Radio Interview

I recently was invited to be a guest on the Dr. Don Radio show and had a great time doing it! We talked about rural and remote medicine, international health and a few other fun topics!  Here is a link to the show:

http://bullheadurgentcare.com/archives/playfiles/12282012p.html

 

Venous Access in Austere Settings: Part One

Obtaining “access” in remote or austere environments is something that can be very difficult and honestly something I worry about often. The ability to give fluid, medications or blood can literally make the difference betwen life or death. Working remotely, I try to have at least TWO methods if I cannot access peripheral veins via a cannula.

In order of personal preference I use:

  • Intraosseous
  • Central line
  • Venous Cutdown

Lets take a look at the first of these in this Part one post:

1) Intraosseous

There are many commercial kits available to insert a needle into bone. Personally, I trained with the older style “cork-screw” models that were primarily reserved for pediatric patients. Currently, the Intraosseous (IO) is becoming very popular. EMS and pre-hospital are starting to use them after even 1-2 failed IV attempts. I know I use them often in the Emergency departments when I need fast access or a second line, quickly. A lot of fantastic data is coming from the military and shows just how safe, effective and fast these devices are.

Below is a video of IO access using the E-Z IO brand “gun” manufactured by Vidacare. I have personally used this device on numerous times and found it very easy. My only complaint is the weight and size of the device which is a consideration when carried in a pack or vest.

 

Next is a  Sternal Access IO that goes by the trade name FAST and manufactured by Pyng. This system is very light and portable but requires a bit more technique to insert, in my opinion. Also, this system requires manual strength to pierce the sternum.

Lastly, we have the B.I.G (bone injection gun) manufactured by Persys. This system uses a spring loaded firing mechanism but still retains a small size, portability and low weight.

There are a few things that are common to all IO devices and that is what can be administered through them and concern for patient comfort. It is important to note that ALL medications given Intravenously can be given through an IO. This includes cardiac drugs, fluid and antibiotics. This even includes contrast medium for CT scans!

As for patient comfort, a small pre-load of lidocaine 1% will help decrease the ache associated with infusion of fluid through an IO. This pain from infusion is due to the swelling of the bone which occurs while liquids are being infused through the medullary cavity. I typically pre-fill the IV tubing with lidocaine and then infuse as normal, allowing the first 1-2 cm of lidocaine filled tubing to flush in first, ahead of the fluid.

Lastly, it is important to note that all IO access will require much greater pressure to infuse as compared to intravenous access sites. Typically, I use a pressure infusion bag that is commonly used in a trauma setting. In a tough spot, a blood pressure cuff has been inflated around the IV bag and provided the necessary pressure to infuse. When giving an injection of a medication from a syringe, remember that this extra pressure is necessary and  normal with the IO access device.

A good basic primer on Intraosseous use can be found here, courtesy of Emedicine.

A nice review of military thoughts on IO access can be read here, courtesy of Military Medicine.

Filariasis basics for travelers

Filariasis

Condition: Infection by a parasitic worm that often causes lymph-edema in the lower extremities

Infectious Agent: Lymphatic filariasis is caused by Wuchereria bancrofti; Brugia malayi and B. timori. All of these are filarial nematodes.

Signs and Symptoms: Most infections are asymptomatic. As the worms mature they may progressively block lymph channels in the lower extremities, scrotum, arms or breasts. This causes the resultant back-up of lymph and presentation of elephantiasis. Secondary skin infections in these effected areas are also common.

Diagnosis: The standard diagnosis is through a blood smear that demonstrates microfilariae under microscopy. The highest concentrations of microfilariae are seen in peripheral blood at nighttime hours and specimens should be drawn between 10PM and 2AM.

Transmission: The bite of infected mosquitoes such as Aedes, Culex, Anopheles and Mansonia species

Treatment: Diethylcarbamazine (DEC) is the drug of choice for travelers with these infections. Although ivermectin does kill microfilariae it has no effect on adult worms. Once elephantiasis has developed there is no corrective methods to reveres the course. Surgical excision of the filarial worms only result in scarring of the lymph channels and worsening the blockage. Local wound care of the effected region is important including hygiene and infection control.

Prevention: Protective measures include mosquito bite prevention such as long sleeves, pants, bed nets, permethrin treated clothing and DEET 30-35% insect repellent.

Epidemiology: This effects approximately 120 million people worldwide. Lymphatic filariasis is seen in Sub-Saharan Africa, Egypt, Southern Asia, Pacific Islands, Brazil, Haiti and the Dominican Republic. Short term travelers to these regions are at low risk for infection. Travelers in these regions for extended periods of time (>3 months) and are intensively exposed to mosquitoes are considered to be at a higher risk for infection.

Blog changes

The Adventure Doc Blog is undergoing a few changes to match the new websites. These will take place over the next few days and your patience is appreciated! In the meantime, please visit our new homepage at:

www.AdventureDoc.org

Remote Medicine, Laboratory set-up and Adventure Doc Clinic

Remote Medicine

I was lucky enough to work at an Indian Health Services clinic/emergency room in Northern Arizona.  This was an amazing experience!  The site was equipped with plain xrays and a basic but adequate supply of medicines.  The ER also doubled as the pharmacy at night to dispense medicines, as there was no pharmacy in the area.  There is the full gambit of medicine there, from trauma to obstetrics, womb to tomb.  I loved it!  The staff was amazing and very competent.  I cannot wait to get back up there again!

Laboratory Set up

The Flying Samaritans operate free clinics in Baja, Mexico.  Some of these clinics might benefit from having some laboratory diagnostics to assist with patient care.  I have been working on this problem.  Using a few books that are very helpful: District Laboratory Practice in Tropical Countries by Monica Cheesbrough.  I am planning to go a basic route including hemaglobin count, white blood cell count and platelets.  I also want the ability to do gram stains for bacteria.  I think cultures are a bit ambitious as we are typically there for a few days only and not enough to grow them out.  Plus, space is quite limited and incubators cost lots of money!     

Adventure Doc Clinic

The clinic is progressing with our vaccine order coming along with our new refrigerator orders.  I have been quite busy rewriting our proposal packages for provider accompaniment services and think we have finally nailed them down.  Unfortunately, we are finally getting rolling right before we leave town to Europe and North Africa.  Story of my life!

Future Considerations 2

I have been giving the concept of travel medicine, wilderness medicine and remote medicine a bit of thought lately.  Building on my previous post that discusses some of the “overlap” between these fields of medicine, I wanted to look at some specific examples and build my case for the statement that these specialities are converging, or should be converging, into one field.

One of my favorite books “Field guide to wilderness medicine” discusses some things that I consider more likely to be found in a tropical medicine manual, such as malaria.  Malaria is a disease that, I consider, largely preventable, in an educated and prepared traveler.  Is this a “wilderness medicine” issue or a “travel/tropical medicine” issue?  I see this these as very, very similiar.

Treatment of acute issues, while outdoors, such as a dislocated shoulder or ankle injury cannot be prevented with a vaccine or chemoprophylaxis.  At least not that I know of!  These types of injuries are considered more “emergency medicine” problems than travel medicine…even though it may have taken place during a holiday trip.  Now, having said that, a good number of emergency medicine physicians might have trouble diagnosing and treating a venomous bite, due to their geographic region of practice.  My point is that this is new “thing called wilderness/travel/expedition medicine” is and should be emerging as a very unique skill set!

Pre-travel consultation should include a review of immunizations, risk of exposures and a good knowledge of the geographical areas the person is headed.  Travel medicine at it’s finest.  Now, the problem comes into play when the members of that trip/expedition run into problems of an acute nature, while away.  The fractured ankle, acute dehydration or trauma are some of these examples. 

As with buying a house, location is everything in medicine.  Access to some really fancy imaging equipment and 24/7 specialist consultation is wonderful.  Trust me, I work at a facility with ALL this.  What about that 25 year old female with acute, right lower quadrant pain?  A pregnancy test could be a literal “life saver” at that point.  I think it takes a very creative and unique health care provider to work with limited resources and support.  This is exactly the nature of wilderness and remote medicine.  “Doing the best you can with what you have” is a common saying I have heard.  This is not emergency medicine at a fully staffed level 1 trauma center.

To me, the “ideal” expedition medicine healthcare provider will be able to conduct a pre-travel risk assesment, advise on vaccines and immunizations, communicate with primary care providers of the “patients/adventurers” and competently deal with acute issues while at their location, then ensure proper follow-up or even rescue, as needed.  Whew…that is a lot and I am sure I am leaving things out!

There are currently several paths for further education in these areas, but all are in their “individual areas”.  Wilderness medicine fellowships exist with Stanford and now, Harvard being two fine examples.  Diploma courses in travel and tropical medicine are available and I have to mention my personal favorite: Tulane SPHTM .  I have completed the program at Tulane and I did receive education in “wilderness medicine” but nothing compared to parasitology, virology and the like.  The Diploma in Mountain Medicine, offered in Europe, is another example of “wilderness” heavy medicine and even search and rescue components!  Australia has a fantastic program for Rural and Remote Medicine, involving what looks like a decent overlap with wilderness medicine.

Has any of these programs managed to blend all of the qualities necessary for the “ideal” expedition/travel/wilderness medicine doc?

Maybe I still believe that the “specialist/generalist” model of skills is ideal for this type of thing, at least as initial training.  But, where to go for an all encompassing training program for advanced study in these areas that allows us to provide total care for our “patients/adventurers”, including pre, during and post adventure care?  There is my rub…

Future Considerations

I find myself entering a unique position. I have just entered my last year of residency training and will be spending it as a Chief Resident. I am now trying to decide what to do, upon completion of my three years of post-graduate medical training. My interests are:

Expedition Medicine

Travel and Tropical Medicine

Global Health

Rural and Remote Medicine

Now, the question is how best to prepare for these types of medical practice? Should I complete a fellowship (additional years of training), perhaps in sport medicine or emergency medicine? Advanced training in sports medicine would help me deal with muscular/skeletal injuries and outdoor sports-related problems. Emergency medicine, with its reductions of dislocated shoulders, laceration repairs and acute problems would be a helpful addition to my skills. There are several rural medicine fellowships, such as the program in Tacoma, Washington.

What about just completing a second residency (3 more years of training)? Instead of doing a rural medicine fellowship (for family medicine doctors), I could just do an additional residency in Emergency medicine. In America, there are several very interesting fellowships open to graduates of Emergency Medicine residencies. The program at Stanford looks especially cool. New Mexico also has a very nice looking Wilderness Medicine program. There is a Family Medicine program, in Montana, that has a wilderness medicine track, but I am already completing my study at a different program.

So how does one gather more knowledge about these specific areas of medicine? Existing specialities I have already begun seeking additional training in include:

Travel and Tropical Medicine
Diploma in Travel and Tropical Medicine and the ASTMH Certificate of Knowledge, Fellow of the Royal Society of Tropical Medicine and the International Society of Travel Medicine

Wilderness Medicine (including Search and Rescue)
The Fellow of the Academy of Wilderness Medicine (FAWM), I am still gathering units for my fellowship through attending conferences like the National Expedition Medicine Conference and the WMS Events.

Global Health
Master’s Degree in Public Health specializing in International Health and Complex Emergencies/Disasters

Rural and Remote Medicine
Co-authored a paper on Portable Field hospitals for Rural and Remote Health

I then began thinking of skills I might be in need of, with this type of career track:

Basic surgical skills such as removing an acute appendicitis, wound incision and drainage, etc

Obstetrical Skills including vaginal and ceserean deliveries

Pediatrics training involving infectious diseases, immunizations and nutrition, plus basic disease treatment

Emergency Medicine’s unique skill set such as fracture and dislocation reductions, toxicology and familiarity with acute issues

Infectious Disease as it especially pertains to tropical medicine such as disease prevention and treatment of illnesses such as malaria

This list is, by no means, a complete skill set and hopefully conveys the wide scope of knowledge practitioners in these fields require. I guess that my point is that there is considerable overlap of medical specialities needed to form a decent skill set for this “new speciality”. I think of it similiar to the growth of Emergency Medicine from Family/General Practice. The job of working in an emergency room was being performed, traditionally, by family medicine doctors with experience giving care to adults, children, obstetrics and general medical training. From this, the concept of a unique skill set that I see Emergency medicine as, evolved.

Is wilderness and travel and expedition and remote medicine all one, unique and new speciality?

Free Books, that are actually good!!

I have seen this site, several times in the last few months. I think it is very cool the books are available for reading by everybody.

Where There is No Doctor
http://www.hesperian.org/publications_download_wtnd.php

Where There is No Dentist
http://www.hesperian.org/publications_download_dentist.php

If you haven’t at least looked through these books, you should. Any level of skill will learn something from these texts.

Adventure Doc

Non-operative Treatment of Appendicitis

I was lucky enough to attend a great pediatric grand-rounds, yesterday, that discussed the non-operative management of acute appendicitis, in children. This idea seemed very interesting, to me, as it has obvious applications to healthcare providers in remote areas that may not have easy access to definitive surgical care.

The information presented discussed aggresive antibiotics for 48 hours with serial ultrasound exams every 6 hours, as an alternative to surgical appendectomy. The antibiotics currently advocated are standard “triple therapy” with ampicillin, gentamicin and metronidazole. The presenter also stressed that this antibiotic combination is falling out of favor and Mefoxin (cefoxitine) or Zosyn (piperacillin/tazobactam) or cefuroxime are being considered as better selections, by some surgeons. The switch to oral antibiotics, from IV, was also discussed and a concensus that once the patient is afebrile, oral metronidazole can be used for 7-10 days.

This raises an interesting question about treatment of appendicitis in remote locations, and involving adults. Obviously, if a surgical consult is available, it should be taken advantage of. However, for the remote generalist, this is not always possible. I just wanted to present this new information (to me) as an increasingly viable option.

A few decent references I have found on this matter are below:

http://linkinghub.elsevier.com/retrieve/pii/S0022346806006476

http://archsurg.ama-assn.org/cgi/content/abstract/140/9/897

http://www.jpedsurg.org/article/S0022-3468(07)00190-X/abstract

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1856578

Great Expedition Medicine Jobs

I was checking out the newsletter from ExpeditionMedicine.co.uk and found myself perusing the “jobs” section. Partially because I am getting closer to finishing my residency and looking for another job and partly because they are just so damn cool!

Check out their list here: http://www.expeditionmedicine.co.uk/jobs.php

Some of my favorites:

If you would like to witness the spectacle of sunrise on Trishul, Nanda Devi other Himalayan mountain peaks, breathe the mountain air, help wonderful people, make a real difference, work with a dedicated team, change your own life and sleep satisfied after watching the sunset on the Himalayas, then read on . . . A small rural Himalayan Hospital is rapidly nearing completion in the Nainital district of the North Indian state of Uttaranchal. CHIRAG HOSPITAL This has come up through the efforts of an NGO, called CHIRAG – Central Himalayan Rural Action Group, that has been active in various sectors including health, for over eighteen years. (www.chirag.org) This hospital is based on the experience of the two rural Himalayan clinics currently running and surveys on the health needs of the local people. It would serve a vital function of providing an inpatient treatment and investigation service for the which currently patients travel over four hours to Haldwani. The core component of these services currently, would be of a General Practice nature, targeted specially at the needs of women and children. Preventive and promotive services remain important. The hospital would be having support from visiting specialists and a network of doctors from India and abroad. In the next phase an operation theatre is planned. Medical camps and meetings to promote health are already a feature, and this hospital would be the hub of educational activities for the future. TWO DOCTORS REQUIRED Ideally General Practitioners, preferably with an interest in women and children’s health. Most important requirement is a ‘passion’ for nature and humanity ! The posts are however, salaried with accommodation provided. Information/Podcast/Contact Uttaranchal is in north India and the hospital is based at a small village called Sarghakhet in the district of Nainital.Click ‘podcast’ to view. CONTACTS: Dr Satyendra Singh Ph. UK 00 44 (0)7804357297 Mr V K Madhavan Executive Director CHIRAG. Please mention Expedition Medicine in your correspondance.

AND

Position; Expedition Medic on GVI’s Amazon Expedition in Ecuador (3 months) Description; Be the Expedition Medics in charge of all medical aspects on a tropical rainforest expedition which is fairly remote. Manage the training of all Expedition Members in wilderness medicine and emergency evacuation procedures. Participate in all forest based surveys as the Expedition Medic. Assist with all areas of the running of the GVI Amazon expedition. Assist leading groups whilst conducting scientific research transects. Work alongside GVI and local biologists carrying out research. Qualifications; Qualified Doctor, nurse or paramedic with minimum 2 years of experience. Expedition or Wilderness experience a definite advantage. Spanish language a bonus. Start dates; January, April, July, and October 2008, preferably a week before the expedition starts. Duration; Min 3 months – short term contract.

AND

The Luangwa Safari Association Medical Fund are seeking a doctor to work at the Kakumbi Rural Health Centre in Zambia. Based in the stunning South Luangwa Valley, one of Africa’s prime safari destinations. Most of the doctor’s time is donated to the Kakumbi Rural Health Centre in Mfuwe near the main entrance to the national park. At the clinic the doctor works as a consultant to the staff nurses seeing patients with a wide variety of health problems ranging from malaria to AIDS to trauma to obstetric issues. The ideal doctor for this position is a GP/family physician or emergency medicine physician with broad clinical training and experience in caring for patients of all ages. Knowledge of tropical medicine is essential, and prior medical work in the tropics or a course in tropical medicine is encouraged but not required. To enjoy the work here, the doctor should be comfortable practicing alone in a remote setting with a limited array of medications and equipment.

Sprayable Bandage

Many thanks to the crew over at www.Wilderness-Survival.net for the tip on this pretty interesting type of “bandage”.

http://www.njbiomaterials.org/web/index.php?p=cembr&s=2288 is the link to a company that is making a spray-on-bandage. This has obvious applications in remote medical settings.

After the large amount of use the rapid hemostatic agents (QuikClot) are seeing in Afghanistan and Iraq, could this be the next line?

Special Forces Medical Handbook

I am reading a very good remote medical book, called the US Army Special Forces Medical Handbook. This book is filled with loads of great remote medical info, without a lot of technical jargon or unwanted information. Topics covered include:

Basic infection control and wound care
Communicable disease
CPR and airways
Nutritional diseases
Pediatrics
Gynecology and obstetrics
Orthopedics
NBC issues
IV therapy and fluids
Emergency War Surgery
Veterinary medicine
Antibiotic therapy

After a bit of discussion, with the gang over at www.Wilderness-Survival.net, I learned about a really amazing page called: http://www.stevespages.com/page7c.htm that has a ton of military manuals available for free download!

The site has bandwidth issues, due to the download size of some files, so please only download and use manuals that will be actually read. Great resource and thanks to Rick over at www.safezonellc.com for the info!

GMRS Expedition/Wilderness/Remote Medicine Course

Imagine yourself:- Packing a disaster medical clinic through the jungle to a remote
village after a hurricane…
- Lifting a patient – and a medic – 350′ straight up a sinkhole wall…
- Calling in a Medevac helicopter to base camp at 17,500′…
- Assuming command of an out of control science expedition team to
save it from itself…
- Managing critical patients for 3 days in a tent until they can be carried
off the mountain…
- Moving 1000 pounds of medical supplies 8000 miles through 3
countries, up 18,000 feet and back home again…

If this sounds cool to you, then you are going to love the new (and free) course put on by Global Medical Rescue Services Ltd.

The course centers around a 350 + page book that is sent to the student, via the internet, in sections, preventing an overload of information and flooding the in-box.

I have already signed up for it and cannot wait to begin!

Here’s that link, again: http://www.gmrsltd.com/2008ShortCourse.html

Remote Medicine Website

I see the specialities of travel and tropical medicine overlap. I also see how wilderness and rural/remote medicine overlap. I feel that in order to practice the unique combination of all these, a health care provider must be a true generalist. Not the best in one thing, but fair in a wide variety of tasks, problems and environments. A sense of humor and ability to improvise are, perhaps the most vital. This is truly a unique speciality in medicine.

A very good website, with a lot of resources for people interested in studying this type of medicine, is www.RemoteMedicine.org. The site is designed to assist health care workers, especially residents doctors, gain experience in this speciality.

The site has downloads relevent to being the one doctor on call. The anaesthesia manual is especially good. The person whom I have communicated with there has been James Li. Dr. Li has been kind enough to advise reading, educational activities and training opportunities with me, for which I am very grateful.

When I am asked about sites to visit to learn about remote medicine, I send them here, first.

Adventure Doc

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