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Journal of Emergency Medicine
WILDERNESS & ENVIRONMENTAL MEDICINE, 21, 371–372 (2010)
ABSTRACTS OF CURRENT LITERATURE SURGICAL ENDOSCOPY
ANNALS OF PLASTIC SURGERY
The Martian Chronicles: Remotely Guided Diagnosis and Treatment in the Arctic Circle
Does Voltage Predict Return to Work and Neuropsychiatric Sequelae Following Electrical Burn Injury?
The authors of this article simulated a laparoscopic appendectomy by a novice operator who relied on telemedicine. As stated in this article, it is not an unrealistic expectation to require surgical intervention in a remote environment such as Antarctica or during space travel. For instance, a Russian doctor has performed an appendectomy on himself during an Antarctic expedition.1 In this “proof of concept” paper, the authors simulated 2 very remote telemedicine scenarios: communication with a care provider on the moon during an ultrasound assisted evaluation of abdominal pain in a patient, and communication with a provider on Mars during a laparoscopic appendectomy. These communication distances were modeled with a delay of 2 seconds to the moon and 15 minutes to Mars. A nonradiologist, nonsurgeon stationed at Devon Island in the high Arctic performed the ultrasound and the surgical procedure with remote guidance by a surgeon at Henry Ford Hospital in Detroit, Michigan. The operator, who was not trained in ultrasound, watched a remotely transmitted 5-minute prerecorded training video. Afterwards, a remote expert helped the operator to visualize the appendix, ovaries, and uterus, taking 20 minutes. A plastic model of the cecum and appendix was placed inside of an opaque box in order to simulate a laparoscopic appendectomy. Video instructions and diagrams were transmitted to the operator. Then, the operator executed the procedure, stopping at detailed holding points such as visualization of the appendix, confirmation of transection points, or closing the abdominal wound. At these holding points, procedural video was transmitted back to the surgeon for approval, feedback, and permission to proceed further. After 2.5 hours the procedure was completed and successful in the observing physician’s estimation. Though this report only simulated a portion of the diagnosis and treatment of a surgical emergency, it does demonstrate that the technology exists to augment patient care in a remote environment. (Surg Endosc. 2010;EPub) C Otto, JM Comtois, A Sargsyan, et al. Prepared by Anil Menon, MD, UTMB/NASA Aerospace Medicine Fellow, Galveston, TX, USA
Increased voltage in electrical injuries causes higher morbidity and mortality. This retrospective study compared high-voltage and low-voltage electrical burns in an effort to assess whether neuropsychiatric sequelae also worsened with increasing voltage. The authors reviewed charts of patients presenting with electrical burns to a regional burn center over a 5-year period. They defined neuropsychiatric sequelae as neuropathic pain, insomnia, nerve compression, major depressive disorder, posttraumatic stress syndrome (PTSD), memory loss, anxiety disorder, and seizures. In total, 115 charts were reviewed and, for comparison, separated into greater than 1000 V (60), less than 1000 V (25), electrical arc injury where voltage is difficult to estimate (29), and lightning strike (1). In regards to neuropsychiatric sequelae, there was no statistical difference between the highvoltage group (48%) and the low-voltage group (44%). Neuropathic pain was most commonly seen in both groups. As expected, overall morbidity was higher in the high-voltage group than the low-voltage group with statistically significant increases in the length of hospital stay, length of intensive care unit stay, amputation, and fasciotomy. With 115 patients, this study may have been underpowered to demonstrate a statistical difference between the two groups. For example, there were 6 cases of PTSD in the high-voltage group but none in the low-voltage group. Nonetheless, as the authors state, this study does make an argument for long-term neuropsychiatric care to help supplement burn care in all electrical burn victims given the high rates of neuropsychiatric sequelae. (Ann Plast Surg. 2010;64:522–525) S Chudasama, J Goverman, JH Donaldson, et al. Prepared by Anil Menon, MD, UTMB/NASA Aerospace Medicine Fellow, Galveston, TX, USA
JOURNAL OF EMERGENCY MEDICINE
Reference
A Localizing Circumferential Compression Device Increases Survival After Coral Snake Envenomation to the Torso of an Animal Model
1. Rogozov LI. Self operation. Sov Antarctic Expedition Inf Bull. 1964;4:223–224. Washington, DC: American Geophysical Union.
Eastern coral snake (Micrurus fulvius) envenomations require immediate transfer to a care facility for supportive care and, when available and indicated, treatment with antivenom. A
372 delay in care can precipitate worsening effects of the toxin, which include respiratory depression and paralysis. Cutaneous manifestations do not indicate severity of disease. Though a circumferential compression device might delay the onset of symptoms in an extremity, it is difficult to apply compression to a torso bite. The first author of this paper patented a compression device for use on the torso and tested it in this study. In this small, unblinded, controlled trial on pigs the authors compared 8-hour survival between 6 pigs to which the device was applied and 3 controls that received no form of compression. Pigs were matched by age and weight. Each pig was injected with 10 mg of M. fulvius venom and compression was applied 1 minute after injection in the test group. The compression device consisted of a molded, rigid loop that was used to encircle the bite site. A strap was then secured around the torso and tightened to increase the pressure on the skin and decrease blood flow from the bite. A statistically significant delay in time to death was appreciated in the compression group with 5 of the 6 pigs living to the 8-hour end point while none of the control group survived to 8 hours. The single treated pig that died before 8 hours was noted to have a misapplication of the compression device during the first 10 minutes. This finding highlights one of the major limitations to this promising adjunct for the treatment of torso envenomations. In this study, the device was applied after 1 minute, which is unlikely to occur under normal conditions, and may negate the utility of this device. If an effective means of delaying coral snake venom absorption and circulation can be developed, this might provide care providers with additional time to locate and obtain an appropriate antivenom to treat victims. Currently no commercial antivenom for Micrurus bites exists in the United States. (J Emerg Med. 2010;17:1–3) JB Hack, JM Deguzman, KL Brewer, et al. Prepared by Anil Menon, MD, UTMB/NASA Aerospace Medicine Fellow, Galveston, TX, USA
NEW ENGLAND JOURNAL OF MEDICINE Morphine After Combat Injury and Post-traumatic Stress Disorder Whether it happens in a military setting or a wilderness environment, physical trauma may cause more damage than the immediately appreciable injuries. Post-traumatic stress disorder (PTSD) is a well-documented downstream consequence of trauma. This study assessed the effect of morphine sulfate administration as a secondary prevention measure to reduce PTSD after trauma. This retrospective chart review identified trauma victims presenting to medical treatment facilities throughout the combat theater during Operation Iraqi Freedom, from January 2004 to December 2006. Of the 790 injured military personnel, 34 were excluded because of incomplete records and 60 were
Abstracts of Current Literature excluded because of evidence of traumatic brain injury, leaving 696 in the study group. Medical records of these patients were reviewed to determine whether they were diagnosed with PTSD in the subsequent 2 years. A total of 243 patients carried a new diagnosis of PTSD and 453 did not. The two groups were statistically similar in terms of age, mechanism of injury, Glasgow Coma Score, Injury Severity Score, and need for intubation. Early administration of morphine sulfate occurred in both groups with 61% receiving it in the PTSD group and 76% in the other group. In those trauma patients receiving morphine sulfate during the initial treatment phase (roughly the first hour), there was a statistically significant reduction in the likelihood of being diagnosed with PTSD (odds ratio 0.47). Benzodiazapene administration did not show a significant correlation with PTSD diagnosis. This study adds to a growing body of evidence that early pain management reduces PTSD following trauma and, though not addressed by the authors, might suggest the importance of equipping wilderness expeditions with opiates. (N Engl J Med. 2010; 362:110 –17) TL Holbrook, MR Galarneau, JL Dye, et al. Prepared by Anil Menon, MD, UTMB/NASA Aerospace Medicine Fellow, Galveston, TX, USA
MORBIDITY AND MORTALITY WEEKLY REPORT Giardiasis Surveillance—United States, 2006 –2008 Giardia intestinalis is the most common parasite seen in the United States. It is a reportable disease in all states except Indiana, Kentucky, Mississippi, North Carolina, and Texas. Reports of both suspected cases and laboratory confirmed cases were collected by the Centers for Disease Control and summarized in this report. Direct fluorescence assay is the gold standard for confirmation. In this report, approximately 20 000 cases were identified annually between 2006 and 2008. A bimodal distribution among age groups showed peaks in 1 to 9 year olds and 35 to 44 year olds. More cases were reported in northern states, though no statistical comparison was done. Twice as many cases were reported at the beginning of the summer, in June and July, and the authors postulated that this was due to increased swimming by children. They reasoned that, while restaurant outbreaks do occur, they are not common, and that this disease can be transmitted in chlorinated pools due to its highly infectious characteristics. Giardia only requires 10 cysts to initiate an infection and over 1 billion are found in single stool samples. In addition, pools are sometimes inadequately chlorinated, allowing increased survival of cysts. (MMWR Surveill Summ. 2010; 59:15–28) JS Yoder, C Harral, MJ Beach. Prepared by Anil Menon, MD, UTMB/NASA Aerospace Medicine Fellow, Galveston, TX, USA
ABSTRACTS OF CURRENT LITERATURE SURGICAL ENDOSCOPY
ANNALS OF PLASTIC SURGERY
The Martian Chronicles: Remotely Guided Diagnosis and Treatment in the Arctic Circle
Does Voltage Predict Return to Work and Neuropsychiatric Sequelae Following Electrical Burn Injury?
The authors of this article simulated a laparoscopic appendectomy by a novice operator who relied on telemedicine. As stated in this article, it is not an unrealistic expectation to require surgical intervention in a remote environment such as Antarctica or during space travel. For instance, a Russian doctor has performed an appendectomy on himself during an Antarctic expedition.1 In this “proof of concept” paper, the authors simulated 2 very remote telemedicine scenarios: communication with a care provider on the moon during an ultrasound assisted evaluation of abdominal pain in a patient, and communication with a provider on Mars during a laparoscopic appendectomy. These communication distances were modeled with a delay of 2 seconds to the moon and 15 minutes to Mars. A nonradiologist, nonsurgeon stationed at Devon Island in the high Arctic performed the ultrasound and the surgical procedure with remote guidance by a surgeon at Henry Ford Hospital in Detroit, Michigan. The operator, who was not trained in ultrasound, watched a remotely transmitted 5-minute prerecorded training video. Afterwards, a remote expert helped the operator to visualize the appendix, ovaries, and uterus, taking 20 minutes. A plastic model of the cecum and appendix was placed inside of an opaque box in order to simulate a laparoscopic appendectomy. Video instructions and diagrams were transmitted to the operator. Then, the operator executed the procedure, stopping at detailed holding points such as visualization of the appendix, confirmation of transection points, or closing the abdominal wound. At these holding points, procedural video was transmitted back to the surgeon for approval, feedback, and permission to proceed further. After 2.5 hours the procedure was completed and successful in the observing physician’s estimation. Though this report only simulated a portion of the diagnosis and treatment of a surgical emergency, it does demonstrate that the technology exists to augment patient care in a remote environment. (Surg Endosc. 2010;EPub) C Otto, JM Comtois, A Sargsyan, et al. Prepared by Anil Menon, MD, UTMB/NASA Aerospace Medicine Fellow, Galveston, TX, USA
Increased voltage in electrical injuries causes higher morbidity and mortality. This retrospective study compared high-voltage and low-voltage electrical burns in an effort to assess whether neuropsychiatric sequelae also worsened with increasing voltage. The authors reviewed charts of patients presenting with electrical burns to a regional burn center over a 5-year period. They defined neuropsychiatric sequelae as neuropathic pain, insomnia, nerve compression, major depressive disorder, posttraumatic stress syndrome (PTSD), memory loss, anxiety disorder, and seizures. In total, 115 charts were reviewed and, for comparison, separated into greater than 1000 V (60), less than 1000 V (25), electrical arc injury where voltage is difficult to estimate (29), and lightning strike (1). In regards to neuropsychiatric sequelae, there was no statistical difference between the highvoltage group (48%) and the low-voltage group (44%). Neuropathic pain was most commonly seen in both groups. As expected, overall morbidity was higher in the high-voltage group than the low-voltage group with statistically significant increases in the length of hospital stay, length of intensive care unit stay, amputation, and fasciotomy. With 115 patients, this study may have been underpowered to demonstrate a statistical difference between the two groups. For example, there were 6 cases of PTSD in the high-voltage group but none in the low-voltage group. Nonetheless, as the authors state, this study does make an argument for long-term neuropsychiatric care to help supplement burn care in all electrical burn victims given the high rates of neuropsychiatric sequelae. (Ann Plast Surg. 2010;64:522–525) S Chudasama, J Goverman, JH Donaldson, et al. Prepared by Anil Menon, MD, UTMB/NASA Aerospace Medicine Fellow, Galveston, TX, USA
JOURNAL OF EMERGENCY MEDICINE
Reference
A Localizing Circumferential Compression Device Increases Survival After Coral Snake Envenomation to the Torso of an Animal Model
1. Rogozov LI. Self operation. Sov Antarctic Expedition Inf Bull. 1964;4:223–224. Washington, DC: American Geophysical Union.
Eastern coral snake (Micrurus fulvius) envenomations require immediate transfer to a care facility for supportive care and, when available and indicated, treatment with antivenom. A
372 delay in care can precipitate worsening effects of the toxin, which include respiratory depression and paralysis. Cutaneous manifestations do not indicate severity of disease. Though a circumferential compression device might delay the onset of symptoms in an extremity, it is difficult to apply compression to a torso bite. The first author of this paper patented a compression device for use on the torso and tested it in this study. In this small, unblinded, controlled trial on pigs the authors compared 8-hour survival between 6 pigs to which the device was applied and 3 controls that received no form of compression. Pigs were matched by age and weight. Each pig was injected with 10 mg of M. fulvius venom and compression was applied 1 minute after injection in the test group. The compression device consisted of a molded, rigid loop that was used to encircle the bite site. A strap was then secured around the torso and tightened to increase the pressure on the skin and decrease blood flow from the bite. A statistically significant delay in time to death was appreciated in the compression group with 5 of the 6 pigs living to the 8-hour end point while none of the control group survived to 8 hours. The single treated pig that died before 8 hours was noted to have a misapplication of the compression device during the first 10 minutes. This finding highlights one of the major limitations to this promising adjunct for the treatment of torso envenomations. In this study, the device was applied after 1 minute, which is unlikely to occur under normal conditions, and may negate the utility of this device. If an effective means of delaying coral snake venom absorption and circulation can be developed, this might provide care providers with additional time to locate and obtain an appropriate antivenom to treat victims. Currently no commercial antivenom for Micrurus bites exists in the United States. (J Emerg Med. 2010;17:1–3) JB Hack, JM Deguzman, KL Brewer, et al. Prepared by Anil Menon, MD, UTMB/NASA Aerospace Medicine Fellow, Galveston, TX, USA
NEW ENGLAND JOURNAL OF MEDICINE Morphine After Combat Injury and Post-traumatic Stress Disorder Whether it happens in a military setting or a wilderness environment, physical trauma may cause more damage than the immediately appreciable injuries. Post-traumatic stress disorder (PTSD) is a well-documented downstream consequence of trauma. This study assessed the effect of morphine sulfate administration as a secondary prevention measure to reduce PTSD after trauma. This retrospective chart review identified trauma victims presenting to medical treatment facilities throughout the combat theater during Operation Iraqi Freedom, from January 2004 to December 2006. Of the 790 injured military personnel, 34 were excluded because of incomplete records and 60 were
Abstracts of Current Literature excluded because of evidence of traumatic brain injury, leaving 696 in the study group. Medical records of these patients were reviewed to determine whether they were diagnosed with PTSD in the subsequent 2 years. A total of 243 patients carried a new diagnosis of PTSD and 453 did not. The two groups were statistically similar in terms of age, mechanism of injury, Glasgow Coma Score, Injury Severity Score, and need for intubation. Early administration of morphine sulfate occurred in both groups with 61% receiving it in the PTSD group and 76% in the other group. In those trauma patients receiving morphine sulfate during the initial treatment phase (roughly the first hour), there was a statistically significant reduction in the likelihood of being diagnosed with PTSD (odds ratio 0.47). Benzodiazapene administration did not show a significant correlation with PTSD diagnosis. This study adds to a growing body of evidence that early pain management reduces PTSD following trauma and, though not addressed by the authors, might suggest the importance of equipping wilderness expeditions with opiates. (N Engl J Med. 2010; 362:110 –17) TL Holbrook, MR Galarneau, JL Dye, et al. Prepared by Anil Menon, MD, UTMB/NASA Aerospace Medicine Fellow, Galveston, TX, USA
MORBIDITY AND MORTALITY WEEKLY REPORT Giardiasis Surveillance—United States, 2006 –2008 Giardia intestinalis is the most common parasite seen in the United States. It is a reportable disease in all states except Indiana, Kentucky, Mississippi, North Carolina, and Texas. Reports of both suspected cases and laboratory confirmed cases were collected by the Centers for Disease Control and summarized in this report. Direct fluorescence assay is the gold standard for confirmation. In this report, approximately 20 000 cases were identified annually between 2006 and 2008. A bimodal distribution among age groups showed peaks in 1 to 9 year olds and 35 to 44 year olds. More cases were reported in northern states, though no statistical comparison was done. Twice as many cases were reported at the beginning of the summer, in June and July, and the authors postulated that this was due to increased swimming by children. They reasoned that, while restaurant outbreaks do occur, they are not common, and that this disease can be transmitted in chlorinated pools due to its highly infectious characteristics. Giardia only requires 10 cysts to initiate an infection and over 1 billion are found in single stool samples. In addition, pools are sometimes inadequately chlorinated, allowing increased survival of cysts. (MMWR Surveill Summ. 2010; 59:15–28) JS Yoder, C Harral, MJ Beach. Prepared by Anil Menon, MD, UTMB/NASA Aerospace Medicine Fellow, Galveston, TX, USA