Monthly Archives: March 2014

There’s an app for that

When you’re out in the sticks, you want to travel light. This limits the amount of diagnostic supplies you can carry, and generally wilderness medics trend towards carrying supplies that can do multiple jobs. Thus, necessity being the mother of invention, these authors wanted to use an item they already carry in a novel way.

Most of us diagnose fractures with radiography. While x-ray machines may be portable, I’ve yet to see any manufacturers produce an off-road version. Prior studies have shown relatively decent sensitivity and specificity using tuning forks and stethoscopes, by way of listening for a difference in vibratory transmission down the length of the bone. The idea is that a fracture will stop propagation of the waves, or at least reduce them significantly. Then you can compare to the unaffected side and identify an occult fracture.

Since carrying a tuning fork in your pack adds weight without a large amount of utility (maybe you can make a mouth harp out of it at the campfire), the authors tried to find another commonly carried object that could reliably produce a constant vibration. What they came up with was an iPhone 3S using the iVibe app. Not wanting to break the bones of alive patients, they used a cadaver model for the fractures, and a convenience sample of 27 EM residents and 1 EM attending.

Sadly, they weren’t very accurate, with a sensitivity of 73% and specificity of 83%. This is lower than the multiple tuning fork studies, and would probably be even lower in the austere environment, with outside noise, and clothed patients. The authors themselves say this is a pilot study that needs further validation. I would argue that as more people carry ultrasound devices, it will supersede the utility of lower sensitivity testing.

I wouldn’t go out planning on using them for that purpose, but if needed, it is better than nothing. And hey, if it keeps you from calling a helicopter to evacuate someone, or allows you to call one appropriately, then maybe it is worthwhile. At least you’re already carrying the phone and the stethoscope.

Novel Approach to the Diagnosis of Fractures in an Austere Environment Using a Stethoscope and a Cellular Phone
http://www.ncbi.nlm.nih.gov/pubmed/24393702

So you’ve pulled off a deer tick

What’s the next step? Perhaps you know the recommendation for a single dose of 200mg of doxycycline for prevention of Lyme disease, but is it based on solid evidence?

Well, the study at hand enrolled 506 patients, which they then pared down to 482 that had the ticks positively identified by an entomologist. They had this many because their power calculations determined they would need a sample size of 129, but once their data indicated that nymphal ticks were highly correlated with erythema migrans, they extended the study to the point it lasted almost 10 years. Due to the length of the study, 6 patients were enrolled twice due to being bitten in separate years.

Even with the large sample size only 9 patients developed EM, with 8 of these occurring in the placebo group. This allowed statistical significance even with relatively low prevalence. This gives them an efficacy rate of 87%, but unfortunately the 95% CI is 25-98%.

It seems like it works, and the theoretical risk of a single dose of antibiotics is fairly low. However, 30% of the doxy group had side effects from that single dose, usually nausea and vomiting.

Based on this study, giving 200mg of doxycycline as a single dose within 72 hours of tick removal appears sensible. You diminish the risks of developing erythema migrans, while also preventing a prolonged course of antibiotics. My only warning would be to tell patients to continue to watch for symptoms of Lyme, as prophylaxis is not 100%.

Prophylaxis with single-dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis tick bite
http://www.ncbi.nlm.nih.gov/pubmed/11450675

How persistant is permethrin?

Malaria and other mosquito-borne infections are a significant cause of morbidity and mortality for many countries, and visitors to those countries are certainly not immune. While travelers certainly do not want to experience illness during or after a trip, the military has an even more vested interest in keeping soldiers healthy. Considering that  more troop casualties result from these infections than there are from direct combat, it is easy to understand why this is such an important area of study for the military.

Applying repellent to clothing is appealing to everyone, as it does not need frequent re-application, often has less of an odor, and has less skin irritation. A side benefit of clothing based repellent is that it is usually advertised as lasting through “many” washes, thus allowing one to apply the product before a trip and possibly not need to carry it with them. But like many commercial products, the validity of those claims is not easy to find out, and often you have to take the company at their word.

The authors of this study set out to determine exactly how effective permethrin-impregnated army uniform cloth was at repelling or killing mosquitoes after multiple washings.

Surprisingly, permethrin stays on the fabric through a large number of washes. Even more surprising, it remains somewhat effective, even after 55 washings. Of course, they weren’t using commercial washing machines, instead agitating with glass rods in beakers, so external validity may vary.

However, how effective it is depends on what you’re asking for. For knockdown (ie, a mosquito landing on the fabric falls off due to toxicity), it goes from 98.3% to 23.3% after 20 washings. 24 hour mortality, on the other hand, remained 100% after 24 hours even after 55 washes. One hour mortality drops after only 10 washes. For repellency, the rate of mosquitoes landing on the sleeves increased from 32% at 0 washes to 51% at 55 washes, both of which were below the 86-87% landing rate of the controls.

Then they go into scanning electron microscopy and energy-dispersive X-ray spectroscopy analysis of the cloth that basically shows that there are measurable permethrin levels on the cloth after 55 washes. This leads you to the logical assumption that the effect is still from the permethrin.

So there you go. Permethrin works, even after washing. You can save some money by not needing to reapply it after every wash, and maybe only every 10 or so (depending on how you’re washing it). Don’t use your dryer though, as you have to air dry the product based on this study. Also make sure not to use fabric softener. This does not preclude use of topical agents on exposed skin, but the combined use can significantly reduce your exposure to mosquito-borne illnesses (or simply itchy bites). 

Knockdown and repellent effect of permethrin-impregnated army uniform cloth against Aedes aegypti after different cycles of washings.
http://www.ncbi.nlm.nih.gov/pubmed/24595642

Does fear make you a better climber?

Climbing requires a significant amount of mental and physical energy. The climber needs to think about their line, their holds, and any potential consequences of any error. Free soloers don’t utilize harnesses, and are more at risk of disaster with any fall.

So can fear help them climb safely? The article doesn’t answer this directly. What it does is show the effect of adding cognitive tasks to physical activities, and should serve as a warning for anyone who performs tasks that have life or death implications.

What they did was interesting, and had jumped off from earlier work. The authors took 15 experienced climbers, and gave them 5 tasks to complete. 3 were bouldering tasks, and 2 were simply memory tasks. The memory tasks were to listen to words during 3 minutes, and recall as many as possible for the 90 seconds afterwards. Of the bouldering tasks, 1 was just going back and forth for 3 minutes, and the other 2 required listening to a list of words while climbing, and then recalling them immediately afterwards. 

What makes it intriguing is the differences between the  memory tasks. Apparently there is a list of Affective Norms for English Words, and it rates words based on emotions. The categories are happiness, sadness, anger, fear, and disgust. So for the seated and climbing memory tasks, one used a list pulled from 40 words with the highest fear score, and the other pulled from 40 words that scored low on all 5 categories.

It is not surprising that there was a difference in recall between seated memory tasks and those with climbing. However, it is surprising that there was a significant difference in climbing efficiency and distance between the fear and neutral dual-tasks. Sure, they’re not huge differences, but the time of the test was only 3 minutes. Combine that with experienced climbers and a course height, limited to less than 3.3m which shouldn’t have been a struggle for them, and it makes the difference real.

The authors state that fear “words” may cause the climber to subconsciously use more caution, or be slower as if they had actual fear. This may or may not be the reason behind the shorter distances and diminished efficiency compared to non-fear-inspiring words. Multiple other references point towards real fear certainly causing decreased performance, so the concept  isn’t completely out there.

The other point that is important is that there was a large difference in recall with physical activity, with the participants remembering less than 50% of the words. Thus, if you take nothing else from this article, remember that half of what you way to the search and rescue guys while they are working will be forgotten, and you’ll make them slower in the process.

Of note, this article uses the word “whilst” 10 times, which has to be some sort of record.

The impact of fear words in a secondary task on complex motor performance: a dual-task climbing study
http://www.ncbi.nlm.nih.gov/pubmed/23873435