野外医学
Wilderness Medicine
 

中华急诊医学杂志，2014,13（5）

Douglas G. Sward, MD, FAWM, FAAEM, and Brad L. Bennett, PhD, NREMT-P, FAWM
Douglas G. Sward, MD, FAWM, FAAEM
Department of Emergency Medicine
University of Maryland School of Medicine
Hyperbaric Medicine
Shock Trauma Center
Baltimore, Maryland, USA

Brad L. Bennett, PhD, NREMT-P, FAWM
Military & Emergency Medicine Department
F. Edward Hébert School of Medicine
Uniformed Services University of the Health Sciences
Bethesda, Maryland, USA

作者声明没有任何利益冲突.

联系作者: Douglas G. Sward, MD, Hyperbaric Medicine, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201. Phone: 401-328-6152. Fax: 410-328-3758. Email: dsward@umm.edu.

翻译：雷源力
浙江大学医学院
georgerexray@gmail.com

校对：肖锋（Feng Xiao）
美国马里兰大学医学院附属医院
北京和睦家医院
fxiao88@gmail.com

摘要
近几个世纪以来，全球范围内人类在野外活动日益增多，这也增加了人类在野外遭受伤害、获得疾病的风险。适应这种需求和爱好，野外医学在此基础上发展起来。除了在物资、人力有限和不能及时转运接受标准治疗外，这个领域的特点还有只能对患有常见病、地区特异疾病或外伤的患者进行独立无援和无流程的处理。野外医学发展迅速，不仅从内科外科的各个亚专科中获取经验、知识，也得益于登山、攀援、潜水等专业领域。野外医学的科研、流行病学研究、循证医学指南也在逐渐发展。野外医学的一大特点是避免伤害和降低风险，该领域内主要的疾病主题包括高原脑水肿、减压病、蛇毒中毒、雷电伤、肢体外伤和胃肠炎。一些（野外医学）专业协会，学术团体和培训机构为普通民众和专业医疗人员提供教学和物资。

关键词：野外医学，高原病，潜水医学，动物毒液，外伤，高温，低温，冻伤，雪崩，战地伤，搜寻与援救，旅行医学，灾难医学


介绍
野外医学是一个有着长远历史的多面性学科。[1]谈到它的定义时我们必须考虑：获得医院内医疗处理的距离和所需的时间、受伤或患病的人员所参与的活动、受到持续性环境暴露的可能，医疗资源的稀缺性，以及救援人员和医护人员所要面对的风险。在野外医学中，一个灵活的计划、患者评估和撤离的方案是必须的。[2,3] Howard D. Backer教授，”野外医学协会”前主席，极具说服力地对野外医学在其偏远性、生理特性、现场灵活处理的需求性和对临床检查判断的依赖性这四个方面进行了描述。[4] 与之形成鲜明对比的是，“街道”医学则受益于拥有大量的救援人员、技术能力、快速的地面和空中转运到有标准治疗机构。
目前进行的野外医学基础研究和流行病学研究，通过报道不同人群、不同区域的发病率和死亡率，来不断完善野外医学的定义。美国国家公园的数据显示，野外医学专家治疗的疾病中最常见的有软组织损伤，扭伤，肌肉劳损，和下肢骨折。[5-7]
早期发展
在1983年，”野外医学协会”（Wilderness Medical Society，WMS）由Greer, Auerbach, Kizer三位来自加利福尼亚北部的医生建立。这个非营利组织的总部设在美国犹他州盐湖城。组织的目的是为了推进野外医学医疗、教学、科研的进步。[8]这个协会在1987年发行了同行评审、索引发行的杂志《野外医学》（Journal of Wilderness Medicine）。该杂志后更名为《野外和环境医学》（Wilderness and Environmental Medicine）。这本杂志为季刊，刊登实验室和临床研究，以及编委评论等。其他发表有关野外医学的文章的杂志还包括：高原医学和生物学（High Altitude Medicine and Biology); 军事医学（Military Medicine); 特殊任务医学杂志（Journal of Special Operations Medicine); 航空和环境医学（Aviation Space and Environmental Medicine); 海底和高压医学（Undersea and Hyperbaric Medicine); 潜水和高压医学（Diving and Hyperbaric Medicine); 实用生理学（Journal of Applied Physiology); 运动和训练医学和科学（Medicine & Science in Sports & Exercise); and 毒素研究杂志（the Journal of Venom Research). 另外的资源还有按季发型的通讯Wilderness Medicine Magazine。该通讯从小册子开始，发展成为了一个在线的、互动性的、具有超链接的出版物。
基本的医疗指南性建议首次发表在《WMS Practice Guidelines for Wilderness Emergency Care（野外医学协会实用指南：野外急诊处理）》，并由William Forgey教授编辑；该书的第五版已在2006年发行。[9]医疗实践的指南由各项问题的专家更新。这些指南按照循证证据等级排序，并作为《Wilderness Medical Society Practice Guidelines （野外医学协会实用指南）》系列单独发行。《野外和环境医学》上发表并编有这些指南的索引。
Paul Auerbach教授编辑了野外医学的基础教材《Wilderness Medicine》[10]。该书第六版发行于2012年，包含了114个章节。

兴趣领域
野外医学包含了很多兴趣领域。一些专家专注于特定的情形（例如雪崩），另一些则兴趣更广泛（例如创伤治疗）。这个章节将会讨论野外医学里几个最受关注的核心领域。

高原
在高原地区旅行正变得日益普遍。在诸如滑雪、登山这一类的活动中，急性高原病（acute mountain sickness，AMS）的发病率很高：估计在仅上升至中等海拔的人群中就有25%的人受该病影响。[11] 高原性肺水肿（high-altitude pulmonary edema，HAPE）和高原性脑水肿（high-altitude cerebral edema，HACE）是两种更严重、危及生命的状况。值得庆幸的是，这两种情况较为少见。[12-15] 上述几种情况的初步处理包括下降到低海拔地区和给氧。药物处理上通常给予患者乙酰唑胺和糖皮质激素[16,17]

潜水医学
娱乐性的潜水和为了达到技术目的的潜水在世界范围内正变得越加普遍。潜水特有的伤害包括减压病和气压性损伤。减压病的发病率在娱乐性、专业性、科研性场所潜水都保持稳定（0.003%‒0.01%）。在科学性场所潜水受到伤害的比率最小[18,19] 减压病的发病是因为减压应应和随之产生的氮气气泡，可能还与促炎症微粒的生成有关。[20]更有趣的是，内耳减压病在近些年来更为频繁地被诊断出来。[21-22]减压病的处理是利用加压氧舱进行加压。为偏远地区设计使用的可移动式的加压舱正在开发中。[23]同时，一些在水下加压治疗的文献报道也已经被发表。[24-27]

动物毒液中毒
蛇咬伤、节肢动物蛰伤和海洋生物的毒液中毒，这些伤在毒理学和病理学上差异很大，不同地区所受的伤也有着截然不同的处理方法。这种差异性主要与当地的动物种类、有无抗毒血清有关。[28]患者对毒液产生的反应往往是自限性的，但是因全身反应而导致凝血功能障碍，或者因为神经毒素导致呼吸停止也是可能的。一些动物毒液，例如立方水母纲（Cubozoa）的毒液，可以大量肾上腺素释放，造成心血管系统衰竭。[29‒36]

外伤
外伤是野外发病的一个主要原因。外伤致死的首要原因是在徒步旅行、山地自行车、雪地骑行中从高处落下所致的头颅伤。虽然大多数创伤都程度较轻、主要集中在下肢，但是户外活动和旅行往往因其而终止或延长。在少见的病例中，外伤可以涉及多个系统，并且危及生命。
野外医学中，外伤这一类别还包括了在前往偏远地区过程中或在偏远地区内的机动车事故。[6]回顾性调查揭示了攀爬活动中遭受创伤的特点和频率。[37‒46]
针对颈椎创伤的处理、制动、基于阿片制剂的止痛和侵入性操作方面的进展正在被该领域专家探讨。[47‒51]非专业的施救者也被教授一些高级技术，例如肩关节复位的方法。[52] 甚至一些专科化的伤害处理方法，例如长时间的背带悬挂，也在被考虑教授给非专业施救者。[53]

高体温
热暴露和热应激会导致从良性的热痉挛到危及生命的的中暑等一系列的疾病。[54] 中暑是一种严重、有时会危及生命的疾病，主要特征是体内中心温度上升并伴随神经系统功能障碍。中暑的发病过程复杂，包括细胞功能障碍、心脏传导障碍、促炎症细胞因子的释放、血管内容量不足和进而导致的循环障碍。[55] 中暑病人的脱水程度可以有不同。与传统的中暑不同的是，强力体力活动后中暑可以在中等温度下发生，特别是在进行野外耐力运动的运动员身上发生。[56]
去除热应激、快速全身降温是减轻高温所导致的脑病、凝血功能障碍和多器官功能衰竭的关键。[57‒59] 最佳的降温方法是将患者全身浸在冰或冷水中，但是这种方法在野外通常并不实用。在这种情况下，将患者皮肤打湿并朝患者扇风可以用来尝试降低体温。这个方法可能会引起患者颤抖，但是并没有证据指出这种颤抖的产热会与降低体核温度的努力相冲突。[60,61]

低温
意外低温可以作为一个原发症状，也可以是其他疾病、创伤的并发症，它是野外医学的一项普遍关注点。当中心温度低于35C伴有创伤时，可以导致酸中毒、凝血功能障碍和多器官功能衰竭，在这种情况下患者的死亡率明显上升。[62,63] 低温产生于机体产热少于冷应激时。值得注意的是，低温也可以在温和适中的气候条件下发生。
人体内多重生理机制和行为机制之间协同以保持体温的正常状态，但是当外界温度到达一定的阈值后，这些体温调节机制会失效。“反常脱衣现象(paradoxic undressing, 受难者感到发热，将衣服全部脱掉)”被认为是因为表皮血管扩张和认知力改变所致；“垂死钻穴(terminal burrowing, 受难者在临死前钻入狭窄和封闭的地方)”则可能是一种原始反射。[65‒67]
低温复苏的基础包括防止热量进一步丢失、复温和对生理功能的支持。[68,69] 对健康的研究对象的野外实地研究和侵入性监测手段已经阐明了降温和“复温后体温下降现象”的生理过程。用于防止热量进一步丢失的简易、商品化方法目前正在开发。[70‒75] 动、静脉吻合复温设备（可以带有负压功能）可以为野外严重低体温患者快速复温。[76,77]
因为复苏治疗过程中对资源的要求和恢复过程中统计数据的不充分，关于低温下心跳骤停的复苏方案很早就产生了争论。在一些病例中，延长复苏时间也可获得了更好的神经系统恢复结果。但是在偏远地区，复苏过程通常得不到所需要的资源。[9,78] 尽管如此，美国阿拉斯加州长久以来就有着一套紧急医疗服务（emergency medical services，EMS）方案，用于指导在抵达医院之前对偏远地区的低温伴有心跳停止患者进行救治。[79,80]

冻伤
冻伤是一个复杂的过程：组织温度的降低导致血管收缩、组织缺血、细胞内外冰晶的形成，这一系列过程导致细胞溶解和死亡。缺血-再灌注损伤可能会在这个过程中出现。因此重复地解冻、冻伤对组织的损伤尤其严重。最近的“野外医学协会”医疗实践指南中讨论了在再次冻伤风险很大的情况下，在野外对冻伤的组织进行复温并保持解冻的组织不再被冻伤，和在再冰冻可能性大的情况下不复温，这两种方法的选择。 [81]
冻伤的野外实地的基本处理包括：在处理伴随的低温和损伤的情况下，注射抗前列腺素剂、止痛、保护性包扎。对不出血的水疱性冻伤进行清创可能是有益处的，但是目前证据不足。在医疗机构中，运用组织纤维蛋白溶酶原激活剂或前列腺素类似物进一步的治疗的方法也有记录。过去，大家利用“等待-观察”的方法来确定冻伤区域织的界限；现在，运用磁共振血管造影（MRA）或骨闪烁显像等影像技术，可以很快的确定组织是否有生机。[81]

雪崩
雪崩最常发生在35%以上坡度的山地，当被雪掩埋的底层崩塌时，覆盖其上的雪层就倾泻下来。遭遇雪崩的人员会受到巨大的创伤力，有窒息并且最终低温的危险。雪崩带来伤害的严重程度通常取决于以下几个因素：人员掩埋的深度、掩埋的时间、气道梗阻情况和同时受到的其他创伤。[82‒84] 雪崩的救援和复苏治疗因为对雪崩掩埋下的生理过程理解的提高而有了明显的进步。这些生理过程包括体温下降、“复温后中心体温降低现象”和呼出的二氧化碳的作用。[85,86] 用于降低与雪崩有关的伤害和死亡风险的技术进步包括：呼出气体分流装置、漂浮装置和无线电收发装置。[87]对于雪崩预报的科学也在进步：详细的预报报告可以互联网上找到。[88] 虽然有了这些进步，北美雪崩的死亡人数仍然呈持续上升趋势。[89]非雪崩导致被雪掩埋（比如树坑和深雪埋致窒息）的造成的发病率和死亡率也有记录。[90]

军事医学
战术/战地医学在上一个世纪有了巨大的进步，包括了战术性作战伤亡医疗指南和对应的训练。通过使用止血带、止血药来控制出血、外科环甲膜切开术、经骨髓穿刺输液、细针穿刺减压、疼痛控制、预防性抗生素应用、低容量战地复苏，上述这些方面有了巨大的进步。这些进步现在正跨领域被运用到平民的紧急医疗服务、战术小队和野外医学中。[91‒98]

流行病学
野外医学的流行病学是一个飞速发展的领域，主要用于描述在野外的发病率和死亡率。详尽的信息还正在被搜集，但是大趋势已经显现 。最常见的伤害是软组织损伤（如：水疱）、扭伤、肌肉劳损和下肢骨折。最常见的死因是头颅创伤、心脏停搏（男性大于55岁）、溺水、低温、高温和自杀。[5,6,10,99‒106] 这些数据对于公众教育、风险降低、旅行安排和医药箱储备非常重要。[7]

搜寻和援救
搜寻和援救任务可以通过各种组织结构领导，最典型的是公民自愿者组织、执法机构或者在很多地方是上述两者的结合。[107] 搜寻和救援参与者的医疗训练背景各异，有掌握基础的急救、野外急救、野外第一反应人员、野外紧急医疗技术人员、医务辅助人员、中级医疗提供者、医生。搜寻和援救任务通常被用于寻找失踪的孩子、旅游者，以及那些患有发育障碍、自闭症、阿尔兹海默症、失忆的人员。[99‒101,108‒112] 搜寻方案的安排上，目前可以按照根据被搜寻者的行为设计的统计模型，运用计算机分析并标示出搜寻区域。[113,114] 直升飞机可以在适当的情况下用于快速发现并救出被搜寻者。

旅行医学
旅行医学包括旅行者所患疾病的流行病学、健康教育和免疫接种。[120] 这个专科在目前这个远距离旅行轻而易举的时代变得尤为重要。[121] 旅行医学中一个特别重要的疾病是疟疾，该疾病，特别是当儿童患病时，有着很高的发病率和死亡率。[122-124] GeoSentinel 监测方法被用于检测疾病的传播并辅助疾病的控制。[125,126]

灾难医学
灾难医学和野外医学有着很大的重合之处。他们两者都是在突发的、不可预知的、困难
的、简陋的条件下进行医疗活动，并且它们的紧急响应和撤离都有不可避免的、固有的延迟。灾难性的情况可以发生在城镇、郊区和乡村，并且都具有在紧急响应、撤出、转移到医疗场所前有延迟的特点。野外或者偏远地区的典型疾病可以在灾难后的余殃显现出来。虽然具有戏剧性效果的场景会抓住媒体的注意力（例如挤压伤、截肢），在灾难中保持基本的卫生条件和水源消毒同向受灾地区部署经过良好训练的应急人员一样重要。

超声仪器
小型便携式超声仪器在各种各样的临床情况下被用作体格检查的补充：创伤（外伤病人重点超声检查Focused Assessment with Sonography in Trauma [FAST]和气胸检查），高原性肺水肿（肺检查），高原性脑水肿（确定视神经鞘的直径）和产科急症（确定胎儿孕周）。[130,131]超声技术在美国军队中有着越来越多的运用，特别是在阿富汗的偏远特种部队军医和偏远的小型伤员接收中心。[132,133] 灾难医学已经将超声用于灾难实地和医院里（当其他资源供不应求或不可用时）[134‒138] 这些情况下，超声仪器常常被用于“美国急诊医生协会紧急超声检查指南“（ACEP’s Emergency Ultrasound Guidelines）中所描述的重点扫描。[139]将超声仪器和电视医疗联系起来的运用是非常诱人的。实时的超声图像甚至可以通过国际空间站传输。[140,141]

“野外医学协会”实践指南
在1979年Forgey发表了《野外医学》一书后，关于野外医学的正式临床医疗和决策建议才逐渐形成。[142] 该书已发行6版，最近的一版发行于2006年。[143]
在过去的几年内，有循证基础的”野外医学协会”医疗实践指南在几个领域内已经发展完善并发表（表1）。这些指南基于病例分析和专家共识，因为对于很多疾病专题而言，运用随机对照方法的研究还没有开展。这些指南是在美国胸科医师协会所建议的模板上发展而来的。[149]

专业组织
“野外医学协会”是野外医学医生和其他医疗提供人员的最主要的专业组织。该协会赞助了北美范围内的很多会议：每年一度的夏季会议、冬季会议和秋季专科会议（主要围绕例如旅行医学、沙漠医学、环境健康等主题）。”野外医学协会”为继续医学教育开发了一系列既往会议的在线视频。“国际野外医学大会“自1991年以来每十年举办一次，为当前有关野外医学的观点、概念的交流提供了平台。国际山地医学协会（the International Society for Mountain Medicine）赞助了国际缺氧问题专题研讨会（the International Hypoxia Symposium）以及高原医学与生理学大会（the Congress on High Altitude Medicine and Physiology）。海下与高压医学协会（the Undersea and Hyperbaric Medical Society），潜水者警报网（the Divers Alert Network）和 南太平洋海下医学医学协会（the South Pacific Undersea Medicine Society）专注于潜水医学。
一些其他专业协会也在野外医学中扮演了重要角色。成立于1988年的国际旅行医学协会（International Society of Travel Medicine [www.istm.org]）专注于与旅行相关的疾病，包括免疫接种建议。该协会也参与了全球感染性疾病的监控。国际旅行医学协会和美国疾病控制与预防中心一起管理GeoSentinel。这是一个监控传染病的全球网络系统，能够提供近乎实时的数据以供分析疾病的演变模式。国际高山营救委员会（the International Commission for Alpine Rescue [www.ikar-cisa.org]）1948年成立并设立在瑞士，代表欧洲登山营救组织。该组织在医学和技术方面发表了登山救援队面临的很多问题的建议。国际山地医学协会（The International Society for Mountain Medicine [http://ismmed.org]），成立于1985年并设立在瑞士，发行了杂志《高原医学和生物》。

专业医生培训
野外医学专科医生培训的目的是培养该专科领域的学术领袖。许多住院医师毕业后的专科培训项目是基于急诊医学和全科医生的教学项目的。一般来说，这些专科培训项目都包含科研部分、教学部分和临床实践部分。一个典型的专科培训包括一年的训练、兼职临床工作和兼职野外医学训练。加州大学弗雷斯诺分校的培训项目可延期1年，使培训者可利用这一年得到公共卫生的硕士学位。乔治•华盛顿大学的项目同样提供了让参加者完成理学硕士和公共卫生硕士学位的机会。第一个设立的、也是最知名的野外医学专科培训项目位于斯坦福大学（加利福尼亚州帕罗奥图市）。美国急诊医学学会给出了另外8个与急诊医学住院医师培训项目相关的专科培训项目。他们分别位于：贝斯塔特医学中心，加州大学旧金山-费雷斯诺医学教育项目，乔治亚医学院，犹他大学，麻省总院，科罗拉多大学，纽约州立大学，罗马琳达大学。 另外，麦迪根陆军医务中心（Madigan Army Medical Center）主持一个培养军队医生的野外医学专科培训项目。
一些全科医学项目同样也开展了野外医学专科培训项目：蒙大拿州全科医学项目(www.riverstonehealth.org)，爱达荷州全科医学住院医生项目 (www.fmridaho.org), and圣文森特野外医学路径(www.stvincenthealth.com)。

野外医学学院
在“野外医学协会”的赞助下，野外医学学会提供超过100小时核心课程的专科培训项目。这个项目同时对参与者的医疗服务、教学、科研和经验有要求。截止2013年6月，学院一共认证了260名专科医生和700多名专科医生申请者。

硕士学位
“野外医学协会”在2009年开设了自己的硕士学位培训项目（http://wms.org/fawm/acad_information.asp）。这个项目为参与者提供了进阶的、亚专科的认证。完成野外医学专科医生培训后的医生可以在该学科内选择亚专科。这个硕士培训项目由学生和一位导师共同开展，并且项目必须在教育、学术活动、实验活动上满足要求。例如，一个以潜水医学为亚专科的硕士项目可以专注于减压病的临床处理。该项目的大多数参与者在2到5年内内满足了项目要求。

山地医学的学位证书
“野外医学协会”与犹他大学、科罗拉多大学合作，授予山地医学的学位证书，以此来证明获得者的学术水平和在山地搜救技术方面的高超技巧（http://wms.org/education/dimm.asp）。从1997年起，国际登山协会、国际登山营救委员会和国际山地医学协会也开始赞助这项学位证书项目。这个项目向医生、护士、医务辅助人员和其他有志于在严峻的环境中工作的人员开放。100小时的课程融合了野外医学、营救技术、在资源匮乏区域自给自足三个方面的讲课教学和实践教学。这些技巧横跨了多个学科，包括探险医学、搜寻和援救任务、登山向导、滑雪救护、登山休闲。这个项目包括四个长为一周的学期，参加者可以在两或三年内完成。参与者必须通过笔试和技能考试来完成该项目。

学生兴趣团体
“野外医学协会”通过与接受其赞助的医学院和指导老师一起举办演讲、研讨会和户外旅行。协会以这样的方式支持学生兴趣团体。这些活动通常由医学院学生在他们受训的第二年组织。到2013年7月份为止，大约有43个兴趣团体处于活跃状态并且举办各种活动。这些兴趣团体大多数在美国和欧洲。除此以外，美国的一些急诊医学和全科医学的培训项目为医学生和住院医生提供1-4周的选修课程（如下述）。

野外医学学校
野外医学的培训是分散的。一些组织（主要是位于北美的组织）在全世界范围内教授野外医学的课程和技巧（见表2）。他们的项目有为大众和院前护理人员准备的初级导论课程，例如：野外急救（wilderness first aid [WFA]，2天课程）、高级野外急救（advanced wilderness first aid [AWFA]，4天课程）、野外第一反应人员（wilderness first responder [WFR]，9天课程）、野外紧急医疗技术人员（4周课程）。课程也有为高级医疗提供者设计的，例如高级野外生命救助。

医疗咨询
在美国，基于街道的紧急医疗服务（EMS）被各州机构和在联邦等级上的交通运输部调控。野外医学的紧急医疗服务目前没有这样的调控系统。假如这样的系统存在的话，医疗咨询可能会因为各州司法权的不同而有差异。目前仅有几个州将野外医学整合到了他们的紧急医疗服务方案中。在宾夕法尼亚和马里兰这两个具有该项整合的州，野外医学医疗实践人员被视为是院前医疗系统的延伸。这些实践人员有医疗咨询、遵循野外医学特定的诊疗方案，并且有质控体系。
许多紧急医疗服务系统的医疗主管对野外医学的实践，特别是对它的特异局限性并不熟悉。为了更好地理解和将野外医学融入院前治疗方案，“野外医学协会”和美国国家紧急医疗服务医师协会（National Association of EMS Physicians，www.naemsp.org）一起制定了野外医学紧急医疗服务主管课程，帮助一些特殊的、对紧急医疗服务有监督指导责任的医生们。这些医生所监督的紧急医疗服务的范围在法律意义上包含了野外环境。[150,151]课程的内容包括搜索与援救、援救技术、滑雪救护和灾难响应。

野外医学研究和拨款
“野外医学协会”提供大量拨款以支持室外和野外活动中与健康相关的科研项目。举例见表3。

未来展望
野外医学的未来会在多个方向上大有发展：教育、科研、培训、技术、通信和环境。有兴趣学习野外医学技巧的人群非常广泛。虽然野外医学的科研在技术上很难操作，但为了加深对野外医学技术的理解、在临床上获得更好的结果，持久的研究是必须的。

参考文献
1. Rodway GW. The foundations of wilderness medicine: some historical features. Wilderness Environ Med 2012; 23: 165‒169.
2. Sholl JM, Curcia EP 3rd. An introduction to wilderness medicine. Emerg Med Clin North Am 2004; 22: 256‒279.
3. Townes DA. Wilderness medicine. Prim Care 2002; 29: 1027‒1048.
4. Backer H. What is wilderness medicine? Wilderness Environ Med 1995; 6: 3–10.
5. Baker J, Pat McKay M. Analysis of emergency medical services activations in Shenandoah National Park from 2003 to 2007. Prehosp Emerg Care 2010; 14: 182–186.
6. Forrester JD, Holstege CP. Injury and illness encountered in Shenandoah National Park. Wilderness Environ Med 2009; 20: 318–326.
7. Heggie TW, Heggie TM. Search and rescue trends and the emergency medical service workload in Utah's National Parks. Wilderness Environ Med 2008; 19: 164‒171.
8. Barry J, Erb B. WMS Footprints: past, present, and future. Wilderness Medical Society. Available at www.wms.org/about/history.asp. Accessed on October 8, 2013.
9. Forgey WW. Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care, 5th ed. Guilford, Connecticut: FalconGuides; 2006.
10. Auerbach PS. Wilderness Medicine, 6th ed. Philadelphia: Elsevier; 2012: 2277.
11. Honigman B, Theis MK, Koziol-McLain J, Roach R, Yip R, Houston C, et al. Acute mountain sickness in a general tourist population at moderate altitudes. Ann Intern Med 1993, 118: 587‒592.
12. Bailey DM, Bartsch P, Knauth M, Baumgartner RW. Emerging concepts in acute mountain sickness and high-altitude cerebral edema: from the molecular to the morphological. Cell Mol Life Sci 2009; 66: 3583–3594.
13. Gallagher SA, Hackett PH. High-altitude illness. Emerg Med Clin North Am 2004; 22: 329–355.
14. Hackett PH, Roach RC. High-altitude illness. N Engl J Med 2001; 345: 107‒114.
15. Imray C, Wright A, Subudhi A, Roach R. Acute mountain sickness: pathophysiology, prevention, and treatment. Prog Cardiovasc Dis 2010; 52: 467‒484.
16. Luks AM, McIntosh SE, Grissom CK, Auerbach PS, Rodway GW, Schoene RB, et al. Wilderness Medical Society consensus guidelines for the prevention and treatment of acute altitude illness. Wilderness Environ Med 2010; 21: 146‒155.
17. Maggiorini M. Prevention and treatment of high-altitude pulmonary edema. Prog Cardiovasc Dis 2010; 52: 500‒506.
18. Ladd G, Stepan V, Stephens L. The Abacus Project: establishing the risk of recreational scuba death and decompression illness. South Pacific Underwater Med Soc J 2002; 32: 124‒128.
19. Dardeau MR, Pollock NW, McDonald CM, Lang MA. The incidence of decompression illness in 10 years of scientific diving. Diving Hyperb Med 2012; 42: 195–200.
20. Thom SR, Milovanoa TN, Bogush M, Yang M, Bhopale VM, Pollock NW, et al. Bubbles, microparticles, and neutrophil activation: changes with exercise level and breathing gas during open-water SCUBA diving. J Appl Physiol 2013; 114: 1396‒1405.
21. Klingmann C. Inner ear decompression sickness in compressed-air diving. Undersea Hyperb Med 2012; 39: 589‒594.
22. Nachum Z, Shupak A, Spitzer O, Sharoni Z, Doweck I, Gordon CR. Inner ear decompression sickness in sport compressed-air diving. Laryngoscope 2001; 111: 851‒856.
23. Vann RD, Butler FK, Mitchell SJ, Moon RE. Decompression illness. Lancet 2011; 377: 153‒164.
24. Blatteau JE, Jean F, Pontier JM, Blanche E, Bompar JM, Meaudre E, et al. Decompression sickness accident management in remote areas: use of immediate in-water recompression therapy. Review and elaboration of a new protocol targeted for a mission at Clipperton atoll. Ann Fr Anesth Reanim 2006; 25: 874‒883. [Article in French.]
25. Blatteau JE, Pontier JM. Effect of in-water recompression with oxygen to 6 msw versus normobaric oxygen breathing on bubble formation in divers. Eur J Appl Physiol 2009; 106: 691‒695.
26. Edmonds C. Underwater oxygen treatment of decompression sickness: a review. South Pacific Underwater Medicine Soc J 1995; 2(3): 17‒26.
27. Mitchell SJ, Doolette DJ, Wachholz CJ, Vann RD. Management of Mild or Marginal Decompression Illness in Remote Locations. Workshop Proceedings, Divers Alert Network, Durham, North Carolina, 2005.
28. Gutiérrez JM. Improving antivenom availability and accessibility: science, technology, and beyond. Toxicon 2012; 60: 676‒687.
29. Currie BJ. Snakes, jellyfish and spiders. Adv Exp Med Biol 2008; 609: 43–52.
30. Currie BJ. Treatment of snakebite in Australia: the current evidence base and questions requiring collaborative multicentre prospective studies. Toxicon 2006; 48: 941–956.
31. Fernandez I, Valladolid G, Varon J, Sternbach G. Encounters with venomous sea-life. J Emerg Med 2011; 40: 103–112.
32. Gold BS, Barish RA, Dart RC. North American snake envenomation: diagnosis, treatment, and management. Emerg Med Clin North Am 2004; 22: 423–443.
33. Isbister GK. Antivenom efficacy or effectiveness: the Australian experience. Toxicology 2010; 268: 148‒154.
34. Lavonas EJ, Ruha AM, Banner W, Bebarta V, Bernstein JN, Bush SP, et al. Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop. BMC Emerg Med 2011; 11: 2.
35. Norris RL. Managing arthropod bites and stings. Phys Sportsmed 1998; 26: 47‒62.
36. Singletary EM, Rochman AS, Bodmer JC, Holstege CP. Envenomations. Med Clin North Am 2005; 89: 1195‒1224.
37. Jones G, Asghar A, Llewellyn DJ. The epidemiology of rock-climbing injuries. Br J Sports Med 2008; 42: 773‒778.
38. Lack DA, Sheets AL, Entin JM, Christenson DC. Rock climbing rescues: causes, injuries, and trends in Boulder County, Colorado. Wilderness Environ Med 2012; 23: 223‒230.
39. Nelson NG, McKenzie LB. Rock climbing injuries treated in emergency departments in the U.S., 1990‒2007. Am J Prev Med 2009; 37: 195‒200.
40. Schöffl V, Hochholzer T, Winkelmann HP, Roloff I, Strecker W. Pulley injuries in sport climbers. Handchir Mikrochir Plast Chir 2004;36: 224‒230. [Article in German]
41. Schöffl V, Morrison A, Schwarz U, Schöffl I, Küpper T. Evaluation of injury and fatality risk in rock and ice climbing. Sports Med 2010; 40: 657‒679.
42. Schöffl V, Morrison A, Schöffl I, Küpper T. The epidemiology of injury in mountaineering, rock and ice climbing. Med Sport Sci 2012; 58: 17‒43.
43. Schöffl VR, Schöffl I. Injuries to the finger flexor pulley system in rock climbers: current concepts. J Hand Surg Am 2006; 31: 647‒654.
44. Schöffl VR, Schöffl I. Finger pain in rock climbers: reaching the right differential diagnosis and therapy. J Sports Med Phys Fitness 2007; 47: 70‒78.
45. Smith LO. Alpine climbing: injuries and illness. Phys Med Rehabil Clin N Am 2006; 17: 633‒644.
46. Yamaguchi T, Ikuta Y. Climber's finger. Hand Surg 2007; 12: 59‒65.
47. Ellerton J, Tomazin I, Brugger H, Paal P. Immobilization and splinting in mountain rescue: Official Recommendations of the International Commission for Mountain Emergency Medicine, ICAR MEDCOM, Intended for Mountain Rescue First Responders, Physicians, and Rescue Organizations. High Alt Med Biol 2009, 10: 337–342.
48. Kotwal RS, O'Connor KC, Johnson TR, Mosely DS, Meyer DE, Holcomb JB. A novel pain management strategy for combat casualty care. Ann Emerg Med 2004; 44: 121‒127.
49. Wedmore IS, Johnson T, Czarnik J, Hendrix S. Pain management in the wilderness and operational setting. Emerg Med Clin North Am 2005; 23: 585‒601.
50. Wharton DR, Bennett BL. Surgical cricothyrotomy in the wilderness: a case report. Wilderness Environ Med2013; 24: 12‒14.
51. Quinn R, Williams J, Bennett B, Stiller G, Islas A, McCord S. Wilderness Medical Society Practice Guidelines for Spine Immobilization in the Austere Environment. Wilderness Environ Med 2013; 24: 241‒252.
52. Ditty J, Chisholm D, Davis SM, Estelle-Schmidt M. Safety and efficacy of attempts to reduce shoulder dislocations by non-medical personnel in the wilderness setting. Wilderness Environ Med 2010; 21: 357–361.e2.
53. Mortimer RB. Risks and management of prolonged suspension in an alpine harness. Wilderness Environ Med 2011; 22: 77–86.
54. Epstein Y, Druyan A, Heled Y. Heat injury prevention--a military perspective. J Strength Cond Res 2012; 26(suppl 2): S82‒S86.
55. Adams T, Stacey E, Stacey S, Martin D. Exertional heat stroke. Br J Hosp Med (Lond) 2012; 73: 72–78.
56. Brown DJ, Brugger H, Boyd J, Paal P. Accidental hypothermia. N Engl J Med 2102; 367: 1930–1938.
57. Casa DJ, Armstrong LE, Kenny GP, O'Connor FG, Huggins RA. Exertional heat stroke: new concepts regarding cause and care. Curr Sports Med Rep 2012; 11: 115–123.
58. Sithinamsuwan P, Piyavechviratana K, Kitthaweesin T, Chusri W, Orrawanhanothai P, Wongsa A, et al; Phramongkutklao Army Hospital Exertional Heatstroke Study Team. Exertional heatstroke: early recognition and outcome with aggressive combined cooling--a 12-year experience. Mil Med 2009; 174: 496‒502.
59. Salathé C, Pellaton C, Vallotton L, Coronado M, Liaudet L. Exertional heatstroke. Rev Med Suisse 2012; 8: 2395‒2399.
60. Casa DJ, McDermott BP, Lee EC, Yeargin SW, Armstrong LE, Maresh CM. Cold water immersion: the gold standard for exertional heatstroke treatment. Exerc Sport Sci Rev 2007; 35: 141–149.
61. Proulx CI, Ducharme MB, Kenny GP. Effect of water temperature on cooling efficiency during hyperthermia in humans. J Appl Physiol 2003; 94: 1317‒1323.
62. Moffatt SE. Hypothermia in trauma. Emerg Med J 2012; 1: 1‒8.
63. Søreide K. Clinical and translational aspects of hypothermia in major trauma patients: from pathophysiology to prevention, prognosis and potential preservation. Injury, January 23, 2013 [Epub ahead of print].
64. Lim C, Duflou J. Hypothermia fatalities in a temperate climate: Sydney, Australia. Pathology 2008; 40: 46‒51.
65. Wedin B, Vanggaard L, Hirvonen J. “Paradoxical undressing” in fatal hypothermia. J Forensic Sci 1979; 24: 543‒553.
66. Rothschild MA, Schneider V. “Terminal burrowing behavior”-- a phenomenon of lethal hypothermia. Int J Legal Med 1995; 107: 250‒256.
67. Brandström H, Eriksson A, Giesbrecht G, Angquist KA, Haney M. Fatal hypothermia: an analysis from a sub-arctic region. Int J Circumpolar Health 2012; 71: 1–7.
68. Geisbrecht GG. Prehospital treatment of hypothermia. Wilderness Environ Med 2001; 12: 24‒31.
69. Geisbrecht GG. Emergency treatment of hypothermia. Emerg Med (Fremantle) 2001; 13: 9‒13.
70. Grissom CK, Harmston CH, McAlpine JC, Radwin MI, Ellington B, Hirshberg EL, et al. Spontaneous endogenous core temperature rewarming after cooling due to snow burial. Wilderness Environ Med 2010; 21: 229‒235.
71. Grissom CK, McAlpine JC, Harmston CH, Radwin MI, Giesbrecht GG, Scholand MB, et al. Hypercapnia effect on core cooling and shivering threshold during snow burial. Aviat Space Environ Med 2008; 79: 735‒742.
72. Grissom CK, Radwin MI, Harmston CH, Hirshberg EL, Crowley TJ. Respiration during snow burial using an artificial air pocket. JAMA 2000; 283:2266‒2271.
73. Grissom CK, Radwin MI, Scholand MB, Harmston CH, Muetterties MC, Bywater TJ. Hypercapnia increases core temperature cooling rate during snow burial. J Appl Physiol 2004; 96: 1365‒1370.
74. Hayward JS, Eckerson JD, Kemna D. Thermal and cardiovascular changes during three methods of resuscitation from mild hypothermia. Resuscitation 1984; 11: 21‒33.
75. Radwin MI, Grissom CK, Scholand MB, Harmston CH. Normal oxygenation and ventilation during snow burial by the exclusion of exhaled carbon dioxide. Wilderness Environ Med 2001; 12: 256‒262.
76. Soreide E, Grahn DA, Brock-Utne JG, Rosen L. A non-invasive means to effectively restore normothermia in cold-stressed individuals: a preliminary report. J Emerg Med 1999; 17: 725‒730.
77. Vanggaard L, Eyolfson D, Xu X, Weseen G, Geisbrecht G. Immersion of distal arms and legs in warm water (AVA rewarming) effectively rewarms mildly hypothermic humans. Aviat Space Environ Med 1999; 70: 1081‒1088.
78. Southwick FS, Dalglish PH Jr. Recovery after prolonged asystolic cardiac arrest in profound hypothermia: a case report and literature review. JAMA 1980; 243: 1250‒1253.
79. Samuelson T. Experience in standardized protocol in hypothermia, boon or bane? The Alaska experience. Arctic Med Res 1991; 50 (suppl 6): 28‒31.
80. State of Alaska. Cold Injuries Guidelines. Juneau, Alaska: Department of Health and Social Services, 2005. Available at www.hypothermia.org/Hypothermia_Ed_pdf/Alaska-Cold-Injuries.pdf. Accessed on October 14, 2013.
81. McIntosh SE, Hamonko M, Freer L, Grissom CK, Auerbach PS, Rodway GW, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite. Wilderness Environ Med 2011; 22: 156‒166.
82. Boyd J, Haegeli P, Abu-Laban RB, Shuster M, Butt JC. Patterns of death among avalanche fatalities: a 21-year review. CMAJ 2009; 180: 507–512.
83. Brugger H, Durrer B, Adler-Kastner L, Falk M, Tschirky F. Field management of avalanche victims. Resuscitation 2001; 51: 7–15.
84. McIntosh SE, Grissom CK, Olivares CR, Kim HS, Tremper B. Cause of death in avalanche fatalities. Wilderness Environ Med 2007; 18: 293‒297.
85. Brugger H, Durrer B, Eisensohn F, Paal P, Strapazzon G, Winterberger E, et al. Resuscitation of avalanche victims: Evidence-based guidelines of the international commission for mountain emergency medicine (ICAR MEDCOM): intended for physicians and other advanced life support personnel. Resuscitation 2013; 84: 539–546.
86. Brugger H, Paal P, Boyd J. Prehospital resuscitation of the buried avalanche victim. High Alt Med Biol 2011; 12: 199–205.
87. Radwin MI, Grissom CK. Technological advances in avalanche survival. Wilderness Environ Med 2002; 13: 143‒152.
88. Avalanche Stats. Utah Avalanche Center, Salt Lake City, Utah. Available at http://utahavalancecenter.org. Accessed on October 22, 2013.
89. Colorado Avalanche Information Center. Available at https://avalanche.state.co.us. Accessed on October 22, 2013.
90. Van Tilburg C. Non-avalanche-related snow immersion deaths: tree well and deep snow immersion asphyxiation. Wilderness Environ Med 2010; 21: 257‒261.
91. Bennett BL, Cailteux-Zevallos B, Kotora J. Cricothyroidotomy bottom-up training review: battlefield lessons learned. Mil Med 2011; 176: 1311–1319.
92. Blackbourne LH, Baer DG, Eastridge BJ, Kheirabadi B, Bagley S, Kragh JF Jr, et al. Military medical revolution: prehospital combat casualty care. J Trauma Acute Care Surg 2012; 73(6 suppl 5): S372–S377.
93. Butler FK Jr, Blackbourne LH. Battlefield trauma care then and now: a decade of Tactical Combat Casualty Care. J Trauma Acute Care Surg 2012; 73(6 suppl 5): S395–S402.
94. Dubick MA. Current concepts in fluid resuscitation for prehospital care of combat casualties. US Army Med Dep J 2011; Apr-Jun: 18‒24.
95. Hessert MJ, Bennett BL. Optimizing emergent surgical cricothyrotomy for use in austere environments. Wilderness Environ Med 2013; 24: 53‒66.
96. Walsh R, Heiner J, Kang C, Hile D, Deering S. Emergency physician evaluation of a novel surgical cricothyroidotomy tool in simulated combat and clinical environments. Mil Med 2013; 178: 29‒33.
97. Pruitt BA Jr. The symbiosis of combat casualty care and civilian trauma care: 1914‒2007. J Trauma 2008; 64(2 suppl): S4‒S8.
98. Bennett BL, Littlejohn L. Review of third-generation tropical hemostatic agents for Combat casualty care. Mil Med 2013 (in press).
99. Boore SM, Bock D. Ten years of search and rescue in Yosemite National Park: examining the past for future prevention. Wilderness Environ Med 2013; 24: 2–7.
100. Ela GK. Epidemiology of wilderness search and rescue in New Hampshire, 1999-2001. Wilderness Environ Med 2004; 15: 11–17.
101. Johnson J, Maertins M, Shalit M, Bierbaum TJ, Goldman DE, Lowe RA. Wilderness emergency medical services: the experiences at Sequoia and Kings Canyon National Parks. Am J Emerg Med 1991; 9: 211‒216.
102. McIntosh SE, Leemon D, Visitacion J, Schimelpfenig T, Fosnocht D. Medical incidents and evacuations on wilderness expeditions. Wilderness Environ Med 2007; 18: 298‒304.
103. Mort AJ, Godden DJ. UK mountain rescue casualties: 2002-2006. Emerg Med J 2010; 27: 309‒312.
104. Mort A, Godden D. Injuries to individuals participating in mountain and wilderness sports: a review. Clin J Sport Med 2011; 21: 530‒536.
105. Schindera ST, Triller J, Steinbach LS, Zimmermann H, Takala J, Anderson SE. Spectrum of injuries from glacial sports. Wilderness Environ Med 2005; 16: 33‒37.
106. Wild FJ. Epidemiology of mountain search and rescue operations in Banff, Yoho, and Kootenay National Parks, 2003‒06. Wilderness Environ Med 2008; 19: 245‒251.
107. Brugger H, Elsensohn F, Syme D, Sumann G, Falk M. A survey of emergency medical services in mountain areas of Europe and North America: official recommendations of the International Commission for Mountain Emergency Medicine (ICAR Medcom). High Alt Med Biol 2005; 6: 226–237.
108. Heggie TW. Search and rescue in Alaska's national parks. Travel Med Infect Dis 2008; 6: 355‒361.
109. Heggie TW, Amundson ME. Dead men walking: search and rescue in US National Parks. Wilderness Environ Med 2009; 20: 244‒249.
110. Heggie TW, Heggie TM. Search and rescue trends associated with recreational travel in US national parks. J Travel Med 2009; 16: 23‒27.
111. Hung EK, Townes DA. Search and rescue in Yosemite National Park: a 10-year review. Wilderness Environ Med 2007; 18: 111‒116.
112. McIntosh SE, Brillhart A, Dow J, Grissom CK. Search and rescue activity on Denali, 1990 to 2008. Wilderness Environ Med 2010; 21: 103‒108.
113. Koester RJ. Lost Person Behavior: A Search and Rescue Guide on Where to Look ‒ for Land, Air, Water. Charlottesville, Virginia: dbS Productions LLC; 2008.
114. Adams AL, Schmidt TA, Newgard CD, Federiuk CS, Christie M, Scorvo S, et al. Search is a time-critical event: when search and rescue missions may become futile. Wilderness Environ Med 2007; 18: 95–101.
115. Carpenter J, Thomas F. A 10-year analysis of 214 HEMS backcountry hoist rescues. Air Med J 2013; 32: 98–101.
116. Grissom CK, Thomas F, James B. Medical helicopters in wilderness search and rescue operations. Air Med J 2006; 25: 18‒25.
117. Tomazin I, Ellerton J, Reisten O, Soteras I, Avbelj M; International Commission for Mountain Emergency Medicine. Medical standards for mountain rescue operations using helicopters: official consensus recommendations of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). High Alt Med Biol 2011; 12: 335-341.
118. Tomazin I, Kovacs T; International Commission for Mountain Emergency Medicine. Medical considerations in the use of helicopters in mountain rescue. High Alt Med Biol 2003; 4: 479‒483.
119. van der Velde J, Linehan L, Cushack S. Helicopter winchmens’ experiences with pain management in challenging environments. Ir Med J 2013; 106: 42‒44.
120. Behrens RH, Carroll B. Travel trends and patterns of travel-associated morbidity. Infect Dis Clin North Am 2012; 26: 791–802.
121. Chen LH, Wilson ME, Davis X, Loutan L, Schwartz E, Keystone J, et al; GeoSentinel Surveillance Network. Illness in long-term travelers visiting GeoSentinel clinics. Emerg Infect Dis 2009 ;15 :1773‒1782.
122. Kheirabadi B. Evaluation of topical hemostatic agents for combat wound treatment. US Army Med Dep J 2011; Apr-Jun: 25‒37.
123. Leder K, Black J, O'Brien D, Greenwood Z, Kain KC, Schwartz E, et al. Malaria in travelers: a review of the GeoSentinel surveillance network. Clin Infect Dis 2004; 39: 1104‒1112.
124. Miller LH, Ackerman HC, Su XZ, Wellems TE. Malaria biology and pathogenesis: insights for new treatments. Nat Med 2013; 19: 156‒167.
125. Marano C, Freedman DO. Global health surveillance and travelers' health. Curr Opin Infect Dis 2009; 22: 423‒429.
126. Jensenius M, Han PV, Schlagenhauf P, Schwartz E, Parola P, Castelli F, et al. Acute and potentially life-threatening tropical diseases in western travelers—a GeoSentinel multicenter study, 1996‒2011. Am J Trop Med Hyg. 2013; 88: 397‒404.
127. Benjamin E, Bassily-Marcus AM, Babu E, Silver L, Martin ML. Principles and practice of disaster relief: lessons from Haiti. Mt Sinai J Med 2011; 78: 306–318.
128. Smith E, Wasiak J, Sen A, Archer F, Burkle FM Jr. Three decades of disasters: a review of disaster-specific literature from 1977-2009. Prehosp Disaster Med 2009; 24: 306‒311.
129. Zhang L, Liu X, Li Y, Liu Y, Liu Z, Lin J, et al. Emergency medical rescue efforts after a major earthquake: lessons from the 2008 Wenchuan earthquake. Lancet 2012; 379: 853‒861.
130. Nelson BP, Melnick ER, Li J. Portable ultrasound for remote environments, Part I: Feasibility of field deployment. J Emerg Med 2011; 40: 190‒197.
131. Nelson BP, Melnick ER, Li J. Portable ultrasound for remote environments, Part III: current indications. J Emerg Med 2011; 40: 313–321.
132. Morgan AR, Vasios WN, Hubler DA, Benson PJ. Special operator level clinical ultrasound: an experience in application and training. J Spec Oper Med 2010; 10: 16‒21.
133. Nations JA, Browning RF. Battlefield applications for handheld ultrasound. Ultrasound Q 2011; 27: 171‒176.
134. Dan D, Mingsong L, Jie T, Xiaobo W, Zhong C, Yan L, et al. Ultrasonographic applications after mass casualty incident caused by Wenchuan earthquake. J Trauma 2010; 68: 1417‒1420.
135. Dean AJ, Ku BS, Zeserson EM. The utility of handheld ultrasound in an austere medical setting in Guatemala after a natural disaster. Am J Disaster Med 2007; 2: 249–256.
136. Ma OJ, Norvell JG, Subramanian S. Ultrasound applications in mass casualties and extreme environments. Crit Care Med 2007; 35(5 suppl): S275‒S279.
137. Shorter M, Macias DJ. Portable handheld ultrasound in austere environments: use in the Haiti disaster. Prehosp Disaster Med 2012; 27: 172‒177.
138. Stawicki SP, Howard JM, Pryor JP, Bahner DP, Whitmill ML, Dean AJ. Portable ultrasonography in mass casualty incidents: the CAVEAT examination. World J Orthop 2010; 1: 10‒19.
139. American College of Emergency Physicians Policy Statement: Emergency Ultrasound Guidelines. Approved October 2008. Available at www.acep.org/ultrasound. Accessed on October 22, 2013.
140. Law J, Macbeth PB. Ultrasound: from Earth to space. Mcgill J Med 2011; 13: 59.
141. Sargsyan AE, Hamilton DR, Jones JA, Melton S, Whitson PA, Kirkpatrick AW, et al. FAST at MACH 20: Clinical Ultrasound Aboard the International Space Station. J Trauma 2005; 58: 35‒39.
142. Forgey W. Wilderness Medicine. Pittsboro, Indiana: Indiana Camp Supply Books, 1979.
143. Forgey WW. Wilderness Medicine, 6th edition. Guilford, Connecticut: FalconGuides, 2012.
149. Guyatt G, Gutterman D, Baumann MH, Addrizzo-Harris D, Hylek EM, Phillips B, et al. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians Task Force. Chest 2006; 129: 174‒181.
144. Davis C, Engeln A, Johnson E, McIntosh SE, Zafren K, Islas AA, et al. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Lightning Injuries. Wilderness Environ Med 2012; 23 :260–269.
145. Drake B, Paterson R, Tabin G, Butler FK Jr, Cushing T; Wilderness Medical Society. Wilderness Medical Society Practice Guidelines for Treatment of Eye Injuries and Illness in the Wilderness. Wilderness Environ Med 2012; 23: 325–336.
146. Gaudio F, Lemery J, Johnson D. Wilderness Medical Society Roundtable Report: recommendations on the use of epinephrine in outdoor education and wilderness settings. Wilderness Environ Med 2010; 21: 185‒187.
147. Winterberger E, Jacomet H, Zafren K, Ruffinen GZ, Jelk B. Wilderness & Environmental Medicine. The Use of Extrication Devices in Crevasse Accidents: Official Statement of the International Commission for Mountain Emergency Medicine and the Terrestrial Rescue Commission of the International Commission for Alpine Rescue Intended for Physicians, Paramedics, and Mountain Rescuers. Wilderness Environ Med 2008; 19: 108‒110.
148. Bennett BL, Hew-Butler T, Hoffman MD, Rogers IR, Rosner MH. Wilderness Medical Society Practice Guidelines for Treatment of Exercise-Associated Hyponatremia. Wilderness Environ Med 2013; 24: 228‒240.
149. Lipman GS, Eifling KP, Ellis MA, Gaudio FG, Otten EM, Grissom CK. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Heat-Related Illness. Wilderness Environ Med, October 16, 2013 [Epub ahead of print].
150. Warden CR, Millin MG, Hawkins SC, Bradley RN. Medical direction of wilderness and other operational emergency medical services programs. Wilderness Environ Med 2012; 23: 37‒43.
151. Bennett BL. A time has come for wilderness emergency medical service: a new direction [editorial]. Wilderness Environ Med 2012; 23: 5‒6.


表1. “野外医学协会”指南的中涉及的主题
高原病[16]
冻伤[81]
雷电伤[144]
眼部外伤[145]
肾上腺素的使用[146]
在冰面裂缝援救中使用解脱装置[147]
运动相关性低血钠[148]
脊柱创伤处理[51]
热相关疾病[149]
麻醉与疼痛控制（出版中）
伤口处理 （待出版）
低温（待出版）
溺水和淹没所致损伤（待出版）



表2. 教授野外医学技能的组织
Stonehearth Open Learning Opportunities (SOLO), Conway, New Hampshire, USA
National Outdoor Leadership School, Wilderness Medicine Institute, Lander, Wyoming, USA
Wilderness Medical Associates International, Portland, Maine, USA; Haliburton, Ontario, Canada; Tsukubamirai, Ibaraki, Japan (runs courses in China regularly)
National Ski Patrol, Lakewood, Colorado, USA (outdoor emergency care)
Advanced Wilderness Life Support, University of Utah, Salt Lake City, Utah, USA
Aerie Backcountry Medicine, Missoula, Montana, USA



表3. 由”野外医学协会”提供的用于支持野外医学科研的资金项目(www.wms.org/research)

Charles S. Houston Award
Audience
Medical students
Article by recent recipients
Fischer MD, Willmann G, Schatz A, Schommer K, Zhour A, Zrenner E, Bartz-Schmidt KU, Gekeler F. Structural and functional changes of the human macula during acute exposure to high altitude. PLoS One. 2012; 7(4): e36155.

Research-in-Training Award
Audience
Residents and fellows of accredited graduate medical education programs or PhD candidates
Articles by recent recipients
Graves JM, Whitehill JM, Stream JO, Vavilala, MS, Rivara FP. Emergency department-reported head injuries from skiing and snowboarding among children and adolescents, 1996–2010. Inj Prev, March 19, 2013 [Epub ahead of print].
Muller MD, Mast JL, Patel H, Sinoway LI. Cardiac mechanics are impaired during fatiguing exercise and cold pressor test in healthy older adults. J Appl Physiol 2013; 114: 186‒194.
Muller MD, Gao Z, Mast JL, Blaha CA, Drew RC, Leuenberger UA, Sinoway LI. Aging attenuates the coronary blood flow response to cold air breathing and isometric handgrip in healthy humans. Am J Physiol Heart Circ Physiol 2012; 302: 1737‒1746.

Herbert N. Hultgren Award
Audience
Members of the Wilderness Medical Society
Article by recent recipients
Chang CY, Trehan I, Wang RJ, Thakwalakwa C, Maleta K, Deitchler M, Manary MJ. Children successfully treated for moderate acute malnutrition remain at risk for malnutrition and death in the subsequent year after recovery. J Nutr 2013; 143: 215‒220.

Peter Hackett-Paul Auerbach Research Grant
Audience
Young investigators, physicians or non-physicians, with projects that will improve wilderness medicine practice

WMS Adventure Travel Research Grant
Audience
Investigators conducting field research associated with the WMS Adventure Travel Experiences