically significant differences in medication errors or administration of aspirin in ACS patients. CONCLUSIONS All wait times increased after implementation of mandatory nursing ratios. Some indicators of quality care improved, whereas others showed no measurable differences. Further research is needed to further define the effect of nursing ratios on quality of patient care.

Lightning Safety Awareness of Visitors in Three California National Parks

OBJECTIVE To assess the level of lightning safety awareness among visitors at 3 national parks in the Sierra Nevada Mountains of California. METHODS A 12-question, short answer convenience sample survey was administered to participants 18 years of age and over concerning popular trails and points of interest with known lightning activity. There were 6 identifying questions and 5 knowledge-based questions pertaining to lightning that were scored on a binary value of 0 or 1 for a total of 10 points for the survey instrument. Volunteers in Fresno, California, were used as a control group. Participants were categorized as Sequoia and Kings Canyon National Park (SEKI), frontcountry (FC), or backcountry (BC); Yosemite National Park (YNP) FC or BC; and Fresno. Analysis of variance (ANOVA) was used to test for differences between groups. RESULTS 467 surveys were included for analysis: 77 in Fresno, 192 in SEKI, and 198 in YNP. National park participants demonstrated greater familiarity with lightning safety than individuals from the metropolitan community (YNP 5.84 and SEKI 5.65 vs Fresno 5.14, P = .0032). There were also differences noted between the BC and FC subgroups (YNP FC 6.07 vs YNP BC 5.62, P = .02; YNP FC 6.07 vs SEKI FC 5.58, P = .02). Overall results showed that participants had certain basic lightning knowledge but lacked familiarity with other key lightning safety recommendations. CONCLUSIONS While there are statistically significant differences in lightning safety awareness between national parks and metropolitan participants, the clinical impact of these findings are debatable. This study provides a starting point for providing educational outreach to visitors in these national parks.

Motion Sickness: Comparison of Metoclopramide and Diphenhydramine to Placebo

OBJECTIVES This is an evaluation of the efficacy of metoclopramide (MTCP) or diphenhydramine (DPH) to relieve symptoms of motion sickness in patients being transported via ambulance in a mountainous setting. METHODS This is a prospective, randomized, double-blinded, placebo-controlled study of patients transported by ambulance in the Sierra Nevada mountains of Fresno County. Consenting patients who met the inclusion criteria were asked to rate their motion sickness every five minutes using a visual analog scale (VAS) during transport. If motion sickness occurred, they were randomized to receive MTCP (20 mg IV), DPH (50 mg IV), or placebo (normal saline), and remaining symptoms were recorded every five minutes. If signs and symptoms of motion sickness persisted after 15 minutes, a rescue dose of MTCP was offered. RESULTS Twenty-six patients were enrolled in the study. Twenty-two (84.6%) developed motion sickness and were randomized to MTCP, DPH, or placebo. Eight patients received MTCP, seven received DPH, and seven received placebo. The MTCP group showed a statistically significant decrease in the mean VAS score at 15 minutes compared to the DPH and placebo groups. There was no significant difference in the decrease in VAS score between the placebo and the DPH group. Twelve out of 22 patients requested a rescue dose of MTCP after 15 minutes. At 25 minutes, there was no significant difference in the VAS score between the three groups. CONCLUSION During ambulance transport in a mountainous setting, the administration of MTCP is superior to both DPH and placebo in the treatment of motion sickness. Diphenhydramine is not superior to placebo.

Needle Thoracostomy in the Prehospital Setting: A Retrospective Observational Study

Abstract Background: The use of needle thoracostomy (NT) is a common prehospital intervention for patients in extremis or cardiac arrest due to trauma; however, controversy surrounds its use. The purpose of this study is to compare outcomes, effectiveness, and complications of NT in an Emergency Medical Services (EMS) system that includes urban, rural, and wilderness environments. Methods: This is a retrospective observational study of all patients who had NT performed in a four county EMS system with a catchment area of greater than 1.6 million people. All prehospital records where NT was performed were queried for demographics, mechanism of injury, initial status, and clinical change following NT. Hospital records were queried for exam findings on arrival to the hospital, any complications from NT, and final outcome. The Trauma Registry was accessed to obtain Injury Severity Scores. Information was manually abstracted by study investigators and univariate analysis utilizing chi-squared and two-tailed t-tests were initially conducted before a multivariate analysis was conducted utilizing a binary logistic regression model. Results: A total of 169 patients with a mean age of 38 years were included in this study; 87% were male and 61% sustained blunt trauma. The overall mortality rate was 79%; 77% in the blunt trauma group; and 83% in the penetrating group, with no significant difference between the two groups relative to mortality (p = 0.336). There was a significant difference in survival between patients who were initially presented as a stat trauma versus as a trauma arrest (52% versus 99%, p > 0.001). The multivariate model with regard to survival supported that reported clinical change after NT (p = 0.001) and status (p = 0.0001) are important indicators of survival. No complications from NT were reported. Conclusions: NT can safely be performed by paramedics in an EMS system that includes urban, rural, and wilderness settings. Its efficacy does not differ between patients suffering from blunt versus penetrating trauma; however, it appears most beneficial for patients who are unstable but still have vital signs.

Teaching Methods Utilized During Medical Resuscitations in an Academic Emergency Department

Introduction One important skill that an emergency medicine trainee must learn is the resuscitation of the critically ill patient. There is research describing clinical teaching strategies used in the emergency department (ED), but less is known about specific methods employed during actual medical resuscitations. Our objective was to identify and describe the teaching methods used during medical resuscitations. Methods This was a prospective study involving review of 22 videotaped, medical resuscitations. Two teams of investigators first each reviewed and scored the amount and types of teaching observed for the same two videos. Each team then watched and scored 10 different videos. We calculated a Cohen’s kappa statistic for the first two videos. For the remaining 20 videos, we determined means and standard deviations, and we calculated independent two-tailed t-tests to compare means between different demographic and clinical situations. Results The Cohen’s kappa statistic was K=0.89 with regard to number of teaching events and K=0.82 for types of teaching observed. Of the resuscitations reviewed, 12 were in coding patients. We identified 148 episodes of teaching, for an average of 7.4 per resuscitation. The amount of teaching did not vary with regard to whether the patient was coding or not (p=0.97), nor based on whether the primary learner was a junior or senior resident (p=0.59). Questioning, affirmatives and advice-giving were the most frequently observed teaching methods. Conclusion Teachers use concise teaching methods to instruct residents who lead medical resuscitations. Further research should focus on the effectiveness of these identified strategies.

Needle Thoracostomy for Patients with Prolonged Transport Times: A Case-control Study

UNLABELLED Introduction The use of prehospital needle thoracostomy (NT) is controversial. Some studies support its use; however, concerns exist regarding misplacement, inappropriate patient selection, and iatrogenic injury. Even less is known about its efficacy in situations where there is a delay to definitive care. Hypothesis/Aim To determine any differences in survival of patients who underwent NT in the setting of prolonged versus short transport times, and to describe differences in mechanisms and complications between the two groups. METHODS This was a retrospective, matched, case-control study of trauma patients in a four county Emergency Medical Service (EMS) system from April 1, 2007 through April 1, 2013. This system serves an urban, rural, and wilderness catchment area. A prehospital database was queried for all patients in whom NT was performed, identifying 182 patients. When these calls were limited to those with prolonged transport times, the search was narrowed to 32 cases. A matched control group, based on age and gender, with short transport times was then created as a comparison. Data collected from prehospital and hospital records included: demographics; mechanism of injury; call status; response to NT; and final outcome. Univariate and multivariate analyses were conducted, as appropriate, to assess the primary outcome of survival and to further elucidate the descriptive data. RESULTS There was no difference in survival between the case and control groups, either when evaluated with univariate (34% vs 25%; P=.41) or multivariate (odds ratio=0.99; 95% CI, 0.96-1.02; P=.57) analyses. Blunt trauma was the most common mechanism in both groups, but penetrating trauma was more common in the control group (30% vs 9%; P=.003). Patients in the control group were also more likely to have no vital signs on initial assessment (62% vs 31%; P=.003). More patients in the case group were described as having clinical improvement after NT (34% vs 19%; P=.03). No complications of NT were reported in either group. CONCLUSIONS There was no significant difference in survival between patients with prolonged versus short transport times who underwent NT. Patients with prolonged transport times were more likely to have sustained blunt trauma, have vital signs on EMS arrival, and to have clinical improvement after NT.

Where wilderness, medicine, technology, and religion collide.

We report a case of a man injured in Yosemite National Park (YNP) whose use of technology and refusal of medical care, based on his Christian Science religious beliefs, created multiple challenges to the providers working to rescue and care for him. This case illustrates how our increasingly diverse and complex world requires flexibility and openness to provide the optimal care, both in the wilderness and in the front country.

Improvised Traction Splints: A Wilderness Medicine Tool or Hindrance?

OBJECTIVES To investigate whether a traction splint made from improvised materials is as efficacious as commercially available devices in terms of traction provided and perceived comfort and stability. METHODS This was a prospective randomized crossover study utilizing 10 healthy, uninjured volunteers. The subjects were randomized to be placed in 4 different traction devices, in differing order, each for 30 minutes. Three of the traction splints are commercially available: The HARE, Sager, and Faretech CT-EMS. The fourth traction device was an improvised splint made as described in Medicine for the Backcountry: A Practical Guide to Wilderness First Aid. At the end of 30 minutes the pounds of force created by each device was measured. The volunteers were also asked at that time to subjectively report the comfort and stability of the splint separately on a scale from 1 to 10. RESULTS All traction splints performed similarly with regard to the primary outcome measure of mean pounds of traction created at the end of 30 minutes of application with results ranging from 10.4 to 13.3 pounds. There was little difference reported by participants in regard to stability or comfort between the 4 traction devices. CONCLUSIONS In this small pilot study, an improvised traction splint was not inferior to commercially available devices. Further research in needed in this area.