Hypothermia Lab

Wow, what a day up at the top of Sandia Peak today as a group of us tested some of the techniques of backcountry rewarming in cases of hypothermia. All were mildly hypothermic as measured clinically and by vital signs. There were slight afterdrops in all except the pair rewarming inside a sleeping bag. Definitely comfortable for the one being warmed, but not for the one warming! The shivering really burned energy, as all the participants were fatigued after the experience. A truly unforgettable learning experience!

Mac Guyver Medicine-does it work?

On Wednesday, February 27 2008, the UNM Wilderness Medicine course participants tested out the commonly accepted, tried and true ideas that are taught in many wilderness medicine courses. Problem is, most classes are in auditoriums of over 400 people, with a keynote speaker in the front. We found many of the ideas to work, but not as well as you would think. We devised ideas that are not normally taught in wilderness settings. Paul Romo is demonstrating yet another use for a foley...as a stethoscope! A good friend, Ken Iserson, gave me this idea with the baby nipple, and we thought of the foley. By the way, Ken will have a great book about MacGuyver medicine coming out this year-a tome that will pique the interest of the wilderness medicine or international medicine traveler alike. At any rate, the usual improvised airway control ideas were taught in our lab today, but the a question comes up...how do you improvise on the BVM?
Dario

UNM Wilderness Course is Underway!

This afternoon, students and medical residents from around the country met at the base of the Sandia Mountains in Albuquerque, NM to initiate the 9th consecutive UNM Wilderness Medicine elective.

The first part of the course teaches wilderness life support, the general approach to wilderness scenarios, and environmental emergencies. The UNM School of Medicine has provided the BATCAVE (basic advanced trauma computer-assisted virtual experience), a computerized human patient simulator, to teach wilderness ACLS and BLS principles. Skills and breakout areas are dedicated to basic and advanced airway techniques using mannequins. Students learn how to use bag valve masks, oral and nasal airways, multilumen airways, laryngeal mask airways, as well as endotracheal intubation and surgical cricothyrotomies. Other sessions are devoted to intravenous and alternative access for fluid resuscitation. Wilderness resuscitation scenarios with computerized mannequins allow students to practice their response to emergencies and understand when to terminate efforts.

Improvisational techniques are emphasized during this first week to provide a framework for subsequent scenario-based training. An entire day is spent at a local ski lodge, where 4 instructors teach students outdoor medical skills. In addition, we cover airway and breathing management, hemodynamic stabilization, splinting, and patient transport scenarios. A hypothermia laboratory session is performed in which 3 volunteers are cooled outside and are promptly rewarmed.

The first weekend of the course is devoted to wilderness survival and land navigation, which evolved from a 4-hour classroom gathering to a 2-day field trip in the New Mexican high desert. Shelter, matchless fires (flint and steel, bow and drill, and several other methods), water procurement, filtration, food, and weather prediction are covered during the first day's session. Three instructors teach 3 groups of 6 to 7 students in 3 stations covering the above topics. The second day consists of training on the use of a map and compass. Students learn a primitive means of route finding, and ways in which to measure distance and time. The course continues with a nighttime land navigation course, using a compass or the stars as a directional indicator. This field trip is consistently rated as one of the most valuable in the course; students feel more confident in dealing with a survival situation, both physically and psychologically.

Half- and full-day field trips near Albuquerque are educational as well as recreational. These trips are introductions to various types of activities, which also allow instructors to evaluate group strengths and weaknesses. A half-day mountain biking trip incorporates approximately 10 mini-lectures with patient scenarios during rest stops. A day of rock climbing instruction is usually performed nearby, where the basics of climbing, rappelling, anchors, knots, technique, and safety are practiced. Although New Mexico lacks an ocean, the excellent Albuquerque Biopark Aquarium is available as a classroom. Diving emergencies, marine envenomations, and marine biology are very popular subjects taught there. Professional divers (who staff the aquarium) demonstrate scuba diving equipment, mock dysbarisms, and marine envenomations. Land envenomations are taught by staff of the New Mexico Poison Control Center. A backcountry yurt near the Taos Ski Valley is our venue for a ski clinic and avalanche awareness course. Snow camping in Taos gives students opportunities to build snow shelters and experience high-altitude at nearly 12,000 feet.

The last module of the course is a 5 day trip to the Cedar Mesa primitive area of southeastern Utah. This remote canyon country provides a spectacular backdrop for lectures on dehydration, lightning injury, flash flood danger, medicinal plants, and land navigation. An hour each day is devoted to wilderness medicine scenarios in rugged sandstone terrain. These lessons demonstrate the difficulty of initiating a rescue effort and transporting patients in the backcountry.

The survival and land navigation training (as well as the medical and leadership aspects of wilderness medicine taught during the month) culminates during the day-long timed exercise called the Eco-Resus Challenge. Students are randomized into groups with an equivalent distribution of ability, gender, and physical conditioning. Each participant is given a general orientation to this grueling event, which takes place in a rugged area outside Albuquerque. All backpacks are examined for items that are deemed contraband (eg. GPS units, radios). Students are staggered into groups that are evenly matched in terms of physical and navigational abilities. These teams must navigate their way to a patient care station and stop to treat and/or transport that patient. Students are given a topographic map for navigation and are expected to use skills obtained during the course to find patients. Groups must navigate their way through the desert into a mountainous woodland. Tasks must be completed at patient care stations that must be completed before continuing to the next objective. Each group must fill out log sheets describing patient encounters in standard format. Simulated patients are to be treated in an appropriate manner for the existing conditions. "Victims" often will require evacuation to the next station. During the course, participants are expected to use a signal device to communicate to an incident commander. Each group is accompanied by an instructor familiar with the course who does not offer assistance, unless necessary for safety.

Students and faculty will finish this course on March 22, 2008 after the Eco-Resus challenge. The most effective rescue teams will be celebrated during a debriefing of the event. Students are encouraged to keep a journal of their experiences during the 4 week elective. Previous participants have contributed original artwork, song, poetry, videos, photo-journals, and even, yes, blogs to the UNM Wilderness Medicine historical record.

Exerpts from the best creative journals will be posted at this site, along with new videos, podcasts, and photography.

The UNM Wilderness Medicine Website is here:
UNM Wilderness

For further reading:
Wilderness and Environmental Medicine

Joe Alcock MD

Airline Emergencies

A recent story in the LA Times highlights the death of an airlines passenger, allegedly because of faulty medical equipment. Click on the picture to right to see the medical kit/equipment that large commercial airliners should have available.

The article in the New England Journal of Medicine "Responding to Medical Events during Commercial Airline Flights" is available here:
http://content.nejm.org/cgi/content/extract/346/14/1067

We will be discussing this and other articles during a fireside UNM Wilderness Medicine journal club later this month in Utah!

Update on the death in the skies:
Woman dies on American Airlines flight

JA

The Basic Medical Kit

The components of a basic medical kit can include:

Cpr mask
Ace wrap
Safety pins
Epipen
Duct tape
Superglue
Soap
Sunscreen
Sam Splint
Tweezers
Gloves
Iodine water tabs
Aspirin & Ibuprofen
Antibiotics, (Narcotic Analgesics)
Moleskin, bandages
Hand Sanitizer
Syringe
Survival Gear
Clothing
Whistle
Cellphone

Note that a stethoscope and blood pressure cuff are unnecessary for this basic kit. Prescription medications and controlled substances are optional and will be the subject of another post.

Survival kit and comprehensive medical kit information can be found here:
Medical Kits

Wilderness Medicine Tip of the Week

While great media attention is devoted to victims of avalanches, the Everest death zone, and shark attacks, it is easy to lose sight of more broadly useful wilderness medicine information.

This winter, several parties of skiers got lost near our regional ski areas. At the time of this writing, two snowboarders have not been found and are presumed to have perished on the mountain. Another group included a wilderness medicine trained physician. They ultimately survived after building a snow cave and calling for help.

Training and appropriate gear are paramount when trying to survive the unexpected night out in the snow. To that end, we will be posting several entries on the wilderness medical kit.

Our medical kit changes depending on whether we are traversing glaciers in the Alps, diving in the Caribbean, or hiking in the Rockies. However, the medical kit should always contain personal protective gear such as sunglasses, sunscreen, and gloves. Medications should include OTCs like ibuprofen, antihistamines, as well as prescription analgesics and antibiotics. Wound care and dressing supplies are important. Finally, survival gear is essential. We are not talking about shark-repellants and grizzly stun-guns here.

Wilderness Medicine Tip of the Week:

Bring a signaling device in the backcountry.

Survival gear includes a communication device. This could be as simple as bringing a cell phone or radio to call for help. (One should bear in mind that cell phone reception is spotty at best in much of the backcountry - but the "pings" between cell towers and the phone can aid in finding victims even when the signal is too weak to make a call). Some authors recommend bringing extra cell phone batteries on a backcountry trip. Don't forget about signal mirrors. Signal mirrors are effective when the sun is shining. Commercial products are available at your sporting goods store. Alternatively signal mirrors may be improvised from a compact disk, the inside of a soda can, or anything shiny. You should also bring a whistle. Some backpacks have an integrated whistle in the chest strap. Even if your backpack doesn't have that feature, whistles are lightweight and are very helpful in a rescue scenario. Other options include visible signals, such as bright clothing, a smoky fire (assuming you are not going to cause the biggest forest fire in the history of Arizona!) and nighttime strobe lights. Divers can carry whistles that attach to their supplemental air supply. Aviators sometimes carry dyes that stain the water if they have to parachute into the ocean. While diving, I carry an inflatable "safety sausage" balloon-like device that is visible from a distance. So while circumstances matter, the concept of a communication device is of utmost importance!

Refer back for more. Soon we will post examples of lightweight and comprehensive medical kits at our websites.

Thanks go to Stephen Guine for providing the classic in wilderness medicine literature: "How it Feels to Be Attacked by a Shark"

Joe Alcock MD

Good Conditions for the Wilderness Class

We went to the Sandia Crest today to check on conditions for the upcoming Wilderness Medicine Elective. The verdict? Great snow for the beginning part of the course. The wilderness medicine course has several modules, including the hypothermia lab in the Sandias, desert survival at Cabezon, backcountry snow camping and avalanche awareness at Taos, and canyon country backpacking in Utah. March is a great month to experience the variety of environments and weather conditions in the high desert of the Southwest. In some years past, we have had very little precipitation, however, for our snow-dependent activities. This year promises to be a good year for our Sandia Mountain and Taos excursions! This photo was taken today by my wife, Satkirin Khalsa. The well-dressed attractive individual in this photo is our dog Nanda.

Avalanche Awareness & Video Link!

This video is a graphic description of both the allure of backcountry skiing and the risk to those who tempt steep powder slopes!

http://revver.com/video/310519/a-dozen-more-turns/

We are going to post this as a permanent link at our sister site:

http://unmwildernessmed.blogspot.com/

Great video, Thanks Diane for the link!

Joe Alcock MD

UNM Wilderness Medicine Course Blog

The UNM Wilderness Medicine Elective starts in 4 days! We are very excited about this year's course, which promises to be a very educational and action-packed four weeks. We have some great additions to our faculty, with Jason Williams of Albuquerque Mountain Search and Rescue playing a prominent role in the planning of this year's course. We will be introducing other faculty and personalities of the elective in upcoming posts.

Jason's photo is posted at our a new blog that is dedicated to the UNM Wilderness course.
you can find the blog here:

http://unmwildernessmed.blogspot.com/

The site you are currently reading - Mountain and Marine Medicine Blog - will continue to bring news of the UNM wilderness medicine events but not on a daily basis.

UNM Wilderness Medicine News will contain directions to events, brief descriptions of the people involved in the course, lecture handouts and useful information for students!

We hope you enjoy the new blog!

Joe Alcock MD

More on the Sandia Ski Area Lab

The upcoming Wilderness Medicine Course is visiting the Sandia Ski area. (Most people do not know that Albuquerque is one of the few major metro areas with its own ski area. In fact, you can access the slopes from the Sandia Tramway which leaves from the Albuquerque foothills.) We will be meeting at the ski lodge area next week. Directions to the Sandia Ski area from Albuquerque are: I40 East to Tijeras. Take route 14 north to Sandia Park. Follow the signs to the Sandia Ski area and park at the lodge for lectures on hypothermia and survival in the snow!

Joe Alcock MD

Travel Medicine Can't Miss Diagnoses

Can't miss diagnoses in travel medicine.

The majority of returned travelers with health complaints have garden variety illness such as gastroenteritis and upper respiratory infections. However, health care providers need to be aware that life threatening travel-related illness also occurs. Some of the "can't miss" diagnoses in returned travelers include:

1) Falciparum malaria

2) Malaria, especially falciparum, in pregnant females

3) Viral hemorrhagic diseases, including ebola virus, marburg virus, lassa fever, and rift valley fever. Dengue shock syndrome and yellow fever can also he complicated by hemorrhagic manifestations. While the viral hemorrhagic fevers are relatively rare, the high mortality rate makes them "can't miss" diagnoses.

Further reading here:
Viral Hemorrhagic Fever

Joe Alcock MD

Sandia Ski Area Hypothermia Lab

Next week the faculty of Mountain and Marine Medicine will accompany students of the Wilderness International and Improvisational Medicine Course to the Sandia Ski area. There, we lecture on hypothermia and frostbite, among other topics. At right is photo of a volunteer who was (temporarily) underdressed for the elements. Faculty and students have "chilled" outside for a few minutes. Students then practice rapidly rewarming these "victims" in a hypothermia wrap and plentiful hot chocolate.

Students who will be joining us should look at this gear list:

Outdoor snow gear - ski wear - sunglasses/screen -swimsuit for some!
Daypack
Ski area: Alpine/Telemark or Snowboards
Backcountry: X-country skis or Snowshoes
Bring or buy lunch/drinks
You may rent cross-country skis/snowshoes at REI - (505) 247-1191
Other gear at Sportz Outdoor (505) 837-9400
Ski Systems (505) 296-9111
UNM outdoor shop 277-8182

Joe Alcock MD
www.mmmedicine.com

Travel Medicine Case (?)

This is the case of a 44 year old male who presented to an Albuquerque hospital after passing a pale 1 meter long parasite. Pictured at right is the worm, which has the appearance of fresh linguine.

The specimen was taken to the lab where it was placed in fixative and then sent to the hospital media department for photographs.

History revealed that the man had not in fact traveled, but was an aficionado of fresh seafood. Additional questioning revealed that he had enjoyed salmon sushi, made at home, prepared from fresh fish. It is unknown whether he used wasabi or a fine sake with his meal!

As for the parasite ID:
Click here to see what happened to our patient:
Answer

When the UNM Wilderness Medicine Course begins next week - we will start by explaining the general approach to wilderness medicine patients: The Scene size-up. The scene size-up has three components: First - Check the scene safety - Is it safe for rescuers to approach and attend to victims. Second - Assess the mechanism of injury - Consider what injury patterns might arise from such a mechanism. Third - Find how many victims are involved - the number of injured persons has large consequences for the rescue effort.

Go to the UNM website for additional information about our March Wilderness Medicine course!

UNM Wilderness Medicine

Hope to see you soon!

Joe Alcock MD
www.mmmedicine.com

Brand New Website

You can find our listing of wilderness medicine CME courses at our brand spanking new website:
http://www.mmmedicine.com/index.cfm
Be sure to bookmark the page!

Joe Alcock MD

UNM Wilderness Medicine Course News

In a little more than 1 week, Darryl Macias MD and I will welcome 20 students for the University of New Mexico's Wilderness International & Improvisational Medicine Course! The first week of the course will take students to the Sandia Mountains for high desert hiking and backcountry and alpine skiing adventures. Each excursion has a heavy didactic component and features scenario-based learning. We will end the week with a visit to the BATCAVE, a computer-driven human mannequin that allows students to practice life-saving techniques in wilderness cardiac and respiratory arrest scenarios. Later, we will visit a backcountry yurt in Taos, the remote desert of north central New Mexico (pictured above), and the canyon country of Utah! Visit this blog for upcoming updates as we track our progress through the month!

Joe Alcock MD
www.mmmedicine.com

New Logo

Mountain & Marine Medicine has a new Logo! Among the many new developments at Mountain & Marine Medicine (M3) is this new image that will soon be emblazoned on new T shirts and other M3 merchandise. Email us for details!
www.mmmedicine.com/contact/

Many props go to our new web designer, Joe Black, for this well-produced emblem that conveys what Mountain and Marine Medicine is all about. Thanks, Joe!

Visit this site frequently for lots of new and exciting changes at M3!!!

Joe Alcock MD

Wilderness Medicine Course pictures can be found at our new Mountain & Marine Medicine Multimedia Page:
http://www.mmmedicine.com/multimedia/
Pictured here is a workshop from our High Altitude and Mountain Medicine Course on Mont Blanc!

Joe Alcock MD

Wilderness Medicine Tip of the Week

This is a New Feature of the Mountain & Marine Medicine Blog:
Each week we will publish a wilderness medicine "pearl", explaining priorities of caring for patients in the out of doors.

Wilderness Medicine Tip of the Week!

Foot fractures are common injuries among climbers, as in this example of a 29 year old male who fell while bouldering.

Calcaneus fractures can be obvious as in the radiograph above, or they can be subtle. The inability to bear weight is an important clue. However, don't forget to finish your exam. Rapid deceleration from a fall from height delivers energy sufficient to break bones elsewhere in the body. This week's tip: 10% of patients with a calcaneus fracture will have a lumbar spine compression fracture. Always protect the victim's neck and back & examine the spine for tenderness!

Check back next week for more! And don't forget to visit
www.MMMedicine.com for great wilderness medicine adventures!

Joe Alcock MD

UNM Wilderness, Improvisational and International Medicine 2008

Hello from Albuquerque to all taking the March class!
We are excited to have you come out at the end of February. Things are on track for another OUTSTANDING course-so get ready to learn, live, and laugh! Although I am honing my survival skills a bit (practicing with a bow and drill for firestarting), I have been "checking" out the snow for you as well. The backcountry skiing and snowshoeing is really good this year, and the weather is mild after several weeks of pretty cold weather. Dress properly...we are all meeting at the Copper open space for orientation at 1pm on Feb 25. You should have received a map. Registration will be done first (we will also do a little "accounting" work). Then, on a nice hike. Give us a jingle at 505-272-5062, or email me at dmacias@salud.unm.edu for questions. If you have anything that you would like to learn other than what is on the WIIM website, let us know. And tell your friends and family not to get too jealous while you embark on this fun educational event...
Cheers, aloha, namaste, and hasta...Darryl (Dario)

High Altitude Medicine

High Altitude Medicine - Rainier July 31, 2008 - August 2 2008

Mountain & Marine Medicine LLC 's Rainier High Altitude Course has been endorsed by the American Academy of Emergency Medicine.

And...the course has been approved for AAFP CME credit for 21.75 prescribed credits. See our site for the full statement:
www.mmmedicine.com

Join us for this exciting event in July 2008!