Urological Emergencies and Diseases in Wilderness Expeditions.

When considering medical emergencies that might affect an expedition, urologic emergencies are typically not included. However, the reality is that manageable and prevalent urologic disease processes can pose significant challenges for the wilderness medicine physician and warrant consideration. The purpose of this review is to identify and discuss the most commonly encountered urologic emergencies and diseases in the wilderness setting and to prepare the expedition medicine physician for management of these urgent conditions. A PubMed and Internet search for urologic emergencies and diseases in wilderness conditions was conducted. We also searched bibliographies for useful supplemental literature and material from leading mountain medicine and wilderness medicine societies as well as population-based studies for common urologic diseases. Urologic emergencies and diseases on expeditions and in wilderness conditions have been reported primarily with retrospective case series and case reports. The most commonly reported urologic emergencies in this setting include urologic trauma, renal calculi, and urinary retention. Parasitic infections in the urinary tract also have been reported to cause urinary symptoms and urinary retention in wilderness conditions. Although urologic diseases in such conditions are uncommon, significant morbidity and even potentially life-threatening sequelae to urologic emergencies were found to occur. Major genitourinary emergencies in expedition medicine are uncommon but involve both potentially manageable urgent conditions and serious life-threatening conditions best treated with urgent stabilization and occasionally medical evacuation. The opportunity exists for increased awareness for management strategies for urologic conditions in the often remote or extreme environments of an expedition.

Impact of a statewide trauma system on the triage, transfer, and inpatient mortality of injured patients.

BACKGROUND: In 2009, Arkansas implemented a statewide trauma system to address the high rates of mortality and morbidity due to trauma. The principal objective of the Arkansas Trauma System is to transport patients to the appropriate facility based on the injuries of the patients. This study evaluated four metrics that were crucial to system health. These measures included: treatment location, scene triage, admission to nondesignated facilities, and inpatient mortality. Furthermore, the authors sought to quantify how the system is selective toward the severely injured regarding triage and treatment location. The authors hypothesized that system implementation should increase the proportion of patients, particularly the severely injured, treated at Level I/II facilities. The system should increase the proportion of patients, especially the severely injured, admitted to Level I/II facilities directly from the scene. The system should result in fewer patients admitted to nondesignated facilities. Lastly, system implementation should result in fewer inpatient deaths. METHODS: A pre-post study design was used for this evaluation. Data from the Arkansas Hospital Discharge data set (2007 through 2012) identified patients who were admitted as a result of their injuries. The ICD-MAP software was used to categorize those with and without severe injuries based on an Injury Severity Score of 16 or greater or head Abbreviated Injury Scale score of 3 or greater. RESULTS: The results indicate that while there was an overall increase in odds of patients being admitted to Level I/II facilities, those with severe injuries were associated with an even greater odds of admission to Level I/II facilities (p < 0.0001). System implementation was also associated with more severely injured patients admitted to Level I/II facilities from the scene. There were also fewer patients admitted to nondesignated hospitals after system implementation (p < 0.0001). System implementation was associated with fewer inpatient deaths (p = 0.02). CONCLUSION: Two years after implementation, the trauma system showed significant progress. The measures evaluated in this study are believed to support the effectiveness of the trauma system. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Injury and illness aboard an Antarctic cruise ship.

OBJECTIVE: The objective of this study was to determine the incidence and patterns of injury and illness among passengers aboard a cruise ship in Antarctica. METHODS: Demographic data on passengers were collected for all participants aboard Antarctica cruises on a single ship during the Antarctic summer cruise season of November 2004 through March 2005. Medical logs from each of 11 cruise trips were reviewed for presentation of injuries and illnesses. RESULTS: A total of 1057 passengers were included in the study, of which 47.4% were male. The mean age of the passengers was 54 years (+/- 16.5 years). The overall incidence rate of injury and illness was 21.7 per 1000 person-days. Motion sickness was the most common condition, comprising 42.3% of all medical encounters by the ship physician, followed by infectious diseases (17.2%) and injury (15.0%). The incidence rate of injury increased significantly with age, whereas the incidence rate of motion sickness decreased significantly with age. There was little variation in the incidence and patterns of injury and illness between genders. CONCLUSIONS: Most illnesses and injuries were due to the motion of the ship, and a large proportion of the passengers aboard the cruise ship in Antarctica were elderly. Injury among older passengers is of special concern.

Incidence of injury in professional mixed martial arts competitions.

Mixed Martial Arts (MMA) competitions were introduced in the United States with the first Ultimate Fighting Championship (UFC) in 1993. In 2001, Nevada and New Jersey sanctioned MMA events after requiring a series of rule changes. The purpose of this study was to determine the incidence of injury in professional MMA fighters. Data from all professional MMA events that took place between September 2001 and December 2004 in the state of Nevada were obtained from the Nevada Athletic Commission. Medical and outcome data from events were analyzed based on a pair-matched case-control design. Both conditional and unconditional logistic regression models were used to assess risk factors for injury. A total of 171 MMA matches involving 220 different fighters occurred during the study period. There were a total of 96 injuries to 78 fighters. Of the 171 matches fought, 69 (40.3%) ended with at least one injured fighter. The overall injury rate was 28.6 injuries per 100 fight participations or 12.5 injuries per 100 competitor rounds. Facial laceration was the most common injury accounting for 47.9% of all injuries, followed by hand injury (13.5%), nose injury (10.4%), and eye injury (8.3%). With adjustment for weight and match outcome, older age was associated with significantly increased risk of injury. The most common conclusion to a MMA fight was a technical knockout (TKO) followed by a tap out. The injury rate in MMA competitions is compatible with other combat sports involving striking. The lower knockout rates in MMA compared to boxing may help prevent brain injury in MMA events. Key PointsMixed martial arts (MMA) has changed since the first MMA matches in the United States and now has increased safety regulations and sanctioning.MMA competitions have an overall high rate of injury.There have been no MMA deaths in the United States.The knockout (KO) rate in MMA appears to be lower than the KO rate of boxing matches.MMA must continue to be supervised by properly trained medical professionals and referees to ensure fighter safety in the future.

Injury risk in professional boxing.

OBJECTIVE: Although a popular endeavor, boxing has fallen under increased scrutiny because of its association with traumatic brain injury. However, few studies have investigated the overall epidemiology of boxing injuries from representative samples, and no study has ever documented the incidence of injuries in female boxers. This study is a review of professional boxing data from the state of Nevada from September 2001 through March 2003. MATERIALS AND METHODS: Medical and outcome data for all professional boxing matches occurring in Nevada between September 2001 and March 2003 (n = 524 matches) were analyzed on the basis of a pair-matched, case-control design. Cases were boxers who received an injury during the boxing matches. Boxers who were not injured served as control subjects. Both conditional and unconditional logistic regression models were used to assess risk factors for injury. RESULTS: The overall incidence rate of injury was 17.1 per 100 boxer-matches, or 3.4 per 100 boxer-rounds. Facial laceration accounted for 51% of all injuries, followed by hand injury (17%), eye injury (14%), and nose injury (5%). Male boxers were significantly more likely than female boxers to receive injuries (3.6 versus 1.2 per 100 boxer-rounds, P = 0.01). Male boxing matches also ended in knockouts and technical knockouts more often than did female matches (P < 0.001). The risk of injury for those who lost the matches was nearly twice the risk for the winners. Those who lost by knockout had double the risk of injury compared with those who lost by other means. Neither age nor weight was significantly associated with the risk of injury. CONCLUSIONS: The injury rate in professional boxing matches is high, particularly among male boxers. Superficial facial lacerations are the most common injury reported. Male boxers have a higher rate of knockout and technical knockouts than female boxers. Further research is necessary to determine the outcomes of injury, particularly the long-term neurologic outcome differences between sexes.

Trends in Arkansas motorcycle trauma after helmet law repeal.

OBJECTIVES: This study aimed to assess the impact of the 1997 Arkansas helmet law repeal on motorcycle registrations, crash and fatality risks, and alcohol involvement in motorcycle crashes. METHODS: Annual motorcycle registration data for the years 1990 through 2001 were obtained from the Arkansas Department of Finance and Administration. These motorcycle registration data were complemented by the motorcycle crash data from the Arkansas State Police Highway Safety Office and motorcycle fatality data for the state of Arkansas from the Fatality Analysis Reporting System. The impact of the repeal on crash rates, helmet usage, and alcohol involvement was assessed through comparisons of data from before (1993 to 1996) and after (1998 to 2001) the repeal. RESULTS: After the repeal, an increase in motorcycle registrations correlated with a marked rise in the total number of crashes and fatalities; however, fatalities per crash remained virtually the same. The proportion of motorcycle fatalities that were not wearing a helmet increased from 47.0% (47/100) before the repeal to 78.2% (104/133) after the repeal (P = 0.001). The overall percentage of fatal motorcycle crashes involving alcohol use remained unchanged after the repeal (37.6% [29/77] to 38.5% [40/104], P = 0.91), but the percentage of fatal crashes involving drinking nonhelmeted drivers increased from 14.2% (11/77) to 33.6% (35/104) (P = 0.003). Inebriated motorcyclists killed in crashes were overwhelmingly non-helmeted (87.5%, 35/40) after the repeal, up from 37.9% (11/29) before the repeal (P < 0.001). CONCLUSIONS: These findings suggest that the repeal of the mandatory helmet law in Arkansas has had a significant adverse effect on road safety.

Current status of International Emergency Medicine fellowships in the United States.

OBJECTIVE: A consensus panel of Emergency Physicians with experience in international health has published a recommended curriculum for a formal fellowship in International Emergency Medicine. This article reviews the current International Emergency. Medicine (IEM) fellowships available to residency-trained Emergency Physicians in the United States. METHODS: Every allopathic Emergency Medicine (EM) residency program in the United States was contacted via e-mail or telephone. Programs that reported having an IEM fellowship were asked detailed information about their program, including: (1) the number of years the program has been offered; (2) the duration of the program; (3) the number of fellows taken each year; (4) the number of fellowship graduates from each program and their current practice patterns; (5) how the fellowship is funded; and (6) whether a Masters Degree in Public Health (MPH) is offered. RESULTS: All 127 allopathic EM residency programs responded. Eight (6.8%) of these programs offered IEM fellowships. Of a total of 29 graduates identified, 23 (79.3%) were employed in academic medicine. All of the fellowships offered formal public health training and were funded by a combination of clinical billing and project-specific grants and scholarships. All IEM fellowships described a curriculum that reflected the previously published recommendations. CONCLUSION: Opportunities in formal training in international health are increasing for graduates of EM residencies in the United States. The proposed curriculum for IEM fellowships seems to have been implemented and graduates of IEM fellowships seem to be applying their training in international projects.

Development of emergency medicine administration in the People's Republic of China.

A collaborative partnership between the Johns Hopkins Hospital, Chaoyang Red Cross Hospital and Chinese Ministry of Health has been established to initiate Emergency Medicine (EM) administrative training in Beijing, China. The Emergency Medical Education and Training Center (EMETC) at Chaoyang Red Cross Hospital was opened as a training facility to foster EM administrative curriculum development and training nationwide. A six-step approach with problem identification, needs assessment, goals and objectives, educational strategies, implementation and evaluation was used to form a locally adapted curriculum. With a train-the-trainers model, the EMETC sponsored several EM administration courses, the first of their kind in China. Since its inception, the EMETC has trained 95 persons from throughout China in EM administration. An EM administration curriculum has been developed and refined. In conclusion, an international partnership between academic hospitals, supported by the local Ministry of Health, to develop a national training facility using this six-step approach may be an attractive strategy for dissemination of EM administration principles.

Malaria primer for clinicians in the United States.

Though low, the incidence of malaria in the United States is not insignificant and can be the source of infection in febrile travelers returning from endemic areas. Clinicians practicing in the United States must have a basic understanding of the malaria life cycle and its treatments to properly diagnose and treat this potentially fatal disease. Malaria chemotherapy can be broken into clinical classes for easier understanding, and any traveler to a malaria-endemic region should be placed on prophylactic medications. Mosquito bite prevention should be undertaken by all travelers, and methods of deterring mosquito bites should be understood.

The West Nile virus: a lesson in emerging infections.

Since its identification in New York City in 1999, the West Nile virus has spread to 45 states and caused human infections in at least 44 states. West Nile virus is difficult to correctly diagnose without a high level of clinical suspicion and can cause severe debilitation or death in those with the most severe symptoms. This paper reviews the epidemiology, surveillance, prevention, clinical features, diagnosis, and treatment of this important emerging infection. Lessons learned from West Nile virus are discussed at the conclusion of the paper.

Arkansas and the motorcyle helmet law.

Motorcycle helmet laws have a long and colorful history dating back to the original work of Britain's Dr. Hugh Cairns during World War II. In Arkansas, the state's mandatory motorcycle helmet law was repealed in 1997 and replaced by a law requiring only those under the age of 21 to wear helmets. Recent work by researchers at the University of Arkansas for Medical Sciences has highlighted the impact of the helmet law repeal and demonstrated an increase in nonhelmeted motorcycle crash admissions, head injury severity, ICU length of stay and financial loss at this institution. In February of 2003, House Bill 1024 was submitted to the Arkansas House Committee on Public Transportation to reinstate the mandatory motorcycle helmet law for all motorcycle riders but was killed in committee. This article is a review of motorcycle helmet laws with particular emphasis on the arguments pro and con and the history of these laws in the state of Arkansas.

Pediatric rapid sequence intubation: a review.

Pediatric rapid sequence intubation is a skill of great importance to emergency medicine physicians. Developing a systematic strategy for approaching an emergent airway aids in the proper handling of this event. This paper is a review of the current recommendations for pediatric rapid sequence intubation including current medications and surgical rescue techniques.

The negative impact of the repeal of the Arkansas motorcycle helmet law.

BACKGROUND: On July 1, 1997, Arkansas became the first state in 14 years to repeal their adult helmet law. We examined the clinical and financial impact of this repeal. METHODS: A 6-year retrospective review was conducted of the University of Arkansas for Medical Sciences trauma registry including the 3 years before and the 3 years after the repeal of the helmet law. A head and neck Abbreviated Injury Scale (AIS) score >or= 3 was considered severe. All patients admitted to the hospital or who died in the emergency department were included in the study. The database of the Arkansas Highway and Transportation Department was also used to determine the number of crashes and fatalities occurring statewide (1995-1999). RESULTS: Although total and fatal crashes in Arkansas were not significantly different (1995-1996 vs. 1998-1999), nonhelmeted deaths at the scene of a crash significantly increased from 19 of 48 (39.6%) (1995-1996) to 40 of 53 (75.5%) (1998-1999) (p < 0.0001). Before repeal, 25% of nonfatal crash admissions were nonhelmeted (18 of 73). This significantly increased to 54% (52 of 96, p< 0.001) after repeal. Overall, patients who were nonhelmeted had significantly higher AIS scores for head and neck, significantly more severe head injuries (AIS score >or= 3), 47% (33 of 70) versus 20% (20 of 99), and significantly longer length of intensive care unit stay. Financially, patients without helmets had significantly higher unreimbursed charges compared with their helmeted counterparts, resulting in a total of 982,560 dollars of additional potentially lost revenue over the length of the study. CONCLUSION: Repeal of the mandatory helmet law was associated with an increase in the nonhelmeted crash scene fatality rate. After the repeal, there was a disproportionately higher admission rate for nonhelmeted motorcycle crash survivors. These patients had an increased use of hospital resources and poorer reimbursement of charges compared with their helmeted counterparts. This resulted in significantly higher unreimbursed charges. States considering repeal of their mandatory adult helmet laws should consider the potential negative financial impact on their health care system and the increased morbidity associated with nonhelmeted motorcycle riders involved in a crash.