Objective.—There exist no prospectively generated analyses of the type and frequency of medical incidents in desert settings. We created a database of every illness and injury during 6 field seasons in the Gobi Desert in order to optimize expedition medical and safety planning.

Methods.—Every incident presenting to the expeditions' physicians, regardless of type, magnitude, treatment, or outcome, was recorded. Incidents ranged from headache, insomnia, and diarrhea to lacerations, infection, fights, psychosis, and foreign body extraction and were thus categorized, segregating urban travel-related complaints from illness and injury occurring in the desert setting. The chronology of incidents and illnesses was observed. The incidence of categorized illness and injury was analyzed using descriptive statistics and was presented in terms of person-days in the field.

Results.—There were 412 incidents recorded during 2689 person-days from 6 field seasons in the Gobi Desert from 2003 through 2007. The expeditions' physicians saw an average of 2.2 incidents·d⁻¹ in the urban setting compared to 3.6 incidents·d⁻¹ in the desert. Circadian rhythm disturbances, gastrointestinal illnesses, and musculoskeletal complaints predominated in the urban setting, while minor trauma, heat-related exposures, and gastrointestinal and orthopedic problems predominated in the desert setting. Our data show an absolute risk of illness or injury of 153.2 incidents per 1000 person-days and a risk of “gastrointestinal” and “trauma” complaints of 21.2 and 23.1 per 1000 person-days, respectively.

Conclusions.—Herein we describe results from the first ever prospective study of the hazards of travel in an arid environment. We observed that there are patterns of injury and illness that are consistent across expeditions to the Gobi Desert. For example, while heat- and wind-exposure–related illness and injury in the desert are quite common, other aspects of the desert environment are very forgiving. Perhaps the most interesting finding in our cohort was the degree to which different problems occurred at different stages of the expeditions. Our data sets suggest several future studies to evaluate patterns of illness and injury and could be an asset to recreational travelers and religious pilgrims, as well as to those sending employees to extreme environments.

Objective.—To determine if an “industry standard” exists for wilderness first aid training and certification of outdoor adventure/education leaders.

Methods.—Regulatory authorities, national organizations, and school/college groups were queried with regard to their requirements for first aid training of their wilderness trek leaders.

Results.—Only 10 of the 22 states with guide licensure programs required any first aid training as a condition of licensure, and none specified a specific course. Of those programs requiring such training, the requirements ranged from a 6-hour standard first aid course to more structured “wilderness first responder” certification.

Conclusions.—There exists no uniform industry standard for first aid training and certification of wilderness leaders. The epidemiology of backcountry injuries as well as what is currently known about clinical skills retention indicate that there may be little evidence basis for much of current practice.

Background.—Scorpion sting envenomation is a life-threatening emergency and a common public health problem in many regions of the world, particularly in children. Children are at greater risk of developing severe cardiac, respiratory, and neurological complications.

Objectives.—The aims of this study were to evaluate demographic, clinical, laboratory, treatment, and outcome characteristics for pediatric patients with scorpion sting envenomation in southeast Turkey and to describe features that may be predictive of the need for pediatric intensive care unit (PICU) care.

Methods.—A total of 52 charts of children (mean age: 7.7 ± 2.8 years; age range: 1.5–15 years) presenting with scorpion sting envenomation to a single hospital in southeastern Turkey were investigated. General characteristics of the children, species of the scorpions, anatomic site of the sting, clinical and laboratory findings, treatment approaches, complications, and outcomes were recorded.

Results.—Twenty-four stings (46.2%) were inflicted by Androctonus crassicauda, 1 (1.9%) by Leiurus quinquestriatus, and the sources of the other stings were not known. Thirty-one patients (59.6%) were admitted from rural areas. Admission from a rural area was a significant risk factor for severe envenomation. Foot-leg was the most frequently stung part of the body (48%). The greatest number of stings occurred in the summer (78.8%). Cold extremities and tachycardia were the most frequently seen clinical findings (38.4% for both). Twenty patients (38.5%) had signs of serious envenomation and required admission to the PICU. Hemoglobin, white blood cell count, activated prothrombin time, aspartate aminotransferase, alanine aminotransferase, and creatine phosphokinase levels were higher in severely envenomed children compared to levels in those with mild-moderate stings. Antivenom was given at a primary or secondary health center before arrival to our hospital in 44 (84.6%) patients, without any apparent difference in the number of patients presenting with mild-moderate and severe envenomed stings. All patients recovered after treatment except for 1 child who died with severe pulmonary edema.

Conclusions.—We found no clinically useful demographic or epidemiological data to guide decision making regarding the need for PICU admission for pediatric victims of scorpion sting in our area. Decisions on transfer and admission to a PICU should be based on the development of systemic findings of envenomation.

Objective.—The prevalence of airflow obstruction in recreational self-contained underwater breathing apparatus (SCUBA) divers is unknown. Since airflow obstruction is a relative contraindication for diving, we conducted a study to determine its prevalence and magnitude in a cohort of recreational divers in Saba, Netherlands Antilles.

Methods.—Prior to diving, divers were asked to complete a diving/health questionnaire and then to perform spirometry administered by trained dive store personnel. Spirometry instrumentation provided immediate feedback regarding test quality.

Results.—Of 8365 eligible divers during the study period (November 1997–March 1999), 668 enrolled and completed questionnaires. Of those completing questionnaires, 46% reported a history of smoking, 13% were current smokers, 15% wheezed, 6% had asthma, 4% used bronchodilators, and 3% took oral steroids. Of 654 completing spirometry, 231 had acceptable spirometry quality and complete questionnaires. By forced expiratory volume in 1 second/forced vital capacity, 10% had mild, 1.7% had moderate, and 0.4% had severe airflow obstruction.

Conclusions.—The prevalence of airflow obstruction was 6% to 15% by report and 12% by spirometry, approximating the combined prevalence of asthma and chronic obstructive pulmonary disease in the general population. Study limitations include possible self-selection and low enrollment rate. Prospective lung function testing can be conducted at remote sites using nonmedical personnel as “testers.” This study could guide future investigations to determine if asthma is a risk factor for decompression illness.

Objective.—To determine whether high altitude travel adversely affects mountain enthusiasts with Raynaud's phenomenon.

Methods.—Volunteers with Raynaud's phenomenon were recruited using announcements disseminated by organizations dedicated to climbing or wilderness travel and Internet discussion boards dedicated to mountain activities to complete an online, anonymous survey. Survey questions addressed demographic variables, aspects of their Raynaud's phenomenon, and features of their mountain activities. Respondents compared experiences with Raynaud's phenomenon between high (>2440 m; 8000 feet) and low elevations and rated agreement with statements concerning their disease and the effects of high altitude.

Results.—One hundred forty-two people, 98% of whom had primary Raynaud's phenomenon, completed the questionnaire. Respondents spent 5 to 7 days per month at elevations above 2440 m and engaged in 5.4 ± 2.0 different activities. Eighty-nine percent of respondents engaged in winter sports and only 22% reported changing their mountain activities because of Raynaud's phenomenon. Respondents reported a variety of tactics to prevent and treat Raynaud's attacks, but only 12% used prophylactic medications. Fifteen percent of respondents reported an episode of frostbite following a Raynaud's phenomenon attack at high altitude. There was considerable heterogeneity in participants' perceptions of the frequency, duration, and severity of attacks at high altitude compared to their home elevation.

Conclusions.—Motivated individuals with primary Raynaud's phenomenon, employing various prevention and treatment strategies, can engage in different activities, including winter sports, at altitudes above 2440 m. Frostbite may be common in this population at high altitude, and care must be taken to prevent its occurrence.

Exercise-associated hyponatremia is hyponatremia occurring during or up to 24 hours after prolonged exertion. In its more severe form, it manifests as cerebral and pulmonary edema. There have now been multiple reports of its occurring in a wilderness setting. It can now be considered the most important medical problem of endurance exercise. The Second International Exercise-Associated Hyponatremia Consensus Conference gives an up-to-date account of the nature and management of this disease. This article reviews key information from this conference and its statement. There is clear evidence that the primary cause of exercise-associated hyponatremia is fluid consumption in excess of that required to replace insensible losses. This is usually further complicated by the presence of inappropriate arginine vasopressin secretion, which decreases the ability to renally excrete the excess fluid consumed. Women, those of low body weight, and those taking nonsteroidal anti-inflammatory drugs are particularly at risk. When able to be biochemically diagnosed, severe exercise-associated hyponatremia is treated with hypertonic saline. In a wilderness setting, the key preventative intervention is moderate fluid consumption based on perceived need (“ad libitum”) and not on a rigid rule.

(Editor's Note: This paper was written at my request in an effort to increase awareness of this important clinical entity among members of the wilderness community, many of whom are involved in activities that place them at risk of its development. I thank the authors for their diligent efforts.)

The world of antisnake venom production is currently a gloomy place to visit. It is described as being in crisis, characterized by shortages, producers leaving the market, high prices, and unsustainability. It has been reduced to a pauper-like status, doomed to relying on charitable handouts for resolution. The worrying aspect of this is that little work has been done to establish the true economics and return on antisnake venom if provided by private companies. Fortunately, it is amenable to economic analysis, and in this manner, a rational approach to further development and distribution can be obtained. This article proposes a model antisnake venom (ASV) production unit and shows the likely economics and return based on the production of various volumes of ASV. It estimates the costs for the key components of the unit, which are production equipment and staffing. A profit and loss account and balance sheet are constructed for the unit, and the effects of ASV volume and neutralizing titres are demonstrated. It is our contention that ASV production can be sustained at affordable prices in the developing world. We recommend that any solution to the ASV shortage must take into account the most cost efficient method(s) of production.

North American rattlesnakes possess venom with primarily cytotoxic and hemotoxic properties. When persons are envenomated by these snakes, thrombocytopenia and coagulopathy commonly occur, yet patients rarely develop severe bleeding. This report describes a 44-year-old Native American man bitten on the index finger by an unknown species of rattlesnake. The man developed massive gastrointestinal hemorrhage that was ultimately treated with recombinant factor VIIa. He presented to an emergency department with a depressed level of consciousness, a blood pressure of 60/20 mm Hg, and heart rate of 148 beats per minute. He was diaphoretic and vomiting bright red blood. Initial laboratory results revealed thrombocytopenia and coagulopathy. Despite aggressive fluid resuscitation and administration of blood and antivenom in the emergency department, the patient continued to have profuse upper gastrointestinal bleeding, with hemoglobin as low as 1.8 g/dL. He received fluids, antivenom, and multiple blood products, with cessation of bleeding after administration of recombinant factor VIIa. Esophagogastroduodenoscopy revealed a single Mallory-Weiss tear as the source of hemorrhage. The patient stabilized after 6 hours of aggressive resuscitation but over the next several days developed several complications, including acute renal failure and gram-negative sepsis. The patient died on hospital day 5. In cases of life-threatening hemorrhage after rattlesnake envenomation in which traditional therapy with antivenom and aggressive supportive measures fail, recombinant factor VIIa should be considered as an additional therapeutic option to achieve hemostasis.

Objectives.—Sleep at extreme altitudes is characterized by the repetitive occurrence of central apneas that in some cases may lead to a marked decrease in arterial oxygen saturation. During the Ludwig Maximilians University Expedition to Mt. Everest (MedEx 2006), nocturnal polygraphic recordings were made at different altitudes and included the first recordings ever made at 7500 m, which were completed on 8 separate occasions during the expedition.

Methods.—The study was performed on the author (K.M., 58 years, 181 cm, 75 kg), who is an experienced high-altitude mountaineer. The standard polygraphic parameters, such as nasal and oral airflow, thoracic and abdominal effort, oxygen saturation, heart rate, body position, movement, and snoring, were collected with a portable sleep recording device (AlphaScreen, SensorMedics, Germany, Hochberg) at different altitudes between 5300 m and 7500 m, and were compared with baseline assessments made in Munich, Germany (altitude 508 m). The daytime value of oxygen saturation at rest was measured at South Col (8000 m) and at the South Summit (8763 m) without breathing supplemental oxygen for at least 10 minutes.

Results.—The number of apneas and hypopneas of central origin increased up to a maximum of 148/h with a minimal blood oxygen saturation of 48% at 7500 m, compared with <5/h at Munich. After 11 days of acclimatization, data recorded at 5300 m showed a marked reduction of disturbed sleep. The Apnea-Hypopnea-Index dropped from 138/h to 51/h, and the minimal blood oxygen saturation rose from 57% to 67%. At South Col (8000 m), the daytime value of oxygen saturation at rest ranged between 53% and 55%, and on South Summit (8673 m) without breathing supplemental oxygen for at least 10 minutes, it fluctuated around 50%.

Conclusions.—These data correlate well compared with those obtained in hypobaric chamber studies and show that regardless of physiologic adjustment to low oxygen conditions at Base Camp altitude, during the final summit attempt oxygen saturation drops further to 55% and even less. Thus recordings of nocturnal oxygen saturation at Camp 3 (7500 m) on Everest, where the night is spent before the summit attempt, may help to show the actual efficiency of hypoxic ventilatory response and to detect the individual hypoxic tolerance to altitudes above 8000 m.

Objective.—To compare the effectiveness of a SAM splint molded into a cervical collar with that of a Philadelphia cervical collar at limiting movement of the cervical spine in 5 different movements.

Methods.—This study was prospectively carried out in 13 healthy volunteer subjects. A hand-held goniometer was then used to measure degrees of maximal extension (starting in a maximally flexed position), rotation (left and right), and lateral flexion (left and right) with each collar. The results were then analyzed for the 5 independent movements using the paired t test to determine the effectiveness of the SAM splint compared with that of the Philadelphia collar.

Results.—There was no statistically significant difference between the Philadelphia collar and the SAM splint at limiting movement of the cervical spine in any of the measured movements or in total allowed degrees of movement.

Conclusion.—The results of this study suggest that the SAM splint, when molded into a cervical collar, is as effective as the Philadelphia collar at limiting movement of the cervical spine.

Although eyes are not frequently injured in the mountains, they are exposed to many adverse factors from the environment. This article, intended for first responders, paramedics, physicians, and mountaineers, is the consensus opinion of the International Commission for Mountain Emergency Medicine (ICAR-MEDCOM). Its aim is to give practical advice on the management of eye problems in mountainous and remote areas. Snow blindness and minor injuries, such as conjunctival and corneal foreign bodies, could immobilize a person and put him or her at risk of other injuries. Blunt or penetrating trauma can result in the loss of sight in the eye; this may be preventable if the injury is managed properly. In almost all cases of severe eye trauma, protecting the eye and arranging an immediate evacuation are necessary. The most common eye problems, however, are due to ultraviolet light and high altitude. People wearing contact lenses and with previous history of eye diseases are more vulnerable. Any sight-threatening eye problem or unexplained visual loss at high altitude necessitates descent. Wearing appropriate eye protection, such as sunglasses with sidepieces and goggles with polarized or photochromic lenses, could prevent most of the common eye problems in mountaineering.