Susanne Spano

Symptomatic Hypotonic Hyponatremia Presenting at High Altitude

We present a case of altered mental status and seizure that occurred at an altitude known to cause high altitude-related illnesses. Based on the presenting symptoms, the patient was initially transferred to the hospital with a presumptive diagnosis of high altitude cerebral edema. On review of imaging and laboratory data, she was found to be experiencing symptomatic hypotonic hyponatremia. This case presented an interesting diagnostic challenge and underscores the importance of maintaining a broad differential diagnosis when evaluating a patient with altered mental status from an alpine setting.

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.

A Lightning Multiple Casualty Incident in Sequoia and Kings Canyon National Parks

Multiple casualty incidents (MCIs) are uncommon in remote wilderness settings. This is a case report of a lightning strike on a Boy Scout troop hiking through Sequoia and Kings Canyon National Parks (SEKI), in which the lightning storm hindered rescue efforts. The purpose of this study was to review the response to a lightning-caused MCI in a wilderness setting, address lightning injury as it relates to field management, and discuss evacuation options in inclement weather incidents occurring in remote locations. An analysis of SEKI search and rescue data and a review of current literature were performed. A lightning strike at 10,600 feet elevation in the Sierra Nevada Mountains affected a party of 5 adults and 7 Boy Scouts (age range 12 to 17 years old). Resources mobilized for the rescue included 5 helicopters, 2 ambulances, 2 hospitals, and 15 field and 14 logistical support personnel. The incident was managed from strike to scene clearance in 4 hours and 20 minutes. There were 2 fatalities, 1 on scene and 1 in the hospital. Storm conditions complicated on-scene communication and evacuation efforts. Exposure to ongoing lightning and a remote wilderness location affected both victims and rescuers in a lightning MCI. Helicopters, the main vehicles of wilderness rescue in SEKI, can be limited by weather, daylight, and terrain. Redundancies in communication systems are vital for episodes of radio failure. Reverse triage should be implemented in lightning injury MCIs. Education of both wilderness travelers and rescuers regarding these issues should be pursued.

The Epidemiology and Medical Morbidity of Long-Distance Backpackers on the John Muir Trail in the Sierra Nevada

INTRODUCTION The baseline characteristics and medical morbidity of hikers on the 354 km (220 mi) John Muir Trail (JMT) have not been previously reported. METHODS Using online and on-site recruitment, hikers completing the JMT in 2014 were directed to an online 83-question survey. Pearson correlations, regression models, and descriptive statistics were applied to data, reported as mean±SD (range). Statistical significance was set at P<0.05. RESULTS Of 771 respondents, 57% were men aged 43±14 (13-76) y; they hiked 15.2±7.6 (5-34) days and traveled 272±129 (45-1207) km (169±80 [28-750] mi). Backpackers lost 3.5±2.6 (+3.6 to -18.2) kg (7.7±5.8 [+8 to -40] lbs). Over half (57%) of respondents reported illness or injury, with blisters (57%), sleep problems (57%), and pack strap pain (46%) most prevalent. Altitude illness affected 37%. Thirty hikers left the trail; of these, 4 required emergency medical services evacuations (3 by helicopter). Increasing age, base pack weight, and body mass index (BMI) were all associated with a decrease in the distance hiked per day. Higher base pack weight was associated with illness or injury, whereas older age was slightly protective. Increasing BMI was associated with a slight increase in medical illness or injury and a strong association with evacuation from the trail. CONCLUSIONS JMT hikers experienced medical issues seen on other national trails. Weight loss was prevalent. Most hikers had medical complaints, with few seeking medical attention. Heavy packs and higher BMIs were associated with undesirable outcomes, while older hikers fared better.

Pressures of Wilderness Improvised Wound Irrigation Techniques: How Do They Compare? ☆ ☆

OBJECTIVE Compare the pressures measured by improvised irrigation techniques to a commercial device and to prior reports. METHODS Devices tested included a commercial 500-mL compressible plastic bottle with splash guard, a 10-mL syringe, a 10-mL syringe with a 14-ga angiocatheter (with needle removed), a 50-mL Sawyer syringe, a plastic bag punctured with a 14-ga needle, a plastic bottle with cap punctured by a 14-ga needle, a plastic bottle with sports top, and a bladder-style hydration system. Each device was leveled on a support, manually compressed, and aimed toward a piece of glass. A high-speed camera placed behind the glass recorded the height of the stream upon impact at its highest and lowest point. Measurements were recorded 5 times for each device. Pressures in pounds per square inch (psi) were calculated. RESULTS The syringe and angiocatheter pressures measured the highest pressures (16-49 psi). The 50-mL syringe (7-11 psi), 14-ga punctured water bottle (7-25 psi), and water bottle with sports top (3-7 psi) all measured at or above the commercial device (4-5 psi). Only the bladder-style hydration system (1-2 psi) and plastic bag with 14-ga needle puncture (2-3 psi) did not reach pressures generated by the commercial device. CONCLUSIONS Pressures are consistent with those previously reported. All systems using compressible water bottles and all syringe-based systems provided pressures at or exceeding a commercial wound irrigation device. A 14-ga punctured plastic bag and bladder-style hydration pack failed to generate similar irrigation pressures.

An Assessment of Diarrhea among Long-Distance Backpackers in the Sierra Nevada

INTRODUCTION Diarrhea is a common problem among long-distance backpackers, ranging in overall incidence from 11-56% as reported by previous studies on the Appalachian Trail and Long Trail. Differences in age, sex, and regularity of standard backcountry hygiene recommendations and practices have been shown to significantly affect the incidence of diarrhea. No study to date has investigated these trends among long-distance backpackers on the John Muir Trail (JMT) in the Sierra Nevada mountain range of California. METHODS Retrospective analysis of online survey data gathered from long-distance backpackers who attempted a JMT trek in 2014. Data were assessed for the significance of variables that might contribute to the incidence and severity of on-trail diarrhea. RESULTS Of 737 valid responders, 16.4% reported experiencing diarrhea (82% with minimal/mild severity; 18% with significant severity). Regular hand sanitizer use was significantly correlated with more severe diarrhea (P < .05), but had no effect on incidence. Regular hand sanitizer users followed all other recommended hygiene practices as frequently as or better than those not using hand sanitizer regularly. Of all backpackers, 88% filtered or treated their drinking water regularly, with 18% of those reporting diarrhea of any severity. CONCLUSIONS JMT backpackers have a comparatively lower incidence of diarrhea than backpackers on other major long-distance backpacking routes in the United States. Most JMT backpackers follow standard backcountry hygiene recommendations, including regular filtration or treatment of drinking water. No statistical significance was found between the incidence of diarrhea and compliance with standard hygiene recommendations. Regular hand sanitizer use was significantly correlated with more severe diarrhea but was not associated with incidence. There was no significant difference in compliance with standard backcountry hygiene practices between regular and infrequent hand sanitizer users.

An Unusual Case of Otorrhagia

A 64-year-old man presented to the Emergency Department complaining of headache and bilateral ear pain after falling face first during a syncopal episode. He denied nausea, vomiting, or focal neurological complaints, and was alert and oriented, with blood-tinged fluid—which formed ‘‘halos’’ on the bed sheets—draining from both ears. A brain computed tomography (CT) scan with axial and coronal views was performed due to a concern for basilar skull fracture and was read as negative by the on-duty radiologist (Figure 1). However, review of the study by the emergency physicians/case authors demonstrated bilateral comminuted fractures and dislocations of the mandibular condyles (Figure 2). The patient was admitted to the Oromaxillofacial Surgery service for repair of his injuries and was discharged the following morning. No basilar skull fracture was identified. The patient was well at 30-day follow-up.

Emergency Medical Services and Remote Medical Oversight in Sequoia and Kings Canyon National Parks, 2011–2013

INTRODUCTION The University of California San Francisco Fresno Department of Emergency Medicine provides base hospital support for the Sequoia and Kings Canyon National Parks (SEKI) emergency medical services (EMS) system. This descriptive epidemiologic study reports reasons the park EMS system is used and interventions provided, detailing the nature of patient encounters, type and frequency of injuries and interventions, reasons for base hospital contact, and patient dispositions. METHODS Patient charts for all EMS encounters in SEKI from 2011 to 2013 were included, and relevant data were extracted by a single reviewer. RESULTS Of the 704 charts reviewed, 570 (81%) were frontcountry patient encounters (within 1.6 km [1 mi] of a paved road); 100 (14%) were backcountry; and 34 (5%) occurred in undefined locations. Regarding sex and age, 58% of patients were men; 22% were younger than 18 y, and 15% were 65 y or older. More than 80% of calls occurred during the months of June through August. The most common complaints were extremity trauma (24%), torso trauma (13%), and lacerations (9%). Almost 50% of patients were transferred to a higher level of care. Medications were administered to 37% of patients, with oxygen being the most common. Procedures were performed 49% of the time, primarily intravenous access and splinting. Base hospital contact was made 38% of the time, most commonly (54%) for advice regarding disposition. CONCLUSIONS SEKI EMS providers encounter a wide variety of patients in various settings, including the backcountry. Resource allocation, training, and protocol development should be tailored to meet their needs.

Death on the Dome: Epidemiology of Recreational Deaths on Half Dome in Yosemite National Park

Introduction One of the most popular destinations in Yosemite National Park is Half Dome. Overcrowding at the turn of the 21st century prompted a restriction of hiker access to cable handrails to the summit without technical rock climbing equipment. Prior epidemiological study of Half Dome deaths is not known to the authors. Our goal was to identify trends among all Half Dome–related fatalities in Yosemite National Park. Methods Multimedia sources were searched for deaths involving the cable handrails, subdome, summit, technical climbing, or base jumping. Results are reported as mean±SD (range). Results Twenty-nine confirmed deaths occurred on Half Dome, with 2 additional deaths likely on Half Dome. Age was 32±14 (16–86) y; 4 were female. Activity at time of death included technical climbing (36%), suicide (26%), utilizing cable handrails (16%), hiking (16%), and base jumping (6%). Of the cable handrail-related fatalities, only 2 were due to weather. There were 3 medically related deaths due to cardiac disease and altitude. Conclusions We identified 31 Half Dome deaths over 85 y. A minority were attributable to unfavorable weather or unskilled hiking participants. Climber registration could provide dependable denominators for accident incidence statistics. A renewed focus on suicide prevention is warranted.

They Had Me in Stitches: A Grand Canyon River Guide’s Case Report and a Review of Wilderness Wound Management Literature

We present a case of failed conservative management of a traumatic wound sustained in a wilderness setting. The patient was initially treated with a povidone-iodine scrub, suture closure, and expectant management by 2 physicians who were paying clients on a multiday river rafting expedition. Empiric antibiotic coverage and irrigation of the dehisced wound were initiated several days after initial treatment. The patient arranged his own evacuation 8 days after injury. Hospitalization, intravenous (IV) antibiotics, and surgical debridement with wound vacuum placement led to a full recovery. This case presents several common wound care pitfalls. The sequelae to these pitfalls are more dramatic in a wilderness setting and underscore the importance of early aggressive management and considering prompt evacuation when treating wounds sustained in the wilderness.