The CoROM Compass - Summer 2019

Summer 2019

The official newsletter of the College of Remote and Offshore Medicine Foundation

Summer 2019

CONTENTS

PAGE

About CoROM

3

Dean’s Desk

4

Message from the Academic Board

5

Dr. Andrew Grech on how educational psychology and learning theory underpins the College’s curriculum and courses

Photo Gallery

6

Course Calendar

7

Where Are They Now?

8

CoROM Remote Paramedic student Cory Igo on his work in Guatemala

Faculty Spotlight

10

Q & A with Eirik Holmstrøm

Case Study

12

Stable PSVT with Dr. Francis Sakita

SPECIAL REPORT

13

Q & A on the Malaria Vaccine Implementation Program (MVIP)

Public Health

15

Nicole Foster on the intersection of public health and remote medicine

Trends in Traumatology

16

Jason Jarvis on the use of topical tranexamic acid

Test Yourself

17

ECG, drug calculation, and clinical case

Resources

18

A selection of medical references and gear

Journal Watch

19

Expired Drugs in the Remote Environment Bacterial Infections Associated with Viperidae Snakebites in Children Is Low-Dose Ketamine an Effective Alternative to Opioids for Acute Pain?

Efficacy of the SuperTowel®: An Alternative Hand-washing Product for Humanitarian Emergencies

Book Review

21

The Horrors of Andersonville by Catherine Gourley Cover photo: Pretty Bay, home of CoROM’s Malta teaching facilities

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

The College was founded in 2014 and is governed by a voluntary Academic Board supported by a faculty of medical professionals from four continents. The College is registered with the National Commission for Further and Higher Education of Malta and is a degree granting educational institution.

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?

Contact us

info@corom.org

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Dean’s Desk The College keeps moving from strength to strength this spring semester: We sent five faculty to teach on the NATO Special Operations Combat Medic course in Pfullendorf, Germany.

Farther east, CoROM directed three successful paramedic transition courses in Ternopil, Ukraine as guests of the Minister of Health. In addition, we ran the tactical medicine workshop and the first-ever malaria diagnostic workshop at the 2019 Special Operations Medicine Scientific Assembly in Charlotte, North Carolina.

Aebhric O’Kelly 18E MA FAWM DipPara CCP-C TP-C

These accomplishments are achieved by the dedication and passion from our faculty. Any successful college can only gain these achievements from the hard work of the members of the educational team. CoROM maintains its upward trajectory due to the high calibre of each faculty member.

As a not-for-profit academic institution, all our faculty work part time for the College.

Each of them are clinically-relevant and currently work as medical professionals. They bring recent patient experiences into the classroom and pass along their knowledge by using real-world clinical practice.

It is my honour to work with these professionals. I am awed at the knowledge, capability, experience and passion that I see from our college faculty. Our graduates are the amongst the best in the industry due to the level of instruction that they receive on our programmes and the passion shown by our faculty.

Aebhric O’Kelly manning the CoROM booth at the 2019 Special Operations Medicine Scientific Assembly

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Message From the Academic Board Dr. Andrew Grech on how educational psychology and learning theory underpin the Dr. Andrew Grech College’s curriculum and courses MD MSc MRCSEd PGCME MAcadMEd The majority of students at the College of Remote & Offshore Medicine are experienced, adult learners who have already worked – or are presently working – in the busy healthcare field.

This means that College programmes must often be squeezed into a hectic life packed with rotas, schedules and rosters.

CCP-C FP-C TP-C CoROM Co-founder and Advisory Board Member

The Academic Board appreciates students’ commitments and has its own commitment to students. We strive to ensure that the learning processes endorsed and applied by the College are driven by best practices in adult medical education and learning theory – meaning our courses are designed to be efficient for adult learners and those with already established experience and knowledge, as well as those just beginning their venture into the exciting world of specialty remote care.

Two theories our Academic Board weave into CoROM course design to make our programmes as effective as possible are experiential learning and constructivist theory. These provide useful concepts for the novice or veteran of medical education.

Experiential learning was first proposed by educational psychology pioneer Carl Rogers in 1969. Its core tenet is simple – the brain cannot properly imagine what the body has never done. This principle is the basis for CoROM’s emphasis on mastery learning of technical and non-technical skills alike. Subject matter is painstakingly designed to pique students’ interests and trigger self-initiated learning loops for long-lasting learning; faculty promote comfortable learning environments with low threat levels to accelerate learning and make the process of assimilating a high cognitive load as efficacious as possible for our students.

Constructivist philosophy is implied by its name – this school of thought advocates the construction of new knowledge and comprehension based upon the foundation of a learner’s own existing knowledge.

Successively higher skillsets are built up from older abilities and students are left empowered and satisfied at having directed their own learning and accommodated new information via literal assimilation. This approach to teaching and learning goes hand in hand with the development of problem-solving skills via problem-based learning, which our faculty recognises as essential for future course graduates working in austere healthcare contexts.

The Academic Board at our College is not simply a team of educators. We recognise the challenges that learning at this level can present and have taken the time to develop a robust approach to education from which every potential student can derive learning value. Both personally and on behalf of the board, I would like to invite any person with even a fleeting interest in remote and offshore medicine to take the plunge and get involved with what we have to offer. There is a distinction between teaching and facilitating education – get in touch to find out more!

Dr Andrew Grech is a founding member of CoROM and member of the Academic Board. Andrew is an anaesthetics and intensive care registrar with a passion for remote, austere and wilderness medicine.

He holds a Master of Science degree in Internal Medicine from the University of Edinburgh and is a Member of the Royal College of Surgeons of Edinburgh. Andrew is also a Member of the Academy of Medical Educators and holds a Postgraduate Certificate in Medical Education from the University of Dundee, as well as maintaining flight, critical care and tactical paramedic certification with the International Board of Specialty Certification. His interests include critical care echocardiography, resuscitation and trauma care, outcomes after critical illness and pursuing Academy of Wilderness Medicine fellowship credits!

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Photo Gallery

Moulaged patient at a field training exercise

Aebhric O’Kelly assists students at the 2019 Special Operations Medicine Scientific Assembly malaria workshop

CoROM scouted Tunisia’s Institut Pasteur in April 2019

Prototype copy of the CoROM 2nd edition field guide

Suturing skills lab

Wound debridement skills lab

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Course Calendar TERNOPIL STATE MEDICAL UNIVERSITY, UKRAINE ITLS 19-21 June

MALTA Foundations in Crit Care 7-11 Oct CC-P 14-19 Oct Remote EMT 18-23 Nov TTEMS 25-29 Nov Advanced TTEMS 2-6 Dec RAMS 9-13 Dec CRP March 2020

SEATTLE

TANZANIA

Suturing Fundamentals 12 June

CRP 15 July-3 Aug TTEMS 5-9 Aug

LEGEND CC-P: International Critical Care Paramedic (with optional pre-study week) CRP: CoROM Remote Paramedic* NSOCM: NATO Special Operations Combat Medic course RAMS: Remote Advanced Medical Skills RMLS: Remote Medical Life Support SOMSA: Special Operations Medicine Association Scientific Assembly TTEMS: Tropical, Travel and Expeditionary Medical Skills * The CRP course also includes 20-30 weeks of online training, plus a 400-hour clinical rotation.

Advanced Certificate and Diploma Courses

Online Courses

Higher Diploma in Remote Paramedic Practice Postgraduate Certificate in Austere Critical Care

Pharmacology for the Remote Medic Minor Illnesses Course Minor Emergencies Course Tactical Medicine Review Level 3 Health and Safety for the Workplace Level 3 Food Safety for the Workplace

Clinical Placements Kilimanjaro Christian Medical Center (KCMC), Tanzania Remote clinics, Northern Tanzania Accident and Emergency, St. Mary’s Hospital, UK HEMS and ambulance placement, Budapest, Hungary

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

Please address newsletter correspondence to editor@corom.org.

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Where Are They Now? CoROM Remote Paramedic student Cory Igo on his volunteer work in Guatemala Cory Igo completed the CRP course in Tanzania during the summer of 2018.

Cory Igo CRP student

From March 18 to April 17, 2019 I worked as a medical volunteer in Quetzaltenango, Guatemala. It is the second largest city with a population of around 150,000 people. The city is in the mountains and is a 4-hour bus drive from the capital. The official language is Spanish, and it was quite rare to meet anyone who spoke English.

My primary work was with the volunteer fire department’s ambulance service. During my time with them we encountered patients with everything from multiple gunshot wounds to a cotton applicator stuck in the ear. The ambulances were poorly equipped. Most of the equipment we brought was in one of two gym-style duffle bags. We did not have a quick resupply area or auxiliary store room so we had to be very conscious of what we used. The bags contained mostly basic equipment from airway adjuncts, splints, BVM, normal saline, sterile water, gauze, etc.

Most of the work we performed was simply patient transport as many of the patients did not need serious interventions. The most common interventions we provided were splinting, wound dressing, Cspine immobilization, and bandaging. Nearly all our patients who required interventions were motorbike accidents and people falling as a result of alcohol intoxication.

In addition to the ambulance service, I also worked in a public clinic during my time in Quetzaltenango.

There we gave vaccinations, distributed medications, and conducted general patient assessments. Many of these patients were pregnant women or new mothers with children between the ages of 1 month to 5 years. During my time in the tuberculosis clinic, the local providers explained to me that the problems with tuberculosis in the region were due to densely populated areas and the consumption of uncooked meats and unprepared milk. Any person with a cough for more than 15 days was urged to come to the clinic and give a sputum sample; the next day they should return and give another sputum sample early in the morning before consuming any food or drink. The clinic’s treatment regimen involved a variety of antibiotics given over a span of over six months.

**** Cory Igo volunteering onboard an ambulance in Quetzaltenango, Guatemala

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Two of the more interesting cases I saw in Guatemala were as follows: Our ambulance responded to a man who had reportedly been stabbed in a nearby village. When we arrived, he was at the police station with the wound already dressed. We exposed the wound, cleaned it and the area surrounding it, and applied a dressing while transporting him to the hospital. At the hospital a surgeon wearing sterile gloves inserted his hand into the wound and probed with his fingers under the skin to the approximate area of where a chest tube would be inserted. I was impressed with this mostly because the surgeon performed this procedure without the use of any analgesics or anaesthetics, and the patient did not display any signs of pain or distress.

On a separate occasion, we responded to a 17-year-old male patient who was unresponsive at his home after playing a football game. He did not respond to verbal commands or pain, and his eyes did not respond to light, so we quickly transported him. While the patient was breathing, his pulse oximetry read 76% with a pulse of 216. The local paramedic began compressing the patient’s chest with one hand while ventilating at a 15:2 ratio. By the time we arrived at the clinic, the patient’s oxygen saturation had risen to 91% and his pulse rate had dropped to 188, and the patient had become responsive to verbal commands.

Cory Igo providing patient care in Guatemala

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Faculty Spotlight Q and A with Eirik Holmstrøm Eirik Holmstrøm is a Norwegian Military Flight Paramedic, U.S. Board Certified Critical Care Paramedic and Tactical Paramedic.

He has deployed several times to places such as Bosnia, Iraq and Afghanistan. Since 2014 he has been working at the International Special Training Center (ISTC) in Germany as a senior officer and instructor at the NATO Special Operations Combat Medic (NSOCM) course.

Eirik Holmstrøm Norway Military Flight Paramedic CCP-C TP-C CoROM Faculty

What aspect of CoROM motivated you to join the College?

I met CoROM when they were engaged by the ISTC to teach the tropical and austere medicine for NSOCM. The knowledge, professionalism and passion they displayed impressed me. CoROM's way of teaching health professionals to performing medicine in the wilderness with few resources is impressive. I was especially motivated by the opportunity to join CoROM's courses in Tanzania, both to learn but also to participate in the projects and courses that are held there.

What is your favorite teaching topic at CoROM? I have not yet had the opportunity to teach for CoROM but look forward to the first course in Tanzania this July and August. My favourite topic of instruction is the performance of field blood transfusions.

More and more people are now seeing the possibility of using blood as the primary fluid for bleeding shock in the acute phase of resuscitation. As Philip Spinella said, “Blood is for bleeding, saltwater is for cooking pasta.” (https://www.researchgate.net/publication/332404622)

Where would you like to see CoROM go in the next five years?

Today there are many different systems of education that lead to paramedic certification without necessarily being approved across all European countries. I hope CoROM becomes a contributor that influences this paradigm and, in the future, can provide education that is approved across all borders.

Eirik at the annual NATO Special Operations Combat Medic course in Pfullendorf, Germany

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Describe a medical case that has had a lasting impact on you.

One night in February 1991 I was working as a newly-graduated EMT in a mountain village in Norway.

It was 200 km by car to the nearest hospital. My partner, local doctor and I were called out for an imminent birth in which the pregnancy was at 26 weeks. Air ambulance was not available due to a snow storm. When we arrived, delivery had already occurred, with the infant in cardiac arrest. I felt helpless but with the quick actions of an experienced colleague and doctor, the child was resuscitated and transported 200 km through a snow storm to the hospital. This event motivated me to constantly search for more knowledge and education to be fully prepared when needed. My wife and I welcomed our first-born in the same year, and the successfully-resuscitated child was in the same class as my daughter during primary and secondary school.

What are your top three go-to references for remote deployments?

Since I strongly endorse field blood transfusions, the THOR (Trauma Hemostasis and Oxygenation Research) website is a must (https://rdcr.org/). THOR contains virtually everything concerning research, upcoming events and teaching for blood transfusion. In addition, there are two websites I often reference: Prolonged Field Care (https://prolongedfieldcare.org/) and Deployed Medicine (https://deployedmedicine.com/). These websites are geared toward military medical practitioners but contain valuable material for civilians too. Of course, I must also mention CoROM's field guide which is always with me ☺.

Eirik Holmstrøm at the Mountain Emergency Medicine course in Zermatt, Switzerland

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Case Study Stable PSVT with Dr. Francis Sakita Greetings from Tanzania,

In this edition, I will share a self-referred case from home. She was a 43 years old lady with a history of heart beat awareness, general body malaise and on and off sweating for the past one week. She denied history of chest pain, difficulty in breathing or fever. Primary survey was unremarkable except for a feeble fast pulse and tachypnoea. Her past medical history was negative for hypertension or diabetes or thyroid diseases.

Dr. Francis Sakita MD, MMED Emergency Physician Head of ED-KCMC CoROM Faculty

Her vitals: BP 128/86 mmHg, HR 189 b/min, RR 24 b/min, Oxygen saturation in room air 99%, Temp 36.5⁰C. Secondary examination was unremarkable. Bedside ECG was performed (figure 1). A diagnosis of stable Paroxysmal Supraventricular Tachycardia (PSVT) was reached and a modified Valsalva maneuver was applied unsuccessfully. IV adenosine was sought, whereby IV adenosine 6mg push could not break the tachycardia the first time. 12mg push of IV adenosine was then used and we managed to convert her into a normal sinus rhythm (figure 2).

Figure 1. ECG on arrival.

Figure 2. ECG after administration of 12 mg adenosine fast IV push.

This was an interesting case which if we would have missed the diagnosis the patient would have become unstable and could have died of something that is treatable. Takeaway points: thorough history-taking and examination, checking of vital signs and bedside EKG were key in the management of this case.

Quiz: What are the different types of supraventricular tachycardia? What is the maximum dose of IV adenosine that can be given? (Look for the answers in the in next edition). Until next time, happy reading!

Reference: eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-7-adultadvanced-cardiovascular-life-support/

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SPECIAL REPORT World Health Organization Q & A on the Malaria Vaccine Implementation Program (MVIP) https://www.who.int/malaria/media/malaria-vaccine-implementation-qa/en/

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Three countries – Ghana, Malawi, and Kenya – are participating in the Malaria Vaccine Implementation Program (MVIP)

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Public Health Nicole Foster on the intersection of public health and remote medicine Public Health can be defined as “Activities that society does collectively to assure the conditions in which people can be healthy. This includes organised community efforts to prevent, identify, pre-empt, and counter threats to the public’s health.” Simply put, it is a community-based approach to health, rather than focusing on the individual.

Nicole Foster BSc, CCP-C, CiiSCM, MPHTM FAWM candidate CoROM Faculty

Modern public health has its roots in the 1850s with the outbreak of a cholera epidemic in London and the work of John Snow (He knew something…). Snow adopted and advocated for modern medical hygiene practices and was a leader in modern epidemiology. After mapping and studying the pattern of cholera cases, he identified that people were becoming ill from a particular water pump. From there, Snow persuaded the local council to remove the handle of the Broad Street pump, preventing the public from drawing water and as legend has it, effectively stopping the cholera epidemic (although legend, the story is a bit more complicated than that!).

Public health has come a long way since then, and includes activities designed to improve the quality of life and prevent illness. Epidemiology, biostatistics, environmental and occupational health, health promotion, communicable disease control, disaster health management, waste management, water, sanitation and hygiene and advocation of policy change to improve community health are all considered subjects under the public health banner.

There are a few major accomplishments in the name of public health, and this is a ’10 great’ achievements of the century from the American CDC: Vaccination Motor-vehicle safety (seatbelts) Safer workplaces Control of infectious disease Decline in deaths from coronary artery disease and stroke Safer and healthier foods Healthier mums and babies Family planning Fluoridation of drinking water Recognition of tobacco as a health hazard On a smaller scale, why should public health matter to you? You may be working on a remote oil platform in the North Sea, or at a mine site in the wilderness of Alaska, or leading a group of trekkers on an expedition. You have a group of people that you are responsible for – you have a community. It’s in the best interest of that community that everyone stays healthy (gastro outbreak in a confined environment is not fun). It is your responsibility to ensure the health of not only each individual, but the community as a whole. http://guides.lib.berkeley.edu/publichealth/whatisph/achievements https://www.phaa.net.au/documents/item/3241

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Trends in Traumatology Jason Jarvis on the use of topical tranexamic acid Tranexamic acid (TXA), the wonder drug of the modern era, continues to be used in new and innovative ways. TXA is a procoagulant drug that blocks the formation of clot-busting plasmin from plasminogen.

First synthesized in Japan in 1962, it was initially used to reduce menstrual bleeding, and for the reduction of haemorrhage during tooth extractions.

TXA eventually gained the attention of the military medical community, who correctly ascertained its potential for saving lives on the battlefield.

Besides TXA’s membership in the WHO Model List of Essential Medicines, the 2010 landmark CRASH-2 study1 was all the proof anyone needed that injectable TXA belonged in the hands of all deployed medics and corpsmen.

2017 ushered in TXA’s next major clinical trial: WOMAN2 (Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage), the findings of which pinned yet another feather onto the cap of TXA: “Tranexamic acid reduces death due to bleeding in women with postpartum haemmorhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.”

Jason Jarvis 18D BS NREMT-P TP-C CoROM Tropical Medicine Lead The Compass editor

Shosuke and Utako Okamoto, the husband and wife research team that discovered TXA in 1962

Beyond the CRASH-2 and WOMAN trials, ongoing experience and research has demonstrated success with TXA applied topically in cases such as epistaxis3 and orthopedic4 surgeries. A field clinical vignette presented at the April 2019 Special Operations Medicine Scientific Assembly described the topical application of TXA to a patient with catastrophic ocular trauma. Following the vignette, a prominent trauma surgeon in attendance affirmed that the use of topical TXA had been a good call, and that it is a technique she uses as well.

At this point in time – as evinced by the absence of the topical route for TXA in either the Medscape or Epocrates drug guides – the technique of applying TXA topically would appear to be an off-label option for which permission should be requested from top cover.

1. https://www.ncbi.nlm.nih.gov/pubmed/20554319 2. https://www.thelancet.com/journals/lancet/article/PIIS01406736(17)30638-4/fulltext 3. https://www.ncbi.nlm.nih.gov/pubmed/30577703 4. https://www.sabm.org/wp-content/uploads/2018/08/Montroy-2018Meta-topical-TXA.pdf

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Test Yourself ECG Your 23-year-old patient presents to your clinic with a recent onset of convulsions. Based on her ECG, she is most likely suffering from which electrolyte disorder?

A. Hypocalcemia B. Hypokalemia C. Hypermagnesemia D. Hypernatremia

Drug Calculation While assigned to a UN peacekeeping compound in South Sudan, you begin treating a 55-year-old 80kg engineer for stable monomorphic ventricular tachycardia. For this case, your CPGs call for a procainamide infusion at 40 mg/minute to a maximum dose of 17 mg/kg. You have 1 gram of procainamide on hand and begin immediate transport via armored motorcade to a Level 3 UN hospital in Juba that is 20 minutes away. Will you have enough procainamide for the trip, assuming that the arrhythmia is not fully suppressed by the drug?

Clinical Case A 12-year-old refugee girl presents to your remote clinic in Bangladesh. You have previously treated her and many other refugees for giardiasis over the past eight months. You note that she has not gained weight since you last saw her four months ago.

Today she complains of chronically dry eyes, loss of night vision, and frequent minor skin infections. Based on her clinical picture, she is most likely suffering from which nutritional disorder?

A. Scurvy B. Vitamin A deficiency C. Vitamin B12 deficiency D. Pellagra Answers will appear in the Autumn edition of The Compass.

Answers to “Test Yourself” from the previous issue: ECG: Pericardial effusion (electrical alterans on ECG) Drug calculation: 0.16 mL of epinephrine 1:1000 Clinical case: Recluse spider bite

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Resources A selection of medical references and gear Medical References (Eirik Holmstrøm’s picks)

Gear

SOF® Tourniquet Generation 4 (SOF®TT-W) available at tacmedsolutions.com

From Tactical Medical Solutions comes an upgrade to their flagship Special Operations Forces Tactical Tourniquet-Wide (SOFTT-W).

While the SOFTT-W has been Committee on Tactical Combat Casualty Care (CoTCCC) approved for several years, its makers continue to innovate.

Gen 4 upgrades include: additional retention clip, 5.5” anodized aluminum windlass, quick-compression buckle, and reinforced material.

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Journal Watch Expired Drugs in the Remote Environment Wilderness and Environmental Medicine.

2019; 30(1): 28-34. https://doi.org/10.1016/j.wem.2018.11.003 Emma Browne, et al.

CONCLUSION The results suggest that the studied drugs [atropine, nifedipine, flucloxacillin, naproxen, and bendroflumethiazide] may be stable beyond expiry, even when not maintained in strictly temperaturecontrolled conditions.

This study was carried out on drugs being shipped from the UK to the British Antarctic Survey Medical Unit. The drugs spent three weeks in the tropics without temperature control.

Bacterial Infections Associated with Viperidae Snakebites in Children: A 14-Year Experience at the Hospital Nacional de Niños de Costa Rica The American Journal of Tropical Medicine and Hygiene.

Volume 100, May 2019, Number 5, pages 1227-1229. https://doi.org/10.4269/ajtmh.18-1015 Helena Brenes-Chacón, et al.

ABSTRACT Secondary bacterial infections following Viperidae snakebite envenomation in children are common.

Among 75 patients admitted because of snakebites at the only pediatric hospital in Costa Rica, 16 (21.3%) had a culture-confirmed secondary bacterial infection. Morganella morganii (37.5%), Aeromonas hydrophila (31.2%), and Providencia rettgeri (18.7%) were the most common pathogens.

Empiric prophylaxis is still recommended and should be based on local etiological agents and antimicrobial susceptibilities.

M. morganii is a Gram-negative commensal bacteria normally found in the intestinal tracts of mammals and reptiles.

The fer-de-lance, or Bothrops aster, is a common viper in Central America.

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Journal Watch Is Low-Dose Ketamine an Effective Alternative to Opioids for Acute Pain?

Annals of Emergency Medicine.

May 2019, Volume 73, Issue 5, Pages e47-e49. https://doi.org/10.1016/j.annemergmed.2018.11.001.

Jonathan M. Kirschner, MD; Benton R. Hunter, MD

TAKE-HOME MESSAGE In adult emergency department (ED) patients with acute pain, low-dose intravenous ketamine (0.3 to 0.5 mg/kg) may provide pain relief within 10 minutes that is similar to that of single-dose intravenous morphine (0.1 mg/kg).

Efficacy of the SuperTowel®: An Alternative Hand-washing Product for Humanitarian Emergencies The American Journal of Tropical Medicine and Hygiene.

Volume 100, May 2019, Number 5, pages 1278-1284. https://doi.org/10.4269/ajtmh.18-0860.

Belen Torondel, et al.

ABSTRACT Handwashing with soap reduces the transmission of diarrheal pathogens, but access to hand-washing facilities, water, and soap in humanitarian emergencies is limited. The SuperTowel® (ST) is a fabric treated with permanent antimicrobial bonding and has been designed as a soap alternative in emergency situations. The aim of this study was to test the efficacy of the ST as a hand-cleaning product. Two sets ® of laboratory tests, with 16 volunteers in each, were conducted to test The SuperTowel is available at realreliefway.com the efficacy of different protypes of the ST. Volunteers pre-contaminated their hands with non-pathogenic Eschericia coli. Comparisons were made between hand cleaning with the ST and handwashing with the reference soap, using a crossover design…The ST prototypes used less water than handwashing with soap, were well accepted, and were considered preferable in communal settings. The ST has the potential to be a suitable complementary hand-cleaning product for humanitarian emergencies.

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Book Review The Horrors of Andersonville: Life and Death Inside a Civil War Prison

By Catherine Gourley Twenty-First Century Books, 2011

Review by Jason Jarvis From prolific author Catherine Gourley comes a visceral accounting of one of the darkest humanitarian tragedies in the history of the United States. The Horrors of Andersonville recounts the travails of the thousands of Union prisoners-of-war who lived, starved, and died in a hastilyconstructed open stockade in the backwaters of Confederate Georgia. Indeed, the prison commandant – Captain Henry Wirz – was the only man tried, convicted, and executed for Civil War crimes, despite his numerous yet futile attempts to garner more resources for the prison from the Confederate government.

Designed to house up to 10,000 Union prisoners, Andersonville’s population ultimately swelled to 32,000, and nearly 15,000 men died in the 14 months that the prison remained open. The deaths were mainly attributable to starvation, exposure, and disease, though many prisoners died at the hands of overzealous guards. A prisoner gang known as the Raiders stole from, beat, and sometimes killed their fellows for want of scarce resources. Lice infestation, dysentery, and scurvy all conspired to make an appalling situation worse than imaginable.

Drawing from diaries and first-hand accounts, Gourley shows that, while Andersonville was undoubtably the nadir of human suffering in its time, Confederate POWs were contending with the North’s own brand of mistreatment. And she has not been the first researcher to cast doubt upon the justification of the North’s execution of Captain Wirz.

“On June 16, John W. Urban entered the gates of Andersonville.

He gaped in horror at what he called a ‘hell-hole.’ The rain was relentless, and the mud was ankle-deep. So crowded was the space that Urban could not believe there was room for even one more man. The gates closed behind him just the same.”

Catherine Gourley is the national program director for Letters About Literature and an award-winning author of more than 30 fiction and non-fiction books for children, young adults and adults.

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COMING SOON Remote and Austere Medicine Field Guide for Practitioners, 2nd edition Contents: Prolonged field care Tropical medicine Extended formulary Snakes and arthropods ACLS & ECGs Paediatric ALS & diseases OB/Gyn Dentistry Ultrasound Dermatology & STIs Field laboratory techniques Environmental medicine …and much more!