Edward Leicester Atkinson (1881-1929): Antarctic explorer, scientist and naval surgeon.

Edward Leicester Atkinson qualified at St Thomas's Hospital in 1906 and joined the Navy in 1908. He was a doctor and parasitologist on Captain Scott's Terra Nova expedition to the Antarctic and had to take charge of the expedition when Scott died on his return from the South Pole. After the expedition he went to China and discovered the cause of schistosomiasis, returning at the start of the First World War in which he served with distinction, winning a DSO and Albert Medal but also being severely injured. After the war he served in various naval posts and became the youngest Surgeon Captain in the Navy before being retired on health grounds in 1928. He died at sea the following year.

Medical memorials of the Heroic Age of Antarctic exploration.

The Heroic Age of Antarctic exploration spanned the period from 1895 to 1922. Medical men who took part in the expeditions of that period made significant contributions to the expeditions in medical treatment of expedition members, geographical discovery and science and, as a result of such contributions, many had geographical features named after them. A recent paper listed five doctors from the Heroic Age who were so honoured. We now add biographical précises of a further 17 personnel, including two medical students who have geographical features named after them.

George Murray Levick (1876-1956), Antarctic explorer.

Murray Levick is best known for being one of the surgeons on Scott's Terra Nova Antarctic expedition (1910-1913) and, as a member of the Northern Party of that expedition, spending a winter living in a snow hole when the ship was unable to collect the men. However, his career encompassed much more than that. He served in the Royal Navy during both World Wars and was a pioneer in physical medicine and rehabilitation. He also founded the British Schools Exploring Society.

Vital signs during and following ambulance transfer.

The aim of this study was to compare vital signs of minimally injured and moderately injured patients during ambulance transport and subsequent emergency department (ED) assessment. We carried out a retrospective chart review. Patients were divided into two groups: minimally injured patients with neck pain (group 1) and moderately injured patients with a closed ankle or wrist fracture (group 2). The Wilcoxon signed-rank test was used to compare vital signs within groups during transport and ED assessment. Groups 1 and 2 included 90 and 118 patients, respectively. In group 1, systolic blood pressure was significantly lower (P=0.001, median difference 8 mmHg) and heart rate was significantly higher (P<0.01, median difference 3 beats/min) during transport than during ED assessment. There was no significant difference in respiratory rate in group 1 or any of the vital signs in group 2. We conclude that transport anxiety has minimal effect on vital signs. In trauma, clinicians should exclude tissue injury before attributing increased systolic blood pressure or heart rate to anxiety.

The value of the difference between ED and prehospital vital signs in predicting outcome in trauma.

INTRODUCTION: Traditional vital signs are seen as an important part of trauma assessment, despite their poor predictive value in this regard. OBJECTIVE: This study evaluated whether the difference between systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR) and shock index (SI) taken in the emergency department (ED) and prehospital can predict 48 h mortality postadmission following trauma. METHODS: Retrospective cohort was obtained from the Trauma Audit and Research Network. Subjects were excluded if head or spinal injuries, prehospital intubation or CPR were present. Main outcome was 48 h mortality. The difference (delta, Δ) between ED and prehospital values were used as study variables (ie, ΔSI=SI-ED minus SI-prehospital). Accuracy was assessed using area under receiver operator characteristic curve (AUROC). AUROC coordinates were used to identify 95% specificity cut points and described further using sensitivity and likelihood ratios (LRs). RESULTS: Significant AUROC statistics were revealed for ΔSBP (0.57) and ΔRR (0.56) for the full sample, ΔSBP (0.62) and ΔSI (0.65) for moderate, and ΔRR (0.6) for severe injury. Best LRs were 3.4 and 2.4 for ΔRR and ΔSI, respectively, but sensitivities were low (<=26%). Cut point values for ΔSBP, ΔRR and ΔSI were 37 mm Hg, 8 breaths/min and 0.2, respectively. DISCUSSION: ΔSBP and ΔRR performed best overall, but ΔSI performed best in the moderate injury group, suggesting earlier identification with ΔSI. Use of Δ values result in good rule-in of 48 h mortality and may supplement trauma treatment decisions.

The value of traditional vital signs, shock index, and age-based markers in predicting trauma mortality.

BACKGROUND: Systolic blood pressure (SBP), heart rate (HR), and respiratory rate are poor predictors of trauma outcome. We postulate that HR/SBP (shock index [SI]) and novel new markers SI × age (SIA), SBP / age (BPAI), maximum HR (220 - age) - HR (minpulse [MP]), and HR / maximum HR (pulse max index [PMI]) are better predictors of 48-hour mortality compared with traditional vital signs. METHODS: Data were extracted from the Trauma Audit and Research Network database. Exclusions included any head or spine injury and prehospital intubation or cardiac arrest. Area under receiver operator characteristic curve (AUROC) was determined for 48-hour mortality for all variables and age. A threshold for each marker was derived using the specificity (rule-in) cutoffs at both 90% and 95% from the receiver operator characteristic curve. Positive likelihood ratios were described for each marker's derived threshold. RESULTS: Vital signs, markers, and age were all significantly associated with 48-hour mortality (p < 0.001). HR, SBP, and respiratory rate fared worst overall (AUROC = 0.69, 0.66, and 0.66, respectively). SIA, MP, PMI, BPAI, and SI were significantly (p < 0.05) better than age at predicting 48-hour mortality (AUROC = 0.79, 0.77, 0.77, 0.74, 0.73, and 0.68, respectively; AUROC for age = 0.68). Thresholds derived for these five markers were values 55 or greater, 44 or less, 70% or greater, 1.5 or less, and 0.9 or greater, respectively, each with a specificity of 95% for 48-hour mortality (positive likelihood ratios were 8.4, 6.1, 6.7, 6.6, and 7.5, respectively). The likelihood of death in 48 hours was 8.4 times more likely if SIA was greater than 55 than if it was lower. CONCLUSION: Older age seems to be significantly associated with early mortality. Newer markers, especially those combining traditional vital signs with age (SIA, BPAI, MP, and PMI), may contribute to better trauma triage of patients with blunt injuries than traditional vital signs. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Effect of spinal immobilization on heart rate, blood pressure and respiratory rate.

INTRODUCTION: Vital signs remain important clinical indicators in the management of trauma. Tissue injury and ischemia cause tachycardia and hypertension, which are mediated via the sympathetic nervous system (SNS). Spinal immobilization is known to cause discomfort, and it is not known how this might influence the SNS and contribute to abnormal vital signs. Hypothesis This study aimed to establish whether the pain and discomfort associated with spinal immobilization and the maneuvers commonly used in injured patients (eg, log roll) affect the Heart rate (HR), Systolic Blood Pressure (SBP) and Respiratory rate (RR). The null hypothesis was that there are no effects. METHODS: A prospective, unblinded, repeated-measure study of 53 healthy subjects was used to test the null hypothesis. Heart rate, BP and RR were measured at rest (five minutes), after spinal immobilization (10 minutes), following log roll, with partial immobilization (10 minutes) and again at rest (five minutes). A visual analog scale (VAS) for both pain and discomfort were also collected at each stage. Results were statistically compared. RESULTS: Pain VAS increased significantly during spinal immobilization (3.8 mm, P < .01). Discomfort VAS increased significantly during spinal immobilization, after log roll and during partial immobilization (17.7 mm, 5.8 mm and 8.9 mm, respectively; P < .001). Vital signs however, showed no clinically relevant changes. Discussion Spinal immobilization does not cause a change in vital signs despite a significant increase in pain and discomfort. Since no relationship appears to exist between immobilization and abnormal vital signs, abnormal vital signs in a clinical situation should not be considered to be the result of immobilization. Likewise, pain and discomfort in immobilized patients should not be disregarded due to lack of changes in vital signs.

Heart rate and systolic blood pressure in patients with minor to moderate, non-haemorrhagic injury versus normal controls.

BACKGROUND: Raised blood pressure (and heart rate (HR)) due to anxiety in a clinical situation is well described and is called the white coat effect (WCE). It is not known whether the pain and anxiety that results from trauma causes a measurable WCE. METHODS: A sample of patients with a non-haemorrhagic injury from the Trauma Audit and Research Network (TARN) was compared with a healthy, non-injury sample from the Health Survey for England (HSE) databases. Two-way analysis of variance with rank transformation of data was used to compare systolic blood pressure (SBP) and HR between the groups at different ages. In the injured group, the SBP and HR were also compared between spinally immobilised and non-immobilised patients. RESULTS: There was a statistically significant difference between the groups for both HR and SBP (p<0.001). Median HR remained approximately 10 bpm higher in the TARN set when compared to the HSE set, irrespective of age. The difference for SBP was not considered clinically relevant (the highest was 5 mm Hg). There was no significant difference between immobilised and non-immobilised patients, for either HR or SBP (p=0.07 and 0.3, respectively). DISCUSSION: Median HR remained approximately 10 bpm higher in the TARN (injury) set compared to the HSE (non-injury, control) set, irrespective of age. Understanding that HR reacts in this way for mild to moderately injured patients is important as it will affect clinical interpretation during the initial assessment.

Dr Reginald Koettlitz (1860-1916): Arctic and Antarctic explorer.

Reginald Koettlitz was born in Ostend but moved to England as a child and qualified at Guy's Hospital. He was a general practitioner in County Durham for eight years before serving as doctor and geologist to the Jackson-Harmsworth Expedition to Franz-Josef Land in 1894-97. Thereafter he made further expeditions to Somaliland, Abyssinia and the Amazon before joining Captain Scott's Discovery Expedition to the Antarctic in 1901-04 as surgeon and botanist. After the expedition he emigrated to South Africa, where he worked as a general practitioner, dying in 1916.

The death of Robert Falcon Scott (1869-1912) and colleagues.

This year, 2012, marks the 100th anniversary of Captain Scott his reaching the South Pole and of his death on the return journey. There has been much discussion on the cause of death of Scott and his colleagues and, in particular, whether he died of scurvy. There has probably been even more discussion on the cause of death of Edgar Evans, one of Scott's companions. This paper reviews the topic.

An Antarctic sealing expedition and the medical diary of William Spiers Bruce (1867-1921).

William Spiers Bruce was a medical student who sailed as ship's surgeon on the Balaena, one of the ships of the Dundee Whaling Expedition to the Antarctic (1892-93). On this expedition he kept a diary listing his medical consultations and the treatments he administered. This paper considers the expedition and the diaries.

Frostbite and other cold injuries in the heroic age of Antarctic exploration.

Frostbite and other cold injuries on the early polar expeditions were common. This paper explains how frostbite was described, prevented, and treated on the Antarctic expeditions of the heroic age, comparing them with modern recommendations. Nonfreezing cold injury probably also occurred but was not differentiated from frostbite, and chilblains were also described.

The role of the expedition doctor: lessons from 100 years ago.

This paper explores the role of the doctor on the expeditions of the heroic age of Antarctic exploration. The medical role includes medical screening of prospective expedition members, choosing medical equipment so as to maintain a balance between being able to cope with any eventuality and the cost and weight of equipment and drugs, health screening during an expedition, first aid training for field parties without a doctor, and, obviously, treatment of any injury or disease that occurs. If injury or illness occurs, the presence of a doctor is of great psychological benefit to the expedition. Although medical experience is important, it is probably more important that the doctor is a "team member," playing a full part in the expedition's aims, whether these are scientific, exploration, or reaching some goal. Most of the lessons learned during these expeditions a hundred years ago are just as relevant today.

Snow blindness and other eye problems during the heroic age of Antarctic exploration.

During the heroic age of Antarctic exploration, snow blindness was a common problem, but not all the descriptions of it fit the modern view of the disease, and some of the explorers complained of long-term problems. This article describes the snow blindness and other eye problems that occurred during this era. It also describes how snow blindness was prevented and treated.

Medicinal brandy.

This paper describes the use of brandy and other forms of alcohol in the latter part of the 19th and early 20th centuries. Its prime use was as a cardiac stimulant as it seemed to increase the cardiac output and blood pressure. However it was also recognised as a depressant and was used as a sedative. Reconciling these two actions caused difficulties. In addition it was used as a food for invalids.

History of accidental hypothermia.

Death from exposure to cold has been recognised for thousands of years but hypothermia as a clinical condition was not generally recognised until the mid-20th century and then only in extreme conditions such as immersion in cold water or snow. In the UK, hypothermia in less extreme conditions was not generally recognised until the 1960s. Recognition of hypothermia required the temperature to be measured and this did not become a clinical tool until the late 1800s and it was not used routinely until the early 1900s. Although John Hunter and James Curry did some physiological experiments in the 1700s, detailed physiological experiments were not done until the early 20th century and the use of therapeutic hypothermia for malignancy and in anaesthesia in the 1930s and 1940s provided more impetus for investigating the physiology of hypothermia in humans and familiarising the medical profession with measuring core temperatures.