Tibial Plateau Fracture After Attack by an Escaped Goat.

Humans come into contact with goats in wild settings. If a goat feels threatened, it may address the perceived threat violently. While out walking, a 55-y-old man was attacked by an escaped domestic goat. Much as goats interact with each other, this goat pushed him over with its horns and then rose up on 2 legs to come back down on him with its head. The man experienced a Schatzker VI bicondylar tibial plateau fracture that required external and then internal fixation. Besides his physical injuries, he experienced acute stress disorder, which is common after traumatic events. Acute stress reactions can progress into chronic posttraumatic stress disorder but also often resolve. Psychological first aid is appropriate after traumatic events, including animal attacks. It is appropriate to screen for posttraumatic stress disorder symptoms after such events and treat or refer if present. After 1 y, the man returned to full function and experienced no posttraumatic stress disorder.

Psychological First Aid for Wilderness Trauma: Interventions for Expedition or Search and Rescue Team Members.

When exposed to actual or threatened death or serious injury in austere settings, expedition members are at risk of acute stress reactions, as are search and rescue members involved with extricating the patient. Acute stress reactions are a normal response to significant trauma and commonly resolve on their own. If they do not, they can lead to post-traumatic stress disorder (PTSD), a set of persistent symptoms that cause significant effects on the person's life. Medication has a limited preventive role in the field for treatment of stress partly because so few are trained to administer it. Contrastingly, psychological first aid can be performed by lay team members with minimal training. Psychological first aid consists of interventions attempting to encourage feelings of safety, calm, self-efficacy, connection, and hope. These are interventions that provide guidance to not make the situation emotionally worse and might have a preventive effect on later development of PTSD. They are valuable in the field not only for the patient but also for affected team members as well as for search and rescue team members who may be indirectly affected by the trauma and experience repercussions later.

Search and Rescue in the Pacific West States.

INTRODUCTION: The training practices and the level of medical oversight of search and rescue (SAR) organizations in the US National Park Service (NPS) Pacific west region is not known. METHODS: A database of SAR teams in the NPS Pacific west region was assembled using public sources. SAR team leaders received an electronic survey between May and December 2019. A descriptive analysis characterizing team size, technical and medical training protocols, and medical oversight was completed. Results are reported as median (interquartile range, range). RESULTS: Of the 250 SAR teams contacted, 39% (n=97) completed our survey. Annual mission volume was 25 (10-50, 1-200). Team size was 30 members (22-58, 1-405). SAR teams most frequently trained in helicopter operations (77%), low-angle rope rescue (75%), and avalanche rescue (43%). Nearly all teams (99%) had members with some medical training: first aid or cardiopulmonary resuscitation (89%), emergency medical technicians (75%), registered nurses or midlevel providers (52%), and physicians (40%). SAR members administered field medical care (84%), often in coordination with EMS (77%). Medical direction was present on a minority of teams (45%), most frequently by a provider specialized in emergency medicine (68%). Expanded medical procedures were permitted on 21% of SAR teams. CONCLUSIONS: SAR teams across the NPS Pacific west region had composition and training standards similar to those surveyed previously in the US intermountain states. Healthcare professionals were present on most teams, typically as team members, not as medical directors. Few SAR teams use medical protocols in remote care environments.

Stress Ulcer Prophylaxis in Hospitalized Patients, Subsequent Use in Primary Care, and Physicians' Opinions About Acid-Suppressive Therapy.

OBJECTIVES: Stress ulcer prophylaxis (SUP) is not indicated in most hospitalized patients. This study determined the prevalence of the use of proton pump inhibitors (PPI) and histamine receptor 2 blockers (H2B) in hospitalized patients, continued PPI/H2B use after discharge, and physicians' opinions about SUP. METHODS: A retrospective electronic chart review, as well as a national survey of residents and faculty in primary care residency programs to determine the appropriateness of SUP. RESULTS: Of 753 charts reviewed, 332 hospitalized patients with outpatient follow-up were included; 303 of them had either PPI or H2B ordered during hospitalization, but only 120 patients had an indication for SUP. Stepwise logistic regression results showed patients with a history of PPI/H2B use were 16.6 times more likely to receive SUP (odds ratio 16.6; 95% confidence interval 2.2-124.7). In addition, a PPI/H2B indication also significantly predicted SUP use (odds ratio 5.1; 95% confidence interval 1.2-22.2). A total of 171 completed surveys were received: 73% residents and 27% faculty. Only 24% reported being aware of SUP guidelines; 17% reported using electronic health record order set suggestions for SUP. CONCLUSIONS: More than 90% of hospitalized patients received SUP; less than half of them had an indication for needing SUP. A large number of patients discharged on PPI/H2B continued to receive it in the outpatient setting at 6 months follow-up. Only 24% of physicians reported using SUP based on guidelines. Physician education and evidence-based validation of electronic health record order sets are potential areas for improvement.

Suspension syndrome: a scoping review and recommendations from the International Commission for Mountain Emergency Medicine (ICAR MEDCOM).

BACKGROUND: Suspension syndrome describes a multifactorial cardio-circulatory collapse during passive hanging on a rope or in a harness system in a vertical or near-vertical position. The pathophysiology is still debated controversially. AIMS: The International Commission for Mountain Emergency Medicine (ICAR MedCom) performed a scoping review to identify all articles with original epidemiological and medical data to understand the pathophysiology of suspension syndrome and develop updated recommendations for the definition, prevention, and management of suspension syndrome. METHODS: A literature search was performed in PubMed, Embase, Web of Science and the Cochrane library. The bibliographies of the eligible articles for this review were additionally screened. RESULTS: The online literature search yielded 210 articles, scanning of the references yielded another 30 articles. Finally, 23 articles were included into this work. CONCLUSIONS: Suspension Syndrome is a rare entity. A neurocardiogenic reflex may lead to bradycardia, arterial hypotension, loss of consciousness and cardiac arrest. Concomitant causes, such as pain from being suspended, traumatic injuries and accidental hypothermia may contribute to the development of the Suspension Syndrome. Preventive factors include using a well-fitting sit harness, which does not cause discomfort while being suspended, and activating the muscle pump of the legs. Expediting help to extricate the suspended person is key. In a peri-arrest situation, the person should be positioned supine and standard advanced life support should be initiated immediately. Reversible causes of cardiac arrest caused or aggravated by suspension syndrome, e.g., hyperkalaemia, pulmonary embolism, hypoxia, and hypothermia, should be considered. In the hospital, blood and further exams should assess organ injuries caused by suspension syndrome.

Risks and management of prolonged suspension in an Alpine harness.

Suspension trauma is a state of shock induced by passive hanging. Those who survive passive suspension are at risk for rhabdomyolysis. In a wilderness setting, one can see this in cases of persons suspended on rope by their harness. In a conscious person, leg movements work the venous pump to return blood to the central circulation. In the person passively hanging, blood pools in the legs leading to hypoperfusion of vital organs. In the experimental setting, passive hanging has led to unconsciousness in a matter of minutes. Based on a previous series of deaths on rope that included 7 after rescue, many authors have recommended nonstandard treatment for shock including keeping rescued patients upright or squatting for 30 minutes prior to laying them down. This recommendation assumes that sudden death is a risk from acute volume overload or exposure to waste products in the returning blood. This suggestion is not supported by the original series that demonstrated sudden deaths after rescue nor by modern understandings of physiology. Search and rescue teams and party members assisting a colleague suspended unconscious on rope should follow standard resuscitation measures to restore circulation to vital organs immediately.

Rhabdomyolysis after prolonged suspension in a cave.

A 29-year-old man was caving and could not ascend his rope. He was rescued after 4+ hours of hanging after which he could not feel his legs and could not move one of them. He was shivering but still alert. In the field, he received calcium chloride, normal saline, and bicarbonate. At the hospital, he was found to have elevated creatine phosphokinase levels that resolved after continued intravenous fluid. Suspension trauma can include early syncope and late rhabdomyolysis. Persons suspended passively must be rescued immediately and given intravenous fluid to prevent rhabdomyolysis and renal failure.

Immune reconstitution inflammatory syndrome presenting as superior vena cava syndrome secondary to Coccidioides lymphadenopathy in an HIV-infected patient.

A 39-year-old man living with AIDS presented with a swollen face. He was found to be HIV infected after presenting with Coccidioides pneumonia 2 years previously and was placed on daily fluconazole and then on highly active antiretroviral therapy. Computed tomography confirmed superior vena cava obstruction secondary to lymphadenopathy. Biopsy confirmed coccidioidomycosis with no evidence of malignancy. To our knowledge, this is the first description of superior vena cave syndrome secondary to coccidioidomycosis and the first description of immune reconstitution inflammatory syndrome involving Coccidioides.

Sertraline demonstrates fungicidal activity in vitro for Coccidioides immitis.

Coccidioidomycosis causes substantial morbidity in endemic areas. Disseminated coccidioidomycosis is an AIDS defining condition and treatment often requires lifelong antifungal therapy. Sertraline, a widely used serotonin-reuptake inhibitor anti-depressant, has demonstrated activity against Candida and Cryptococcus sp. both in vitro and in vivo. To evaluate if sertraline has activity against Coccidioides, the minimal inhibitory concentration (MIC) and minimal fungicidal concentration (MFC) of sertraline for four clinical isolates of C. immitis were determined. Sertraline was observed to have an MIC range of 4-8 µg/ml and MFC also of 4-8 µg/ml for Coccidioides. These MIC and MFC results for C. immitis are similar to those reported for Cryptococcus sp. suggesting sertraline may potentially have utility for the treatment of coccidioidomycosis.

The Significance of Harm Reduction as a Social and Health Care Intervention for Injecting Drug Users: An Exploratory Study of a Needle Exchange Program in Fresno, California.

Infectious disease remains a significant social and health concern in the United States. Preventing more people from contracting HIV/AIDS or Hepatitis C (HCV), requires a complex understanding of the interconnection between the biomedical and social dimensions of infectious disease. Opiate addiction in the US has skyrocketed in recent years. Preventing more cases of HIV/AIDS and HCV will require dealing with the social determinants of health. Needle exchange programs (NEPs) are based on a harm reduction approach that seeks to minimize the risk of infection and damage to the user and community. This article presents an exploratory small-scale quantitative study of the injection drug using habits of a group of injection drug users (IDUs) at a needle exchange program in Fresno, California. Respondents reported significant decreases in high risk IDU behaviors, including sharing of needles and to a lesser extent re-using of needles. They also reported frequent use of clean paraphernalia. Greater collaboration between social and health outreach professionals at NEPs could provide important frontline assistance to people excluded from mainstream office-based services and enhance efforts to reduce HIV/AIDS or HCV infection.

Leptospirosis in a caver returned from Sarawak, Malaysia.

This article describes a case of leptospirosis in a man who returned from caving in Sarawak, Malaysia, and includes a discussion of epidemiology, pathophysiology, diagnosis, prevention, and treatment. The patient presented with symptoms of leptospirosis, which was confirmed by microhemagglutination titers. He became infected despite taking doxycycline daily for malaria prophylaxis. Leptospirosis is an important consideration in any returned traveler with fever. The spirochete spreads from animals to humans via water. Caving in tropical endemic zones may increase exposure risk due to the combination of multiple skin abrasions with immersions. Water in caves may increase infection risk because of increased water pH. Standard prophylaxis may be inadequate in cases of high-risk exposures.