Emergency medicine in Nepal: are we going the right way and fast enough?

Nepal is a landlocked country with variable topography including the world's tallest mountains, tropical forests, and Gangetic plains. This topography leads to diverse healthcare needs, from tropical diseases in plains, to road traffic accidents in hills, and to disaster-related emergencies from floods and landslides during monsoon season and unpredictable earthquakes. Emergency medicine care is underdeveloped and is currently being provided by general practitioners. The capital city Kathmandu has a few tertiary healthcare centers with emergency medicine fellowship-trained general practitioners staffing them, but most of the hospitals outside of Kathmandu are staffed by minimally trained or untrained medical officers. Even though emergency medicine is recognized as a specialty, Nepal still does not have an emergency medicine residency training program. To improve emergency care in the country, the government of Nepal should be focused on facilitating the start of emergency medicine residency in Nepal.

A Review of Medical Problems in Himalayan Porters.

Porters have accompanied trekkers and climbers to high altitude since the earliest expeditions in the Himalayas. As the existing body of knowledge on high-altitude medicine expands, the focus remains on trekkers or climbers. And published literature on medical problems in the large porter population remains sparse. It is well known that porters working at high altitude in the Nepal Himalayas are often lowland dwellers and are as prone to high-altitude illnesses such as acute mountain sickness, high-altitude pulmonary edema, and high-altitude cerebral edema as the trekkers are. Other illnesses such as diarrhea, respiratory illnesses, and infections also occur in this population. In this review, studies reporting these findings will be discussed along with the local context of socioeconomic barriers to adequate health care for these porters.

Extramedullary Manifestations of Chronic Myelomonocytic Leukemia: Do We Treat like an Acute Myeloid Leukemia?

Chronic myelomonocytic leukemia (CMML) is a relatively rare clonal hematologic disorder with features of myelodysplastic syndrome and myeloproliferative disease. Extramedullary leukemic involvement is rarely a presenting feature of CMML. As there are no clear guidelines in regard to the treatment of patients with extramedullary manifestations, its management is challenging. In this report, we discuss the management of our patient who presented with submandibular lymphadenopathy and gingivitis and was diagnosed with CMML.

Friction Blister by Climbing Harness: A Case Report.

An experienced 24-y-old climber on Mount Everest presented to the Base Camp medical clinic with a friction blister on his right flank. The blister was filled with clear fluid and was located about 3 cm posterior and 3 cm superior to the highest point of the right iliac crest, the site where a climbing harness would support the climber while hanging. A diagnosis of friction blister caused by a climbing harness used while traversing between Camp 2 and Camp 3 of Mount Everest was made. The blister was managed with hydrocolloid dressing, and the patient resumed climbing after 1 wk. The lesion healed with scarring at 2 wk. Friction blisters of the feet are common in climbers wearing ill-fitting shoes, but friction blisters caused by climbing harnesses are unusual and have not been reported in the literature as far as the authors are aware. All existing guidelines for blister management pertain to blisters of the feet, and there are inconsistencies in recommendations made by various authors. This unusual case in an extreme environment provides a good learning opportunity.

Successful Summit of Two 8000 m Peaks After Recent High Altitude Pulmonary Edema.

There is little information in the literature on the safety of reascent to high altitude shortly after resolution of severe acute altitude illness, including high altitude pulmonary or cerebral edema. We present a case of a 52-y-old male climber who was diagnosed with high altitude pulmonary edema during the 2018 Everest spring climbing season, descended to low altitude for 9 d, received treatment, and returned to continue climbing with a very rapid ascent rate. Despite a very recent history of high altitude pulmonary edema and not using pharmacologic prophylaxis over a very rapid reascent profile, the climber successfully summited Mt. Everest (8848 m) and Lhotse (8516 m) without any problems.

Comparison of Scapular Manipulation With External Rotation Method of Reduction of Acute Anterior Shoulder Dislocation for Sedation Requirements and Success Rates.

BACKGROUND: Anterior shoulder dislocation is a common sports-related musculoskeletal injury. Various methods have been described for reduction of the dislocation. A method that requires less sedation without compromising the success rate is likely to be highly useful in austere and prehospital settings. This study compares scapular manipulation with external rotation method for requirement of sedation and success rates. METHODS: Forty-six patients with anterior shoulder dislocation were allocated alternatively to reduction using either scapular manipulation (SMM) or external rotation (ERM) techniques. The groups were compared for sedation requirements, pain scores, and success rates. RESULTS: Reductions using SMM had fewer requirements for sedation (13% versus 39%; p < .05) and higher first-pass success rates (87% versus 61%; p < .05) as compared with ERM for anterior shoulder dislocation reduction. The numeric rating score of pain during reduction procedures was less in SMM (mean, 1.65 [standard deviation, 1.6]) than in ERM group (mean, 4.30 [standard deviation, 1.8]; p < .01). CONCLUSION: The SMM required less sedation and had higher first-pass success rates than ERM for reduction of anterior shoulder dislocation. The SMM is thus likely to be of advantage in resource-limited austere settings.