The Compass Journal - October 2024

The Journal of the College of Remote and Offshore Medicine Foundation Autumn 2024, Volume 7, Issue 24

Autumn 2024, Volume 7, Issue 24

CONTENTS

PAGE

Dean’s Desk

3

Editor’s Notes

5

Case Report

6

Clinical Pearls

9

Tropical Medicine Update

11

Improvised Medicine

13

Test Yourself

14

Resources

16

CoROM Cast

17

Audio Files

18

Envisioning Information

19

Journal Watch

20

Utilization of POCUS for assessment of optic nerve and elevated ICP Identifying substance exposure using BAD COLDS and CRESS Moving toward a malaria vaccine for adults Cut pants as pelvic binder

ECG, clinical calculation, species identification, and clinical case A selection of medical references and gear Episode #106 – SOF education with Bill Vasios

Foxpedition, Prolonged Field Care, This Week in Parasitism A basic flowchart of viral families

Electrification and specialist training associated with decreased neonatal mortality and increased admissions in Sierra Leone Incidence of compartment syndrome with routine use of regional anesthesia for patients with long bone fractures Limb hemorrhage control failure with counterfeit tourniquets: A Ukrainian war MEDEVAC case report Appropriate dose of tranexamic acid in the topical treatment of anterior epistaxis, 500 mg vs 1000 mg

About CoROM

22

Calendar

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Cover photo: Black Sand Beach, Vik, Iceland.

Photo courtesy of Dr. Glenn Geelhoed

“Those sea stacks are said to be the two trolls that are now the residual of a horde of Nordic trolls that swooped down upon a 10masted ship offshore, and lured it into the vicious surf's destruction by night. As dawn was breaking, two of the trolls were preoccupied with plunder and they were still there when the sun came up. They were petrified by the daylight, and are still standing in the surf over the wreckage of their plunder. Good Nordic myths aside, these igneous pillars are the eroded outposts of the furthest southern intrusion of the big volcanic system that had lain dormant for eight centuries until it erupted in December 2023, and has now erupted six more times in the interval since then, with steaming vents from the geothermal heat billowing around me as I took this photo.”

All images used in this publication are either in the public domain, licensed for free use, or used with explicit permission. The College of Remote and Offshore Medicine respects intellectual property rights and strives to ensure compliance with all copyright laws. If you believe any image has been used inappropriately, please contact us immediately at info@corom.edu.mt so we can address the issue promptly.

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Dean’s Desk Medicine in the Mediterranean 2025 We’re thrilled to invite you and your colleagues to join us for an unforgettable three-day adventure in remote and austere medicine! Get ready to dive into an exclusive conference designed for healthcare providers who thrive in wilderness, remote, and extreme environments. This year’s event is packed with world-class educators, captivating topics, and plenty of opportunities to connect with fellow professionals in the field.

John Clark

JD MBA NRP

Running from Friday, 31st January to Sunday, 2nd February 2025, this conference is an exciting mix of hands-on workshops, cutting-edge lectures, and vibrant networking events. With only 100 spots available, you'll enjoy a personalised experience. Registration is just €350, and workshops are included—but act fast, as they’re capped at 20 participants each for maximum interaction! Plus, if you’re looking to boost your credentials, you can sit for any IBSC Board Certification exam, including the new Wilderness Paramedic (WP-C), with pre-registration required at [IBSCertifications.org](http://www.IBSCertifications.org). And yes—this conference is FAWM, EACCME, AMA Category 1, and CAPCE approved, so you’ll be earning essential professional credits while having a blast.

What’s in store?

- Friday kicks off with our small group workshops, covering improvised medicine, facial trauma management, dental emergencies, and prehospital ultrasound—learn, practice, and have fun!

- Dr. Sean Keenan will rock the stage as our keynote speaker, exploring the past, present, and future of Prolonged Field Care—don’t miss it!

- Hot topics across the weekend include everything from human factors in prehospital care to marine dangerous animals and mental health for healthcare providers. There’s even a session on high-altitude care for those who like life on the edge!

- Saturday night’s reception at the Penny Black Pub is the perfect way to unwind, chat with experts, and toast to the amazing weekend—don't forget your dancing shoes!

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But that’s not all! This year, we’re rolling out our very first Scientific Forum, featuring poster presentations of original research. Posters will be judged on Saturday (1 February), and the best presentation will win the prestigious Outstanding Research Award. What’s more, accepted abstracts will be published in a special edition of the CoROM Compass Journal in Spring 2025. (Psst… if your poster is accepted, you’ll get a discounted conference rate of just €150—a great reason to submit your research!)

Lock in your spot before 31st October 2024 and get ready for an experience like no other. This is your chance to level up your skills, gain cutting-edge knowledge, and mingle with the best in the business—all while having an awesome time. For all the details, including registration and payment info, head to https://corom.edu.mt/medicine-in-the-mediterranean-2025/. The best news is that CoROM is running a housing bureau to book your conference, meals, receptions and lodging all with one contact.

Calling all sponsors! If you’re looking to get your brand in front of leading remote and austere medical professionals, we’ve got fantastic opportunities for you to showcase your expertise. Join us, and be part of something truly special! Email info@corom.edu.mt to have someone connect to learn more.

We can’t wait to welcome you to Malta for this epic event—see you there!

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Editor’s Notes I am proud to feature another superb medical case report in this issue of the Compass, from CoROM’s own Dr. Slaven Bajic and his colleague Dr. Milan Bozickovic. Dr. Tom Mallinson presents more clinical pearls, while Aebhric O’Kelly offers up tips on medical improvisation in austere settings.

Our cover is graced with a wonderful photo taken by Dr. Glenn Geelhoed during his recent marathon in Iceland. This issue’s Tropical Medicine Update features research I have been waiting many years to see – malaria vaccine trials in adults using the recently approved R21 vaccine. To date, children are the sole beneficiaries of malaria vaccines, but it is only a matter of time before they are approved for use in adults. The first steps toward malaria vaccines for adults have now been taken.

Jason Jarvis MSc 18D NR-Paramedic

page 14

The buzz for the 2025 Medicine in the Mediterranean conference is building daily, and we hope to see many of you in Malta next year.

Jason 7 October 2024

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page 6

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Jason Jarvis is a paramedic and former U.S. Army Special Forces Medic (18D) with years of accumulated experience in countries such as Laos, Burma, Iraq and Afghanistan. He is a freelance medical educator who teaches for CoROM, the U.N., the U.S. Department of Defense, Harborview Medical Center, and Seattle Children’s Hospital. Jason is a PhD student in Widener University’s Health Professions Education program and holds a master’s degree in Infectious Diseases from the London School of Hygiene and Tropical Medicine.

Please address journal correspondence to editor@corom.org.

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Case Report Utilization of POCUS for assessment of optic nerve and elevated ICP in emergency medicine Slaven Bajic

Abstract This case report highlights the critical role of Point-of-Care Ultrasound (POCUS) in the emergency assessment of elevated intracranial pressure (ICP) through optic nerve sheath diameter (ONSD) measurement. We present the case of a 75-year-old female who was brought to the emergency department (ED) in an unconscious state, where the application of POCUS expedited the diagnosis of elevated ICP due to a subarachnoid hemorrhage (SAH).

Introduction

MD, Emergency Medicine Specialist, MCoROM

Milan Bozickovic

MD, Emergency Elevated intracranial pressure (ICP) is a life-threatening Medicine Resident condition that requires prompt recognition and management.

Traditional diagnostic methods, such as computed tomography (CT) and magnetic resonance imaging (MRI), though effective, can be time-consuming and may not always be immediately available.

POCUS offers a rapid, non-invasive, and bedside method to assess elevated ICP by measuring the optic nerve sheath diameter (ONSD). This case report demonstrates the utility of POCUS in diagnosing elevated ICP in an unconscious patient in the emergency setting.

Case Presentation A 75-year-old female was brought to the emergency department by paramedics after being found unconscious at home. According to the paramedics' report, the patient had experienced sudden vomiting followed by a loss of consciousness. On their arrival, they noted the patient’s eyes were deviated to the right side with constricted pupils. The patient was intubated and mechanically ventilated before transport.

Upon arrival at the ED, the patient was admitted to the resuscitation room for further evaluation. BP was 119/70 mmHg, HR 83/min, SpO2 92%. Pupils were 2 mm wide, reactive, without face asymmetry. In the limb area muscle tone was flaccid bilaterally, plantar responses bilaterally in flexion.

During D phase of the primary survey, POCUS was utilized to assess the optic nerve sheath diameter (ONSD). The ultrasound revealed a widened ONSD of 6.4 mm in the right eye, raising suspicion of elevated ICP and prompting an immediate hypothesis of a cerebrovascular event, likely a stroke.

POCUS imagery of optic nerve sheath diameter, oculus dexter

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Following the POCUS assessment, the patient was swiftly transferred to the head CT scan and CT angiography (CTA) of the cerebral arteries. Imaging confirmed the presence of a massive subarachnoid hemorrhage (SAH) caused by a ruptured anterior communicating artery (ACoA) aneurysm.

CT image of the patient

Given the severity of the condition, the patient was transferred to the Neurological Clinic at the University Clinical Center in Ljubljana for specialized treatment.

Discussion This case underscores the vital role of POCUS in the emergency assessment of unconscious patients, particularly in identifying elevated ICP through ONSD measurement. The ability to perform a rapid bedside evaluation in critically ill patients is invaluable in emergency medicine, where time is of the essence. In this case, the use of POCUS enabled the emergency team to quickly suspect a severe intracranial event, which was later confirmed by advanced imaging studies.

The optic nerve is an extension of the central nervous system, and its sheath is continuous with the subarachnoid space. Therefore, an increase in ICP leads to a dilation of the optic nerve sheath. Numerous studies have validated the correlation between increased ONSD on ultrasound and elevated ICP. The standard upper limit for ONSD is generally considered to be 5 mm; however, values above this threshold, particularly in the range observed in our patient, are strongly suggestive of elevated ICP.

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By facilitating an early diagnosis, POCUS can significantly shorten the time to definitive imaging and intervention, potentially improving outcomes in patients with elevated ICP. This case illustrates how the integration of POCUS into the standard resuscitation protocol can enhance clinical decision-making in the emergency department.

Conclusion The use of POCUS for the assessment of elevated ICP in the emergency setting is a crucial diagnostic tool, especially in unconscious patients. In this case, it allowed for the rapid identification of elevated ICP and the prompt transfer of the patient to a tertiary care center for specialized treatment. As this case demonstrates, POCUS should be considered an essential component of the emergency physician's diagnostic toolkit.

Conflict of Interest: The authors have no conflict of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.

References 1. Blaivas, M., Theodoro, D., & Sierzenski, P. R. (2003). Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath. Academic Emergency Medicine, 10(4), 376-381.

2. Moretti, R., & Pizzi, B. (2011). Optic nerve ultrasound for detection of intracranial hypertension in intracranial hemorrhage patients. Critical Care, 15(1), R67.

3. Dubourg, J., Javouhey, E., Geeraerts, T., Messerer, M., & Kassai, B. (2011).

Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and meta-analysis. Intensive Care Medicine, 37, 1059– 1068.

4. Raboel, P. H., Bartek, J., Andresen, M., Bellander, B. M., & Romner, B. (2012).

Intracranial pressure monitoring: Invasive versus non-invasive methods—A review.

Critical Care Research and Practice, 2012, 950393.

5. Geeraerts, T., Merceron, S., Benhamou, D., Vigué, B., & Duranteau, J. (2008). Noninvasive assessment of intracranial pressure using ocular sonography in neurocritical care patients. Intensive Care Medicine, 34(11), 2062-2067.

Dr. Slaven Bajic is an emergency medicine physician with extensive experience in both ER and prehospital settings. He has also worked in remote areas and war zones, including leading the ER at the Role 2E military hospital in Koulikoro, Mali.

He is a certified POCUS ultrasound instructor for COROM, Winfocus and EUSEM. Dr. Bajic is an Emergency Medicine Specialist at Izola General Hospital, Izola, Slovenia.

Dr. Milan Bozickovic is an emergency medicine physician working in the emergency department and prehospital unit. He is a trainee within the Winfocus ultrasound mentorship program, and is passionate about working with POCUS ultrasound and in the delivery of emergency care in high pressure environments.

Dr. Bozickovic is an Emergency Medicine Resident at Izola General Hospital, Izola, Slovenia.

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Clinical Pearls Identifying substance exposure using BAD COLDS and CRESS Identifying chemical, biological, radiological, and nuclear (CBRN) or hazardous chemical (Hazchem) exposures in patients is crucial for timely and effective treatment, ensuring both patient safety and the protection of clinicians.

The mnemonics of BAD COLDS and CRESS allow responders and clinicians to paint a picture in relation to patient exposure to unknown substances in a Hazmat or CBRN situation (JESIP, 2023). The first of these seeks to gather information about the substance, or substances, through its physical characteristics. The second, CRESS, is an aide memoir for common toxidromes.

Tom Mallinson

BSc (Hons) MBChB PGCHE DipMSK (FSEM) MRCGP (2020) MCPara MCoROM DFSEM (UK) FHEA FFRRHHEd FAWM FRGS

BAD COLDS tool for assessing unknown substances is an eight-stage process for gathering information: Behaviour, Appearance, Dissemination, Colour, Odour, Likeness, Deliberate and Symptoms seen in patients.

•BEHAVIOUR - What behaviour is the substance exhibiting? Is it boiling, bubbling or running like water?

•APPEARANCE – What physical state is it in (liquid, solid or gas)? Is it a powder? If so what type (fine powder, granules or crystalline)? Is it a liquid, a gel or a waxy solid?

•DISSEMINATION - How has it been disseminated? Was it thrown, sprayed, or actively spread?

•COLOUR – What colour is it?

•ODOUR – What did it smell like? (Do not seek to smell unknown, potentially hazardous substances) •LIKENESS - Does it have the appearance of something you recognise?

•DELIBERATE - Did the release of the unknown substance look deliberate or accidental?

•SYMPTOMS – Are people exhibiting any signs or symptoms (use the CRESS tool to describe them)?

Gathering this information will help experts in CBRN and Hazchem/Hazmat to identify the substance involved. The CRESS tool provides further assessment in cases where patients are already showing signs and symptoms of exposure to a substance (Barbee, et al., 2019).

CRESS guides us through assessing signs and symptoms to identify a specific toxidrome.

A toxidrome is sometimes referred to as a “clinical fingerprint” caused by a constellation of signs and symptoms results from exposure to a noxious chemical or agent. The CRESS tool can be expanded to include a range of other disorders or toxic agents dependent on your prior risk assessment (Table 2).

In clinical practice the two key differentials to identify in terms of treatment are opioid toxicity (to give naloxone) and nerve agent toxicity (to give atropine and pralidoxime chloride). Biological agents are unlikely to produce rapid symptoms. Exposure to high dose radiation (>6 Gray) may lead to onset of symptoms in under 60 minutes, such as nausea, vomiting, diarrhea, and fever.

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Prompt recognition and identification of CBRN or Hazchem exposures is essential to mitigate health risks, ensure appropriate medical care, and safeguard the well-being of both patients and healthcare professionals. The use of the BAD COLDS and CRESS tools can assist in the identification of such agents.

CRESS TOOL Consciousness (Unconscious, seizures, reduced consciousness or agitated) Respirations (Present or absent, labored, increased or decreased) Eyes (Are pupils: constricted, dilated or normal) Secretions (Dry, normal or increased secretions) Skin (Diaphoretic, dry, hot or cyanotic) Table 1) CRESS Tool. Adapted from (Barbee, et al., 2019)

CRESS

Atropine

Chlorine

Consciousness

Agitated / confused

Normal

Respirations

Increased

Increased

Eyes Secretions Skin

Other Features

Dilated pupils / blurred vision Dry mouth

Normal Increased

Dry / Flushed

Normal

Tachycardia

Gases with strong odours

Cyanide

Nerve Agent

Opioid

Convulsions

Reduced

Increased / apnoeic

Reduced / apnoeic

Normal / dilated pupils

Constricted pupils

Constricted pupils

Normal Normal / cherry red / ashen Rapid onset cardiac arrest, odour of bitter almonds

Increased

Normal

Diaphoretic

Normal / cyanotic

Vomiting, incontinence, bradycardia, headache

Hypotension & bradycardia

Convulsions / unconscious Increased or apnoeic

Table 2) CRESS Tool with selected toxic agents

Works Cited Barbee, G. et al., 2019. Chemical, Biological, Radiological and Nuclear (CBRN) Injury Response Part 2: Medical Management of Chemical Agent Exposure. United States of America.: Joint Trauma System Department of Defense.

JESIP, 2023. Initial Operational Response (IOR) to Incidents Suspected to Involve Hazardous Substances or CBRN Materials. 1 ed. United Kingdom: National CBRN Centre.

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Tropical Medicine Update Moving toward a malaria vaccine for adults

Jason Jarvis MSc 18D NR-Paramedic

The war against malaria has raged for millions of years, a co-evolutionary tit-fortat that has left indelible stamps upon the genes of the various Plasmodium malaria species, as well as upon the DNA of Homo sapiens and other vertebrates.

In the latest victory against this ancient parasite, mankind has harnessed the power of the adaptive immune system in the form of the R21 and RTS,S vaccines.

Both vaccines have been approved for use by the World Health Organization and have rolled out into sub-Saharan Africa. As the vast majority of malaria deaths occur in young children living in this region, the target for these nascent vaccines has understandably been this specific population.

The job of the medical practitioner operating in austere locations is to focus on one or both categories of persons he or she may encounter: 1) the men, women, and children who are native to a particular austere setting, and 2) visitors to these austere settings, whose ranks may include refugees, researchers, soldiers, humanitarians, diplomats, contractors, journalists, film crews, energy sector workers, adventurers, mercenaries, educators, tourists, and so forth. Malaria vaccines have rolled out to curb morbidity and mortality in the first category, but what of the second? It is the issue of extending malaria vaccination beyond their current demographic that this article addresses.

On 6 June 2024, NPJ Vaccines published research on the immunogenicity of R21 in Thai adults.1 This randomised trial by Hanboonkunupakarn et al., aimed to “(1) assess the tolerability, safety, and immunogenicity of R21/Matrix-M in Thai adults, (2) confirm that the co-administration of antimalarial drugs with the malaria vaccine R21/Matrix-M does not reduce the immunogenicity of the vaccine, and (3) assess the pharmacokinetics of the antimalarial drug piperaquine given in this study in combination with dihydroartemisinin and a single low dose of primaquine (SLDPQ) in subjects who concurrently receive R21/Matrix-M .”

This was a phase 2, open-label, computer-randomised, controlled safety, and immunogenicity trial of R21/Matrix-M in healthy, adult Thai participants conducted in the Clinical Therapeutics Unit, Faculty of Tropical Medicine, Mahidol University in Bangkok, Thailand between January and September 2023.1

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Malaria vaccine targets corresponding to parasite lifecycle stages. Includes R21, RTS,S and other malaria vaccine candidates.α

DISCUSSION A combined malaria vaccine and mass drug administration strategy has the potential to accelerate falciparum malaria elimination in low transmission settings.

The R21/MATRIX-M pre-erythrocytic malaria vaccine is a candidate for deployment in such a strategy. The vaccine was safe and well tolerated in combination with dihydroartemisinin-piperaquine-primaquine. There were no severe adverse events associated with R21/ Matrix-M or the antimalarials.

Participants receiving the vaccine combined with antimalarial drugs (Group 1) reported more unsolicited adverse events compared to participants in Group 2 receiving the vaccine only. These adverse events included a range of non-specific complaints. It is unlikely that the combination of R21/Matrix-M with antimalarial drugs triggers specific adverse events. Reassuringly the pharmacokinetics of piperaquine was very similar when administered with or without R21/MATRIX-M .

There is no evidence of pharmacokinetic interactions between R21/Matrix-M and the antimalarial drugs used in the study. R21/Matrix-M was highly immunogenic.1 1 Hanboonkunupakarn B, Mukaka M, Jittamala P, et al. A randomised trial of malaria vaccine R21/Matrix-M with and without antimalarial drugs in Thai adults. NPJ Vaccines.

2024;9(1):124. Published 2024 Jul 6. doi:10.1038/s41541-024-00920-1

The seal of Thailand’s Mahidol University

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Improvised Medicine Cut pants as pelvic binder Pelvic fractures are a catastrophic injury that often presents with massive internal haemorrhage. It is essential to minimise internal bleeding as quickly as possible. For many decades, we have successfully used pelvic binding to deal with this issue.

When I first started in medicine, we used bed sheets. Now, there are far better options with commercial pelvic binders.

But when working in austere environments, we don’t always have them to hand. Therefore, we need to know how to bind a pelvis with an improvised device.

Aebhric O’Kelly M.Psy DTN FRSM FAWM

According to Loftus (2017), the use of cutting combat trousers to create an improvised pelvic binder provided equal pressure to pressures that were measured by commercially accepted pelvic binders.

The pressure needed to close an open-book pelvic fracture is 130 newtons or just over 13 kilos. The SAM Sling has a buckle that automatically engages when 150 newtons, or just over 15 kilos, of pressure is applied. The challenge is how to gauge that pressure when implementing an improvised option.

One important goal is evacuation. According to Howe (2023), all improvised and commercial binders lost pressure after two hours. Therefore, it is imperative to prioritise evacuation to a surgical facility quickly. This means that for those of us working in austere environments, we need to prioritise our pelvic fractures for evacuation. It also means that we may need to re-evaluate our improvised pelvic binder every two hours. We may need to add more pressure since the evidence shows that even commercial pelvic binders lose pressure over time.

References Grimm MR, Vrahas MS, Thomas KA. Pressure-volume characteristics of the intact and disrupted pelvic retroperitoneum. J Trauma 1998;44:454–9. doi:10.1097/00005373199803000-00006 Loftus A, et al. Combat trousers as effective improvised pelvic binders A comparative cadaveric study. J Spec Oper Med 2017;17:35–9. doi:10.55460/1P7E-2OL4 Howe T, et al Mechanical assessment of proprietary and improvised pelvic binders for use in the prehospital environment BMJ Mil Health Published Online First: 04 August 2023. doi: 10.1136/military-2023-002398

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Test Yourself ECG Which of the following best describes this ECG ?

A. Sinus tachycardia B. Junctional rhythm C. First degree atrioventricular block D. Third degree atrioventricular block

Clinical Calculation One of the patients under your care during a protracted cave rescue in Turkey is suffering from congestive heart failure.

The patient weighs 80 kg and you have given her a loading dose of milrinone at 50 μg/kg. Top cover now advises an infusion of this drug at 0.45 μg/kg/ minute. Using a concentration of 40 mg in 200 mL, at how many drops per minute will you infuse the milrinone?

Your intravenous giving set is calibrated to 60 drops per milliliter.

Species Identification A team member has been bitten by a snake while trekking through Panama.

What type of snake is this?

A. Bushmaster

B. Fer-de-lance C. Russell’s viper D. Cantil pit viper

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Test Yourself Clinical Case While assisting with a hurricane relief effort in Cuba, you attend a patient complaining of an intensely itchy rash on one of his feet. The patient is a 37-year-old male who says he lost his shoes while retrieving his children from floodwaters 3 days ago. Symptom onset was 2 days ago.

Based on this patient’s history and symptomology, which of the following conditions do you suspect?

A. Leptospirosis B. Erythema migrans C. Cercarial dermatitis D. Cutaneous larva migrans

Answers will appear in the Winter 2025 Compass

Answers to “Test Yourself” from the previous issue: ECG: A. Pericarditis Clinical calculation: pH = 7.23 Species identification: D. House dust mite Clinical case: C. Anion-gap metabolic acidosis

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Resources A selection of medical references and gear Medical Reference (editor’s pick)

Gear Anykit 4-inch IPS Digital Otoscope with Gyroscope available from anykit.com

$84.99

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The CoROM Cast Episode 106

SOF Education with Bill Vasios https://open.spotify.com/episode/0v95CZhflkTYKYRFj6k7R1 This week, Aebhric O’Kelly interviews Bill Vasios, a physician assistant who started as an 18D and had several other 18-series jobs. Bill is pursuing a PhD in education focusing on instructional design and technology. He is also doing a simulation fellowship at East Carolina University. They talk about online learning, designing a perfect online learning system, the challenges of teaching in the medical field, and the importance of credible sources in education.

HIGHLIGHTS

08:18

Designing an adaptive learning system

12:22

The challenges of teaching in the medical field

14:12

The future of online learning in the medical field

16:24

Balancing online and face-to-face learning

23:51

Creating curriculum for SOF medics

35:10

Selection and Robin Sage

40:47

The SOLCUS program and ultrasound in SF

49:04

Advice for new medics and the importance of continuous learning

53:05

The art of effective teaching and mentoring

56:30

Challenges of ultrasound training and sustainment

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Audio Files A selection of medical podcasts Foxpedition Episode 9

Real-life medical challenges in close protection

https://open.spotify.com/episode/3VM5yYJ3YcUikTIE2Wj07g

Prolonged Field Care Episode 200

Maritime

https://open.spotify.com/episode/1hNR45LJJ9jvOZBVSVJs1P

This Week in Parasitism Episode 238

Eliminating sleeping sickness

https://open.spotify.com/episode/42mYGoov42ToC7jiYkt7Tj

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Envisioning Information

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Journal Watch Electrification and specialist training associated with decreased neonatal mortality and increased admissions in Sierra Leone Acta Paediatrica

Conroy N, Barr DA, Nalley J, Conteh JEM, Mitchell L, Bury G. Electrification and specialist training associated with decreased neonatal mortality and increased admissions in Sierra Leone. Acta Paediatr. Published online September 20, 2024. doi:10.1111/apa.17431

ABSTRACT Aim: The aim of this study was to describe the evolution of a regional neonatal service in Sierra Leone and changes in mortality and service use as it transitioned from a non-specialist service to a dedicated special care baby unit (SCBU).

Methods: This was a retrospective observational study. Anonymised data were taken from the ward admissions books at Bo Government Hospital, and trends in admissions and mortality within the neonatal service were examined for each stage of the department's evolution.

Results: Four phases of the service's development were identified between November 2015 and October 2019. Records of 2377 admissions and 333 deaths were identified. The average number of admissions per month and deaths per month varied by service development phase. There was a trend towards reduced death rates and increased numbers of admissions as the unit evolved into a dedicated neonatal unit with a reliable electricity supply.

Conclusions: The development of an adequately sized SCBU with a reliable electricity supply and specially trained staff was associated with a reduction in the death rate and an increase in admissions.

Incidence of compartment syndrome with routine use of regional anesthesia for patients with long bone fractures Regional Anesthesia and Pain Medicine

Chembrovich S, Ihnatsenka B, Smith C, et al Incidence of acute compartment syndrome with routine use of regional anesthesia for patients with long bone fractures: a large single-center retrospective review from a level I trauma tertiary academic institution. Regional Anesthesia & Pain Medicine 2024;49:505-510.

ABSTRACT Conclusion: Current recommendations on using peripheral nerve blocks (PNBs) in patients at risk for ACS have been mainly based on expert opinion and dated case reports. Due to the nature of the condition, prospective data are lacking.

Our large observational dataset evaluated the risk of missing or delaying ACS diagnosis when PNBs were offered for trauma patients and demonstrated a relatively low incidence of ACS despite the routine use of PNBs under strictly protocolized conditions when patients were managed by a dedicated multidisciplinary care team.

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Journal Watch Limb hemorrhage control failure with counterfeit tourniquets: A Ukrainian war MEDEVAC case report Journal of Special Operations Medicine

Lagazzi E, Bublii R, Bonetti M, Samotowka MA. Limb Hemorrhage Control Failure with Counterfeit Tourniquet: A Ukrainian War MEDEVAC Case Report. J Spec Oper Med. 2024;24(3):67-69. doi:10.55460/60U2-4ATN

ABSTRACT Rapid and effective tourniquet application is crucial in life-threatening limb hemorrhage to minimize mortality. However, the widespread availability of counterfeit tourniquets is a growing concern, as these devices may lack essential quality control measures, potentially compromising patient care. We describe one case where the delayed mechanical failure of a Combat Application Tourniquet (CAT)-like tourniquet caused the death of a Ukrainian soldier during evacuation to an urban trauma center. In April 2022, a 19-year-old male underwent a bilateral below-the-knee amputation from an antipersonnel landmine. Massive hemorrhage prompted the use of bilateral CAT-like tourniquets. During transportation, the right tourniquet's windlass broke, resulting in a brisk hemorrhage. Due to the high patient-to-healthcare-personnel ratio, the bleeding remained unaddressed for an unknown amount of time, resulting in death from hemorrhagic shock. This study underscores the need for robust quality control measures and the establishment of strict regulations against deploying counterfeit tourniquets to avoid preventable deaths.

Appropriate dose of tranexamic acid in the topical treatment of anterior epistaxis, 500 mg vs 1000 mg Science Progress

Arikan C, Akyol PY. Appropriate dose of tranexamic acid in the topical treatment of anterior epistaxis, 500 mg vs 1000 mg: A double-blind randomized controlled trial. Sci Prog.

2024;107(4):368504241264993. doi:10.1177/00368504241264993

ABSTRACT Materials and methods: This phase 4 clinical trial was a randomized, controlled, and double-blind trial. A total of 152 patients were divided into three groups. Group 1 was treated with 1000 mg TXA, Group 2 with 500 mg TXA, and Group 3 with saline.

Results: Based on multinomial logistic regression analysis, the bleeding frequency at the 5th minute was 2.9 times and rebleeding status was 4.3 times less in Group 1 (1000 mg TXA) than in Group 3 (saline). There were no differences between the three groups in terms of side effects or salvage therapy.

Conclusion: In addition to its superiority in treatment, 1000 mg of TXA is recommended because of the decreased rate of recurrent bleeding and low incidence of side effects.

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About CoROM The College of Remote and Offshore Medicine Foundation is an academic not-forprofit organisation for healthcare professionals working in the remote, offshore, military and security industries.

The College was founded in 2016 and is governed by a Board of Regents supported by a faculty of medical professionals from four continents. The College is a Higher Education Institution registered with the Malta Further and Higher Education Authority. License No. 2018-022.

CoROM focuses on the improvement of medical training and the practice of healthcare for those working in remote, austere and resource-poor environments.

What does CoROM specialise in?

Tropical Medicine We provide clinical research and academic training in Tropical Medicine for medical professionals located worldwide.

CoROM provides the Tropical Medicine module for the NATO Special Operations Combat Medic (NSOCM) course at the International Special Training Centre in Pfullendorf, Germany.

Austere Medicine and Prolonged Field Care The tyranny of distance requires that medical professionals working in Africa, Asia and the Middle East must have the ability to provide best practice medicine for extended periods of time.

CoROM focuses on the practice of medicine with limited resources and the ability to improvise whilst providing excellent medical care.

Austere Critical Care The ability to provide care for critically ill casualties must be available regardless of location and resources.

CoROM provides Critical Care Transport curriculum and expands into the provision of critical care in less than ideal environments.

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Who is CoROM working with?

UNITED NATIONS

Calendar SEATTLE

NORWAY

MFSLR Dates TBD

MALTA

AEC 2-5 November ITLS AEC 19-20 December REMT Tropical Medicine Dates TBD APUS ICARE TTEMS RPP104 Commencement Medicine in the Mediterranean conference AREMT CLS/TAC TTEMS APUS ICARE AREMT BSc RPP/Y1 module AREMT BSc RPP/Y1 module

NORTH CAROLINA

11-12 October 14-19 October 2-3 November 4-8 November 11-15 November 18 Nov-7 December 31 January 2025 31 Jan-2 Feb 2025 3-8 Feb 2025 10 Feb 2025 17-21 Feb 2025 22-23 Feb 2025 24-28 Feb 2025 7-12 April 2025 12-31 May 2025 8-13 Sept 2025 27 Oct-15 Nov 2025

TANZANIA

SOMSA Conference 5-9 May 2025 Tactical Medicine Review (Clark, HolmstrØm) Improvised Medicine (O’Kelly, Mallinson, Shertz, Loos) Austere Clinical Laboratory Diagnosis (O’Kelly)

Clinical Tropical Medicine Dates TBD

Degree Programmes

Bachelor of Science Remote Paramedic Practice Master of Science in Austere Critical Care Master of Global Health Leadership and Practice Doctor of Health Studies

Advanced Certificate & Diploma Courses Diploma Remote Paramedic Higher Diploma of Remote Paramedic Practice PG Diploma in Austere Critical Care PG Cert Tropical Medicine & Hygiene Award in Tropical & Expedition Medicine

Online Courses

Critical Care Transport Basics of Resource Limited Critical Care Aeromedical Retrieval Medicine for Extreme Altitude Pharmacology for the Remote Medic Minor Illnesses Course Minor Emergencies Course Tactical Medicine Review

Clinical Placements

Kilimanjaro Christian Medical Center (KCMC), Tanzania Remote clinics, Northern Tanzania Ternopil State Medical University, Ukraine Kibosho District Hospital, Kilimanjaro Ghana National Ambulance Service

ACC AEC ACLS AHA APUS AREMT ATTEMS FiCC IBSC MFSLR

PALS PARSIC PG Cert RMLS RPP104 SOMSA TTEMS

LEGEND Acute Critical Care Austere Emergency Care Advanced Cardiac Life Support American Heart Association Austere and Prehospital Ultrasound Award in Remote Emergency Medical Technician Advanced Tropical, Travel and Expedition Medical Skills Foundations in Critical Care (RPP203) International Board of Specialty Certifications Mastering Fundamentals of Skin Laceration Repair Paediatric Advanced Life Support Prehospital Airway and Rapid Sequence Induction course Postgraduate certificate Remote Medical Life Support Fundamentals of Paramedic Practice (in-classroom) Special Operations Medical Association Scientific Assembly Tropical, Travel and Expedition Medical Skills

For more information about training with CoROM, please visit corom.edu.mt

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Medicine in the Mediterranean 2024 was a resounding success!

Huge thanks to all attendees and the fantastic group of speakers and faculty who made it all possible! We’re making plans for MiM 2025 – please join us.

Call for Speakers: The Medicine in the Mediterranean Conference, sponsored by the College of Remote and Offshore Medicine, is seeking dynamic speakers to present on topics related to prehospital, remote EMT, and austere medicine. The conference will take place from January 31st to February 2nd, 2025, in the historic city of Valletta, Malta.

We are inviting passionate experts in wilderness prehospital care, remote paramedic practice, and austere medicine to share their knowledge and experiences with our diverse audience. Presentations should be engaging, current, and approximately 1 hour in length.

If you are a leader in your field and have valuable insights to offer in these areas, we encourage you to submit your proposal to be a speaker at our conference. This is an excellent opportunity to connect with fellow professionals, exchange ideas, and contribute to the advancement of prehospital and remote medical care.

Submission Guidelines: – Presentation topics should focus on wilderness prehospital care, remote EMT practices, or austere medicine.

– Proposals should include a brief description of the presentation, outlining key points and learning objectives.

– Speakers must be able to deliver engaging and informative presentations that cater to a diverse audience.

– Presentations should be approximately 1 hour in length, including time for Q&A. Important Dates: – Submission Deadline: 1 August 2024 – Notification of Acceptance: 15 September 2024 Please submit your proposal and your CV along with any inquiries to info@corom.edu.mt with the subject line to include “MiM Presentation Idea” by the submission deadline. We look forward to receiving your submissions and welcoming you to the Medicine in the Mediterranean Conference in Valletta, Malta!

Volunteers Wanted Mission to Heal goes where medical need is greatest. We visit remote regions to teach basic surgical skills to local healthcare practitioners so they can care for their community year-round. Due to our educational approach, we need a variety of expertise on these missions. We welcome the following specialists to volunteer with us: Nurse Anesthetists Tropical Medicine Specialists Obstetricians & Gynecologists Optometrists & Ophthalmologists Dentists & Oral Surgeons

General Surgeons OR Nurses Triage Nurses Medical & Dental Students Residents

As you can see, it’s a wide-ranging list – but it’s not all inclusive. If you have a specialty that’s not listed here, but would love to volunteer with us, there is still a place for you!

Why volunteer?

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Get a transformational learning experience where you learn just as much as you teach.

Experience a culture outside of your own.

Experience how healthcare is practiced in other countries.

Use your expertise to benefit the less fortunate.

As one of our volunteers said to us, “We want to volunteer with you because you actually do.”

Useful links: Volunteer with Mission to Heal - https://missiontoheal.org/apply/ Volunteer FAQ’s - https://missiontoheal.org/faqs/ Our approach to missions - https://missiontoheal.org/approach/ Volunteer reflections - https://missiontoheal.org/blog/ Questions about M2H missions – samuel.jangala@missiontoheal.org

2025 Missions:

Kenya I February 7-23 Kenya II April 11-27 Kenya III June 13-29 Kenya IV August 8-24

https://www.masteryourmedics.com/pages/fastcanada2025

Contents: Prolonged field care Tropical medicine Extended formulary EMS drug cards Calculators Snakes & arthropods ACLS & ECGs Paediatric ALS Paediatric diseases OB/Gyn Dentistry Ultrasound Dermatology & STIs Field laboratory Environmental medicine Call-for-evacuation templates Canine medicine …and much more!