Author: admin_nomad

Working in remote environments, whether on an expedition, a media production or a healthcare setting in a resource poor environment can be rewarding, fulfilling and challenging in equal parts. Of the challenges posed to the clinician by the nature of this work, distance (and ultimately time) from ‘definitive medical care’ may represent the greatest threat to the members of your team (Renouf and Pollard, 2016). Dealing with acutely unwell patients has added complications due to resource limitations, environmental conditions and evacuation times. The remote clinician may therefore be required to make early clinical as well as logistical decisions in order to manifest the best outcomes for their patient (Imray et al., 2015., Duchatau et al. 2009).

‘Early Warning Scores’ (EWS) have been developed for both in-hospital as well as pre-hospital use in order to identify acutely unwell patients, to ensure rapid and efficient clinical responses, and to optimise patient outcomes (NICE, 2020, Medina-Lozano et al., 2020). These systems benefit patient care by creating a standardised score of illness severity, thereby allowing consistent decision making and clinical responses (Downey et al., 2017).

Also known as ‘Track and Trigger’ scores, these systems look at a range of physiological parameters and score them based on their relative derangement from the norm. They allow for the tracking of patient recovery or deterioration, and can trigger clinical interventions and evacuation.

The ‘NEWS2’ score has been used in the UK both in hospital and prehospitally since its introduction in 2017. It is becoming widely used globally, and its accuracy in identifying critically unwell patients in the prehospital setting is widely supported in the literature (Martín-Rodríguez et al., 2019, 2020, Shaw et al., 2017). The system uses six physiological parameters as shown in figure 1.

Fig.1 NEWS2 Early Warning System

The patient’s aggregate score can trigger responses (as can individual parameters with significant derangement) and the score can be monitored over time to assess any improvement or deterioration. This can be particularly useful for the clinician caring for teammates in the field, making evacuation decisions and extracting casualties.

The physiological parameters are generally easily recorded, with lightweight portable equipment (Fig. 2).

Fig. 2 Small observation kit for use by medic on the move

There may be difficulties in attaining certain parameters in some situations. Notably achieving a reliable core body temperature in trauma patients using either a sublingual or tympanic thermometer is likely to be unrealistic (Keene et al., 2017., Skaiaa et al., 2015). The option to use the Swiss Staging model (fig. 3) for predicting severity of hypothermia exists for certain cold stressed patients (Haverkamp et al., 2020., Pasquier et al., 2019) but a reliable core temperature should be achieved as soon as possible (Karlsen et al., 2013., Gerecht et al, 2014).

Fig 3. Swiss Staging Model for Hypothermia

Another difficulty with the system is the potential inability to deliver oxygen in a remote setting. In some situations, this may correlate to low oxygen saturations, thereby triggering the system. There may also be times, for example major trauma in a patient with adequate saturations, where the clinician is required to take a judgement on whether they ‘would’ apply oxygen if it were available, and score the patient accordingly.

There exist other EWS systems in use which may be equally useful to the remote area medic. The Modified Early Warning System (MEWS), Search Out Severity (SOS) and the quick Sequential Organ Failure Assessment (qSOFA) are all relevant and the remote clinician may need to select the appropriate tool depending on the specific situation, patient and local medical facility.

These EWS systems could be used by the remote clinician to support their interventions and in the often complex decision making processes around evacuation criteria.

References

Downey, C.L., Tahir, W., Randell, R., Brown, J.M. and Jayne, D.G., 2017. Strengths and limitations of early warning scores: a systematic review and narrative synthesis. International Journal of Nursing Studies, 76, pp.106-119.

Duchateau, F.X., Verner, L., Cha, O. and Corder, B., 2009. Decision criteria of immediate aeromedical evacuation. Journal of travel medicine, 16(6), pp.391-394.

Gerecht, R., 2014. Trauma’s Lethal Triad of Hypothermia, Acidosis & Coagulopathy Create a Deadly Cycle for Trauma Patients. JEMS, 39(4), pp.56-60.

Haverkamp, F.J., Giesbrecht, G.G. and Tan, E.C., 2018. The prehospital management of hypothermia—an up-to-date overview. Injury, 49(2), pp.149-164.

Imray, C.H., Grocott, M.P., Wilson, M.H., Hughes, A. and Auerbach, P.S., 2015. Extreme, expedition, and wilderness medicine. The Lancet, 386(10012), pp.2520-2525.

Karlsen, A.M., Thomassen, Ø., Vikenes, B.H. and Brattebø, G., 2013. Equipment to prevent, diagnose, and treat hypothermia: a survey of Norwegian pre-hospital services. Scandinavian journal of trauma, resuscitation and emergency medicine, 21(1), pp.1-5.

Keene, T., Brearley, M., Bowen, B. and Walker, A., 2015. Accuracy of tympanic temperature measurement in firefighters completing a simulated structural firefighting task. Prehospital and disaster medicine, 30(5), p.461.

Keene, C.M., Kong, V.Y., Clarke, D.L. and Brysiewicz, P., 2017. The effect of the quality of vital sign recording on clinical decision making in a regional acute care trauma ward. Chinese Journal of Traumatology, 20(5), pp.283-287.

National Institute for Health and Care Excellence. 2020. National Early Warning Score systems that alert to deteriorating adult patients in hospital. [Accessed: 29/04/2020] Available at: www.nice.org.uk/advice/mib205/chapter/The-technology

Martín-Rodríguez, F., Castro-Villamor, M.Á., del Pozo Vegas, C., Martín-Conty, J.L., Mayo-Iscar, A., Benito, J.F.D., del Brio Ibañez, P., Arnillas-Gómez, P., Escudero-Cuadrillero, C. and López-Izquierdo, R., 2019. Analysis of the early warning score to detect critical or high-risk patients in the prehospital setting. Internal and emergency medicine, 14(4), pp.581-589.

Martín-Rodríguez, F., López-Izquierdo, R., del Pozo Vegas, C., Benito, J.F.D., Rodríguez, V.C., Rasilla, M.N.D., Conty, J.L.M., Iscar, A.M., de la Torre, S.O., Martín, V.M. and Villamor, M.A.C., 2019. Accuracy of national early warning score 2 (news2) in prehospital triage on in-hospital early mortality: a multi-center observational prospective cohort study. Prehospital and disaster medicine, 34(6), pp.610-618.

Martín-Rodríguez, F., Sanz-García, A., Medina-Lozano, E., Castro Villamor, M.Á., Carbajosa Rodríguez, V., del Pozo Vegas, C., Fadrique Millán, L.N., Rabbione, G.O., Martín-Conty, J.L. and López-Izquierdo, R., 2020. The value of prehospital early warning scores to predict in-hospital clinical deterioration: a multicentre, observational base-ambulance study. Prehospital Emergency Care, pp.1-10.

Medina-Lozano, E., Martín-Rodríguez, F., Castro-Villamor, M.Á., Escudero-Cuadrillero, C., del Pozo Vegas, C. and López-Izquierdo, R., 2020. Accuracy of early warning scores for predicting serious adverse events in pre-hospital traumatic injury. Injury, 51(7), pp.1554-1560.

Pasquier, M., Carron, P.N., Rodrigues, A., Dami, F., Frochaux, V., Sartori, C., Deslarzes, T. and Rousson, V., 2019. An evaluation of the Swiss staging model for hypothermia using hospital cases and case reports from the literature. Scandinavian journal of trauma, resuscitation and emergency medicine, 27(1), p.60.

Renouf, T. and Pollard, M., 2016. Emergency medicine in remote regions. Cureus, 8(9).

Silcock, D.J., Corfield, A.R., Gowens, P.A. and Rooney, K.D., 2015. Validation of the National Early Warning Score in the prehospital setting. Resuscitation, 89, pp.31-35.

Shaw, J., Fothergill, R.T., Clark, S. and Moore, F., 2017. Can the prehospital National Early Warning Score identify patients most at risk from subsequent deterioration? Emergency Medicine Journal, 34(8), pp.533-537.

Skaiaa, S.C., Brattebø, G., Aßmus, J. and Thomassen, Ø., 2015. The impact of environmental factors in pre-hospital thermistor-based tympanic temperature measurement: a pilot field study. Scandinavian journal of trauma, resuscitation and emergency medicine, 23(1), pp.1-7.

Anaphylaxis is a life-threatening emergency and is becoming more common year on year (Pawankar et al, 2013).

It is an acute hypersensitivity reaction affecting the skin, respiratory tract, gastrointestinal tract, cardio-vascular system and central nervous system (Kane and Cone, 2015) (Ben-Shoshan and Clarke, 2010).

Anaphylaxis pathophysiology resembles that of a normal immune response, except it is systemic, over exaggerated and usually in response to an allergen which would normally be regarded as harmless (Allergy UK, 2015). These allergens can take many forms, and frequently include food, pollen, medications and venoms (Simons and Estelle, 2010).

RECOGNITION

The most pressing issue when dealing with anaphylaxis is diagnosis, as delay in recognising the condition is regularly associated with poor patient outcomes (Rudders et al, 2011).

• Two of the ‘classic’ signs are swelling and hives which may present visibly over the patients face and body (Jacobsen and Gratton, 2011). This can be seen as an early warning, and helps distinguish from other similar conditions such as a severe asthma attack.

• The respiratory system will be affected if the lumen of the airways closes up due to inflammation and bronchospasm. In the upper airways this results in stridor, while bronchospasm (wheezing) is pathophysiology associated with the lower airways (Bethel, 2013). Increased mucous production also reduces the permeability of the respiratory membrane to gaseous exchange.

• A marked reduction of blood pressure caused by the systemic vasodilatation of the blood vessels in combination with the reduced blood volume is another sign (Philpis et al. 2001). The resulting inability of the patient to maintain adequate perfusion pressures is associated with the onset of hypovolemic shock as the volume of fluid within the cardiovascular system falls (Waugh and Grant, 2014).

• Due to the high density of mast cells within the digestive system, there is often a disturbance to the gastrointestinal tract. This may cause diarrhoea and vomiting to be an associated symptom following increased smooth muscle contraction (Jevon et al. 2004).

• A patient’s history of exposure is vitally important to consider when making a diagnosis and should be considered in combination with the existence of risk factors and clinical symptoms (Bethel, 2013).

MANAGEMENT

The initial management of anaphylactic patients involves the removal of the trigger, if possible followed by intra-muscular adrenaline, high flow oxygen, chlorphenamine (or other anti-histamine), intra-venous access with possible fluid challenge, hydrocortisone, and salbutamol.

Treatment priority is intra-muscular Adrenaline and ensuring adequate patient oxygenation (National Association of EMS Physicians, 2011) (Arnold and Williams, 2011). Adrenaline counteracts the effects of the Histamine release, causing vasoconstriction. This will in turn raise blood pressure and reduce swelling (NHS Choices, 2015). Adrenaline will also cause bronco-dilation due to its effect as a sympathetomimemic.

Anaphylaxis can have a devastating effect on the body, and is a time-critical emergency in any environment. If not treated quickly and aggressively it can lead to anaphylactic shock and death. The first line treatment of patients is adrenaline to prevent further deterioration and a fluid challenge for those who are no longer perfusing. Interventions should be based both on recommendations from clinical guidelines as well as evidence-based research, and should always be carried out in accordance with safe and best practice. The importance of education and preparation is paramount for people predisposed to anaphylaxis, as avoiding allergens and early recognition of symptoms may well save their lives.

The emergence of the solo female traveller market globally is a positive step forward in  gender equality, yet solo female travellers can face unique risks.

These risks can be mitigated through appropriate research, planning and preparation prior to departure. Learning about your personal security and actively putting this into practice through subtle techniques when on the road will also help to reduce risks faced.

Yang et al. (2018)| reveal that women can empower themselves through negotiating risk on their travels.

Be prepared. Be a Nomad.

1. Ahokas, S., 2017. Safety of female travellers.
2. Yang, E.C.L., Khoo-Lattimore, C. and Arcodia, C., 2018. Power and empowerment: How Asian solo female travellers perceive and negotiate risks. Tourism Management, 68, pp.32-45.

High Altitude (HA) illness describes a range of conditions; Acute Mountain Sickness (AMS), High Altitude Pulmonary Oedema (HAPE) and High Altitude Cerebral Oedema (HACE).

Acute Mountain Sickness (AMS) is the most common, affecting up to 60% of individuals who ascend over 600 meters(m)/day above 4000m (Maggiorini, 2006).

AMS is characterised by a non-specific set of symptoms experienced at HA including headache, sleep disturbance, nausea and vomiting, dyspnoea, tachycardia and malaise (Borowska et al., 2014; Carod-Artal, 2014).

No objective physiological variable has been identified to diagnose AMS, and it is thus scored via self-assessment questionnaire’s, notably the Lake Louise Score (LLS) (Roach et al., 1993; Shah et al., 2105).

The presence of a headache with a LLS over 3 indicates AMS in individuals who have rapidly ascended above 2500m.

Sharpen the Axe.

Assessing the level of hypothermia in cold stressed patients is incredibly important for rescuers.

Two key issues make this relevant;

Firstly, severely hypothermic patients are at a high risk of developing a cardiac arrest (ventricular fibrillation) if not handled carefully, a condition known as ‘circum rescue collapse’ (Zafren et al, 2014).

Secondly, the lack of thermo genetic effort in moderate and severe categories of hypothermia mean that passive re-warming alone is inadequate, and more active re-warming techniques will be required (Epstein and Anna, 2006).

At Nomad we find the “Swiss Staging” model for hypothermia particularly useful as it uses clinical symptoms to estimate the patient’s core temperature without the use of a thermometer. This is useful for rescuers who are unable to obtain an accurate thermometer reading due to situational demands or the fallibility of equipment.

Pasquier, M., Carron, P.N., Rodrigues, A., Dami, F., Frochaux, V., Sartori, C., Deslarzes, T. and Rousson, V., 2019. An evaluation of the Swiss staging model for hypothermia using hospital cases and case reports from the literature. Scandinavian journal of trauma, resuscitation and emergency medicine, 27(1), p.60.

‘Acute Anxiety Predicts Components of the Cold Shock Response on Cold Water Immersion: Toward an Integrated Psychophysiological Model of Acute Cold Water Survival’ (2017) Barwood et al.

Great paper.

Drowning is one of the leading causes of accidental death globally.

Sudden cooling of the skin during Cold Water Immersion (CWI) can initiate the Cold Shock Response (CSR); tachycardia, peripheral vasoconstriction, hypertension, inspiratory gasping and hyperventilation among others. ⠀⠀⠀⠀

We can train to control the effects of CWI through habitual short immersions, reducing the response to a stimulus of similar magnitude. ⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀
We can also use the power of the mind to combat the exacerbating impact that acute anxiety can have on even well trained individuals. ⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀
Train the body, train the mind. ⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀

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