Desert Medicine.

Deserts are defined by their arid nature, characterized by little rainfall, and often featuring vast stretches of sandy terrain with sparse vegetation. The resulting variations in temperature, humidity, and topography predispose patients to medical conditions that practitioners in both rural and urban deserts must recognize and manage. This article will equip medical practitioners with the essential knowledge and tools to navigate these complexities, including a description of specific environmental considerations and challenges encountered while providing care in these desert locations, common conditions associated with extreme heat and solar radiation, and animal encounters.

Lightning Strike Injuries.

Lightning is a common environmental hazard, and is a significant cause of global injury and death. Care and evaluation should follow general trauma guidelines, but several unique aspects of lightning injuries necessitate deviations from standard care that can improve survival and overall outcomes. When evaluating lightning strike patients, some common injury patterns are pathognomonic for lightning strikes and easy to recognize, while others are subtle and require heightened awareness. While most lightning-related injuries resolve spontaneously, some may have significant long-term symptoms. Anticipatory guidance and specialty referral may be needed for appropriate follow-up, evaluation, and treatment.

Rethinking urban wilderness: Status, hotspots, and prospects of ecosystem services.

An urban wilderness (UW) portrays a coupled relationship between natural dominance and human management in urban spaces. Superior ecosystem services support sustainable urban development. Systematic assessments of the status, changes, and trends of urban wilderness ecosystem services (UWESs) are a debated and complex issue in the field of ecology despite their importance as key components for ensuring the sustainable development of human society. We aimed to analyze the scientific literature on UWESs published between 2000 and 2022. Hence, we used bibliometric methods to comprehensively understand the research lineages, hotspots, and trends in UWESs. We found that the research has roughly encompassed two phases: initial exploration (2000-2011)and rapid growth (2012-2022). The number of publications has shown a continuous growth trend; the research hotspots include UWs compared with urban greenfield ecosystems, the spatio-temporal dynamics of UWs, ecosystem services and value assessments, and the coupling and linkage between ecosystem maintenance and human health. We summarized relevant trends for the concept of harmonious coexistence between human beings and nature, focusing on spatio-temporal dynamics and multidisciplinary integration as well as reinforcing the link with human health. This study can serve as a reference for demonstrating the value of UWESs and their practical application in a UW.

Wilderness Medical Society Clinical Practice Guidelines for Medical Direction of Search and Rescue Teams.

The Wilderness Medical Society convened a panel to review available evidence supporting practices for medical direction of search and rescue teams. This panel included of members of the Wilderness Medical Society Search and Rescue Committee, the National Association of EMS Physicians Wilderness Committee, and leadership of the Mountain Rescue Association. Literature about definitions and terminology, epidemiology, currently accepted best practices, and regulatory and legal considerations was reviewed. The panel graded available evidence supporting practices according to the American College of Chest Physicians criteria and then made recommendations based on that evidence. Recommendations were based on the panel's collective clinical experience and judgment when published evidence was lacking.

Randomized Controlled Trial of Telementoring During Resource-Limited Patient Care Simulation Improves Caregiver Performance and Patient Survival.

OBJECTIVES: To determine the impact of telementoring on caregiver performance during a high-fidelity medical simulation model (HFMSM) of a critically ill patient in a resource-limited setting. DESIGN: A two-center, randomized, controlled study using a HFMSM of a patient with community-acquired pneumonia complicated by acute respiratory distress syndrome. SETTING: A notional clinic in a remote location staffed by a single clinician and nonmedical assistant. PARTICIPANTS: Clinicians with limited experience managing critically ill patients. INTERVENTIONS: Telemedicine (TM) support. MEASUREMENTS: The primary outcome was clinical performance as measured by accuracy, reliability, and efficiency of care. Secondary outcomes were patient survival, procedural quality, subjective assessment of the HFMSM, and perceived workload. MAIN RESULTS: TM participants (N = 11) performed better than non-TM (NTM, N = 12) in providing expected care (accuracy), delivering care more consistently (reliability), and without consistent differences in efficiency (timeliness of care). Accuracy: TM completed 91% and NTM 42% of expected tasks and procedures. Efficiency: groups did not differ in the mean (± sd) minutes it took to obtain an advanced airway successfully (TM 15.2 ± 10.5 vs. NTM 22.8 ± 8.4, p = 0.10) or decompress a tension pneumothorax with a needle (TM 0.7 ± 0.5 vs. NTM 0.6 ± 0.9, p = 0.65). TM was slower than NTM in completing thoracostomy (22.3 ± 10.2 vs. 12.3 ± 4.8, p = 0.03). Reliability: TM performed 13 of 17 (76%) tasks with more consistent timing than NTM. TM completed 68% and NTM 29% of procedural quality metrics. Eighty-two percent of the TM participants versus 17% of the NTM participants simulated patients survived (p = 0.003). The groups similarly perceived the HFMSM as realistic, managed their patients with personal ownership, and experienced comparable workload and stress. CONCLUSIONS: Remote expertise provided with TM to caregivers in resource-limited settings improves caregiver performance, quality of care, and potentially real patient survival. HFMSM can be used to study interventions in ways not possible with real patients.

Adapting nitric oxide: A review of its foundation, uses in austere medical conditions, and emerging applications.

Nitric oxide was first identified as a novel and effective treatment for persistent pulmonary hypertension of the newborn (PPHN), and has since been found to be efficacious in treating acute respiratory distress syndrome (ARDS) and pulmonary hypertension. Physicians and researchers have also found it shows promise in resource-constrained settings, both within and outside of the hospital, such as in high altitude pulmonary edema (HAPE) and COVID-19. The treatment has been well tolerated in these settings, and is both efficacious and versatile when studied across a variety of clinical environments. Advancements in inhaled nitric oxide continue, and the gas is worthy of investigation as physicians contend with new respiratory and cardiovascular illnesses, as well as unforeseen logistical challenges.

A retrospective analysis of mission reports in the national Swedish Police Registry on mountain rescue 2018-2022: here be snowmobiles.

BACKGROUND: Increasing mountain activity and decreasing participant preparedness, as well as climate change, suggest needs to tailor mountain rescue. In Sweden, previous medical research of these services are lacking. The aim of the study is to describe Swedish mountain rescue missions as a basis for future studies, public education, resource allocation, and rescuer training. METHODS: Retrospective analysis of all mission reports in the national Swedish Police Registry on Mountain Rescue 2018-2022 (n = 1543). Outcome measures were frequencies and characteristics of missions, casualties, fatalities, traumatic injuries, medical conditions, and incident mechanisms. RESULTS: Jämtland county had the highest proportion of missions (38%), followed by Norrbotten county (36%). 2% of missions involved ≥ 4 casualties, and 44% involved ≥ 4 mountain rescuers. Helicopter use was recorded in 59% of missions. Non-Swedish citizens were rescued in 12% of missions. 37% of casualties were females. 14% of casualties were ≥ 66 or ≤ 12 years of age. Of a total 39 fatalities, cardiac event (n = 14) was the most frequent cause of death, followed by trauma (n = 10) and drowning (n = 8). There was one avalanche fatality. 8 fatalities were related to snowmobiling, and of the total 1543 missions, 309 (20%) were addressing snowmobiling incidents. Of non-fatal casualties, 431 involved a medical condition, of which 90 (21%) suffered hypothermia and 73 (17%) cardiovascular illness. CONCLUSIONS: These baseline data suggest snowmobiling, cardiac events, drownings, multi-casualty incidents, and backcountry internal medicine merit future study and intervention.

A review of global wilderness area identification since the 21st century.

Wilderness areas are natural landscape elements that are relatively undisrupted by human activity and play a critical role in maintaining ecological equilibrium, preserving naturalness, and ensuring ecosystem resilience. Since 2000, monitoring of global wilderness areas has increased owing to the availability of spatial map data and remote sensing imagery related to human activity and/or human footprint. Progress has been made in the remote sensing of wilderness areas by relying on available historical literature (e.g., published papers, books, and reports). However, to our knowledge, a synthesis of wilderness area research from a remote sensing perspective has not yet been performed. In this preliminary review, we discuss the concept of wilderness in different historical eras and systematically summarize dynamic wilderness monitoring at local, national, and global scales, available remotely sensed indicators, disparities and commonalities in identification methods, and mapping uncertainties. Finally, since this field remains in its initial stage owing to a lack of unified standards and vertical/horizontal comparisons, we present insights into future research directions, particularly with regard to remote sensing. The findings of this review may help to improve the overall understanding of current wilderness patterns (i.e., increases/decreases) and the mechanisms by which they change, as well as provide guidance for global nature conservation programs.

Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update.

The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.

Quality of Cardiopulmonary Resuscitation in Avalanche Victims with a Single Rescuer: A Prospective, Crossover, Manikin Pilot Study.

Tanaka, Shota, Koshi Nakagawa, Yosuke Kanagawa, Takashi Katsurahara, Kazuki Kozakai, Ken Tsuhako, Fumitaka Yoshikawa, Soh Gotoh, Kensuke Osanai, Madoka Sono, Hironori Inoue, Shuji Sakanashi, Hiroyuki Takahashi, and Hideharu Tanaka. Quality of cardiopulmonary resuscitation in avalanche victims with a single rescuer: a prospective, crossover, manikin pilot study. High Alt Med Biol. 25:60-67, 2024. Background: Winter outdoor recreational activities such as off-piste skiing have gained popularity and, as a result, the number of avalanche-related deaths has increased. However, the quality of cardiopulmonary resuscitation (CPR) at avalanche sites remains unclear. Our study compared the quality of CPR performed in a simulated avalanche burial on a snowy mountain with that performed indoors. Methods: Ten prehospital health care providers participated in the crossover pilot study. Various methods, including over-the-head CPR (OTH-CPR) and standard CPR, were used to perform avalanche resuscitation, with five rescue breaths, followed by 30 chest compressions and two breaths. The quality CPR was judged by four variables of chest compression and ventilation. Results: The OTH-CPR performed indoors was better in quality: 5.33% [95% confidence interval (CI) -14.2 to 3.5] higher in adequate compression depth (94.3 ± 10.6% on the snow vs. 99.3 ± 1.1% indoors), 3.4% [95% CI -16.1 to 22.9] higher in adequate compression rate (70.4 ± 38.0% vs. 76.1 ± 35.7%), and 2.3% [95% CI -6.4 to 1.72] higher in adequate recoil (96.9 ± 4.8% vs. 99.2 ± 1.6%) than OTH-CPR on the snow. In terms of ventilation quality, OTH-CPR performed indoors had a 50% higher ventilation score [95% CI -73.0 to -27.0] than OTH-CPR on the snow (1.4 ± 4.3% vs. 45.9 ± 32.6%, Cohen's d = -1.81). Conclusions: Chest compression quality was slightly impaired in the avalanche scenarios on the snow than in indoor settings. Asphyxiation is the main cause of avalanche-related deaths; however, low ventilation quality was observed on snow compared with the indoor setting.

Characteristics of Fatal Accidents due to Exogenous Causes at Ski Resorts in Japan Over the Past 13 Years: A Retrospective Descriptive Study.

INTRODUCTION: The characteristics of ski- and snowboard-related fatalities at Japanese ski resorts remain unknown. We aimed to analyze the characteristics of this in the current study. METHODS: Using the Ski Resort Injury Report data for the 13-y period between the 2011-12 and 2022-23 seasons, we described the characteristics of fatal accidents due to exogenous causes. RESULTS: Eighty-four subjects (48 skiers and 36 snowboarders) were analyzed. Males accounted for 73 cases of all 84 fatalities (86.9%), including 44 skiers (91.7%) and 29 snowboarders (80.6%). Skiers aged ≥50 y and snowboarders aged 20-35 y had the highest number of fatal accidents (32 and 18 cases, respectively). Regarding location, 26 fatal accidents occurred on slopes, and 58 occurred out of slopes (skiers, 11 and 37 cases; snowboarders, 15 and 21 cases, respectively). Among skiers, head and neck trauma accounted for the cause of death in 13 cases (27.1%) and asphyxiation in 11 cases (22.9%). Among snowboarders, head and neck trauma accounted for the cause of death in 14 cases (38.9%) and asphyxiation in 14 cases (38.9%). CONCLUSIONS: Males, particularly those aged ≥50 among skiers and 20-35 among snowboarders, should be wary of the potential for injuries to the head, neck, and airway when skiing or snowboarding. In this study, traumatic deaths from crashing into trees and asphyxiation from deep snow immersion accidents accounted for approximately half of fatal ski accidents in Japan.

Wilderness Medical Society Clinical Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents: 2024 Update.

To provide guidance to the general public, clinicians, and avalanche professionals about best practices, the Wilderness Medical Society convened an expert panel to revise the evidence-based guidelines for the prevention, rescue, and resuscitation of avalanche and nonavalanche snow burial victims. The original panel authored the Wilderness Medical Society Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents in 2017. A second panel was convened to update these guidelines and make recommendations based on quality of supporting evidence.

Frostbite treatment: a systematic review with meta-analyses.

INTRODUCTION: Our objective was to perform a systematic review of the outcomes of various frostbite treatments to determine which treatments are effective. We also planned to perform meta-analyses of the outcomes of individual treatments for which suitable data were available. MAIN BODY: We performed a systematic review and meta-analyses in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched PubMed, Cochrane Trials, and EMBase to identify primary references from January 1, 1900, to June 18, 2022. After eliminating duplicates, we screened abstracts to identify eligible studies containing information on treatment and outcomes of Grade 2 to 4 frostbite. We performed meta-analyses of groups of articles that provided sufficient data. We registered our review in the prospective registry of systematic reviews PROSPERO (Nr. 293,693). We identified 4,835 potentially relevant studies. We excluded 4,610 studies after abstract screening. We evaluated the full text of the remaining 225 studies, excluding 154. Ultimately, we included 71 articles with 978 cases of frostbite originating from 1 randomized controlled trial, 20 cohort studies and 51 case reports. We found wide variations in classifications of treatments and outcomes. The two meta-analyses we performed both found that patients treated with thrombolytics within 24 h had better outcomes than patients treated with other modalities. The one randomized controlled trial found that the prostacyclin analog iloprost was beneficial in severe frostbite if administered within 48 h. CONCLUSIONS: Iloprost and thrombolysis may be beneficial for treating frostbite. The effectiveness of other commonly used treatments has not been validated. More prospective data from clinical trials or an international registry may help to inform optimal treatment.

Twinkle Artifact Observed During POCUS of a Human Myiasis Caused by the Dermatobia hominisBotfly.

An 81-year-old man presented to urgent care for assessment of an area of erythema and tenderness on his right thigh after recent travel to Belize. Point of care ultrasound (POCUS) revealed a hyperechoic structure with acoustic shadowing in the subcutaneous tissue. Colour Doppler assessment of the structure produced a twinkle artifact. The structure was removed and pathology identified the object as a Dermatobia hominis larva (human botfly). The use of POCUS helped identify and localize the subcutaneous foreign body. The use of colour Doppler produced the twinkle artifact, which has not been previously reported as a finding produced during ultrasonographic assessment of botfly larvae.

Wilderness areas under threat from global redistribution of agriculture.

Agriculture expansion is already the primary cause of terrestrial biodiversity loss globally1,2; yet, to meet the demands of growing human populations, production is expected to have to double by 2050.3 The challenge of achieving expansion without further detriment to the environment and biodiversity is huge and potentially compounded by climate change, which may necessitate shifting agriculture zones poleward to regions with more suitable climates,4 threatening species or areas of conservation priority.5,6,7 However, the possible future overlap between agricultural suitability and wilderness areas, increasingly recognized for significant biodiversity, cultural, and climate regulation values, has not yet been examined. Here, using high-resolution climate data, we model global present and future climate suitability for 1,708 crop varieties. We project, over the next 40 years, that 2.7 million km2 of land within wilderness will become newly suitable for agriculture, equivalent to 7% of the total wilderness area outside Antarctica. The increase in potentially cultivable land in wilderness areas is particularly acute at higher latitudes in the northern hemisphere, where 76.3% of newly suitable land is currently wilderness, equivalent to 10.2% of the total wilderness area. Our results highlight an important and previously unidentified possible consequence of the disproportionate warming known to be occurring in high northern latitudes. Because we find that, globally, 72.0% of currently cultivable land is predicted to experience a net loss in total crop diversity, agricultural expansion is a major emerging threat to wilderness. Without protection, the vital integrity of these valuable areas could be irreversibly lost.

Mobility Solutions After a Lower Extremity Fracture and Applicability to Battlefield and Wilderness Medicine.

The potential for delayed evacuation of injured Service members from austere environments highlights the need to develop solutions that can stabilize a wound and enable mobility during these prolonged casualty care (PCC) scenarios. Lower extremity fractures have traditionally been treated by immobilization (splinting) followed by air evacuation - a paradigm not practical in PCC scenarios. In the civilian sector, treatment of extremity injuries sustained during remote recreational activities have similar challenges, particularly when adverse weather or terrain precludes early ground or air rescue. This review examines currently available fracture treatment solutions to include splinting, orthotic devices, and biological interventions and evaluates their feasibility: 1) for prolonged use in austere environments and 2) to enable patient mobilization. This review returned three common types of splints to include: a simple box splint, pneumatic splints, and traction splints. None of these splinting techniques allowed for ambulation. However, fixed facility-based orthotic interventions that include weight-bearing features may be combined with common splinting techniques to improve mobility. Biologically-focused technologies to stabilize a long bone fracture are still in their infancy. Integrating design features across these technologies could generate advanced treatments which would enable mobility, thus maximizing survivability until patient evacuation is feasible.

What is Nature-Based Medicine and What Does It Do?

One's personal health and well-being can improve with activity in natural environments or decline without it. Many chronic illnesses to which personal nature deficiency contributes-including anxiety, depression, attention deficit, diabetes, hypertension, myopia, and obesity-have been exacerbated with the pandemic. That those illnesses may be preventable, treatable, and even reversible with an added nature-based approach may seem novel, but it is not. Though the field of nature-based medicine is just emerging in the U.S., it has been taught and practiced in Asia and the EU for decades. As the prescriptive, evidence-based use of natural settings and nature-based interventions, it aims to prevent and treat disease and improve well-being. Nature-based medicine blends particular activity in nature with the science of medicine to attempt to empower self-care safely, effectively, and happily. Its vision is to be readily available to all, regardless of proximity to blue (water-related) or green (land-related) space. The common sense of nature-based medicine belies its scientific evidence base, which is growing but not well-known, so it may seem unfamiliar to prescribe nature to patients. It will take education, training and practice to help patients access nature-based medicine and to help clinicians prescribe it.

Wilderness Is the Prototype of Nature Regardless of the Individual's Connection to Nature. An Empirical Verification of the Solastalgia Effect.

(1) Background: Connectedness with Nature is a personality trait that influences our relationship with Nature. But Nature is not all the same. Wilderness is Nature in its original form, the form within which human beings have evolved as a species, while what we refer to as domesticated and urban Nature are relatively recent products of our interaction with the environment. (2) Aim: The main purpose of this study was to verify whether the individual trait "connection to Nature" influences the perception of restoration, preference for and familiarity with three types of Nature: wilderness, domesticated and urban. (3) Results: Regardless of the level of connection to Nature, wilderness is always perceived as more restorative than the domesticated or urban environment. Individuals with higher connectedness prefer wilderness more than others, and they are able to recognise the restorative value of domesticated environments more than those with medium or low levels of connectedness. Less connected individuals tend to prefer domesticated environments, although wilderness is more familiar to them. (4) Conclusions: This study shows that, despite our detachment from Nature, wilderness is the prototype of Nature, and this finding offers a plausible evolutionary explanation of solastalgia.