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.

The SAMPLE history in the wilderness medicine patient

A SAMPLE history is a structured way of recording a patient’s history. It is not the only way, and perhaps not the best, but provides a good workable system for the lay person. Signs and Symptoms Allergies Medications Past Medical History  Last (Eaten, Bowel Open, Urinated etc) Events leading up to current situation

Breen, Chris; Ellis, Dr Craig (2011-11-18). Wilderness and Survival Medicine (p. 17).  . Kindle Edition. 

Causes of unconsciousness in the wilderness setting

There are several common causes of unconsciousness which can be described using the acronym FISHSHAPED which stands for fainting, intoxication, stroke, sepsis (infection), heart attack, shock, heat imbalance, anaphylaxis, poisoning, epilepsy and diabetes or dysrythmias (abnormal heart rhythms). 

Breen, Chris; Ellis, Dr Craig (2011-11-18). Wilderness and Survival Medicine (p. 8).  . Kindle Edition. 

Methods to carry and evacuate an injured person in the wilderness

1. Using a Bivi bag and dragging the person

2. Making a Bivi-roll carry
3. The pole sack carry
4. The two-person split-rope carry

Wilderness emergency evacuation

Refers to the removal of a casualty in order to deliver them to a safer place where medical care in the form of first aid can be administered, or to a safer place relatively free from risks whilst awaiting the arrival of the rescue team.

NEW! Wilderness First Aid Provider course

After many requests to develop a shorter version of the Wilderness Emergency Medicine course for entry-level health care workers in SA, I have come up with this one-day version of the WEM's course to serve just that purpose. I am hoping to get this accredited for at least 8 CPD / CEU points and to position it as a more affordable introduction to wilderness medicine.

Cellophane as a field dressing

Cellophane, plastic food wrappers, or plastic sheeting of any kind makes an excellent wound covering. Held down with tape of any type, a cellophane dressing is non-adherent, seepage leaks from the unsealed edges, the wound can be observed, and the increased and appropriate moisture level of the dressing increases the rate of wound healing.

William W. Forgey  M.D.. Wilderness Medicine, 6th: Beyond First Aid (Kindle Locations 2802-2804). Kindle Edition.

Preventing high altitude illnesses

To prevent high altitude illnesses it is helpful to "climb high, but camp low"-that is, spend nights at the lowest camp elevation feasible.

William W. Forgey  M.D.. Wilderness Medicine, 6th: Beyond First Aid (Kindle Locations 2710-2711). Kindle Edition.

Stand a chance to win "Achieving the Impossible"

Register now for the first Wilderness Emergency Medicine course on the 20-22 September 2013 and stand a chance to win an autographed copy of "Achieving the Impossible" by Lewis Gordon Pugh, famous explorer, athlete and environmental champion.

New course dates

The next course is to be held on 20-22 September 2013.

Due South: Industry partner

Industry partner DUE SOUTH has freely sponsored a small prize for the best candidate on the first course

CPD accreditation

35 clinical and 5 ethics points for WEM through SAMA

Course registration now open

Contact wildernessemergencymedicine@yahoo.com to register for Wilderness Emergency Medicine on 30-31 August and 1 September

Scorpion ID chart

Great outdoor shopping for wilderness / survival gear

I spent this Saturday visiting my favorite shops at Gateway whilst the wife was doing a spot of shopping. I tried to decide where I would get the best in wilderness gear and could not make up my mind so I settled on both Due South and Cape Union Mart. Try them out for yourself and let me know...

         

Recommended reading for ropework component of Wilderness Emergency Medicine course

The ultimate encyclopedia of knots & ropework by Geoffrey Budworth

Wound irrigation in the field

Pre-course assignment 3

During a search and rescue attempt of a hiking party that have become lost, the team leader for the search and rescue team commands the entire team to abandon the search due to encroaching adverse weather conditions, which have been reported by the meteorological centre. There is a 60% chance of these adverse conditions, but the team leader does not want to risk the team. Discuss any ethical issues which need to be taken into consideration when abandoning such a rescue.

Pre-course assignment 2

What would you consider as the most important items to carry in a wilderness first aid kit? Consider a kit for a temperate climate, one for a cold environment, and one for a desert environment. What would be your region-specific considerations for each kit.

Pre-course assignment 1

Wilderness Emergency Medicine is dependent on the versatility of tools and resources, which means carrying less, but with items having more than one use. Discuss 5 drugs that can be considered as essentials for the wilderness emergency medical kit, which have more than one use and how would you carry these drugs in the wilderness emergency kit.

Awesome field guide for any Wilderness Emergency Medical practitioner

Snakes & snake bite in Southern Africa by Johan Marais

Recommended manual for Wilderness Emergency Medicine course in SA

Preparing for REMOTE wilderness expeditions

• Region specific considerations
• climatological
• meteorological
• geographical
• topographical
• geological
• hydrological
• Environmental resources
• Mental preparation
• Organisational including group psychology and sociological considerations
• Time (the resource you cannot negotiate)
• Equipment / expertise / exercise tolerance and physical abilities of team / evacuation plan

Snow blindness

Also known as ultra-violet eye injury. It is a severely painful condition primarily caused by ultra-violet B radiation reflected by snow, and sometimes even water and sand. This is usually a self-limiting problem and can be mitigated by wearing appropriate eye protection.

Causes of shock in the wilderness emergency medicine environment

Liebermeister's Rule and Faget's Sign: Useful clinical guides in the wilderness environment

For every 1 degree Celcius increase in body temperature, the heart rate increases by approximately 10 beats per minute (Liebermeister's Rule), except in situations where there is a relative bradycardia in a patient with a fever (Faget's Sign). This occurs in:

• Yellow fever
• Typhoid
• Tularaemia
• Brucellosis
• Colorado tick fever
• Legionella pneumonia
• Mycoplasma pneumonia
• Drug fever (Beta blockers)(Beta-Faget Sign)

Blood pressure estimates

With lack of appropriate equipment in the field, simple vital sign assessments might become challenging tasks. Estimation of blood pressure in a patient in the wilderness environment is one example. Without sphygomomanometers, the closest clinical assessment one can do is to determine the presence of various pulses. The presence of a radial pulse denotes a systolic BP of at least 80 mmHg. The presence of a femoral pulse implies a systolic BP of at least 70 mmHg. A palpable carotid pulse implies a perfusing systolic BP of at least 60 mmHg. There have been arguments against these estimates as they can be sometimes unreliable. However, in the field without appropriate equipment, these are acceptable.

Continuous management of the wilderness emergency medicine patient whilst awaiting evacuation

The best way to probably monitor and record the care of the wilderness emergency medicine patient whilst awaiting evacuation is to use a SOAP NOTE. The SOAP note is a detailed periodic documentation of the continued care of the patient. It comprises the following elements:

• Subjective data: further new complaints and a subjective assessment of the change in the severity and conditions of existing complaints such as pain score
• Objective data: continued vital signs and clinical monitoring for deterioration
• Assessment: a periodic appraisal of the status of the patient
• Plan: a detailed periodic management plan for ongoing and additional care requirements

Wilderness emergency assessment of the patient: Initial assessment

The primary survey of the wilderness emergency medicine patient needs to include an initial survey of the environment. The aspects to consider here are:

• Immediate hazards in the environment and what needs to be done to protect the rescuers and the victim
• Environmental support and mitigation: what can the environment offer by way of assistance in the care of the patient's primary survey needs and how can you use the environment to mitigate the risk against worsening of the patient's vital signs (eg thermoregulatory control)
• Long-term hazards that will create obstacles to the on-going care of the patient whilst awaiting evacuation
• Environmental management to support the patient during the waiting period whilst awaiting evacuation (shelter, warmth, food etc) (Consider the survival Maslow's hierarchy of needs)

Welcome to the Wilderness Emergency Medicine Course

I am an Emergency Medicine doctor with a special interest in austere environment's emergency medicine. I have worked in remote environments in the wilderness and mountains and on expeditions and love the outdoors. My desire to contribute to the development of emergency medicine in SA met with an obstacle when I saw the focus was on the more traditional aspects and curriculum of emergency medicine. This is understandably so as the specialty cannot develop without core content being developed. However, with my own passion for the esoteric parts of emergency medicine I decided to see what was out there for us in SA with regard to austere environment's emergency medicine. Unfortunately, wilderness emergency medicine is a very young branch of emergency medicine and great efforts were made by some of the great outdoor doctors from Wild Medix and Destination Medicine to offer courses in this regard. These courses were offered as first aid courses and the uptake has not been very promising. My goal then was to develop an intense and comprehensive Wilderness Emergency Medicine course that was accessible and affordable to most practitioners in the field of pre-hospital emergency medicine. Research into international course offerings showed that importing a course was a possibility, except for the costs involved that was mostly due to rand-dollar exchange rates. So, after chatting to several colleagues, I decided to develop my own course from scratch. The first step was to choose course content and develop a synopsis, which is now well developed. The next step is CPD / CEU accreditation including points for ethics to make it fairly meaningful, which is currently in process. I have also secured the services of an internationally experienced mountain climbing and rescue expert to deliver the mountaineering basics, an experienced paramedic with rescue and survival skills to assist with the wilderness component and a trauma surgeon with the same outdoor passion as me to assist with the medical component. The end result is a fantastic opportunity for anyone with a love for the outdoors and a passion for emergency medicine...the Wilderness Emergency Medicine course.