Wilderness Medicine Updates
The podcast for medical providers at the edges, bringing you digestible updates at the growing edge of Wilderness Medicine, Wilderness EMS, Search and Rescue, and more.
Wilderness Medicine Updates
Ep. 8 - SAR Provider Injuries & Traveler's Diarrhea Treatment
In this two-part episode, I review an article from the Annals of Emergency Medicine "Occupational Accidents Among Search and Rescue Providers During Mountain Rescue Operations and Training Events"
https://doi.org/10.1016/j.annemergmed.2022.12.015
In the second half, we review the treatment of diarrhea in the returning traveler.
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Hello and welcome back to Wilderness Medicine Updates, the show for providers at the edges. I'm your host, patrick Pink. On today's episode, we're going to deliver two punches left and right the first on Occupational Accidents Among SAR Providers and the second a review of treatment of diarrhea in the returning traveler. If you want to jump to one or the other, take a look down at the bottom of your iTunes player or whatever platform you're using, and you can use the chapters function to jump straight to where you want to go. We're going to begin first with Occupational Accidents Among SAR Providers. This is a review of a paper entitled Occupational Accidents Among Search and Rescue Providers during Mountain Rescue Operations and Training Events. This was published by Mario Milani et al in Annals of Emergency Medicine in June of 2023.
Speaker 1:This study is an interesting review of a database of insurance claims maintained by the Italian Search and Rescue Operation. Corpo Nazionale so corso alpino is piliologico, or the CNSAS, as we'll call it from here on out, keeps a database of any insurance claims made by their providers, and the authors looked at a period from 1999 to 2019. They used this to take a look back at all of the injuries, illnesses and other claims that took their professional rescue providers out of circulation and away from work. A background on this organization is that this is a nationally operated search and rescue service. They've grown their rescue operations tremendously over time and they generally operate around 10,000 operations per year and they've rescued a total of 203,917 people from the mountains since their founding in 1954. The authors note that the reason to approach the topic of hazards for SAR providers is that they operate like an EMS service, but in a much more challenging environment, and EMS providers are generally hurt at a much higher rate than their in-hospital colleagues In urban EMS settings. This is usually because these providers are operating unsecured inside of moving vehicles like ambulances, or they're operating at road sides, where further accidents can occur. In the mountains we're talking about a difficult operating environment, with adverse weather, rain, and also using vehicles and helicopters under challenging circumstances. So the authors here looked at a dataset that included all accidents that resulted in the provider leaving the service and taking recovery time.
Speaker 1:Over this 20 year period from 1999 to 2019, there were 784 CNSAS providers who were injured in 755 accidents. 41% of those cases happened during rescue operations and 59% occurred during training. There was a strong seasonal distribution, where training accidents tended to happen during the spring, and operational accidents tended to happen during the summer, likely reflecting when those things tend to occur During this period of time. There were at least 20,000 professional operators in the field each year, although it does vary from year to year, so that results in about 39.2 providers per year who were injured during this period of time. Of those accidents, 751 of the 755 cases, or 96%, resulted from a traumatic mechanism, whereas only 33 or 4% were classified as either medical or environmental illness cases. In the trauma category, high energy falls, ie falling from higher than standing height, was the most common mechanism leading to trauma, accounting for 44% of cases. Helicopters and car crashes were the cause of accidents in 29 cases during rescue operations and 13 during training events, and lower limb injuries were the most common, upper limb injuries less common. 80% of injuries were classified as a moderate injury, whereas very low acuity injuries like contact with bodily fluids, and very high acuity injuries or deaths were only reported during rescue operations.
Speaker 1:The authors did look at the fatal accidents and from 1999 to 2019, there were eight fatal accidents involving 16 victims in total. The causes of death highlighted here included fall in a snow field, fall, helicopter crash, avalanche, myocardial infarction, landslide, helicopter crash and car accident. So what can we take away from this review of injury data from a large professional rescuer database over the last 20 years? The first is that most of these injury cases resulted in non-fatal injuries or illnesses that resulted in lost workdays. Fatalities were relatively rare, happened only during rescue operations, and injuries were much more common during training. Similarly to the patterns of injuries that we see in recreationalists, falls resulting in lower extremity injuries like fractures, strains and sprains were the main type of injuries seen in the mountain search and rescue population. There were four fatalities from avalanches and two from a landslide, which does highlight that the operational conditions are very different and pose unique hazards in comparison to urban EMS services.
Speaker 1:It's also worth noting that a significant proportion of the fatal accidents involved the use of a vehicle, including two car crashes and two helicopter crashes, and these were also the only settings in which multiple providers were killed. So anytime that we are employing a vehicle, an aircraft, in rescue operations, it does pose a higher risk of fatality as a result of an accident rather than simple injury. Interestingly, even though the mean age of their mountain rescue providers changed over this period of time, trending upwards from 37.8 years of age to 45.2 years of age. Across the study period, medical causes of illness and environmental illnesses were much less common in this population. Now this program does have an aggressive screening program where all professional providers under the age of 50 are screened every three years by a physician and everyone over the age of 50 is screened annually before they're allowed to participate. What are the limitations here? So it's possible that their data doesn't include any minor accidents, because anything that lets someone return to work essentially immediately and doesn't result in an insurance claim isn't covered here. Additionally, they don't really know how to calculate recovery time for these folks, because the only data they have is when they're away from work, so they make some assumptions there.
Speaker 1:What should we take away from this as mountain rescue providers? I think that this study emphasizes that the greatest risk to us as professional rescuers in the mountain environment is in proportion to how we spend our time. So the majority of time is spent in training, and so the majority of accidents occur in training. The kinds of injuries that we sustain are what we might expect falls, and it is likely a result of the challenging operating environment. I think that in the United States we would probably see a different pattern of traumatic versus medical causes of injury, and here's why there are not very many professional rescue operations in the United States outside of the National Park Service. The majority of people involved in search and rescue are volunteers, so their conditioning may actually be much less than those who are conducting 10,000 rescue operations annually. Accordingly, I would expect to see a higher degree of medical and environmental related causes of illness in an American rescue population, or in any population where it is predominantly volunteers who are providing care. So I thank Dr Milani at all for their interesting article, and the quick review that we've provided you here is just touching on some of what they've discussed in this article. If you want more, look in Volume 81, Number 6, that's June 2023 in the Annals of Emergency Medicine.
Speaker 1:Now let's move on to talk about diarrhea in the returning traveler. A friend of mine went on a long weekend trip to Mexico City a few months ago, which he said was like a vibrant and verdant, slightly rough around the edges variant of Paris. One night he had a marvelous course meal at a top 50 restaurant, and the following night he ate tacos and watched some luchador wrestling. That night he fell happily asleep, only to be rudely awakened by a stomach and knots and overwhelming nausea For the following week. Even though he returned to the US, he had persistent abdominal cramping and diarrhea. He asked me whether he should consider antibiotics, so I thought it was time for a refresh on the subject.
Speaker 1:First, some background. Traveller's diarrhea is defined by the presence of multiple loose stools in the context of travel, accompanied by either abdominal pain and cramping, fever, blood in the stool or nausea and vomiting. The problem of diarrhea in a quote returning traveler is not uncommon. Of those who spend at least two weeks in a developing country, somewhere around 20-60% will experience some kind of diarrheal illness. The less developed the country, the higher the risk of illness. The management and diagnosis of traveler's diarrhea is pretty different depending on whether it's acute or persistent. Acute, in this case we mean to be less than two weeks in duration, and persistent is anything of longer duration.
Speaker 1:Acute Traveller's Diarrhea the majority of cases of Traveller's Diarrhea in the acute phase are caused by self-limiting bacterial infections. Organisms include Salmonella, shigella, campylobacter E coli and Plesiamonas, among others. Viruses Norovirus among them, account for around a third of cases, and parasites, mostly Giardia and Entomibia, account for the remainder Low. Diagnostics have advanced significantly in recent years, with PCR panels quickly replacing stool culture and microscopy. The actual usefulness of this testing is unclear and generally there's no need for testing Because of bacterial predominance.
Speaker 1:Acute diarrhea does often respond to antibiotic therapy. Cyprophyloxacin is the classic medication for treatment of Traveller's Diarrhea. However, fluoroquine alone resistance is on the rise and azithromycin is a strong alternative. Still, because most cases are self-limited, because some are due to viruses, and because antibiotics can cause their own slew of GI problems, there's no real indication for treatment. Additionally, if there's blood in the stool or fever, antibiotics are contraindicated as they can cause complications when treating enterohemorrhagic E coli, also known as e-HEC, causing such problems as hemolytic uremic syndrome and kidney failure. An alternative to antibiotics is to treat the diarrhea itself with Loparamide, an opioid medication that's poorly absorbed in the gut, which thus makes it possible for use for its side effect, which is constipation. Loparamide is also contraindicated in bloody diarrhea or diarrhea with fever, as these symptoms suggest a toxin-forming bacteria, and in these cases it's better out than in. Dosing for Loparamide is a 4mg oral loading dose and then 2mg PO for each loose stool, to a maximum of 16mg per day in adults.
Speaker 1:Persistent Traveller's Diarrhea. This is a deep, deep hole, no pun intended. There are essentially three main causes of persistent diarrhea, which is anything around 14 days or longer. The first is a persistent infection or a secondary infection after an initial infection. Some infectious causes are responsible for longer courses of illness, namely parasites like GRD-iasis, which should be strongly suspected and tested for in any diarrhea lasting longer than 14 days. The second is what's called post-infectious phenomena. Some infections can cause gut dysregulation and subsequently, difficulty digesting fructose, lactose and other food compounds. This is also something that can result from taking antibiotics and another reason to think carefully before using them. Third is underlying GI disease. Interestingly, underlying chronic GI diseases can be unmasked by an acute diarrheal infection, including celiac, spru, crohn's disease and ulcerative colitis. There are even some theories that inflammation in the setting of diarrhea can lead to the initiation or development of these diseases.
Speaker 1:Back to the case. Would antibiotics work for my friend? Perhaps, if he is one of the predominance of cases caused by bacteria, but his diarrhea is likely to resolve on its own, antibiotics could cause their own problems, including a malabsorptive syndrome or C difficile infection. Sure, if he continues to have diarrhea beyond 14 days, then things get more interesting and there might be a reason to start thinking harder and considering some testing, mostly for parasites like Giardia. In the meantime, I'll try some LeParamide. Did I say that? Yeah, this patient is me.
Speaker 1:Thank you, as always, for listening to Wilderness Medicine Updates. I always appreciate your attention and time, and if you have a friend, a relative, a fellow resident, a fellow, a paramedic, a nurse who you think would benefit from listening to this podcast, please do share it. As always, reviews on iTunes are much appreciated, as that helps to get this podcast out. I hope you enjoyed this video. If you did, please like, share and subscribe to my channel and, as always, reviews on iTunes are much appreciated, as that helps to get this podcast out to more people like yourselves. Finally, if you happen to listen to the last Fast Push episode, number 2.1, called Safety Third and you were one of the lucky people who got the original version in which my voice sounded like a chipmunk thanks for your patience Something went totally sideways in post-processing there and thanks to my dad, jeff, who pointed that out to me so I could fix that and get that back out to you all.
Speaker 1:This is a learning curve for me and I hope you don't mind the ride. So, as always, don't hesitate to reach out at WildMedUpdates on Twitter or reach out to me at WildernessMedicineUpdates at gmailcom with any questions, episodes you'd like to hear, feedback or thoughts. Until next time, stay fit, stay focused and have fun.
