Objective.—To study the scope of clinical activities and the postoperational attitudes of mental health professionals responding emergently to a mass urban evacuation.

Methods.—Eleven mental health care providers participating in a reception team for medical evacuees after Hurricane Katrina were asked to complete a survey seeking data regarding cases encountered, psychopharmacologic interventions, and mental health support for evacuated medical personnel. Participants rated their levels of agreement with statements characterizing various aspects of the clinical experience.

Results.—Nine of 11 providers returned surveys, for a response rate of 82%. Among 35 evacuees requiring immediate psychiatric consultation, acute stress disorder and dementia, equally represented among these cases, accounted for half the diagnoses. Medication interventions were relatively uncommon. Consultants provided mental health support to 14 evacuated medical professionals. Although somewhat uncertain about their role, psychiatric consultants strongly agreed that they would be willing to serve in future disaster operations of this type.

Conclusions.—In major disasters, psychiatric consultants are likely to play a critical role in providing emergency mental health services for both medical evacuees and evacuated medical professionals.

Background.—Every year over 22 000 people raft the Colorado River through the Grand Canyon in Arizona. Since 1994, over 400 rafters in 6 separate outbreaks have become ill with norovirus while rafting this stretch of the river.

Objectives.—To assess potential causes of these outbreaks, Colorado River water, water from nearby wastewater treatment plants, and a drinking water source were sampled and tested for norovirus and other water quality indicators.

Methods.—Colorado River water was collected and sampled during the 2004 rafting season. Water from wastewater treatment plants near the Lee's Ferry launch site and drinking water from the Lee's Ferry launch site were also examined during the 2003 and 2004 rafting seasons. Stool samples from ill rafters and composite stool samples from onboard toilet-cans were tested for the presence of norovirus during the 2003 and 2004 outbreaks. Parameters examined included the following: norovirus by reverse transcriptase– polymerase chain reaction, coliforms, Escherichia coli, temperature, turbidity, and pH.

Results.—No norovirus was detected in the Colorado River during the 2004 field sampling. Norovirus was detected in the Glen Canyon Dam Wastewater Treatment Plant on one occasion in 2004. Drinking water from the Lee's Ferry launch site was negative for norovirus in 2003, and Colorado River water from the Lee's Ferry launch site was negative for norovirus in 2004. In 2003, 3 of 10 stool samples from ill rafters or onboard toilet-cans were positive for norovirus. Neither of 2 stool samples collected in 2004 was positive for norovirus.

Conclusions.—Colorado River water tested during nonoutbreak periods was negative for norovirus, indicating that there is not an ongoing high level of norovirus contamination in the river. No source or sources of contamination could be identified from the testing. Potential sources of norovirus outbreaks among rafters include drinking contaminated river water, consuming contaminated foodstuff, rafter importation of the virus and subsequent person-to-person spread, and contaminated fomites, campsites, or equipment. It is likely outbreaks are the result of more than one source of norovirus, and the exact source remains unknown for several outbreaks.

Objective.—To document the prevalence of hypothermia in a mass participation endurance open water swimming event and to determine demographic and individual factors that may predict failure to finish the race and hypothermia.

Methods.—A prospective observational study in competitors in a 19.2-km open water swimming race in Perth, Western Australia. Pre-race information collected included age, sex, training and race experience, medical history, and body mass index (BMI). Body temperatures at 5 minutes postrace were measured using an equilibrated oral- or rectal-reading low-range glass mercury thermometer. Logistic regression was used to develop models predicting hypothermia (defined as a temperature of <35°C) and failure to finish the race.

Results.—One hundred and nine competitors (70 male, 39 female) with a combined mean age of 38.4 ± 12.1 years were studied. Hypothermia was the most common race-related illness, identified in 26 of 35 swimmers screened as requiring temperature measurement, including 5 who required short-stay hospital care and 2 who required critical care transfer. Longer race duration (odds ratio [OR] 1.77, 95% CI 1.10–2.84, P = .018) was associated with an increased risk of hypothermia, and higher BMI (OR 0.57, 95% CI 0.41–0.79, P = .001) was associated with a decreased risk of hypothermia. Weak predictors of failure to finish were age (OR 1.06, 95% CI 1.01–1.11, P = .012) and hours spent training (OR 1.08, 95% CI 1.01–1.16, P = .025).

Conclusions.—Hypothermia is a common condition affecting mass participation long-distance open water swimmers. Increased BMI appears to be protective against hypothermia, while prolonged duration of the swim predicts an increased risk of hypothermia. The weak predictors of failing to finish are of questionable clinical significance.

Introduction.—Dog attacks are a major public health concern worldwide. Dogs bite over 4 million people resulting in the hospitalization of 6000 to 13 000 people each year in the United States. Rarely deaths may occur after an attack.

Methods.—This study utilized the compressed mortality files from CDC WONDER to evaluate deaths from dog attacks over the 27-year period 1979–2005.

Results.—An average of approximately 19 deaths was reported annually from dog attacks during this time period. Males and children less than 10 years of age had the highest rate of death from dog attacks. Deaths have been reported in 49 states with Alaska reporting the highest death rate from dog attacks. The number of deaths and death rate from dog attacks appear to be increasing.

Conclusions.—Deaths from dog attacks appear to be increasing as the population of both humans and dogs has increased during this time period. Children have the greatest risk of death. There is a need for a national reporting system on dog bites to fully capture the extent of fatalities and look at risk factors surrounding the attack. The development of effective prevention practices is dependent upon examination of these risk factors.

Background.—Increases in arterial oxygen saturation (SaO₂) in response to intermittent hypoxic exposure (IHE) are well established. However, IHE protocols have historically involved static hypoxic environments. The effect of a dynamic hypoxic environment on SaO₂ is not known.

Objective.—The purpose of this study was to examine the effect of dynamic IHE conditioning on SaO₂ using the Cyclical Variable Altitude Conditioning Unit.

Methods.—Thirteen trained participants (9 males, age 30.1 ± 9.2 years; 4 females, age 30.3 ± 8.9 years) residing at or near sea level were exposed to a 7-week IHE conditioning protocol (mean total exposure time = 30.8 hours). Participants were exposed to a constantly varying series of hypobaric pressures simulating altitudes from sea level to 6858 m (22 500 feet) in progressive conditioning tiers, creating a dynamic hypoxic environment. SaO₂ was evaluated using pulse oximetry (SpO₂) 4 times: at 2740, 3360, and 4570 m, prior to and following the first 3 weeks of IHE, and at 4570, 5490, and 6400 m at the start and end of the final 4 weeks.

Results.—SpO₂ improved 3.5%, 3.8%, and 4.1% at 2470, 3360, and 4570 m, respectively (P < .05), and 3.3%, 3.4%, and 5.9% at 4570, 5490, and 6400 m, respectively (P < .05). At 4570 m, SpO₂ increased from 81.7% ± 6.5% to 89.1% ± 3.2% over the entire 7-week conditioning period.

Discussion.—The dynamic intermittent hypoxic conditioning protocol used in the present study resulted in an acclimation response, such that SpO₂ was significantly increased at all altitudes tested, with shorter exposure times than generally reported.

Objective.—Small chemical hand and foot warmers are used by many winter sport athletes and other outdoor enthusiasts. The purpose of this study was to characterize the thermal behaviors of 14 commercially available hand and foot warmers.

Methods.—Both types of warmers were instrumented with a fast-responding thermistor. One of each pair of warmers was placed in a boot or glove. Temperature was recorded in a data logger for a period of hours to more than a day until the heat output of the devices ceased and returned to room temperature. Thermal behaviors were characterized and graphed, including peak temperature, time to peak temperature, and duration of temperature greater than 30°C. Reliability was determined by comparing thermal behavior of 2 hand or foot warmers of the same type and from the same manufacturer. Comparisons were also made between package claims and measured behaviors.

Results.—Measured outcomes were most noteworthy in their variability within and between manufacturers and types of warmers. A strong correlation was found between the masses of the warmers and their duration of heat production.

Conclusions.—Although there is a paucity of research information on these types of warmers, this experiment showed that some of the devices exceeded packaging claims while others fell short; that the thermal behavior over time of the devices was variable; and that there appears to be a simple but strong relationship between the mass of the devices and the duration of their heat production.

Objective.—To introduce and describe the US Border Patrol (USBP) Tucson Sector Border Patrol Search, Trauma and Rescue Unit (BORSTAR) and to analyze whether the frequency of its activities were associated with the amount of total border patrol law enforcement activities in the area.

Methods.—Descriptive and nonparametric analysis was conducted on data that were obtained on total USBP apprehensions of undocumented immigrants and BORSTAR activities for a consecutive 3-year period.

Results.—From October 2004 to September 2007 over 1 million apprehensions occurred within the Tucson Sector. During this time, a large number of search, rescue, and medical intervention events occurred. However, only a weak association was found between the frequency of apprehensions and BORSTAR activities.

Conclusions.—The BORSTAR unit of the Tucson Sector commonly encounters harsh conditions and provides search, rescue, and medical interventions to undocumented immigrants. The frequency of BORSTAR activities is not strongly associated with the volume of USBP law enforcement activities.

The global problem of venomous snakebite continues to attract attention despite it being described as a “neglected” issue. The current focus of the World Health Organization (WHO) remains anti– snake venom quality, although “availability and sustainability” of supply are consistently described as the key issues. Sustainability of antivenom supply has been elusive, with cost and pricing in developing countries being cited as the major reasons. The current WHO approach fails to explore the cost issue, but rather focuses on quality improvements, which may well adversely affect the costs of a product already perceived to be ‘unaffordable.’ The reference to cost and price indicates a marketing-based perspective may well give more relevant solutions to the snakebite crisis. This paper introduces a marketing model to examine global snakebite and to identify if the current approach is relevant and effective. The “4 Ps” model examines if the correct products are available, whether sufficient information exists concerning estimated market size, whether the assumptions frequently made about the costs of the product are correct and fully understood, if the product is promoted properly, and whether the method by which the product reaches the end user is optimum. The resulting analysis demonstrates that the current approach is characterized by a misunderstanding of the nature of the global snakebite problem. Further, a lack of implementation of key solutions, such as training doctors in developing countries with relevant protocols, has inevitably led to a lack of improvement in the snakebite arena over the last 30 years.

Ankle fracture/dislocations are generally low-energy injuries most commonly seen in older adults. Prompt reduction is indicated when evacuation to definitive care would be prolonged or neurovascular compromise to the foot is suspected. Reduction restores neurovascular integrity, realigns joint contact surfaces, reduces pain, and decreases soft-tissue edema. The hematoma block is a safe, easy, and effective method of obtaining adequate anesthesia to allow manipulation of displaced fractures. Although most commonly used for distal radius fractures, the hematoma block has been demonstrated to be as effective as conscious sedation for ankle reduction analgesia. Use of hematoma block is ideal for the wilderness setting because it requires few supplies, is easy to perform, and is effective. Quigley's traction consists of suspending the injured leg in a tubular fabric sling to allow gradual relaxation of deforming muscle forces and eventual reduction of a displaced ankle. For those displaced ankle fractures that are not amenable to reduction by direct manipulation, Quigley's traction applied after hematoma block may allow successful reduction. Improvised Quigley's traction can be built in a wilderness setting using available clothing. After successful reduction, fractured ankles should be adequately stabilized and the affected extremity should be kept nonweight bearing. The hematoma block and improvised Quigley's traction are valuable skills for the wilderness medical provider and may facilitate a successful and relatively pain-free reduction of dislocated ankle fractures in a wilderness setting.

Objective.—To demonstrate that the Snow Snorkel can be used safely by healthy volunteers buried in snow for up to 1 hour.

Methods.—Nine healthy male volunteers were placed in a shoulder-width trench and buried with snow to a depth of 30 to 40 cm. The study was divided into 2 stages. The first stage (Stage 1) was performed with the Snow Snorkel in operation (60-minute duration) and was then followed by a second stage (Stage 2) (15-minute duration) when the device was removed. Arterial oxygen saturation (SaO₂), heart rate (HR), respiratory rate (RR), axillary temperature (T), and 3-lead electrocardiography (ECG) were monitored throughout the study.

Results.—Of the 9 volunteers who were enrolled, 7 were able to complete Stage 1, while only 3 were able to complete Stage 2. In those who completed Stage 1, the mean HR fell by 14.1 beats/min (P = .002), while RR (P = .5) and SaO₂ (P = .7) remained unchanged compared to baseline measurements. There were no changes in T or ECG.

Conclusions.—Simple systems such as the Snow Snorkel are effective during snow burial and warrant further investigation.

Objective.—To determine the efficacy of 2 different sources of Ginkgo biloba extract (GBE) in reducing the incidence and severity of acute mountain sickness (AMS) following rapid ascent to high altitude.

Methods.—Two randomized, double-blind, placebo-controlled cohort studies were conducted in which participants were treated with GBE (240 mg·d⁻¹) or placebo prior to and including the day of ascent from 1600 m to 4300 m (ascent in 2 hours by car). Acute mountain sickness was diagnosed if the Environmental Symptom Questionnaire III acute mountain sickness–cerebral (AMS-C) score was ≥0.7 and the Lake Louise Symptom (LLS) score was ≥3 and the participant reported a headache. Symptom severity was also determined by these scores.

Results.—Results were conflicting: Ginkgo biloba reduced the incidence and severity of AMS compared to placebo in the first but not the second study. In the first study, GBE reduced AMS incidence (7/21) vs placebo (13/19) (P = .027, number needed to treat = 3), and it also reduced severity (AMS-C = 0.77 ± 0.26 vs 1.59 ± 0.27, P = .029). In the second study, GBE did not reduce incidence or severity of AMS (GBE 4/15 vs placebo 10/22, P = .247; AMS-C = 0.48 ± 0.13 vs 0.58 ± 0.11, P = .272). The primary difference between the 2 studies was the source of GBE.

Conclusions.—The source and composition of GBE products may determine the effectiveness of GBE for prophylaxis of AMS.

Objective.—This study investigated the effects of a high–sympathetic stimulus environment (high-altitude hypoxia) on limb-specific systolic blood pressure (sBP) and ankle-brachial index (ABI) in normal volunteers. We hypothesized that currently accepted normal values for ABI may in fact not reflect an actual normal vascular state in all patients.

Methods.—Twenty climbers (17 males, 3 females) from Gatineau-Hull (Québec, Canada) participated in this study and ascended Mount Kilimanjaro, Africa. Ankle-brachial index measurements were performed at sea level and on Mount Kilimanjaro at ∼4100 m. The data were analyzed using predictive analytics software SPSS 14.0. Data obtained at sea level were compared to those obtained at ∼4100 m, with participants serving as their own controls.

Results.—Ankle-brachial indices measured at ∼4100 m (mean = 1.20) were greater than those measured at sea level (mean = 0.97) (n = −6.23; 95% CI: −.32 to −.17; P < .001). There were no significant differences between the systolic brachial pressures at ∼4100 m when compared to those at sea level (P = .814). Contrarily, systolic ankle pressures at sea level (mean = 132) were significantly greater than those measured at ∼4100 m (mean = 152) (t = −3.5, 95% CI: −29 to −7.4; P = .002).

Conclusions.—This study is the first to physiologically demonstrate that in response to a high adrenergic stimulus in healthy volunteers there is a greater increase in sBP in the legs vs the arms.

Fatalities secondary to inhalation of volcanic gases in the United States have rarely been reported. We report the deaths of 3 ski patrol members at a popular California ski resort. After a snowstorm, ski patrol members were fencing off a well-known volcanic fumarole when the snow around the vent collapsed. Two members slid into the deep hole and rapidly lost consciousness. A third member carrying oxygen descended into the hole and also lost consciousness. A fourth member affixed an oxygen mask, but still lost consciousness upon descent. The 3 initial victims expired at the scene, while the fourth victim survived. Autopsy results for all 3 were consistent with a suffocation/asphyxiation death. In the case described, the involved fumarole is a well-known source of toxic gases. Atmospheric sampling data dating back decades demonstrate that carbon dioxide levels typically range from 97% to 99%, nitrogen gas from 1% to 3%, and hydrogen sulfide from .004% to .07%. Other gases in smaller concentrations include oxygen, hydrogen, and carbon monoxide. Given the rapidity with which our victims lost consciousness and the historical data available on the Mammoth Mountain Fumarole (MMF), it is plausible that our patients suffered from acute asphyxiation, although the contribution of the directly toxic effects of the gases involved cannot be ruled out. During winter months, snow can build up and disguise volcanic vents and potentially trap toxic fumes to form dangerous, gas-filled pits. Recognition of such potential hazards is essential when working in or venturing into volcanically active areas during the winter.