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.

Medical Oversight, Educational Core Content, and Proposed Scopes of Practice of Wilderness EMS Providers: A Joint Project Developed by Wilderness EMS Educators, Medical Directors, and Regulators Using a Delphi Approach.

INTRODUCTION: A disparity exists between the skills needed to manage patients in wilderness EMS environments and the scopes of practice that are traditionally approved by state EMS regulators. In response, the National Association of EMS Physicians Wilderness EMS Committee led a project to define the educational core content supporting scopes of practice of wilderness EMS providers and the conditions when wilderness EMS providers should be required to have medical oversight. METHODS: Using a Delphi process, a group of experts in wilderness EMS, representing educators, medical directors, and regulators, developed model educational core content. This core content is a foundation for wilderness EMS provider scopes of practice and builds on both the National EMS Education Standards and the National EMS Scope of Practice Model. These experts also identified the conditions when oversight is needed for wilderness EMS providers. RESULTS: By consensus, this group of experts identified the educational core content for four unique levels of wilderness EMS providers: Wilderness Emergency Medical Responder (WEMR), Wilderness Emergency Medical Technician (WEMT), Wilderness Advanced Emergency Medical Technician (WAEMT), and Wilderness Paramedic (WParamedic). These levels include specialized skills and techniques pertinent to the operational environment. The skills and techniques increase in complexity with more advanced certification levels, and address the unique circumstances of providing care to patients in the wilderness environment. Furthermore, this group identified that providers having a defined duty to act should be functioning with medical oversight. CONCLUSION: This group of experts defined the educational core content supporting the specific scopes of practice that each certification level of wilderness EMS provider should have when providing patient care in the wilderness setting. Wilderness EMS providers are, indeed, providing health care and should thus function within defined scopes of practice and with physician medical director oversight.

Trends in Skin and Soft Tissue-Related Injuries in NOLS Wilderness Expeditions from 1984 to 2012.

OBJECTIVE: Wilderness expeditions inevitably involve risk to participants. Understanding of expedition-related illnesses and injuries allows institutions and individuals to develop strategies to mitigate risk. We describe findings and trends in soft tissue injuries, the second-most common type of injury, among participants in the National Outdoor Leadership School expeditions from 1984 to 2012. METHODS: Injuries and illnesses sustained by students and staff have been recorded continuously since 1984 in the extensive National Outdoor Leadership School database. We performed a retrospective analysis of incidence of soft tissue injuries in this population. Data before 1996 were standardized in order to make use of the entire dataset. RESULTS: Of 9734 total reported incidents, 2151 (22%) were soft tissue related, 707 (33%) of which required evacuation. The sex distribution of incidents was similar to the sex distribution of participants. The largest incidence of soft tissue injuries occurred independent of activity (711 incidents, 33%). The most commonly associated activities were hiking (528 incidents, 25%), camping (301 incidents, 14%), and cooking (205 incidents, 10%). Over the study period, rates of injury declined overall and in every individual category except cooking. CONCLUSIONS: Over this 28-year period, the incidence of soft tissue injuries associated with the most common activities decreased. Incidence of activity-independent injuries did not change significantly, but reported severity decreased. These data provide unique insights to help improve wilderness risk management for institutions and individuals and suggest areas in which educational efforts may further reduce risk.

Prolonged Exposure Dermatosis: Reporting High Incidence of an Undiagnosed Facial Dermatosis on a Winter Wilderness Expedition.

OBJECTIVE: Previously unclassified inflammatory skin lesions referred to as sun bumps have been observed throughout the year on participants of wilderness trips; however, the underlying cause and diagnosis remain unclear. The purpose of this prospective observational study was to document the incidence, characteristics, and risk factors associated with these skin lesions as they occurred on a winter wilderness expedition. METHODS: For this study, the lesions were defined as pruritic or erythematous skin lesions occurring while in the wilderness. Seventy-four participants in a wilderness ski touring course in Wyoming fully completed a 44-question written survey concerning occurrence and risk factors for these lesions. Weather information and photographs were collected. RESULTS: Twenty-six percent of participants had similar lesions. The lesions were described as edematous pale papules and plaques with erosions and crusts on an erythematous background. The face was involved in 90% of affected persons. Lesions occurred after an average of 8.7 days in the wilderness and resolved 10.6 days later. Skin that was less prone to sunburn was associated with a decreased incidence (odds ratio 0.44). No association could be found between lesion incidence and history of polymorphous light eruption, sun exposure, ambient temperature, affected contacts, sex, or body mass index. CONCLUSIONS: Overall, the lesions were common among study participants but occurred only after prolonged exposure to wilderness conditions. It was not possible to classify the skin condition as an example of any known diagnosis. We propose the name "prolonged exposure dermatosis" for this condition until further studies better define its etiology, prevention, and treatment.

An examination of wilderness first aid knowledge, self-efficacy, and skill retention.

OBJECTIVE: The purpose of this study was to examine the retention of wilderness first aid (WFA) knowledge, self-efficacy beliefs, and skills over time in a sample of WFA course participants. METHODS: Seventy-two open enrollment (volunteer) WFA course participants were assessed at 4 months, 8 months, or 12 months after training. Changes in WFA knowledge and self-efficacy were assessed by written instruments after the course and at the follow-up interval (4, 8, or 12 months). The WFA skills were assessed by a scored medical scenario at the follow-up interval. RESULTS: As the time interval increased, WFA knowledge, self-efficacy, and skill proficiency decreased. The WFA knowledge and self-efficacy beliefs were not highly correlated with skill performance. CONCLUSIONS: Without additional training, regular use of the course content, or efforts to refresh thinking on key topics, the ability of WFA students to effectively apply their learning will likely decrease as time from training increases. With respect to these WFA courses, student scores on written tests did not accurately reflect competence in performing practical skills related to a medical scenario. In addition, student self-confidence in the ability to perform such skills did not strongly correlate with actual skills and ability.

Injuries related to hiking with a pack during National Outdoor Leadership School courses: a risk factor analysis.

OBJECTIVES: To determine if packweight, anthropometry, and individual characteristics are related to acute musculoskeletal and soft tissue injuries while wearing backpacks on wilderness expeditions. METHODS: This was a review of prospectively gathered data on participants and instructors enrolled in National Outdoor Leadership School Rocky Mountain hiking courses between March 2008 and October 2009. Packweight, height, body weight, age, and gender were collected. Individuals that suffered acute musculoskeletal and soft tissue injuries while hiking with a backpack were recorded and compared to individuals that did not suffer injuries. Logistic regression was used to determine which variables were significantly correlated with injuries. Odds ratios with associated confidence intervals and p-values are reported. RESULTS: One thousand two hundred and one individuals were included in the final analysis. Twenty-six individuals of this population suffered reportable musculoskeletal and soft tissue injuries while hiking with a pack. None of the factors examined (packweight, height, body weight, age, gender, or packweight to body weight ratio) were significant in predicting acute injury. CONCLUSIONS: Based on our results, an individual's packweight, anthropometry, and individual characteristics neither increase nor decrease their risk of experiencing a musculoskeletal or soft tissue injury while hiking with a backpack. Other factors, including fitness, pretrip training, and footwear, should be examined to determine appropriate strategies to reduce significant musculoskeletal and soft tissue injuries on wilderness expeditions.

Ultraviolet keratitis among mountaineers and outdoor recreationalists.

OBJECTIVE: Ultraviolet (UV) keratitis is a self-limited, inflammatory condition resulting in pain and temporary visual disturbance following acute UV radiation exposure. It may afflict mountaineers and other outdoor recreationalists because snow, water, and sand reflect a high percentage of UV radiation reaching the earth's surface. We examined the cases of UV keratitis that have occurred on National Outdoor Leadership School (NOLS) courses in order to better understand its epidemiology and to help prevent this affliction on wilderness expeditions. METHODS: We retrospectively reviewed all cases of UV keratitis that occurred on NOLS courses from 1984-2009. Subject demographics and contributing factors were recorded and descriptive information reported. RESULTS: Fifteen cases of UV keratitis occurred during the study period with an overall incidence of 0.06% in those exposed. All cases occurred in mountainous or snowy terrain except one case which occurred while boating on a river. Thirteen of the 15 (87%) cases occurred in participants who were not wearing sunglasses. Two cases (13%) occurred in participants who were wearing sunglasses without side shields. Ten cases (71%) occurred in sunny conditions, and 4 cases (29%) occurred in cloudy or low visibility conditions. In all cases, symptoms resolved within 36 hours after cessation of UV exposure. CONCLUSION: Appropriate eye protection, including adequate lenses with appropriate side shields, should be worn in mountain or water environments in order to prevent UV keratitis. This data supports the conventional conception of UV keratitis as a relatively mild and self-limited condition, if treated appropriately.

Medical incidents and evacuations on wilderness expeditions.

OBJECTIVE: Expedition activities such as mountaineering, rock climbing, river running, sea kayaking, and canoeing all involve an element of risk. Organizations that provide group wilderness and adventure experiences are responsible for managing the risk of their courses. The leaders and medical providers of these trips must therefore be prepared to anticipate and manage medical problems that may arise. The aim of this study is to provide the medical community with a better understanding of the specific injuries and illnesses that occur on wilderness expeditions. METHODS: A retrospective descriptive study was done examining the medical incidents that occurred on wilderness-based courses during the 3-year period from September 1, 2002, through August 31, 2005. Participants and staff of the National Outdoor Leadership School (NOLS) served as the study population. RESULTS: Injuries occurred at a rate of 1.18 per 1000 program days, and illnesses at a rate of 1.08 per 1000 program days. There were no fatalities during the time period. Athletic injuries (sprains, strains) and gastrointestinal illnesses were the most common medical incidents. Hypothermia, seizures, appendicitis, heat stroke, and pregnancy occurred but with low frequency. Fractures, dental emergencies, tick fever, athletic injuries, and nonspecific body pains were the conditions most frequently requiring evacuation. CONCLUSIONS: The rate of medical incidents on NOLS courses declined during the 1990s and has remained relatively steady apart from a slight increase in 2004 and 2005. Athletic injuries continue to be a difficulty, as they frequently result in evacuation even though their ultimate outcome is usually benign. Evacuation decisions should be made considering both the potential severity of the medical condition as well as patient comfort. Wilderness medical personnel must be familiar with a diverse range of medical conditions in order to provide optimal care.

Wilderness injury, illness, and evacuation: National Outdoor Leadership School's incident profiles, 1999-2002.

OBJECTIVE: This paper describes field injury, illness, near miss, and evacuation profiles of the National Outdoor Leadership School (NOLS). METHODS: The NOLS incident database is used to record injuries, illnesses, near-miss incidents (close calls), evacuations, and nonmedical incidents. The database has been used continually since 1984. RESULTS: During the period September 1, 1998, through August 31, 2002, there were 630,937 program days on which 1940 incidents were reported involving 1679 students and 233 staff. Athletic injuries account for 50% of all injuries, and soft-tissue injuries account for 30%. Athletic injuries are most often sprains and strains of knees (35%), ankles (30%), and backs (13%). Falls and slips around camp or while hiking are the leading contributing factors. The most common illnesses are gastrointestinal symptoms such as nausea, vomiting, and diarrhea (26.4%) and all flu-like illness, including flu symptoms and respiratory symptoms (16.6%). Rock fall was the leading near-miss incident. Two hundred fifty-seven (53%) medical evacuees received treatment and were able to rejoin and finish their course. There was one fatality from 1999 to 2002. The fatality rate for this period is 0.002 per 1000 program days. CONCLUSIONS: The number of injuries and, specifically, the number of athletic injuries have declined. The number and rate of near-miss incidents increased as a result of better reporting; the rate of nonmedical incidents held steady. Motivation continues to be our leading category of nonmedical incident. Efforts at collecting incident data provide a useful measurement from which we can gauge our risk-management performance.