Upcoming courses...

The next Wilderness Emergency Medicine First Aid Provider (1-day) is on the 30 May 2014 and the next Wilderness Emergency Medicine (2-day) is on the 14-15 June 2014. Please email wildernessemergencymedicine@yahoo.com for further details.

Course feedback 12-13 April 2014

Another successful Wilderness Emergency Medicine course was run at the Kenneth Stainbank Nature Reserve in Durban. Awesome interactive lectures from emergency medicine, survival, pre-hospital medicine and rescue experts, interspersed with scenarios that the candidates had to run. The use of high-fidelity simulations was a new component to the course this year and added a fresh approach to teaching integrated aspects of patient care and rescue in the austere wilderness field.

Instructors' meeting

The instructors got together tonight thanks to the advantages of social networking tools and had a very productive planning meeting for the course this weekend. In discussions, I realised that the internet, and more especially, social media can be a very useful tool in the development of the field of Wilderness Emergency Medicine. It certainly has a role to play in marketing and now in interpersonal interactions at the academic level. I have been witness to the development of the FOAMed philosophy of education in emergency medicine and critical care, and am eager to try the same for wilderness emergency medicine as well. Therefore, I will be exploring ways in which social media can be used to advance the field of WEM.

Back from nowhere

So it's been a while since my last blog post and it's fast approaching the next Wilderness Emergency Medicine course this weekend. People may think that running a course is fairly easy to set up and run, but when you are setting up a course from scratch and doing everything yourself, it is quite a daunting task. However, the satisfaction rests with a successful exercise with candidates learning much from the instructors and ultimately having a great time in the field. Taking feedback from the last course in September 2013, I have changed the course dramatically, adding in several practical high-fidelity scenarios, and decreasing the number of didactic lectures, making the course more practical. There are also lots of demonstrations within the lecture components. This is going to be a very new and different and certainly a very exciting event. There are also a few new candidate instructors and observers who will be evaluated as instructors, hoping to increase the faculty for this programme.

Next course: April 2014 ****STAY POSTED****

Snakes and snakebites in South Africa

There's always much published about the management of snakebites especially in South Africa with some proponents saying that the identification of snakes is not important as the syndromic management will suffice for the management of envenomation syndromes. Others argue that knowing one or two of the more dangerous snakes in South Africa is important as they do have clinical relevance.

From a wilderness emergency medicine perspective, there is probably no actual role for giving snakebite anti-venom in the field, due to the many logistical problems with the anti-venom itself, as well as the very real risk of anaphylaxis, although, in very remote areas with a crashing envenomation patient one might certainly consider giving it if appropriate resuscitation equipment and skills are available.

In any event, the identification of the snake that caused the envenomation is important as it determines the urgency to evacuate the casualty from the field. Therefore, clinical wilderness emergency medicine relevant points of note in snake envenomation syndromes are the following:

• Fang morphology
• Venom chemistry
• Snake types
• Clinical syndromes
• Management

Snakes are described as either front-fanged or back-fanged in SA, with the front-fanged further sub-divided as front hinged-fanged or front fixed-fanged. The front hinged-fanged are the viperidae (adders) and the front fixed-fanged are the elapidae (mambas and cobras). The back-fanged are the colubridae (boomslang and vine snake). The clinical relevance of this is on the depth of penetration into the tissues affected which determines the rapidity of onset of symptoms.

Previously, snakes were described as having neurotoxic, cytotoxic, haemotoxic and myotoxic venom, but studies have actually shown that venom chemistry is very complex with venoms containing varied types of proteins and other biologically reactive substances, with the effects of the venom dependent on the predominant chemical present. This predominant chemical and its resultant effects have paved the way for describing the envenomation as a syndrome or symptom complex which is managed appropriately.

The snakes themselves are classed as elapids (mambas and cobras) with the cobras sub-divided into spitting and non-spitting cobras. The mambas are predominantly neurotoxic in effects, whilst the cobras show a combination of neurotoxicity and cytotoxicity. The viperidae in SA are adders which show a predominantly cytotoxic reaction. The colubrids are predominantly haemotoxic.

The envenomation syndromes have been largely described as:

• Painful progressive swelling
• Progressive paralysis
• Bleeding abnormality

and more recently as:

• Neurotoxic with a cytotoxic component
• Cytotoxic with a neurotoxic component
• Cytotoxic with a haemotoxic component
• Predominantly haemotoxic
• Localised painful or painless swelling

First aid in the field involves applying a firm crepe bandage for the entire length of the limb involved, without the use of tourniquets or sucking the victim's wounds, and the application of splintage and keeping the patient immobilised.

The further management involves an assessment of the situation in the field and deciding on whether this patient needs to be extracted from the field by litter or carry, or requires a rapid extraction by aeromedical or other means. The use of anti-venom is definitely strongly discouraged in the field, unless strongly indicated due to envenomation sydrome and delay in extraction, and the availability of skills and resources to resuscitate the patient with advanced life support if necessary.

Check out this puff adder in captivity @ http://youtu.be/f_nCbHi6oKw

September 2013 Course

The inaugural course was hugely successful. The first day started with the mountaineering component courtesy of Gavin Raubenheimer and Peak High Mountaineering. The candidates learnt abseiling and belaying techniques as well as improvised systems for belaying and abseiling. Rope systems for wilderness rescue carrys and stretchers were also taught.

Candidates were then directed to Shongweni Dam where they camped out for the duration of the medical and survival components of the course. Awards were given for the best novice climber ("Mountain Goat") award as well as the Congeniality Award, selected by vote among the candidates. All in all it was a great learning experience.