The Intersection of Telemedicine and Wilderness Care: Past, Present, and Future.

Wilderness medicine and telemedicine seemingly exist at opposite ends of the clinical continuum. However, these 2 specialties share a common history and the literature abounds with examples of successful deployment of telemedicine to resource limited settings. The recent widespread adoption of telemedicine has important ramifications for wilderness providers. Telemedicine is inherently reliant on some sort of technology. There is a wide spectrum of complexity involved, but in general these systems rely on a hardware component, a software component, and a network system to transmit information from place to place. Today, connectivity is nearly ubiquitous through access to cellular networks, Wi-Fi, or communication satellites. However, bandwidth, defined as the amount of data which can be transmitted through a given connection over time, remains a limiting factor for many austere settings. Telemedicine services are typically organized into 4 categories: 1) live/interactive; 2) store and forward; 3) remote patient monitoring; and 4) mHealth. Each of these categories has an applicable wilderness medicine use case which will be reviewed in this paper. Though the regulatory environment remains complex, there is enormous potential for telemedicine to enhance the practice of wilderness medicine. Drones are likely to transform wilderness medicine supply chains by facilitating delivery of food, shelter, and medicines and are able to enhance search and rescue efforts. Remote consultations can be paired with remote patient monitoring technology to deliver highly specialized care to austere environments. Early feasibility studies are promising, but further prospective data will be required to define future best practices for wilderness telemedicine.

Wilderness Medical Society Clinical Practice Guidelines on Anaphylaxis.

The Wilderness Medical Society convened a panel to review the literature and develop evidence-based clinical practice guidelines on the treatment of anaphylaxis, with an emphasis on a field-based perspective. The review also included literature regarding the definition, epidemiology, clinical manifestations, and prevention of anaphylaxis. The increasing prevalence of food allergies in the United States raises concern for a corresponding rise in the incidence of anaphylaxis. Intramuscular epinephrine is the primary treatment for anaphylaxis and should be administered before adjunctive treatments such as antihistamines, corticosteroids, and inhaled ß agonists. For outdoor schools and organizations, selecting a method to administer epinephrine in the field is based on considerations of cost, safety, and first responder training, as well as federal guidelines and state-specific laws.

Mortality in Puerto Rico after Hurricane Maria.

BACKGROUND: Quantifying the effect of natural disasters on society is critical for recovery of public health services and infrastructure. The death toll can be difficult to assess in the aftermath of a major disaster. In September 2017, Hurricane Maria caused massive infrastructural damage to Puerto Rico, but its effect on mortality remains contentious. The official death count is 64. METHODS: Using a representative, stratified sample, we surveyed 3299 randomly chosen households across Puerto Rico to produce an independent estimate of all-cause mortality after the hurricane. Respondents were asked about displacement, infrastructure loss, and causes of death. We calculated excess deaths by comparing our estimated post-hurricane mortality rate with official rates for the same period in 2016. RESULTS: From the survey data, we estimated a mortality rate of 14.3 deaths (95% confidence interval [CI], 9.8 to 18.9) per 1000 persons from September 20 through December 31, 2017. This rate yielded a total of 4645 excess deaths during this period (95% CI, 793 to 8498), equivalent to a 62% increase in the mortality rate as compared with the same period in 2016. However, this number is likely to be an underestimate because of survivor bias. The mortality rate remained high through the end of December 2017, and one third of the deaths were attributed to delayed or interrupted health care. Hurricane-related migration was substantial. CONCLUSIONS: This household-based survey suggests that the number of excess deaths related to Hurricane Maria in Puerto Rico is more than 70 times the official estimate. (Funded by the Harvard T.H. Chan School of Public Health and others.).

The Climate-Smart Emergency Department: A Primer.

Climate change and environmental pollution from health care present urgent, complex challenges. The US health care sector produces 10% of total US greenhouse gas emissions, which have negative influences on human and environmental health. The emergency department (ED) is an important place in the hospital to become more environmentally responsible and "climate smart," a term referring to the combination of low-carbon and resilient health care strategies. Our intent is to educate and motivate emergency providers to action by providing a guide to sustainable health care and an approach to creating a climate-smart ED.

Clinical Implications of Climate Change on US Emergency Medicine: Challenges and Opportunities.

The adverse influences of climate change are manifesting as health burdens relevant to clinical practice, affecting the very underpinnings of health and stressing the health care system. Emergency medicine is likely to bear a large burden, with its focus on urgent and emergency care, through its role as a safety-net provider for vulnerable populations and as a leader in disaster medicine. Clinically, climate change is affecting emergency medicine practice through the amplification of climate-related disease patterns and epidemiologic shifts for conditions diagnosed and treated in emergency departments (EDs), especially for vulnerable populations. In addition, climate-driven intensification of extreme weather is disrupting health care delivery in EDs and health care systems. Thus, there are significant opportunities for emergency medicine to lead the medical response to climate change through 7 key areas: clinical practice improvements, building resilient EDs and health care systems, adaptation and public health engagement, disaster preparedness, mitigation, research, and education. In the face of this growing health threat, systemwide preparation rooted in local leadership and responsiveness is necessary to efficiently and effectively care for our vulnerable communities.

Psychological Care Augmented by Telemedicine after a Polar Bear Encounter at an Arctic Research Station: A Case Report.

Background: Psychologically stressful events can be particularly challenging in the wilderness or extreme environments due to a lack of immediate medical or psychological support. Telemedicine consultations may provide a means to supply medical providers in austere environments with expertise when confronted with these situations. Methods: In this study, we detail a case of psychological care imparted to residents at a remote, arctic research station after they encountered a polar bear. The health care provider at the camp was not a dedicated mental health professional but was able to deliver psychological care with assistance from a trained provider through use of telemedicine. We provide a brief overview of the evidence behind psychological first aid and incident support sessions for the treatment of stress injuries. We also review the evidence for telemedicine for psychological care in wilderness situations and describe its use in this scenario. Results: All station residents were able to resume regular arctic activities. Resident feedback was that the sessions were advantageous. Conclusions: We anticipate the need for psychological care in austere situations to increase in the future, and further training in this field and the advancement of telemedicine consultation will be of benefit to wilderness providers.

Climate Change and the Kidney.

The worldwide increase in temperature has resulted in a marked increase in heat waves (heat extremes) that carries a markedly increased risk for morbidity and mortality. The kidney has a unique role not only in protecting the host from heat and dehydration but also is an important site of heat-associated disease. Here we review the potential impact of global warming and heat extremes on kidney diseases. High temperatures can result in increased core temperatures, dehydration, and blood hyperosmolality. Heatstroke (both clinical and subclinical whole-body hyperthermia) may have a major role in causing both acute kidney disease, leading to increased risk of acute kidney injury from rhabdomyolysis, or heat-induced inflammatory injury to the kidney. Recurrent heat and dehydration can result in chronic kidney disease (CKD) in animals and theoretically plays a role in epidemics of CKD developing in hot regions of the world where workers are exposed to extreme heat. Heat stress and dehydration also has a role in kidney stone formation, and poor hydration habits may increase the risk for recurrent urinary tract infections. The resultant social and economic consequences include disability and loss of productivity and employment. Given the rise in world temperatures, there is a major need to better understand how heat stress can induce kidney disease, how best to provide adequate hydration, and ways to reduce the negative effects of chronic heat exposure.

Climate change and women's health: Impacts and policy directions.

In a Policy Forum, Cecilia Sorensen and colleagues discuss the implications of climate change for women's health.

Ethical, Legal, and Administrative Considerations for Preparticipation Evaluation for Wilderness Sports and Adventures.

Preparticipation evaluations (PPEs) are common in team, organized, or traditional sports but not common in wilderness sports or adventures. Regarding ethical, legal, and administrative considerations, the same principles can be used as in traditional sports. Clinicians should be trained to perform such a PPE to avoid missing essential components and to maximize the quality of the PPE. In general, participants' privacy should be observed; office-based settings may be best for professional and billing purposes, and adequate documentation of a complete evaluation, including clearance issues, should be essential components. Additional environmental and personal health issues relative to the wilderness activity should be documented, and referral for further screening should be made as deemed necessary, if unable to be performed by the primary clinician. Travel medicine principles should be incorporated, and recommendations for travel or adventure insurance should be made.

Wilderness Preparticipation Evaluation and Considerations for Special Populations.

Children, older adults, disabled and special needs athletes, and female athletes who participate in outdoor and wilderness sports and activities each face unique risks. For children and adolescents traveling to high altitude, the preparticipation physical evaluation should focus on risk assessment, prevention strategies, early recognition of altitude-related symptoms, management plans, and appropriate follow-up. As the risk and prevalence of chronic disease increases with age, both older patients and providers need to be aware of disease and medication-specific risks relative to wilderness sport and activity participation. Disabled and special needs athletes benefit from careful pre-event planning for the potential medical issues and equipment modifications that may affect their health in wilderness environments. Issues that demand special consideration for female adventurers include pregnancy, contraceptive use, menses, and ferritin levels at altitude. A careful preparticipation evaluation that factors in unique, population-specific risks will help special populations stay healthy and safe on wilderness adventures. The PubMed and SportDiscus databases were searched in 2014 using both MeSH terms and text words and include peer-reviewed English language articles from 1977 to 2014. Additional information was accessed from Web-based sources to produce this narrative review on preparticipation evaluation for special populations undertaking wilderness adventures. Key words include children, adolescent, pediatric, seniors, elderly, disabled, special needs, female, athlete, preparticipiation examination, wilderness medicine, and sports.

Ethical, Legal, and Administrative Considerations for Preparticipation Evaluation for Wilderness Sports and Adventures.

Preparticipation evaluations (PPEs) are common in team, organized, or traditional sports but not common in wilderness sports or adventures. Regarding ethical, legal, and administrative considerations, the same principles can be used as in traditional sports. Clinicians should be trained to perform such a PPE to avoid missing essential components and to maximize the quality of the PPE. In general, participants' privacy should be observed; office-based settings may be best for professional and billing purposes, and adequate documentation of a complete evaluation, including clearance issues, should be essential components. Additional environmental and personal health issues relative to the wilderness activity should be documented, and referral for further screening should be made as deemed necessary, if unable to be performed by the primary clinician. Travel medicine principles should be incorporated, and recommendations for travel or adventure insurance should be made.

Wilderness Preparticipation Evaluation and Considerations for Special Populations.

Children, older adults, disabled and special needs athletes, and female athletes who participate in outdoor and wilderness sports and activities each face unique risks. For children and adolescents traveling to high altitude, the preparticipation physical evaluation should focus on risk assessment, prevention strategies, early recognition of altitude-related symptoms, management plans, and appropriate follow-up. As the risk and prevalence of chronic disease increases with age, both older patients and providers need to be aware of disease and medication-specific risks relative to wilderness sport and activity participation. Disabled and special needs athletes benefit from careful pre-event planning for the potential medical issues and equipment modifications that may affect their health in wilderness environments. Issues that demand special consideration for female adventurers include pregnancy, contraceptive use, menses, and ferritin levels at altitude. A careful preparticipation evaluation that factors in unique, population- specific risks will help special populations stay healthy and safe on wilderness adventures. The PubMed and SportDiscus databases were searched in 2014 using both MeSH terms and text words and include peer-reviewed English language articles from 1977 to 2014. Additional information was accessed from Web-based sources to produce this narrative review on preparticipation evaluation for special populations undertaking wilderness adventures. Key words include children, adolescent, pediatric, seniors, elderly, disabled, special needs, female, athlete, preparticipiation examination, wilderness medicine, and sports.

Wilderness Medical Society practice guidelines for the use of epinephrine in outdoor education and wilderness settings: 2014 update.

The Epinephrine Roundtable took place on July 27, 2008, during the 25th Annual Meeting of the Wilderness Medical Society (WMS) in Snowmass, CO. The WMS convened this roundtable to explore areas of consensus and uncertainty in the field treatment of anaphylaxis. Panelists were selected on the basis of their relevant academic or professional experience. There is a paucity of data that address the treatment of anaphylaxis in the wilderness. Anaphylaxis is a rare disease, with a sudden onset and drastic course that does not lend itself to study in randomized, controlled trials. Therefore, the panel endorsed the following position based on the limited available evidence and review of published articles, as well as expert consensus. The position represents the consensus of the panelists and is endorsed by the WMS. In 2014, the authors reviewed relevant articles published since the Epinephrine Roundtable. The following is an updated version of the original guidelines published in Wilderness & Environmental Medicine 2010;21(4):185-187.

Enabling Human Space Exploration Missions Through Progressively Earth Independent Medical Operations (EIMO).

Goal: Current Space Medicine operations depend on terrestrial support to manage medical events. As astronauts travel to destinations such as the Moon, Mars, and beyond, distance will substantially limit this support and require increasing medical autonomy from the crew. This paper defines Earth Independent Medical Operations (EIMO) and identifies key elements of a conceptual EIMO system. Methods: The NASA Human Research Program Exploration Medical Capability Element held a 2-day conference at Johnson Space Center in Houston, TX with NASA experts representing all aspects of Space Medicine. Results: EIMO will be a process enabling progressively resilient deep space exploration systems and crews to reduce risk and increase mission success. Terrestrial assets will continue to provide pre-mission screening, planning, health maintenance, and prevention, while onboard medical care will increasingly be the purview of the crew. Conclusions: This paper defines and describes the key components of EIMO.

Creating climate-informed physician leaders: The evolution of a physician fellowship in climate and health science policy.

Climate change poses numerous near and long-term challenges for our society, and the human health consequences are increasingly recognized as unprecedented. Responding to these health hazards requires a healthcare workforce composed of climate-informed clinicians. As trusted messengers, physicians play a vital role in informing and preparing the public for health impacts of climate change. We describe an evolving graduate medical education fellowship for physicians from all specialties capable of training leaders in this field. Our program pairs fellows with federal and non-governmental partners to provide expertise in climate policy and empower them to be change agents. The accelerating response to climate change from the federal government coupled with an increased recognition of the impacts of climate hazards on health demands a climate-informed clinical workforce. The expansion of this fellowship to accommodate trainees from multiple specialties and its innovative structure leveraging local and national partnerships sets a standard for how similar programs can be developed in addressing the greatest public health threat and opportunity of the century.

Because it's there The education of George Mallory.

Initiative, creativity, and resolve represent both the pillars of the Wilderness Medical Society (WMS) and the story of George Mallory. His journey from humble beginnings to his rise to become one of history's most legendary mountaineers is a testament to the impact of great mentors as well as the development of Mallory as a mentor himself. In this light, the path of George Mallory in mountaineering and the role of WMS in wilderness medicine share a common theme. This essay is not only a tribute to George Mallory but also a testament to the importance of mentorship and the role of WMS in inspiring mentorship and education to future pioneers.

Evidence-Based Heatstroke Management in the Emergency Department.

INTRODUCTION: Climate change is causing an increase in the frequency and intensity of extreme heat events, which disproportionately impact the health of vulnerable populations. Heatstroke, the most serious heat-related illness, is a medical emergency that causes multiorgan failure and death without intervention. Rapid recognition and aggressive early treatment are essential to reduce morbidity and mortality. The objective of this study was to evaluate current standards of care for the emergent management of heatstroke and propose an evidence-based algorithm to expedite care. METHODS: We systematically searched PubMed, Embase, and key journals, and reviewed bibliographies. Original research articles, including case studies, were selected if they specifically addressed the recognition and management of heatstroke in any prehospital, emergency department (ED), or intensive care unit population. Reviewers evaluated study quality and abstracted information regarding demographics, scenario, management, and outcome. RESULTS: In total, 63 articles met full inclusion criteria after full-text review and were included for analysis. Three key themes identified during the qualitative review process included recognition, rapid cooling, and supportive care. Rapid recognition and expedited external or internal cooling methods coupled with multidisciplinary management were associated with improved outcomes. Delays in care are associated with adverse outcomes. We found no current scalable ED alert process to expedite early goal-directed therapies. CONCLUSION: Given the increased risk of exposure to heat waves and the time-sensitivity of the condition, EDs and healthcare systems should adopt processes for rapid recognition and management of heatstroke. This study proposes an evidence-based prehospital and ED heat alert pathway to improve early diagnosis and resource mobilization. We also provide an evidence-based treatment pathway to facilitate efficient patient cooling. It is hoped that this protocol will improve care and help healthcare systems adapt to changing environmental conditions.

Associations Between Wildfire-Related PM2.5 and Intensive Care Unit Admissions in the United States, 2006-2015.

Wildfire smoke is a growing public health concern in the United States. Numerous studies have documented associations between ambient smoke exposure and severe patient outcomes for single-fire seasons or limited geographic regions. However, there are few national-scale health studies of wildfire smoke in the United States, few studies investigating Intensive Care Unit (ICU) admissions as an outcome, and few specifically framed around hospital operations. This study retrospectively examined the associations between ambient wildfire-related PM2.5 at a hospital ZIP code with total hospital ICU admissions using a national-scale hospitalization data set. Wildfire smoke was characterized using a combination of kriged PM2.5 monitor observations and satellite-derived plume polygons from National Oceanic and Atmospheric Administration's Hazard Mapping System. ICU admissions data were acquired from Premier, Inc. and encompass 15%-20% of all U.S. ICU admissions during the study period. Associations were estimated using a distributed-lag conditional Poisson model under a time-stratified case-crossover design. We found that a 10 µg/m3 increase in daily wildfire PM2.5 was associated with a 2.7% (95% CI: 1.3, 4.1; p = 0.00018) increase in ICU admissions 5 days later. Under stratification, positive associations were found among patients aged 0-20 and 60+, patients living in the Midwest Census Region, patients admitted in the years 2013-2015, and non-Black patients, though other results were mixed. Following a simulated severe 7-day 120 µg/m3 smoke event, our results predict ICU bed utilization peaking at 131% (95% CI: 43, 239; p < 10-5) over baseline. Our work suggests that hospitals may need to preposition vital critical care resources when severe smoke events are forecast.

Training Clinical And Public Health Leaders In Climate And Health.

The effects of climate change are accelerating and undermining human health and well-being in many different ways. There is no doubt that the health care sector will need to adapt, and although it has begun to develop more targeted strategies to address climate-related challenges, a broad knowledge gap persists. There is a critical need to develop and cultivate new knowledge and skill sets among health professionals, including those in public health, environmental science, policy, and communication roles. This article describes specific initiatives to train future leaders to be proficient in understanding the linkages between climate change and health. We present an agenda for expanding education on climate and health through health professional schools and graduate and postgraduate curricula, as well as in professional and continuing education settings. Our agenda also identifies ways to promote sustainability in clinical practice and health care management and policy. Throughout, we cite metrics by which to measure progress and highlight potential barriers to achieving these educational objectives on a larger scale.