Dr Holly Andrews / Anaesthetics CT3 / Evidence Explorer lead / Cornwall
Dr James Spittle / Foundation Doctor / South Yorkshire
Dr James Spittle BSc (Hons) BMBS.
When not working as a Foundation Doctor in South Yorkshire, James spends most of his time cycling and climbing. Whilst studying in Exeter he helped set up and run the wilderness medicine and anaesthetic societies as well as providing medical cover for a number of events including Glastonbury festival. He has a keen interest in pre-hospital, mountain and sports medicine/physiology and has been invaluable in the production of the expedition section of this winter edition of Evidence Explorer.
- Introduction to Papers of the Quarter
- Expedition and Wilderness Medicine
- Global Health and Humanitarian Medicine
- The long-list extras
Welcome to the Winter edition of Evidence Explorer. This quarter we’ve had Dr James Spittle on board scouring journals in the expedition and wilderness sector. He’s picked out some interesting reads with thought-provoking ideas that may just spark changes in your own practice, or build ideas for study and research. The global health journals were packed with hard-hitting articles both before and after COP-27 in the latter part of 2022, and we’ve picked a few of these for summary alongside some other important reads. This latter section has been particularly fruitful over the past months and so we’ve included the long-list footer again which is worth a scan.
As always, do get in contact if you’d like to be involved with contributing to future releases of this feature – we always look forward to hearing from you.
We have a broad range of topics summarised in the expedition section this quarter; from trying to answer questions on how best to clean wounds, to discussing the benefits and development of using whole blood transfusions in pre-hospital resuscitation and stabilisation. The esteemed Dr Basnyat and his team have produced evidence-based statements on teaching and expanding knowledge for the layperson on illness at altitude which James has summarised below, along with an interesting letter about new, lightweight kit in a mountain clinic.
Strengthening Altitude Knowledge: A Delphi Study to Define Minimum Knowledge of Altitude Illness for Laypersons Traveling to High Altitude
Remco R. Berendsen, Peter Bärtsch, Buddha Basnyat, et al. High Altitude Medicine & Biology. Dec 2022
Poor knowledge of altitude illness is known to accompany an increased risk of the spectrum of acute mountain sickness, however, few if any guidelines target the layperson. This paper aimed to fill that void, seeking expert consensus on the essential knowledge required for people planning to travel to high altitudes. Utilising a Delphi method, involving three rounds and two expert groups, it creates 28 essential knowledge statements in five categories (altitude physiology, sleeping at altitude, AMS, HACE, and HAPE). These statements can be incorporated into our teaching and practice, empowering our teams/clients to look after themselves, or indeed filling in gaps in our own knowledge. A worthwhile read.
A survey to define the pre-hospital blood resuscitation practices of UK Air Ambulances
Ed Barnard, Laura Green, Tom Woolley, et al. Emergency Medicine Journal. December 2022
Prehospital use of whole blood for ill and injured patients during critical care transport
Philip S. Nawrocki,Brendan Mulcahy,Michael Shukis, et al. Air medical journal. September-October 2022.
Those of us working in the UK pre-hospital setting will know crystalloids and/or packed red blood cells (PRBCs) have been used for a while now. This first paper shows UK Air Ambulances (AAs) carry a mean of 2.6 (±0.9) red cells and 3.0 (±1.1) plasma units. Also of note, they found the mean prehospital time (999-call to hospital arrival) to be 92.2 (±18.6) minutes.
There is a growing argument for the use of whole blood (WB) in the pre-hospital setting. This would provide patients with platelets (which WB contains), which given their difficulty to store (5-day shelf life, 20-24 degree storage, agitation requirement) are not carried as a separated component by AAs. It could also be seen as more efficient with only one blood product being transfused, making things simpler and notably lighter.
Our second paper comes from the United States and shows that WB can be used in the prehospital setting, as well as being associated with low incidences of adverse events such as transfusion reactions.
This leads to us highlighting a new clinical trial which commenced in December 2022 and will be running over a two-year period. The Study of Whole blood In Frontline Trauma (SWIFT) trial will involve 10 UK air ambulance trusts. It will compare outcomes such as survival and amount of blood needed 24 hours after injury between patient groups receiving PRBC with those receiving WB. One to watch out for in a future evidence explorer…
Letter to the Editor: A Compact and Lightweight X-Ray Unit in a Mountain Clinic
Rikiya Kameno, Yutaka Igarashi, Kunio Hirai et al. High Altitude Medicine & Biology. December 2022.
Those of us who have worked in mountain clinics may be more familiar with the equipment (or lack thereof) available in such an environment. This intriguing letter is the first to detail the availability of compact and lightweight x-ray units at high altitude using a rechargeable machine weighing roughly three and a half kilograms. Could a portable machine overcome the previous barriers to imaging such an environment creates, or does it just add to our ever-growing kit list? This machine was used to image a number of anatomical areas including the chest, abdomen, joints (shoulder, wrist, knee), clavicle, and lumbar spine. With trauma and respiratory diseases being common to mountain clinics this tool could be a significant addition to the arsenal; could it help identify those in need of a hastier extraction or simply add time to doing so?
Water for wound cleansing
Fernandez R, Green H, Griffiths R et al. Cochrane database systems review. September 2022
Normal saline is often used for cleaning wounds as it is a sterile, isotonic solution and therefore not thought to interfere with the normal healing process. Unfortunately saline is relatively expensive, difficult to transport and at times hard to come by, therefore not ideal for the prehospital setting. Yet it is unclear whether there is any significant benefit over using tap water or indeed any other more available fluids, this Cochrane review tried to answer this question.
It looks at 13 trials with a total of 2504 participants (the majority, 2204, being in the tap water versus normal saline comparison), aged between 2 and 95 years, suffering from open fractures, surgical wounds, traumatic wounds, anal fissures and chronic wounds. Comparisons included care with no cleaning, normal saline (0.9%), tap water, cooled boiled water and distilled water. Outcomes assessed included patient satisfaction, pain, wound healing, and infection rates.
Unfortunately, the authors were unable to come to firm conclusions as across all outcomes the evidence identified was mostly of low or very low certainty. Of interest there was no strong signal of harm from using tap water in place of saline, paving the way for further large, well-designed, randomised controlled trials in order to answer this question once and for all.
Three major topics sprung out to us this quarter in the global health sector with multiple publications on each.
Firstly we present two distinct articles discussing the relationship between colonialism and health, how historical rhetoric is shaping today’s practice, and more importantly giving helpful advice on how we can begin to undo the destructive health structures of a colonial past.
We then shift focus to the interaction of planetary health and human health and summarise two articles released around the period of the COP27 climate conference.
Finally, we have two excellent publications on the subject of antimicrobial resistance, the presentation of an interesting large-scale study on the interaction of poverty and antibiotics, and another detailing how IT systems are paving the way to a brighter future for use of antibiotics in LMICs.
Dismantling and reimagining global health education
Gichane W, Wallace D. Global Health Action. Oct 2022
Many of us interested in a career in global health will pursue higher education on the subject but with over 95% of master’s programmes located in high-income countries, does that education accurately and fairly represent global health in its truest and most equal standing? In this thought-provoking article, assistant professors Margaret Gichane and Deshira Wallace discuss the biased admissions criteria and curriculum and the potential immense harms of the student placements that occur as part of global health masters programmes in place today. They go on to say that worryingly, the current education set-up is contributing to the legacy of the colonial tropical medicine that stood before. They present their recommendations as succinct bullet points at the end of their piece. Perhaps an idea to cross reference these points to any global health programme you are involved with or due to start. Speak up and ask these difficult questions to those who head up the courses and together we can continue to strive to improve global health education for the globe.
Shifting paradigm from biomedical to decolonised methods in Inuit public health research in Canada: a scoping review
Belaid L, Budgell R, Sauve C. BMJ Global Health. Nov 2022
This large scoping review expanded on the decolonisation topic focusing particularly on the Inuit communities in Canada. The National Inuit Strategy on Research (NISR) advocates for self-determination in research and has been doing so for some time but sadly found poor results. Only 76 out of 356 studies involving Inuit communities showed any community engagement in their methodologies, and worse still there was limited evidence across all studies that their results were translated into culturally appropriate and beneficial public health interventions. The article goes on to give disappointing statistics from across a vast array of studies undertaken with the Inuit population showing poor compliance with standards set by the NISR. If you have time for nothing else – the introduction of this article is well worth a read. It explores evidence and explains the term ‘cultural safety’ and how in fact, research can and does have deleterious effects on local indigenous communities when undertaken without full consideration and thorough involvement with those it affects.
COP27 climate change conference: urgent action needed for Africa and the world
Chris Zielinski et al. BMJ Global Health. Oct 2022
Glance at any journal related to Global Health in the run-up to COP27 last year and you will see this article published. The BMJ, The Lancet Global Health, and Journal of Global Health are among the giants in the publishing world to share this article, and in fact, it comes as a consensus statement from 231 health journals and their editors. Clearly an incredibly important topic, the news of which needs to be disseminated. The authors open by reminding us that pledges made in the 2015 Paris agreement to provide climate finance to LMICs are yet to materialise and call for urgent action from COP to deliver climate justice to vulnerable countries. They go on to state the shocking stats related to CO2 emissions. Since the industrial revolution, North America and Europe have produced 62% of global emissions and Africa only 3%. Yet arguably Africa is feeling some of the most intense pressures from the climatic consequences. Drought, severe cyclones and flooding seen from extremes of weather are forcing migration, loss of shelter, hunger and malnutrition. Changes in vector ecology and damage to environmental hygiene are seeing a surge in diseases such as malaria and dengue fever, and water-borne diseases and diarrhoeal illnesses are on the rise from reducing water quality. This is a succinct, emotive and highly impactful statement – a must-read for anyone looking for an introduction to the inequalities in health and the environment.
The outcome of COP27 thankfully was positive in this regard with the development of the ‘COP27 loss and damage fund’. Head here for a summary from the UN on how they hope this will be instituted.
Sustaining planetary health in the anthropocene
Shilu Tong, Hilary Bambrick. Journal Of Global Health. Nov 2022
The World Health Organization (WHO) recently estimated that more than 13 million deaths occur annually due to avoidable environmental causes including climate change, air pollution, and other exposures. This article expands on the cause of these arguably unavoidable deaths and talks of the ‘anthropocene epoch’ – the era that we find ourselves living in where the presence of human life is having a significant impact on planetary health ecosystems. The authors call for urgent action to improve planetary health and propose 4 main strategies. Understanding the major drivers of global change and implementing intervention policies to slow down or halt these changes is their first point. They name consumeristic behaviours and inappropriate use of technology as two priorities to tackle. As the fallout of COP27 has highlighted, the authors of this paper also agree that planetary health can only be sustained if socioeconomic inequities and environmental injustice are lessened. They also mention indigenous cultures and how we must see ourselves as part of a global village to learn planetary stewardship from all. They conclude with a powerful final paragraph stating that collective action must be built across generations as planetary health will not be solved within one generation, and we must build sustainable action that continues, is handed over and built upon.
The role of multidimensional poverty in antibiotic misuse: a mixed-methods study of self-medication and non-adherence in Kenya, Tanzania, and Uganda
Green D, Keenan K, Fredricks K et al. The Lancet Global Health. Jan 2023
Antimicrobial resistance is a growing threat to global public health and it is widely accepted that antibiotic misuse and overuse are the greatest drivers. This includes behaviours such as incomplete adherence, use without a prescription and the indiscriminate use of broad-spectrum preparations. It has been proposed that poverty in its multiple dimensions has an important role to play in this resistance acceleration, but evidence of this relationship was sparse. This unique study aimed to plug that gap and produced some interesting results. The authors here measured poverty in a more representative, multi-dimensional and holistic manner than previous studies have. Contrary to both previous studies and public discourse they found that antibiotic non-adherence and self-medication were least common in those living in the most deprived settings. They go on to discuss the likely reasons for this and unpick how socioeconomic hierarchy and education impact antibiotic use behaviours. They provide evidence that it is the structural barriers of poorly resourced and inaccessible healthcare provision that is the driving force behind misuse rather than individual education or health beliefs. A really interesting read. Skip to the discussion if you are time-poor, the authors present their findings in a thought-provoking and digestible manner useful to all.
An additional editorial on the same topic:
Poverty and antibiotic misuse: a complex association
Obua C, Talib Z, Haberer J. The Lancet Global Health. Jan 2023
Strengthening digital monitoring of antibiotic resistance in low-resource settings
Yogita Thakral, Sundeep Sahay, Arunima Mukherjee. Journal Of Global Health. Oct 2022
More on antibiotic resistance here with the presentation of a novel solution to the growing public health concern. The authors open with a powerful quote from the former secretary-general of the World Health Organization, M Chan, who describes antibiotic resistance as a “slow-moving tsunami” threatening “the end of modern medicine as we know it”. They then go on to discuss the details of how they designed and implemented an antibiotic resistance monitoring programme in India where the scale of the problem is particularly acute. They conclude by detailing how their systems can and will be adapted for multiple settings. An interesting and succinct read relevant for those who are interested in technology and how it can be used simply for major public health benefits globally.
Here we present the articles that are definitely worth a read for those with a little more time on their hands:
Expedition and Wilderness Medicine
Importance of Trail Safety Education for All Fitness Levels
Ryan G. Wilderness Medicine Magazine. December 2022.
Trends in SOS Incidents from Satellite Communication Devices
Thurman J. Wilderness Medicine Magazine. December 2022.
Temperature measurement of babies born in the pre-hospital setting: analysis of ambulance service data and qualitative interviews with paramedics
GoodwinL, Voss S, McClelland G, et al. Emergency Medicine Journal. November 2022
Differences in the thermal properties and surface temperature of prehospital antihypothermia devices: an in vitro study
Dvir E, Epstein D, Berzon B. Emergency Medicine Journal. November 2022
Perceptions Among Backcountry Skiers During the COVID-19 Pandemic: Avalanche Safety and Backcountry Habits of New and Established Skiers
Valle E, Cobourn AP, Spencer JH et al. Wilderness and Environmental Medicine Journal. December 2022
Wilderness-Telemedicine, a New Training Paradigm
Lafleur J,Sikka N, Hood C. Wilderness and Environmental Medicine Journal. December 2022.