Contents
- Introduction and Collaborators
- Global Health and Humanitarian Medicine Section
- Expedition and Wilderness Medicine Section
- Want to get involved?
At last, the crocuses are out and the sun is shining. Here at Adventure Medic we can’t wait for the spring to arrive, but let’s take a moment to back over all the wonderful research that came out this winter. Once again, thank you to our fabulous collaborators who have taken the time to comb through over twenty journals to find some of the best articles out there.
Dr Lydia Potter is an F3 doctor living in Conwy, Snowdonia. She is currently doing a less-than-full-time Junior Clinical Fellow job in Emergency Medicine and Paediatrics in Ysbyty Gwynedd, Bangor. In her spare time, she is part of the RNLI boat crew in Conwy and teaches on Unique Expeditions’ UK courses. She has experience providing medical cover for expeditions, ultra-endurance races, sports matches and festivals in the UK and abroad. She is working towards her Mountain Leader qualification. When not at work, you can find her open-water swimming, hiking, climbing or bouldering in Eryri National Park. After her F3 year, she is hoping to enter EM ACCS, continue doing expedition medicine work, and eventually sub-specialise in PHEM.
Dr Klara Weaver is an acute medical and emergency medicine doctor currently practicing in the highlands. She has been involved in expedition medicine for the past five years from Antarctica to Mongolia and everywhere in-between. She is looking forward to starting GP training in the Highlands and in her spare time is a passionate mountaineer and lover of cold places.
Global Health and Humanitarian Medicine
In global health and humanitarian medicine we present eight papers from across the world. We begin with an evidence-based call for the climate crisis to be treated as a global health emergency, an unflinching statement piece published by an authorship group of 200 health journals. From there, we journey to the Philippines to discuss a randomised controlled trial from Reñosa et al., testing a novel initiative to improve vaccination compliance.
We then dive into an exploratory analysis by Koua et al., regarding the trends of public health emergencies over the last 22 years in the World Health Organisation (WHO) African region. From Bangladesh we look at a Lancet article by Levine et al., comparing tools for assessing dehydration status in patients with acute diarrhoea. All health systems must be financed securely, and Nabyonha-Orem et al. have carried out a scoping review of innovative health financing mechanisms in the WHO African region to assess methods to address underfunding. Bartlett et al. carried out a systematic review to determine the level of critical care delivery available in low- and low-middle-income countries according to the literature.
Menstrual health is vital and Plesons et al. developed a fantastic set of research priorities from consultative processes with relevant stakeholders in the context of global health. Our final stop is the conflicts in Syria where a qualitative analysis from Abbara et al. looks at the impact of attacks on the personal and professional lives of health workers.
Time to treat the climate and nature crisis as one indivisible global health emergency
Zielinksi C (on behalf of authorship group of 200 health journals). BMJ Global Health (published simultaneously in multiple journals). Date of issue: 25th October 2023
The article’s title says it all. The time has come to recognise the global health emergency that is rapidly developing as a result of the climate crisis. This statement piece, authored by over 200 health journals, has been published simultaneously in multiple periodicals. It urges political leaders, the United Nations and health professionals worldwide to recognise the severity of the environmental crisis in terms of global health. Additionally, the paper calls on the World Health Organisation to declare the climate and nature crisis a global health emergency by their assembly in May 2024.
A key point in this piece is that climate change and biodiversity loss should be treated as part of the same complex problem and not separate challenges. There is no doubt of the catastrophic harm to health that is arising from the loss of nature: shortages of food, water, increased poverty, air pollution, increased spread of infectious diseases, and millions of climate refugees due to extreme weather events and lack of shelter. This short but powerful article is definitely worth a read to fully appreciate the true impact on health from the climate and nature crisis, and will fire up you up to become the advocates that our planet and patients need.
Human-centred design bolsters vaccine confidence in the Philippines: results of a randomised controlled trial
Reñosa M, Wachinger J, Guevarra J et al. BMJ Global Health. Date of issue: 21st October 2023.
Vaccination non-compliance is a threat to public health, leading to outbreaks of preventable diseases that can tear through populations. In the Calabarzon region of the Phillipines, Reñosa et al. used a human-centred design to create a story-based video intervention to address vaccine hesitancy within Filipino families and community leaders. This was authorised by the Department of Health. The intervention was a 5-minute cartoon with narrated stories of Filipino families, with concerns about vaccinations, learning the benefits of vaccinations, subsequently vaccinating their children and creating a strong community with immunisation against measles. The design process was 12-15 months, and the video was created with Filipino cartoonists, local voice actors, and community experts. It was named ‘Salubong: Building Vaccine Confidence’. ‘Salubong’ is a Filipino term meaning the welcoming of someone into one’s life. The phrase in this context referred to welcoming of vaccines into the community.
Once the video was created, a randomised controlled trial was carried out with 719 caregivers of children to test the video against a control video (a ‘How to fight COVID-19’ video produced by the Phillipines Department of Health). The cohort included both urban and rural residents. The participants were asked questions about vaccine attitudes before and after the videos. The results were encouraging, with 62% of the intervention group improving their vaccine attitude scores versus 37% of the control group (p<0.001). This study shows the potential of realistic narratives to improve vaccination confidence in areas with vaccine hesitancy to improve public health. The intervention video is available for viewing at https://www.youtube.com/watch?v=M8nEj5G9Iuc.
Trends in public health emergencies in the WHO African Region: an analysis of the past two decades public health events from 2001 to 2022
Koua EL, Njingang JR, Kimeyi JP et al. BMJ Global Health. Date of issue: 9th October 2023
Africa has the highest burden of public health emergencies globally. This paper from the WHO Regional Office for Africa is an exploratory analysis of the public health data over the past 22 years in this region. The aim was to explore the trends to inform public health strategies and develop tools to improve the response to these events. The WHO divides the world into six regions for the purposes of reporting, analysis, and administration. The WHO Africa region includes 47 member states, covering the majority of the continent, but excluding Western Sahara, Morocco, Tunisia, Libya, Egypt, Sudan, Djibouti and Somalia (all of which are part of the Eastern Mediterranean Region).
The results of the analysis show that between 2001 and 2022, there were 2234 public health events, with an average of 102 annually during the 22-year period. 92% of the events classed as ‘substantiated’ were infectious diseases (n=1730) and 5% (n=92) were humanitarian crises (e.g. natural disasters or conflict). The number of zoonotic disease outbreaks was found to have significantly increased (87% increase) over the past two decades. The average annual outbreak was 26; however, the highest number of outbreaks was recorded in 2022 (n=55). Recent studies suggest climate change is exacerbating the infectious diseases burden by bringing people and disease-causing organisms closer together. This paper comments on this suggestion, agreeing that there is a possibility of this increase being an indirect reflection of climate change. For the clinician with an interest in African public health, we would advise reading this paper in full to appreciate the geographic patterns and changes over time of each zoonotic disease.
A comparison of the NIRUDAK models and WHO algorithm for dehydration assessment in older children and adults with acute diarrhoea: a prospective observational study
Levine AC, Gainey M, Qu K et al. The Lancet Global Health. Date of issue: November 2023.
Diarrhoea is the eighth leading cause of mortality worldwide and the fifth within low-income countries. Death occurs due to severe dehydration, therefore rehydration is the most vital step in improving morbidity and mortality. Despite the clear importance of being able to accurately assess one’s hydration status, no validated tools exist to assist clinicians in assessing the severity of dehydration in older children and adults. This study by Levine et al. aimed to validate the clinical decision support tool and scoring system NIRUDAK (Novel, Innovative Research for Understanding Dehydration in Adults and Kids).
This scoring system is a 14-point system to assess the severity of dehydration in older children and adults with acute diarrhoea. Points are scored for skin pinch (rapid, slow, very slow), eye level (normal, sunken), respiration depth (normal, deep), urine output (normal, decreased, minimal/none) and radial pulse (strong, decreased, absent). This prospective cohort study took place in Bangladesh over one year and included 1580 patients over 5 years old with acute diarrhoea. All patients were scored using NIRUDAK and the WHO IMIA algorithm (current WHO guidelines) and were weighed every 4 hours to determine their percentage weight change with rehydration. Accuracy and reliability were then assessed using the ordinal c-index and the intraclass correlation coefficient. This study has validated the NIRUDAK model and demonstrates the tool predicts a patient’s dehydration status with greater accuracy and reliability than the current WHO IMAI algorithm. This tool is therefore a useful addition to the global health clinician’s toolbox when assessing the hydration status of a patient with acute diarrhoea.
The nature and contribution of innovative health financing mechanisms in the World Health Organisation African region: a scoping review
Nabyonha-Orem J, Christmals CD, Addai KF et al. Journal of Global Health. Date of issue: 15th November 2023.
Medical provision is often only available with substantial funding. A second paper this quarter out of the WHO Regional Office for Africa is this scoping review by Nabyonha-Orem et al. analysing the nature, type, and factors that affect the implementation of novel financing mechanisms within the WHO Africa region. This scoping review searched the literature from 2010 to 2022, including government policy documents, reports, and published studies regarding health financing for all population groups in the WHO African region. 41 documents were included in total, describing 10 innovative financing mechanisms (tobacco tax, alcohol tax, sugar tax, airline levy, oil/gas/minerals, HIV/AIDS trust fund, social impact bond, financial transactions tax, mobile phone tax, and equity funds) within 43 of the 47 WHO African region countries. A summary table is available within the paper showing which method/s each country utilises. Whilst this paper is not medical, for any clinicians with global health aspirations, it is an interesting read to appreciate the complexities of health financing.
Critical care delivery across healthcare systems in low-income and low-middle-income country settings: A systematic review
Bartlett ES, Lim A, Kivlehan S et al. Journal of Global Health. Date of issue: 1st December 2023
Provision of good quality critical care services is a vital part of any healthcare system. In addition to resource limitations, low- and low-middle-income countries have a greater burden of critical illness and therefore a higher morbidity and mortality rate from these. This systematic review by Bartlett et al aimed to identify the range of critical care interventions and services provided within low- and low-middle-income countries. The literature search was from 2008 – 2020 and identified 1620 studies in total from relevant countries (low- and low-middle-income countries as defined by the World Bank classification). This has allowed a comprehensive systematic review to be produced detailing the critical care interventions available within these countries according to the literature.
Research priorities for improving menstrual health across the life-course in low- and middle- income countries
Plesons M, Torondel B, Caruso BA et al. Global Health Action. Date of issue: 27th November 2023.
This study from the Global Menstrual Collective’s Research and Evidence Group by Plesons et al. aimed to identify research priorities for menstrual health in low- and middle-income countries. 82 individuals from stakeholder groups with expertise in menstrual health were asked to identify research priorities to guide improvements in menstrual health. The results showed that top research priorities were not limited to one area of expertise, but were distributed across a variety of topics, including menstrual pain, socio-cultural factors, menstrual products, and participation in school/work. This indicates research gaps exist throughout a number of domains related to menstrual health. A large number of research questions were also identified regarding ‘understanding the problem’, showing us that knowledge gaps remain regarding the menstrual experience, limiting our understanding of how to assess and meet the requirements of those menstruating in these countries. It is clear significant work is required to improve menstrual health in low- and middle-income countries, but we hope that the identification of these research priorities can be utilised by policy makers, researchers and funders to guide studies in this area.
“Actually, the psychological wounds are more difficult than physical injuries”: a qualitative analysis of the impacts of attacks on health on the personal and professional lives of health workers in the Syrian conflict
Abbara A, Rayes D, Tappis H et al. Conflict and Health. Date of issue: 9th October 2023.
Healthcare staff working in regions of conflict face substantial risks to their personal and professional lives, including risk of death. In Syria, violence against healthcare facilities has been frequent, with the Syrian American Medical Society facing over 222 attacks on their programmes since 2015. This qualitative analysis recruited Syrian health workers (in clinical and administrative roles) who had experienced attacks against their facility between 2013 and 2020. Open-ended, semi-structured interviews were conducted to explore their experiences and views.
From this study, it is clear that attacks on Syrian healthcare workers have left significant, complex and long-lasting impacts. Coping mechanisms discussed were behavioural, cognitive, emotional and religious, the latter often being very important for participants. Interviewees also discussed the solidarity with their colleagues and a responsibility they feel towards their community. Mitigating attacks on healthcare workers is an important, but deeply complex, issue. Organisations should consider their support mechanisms to help staff cope with the danger, stress and moral injury of working in these settings. For the interested reader, the full text article contains quotes from interview transcripts. We recommend reading these to fully appreciate the themes discussed in the paper.
Expedition and Wilderness Medicine
There is plenty in this quarterly evidence explorer to evoke your interest. From the mountainside to outer space, there is no place that humans and medicine will not go. We evaluate termination of CPR during mountain rescue efforts, the use of drones in search and rescue, Selective Serotonin Reuptake Inhibitors (SSRIs) in space, and ultrasound scanning in austere environments. We hope you enjoy this selection of articles.
Notable mention – High Altitude Medicine and Biology ran a special edition on ‘Women at Altitude’, however the results of the majority of the papers (n=4) simply showed a massive data gap for women at altitude in a variety of clinical settings.
Termination of Cardiopulmonary Resuscitation in Mountain Rescue: A Scoping Review and ICAR MedCom 2023 Recommendations
Viktor Lugnet, Miles McDonough, Les Gordon, Mercedes Galindez, Nicolas Mena Reyes, Alison Sheets, Ken Zafren, Peter Paal. High Altitude Medicine & Biology. Date of Issue: December 2023.
It is a situation no expedition medic wants to find themselves in, but in remote environments and extreme conditions cardiac arrest is an important scenario to consider when planning a trip. Building on the 2012 recommendations, Lugnet et al add new, evidence-based advisories around the use of mechanical chest compression devices, point of care ultrasound (POCUS), relevance of water temperature to resuscitation in drowning, and criteria for burial time in avalanche rescue.
Lugnet et al, in line with the UK Resusitation Council, cautions against routine use of mechanical chest compression devices, but acknowledges the benefit of their use in prolonged or strenuous rescues, where manual compressions are less likely to remain consistent and effective. POCUS is to be used, where available, to aid decision making in termination of resuscitation. Regarding drowning, the authors recommend withholding CPR in a drowning victim with a submersion time >30 minutes in water >6°C or >90 minutes in water <6°C. Finally, regarding avalanches, the advice is to provide full resuscitative efforts for an avalanche victim with a core temperature <30°C with a patent airway and without lethal injuries, and transport to an extracorporeal life support capable centre. CPR should not be commenced in those in asystole and obstructed airway, with a burial time of >60 minutes.
Use of Unmanned Aerial Vehicles (UAVs) in Wilderness Search and Rescue (WSAR) Operations: A Scoping Review
Craig Vincent-Lambert, , Anje Pretorius, BHS EMC, and Bernard Van Tonder, M EMC. Wilderness & Environmental Medicine, Volume 34, Issue 4. Date of Issue: December 2023
Love them or hate them, drones are everywhere. But with an increasing pressure on WSAR services, and an improvement in drone technology, graphics and durability, could they become a valuable tool in the SAR toolkit?
Vincent-Lampbert et al conduced a scoping review of the literature, finding 21 sources that focused on UAVs in WSAR operations. Benefits described included the ability for UAVs to perform pre-programmed search patterns, thermal imaging, reduction in time to locate, and the ability of UAVs to tackle terrain deemed too risky for humans. It was recognised by the authors that limitations include drone-specific software, user fatigue, obscured view, weather conditions, and also the vast differences in average flight times between models. The conclusion drawn by the author is that UAVs are a useful tool that can aid but not replace human search efforts. They called for more specific language to differentiate “drones” from UAVs in the SAR environment as a marker of WSAR capability.
Selective Serotonin Reuptake Inhibitors and Other Treatment Modalities for Deep Space Missions
El-Khoury, Bashir B.; Ray, Kristi L.; Altchuler, Steven I.; Reichard, John F.; Dukes, Charles H. Aerospace Medicine and Human Performance, Volume 94, Number 11. Date of Issue: November 2023
Modern humans are more stressed and anxious than ever, despite improved mental health awareness and de-stigmatisation encouraging more people to act positively for their mental health. Serotonin reuptake inhibitors (SSRIs) are useful treatment for depression and anxiety. However, with space tourism on the 25-50 year horizon, and gathering data on humans in space, it may be time to call it quits on SSRIs when out of Earth’s atmosphere.
SSRIs have well documented side effects with longer term use, including weight gain, sleep disturbance and a moderate increase in bleeding risk (especially in conjunction with NSAIDS). However, as highlighted by this meta-analysis by El-Khoury et al, the literature shows a troubling link between long term SSRI use and decrease in bone mass. Bone loss in spaceflight is already a known phenomena, attributed mostly to microgravity, high sodium and protein intake, increased ambient CO2 levels and reduced sun exposure. El-Khoury et all raise the question whether SSRI’s should be allowed in the spaceflight population, and suggest potential alternative therapies such as Transcranial magnetic stimulation, cranial electrotherapy stimulation, and off-label ketamine prescription, along with managing the initial risk of the selected population.
Ultrasound (US) Gel Alternatives in an Austere Environment
Julia DeLuca, BS, Daniel Doynow, DO, MPH, Jacob Grondin, BS, Ellen Lockhart, MS, and Stephanie Lareau, MD. Wilderness & Environmental Medicine, Volume 34, Issue 4. Date of Issue: December 2023
Point of care ultrasound is breaking into the prehospital and wilderness medicine scene in an increasing variety of ways. With advances in probe portability, interface with existing smart phones, and telemedicine technology, they seem an inevitable part of the wilderness medic’s toolkit. However, on expeditions, pack space and weight can be limited. DeLuca et al, used survey based data to rate commonly found mediums that could substitute for ultrasound gel, and to evaluate whether control picture quality was good enough for clinical diagnosis. They found that alternatives, including vegetable oil (88.5%), aloe vera (80.9%), and shampoo (69.2%), were rated equal or better quality US mediums when compared to traditional gel, and were sufficient for diagnosing acute pathologies. Whilst this may not change the face of expedition medicine as we know it, knowing MacGyver workarounds for POCUS could save you space and stress in remote field care.
