Performance of a Chemical Heat Blanket in Dry, Damp, and Wet Conditions Inside a Mountain Rescue Hypothermia Wrap.

INTRODUCTION: Casualties with accidental hypothermia are evacuated using multilayer wraps, typically including a chemical heat blanket (CHB), a vapor barrier, and an insulating outer bag. We investigated CHB performance against dry, damp, and wet fabric, in a multilayer wrap, in response to a case report indicating diminished performance when wet. METHODS: We wrapped a torso manikin in a base layer, CHB, vapor barrier, casualty bag, and vacuum mattress, recording CHB panel temperatures at intervals of up to 7 h. Experimental conditions were dry, damp, and wet clothing, with 2 blankets tested in each condition. We subsequently used a forward-looking infrared camera to assess whether the panels heated evenly and heat flux sensors to quantify heat transfer across 2 dry, 1 damp, and 1 wet fleece under CHB panels. RESULTS: Chemical heat blankets maintained heat output for >7 h inside the wraps. Median (IQR) panel steady state temperatures were 52°C (39-56°C) against dry fleece, 41°C (36-45°C) against damp fleece, and 30°C (29-33°C) against wet fleece. Peak panel temperature was 67°C. The heat flux results indicated that CHBs generated similar quantities of heat in dry and damp conditions, as the lower temperatures were compensated by more efficient transfer of heat across the moist clothing layer. Chemical heat blanket heat output was diminished in wet conditions. CONCLUSIONS: Rescuers should cut off saturated clothing in a protected environment before wrapping casualties, but damp clothing need not be removed. Because of the high peak temperatures recorded on the surfaces of CHBs, they should not be placed directly against skin, and compression straps should not be placed directly over CHBs.

Healthcare provider experiences of deploying a continuous remote patient monitoring pilot program during the COVID-19 pandemic: a structured qualitative analysis.

Objective: To describe the healthcare provider (HCP) experience of launching a COVID-19 remote patient monitoring (CRPM) program during the global COVID-19 pandemic. Methods: We conducted qualitative, semi-structured interviews with eight HCPs involved in deploying the CRPM pilot program in the Military Health System (MHS) from June to December 2020. Interviews were audio recorded, transcribed, and analyzed thematically using an inductive approach. We then deductively mapped themes from interviews to the updated Consolidated Framework for Implementation Research (CFIR). Results: We identified the following main themes mapped to CFIR domains listed in parentheses: external and internal environments (outer and inner settings), processes around implementation (implementation process domain), the right people (individuals domain), and program characteristics (innovation domain). Participants believed that buy-in from leadership and HCPs was critical for successful program implementation. HCP participants showed qualities of clinical champions and believed in the CRPM program. Conclusion: The MHS deployed a successful remote patient monitoring pilot program during the global COVID-19 pandemic. HCPs found the CRPM program and the technology enabling the program to be acceptable, feasible, and usable. HCP participants exhibited characteristics of clinical champions. Leadership engagement was the most often-cited key factor for successful program implementation.

Remote patient monitoring to facilitate same-day discharge after laparoscopic sleeve gastrectomy: a pilot evaluation.

BACKGROUND: Limited hospital inpatient capacity, exacerbated by SARS-CoV-2 (COVID-19) and associated staffing shortages, has driven interest in converting surgeries historically done as inpatient procedures to same-day surgeries (SDS). Remote patient monitoring (RPM) has the potential to increase safety and confidence in SDS but has had mixed success in a bariatric population. OBJECTIVES: Assess the feasibility of and adherence to a protocol offering patients same-day laparoscopic sleeve gastrectomy (SG) supported by RPM with an updated wearable device. Secondary outcomes were readmissions, costs, adherence, and clinical alarm rates. SETTING: Academic, military tertiary referral center (United States). METHODS: A single-center, retrospective case control study of patients undergoing SG, comparing SDS with RPM to patients admitted to the hospital for SG during this time. Patients for SDS were selected by set inclusion/exclusion criteria and patient/surgeon preference, and perioperative management was standardized. RESULTS: Twenty patients were enrolled in the SDS group, then compared with 53 inpatients. Inpatients were older (46 versus 39, P = .006), but with no significant differences in sex, preoperative body mass index, or co-morbidities. RPM wearable and blood pressure adherence was found to be 97% and 80%, respectively. Readmission rates were similar (10% versus 7.5%, P > .05). RPM alarm rates were .5 (0-1.3) per patient for each 24-hour home monitoring period. SDS patients also demonstrated the potential for cost savings over inpatient SG, depending on the number of patients monitored per day as well as the healthcare setting. CONCLUSIONS: SG as SDS with RPM was a feasible approach. It should be evaluated in other surgical procedures and higher-risk patient populations.

Financial and Clinical Impact of Virtual Care During the COVID-19 Pandemic: Difference-in-Differences Analysis.

BACKGROUND: Virtual care (VC) and remote patient monitoring programs were deployed widely during the COVID-19 pandemic. Deployments were heterogeneous and evolved as the pandemic progressed, complicating subsequent attempts to quantify their impact. The unique arrangement of the US Military Health System (MHS) enabled direct comparison between facilities that did and did not implement a standardized VC program. The VC program enrolled patients symptomatic for COVID-19 or at risk for severe disease. Patients' vital signs were continuously monitored at home with a wearable device (Current Health). A central team monitored vital signs and conducted daily or twice-daily reviews (the nurse-to-patient ratio was 1:30). OBJECTIVE: Our goal was to describe the operational model of a VC program for COVID-19, evaluate its financial impact, and detail its clinical outcomes. METHODS: This was a retrospective difference-in-differences (DiD) evaluation that compared 8 military treatment facilities (MTFs) with and 39 MTFs without a VC program. Tricare Prime beneficiaries diagnosed with COVID-19 (Medicare Severity Diagnosis Related Group 177 or International Classification of Diseases-10 codes U07.1/07.2) who were eligible for care within the MHS and aged 21 years and or older between December 2020 and December 2021 were included. Primary outcomes were length of stay and associated cost savings; secondary outcomes were escalation to physical care from home, 30-day readmissions after VC discharge, adherence to the wearable, and alarms per patient-day. RESULTS: A total of 1838 patients with COVID-19 were admitted to an MTF with a VC program of 3988 admitted to the MHS. Of these patients, 237 (13%) were enrolled in the VC program. The DiD analysis indicated that centers with the program had a 12% lower length of stay averaged across all COVID-19 patients, saving US $2047 per patient. The total cost of equipping, establishing, and staffing the VC program was estimated at US $3816 per day. Total net savings were estimated at US $2.3 million in the first year of the program across the MHS. The wearables were activated by 231 patients (97.5%) and were monitored through the Current Health platform for a total of 3474 (median 7.9, range 3.2-16.5) days. Wearable adherence was 85% (IQR 63%-94%). Patients triggered a median of 1.6 (IQR 0.7-5.2) vital sign alarms per patient per day; 203 (85.7%) were monitored at home and then directly discharged from VC; 27 (11.4%) were escalated to a physical hospital bed as part of their initial admission. There were no increases in 30-day readmissions or emergency department visits. CONCLUSIONS: Monitored patients were adherent to the wearable device and triggered a manageable number of alarms/day for the monitoring-team-to-patient ratio. Despite only enrolling 13% of COVID-19 patients at centers where it was available, the program offered substantial savings averaged across all patients in those centers without adversely affecting clinical outcomes.

Successful implementation of round-the-clock care in a virtual ward during the COVID-19 pandemic.

The COVID-19 pandemic led to unprecedented demand on NHS infrastructure. Virtual wards (VW) were created in response, using technology to monitor patients remotely. Their implementation required new systems of staffing, escalation, risk management and information governance. The Norfolk and Norwich University Hospitals Foundation Trust offered an example of a highly successful VW. It cared for 852 patients in its first year of operation, providing 24/7 nursing cover, supported by pharmacists and junior doctors, daily consultant-led ward rounds and virtual visits. The remote care platform collected continuous vital sign observations and generated custom alarms. The care team triaged, then escalated to nurse-specialists or consultants as required. Patients reported increased confidence and relief at earlier discharge. Staff highlighted the benefits of working from home, even if isolating or shielding. Challenges included developing awareness of the new service, overcoming concerns around increased workload and transitioning from emergency to long-term funding. The ward subsequently expanded from COVID-19 to nine other use cases.

Remote care and triage of obstetric patients with COVID-19 in the community: operational considerations.

BACKGROUND: During the SARS-CoV-2 (COVID-19) pandemic, routine antenatal care was disrupted, and pregnant women positive for COVID-19 were at increased risk of caesarean section, intensive care admission or neonatal unit admission for their baby. Virtual care and telehealth can reduce barriers to care and improve maternity outcomes, and adoption has been encouraged by health authorities in the United Kingdom. METHODS: Norfolk and Norwich University Hospitals Trust deployed a flexible maternity virtual ward (MVW) service using the Current Health platform to care for pregnant women during the pandemic. Patients were monitored either intermittently with finger pulse oximetry or continuously with a wearable device. We outline the MVW technology, intervention and staffing model, triage criteria and patient feedback, as an example of an operational model for other institutions. RESULTS: Between October 2021 and February 2022, 429 patients were referred, of which 228 were admitted to the MVW. Total bed-days was 1,182, mean length of stay was 6 days (SD 2.3, range 1-14 days). Fifteen (6.6%) required hospital admission and one (0.4%) critical care. There were no deaths. Feedback alluded to feelings of increased safety, comfort, and ease with the technology. CONCLUSIONS: The MVW offered a safety net to pregnant women positive for COVID-19. It provided reassurance for staff, while relieving pressures on infrastructure. When setting up similar services in future, attention should be given to identifying clinical champions, triage criteria, technology and alarm selection, and establishing flexible escalation pathways that can adapt to changing patterns of disease.

Deployment of an End-to-End Remote, Digitalized Clinical Study Protocol in COVID-19: Process Evaluation.

BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic may accelerate the adoption of digital, decentralized clinical trials. Conceptual recommendations for digitalized and remote clinical studies and technology are available to enable digitalization. Fully remote studies may break down some of the participation barriers in traditional trials. However, they add logistical complexity and offer fewer opportunities to intervene following a technical failure or adverse event. OBJECTIVE: Our group designed an end-to-end digitalized clinical study protocol, using the Food and Drug Administration (FDA)-cleared Current Health (CH) remote monitoring platform to collect symptoms and continuous physiological data of individuals recently infected with COVID-19 in the community. The purpose of this work is to provide a detailed example of an end-to-end digitalized protocol implementation based on conceptual recommendations by describing the study setup in detail, evaluating its performance, and identifying points of success and failure. METHODS: Primary recruitment was via social media and word of mouth. Informed consent was obtained during a virtual appointment, and the CH-monitoring kit was shipped directly to the participants. The wearable continuously recorded pulse rate (PR), respiratory rate (RR), oxygen saturation (SpO2), skin temperature, and step count, while a tablet administered symptom surveys. Data were transmitted in real time to the CH cloud-based platform and displayed in the web-based dashboard, with alerts to the study team if the wearable was not charged or worn. The study duration was up to 30 days. The time to recruit, screen, consent, set up equipment, and collect data was quantified, and advertising engagement was tracked with a web analytics service. RESULTS: Of 13 different study advertisements, 5 (38.5%) were live on social media at any one time. In total, 38 eligibility forms were completed, and 19 (50%) respondents met the eligibility criteria. Of these, 9 (47.4%) were contactable and 8 (88.9%) provided informed consent. Deployment times ranged from 22 to 110 hours, and participants set up the equipment and started transmitting vital signs within 7.6 (IQR 6.3-10) hours of delivery. The mean wearable adherence was 70% (SD 19%), and the mean daily survey adherence was 88% (SD 21%) for the 8 participants. Vital signs were in normal ranges during study participation, and symptoms decreased over time. CONCLUSIONS: Evaluation of clinical study implementation is important to capture what works and what might need to be modified. A well-calibrated approach to online advertising and enrollment can remove barriers to recruitment and lower costs but remains the most challenging part of research. Equipment was effectively and promptly shipped to participants and removed the risk of illness transmission associated with in-person encounters during a pandemic. Wearable technology incorporating continuous, clinical-grade monitoring offered an unprecedented level of detail and ecological validity. However, study planning, relationship building, and troubleshooting are more complex in the remote setting. The relevance of a study to potential participants remains key to its success.

Participant Experiences of a COVID-19 Virtual Clinical Study Using the Current Health Remote Monitoring Platform: Case Study and Qualitative Analysis.

BACKGROUND: During the COVID-19 pandemic, individuals with a positive viral test were enrolled in a study, within 48 hours, to remotely monitor their vital signs to characterize disease progression and recovery. A virtual trial design was adopted to reduce risks to participants and the research community in a study titled Risk Stratification and Early Alerting Regarding COVID-19 Hospitalization (RiskSEARCH). The Food and Drug Administration-cleared Current Health platform with a wearable device is a continuous remote patient monitoring technology that supports hospital-at-home care and is used as a data collection tool. Enrolled participants wore the Current Health wearable device continuously for up to 30 days and took a daily symptom survey via a tablet that was provided. A qualitative substudy was conducted in parallel to better understand virtual trial implementation, including barriers and facilitators for participants. OBJECTIVE: This study aimed to understand the barriers and facilitators of the user experience of interacting with a virtual care platform and research team, while participating in a fully virtual study using qualitative and quantitative data. METHODS: Semistructured interviews were conducted to understand participants' experience of participating in a virtual study during a global pandemic. The schedule included their experience of enrollment and their interactions with equipment and study staff. A total of 3 RiskSEARCH participants were interviewed over telephone, and transcriptions were inductively coded and analyzed using thematic analysis. Themes were mapped onto the Theoretical Domains Framework (TDF) to identify and describe the factors that influenced study adherence. Quantitative metrics, including adherence to wearable and scheduled tasks collected as part of the RiskSEARCH main study, were paired with the interviews to present an overall picture of participation. RESULTS: All participants exceeded our definition of a fully adherent participant and reported that participation was feasible and had a low burden. The symptoms progressively resolved during the trial. Inductive thematic analysis identified 13 main themes from the interview data, which were deductively mapped onto 11 of the 14 TDF domains, highlighting barriers and facilitators for each. CONCLUSIONS: Participants in the RiskSEARCH substudy showed high levels of adherence and engagement throughout participation. Although participants experienced some challenges in setting up and maintaining the Current Health kit (eg, charging devices), they reported feeling that the requirements of participation were both reasonable and realistic. We demonstrated that the TDF can be used for inductive thematic analysis. We anticipate expanding this work in future virtual studies and trials to identify barriers and enabling factors for implementation.

Quantifying Risk in Air Sports: Flying Activity and Incident Rates in Paragliding.

INTRODUCTION: The volume, nature, and risks of paragliding are poorly quantified. More comprehensive understanding, including incident rates allowing comparison to similar disciplines, will help direct and appraise safety interventions. METHODS: Paraglider pilots were surveyed regarding experience, incidents, recordkeeping, and risk perception. The survey could not capture those who had left the sport or died, so a subset of responses from UK pilots was compared to records from an incident database. RESULTS: There were 1788 (25%) responses from 7262 surveyed. Respondents flew a total of 87,909 h in 96,042 flights during 2019. Local flying was most frequent (n=37,680 flights, 39%) but a higher proportion of hours were spent flying cross-country (n=33,933 h, 39%). The remainder were spent in competition, hike and fly, tandem, aerobatic, or instructional flight. Flying incidents led to 103 (6%) respondents seeking medical attention, attending hospital, or missing a day of work in 2019. Near misses were reported by 423 (26%) pilots. Asymmetry and rotational forces typically led to incidents, and limb and back injuries resulted. Pilots frequently failed to throw their reserve parachutes. Only 3 (0.6%) incidents involved equipment failure, with the remainder attributed to control or decision errors. Incident rates of paragliding were estimated as 1.4 (1.1-1.9) deaths and 20 (18-27) serious injuries per 100,000 flights, approximately twice as risky as general aviation and skydiving. CONCLUSIONS: Incidents usually resulted from pilot error (control and decision), rather than equipment failure. Future safety interventions should focus on improving glider control skills and encouraging reserve parachute deployment.

Assessment of Remote Vital Sign Monitoring and Alarms in a Real-World Healthcare at Home Dataset.

The importance of vital sign monitoring to detect deterioration increases during healthcare at home. Continuous monitoring with wearables increases assessment frequency but may create information overload for clinicians. The goal of this work was to demonstrate the impact of vital sign observation frequency and alarm settings on alarms in a real-world dataset. Vital signs were collected from 76 patients admitted to healthcare at home programs using the Current Health (CH) platform; its wearable continuously measured respiratory rate (RR), pulse rate (PR), and oxygen saturation (SpO2). Total alarms, alarm rate, patient rate, and detection time were calculated for three alarm rulesets to detect changes in SpO2, PR, and RR under four vital sign observation frequencies and four window sizes for the alarm algorithms' median filter. Total alarms ranged from 65 to 3113. The alarm rate and early detection increased with the observation frequency for all alarm rulesets. Median filter windows reduced alarms triggered by normal fluctuations in vital signs without compromising the granularity of time between assessments. Frequent assessments enabled with continuous monitoring support early intervention but need to pair with settings that balance sensitivity, specificity, clinical risk, and provider capacity to respond when a patient is home to minimize clinician burden.

Paraglider Reserve Parachute Deployment Under Radial Acceleration.

INTRODUCTION: The paragliding reserve parachute system is safety-critical but underused, unstandardized, and known to fail. This study aimed to characterize reserve parachute deployment under radial acceleration to make recommendations for system design and paraglider pilot training.METHODS: There were 88 licensed amateur paraglider pilots who were filmed deploying their reserve parachutes from a centrifuge. Of those, 43 traveled forward at 4 G simulating a spiral dive, and 45 traveled backward at 3 G simulating a rotational maneuver known as SAT. Tests incorporated ecologically valid body, hand, and gaze positions, and cognitive loading and switching akin to real deployment. The footage was reviewed by subject matter experts and compared to previous work in linear acceleration.RESULTS: Of the pilots, 2.3 failed to extract the reserve container from the harness. SAT appeared more cognitively demanding than spiral, despite lower G. Participants located the reserve handle by touch not sight. The direction of travel influenced their initial contact with the harness: 82.9 searched first on their hip in spiral, 63.4 searched first on their thigh in SAT. Search patterns followed skeletal landmarks. Participants had little directional control over their throw.CONCLUSIONS: Paraglider pilots are part of the reserve system. Maladaptive behaviors observed under stress highlighted that components must work in harmony with pilots natural responses, with minimal cognitive demands or need for innovation or problem-solving. Recommendations include positioning prominent, tactile reserve handles overlying the pilots hip; deployment bags extractable with any angle of pull; deployment in a single sweeping backward action; and significantly increasing reserve deployment drills.Wilkes M, Long G, Charles R, Massey H, Eglin C, Tipton MJ. Paraglider reserve parachute deployment under radial acceleration. Aerosp Med Hum Perform. 2021; 92(7):579587.

Telemedicine for Patient Management on Expeditions in Remote and Austere Environments: A Systematic Review.

Telemedicine potentially offers enormous value to expeditions to remote environments. For healthcare professionals, telemedicine can provide access to specialist advice. Where no healthcare professionals are present, telemedicine may be the sole source of expert care. This systematic review appraises and summarizes the current literature regarding telemedicine in patient management on expeditions to remote locations and identifies areas for future research. MEDLINE and EMBASE were systematically searched for relevant articles from 1980 through February 2018. Data were handled according to the PRISMA process and analyzed using type-specific critical appraisal checklists where possible. Two hundred twenty-five articles were identified, 33 of which were included in this systematic review. They encompassed a variety of remote environments, including maritime (13), polar (9), mountainous (5), jungle (1), and multiple austere environments (6). Although some environments were better reported than others, many overarching concepts were generalizable. Through channels of communication that included telephone, radio, videoconferencing, and email, telemedicine has been used effectively in a range of environments to initiate treatment, follow up with patients, and determine the appropriateness of evacuation. Telementoring, in which a remote expert guides a local care provider in performing a procedure or task, is a promising aspect of telemedicine that is currently being developed. As technology advances, the scope of telemedicine will continue to expand. However, each new telemedical development must be shown to do more than simply function in a remote environment. Instead, new technologies should be tested for improved patient, practitioner, or expedition outcomes, within a telemedical system.

The Lake Louise Score: A Critical Assessment of Its Specificity.

Moore, James, Martin J. MacInnis, Jon Dallimore, and Matt Wilkes. The Lake Louise Score: A Critical Assessment of Its Specificity. High Alt Med Biol. 21:237-242, 2020. Introduction: The Lake Louise Score (LLS) has low specificity for diagnosing acute mountain sickness (AMS). As this tool is used for research and clinical decision making, it is important to understand the origins of this poor specificity. We reviewed AMS diagnoses in a population trekking at low altitude ("false positives") to critically assess LLS specificity. Method: We retrospectively analyzed data from a sample of 123 adolescents trekking at low altitude to establish the predominant causes of false-positive AMS diagnoses (1993 LLS criteria), separately removing each LLS component to assess its contribution to the final score. Exploratory factor analysis (EFA) was applied to the data to establish component patterns. Results: Removal of LLS components individually showed fatigue contributed slightly more to false-positive AMS diagnoses than sleep quality in this group. An EFA from morning data highlighted sleep quality as a stand-alone factor in the measurement of AMS. Although of smaller significance, an EFA of the evening data highlighted fatigue and headache as the stand-alone factor. Conclusion: Our findings not only supported the recent removal of sleep quality from the LLS, but also demonstrated that fatigue had an equal part to play in the misdiagnosis of AMS in this population. These data highlighted the poor specificity of the LLS and suggest that the measurement of illness at altitude undergo further review.

Natural Climbers: Insights from Avian Physiology at High Altitude.

High altitudes are physiologically challenging: the hypobaric hypoxia, cold, and increased ultraviolet radiation mean humans ascending to high altitude faster than they acclimatize risk life-threatening illnesses. Despite such challenges, birds can thrive at high altitudes and some even complete metabolically costly migrations across the world's highest mountain ranges. We outline the aspects of avian anatomy and physiology that confer advantages at each level of the oxygen transport cascade and compare them with those of human and nonhuman mammals. We also discuss additional adaptations that have been described for high-altitude specialist species of birds and how these are mirrored in high-altitude adapted mammals.

Cognitive Function in Simulated Paragliding Flight.

INTRODUCTION: Paragliding is an emerging discipline of aviation, with recreational pilots flying distances over 100 km. It remains risky. Accidents typically relate to pilot error rather than equipment failure. We measured cognition and physiological responses during simulated flight, to investigate whether errors might be due to pilot impairment, rather than misjudgment.METHODS: There were 10 male paraglider pilots (aged 19-58 yr) who undertook a simulated flight in an environmental chamber from sea level (0.209 FIo2) to 1524 m (0.174 FIo2), 2438 m (0.156 FIo2), and 3658 m (0.133 FIo2), over approximately 2 h. They experienced normobaric hypoxia, environmental cooling and headwind, completing logical reasoning, mannikin, mathematical processing, Stroop Color-Word and Tower Puzzle tasks; as well as measures of risk-taking (BART), mood (POMS), and subjective experience.RESULTS: Results were compared to ten controls, matched by age, sex, and flying experience. Physiological measures were oxygen consumption, carbon dioxide production, ventilation, heart rate, oxygen saturation, rectal and skin temperatures, blood glucose, blood lactate, and urine production. There were no significant differences between pilots and controls at any altitude. Results were heterogenous within and between individuals. As altitude increased, oxygen consumption and minute volume increased significantly, while oxygen saturations fell (98.3% [baseline] to 88.5% [peak]). Rectal temperatures fell by a statistically (but not clinically) significant amount (37.6°C to 37.3°C), while finger skin temperatures dropped steeply (32.2°C to 13.9°C).DISCUSSION: Results suggest cognitive impairment is unlikely to be a primary cause of pilot error during paragliding flights (of less than 2 h, below 3658 m), though hand protection requires improvement.Wilkes M, Long G, Massey H, Eglin C, Tipton MJ. Cognitive function in simulated paragliding flight. Aerosp Med Hum Perform. 2019; 90(10):851-859.

Delayed-Onset High Altitude Pulmonary Edema: A Case Report.

High altitude pulmonary edema (HAPE) is a life-threatening altitude illness that usually occurs in insufficiently acclimatized climbers in the first few days at altitudes above 2500 m. Acetazolamide is recommended for prophylaxis of acute mountain sickness, but a role for acetazolamide in the prevention of HAPE has not been established. We report a case of a trekker with previous high altitude experience who developed HAPE 8 d after arrival to altitude despite what was believed to be a conservative ascent profile.

Methoxyflurane for Procedural Analgesia at 4470 m Altitude.

Methoxyflurane is a volatile, fluorinated anesthetic agent with analgesic properties. Although no longer used as an anesthetic due to concerns regarding renal toxicity in high doses, it has enjoyed a resurgence as an inhaled analgesic in prehospital care and in the emergency department. The agent is nonflammable and leads to rapid, titratable analgesia without intravenous access. The Penthrox inhaler device is light, robust, and straightforward to administer. Consequently, it has been proposed as an ideal analgesic for the remote high altitude setting. We report its use for procedural analgesia during suprapubic aspiration for acute urinary retention at a remote rescue post at night, in cold winter conditions, at 4470 m altitude in Machermo, Nepal. We found that methoxyflurane provided rapid, effective analgesia for our patient's visceral and procedural pain. The inhaler was easy to administer, and the patient remained responsive to voice, with satisfactory oxygen saturation and respiratory rate throughout. We also briefly review the administration, dosing, efficacy, and safety of methoxyflurane and its role in remote medical care.

The Physiology of Paragliding Flight at Moderate and Extreme Altitudes.

Wilkes, Matt, Martin J. MacInnis, Lucy A. Hawkes, Heather Massey, Clare Eglin, and Michael J. Tipton. The physiology of paragliding flight at moderate and extreme altitudes. High Alt Med Biol 19:42-51, 2018.-Paragliding is a form of free flight, with extreme-altitude paragliding being an emerging discipline. We aimed to describe the physiological demands and the impact of environmental stressors of paragliding at moderate and extreme altitudes. We recorded oxygen consumption (VO2), heart rate (HR), respiratory frequency (fR), tidal volume (VT), oxygen saturation, accelerometry (G), and altitude in 9.3 hours of flight at moderate altitudes (to 3073 m, n = 4), 19.3 hours at extreme altitude (to 7458 m, n = 2), and during high-G maneuvers (n = 2). We also analyzed HR data from an additional 17 pilots (138 hours) using the Flymaster Live database to corroborate our findings. All pilots were male. Overall energy expenditure at moderate altitude was low [1.7 (0.6) metabolic equivalents], but physiological parameters were notably higher during takeoff (p < 0.05). Pilots transiently reached ∼7 G during maneuvers. Mean HR at extreme altitude [112 (14) bpm] was elevated compared to moderate altitude [98 (15) bpm, p = 0.048]. Differences in pilots' VT and fR at moderate and extreme altitudes were not statistically significant (p = 0.96 and p = 0.058, respectively). Thus, we conclude that physical exertion in paragliding is low, suggesting that any subjective fatigue felt by pilots is likely to be cognitive or environmental. Future research should focus on reducing mental workload, enhancing cognitive function, and improving environmental protection.