Winter 2024 Compass

The Journal of the College of Remote and Offshore Medicine Foundation Winter 2024, Volume 7, Issue 21

Winter 2024, Volume 7, Issue 21

CONTENTS

PAGE

Dean’s Desk

3

Editor’s Notes

5

Clinical Pearls

6

Tropical Medicine Update

8

Improvised Medicine

18

Trends in Traumatology

20

Test Yourself

23

Resources

25

Audio Files

26

Envisioning Information

27

Journal Watch

31

Hydrocele etiologies

Combating mosquito-borne diseases: R21, Qdenga, and Ixchiq vaccines

3D-printed medical kit

The initial management of modern battlefield ballistic facial injuries

ECG, clinical calculation, species identification, and clinical case

A selection of medical references and gear

Bedside Rounds, The Medicine Grand Rounders, Anatomy & Physiology

Khan Academy, Life in the Fast Lane

2023 American Heart Association focused update on ACLS support WHO officially recognizes noma as a neglected tropical disease Scorpion stings in Minas Gerais (Brazil): a monocentric retrospective study Pain control and point-of-care ultrasound: an approach to rib fractures

About CoROM

30

Calendar

32 Malta’s La Valette Hall.

Formerly Sacra Infermeria’s Great Magazine Ward, located in the basement of the infirmary.

The Knights of St. John used the 109 beds to care for sailors and soldiers of the Order, as well as galley-slaves.

Photo credit: Mediterranean Conference Centre

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Dean’s Desk Embracing Growth, Excellence, and a Bright Future As we bid farewell to 2023, I am delighted to extend my heartfelt wishes for a joyous and prosperous New Year.

The start of a new year is not only a time for reflection but also an opportunity to look forward to the exciting possibilities that lie ahead.

In the spirit of progress and development, I am thrilled to share significant updates that will shape the future of our institution. Over the past year, our college has experienced measured growth, marked by advancements in educational excellence and an expanding student body.

These achievements stand as a testament to the collective efforts and steadfast dedication of our esteemed faculty and staff.

John Clark

JD MBA NRP

As we step into this new year, I reiterate our commitment to providing the highest quality education, equipping our students with the skills and knowledge essential for success in an increasingly complex world. Excellence is not merely a goal but an ongoing journey, and I am confident that together, we will set new benchmarks and elevate our standards of academic achievement.

Acknowledging that growth brings change, I am pleased to announce the addition of several new staff and faculty members to our academic community. While we welcome new faces, we also bid farewell to a founding member, Anna O’Kelley, who has played a pivotal role in shaping the College over the past seven years.

Her fingerprints are all over much of the processes and even in her absence, you will still see emails from her and reminders that have her name on them as we slowly revise processes and change systems that she had set up. We express our gratitude for her dedication and selfless commitment to the well-being of our students. Well done.

To bolster our student services, we welcome Angela Jedlicka, RN, MSN, EMT, as our new Registrar. Angela brings enthusiasm and a deep commitment to CoROM's mission. In her role, she has facilitated the transition to DreamClass, enhancing our student information system for a more streamlined application process and improved management of grades, transcripts, and student progress. Angie is a full-time bedside RN in a critical access hospital for the United States Indian Health Services in the American Southwest.

Eirik Holmstrøm, a retired Captain from the Norwegian Armed Forces and a paramedic in Kongsberg, Norway, now leads classroom facilities in Pretty Bay and coordinates online courses, short courses, and offsite training programs. His wealth of knowledge and operational expertise adds tremendous value to CoROM. Our Bachelor programs receive additional support with the inclusion of Mike Morrow, a seasoned paramedic with extensive experience in both urban and remote settings, having spent almost a decade as a flight paramedic out of Bethel, Alaska. He collaborates with the team to support students across various years of the program.

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We have also brought on two amazing individuals as faculty: First, Dr. Will Smith, MD, Paramedic, FAEMS, FAWM will primarily be involved with the Master of Science in Austere Critical Care programme. Dr. Smith is an emergency department physician at St. John’s Health in Jackson, Wyoming, USA, a Clinical Assistant Professor at the University of Washington School of Medicine (Seattle, Washington, USA), a Colonel in the U.S. Army Reserve Medical Corps, and serves as the Medical Director for the U.S. National Park Service, is a CoMedical Director and EMS physician for Grand Teton National Park, Teton County Search & Rescue, Bridger Teton National Forest, and Jackson Hole Fire/EMS in the USA. Second is Dr. Fenella Corrick, BMBCh, PhD, MRCGP, AFHEA. Dr Corrick gained her medical degree from the University of Oxford. She is a General Practitioner and Emergency Medicine doctor in Rural Scotland who in her free time responds to prehospital emergencies for the Scottish Ambulance Service as a volunteer for BASICS Scotland. She has served as a Mountain Rescue doctor for teams in England and Scotland. She has postgraduate qualifications in Primary Care, Musculoskeletal Medicine and Paediatrics, as well as a PhD from the University of Nottingham. Dr. Corrick has experience teaching and supervising students at both undergraduate and postgraduate level. Ella will be working with Dr. Aslanidis in the Doctorate in Health Studies program and coordinating student research.

Our student body, now exceeding 100 enrolled students, is a testament to the trust and confidence the community places in our institution. As we welcome new students, let us continue fostering an inclusive and supportive environment that nurtures their intellectual curiosity and passion for learning.

In conclusion, let us approach the coming year with enthusiasm, resilience, and a shared commitment to the values that define our institution. Together, we will navigate new territories, achieve milestones, and build a legacy of educational excellence.

Thank you for your unwavering dedication and hard work. Here's to a year filled with growth, success, and the realization of our collective aspirations.

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Editor’s Notes 2023 turned out to be a great year, both professionally and from a broader public health perspective.

I am overjoyed to have at last completed my Master’s degree program in Infectious Diseases from the London School of Hygiene and Tropical Medicine. My final project report was written on up-and-coming malaria vaccines, and I am happy to report that one of the leading vaccines – R21 – was just WHO-approved for clinical use in sub-Saharan Africa. Besides the R21 malaria vaccine, the Qdenga vaccine now exists as a powerful tool in our arsenal against the dengue virus, and even the modest mosquito-borne virus chikungunya has been knocked down a peg with the advent of the Ixchiq vaccine. On page 8 of this journal I detail the basic science of these mosquito-borne diseases and the outlook for these new vaccines.

Jason Jarvis MSc 18D NR-Paramedic

page 29

The indefatigable Dr. Geelhoed returns to The Compass with a primer on hydrocele etiologies in the tropics, and Aebhric O’Kelly expounds upon the value of 3D printers in the austere medical environment.

I hope that many of CoROM’s students and faculty will find the time to turn out for our first-ever Medicine in the Mediterranean conference, running in Valletta, Malta from 2-4 February. To all readers of The Compass, I wish a happy 2024.

page 24

Sincerely,

Jason

page 27

5 January 2023

page 15

Jason Jarvis is CoROM’s Press Chair and Tropical Medicine Programme Lead. He is a paramedic and former U.S. Army Special Forces Medic (18D) with years of accumulated experience as an austere primary care practitioner in resource-poor countries such as Laos, Burma, Iraq and Afghanistan. He recently completed his second transect of Africa, teaching predeployment medicine courses for UN peacekeeper clinicians in Ghana, Rwanda and Kenya. Based in Seattle, Jason is a freelance medical educator who teaches advanced trauma courses, minor surgical procedures, ACLS for Experienced Providers, and PALS. He has presented several times at the Special Operations Medical Scientific Assembly, and is an article reviewer for International Health. Jason 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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Clinical Pearls Hydrocele etiologies 'Hydrocele' is a term that describes a collection of a watery fluid from a secreting cystic lining. It is usually used to denote a collection of liquid around a testis. There are two major distinctions: the first is congenital. When the peritoneal reflection around the testis as it descends into the scrotum has no connection to the intra-abdominal peritoneum, this is called a congenital hydrocele.

Glenn Geelhoed

MD, AB, BS, MA, DTMH, MPH, MPhil, EdD, ScD, FACS, MAMSE

Often, it may be associated with a track of residual peritoneal remnant that is called a 'patent processus vaginalis' which is a descriptor of the track of peritoneum left behind, and in some instances, still capable of letting watery secretion through from the area around the testis back into the peritoneum. It is necessary to distinguish this from an indirect inguinal hernia with much the same embryologic developmental history.

The two most common congenital defects in the groin in infants, therefore, are indirect inguinal hernia and hydrocele.

A second form is an acquired hydrocele and that typically is found in areas where there is a high prevalence of filariasis, also known, perhaps less accurately but more descriptively, as elephantiasis. Uganda is one such region where a filarial worm known as Wuchereria bancrofti is endemic from mosquito transmission.

Female Anopheles mosquitos transmit malaria; but other species of mosquitos like Aedes and Culex, which typically breed in contaminated cesspools do NOT transmit human malaria, but are the transmitters of filariasis. In Northern Uganda in the area of Olun Province, this condition is so prevalent as to affect almost half the adult male population. It is in this region where we had set up a center two years ago in Northern Uganda to both treat and prevent adult acquired hydrocele.

When the small filarial worms invade the lymphatics, they may set up a lymphangitis which causes a lymphedema from obstruction, particularly secondary to a bacterium that the filarial worm carries called Wohlbachia. It is possible to treat this with special medications that can manage in the early stages to prevent hydrocele by using ivermectin to keep the filaria worm from reproducing and doxycycline to control the Wohlbachia. However, after lymphangitis has resulted in lymphatic obstruction, the lymphedema and hydrocele that results have given the descriptive name elephantiasis, which is one of the four principal neglected tropical diseases.

Photo credit: Boston Children’s Hospital

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One of the very good features of searching for and identifying adult hydrocele is that it can be resolved by a simple and easily taught operation. This condition is one that is potentially fixable by the local staff once they learn how this procedure works, in a 'quick uptake' surgical skill. The operation entails a scrotal, (not inguinal, approach, as is needed for hernia repair.) An incision in the sac around the testis, into the lining that secretes the fluid drains the fluid collection. Through the simple trick of the inversion of the lining like turning a flexible water skin inside out, the secreted fluid can no longer accumulate, as it is picked up in the extracellular fluid in return to venous circulation.

I have always considered it one of the primary tropical operations to teach in areas of high hydrocele endemicity, because it takes no more than one direct involvement in the operation in order that the learner can continue to perform this procedure in subsequent patients, and it is a skill that is thereby readily indigenized to reduce morbidity in the affected populations.

Stage 2/3 filarial elephantiasis secondary to chronic infection with the Wuchereria bancrofti nematode. Massive hydrocele may also manifest.

Photo credit: Liverpool School of Tropical Medicine

Dr. Glenn Geelhoed received his BS and AB cum laude from Calvin College and MD cum laude from the University of Michigan. He completed his surgical internship and residency through Harvard University at Peter Bent Brigham Hospital and Boston Children’s Hospital Medical Center. To assist in developing further volunteer surgical services in underserved areas of the developing world, Glenn completed masters degrees in international affairs, epidemiology, health promotion and disease prevention, anthropology, and a philosophy degree in human sciences.

He still works as a professor of surgery at George Washington University Medical Center in Washington D.C. and is a member of numerous medical, surgical, and international academic societies. Glenn is an avid game hunter and runner. He has completed more than 135 marathons across the globe. He is also a widely published author accredited with several books and more than 500 published journal articles and chapters in books. He has two sons and five grandchildren.

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Tropical Medicine Update Combating mosquito-borne diseases: R21, Qdenga, and Ixchiq vaccines The year 2023 saw the advent of three promising vaccines to combat common mosquito-borne diseases: R21 (malaria), Qdenga (dengue virus), and Ixchiq (chikungunya virus).

Jason Jarvis MSc 18D NR-Paramedic

The R21/Matrix-M malaria vaccine gained WHO approval in October of 2023. R21 targets the Plasmodium falciparum malaria species and consists of hepatitis B surface antigen (HBsAg) fused to the C-terminus and the central repeats of the circumsporozoite protein (CSP). This formulation is similar to the existing RTS,S malaria vaccine, however, the R21 vaccine contains less HBsAg. The R21 formulation is combined with Matrix-M, a saponin-based adjuvant derived from the bark of the Quijalla saponaria tree.

To date, R21 has been trialed in the 5-17-month-old age range.1 The peak vaccine efficacy (VE) of R21 at six months post-vaccination was 77% (confidence interval (CI) 95%, 67% to 84%), while peak VE at one-year postvaccination was also 77% (CI 95%, 67% to 84%) against children with natural exposure to malaria. It should be noted that the R21 study was conducted in a highly seasonal transmission setting (Burkina Faso) in which few cases occurred during the second half of the year. To date, there are no longer-term follow up results available. VE was defined as protection from clinical malaria (primary case definition: axillary temperature ≥37.5°C and parasite density >5000 parasites/mcg; secondary case definition: axillary temperature ≥37.5°C or history of fever during past 24 hours, and parasite density >0 parasites/mcg; crosssectional asymptomatic P. f. infection defined as axillary temperature <37.5°C, absence of fever within past 24 hours, and parasite density >0 parasites/mcg).

A compelling documentary entitled The Battle to Beat Malaria was recently released on PBS, which details the late-stage development of R21 up until its final approval.

It is available at the following link: https://www.pbs.org/wgbh/nova/video/thebattle-to-beat-malaria/.

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

The R21 malaria vaccine was developed by Oxford University in conjunction with the Serum Institute of India.

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Malaria is a parasitic protozoa belonging to phylum Apicomplexa. Apicomplexans do not possess flagella or cilia but instead use an adhesion-gliding mechanism of locomotion. Notable members of this phylum include Plasmodium species (malaria), Cryptosporidium species, Toxoplasma gondii (toxoplasmosis), Babesia microti (babesiosis), and Cyclospora cayetanensis (cyclosporiasis). Malaria is vectored by Anopheles genus mosquitoes.

Domain Kingdom Phylum Class Order Family Genus Species

MALARIA Eukaryota Protista Apicomplexa Aconoidasida Haemosporida Plasmodiidae Plasmodium falciparum, vivax, ovale, malariae, knowlesi Red blood cells parasitized with Plasmodium falciparum malaria.

1000x magnification with oil immersion.

Female Anopheles maculipennis mosquito

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Malaria endemicity

https://www.cdc.gov/malaria/about/distribution.html

“CDC is currently collaborating with the Arkansas Department of Health (ADH) on one locally acquired case of Plasmodium vivax (P. vivax) malaria in a Saline County, Arkansas resident. The patient was treated and is now recovering.

Between May-August 2023, nine locally acquired cases of malaria were reported. This total included seven cases of P. vivax malaria in Sarasota County, FL, one case (P. vivax) in Cameron County, TX, and one case of P. falciparum malaria in a Maryland resident who lives in the National Capital Region. All patients were promptly treated at area hospitals and have recovered. There is no evidence to suggest that any of the cases are related.

Most malaria cases diagnosed in the United States are imported, usually by persons who travel to countries where malaria is endemic (regularly occurring). However, locally acquired mosquito-transmitted malaria cases can occur, as Anopheles mosquito vectors exist throughout the United States. The most recent cases were in 2003. Eight cases of locally acquired P. vivax malaria were identified in Palm Beach County, FL.” https://www.cdc.gov/malaria/new _info/2023/malaria_US.html Last reviewed: 19 October, 2023

Cameron County, Texas

National Capital Region

Saline County, Arkansas

Sarasota County, Florida

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The TAK-003 (Qdenga) dengue vaccine gained WHO approval in October of 2023.

Qdenga targets all four dengue virus serotypes.

Dengue is a flavivirus that is transmitted by the daytime-biting female Aedes genus mosquito throughout the tropics and subtropics. Aedes mosquitoes are hardy and highly invasive; their endemic range spreads further into temperate climes with each passing year.

As the R21 malaria vaccine followed in the footsteps of the RTS,S vaccine, Qdenga is the second dengue vaccine to gain WHO approval, and – like R21 – it is likely to become the dominant vaccine in its category. Qdenga was preceded by the Dengvaxia® vaccine. Dengvaxia is effective but saddled with a contraindication unique among vaccines: due to adverse events associated with the immunization of dengue-naïve people, it is recommended that only people with previous exposure to the dengue virus receive Dengvaxia. Qdenga is not only highly effective, but may be administered to those with or without previous dengue exposure.

Excerpts from the Qdenga principal phase 3 vaccination trial follow, as well as a dengue virus infographic.

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“Approximately 96 million cases of dengue manifest clinically every year, with 500,000 requiring hospitalization. Illness owing to infection by any of the four cocirculating DENV serotypes in endemic regions can result in a range of symptoms, from asymptomatic disease to debilitating but transient dengue fever, lifethreatening dengue hemorrhagic fever, and dengue shock syndrome. Infection with one DENV serotype produces life-long homologous immunity but may increase the risk of severe disease following a secondary heterotypic infection: 81% of DENV diagnosed children in one study presented with a secondary DENV infection and, of these, 53% had dengue hemorrhagic fever…

Seroconversion rates for all dengue serotypes in the present study were robust and persistent (>85%) through to 6 months after the second dose. This persistency of neutralizing antibody response and maintenance of high seroconversion rates up to 6 months after the scheduled two doses, coupled with higher GMTs for the DENV-2 serotype than those for DENV-1, DENV-3, and DENV-4 is a pattern that is consistent with the data observed in the pivotal TAK-003 efficacy trial, DEN-301,19,20,29 and other Phase 230–32 and 3 TAK-003 trials…

To date, TAK-003 has been licensed for prevention against dengue in the European Union, Great Britain, Brazil, Argentina, Thailand, and Indonesia, among other countries.”2

Dengue endemicity

https://www.cdc.gov/dengue/areas withrisk/around-the-world.html

Male Aedes aegypti mosquito

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Dengue is a member of the Flavivirus family of RNA viruses, which includes St. Louis encephalitis, yellow fever, West Nile, hepatitis C, and Zika. Infographic adapted from Eleanor Lutz.

Female Aedes aegypti mosquito

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Ixchiq, the world’s first vaccine against the chikungunya virus, was U.S. FDA approved in November 2023.

Chikungunya is an RNA togavirus, infection with which exhibits a clinical picture (fever, arthritis, rash) similar to other arboviruses such as dengue, Barmah forest, Mayaro, O’nyong-nyong, Ross River, and Sindbis. Chikungunya is vectored by Aedes genus mosquitoes and is endemic to sub-Saharan Africa, Southeast Asia, central Asia, tropical Pacific islands, the Americas, France, Italy, and the Arabian peninsula. Valneva Austria GmbH owns the license to the Ixchiq vaccine. Below is reprinted the highlights of Ixchiq’s prescribing information.3

https://www.cdc.gov/chikungunya/geo/index.html

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Chikungunya is a member of the Togavirus family of RNA viruses, which includes rubella, eastern equine encephalitis, and western equine encephalitis.

Infographic adapted from Eleanor Lutz.

CHIKUNGUNYA FEBRILE DISEASE W/ MILD TO SEVERE PERIPHERAL ARTHRALGIA, FOLLOWED

BY TRUNK AND LIMB RASH. BUCCAL AND PALATAL ENANTHEMA MAY OCCUR.α

α Control of Communicable Diseases, 20th edition page 33

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1 Datoo, M. S., Natama, M. H., Somé, A., et al. (2021). Efficacy of a low-dose candidate malaria vaccine, R21 in adjuvant Matrix-M, with seasonal administration to children in Burkina Faso: a randomised controlled trial. Lancet (London, England), 397(10287), 1809–1818. https://doi.org/10.1016/S0140-6736(21)00943-0 2 Patel, S. S., Winkle, P., Faccin, A., Nordio, F., LeFevre, I., & Tsoukas, C. G. (2023). An open-label, Phase 3 trial of TAK-003, a live attenuated dengue tetravalent vaccine, in healthy US adults: immunogenicity and safety when administered during the second half of a 24month shelf-life. Human vaccines & immunotherapeutics, 19(2), 2254964. https://doi.org/10.1080/21645515.2023.2254964 3 https://www.fda.gov/media/173758/download?attachment

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Improvised Medicine 3D-printed medical kit As a remote healthcare professional, you find ways to create and improvise equipment to supply your clinic. We don’t immediately think about using high technology to fix a low technology problem. Thankfully, printable technology has an answer for us.

Aebhric O’Kelly M.Psy DTN FRSM FAWM

Improvised medicine can include high-tech options. For example, 3D-printed tourniquets are being created in Ukraine. (Melau et al, 2023). In Gaza, they manufacture tourniquets, stethoscopes and otoscopes for use in the conflict (Lawrence, 2023).

SYGNIS 3D-Printed Tourniquet

Photo credit: https://www.behance.net/gallery/157749951/SYGNIS-Tourniquet-open-source-combatverified

A 2018 study by Kats et al., showed that a Kenyan remote clinic has only 77% of the WHO-recommended equipment to hand. Some of the dispensaries only had 23% of the list. Based upon data from eight rural hospitals of varying sizes in Kisumu, Kenya, researchers identified four classes of products across four categories of use that can benefit from low-volume, localised manufacturing using 3D printing.

3D printers are portable and can be brought into a remote clinic. Prices range from €150 up to thousands.

In the context of the conflict in Ukraine, 3D printing tourniquets can be highly beneficial. This technology enables rapid, on-site production of essential medical devices, crucial in a warzone where medical supplies are often scarce and logistics are challenging. It ensures that life-saving equipment like tourniquets is readily available to medical providers, enhancing their ability to provide immediate care in critical situations. This can substantially improve medical response and potentially save more lives in the challenging and resource-limited conditions of the conflict.

The Bottom Line: Embrace the technological advances that benefit the Remote Medic.

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Photo credit: https://hackaday.com/wp-content/uploads/2022/05/1920x1080-vtime29_02-take2022-0518-11.25.30.png?w=800 References: Melau J, Bergan-Skar P, Callender N, Rognhaug M, Bekkestad E. 3D-Printed Tourniquets Used at the Battlefront in Ukraine: A Pilot Study. J Spec Oper Med. 2023 Dec 22:7NII-VT7T. doi: 10.55460/7NII-VT7T. Epub ahead of print. PMID: 38133635.

Lawrence, L. In Gaza, the Glia Project 3D prints tourniquets and stethoscopes. https://www.statnews.com/2023/10/31/gaza-glia-project-tourniquet-stethoscope-3d-print/.

31, October, 2023. STAT news. Accessed 28Dec23.

Kats D, et al. "Paper 3D Printing to Supplement Rural Healthcare Supplies — What Do Healthcare Facilities Want?," 2018 IEEE Global Humanitarian Technology Conference (GHTC), San Jose, CA, USA, 2018, pp. 1-8, doi: 10.1109/GHTC.2018.8601529.

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Trends in Traumatology The initial management of modern battlefield ballistic facial injuries For this issue’s Trends in Traumatology piece I chose a topic that is one of the most challenging traumatic situations in any setting, let alone an austere field setting: massive facial injuries. What can make the management of such an injury difficult is fourfold:

Jason Jarvis MSc 18D NR-Paramedic

1) If the extent of the injury is severe, the healthcare practitioner is confronted with an urgent need to correct massive bleeding plus probable airway occlusion and subsequent compromised breathing. Whether one is following the MARCH treatment mnemonic or CABCs, a single injury has potentially put a casualty in jeopardy of dying of one, two or all three of the first three causes of traumatic death, temporally-speaking.

2) Standard hemorrhage control modalities, i.e., tourniquets, bandaging, direct pressure, hemostatic agents, etc., do not lend themselves to easy application to this part of the human anatomy. The now-ubiquitous and much-vaunted arterial tourniquet is completely impractical in cases of facial ballistic trauma.

3) Attempts to “pack the wound” in and around the face may only serve to compromise the airway, and, conversely, aggressive management of the airway may further exacerbate bleeding.

4) Psychologically speaking, facial trauma can be one of the most distressing experiences a healthcare practitioner can encounter. Gross deformity of that most characteristic of all human physical attributes can unnerve even the most poised among us, potentially leading to “shaky hand syndrome” in a best-case scenario, or a full-blown operator freeze in a worst-case scenario.

A recent literature review by the Australasian Military Medical Association entitled “The face of war: the initial management of modern battlefield ballistic facial injuries” expounds upon this injury pattern on the following pages.1

“…the primary cause of death in head and face injuries is airway compromise.”

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“Clinicians should have a high index of suspicion of haemo or pneumothorax in penetrating neck wounds.

Haemorrhage from the face, although relatively rare, can be managed by pressure (e.g. nasal packing), diathermy, fracture reduction and immobilization, suturing, embolization of the bleeding vessel or tying of the external carotid artery.”

Photo credit: Journal of Neurosurgery

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“Definitive surgery is delayed until the patient’s condition has been optimized. Maxillofacial damage control surgery is restricted to tracheostomy, the arrest of haemorrhage, initial wound debridement, simple reduction and immobilisation of fractures and sight saving procedures such as lateral canthotomy.”

Cricothyroidotomy

Lateral canthotomy

1 https://jmvh.org/article/the-face-of-war-the-initial-management-of-modernbattlefield-ballistic-facial-injuries/

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Test Yourself ECG Which of the following conditions can be diagnosed based on this 12lead?

A. Rickets B. Hyperlipidemia C. Addison’s disease D. Hyperparathyroidism

Clinical Calculation The anesthetist at the Mae Tao Clinic is preparing to treat a burn patient and has requested 0.25% bupivacaine with 1:200,000 epinephrine.

Bupivacaine premixed with epinephrine is not available, but the anesthetist asks if you can combine epinephrine with bupivacaine to achieve the 1:200,000 concentration. How much 1:1000 epinephrine should you add to the 50mL vial of bupivacaine?

Species Identification While on a training mission in northern Togo, one of your teammates brings to you a large fly that he killed after it bit him. With which of the following diseases might this person now be infected?

A. Trachoma B. River blindness C. African eye worm D. African sleeping sickness

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Test Yourself Clinical Case Following a boating accident in the Coral Sea, you decide to initiate a massive blood transfusion to a 40-year-old male suffering from decompensated hemorrhagic shock. Utilizing your walking blood bank clinical practice guidelines, you have performed Eldon card tests upon your patient and several donors to ascertain their blood types. Based upon the following findings, which combination of donor blood will lead to the best outcome?

Patient Donor 1 Donor 2 Donor 3 Donor 4 Donor 5 Donor 6 Donor 7 Donor 8 Donor 9 Donor 10 A. Fresh whole blood from donors 1, 6, 7, 9 (one unit per donor) B. Fresh whole blood from donors 3, 6, 8, 10 (one unit per donor) C. Fresh whole blood from donors 1, 4, 6, 9 (one unit per donor) D. Fresh whole blood from donors 2, 4, 5, 6 (one unit per donor) Answers will appear in the Spring 2024 Compass

Answers to “Test Yourself” from the previous issue: ECG: C. Left atrial hypertrophy Clinical calculation: Infuse octreotide at 33 gtt/minute Clinical case: D. Guillain-Barré syndrome

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

Gear JADE (Junctional Assistance Device for Extremities) available from zacharyleblanc@vitachsolutions.com

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Audio Files A selection of medical podcast episodes

What happens when a patient far from surgical care – say, at the bottom of the Pacific ocean on a submarine, or at a research base in Antarctica in the middle of winter – develops a surgical abdomen? This dilemma was the impetus to build the first truly effective clinical decision support system – and to grapple with what it means when a computer can make better decisions that a doctor. In this episode, we discuss the dramatic stories of appendectomies at Novolazarevskaya and aboard the submarine Seadragon. Also, there’s a brand new #AdamAnswers about the origin of the word “scut.” https://open.spotify.com/episode/1RTdpagx9TjYab0LUAiaYg

Dr. Matt Siuba discusses his approach to undifferentiated shock for learners. https://open.spotify.com/episode/3gXdEBy3LKVlwUfnKoKdY4

For those learning A & P for the first time – or advanced providers getting back to basics – this podcast series pairs well with the Khan Academy videos featured on the following page. https://open.spotify.com/episode/6eTPSTWIuwxd0KXNqnQhbM

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Envisioning Information Health and Medicine Series https://www.khanacademy.org/science/health-andmedicine/human-anatomy-and-physiology/heartintroduction/v/meet-the-heart

Precipitous Birth in the ED https://litfl.com/precipitous-birth-in-the-ed/

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Journal Watch 2023 American Heart Association focused update on ACLS American Heart Association Perman SM, et al.

2023 November. https://cpr.heart.org/-/media/CPR-Files/CPR-Guidelines-Files/2023-ACLS-FocusedUpdates/Hghlghts_2023GLFU_ALS.pdf

EDITOR’S SYNOPSIS The AHA 2023 Focused Update covers the following topics: extracorporeal cardiopulmonary oxygenation; coronary angiography after cardiac arrest; temperature control after cardiac arrest; seizure management; organ donation; and diversity, equity, and inclusion.

Temperature control looks to replace the term targeted temperature management, and is elucidated in the accompanying text box.

WHO officially recognizes noma as a neglected tropical disease World Health Organization 2023 December 15. https://www.who.int/news/item/15-12-2023-who-officiallyrecognizes-noma-as-a-neglected-tropical-disease

EXCERPT Noma, a severe gangrenous disease of the mouth and face, primarily affects malnourished young children (between the ages of 2 and 6 years) in regions of extreme poverty. It starts as an inflammation of the gums, which, if not treated early, spreads quickly to destroy facial tissues and bones. It frequently leads to death, with survivors suffering severe disfigurement.

Accurate estimation of the number of noma cases is challenging due to the rapid progression of the disease and the associated stigma, which contributes to leaving many cases undiagnosed.

Cases of noma are mostly found in sub-Saharan Africa, although cases have also been reported in the Americas and Asia.

Evidence indicates that noma is caused by bacteria found in the mouth. There are multiple risk factors associated with this disease, including poor oral hygiene, malnutrition, weakened immune systems, infections, and extreme poverty. Noma isn't contagious but tends to strike when the body's defenses are down.

Early detection is essential, as therapy is most effective at the early stages of disease when it causes severe swollen gums, known as acute necrotizing gingivitis. Treatment involves antibiotics, advice and support on practices to improve oral hygiene with disinfectant mouthwash (salt water or chlorhexidine could be used) and nutritional supplements.

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Journal Watch Scorpion stings in Minas Gerais (Brazil): a monocentric retrospective study evaluating all envenoming cases of local scorpionism Wilderness and Environmental Medicine Ornelas RC, et al.

2023 December. doi: 10.1016/j.wem.2023.06.005.

RESULTS There were 3032 accidents, and the male-tofemale ratio was 1.17:1 (male, 54%; females, 46%). Accidents occurred every month, but there was an increase in June, July, and October to January. In most cases, the time between the scorpion sting and medical care was between 1 and 3 h (n=1304; 43%). The most frequent clinical and systemic manifestations were pain at the bite site (94%) and vagal symptoms (7%).

Cases were mild (n=2750, 91%), moderate (n=221, 7%), and severe (n=56, 2%). Children younger than 10 y constituted the most cases, 522 (17%). There was a significant difference between clinical severity and age (P<0.01). Ten patients developed acute pulmonary edema. Two 4-y-old children died. All severely envenomated patients as well as 74% and 2% of mild and moderately envenomated patients, respectively, received specific scorpion antivenoms.

Tityus serrulatus scorpion

Pain control and point-of-care ultrasound: an approach to rib fractures for the austere provider Journal of Special Operations Medicine Synder R, Brillhart DB. 2023 October 5;23(3):70-73. doi: 10.55460/5EY1-GPAM.

ABSTRACT Rib fractures are common injuries that cause significant discomfort and can lead to severe pulmonary complications. Rib injury most often results from high-velocity traumatic mechanisms, while rarely representing underlying metastatic disease or secondary injury due to pulmonary illness. Because most rib fractures are caused by obvious trauma, algorithms are focused on treatment rather than investigating the exact mechanism of rib fractures. Chest radiographs are often the initial imaging performed but have proven to be unreliable in identification of rib fracture. Computed tomography (CT) is a diagnostic option as it is more sensitive and specific than simple radiographs. However, both modalities are generally unavailable to Special Operations Forces (SOF) medical personnel working in austere locations. These medical providers could potentially diagnose and treat rib fractures in any environment using a standardized approach that includes clarity of mechanism, pain relief, and point-of-care ultrasound (POCUS). This case demonstrates an approach to the diagnosis and treatment of a rib fracture in a 47-year-old male who presented to a military treatment facility with unlocalized flank and back pain, but the methods employed have applicability to the austere provider working far from the resources of a medical center.

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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 2014 and is governed by a voluntary Academic Board 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 TTEMS Dates TBD

AEC Dates TBD Tropical Medicine Dates TBD

MALTA

Medicine in the Mediterranean conference 2-4 Feb

APUS ICARE REMT REMT APUS ICARE TTEMS ATTEMS BSc RPP Y2 AEC REMT APUS ICARE TTEMS

NORTH CAROLINA

5-6 Feb 7-11 Feb 12-17 Feb 1-6 April 13-14 April 15-19 April 22-26 April 29 Apr–3 May 6-25 May 27-30 May 13-18 October 2-3 November 4-8 November 11-15 November

TANZANIA

SOMSA Conference 13-18 May 2024 Tactical Medicine Review (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 Diploma of Aeromedical Retrieval Medicine for Extreme Altitude PG Cert Tropical Medicine & Hygiene

Online Courses

Critical Care Transport 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 HEMS and ambulance placement, Budapest, Hungary Kibosho District Hospital, Kilimanjaro Ghana National Ambulance Service

ACC AEC ACLS AHA APUS ATTEMS FiCC IBSC MFSLR PALS PARSIC PG Cert RAMS RMLS RPP104 SOMSA TTEMS

LEGEND Acute Critical Care Austere Emergency Care Advanced Cardiac Life Support American Heart Association Austere and Prehospital Ultrasound 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 Advanced Medical Skills 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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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!