Sanjeev Malik

Postexercise Peripheral Oxygen Saturation After Completion of the 6-Minute Walk Test Predicts Successfully Reaching the Summit of Aconcagua

OBJECTIVE The 6-minute walk test (6MWT) is a single measurement of functional status in patients with cardiovascular disease. It has not been studied at high altitude. We investigate the screening value of 6-minute walk distance (6MWD) and postexercise vital sign (VS) measurements as predictors of successfully reaching the summit or development of acute mountain sickness (AMS) on Aconcagua (6962 m). METHODS Prospective observational cohort in Aconcagua Provincial Park, Argentina. Adults climbing the normal route who registered with base camp physicians were included. There were no exclusion criteria. VSs were measured before (resting) and after (postexercise) completion of 6MWT while volunteers acclimatized at Plaza de Mulas base camp (4365 m). Volunteers proceeded towards the summit at their own pace and upon descent returned a questionnaire with maximum altitude reached and Lake Louise AMS Self-report Score (LLSelf). RESULTS One hundred twenty-four volunteers completed the 6MWT. Sixty-four volunteers (51.6%) completed questionnaires; 56% summited. Median LLSelf was 4 (IQR: 3.0-6.5). There was no association between any resting or postexercise VS measurements and AMS. However, mean postexercise SpO(2) was 80.8% in summiters and 76.4% in nonsummiters, a difference of -4.4% (95% CI: -6.7 to -2.0, p = 0.0005). Postexercise SpO(2) < 75% had 97.2% sensitivity and negative likelihood ratio of 0.086 in predicting the outcome of successfully reaching the summit: only one climber with SpO(2) < 75% successfully reached the summit. CONCLUSIONS This study provides the first published data on 6MWD recorded in the field at high altitude. Postexercise SpO(2) < 75% may be a useful screening test for predicting the outcome of successfully reaching the summit of Aconcagua.

Large-volume hypertonic saline therapy in endurance athlete with exercise-associated hyponatremic encephalopathy

BACKGROUND Small-volume boluses of intravenous hypertonic saline are the recommended therapy for exercise-associated hyponatremic encephalopathy (EAHE). Failure to properly diagnose and treat EAHE has been associated with significant morbidity and death. To prevent this, current consensus statement guidelines recommend up to three 100-mL boluses of 3% NaCl spaced at 10-min intervals to correct symptoms. Due to lack of evidence, however, guidelines are vague regarding the maximal volume that can be safely administered in a given time period beyond these initial boluses. OBJECTIVES This case report will review the underlying pathophysiology, clinical presentation, diagnosis, and management of EAHE in a patient refractory to initial treatment. CASE REPORT We report a case of EAHE in an experienced marathon runner requiring large-volume infusion (950 mL) of 3% NaCl therapy for resolution of symptoms without any adverse events. CONCLUSION Although further research is needed, this case may provide helpful information for acute care and sports medicine physicians who encounter patients with EAHE refractory to initial therapy.

Visual Analog Scale (VAS) for Assessment of Acute Mountain Sickness (AMS) on Aconcagua

OBJECTIVE The Lake Louise AMS Self-Report Score (LLSelf) is a commonly used, validated assessment of acute mountain sickness (AMS). We compared LLSelf and visual analog scales (VAS) to quantify AMS on Aconcagua (6962 m). METHODS Prospective observational cohort study at Plaza de Mulas base camp (4365 m), Aconcagua Provincial Park, Argentina. Volunteers climbing in January 2009 were enrolled at base camp and ascended at their own pace. They completed the LLSelf, an overall VAS [VAS(o)], and 5 individual VAS [VAS(i)] corresponding to the items of the LLSelf when symptoms were maximal. Composite VAS [VAS(c)] was calculated as the sum of the 5 VAS(i). RESULTS A total of 127 volunteers consented to the study. Response rate was 52.0%. AMS occurred in 77.3% of volunteers, while 48.5% developed severe AMS. Median (interquartile range, IQR) LLSelf was 4 (3-7). Median (IQR) VAS(o) was 36 mm (23-59). VAS(o) was linear and correlated with LLSelf: slope = 6.7 (95% CI: 4.4-9.0), intercept = 3.0 (95% CI: -10.0-16.1), ρ = 0.71, τ = 0.55, R(2) = 0.45, p < 0.001. Median (IQR) VAS(c) was 29 (13-44). VAS(c) was also linear and correlated with LLSelf: slope = 5.9 (95% CI: 4.9-6.9), intercept = -0.6 (95% CI: -6.3-5.1), ρ = 0.83, τ = 0.68, R(2) = 0.73, p < 0.001. The relationship between the 5 VAS(i) and LLSelf(i) was less significant and less linear than that between VAS(o), VAS(c), and LLSelf. CONCLUSIONS While both VAS(o) and VAS(c) for assessment of AMS appear to be linear with respect to LLSelf, the amount of scatter within the VAS is considerable. The LLSelf remains the gold standard for the diagnosis of AMS.

Enhancing community disaster resilience through mass sporting events.

Disaster response requires rapid, complex action by multiple agencies that may rarely interact during nondisaster periods. Failures in communication and coordination between agencies have been pitfalls in the advancement of disaster preparedness. Recommendations of the Federal Emergency Management Agency address these needs and demonstrate commitment to successful disaster management, but they are challenging for communities to ensure. In this article we describe the application of Federal Emergency Management Agency guidelines to the 2008 and 2009 Chicago Marathon and discuss the details of our implementation strategy with a focus on optimizing communication. We believe that it is possible to enhance community disaster preparedness through practical application during mass sporting events.

Emergent Evaluation of Injuries to the Shoulder, Clavicle, and Humerus

This article provides a review of the evaluation and treatment of common injuries to the shoulder, humerus, and clavicle in the emergency department (ED) setting. In addition to a focused review of the shoulders physical examination, topics include common emergent injuries such as glenohumeral dislocations, proximal humerus fractures, and acromioclavicular separations as well as less common, but important injuries including pectoralis and biceps tendon injuries and sternoclavicular dislocations. Accurate recognition and management of these injuries is essential in the optimal care of patients in the ED.

The collapsed athlete

As the field of sports medicine has evolved and expanded, emergency preparedness has become a critical skill in the repertoire of the sideline physician. While the large majority of medical encounters are nonemergent and self-limited, both quick recognition and appropriate response to life-threatening conditions are critical to a favorable outcome in a collapsed athlete.

Prior Altitude Experience of Climbers Attempting to Summit Aconcagua

Aconcagua (6962 m) is one of the seven summits and the highest mountain outside of Asia. Climbers of varying experience are drawn to its nontechnical route. Our objective was to detail the prior altitude experience of climbers attempting to summit Aconcagua. We asked all climbers on the normal route of Aconcagua to complete questionnaires with demographics and prior high altitude experience while acclimatizing at Plaza de Mulas base camp during 9 nonconsecutive days in January 2009. 127 volunteers from 22 countries were enrolled. Mean age was 39.8 years and 88.2% were male. Median altitude at place of residence was 200 m (IQR: 30, 700). Median previous maximum altitude reached was 5895 m (IQR: 5365, 6150). 7.1% of climbers had never been above 4000 m. Median previous maximum sleeping altitude was 4800 m (IQR: 4300, 5486). 12.6% of climbers had never slept above 4000 m. Climbers who performed acclimatization treks spent a mean of 3.6 (2.5, 4.7) days at>3000 m in the previous 2 months. However, 50.4% of climbers performed no acclimatization treks. Although the majority of mountaineers who attempt Aconcagua have prior high altitude experience, a substantial minority has never been above 4000 m.

Effectiveness of Resident Physicians as Triage Liaison Providers in an Academic Emergency Department

Introduction Emergency department (ED) crowding is associated with detrimental effects on ED quality of care. Triage liaison providers (TLP) have been used to mitigate the effects of crowding. Prior studies have evaluated attending physicians and advanced practice providers as TLPs, with limited data evaluating resident physicians as TLPs. This study compares operational performance outcomes between resident and attending physicians as TLPs. Methods This retrospective cohort study compared aggregate operational performance at an urban, academic ED during pre- and post-TLP periods. The primary outcome was defined as cost-effectiveness based upon return on investment (ROI). Secondary outcomes were defined as differences in median ED length of stay (LOS), median door-to-provider (DTP) time, proportion of left without being seen (LWBS), and proportion of “very good” overall patient satisfaction scores. Results Annual profit generated for physician-based collections through LWBS capture (after deducting respective salary costs) equated to a gain (ROI: 54%) for resident TLPs and a loss (ROI: −31%) for attending TLPs. Accounting for hospital-based collections made both profitable, with gains for resident TLPs (ROI: 317%) and for attending TLPs (ROI: 86%). Median DTP time for resident TLPs was significantly lower (p<0.0001) than attending or historical control. Proportion of “very good” patient satisfaction scores and LWBS was improved for both resident and attending TLPs over historical control. Overall median LOS was not significantly different. Conclusion Resident and attending TLPs improved DTP time, patient satisfaction, and LWBS rates. Both resident and attending TLPs are cost effective, with residents having a more favorable financial profile.

Medical Care at a Large Vertical Running Event

Abstract Objective: Vertical running events, during which participants race up the stairwells of skyscrapers, are becoming increasingly popular. Such events have unique and specific operational and clinical considerations for event medical directors, but descriptions of the medical care provided at these events are lacking. We sought to perform a descriptive analysis of the medical care delivered at a single, large vertical running event. Methods: A retrospective chart review of medical encounters at a large vertical running event from 2011–2017 was performed. Participants competed in either the full course (94 stories) or half course (54 stories); potential patients also included observers. Medical staffing included a main medical station at the finish line, medical way stations along the routes (within stairwells), and medical response teams. Descriptive statistics were used for analysis. Results: During the study period, a total of 23,920 participants completed the event, with 84.6% participating in the full course. Medical staff treated 150 unique patients during 154 medical encounters (0.6% treatment rate). The median age of patients was 36 (IQR 27, 43), and 40.3% were male. Most encounters (66.4%) occurred at the finish line main medical area. Of medical encounters occurring along the race routes, 56.1% of encounters occurred before the halfway point in the full course. Encounters were clustered around medical way stations along the half course. The most common chief complaints were gastrointestinal (27.3%), respiratory (25.3%), syncope/near-syncope (24.7%), trauma (12.3%), and chest pain (10.4%). One cardiac arrest was observed. The most frequent interventions were oral fluids or food (40.3%), respiratory care (18.2%), and minor trauma care (12.3%). An electrocardiogram (ECG) was obtained in 10.4% of encounters, and intravenous fluids were started on 1.9% of patients. Eleven patients (7.3% of treated patients and 0.05% of all participants) were transported by ambulance. Conclusions: Medical encounters during vertical running events, the majority of which are not life-threatening, mainly occur at the finish line but can occur at any point along the route. Understanding the nature and location of medical encounters along a vertical running event route can help inform event medical directors supervising care at these increasingly popular events.

The care of VIPs in the emergency department: Triage, treatment and ethics

Abstract People identified as Very Important Persons (VIPs) often present or are referred to the Emergency Department (ED). Celebrities are a small subset of this group, but many others are included. Triage of these patients, including occasional prioritization, creates practical and ethical challenges. Treatment also provides challenges with the risks of over testing, overtreatment, over consultation, and over or under admission to the hospital. This article presents a practical and ethical framework for addressing the care of VIPs in the ED.