Scott E. McIntosh

Wilderness medical society consensus guidelines for the prevention and treatment of acute altitude illness

To provide guidance to clinicians about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the prevention and treatment of acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE). These guidelines present the main prophylactic and therapeutic modalities for each disorder and provide recommendations for their roles in disease management. Recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches to the prevention and management of each disorder that incorporate these recommendations.

Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2014 Update

To provide guidance to clinicians about best practices, the Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for prevention and treatment of acute mountain sickness, high altitude cerebral edema, and high altitude pulmonary edema. These guidelines present the main prophylactic and therapeutic modalities for each disorder and provide recommendations about their role in disease management. Recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches to prevention and management of each disorder that incorporate these recommendations. This is an updated version of the original WMS Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness published in Wilderness & Environmental Medicine 2010;21(2):146-155.

Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Frostbite

The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for the prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks/burdens for each modality according to methodology stipulated by the American College of Chest Physicians.

Wilderness Medical Society Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2014 Update

To provide guidance to clinicians, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the out-of-hospital evaluation and treatment of victims of accidental hypothermia. The guidelines present the main diagnostic and therapeutic modalities and provide recommendations for the management of hypothermic patients. The panel graded the recommendations based on the quality of supporting evidence and the balance between benefits and risks/burdens according the criteria published by the American College of Chest Physicians. The guidelines also provide suggested general approaches to the evaluation and treatment of accidental hypothermia that incorporate specific recommendations.

Cause of Death in Avalanche Fatalities

Abstract Objective.—Avalanches pose a life-threatening risk to participants of outdoor winter activities. Determining the causes of death in avalanche fatalities can aid rescue and resuscitation strategies and hopefully improve survival. Methods.—The study population included all avalanche fatalities in Utah from the 1989–90 to 2005–06 winter seasons. The Utah Avalanche Center and Medical Examiner records were reviewed to identify accident circumstances, autopsy findings, and causes of death. Results.—Fifty-six avalanche deaths were identified during the study period. Most deaths occurred while participating in recreational backcountry activities; 85.7% of deaths were due to asphyxiation, 8.9% were due to a combination of asphyxiation and trauma, and 5.4% were due to trauma alone. Head injuries were frequent in those killed solely by trauma. Conclusions.—Most avalanche deaths in Utah result from asphyxia. Therefore, most victims are alive in the postavalanche period and have the potential for live recovery. Rescue strategies that employ rapid recovery as well as techniques that prolong survival while buried provide the best means of improving outcome.

Medical Incidents and Evacuations on Wilderness Expeditions

Abstract Category 1 Continuing Medical Education credit for physicians is available to Wilderness Medical Society members for this article. Go to http://wms.org/cme/cme.asp?whatarticle=1843 to access the instructions and test questions. Objective.—Expedition activities such as mountaineering, rock climbing, river running, sea kayaking, and canoeing all involve an element of risk. Organizations that provide group wilderness and adventure experiences are responsible for managing the risk of their courses. The leaders and medical providers of these trips must therefore be prepared to anticipate and manage medical problems that may arise. The aim of this study is to provide the medical community with a better understanding of the specific injuries and illnesses that occur on wilderness expeditions. Methods.—A retrospective descriptive study was done examining the medical incidents that occurred on wilderness-based courses during the 3-year period from September 1, 2002, through August 31, 2005. Participants and staff of the National Outdoor Leadership School (NOLS) served as the study population. Results.—Injuries occurred at a rate of 1.18 per 1000 program days, and illnesses at a rate of 1.08 per 1000 program days. There were no fatalities during the time period. Athletic injuries (sprains, strains) and gastrointestinal illnesses were the most common medical incidents. Hypothermia, seizures, appendicitis, heat stroke, and pregnancy occurred but with low frequency. Fractures, dental emergencies, tick fever, athletic injuries, and nonspecific body pains were the conditions most frequently requiring evacuation. Conclusions.—The rate of medical incidents on NOLS courses declined during the 1990s and has remained relatively steady apart from a slight increase in 2004 and 2005. Athletic injuries continue to be a difficulty, as they frequently result in evacuation even though their ultimate outcome is usually benign. Evacuation decisions should be made considering both the potential severity of the medical condition as well as patient comfort. Wilderness medical personnel must be familiar with a diverse range of medical conditions in order to provide optimal care.

Mountaineering fatalities on Denali

Mount McKinley, or Denali, is the tallest mountain in North America and attracts over 1,000 climbers annually from around the world. Since Denali is located within a national park, the National Park Service (NPS) manages mountaineering activities and attempts to maintain a balance of an adventurous experience while promoting safety. We retrospectively reviewed the fatalities on Denali from 1903 to 2006 to assist the NPS, medical personnel, and mountaineers improve safety and reduce fatalities on the mountain. Historical records and the NPS climber database were reviewed. Demographics, mechanisms, and circumstances surrounding each fatality were examined. Fatality rates and odds ratios for country of origin were calculated. From 1903 through the end of the 2006 climbing season, 96 individuals died on Denali. The fatality rate is declining and is 3.08/1,000 summit attempts. Of the 96 deaths, 92% were male, 51% occurred on the West Buttress route, and 45% were due to injuries sustained from falls. Sixty-one percent occurred on the descent and the largest number of deaths in 1 year occurred in 1992. Climbers from Asia had the highest odds of dying on the mountain. Fatalities were decreased by 53% after a NPS registration system was established in 1995. Although mountaineering remains a high-risk activity, safety on Denali is improving. Certain groups have a significantly higher chance of dying. Registration systems and screening methods provide ways to target at-risk groups and improve safety on high altitude mountains such as Denali.

Frostbite: a practical approach to hospital management

Frostbite presentation to hospital is relatively infrequent, and the optimal management of the more severely injured patient requires a multidisciplinary integration of specialist care. Clinicians with an interest in wilderness medicine/freezing cold injury have the awareness of specific potential interventions but may lack the skill or experience to implement the knowledge. The on-call specialist clinician (vascular, general surgery, orthopaedic, plastic surgeon or interventional radiologist), who is likely to receive these patients, may have the skill and knowledge to administer potentially limb-saving intervention but may be unaware of the available treatment options for frostbite. Over the last 10 years, frostbite management has improved with clear guidelines and management protocols available for both the medically trained and winter sports enthusiasts. Many specialist surgeons are unaware that patients with severe frostbite injuries presenting within 24 h of the injury may be good candidates for treatment with either TPA or iloprost. In this review, we aim to give a brief overview of field frostbite care and a practical guide to the hospital management of frostbite with a stepwise approach to thrombolysis and prostacyclin administration for clinicians.

Search and rescue activity on Denali, 1990 to 2008.

OBJECTIVE To describe search and rescue activity performed by the National Park Service (NPS) on Denali, the highest point in North America. METHODS A retrospective review was performed of all search and rescue (SAR) operations by the NPS from 1990 to 2008. Descriptive analysis was used to describe these cases as well as chi-square and logistic regression analysis to determine which mountaineers were more likely to require a rescue. RESULTS During the study period, 1.16% of all Denali climbers required NPS SAR response. The majority of medical cases (68.9%) were due to high altitude and cold injuries, and the majority of traumatic cases (76.2%) resulted from a fall. Mountaineers that attempt routes other than the standard West Buttress route are more likely to require rescue. Climbers are 3% more likely to require a rescue with each year of advancing age. Similarly, mountaineers from Asia are more likely to require a rescue (odds ratio = 4.1), although this trend has diminished in the past decade. CONCLUSIONS Mountaineers and rescuers should educate themselves on the environmental, logistical, and medical origins of Denali rescues. Certain demographic groups on certain routes are more likely to require a rescue on Denali. Rescuers should be aware of these groups and have the knowledge and capabilities to care for the medical issues that are common on SAR responses.

Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Frostbite: 2014 Update

The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for the prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each modality according to methodology stipulated by the American College of Chest Physicians. This is an updated version of the original guidelines published in Wilderness & Environmental Medicine 2011;22(2):156-166.