July 28, 2023 • 15 mins
In this two-part episode, I review an article from the Annals of Emergency Medicine "Occupational Accidents Among Search and Rescue Providers During Mountain Rescue Operations and Training Events"
https://doi.org/10.1016/j.annemergmed.2022.12.015
In the second half, we review the treatment of diarrhea in the returning traveler.
As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.
Connect with us by email at wildernessmedicineupdates@gmail.com.
You can pay us a compliment and share the show with a new listener on any popular platform here.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:15):
Hello and welcome back to Wilderness Medicine
Updates, the show for providersat the edges.
I'm your host, patrick Pink.
On today's episode, we're goingto deliver two punches left and
right the first on OccupationalAccidents Among SAR Providers
and the second a review oftreatment of diarrhea in the
returning traveler.
If you want to jump to one orthe other, take a look down at
(00:37):
the bottom of your iTunes playeror whatever platform you're
using, and you can use thechapters function to jump
straight to where you want to go.
We're going to begin first withOccupational Accidents Among
SAR Providers.
This is a review of a paperentitled Occupational Accidents
Among Search and RescueProviders during Mountain Rescue
Operations and Training Events.
(00:58):
This was published by MarioMilani et al in Annals of
Emergency Medicine in June of2023.
This study is an interestingreview of a database of
insurance claims maintained bythe Italian Search and Rescue
Operation.
Corpo Nazionale so corso alpinois piliologico, or the CNSAS,
(01:24):
as we'll call it from here onout, keeps a database of any
insurance claims made by theirproviders, and the authors
looked at a period from 1999 to2019.
They used this to take a lookback at all of the injuries,
illnesses and other claims thattook their professional rescue
providers out of circulation andaway from work.
(01:45):
A background on thisorganization is that this is a
nationally operated search andrescue service.
They've grown their rescueoperations tremendously over
time and they generally operatearound 10,000 operations per
year and they've rescued a totalof 203,917 people from the
mountains since their foundingin 1954.
(02:07):
The authors note that thereason to approach the topic of
hazards for SAR providers isthat they operate like an EMS
service, but in a much morechallenging environment, and EMS
providers are generally hurt ata much higher rate than their
in-hospital colleagues In urbanEMS settings.
This is usually because theseproviders are operating
unsecured inside of movingvehicles like ambulances, or
(02:30):
they're operating at road sides,where further accidents can
occur.
In the mountains we're talkingabout a difficult operating
environment, with adverseweather, rain, and also using
vehicles and helicopters underchallenging circumstances.
So the authors here looked at adataset that included all
accidents that resulted in theprovider leaving the service and
(02:52):
taking recovery time.
Over this 20 year period from1999 to 2019, there were 784
CNSAS providers who were injuredin 755 accidents.
41% of those cases happenedduring rescue operations and 59%
occurred during training.
There was a strong seasonaldistribution, where training
(03:12):
accidents tended to happenduring the spring, and
operational accidents tended tohappen during the summer, likely
reflecting when those thingstend to occur During this period
of time.
There were at least 20,000professional operators in the
field each year, although itdoes vary from year to year, so
that results in about 39.2providers per year who were
(03:34):
injured during this period oftime.
Of those accidents, 751 of the755 cases, or 96%, resulted from
a traumatic mechanism, whereasonly 33 or 4% were classified as
either medical or environmentalillness cases.
In the trauma category, highenergy falls, ie falling from
higher than standing height, wasthe most common mechanism
(03:56):
leading to trauma, accountingfor 44% of cases.
Helicopters and car crasheswere the cause of accidents in
29 cases during rescueoperations and 13 during
training events, and lower limbinjuries were the most common,
upper limb injuries less common.
80% of injuries were classifiedas a moderate injury, whereas
(04:18):
very low acuity injuries likecontact with bodily fluids, and
very high acuity injuries ordeaths were only reported during
rescue operations.
The authors did look at thefatal accidents and from 1999 to
2019, there were eight fatalaccidents involving 16 victims
in total.
The causes of death highlightedhere included fall in a snow
(04:40):
field, fall, helicopter crash,avalanche, myocardial infarction
, landslide, helicopter crashand car accident.
So what can we take away fromthis review of injury data from
a large professional rescuerdatabase over the last 20 years?
The first is that most of theseinjury cases resulted in
(05:01):
non-fatal injuries or illnessesthat resulted in lost workdays.
Fatalities were relatively rare, happened only during rescue
operations, and injuries weremuch more common during training
.
Similarly to the patterns ofinjuries that we see in
recreationalists, fallsresulting in lower extremity
injuries like fractures, strainsand sprains were the main type
(05:22):
of injuries seen in the mountainsearch and rescue population.
There were four fatalities fromavalanches and two from a
landslide, which does highlightthat the operational conditions
are very different and poseunique hazards in comparison to
urban EMS services.
It's also worth noting that asignificant proportion of the
fatal accidents involved the useof a vehicle, including two car
(05:46):
crashes and two helicoptercrashes, and these were also the
only settings in which multipleproviders were killed.
So anytime that we areemploying a vehicle, an aircraft
, in rescue operations, it doespose a higher risk of fatality
as a result of an accidentrather than simple injury.
Interestingly, even though themean age of their mountain
rescue providers changed overthis period of time, trending
(06:09):
upwards from 37.8 years of ageto 45.2 years of age.
Across the study period,medical causes of illness and
environmental illnesses weremuch less common in this
population.
Now this program does have anaggressive screening program
where all professional providersunder the age of 50 are
screened every three years by aphysician and everyone over the
(06:31):
age of 50 is screened annuallybefore they're allowed to
participate.
What are the limitations here?
So it's possible that theirdata doesn't include any minor
accidents, because anything thatlets someone return to work
essentially immediately anddoesn't result in an insurance
claim isn't covered here.
Additionally, they don't reallyknow how to calculate recovery
time for these folks, becausethe only data they have is when
(06:52):
they're away from work, so theymake some assumptions there.
What should we take away fromthis as mountain rescue
providers?
I think that this studyemphasizes that the greatest
risk to us as professionalrescuers in the mountain
environment is in proportion tohow we spend our time.
So the majority of time isspent in training, and so the
majority of accidents occur intraining.
(07:13):
The kinds of injuries that wesustain are what we might expect
falls, and it is likely aresult of the challenging
operating environment.
I think that in the UnitedStates we would probably see a
different pattern of traumaticversus medical causes of injury,
and here's why there are notvery many professional rescue
operations in the United Statesoutside of the National Park
(07:35):
Service.
The majority of people involvedin search and rescue are
volunteers, so theirconditioning may actually be
much less than those who areconducting 10,000 rescue
operations annually.
Accordingly, I would expect tosee a higher degree of medical
and environmental related causesof illness in an American
(07:56):
rescue population, or in anypopulation where it is
predominantly volunteers who areproviding care.
So I thank Dr Milani at all fortheir interesting article, and
the quick review that we'veprovided you here is just
touching on some of what they'vediscussed in this article.
If you want more, look inVolume 81, Number 6, that's June
(08:17):
2023 in the Annals of EmergencyMedicine.
Now let's move on to talk aboutdiarrhea in the returning
traveler.
A friend of mine went on a longweekend trip to Mexico City a
(08:39):
few months ago, which he saidwas like a vibrant and verdant,
slightly rough around the edgesvariant of Paris.
One night he had a marvelouscourse meal at a top 50
restaurant, and the followingnight he ate tacos and watched
some luchador wrestling.
That night he fell happilyasleep, only to be rudely
awakened by a stomach and knotsand overwhelming nausea For the
(09:03):
following week.
Even though he returned to theUS, he had persistent abdominal
cramping and diarrhea.
He asked me whether he shouldconsider antibiotics, so I
thought it was time for arefresh on the subject.
First, some background.
Traveller's diarrhea is definedby the presence of multiple
loose stools in the context oftravel, accompanied by either
(09:26):
abdominal pain and cramping,fever, blood in the stool or
nausea and vomiting.
The problem of diarrhea in aquote returning traveler is not
uncommon.
Of those who spend at least twoweeks in a developing country,
somewhere around 20-60% willexperience some kind of
diarrheal illness.
The less developed the country,the higher the risk of illness.
(09:50):
The management and diagnosis oftraveler's diarrhea is pretty
different depending on whetherit's acute or persistent.
Acute, in this case we mean tobe less than two weeks in
duration, and persistent isanything of longer duration.
Acute Traveller's Diarrhea themajority of cases of Traveller's
(10:11):
Diarrhea in the acute phase arecaused by self-limiting
bacterial infections.
Organisms include Salmonella,shigella, campylobacter E coli
and Plesiamonas, among others.
Viruses Norovirus among them,account for around a third of
cases, and parasites, mostlyGiardia and Entomibia, account
(10:32):
for the remainder Low.
Diagnostics have advancedsignificantly in recent years,
with PCR panels quicklyreplacing stool culture and
microscopy.
The actual usefulness of thistesting is unclear and generally
there's no need for testingBecause of bacterial
predominance.
Acute diarrhea does oftenrespond to antibiotic therapy.
(10:53):
Cyprophyloxacin is the classicmedication for treatment of
Traveller's Diarrhea.
However, fluoroquine aloneresistance is on the rise and
azithromycin is a strongalternative.
Still, because most cases areself-limited, because some are
due to viruses, and becauseantibiotics can cause their own
slew of GI problems, there's noreal indication for treatment.
(11:17):
Additionally, if there's bloodin the stool or fever,
antibiotics are contraindicatedas they can cause complications
when treating enterohemorrhagicE coli, also known as e-HEC,
causing such problems ashemolytic uremic syndrome and
kidney failure.
An alternative to antibioticsis to treat the diarrhea itself
(11:37):
with Loparamide, an opioidmedication that's poorly
absorbed in the gut, which thusmakes it possible for use for
its side effect, which isconstipation.
Loparamide is alsocontraindicated in bloody
diarrhea or diarrhea with fever,as these symptoms suggest a
toxin-forming bacteria, and inthese cases it's better out than
(11:57):
in.
Dosing for Loparamide is a 4mgoral loading dose and then 2mg
PO for each loose stool, to amaximum of 16mg per day in
adults.
Persistent Traveller's Diarrhea.
This is a deep, deep hole, nopun intended.
There are essentially threemain causes of persistent
(12:20):
diarrhea, which is anythingaround 14 days or longer.
The first is a persistentinfection or a secondary
infection after an initialinfection.
Some infectious causes areresponsible for longer courses
of illness, namely parasiteslike GRD-iasis, which should be
strongly suspected and testedfor in any diarrhea lasting
(12:42):
longer than 14 days.
The second is what's calledpost-infectious phenomena.
Some infections can cause gutdysregulation and subsequently,
difficulty digesting fructose,lactose and other food compounds
.
This is also something that canresult from taking antibiotics
and another reason to thinkcarefully before using them.
Third is underlying GI disease.
(13:07):
Interestingly, underlyingchronic GI diseases can be
unmasked by an acute diarrhealinfection, including celiac,
spru, crohn's disease andulcerative colitis.
There are even some theoriesthat inflammation in the setting
of diarrhea can lead to theinitiation or development of
these diseases.
Back to the case.
Would antibiotics work for myfriend?
(13:29):
Perhaps, if he is one of thepredominance of cases caused by
bacteria, but his diarrhea islikely to resolve on its own,
antibiotics could cause theirown problems, including a
malabsorptive syndrome or Cdifficile infection.
Sure, if he continues to havediarrhea beyond 14 days, then
(13:49):
things get more interesting andthere might be a reason to start
thinking harder and consideringsome testing, mostly for
parasites like Giardia.
In the meantime, I'll try someLeParamide.
Did I say that?
Yeah, this patient is me.
(14:14):
Thank you, as always, forlistening to Wilderness Medicine
Updates.
I always appreciate yourattention and time, and if you
have a friend, a relative, afellow resident, a fellow, a
paramedic, a nurse who you thinkwould benefit from listening to
(14:37):
this podcast, please do shareit.
As always, reviews on iTunesare much appreciated, as that
helps to get this podcast out.
I hope you enjoyed this video.
If you did, please like, shareand subscribe to my channel and,
as always, reviews on iTunesare much appreciated, as that
helps to get this podcast out tomore people like yourselves.
(14:58):
Finally, if you happen tolisten to the last Fast Push
episode, number 2.1, calledSafety Third and you were one of
the lucky people who got theoriginal version in which my
voice sounded like a chipmunkthanks for your patience
Something went totally sidewaysin post-processing there and
thanks to my dad, jeff, whopointed that out to me so I
(15:19):
could fix that and get that backout to you all.
This is a learning curve for meand I hope you don't mind the
ride.
So, as always, don't hesitateto reach out at WildMedUpdates
on Twitter or reach out to me atWildernessMedicineUpdates at
gmailcom with any questions,episodes you'd like to hear,
feedback or thoughts.
(15:39):
Until next time, stay fit, stayfocused and have fun.
Hello and welcome back to Wilderness Medicine
Updates, the show for providersat the edges.
I'm your host, patrick Pink.
On today's episode, we're goingto deliver two punches left and
right the first on OccupationalAccidents Among SAR Providers
and the second a review oftreatment of diarrhea in the
returning traveler.
If you want to jump to one orthe other, take a look down at
(00:37):
the bottom of your iTunes playeror whatever platform you're
using, and you can use thechapters function to jump
straight to where you want to go.
We're going to begin first withOccupational Accidents Among
SAR Providers.
This is a review of a paperentitled Occupational Accidents
Among Search and RescueProviders during Mountain Rescue
Operations and Training Events.
(00:58):
This was published by MarioMilani et al in Annals of
Emergency Medicine in June of2023.
This study is an interestingreview of a database of
insurance claims maintained bythe Italian Search and Rescue
Operation.
Corpo Nazionale so corso alpinois piliologico, or the CNSAS,
(01:24):
as we'll call it from here onout, keeps a database of any
insurance claims made by theirproviders, and the authors
looked at a period from 1999 to2019.
They used this to take a lookback at all of the injuries,
illnesses and other claims thattook their professional rescue
providers out of circulation andaway from work.
(01:45):
A background on thisorganization is that this is a
nationally operated search andrescue service.
They've grown their rescueoperations tremendously over
time and they generally operatearound 10,000 operations per
year and they've rescued a totalof 203,917 people from the
mountains since their foundingin 1954.
(02:07):
The authors note that thereason to approach the topic of
hazards for SAR providers isthat they operate like an EMS
service, but in a much morechallenging environment, and EMS
providers are generally hurt ata much higher rate than their
in-hospital colleagues In urbanEMS settings.
This is usually because theseproviders are operating
unsecured inside of movingvehicles like ambulances, or
(02:30):
they're operating at road sides,where further accidents can
occur.
In the mountains we're talkingabout a difficult operating
environment, with adverseweather, rain, and also using
vehicles and helicopters underchallenging circumstances.
So the authors here looked at adataset that included all
accidents that resulted in theprovider leaving the service and
(02:52):
taking recovery time.
Over this 20 year period from1999 to 2019, there were 784
CNSAS providers who were injuredin 755 accidents.
41% of those cases happenedduring rescue operations and 59%
occurred during training.
There was a strong seasonaldistribution, where training
(03:12):
accidents tended to happenduring the spring, and
operational accidents tended tohappen during the summer, likely
reflecting when those thingstend to occur During this period
of time.
There were at least 20,000professional operators in the
field each year, although itdoes vary from year to year, so
that results in about 39.2providers per year who were
(03:34):
injured during this period oftime.
Of those accidents, 751 of the755 cases, or 96%, resulted from
a traumatic mechanism, whereasonly 33 or 4% were classified as
either medical or environmentalillness cases.
In the trauma category, highenergy falls, ie falling from
higher than standing height, wasthe most common mechanism
(03:56):
leading to trauma, accountingfor 44% of cases.
Helicopters and car crasheswere the cause of accidents in
29 cases during rescueoperations and 13 during
training events, and lower limbinjuries were the most common,
upper limb injuries less common.
80% of injuries were classifiedas a moderate injury, whereas
(04:18):
very low acuity injuries likecontact with bodily fluids, and
very high acuity injuries ordeaths were only reported during
rescue operations.
The authors did look at thefatal accidents and from 1999 to
2019, there were eight fatalaccidents involving 16 victims
in total.
The causes of death highlightedhere included fall in a snow
(04:40):
field, fall, helicopter crash,avalanche, myocardial infarction
, landslide, helicopter crashand car accident.
So what can we take away fromthis review of injury data from
a large professional rescuerdatabase over the last 20 years?
The first is that most of theseinjury cases resulted in
(05:01):
non-fatal injuries or illnessesthat resulted in lost workdays.
Fatalities were relatively rare, happened only during rescue
operations, and injuries weremuch more common during training
.
Similarly to the patterns ofinjuries that we see in
recreationalists, fallsresulting in lower extremity
injuries like fractures, strainsand sprains were the main type
(05:22):
of injuries seen in the mountainsearch and rescue population.
There were four fatalities fromavalanches and two from a
landslide, which does highlightthat the operational conditions
are very different and poseunique hazards in comparison to
urban EMS services.
It's also worth noting that asignificant proportion of the
fatal accidents involved the useof a vehicle, including two car
(05:46):
crashes and two helicoptercrashes, and these were also the
only settings in which multipleproviders were killed.
So anytime that we areemploying a vehicle, an aircraft
, in rescue operations, it doespose a higher risk of fatality
as a result of an accidentrather than simple injury.
Interestingly, even though themean age of their mountain
rescue providers changed overthis period of time, trending
(06:09):
upwards from 37.8 years of ageto 45.2 years of age.
Across the study period,medical causes of illness and
environmental illnesses weremuch less common in this
population.
Now this program does have anaggressive screening program
where all professional providersunder the age of 50 are
screened every three years by aphysician and everyone over the
(06:31):
age of 50 is screened annuallybefore they're allowed to
participate.
What are the limitations here?
So it's possible that theirdata doesn't include any minor
accidents, because anything thatlets someone return to work
essentially immediately anddoesn't result in an insurance
claim isn't covered here.
Additionally, they don't reallyknow how to calculate recovery
time for these folks, becausethe only data they have is when
(06:52):
they're away from work, so theymake some assumptions there.
What should we take away fromthis as mountain rescue
providers?
I think that this studyemphasizes that the greatest
risk to us as professionalrescuers in the mountain
environment is in proportion tohow we spend our time.
So the majority of time isspent in training, and so the
majority of accidents occur intraining.
(07:13):
The kinds of injuries that wesustain are what we might expect
falls, and it is likely aresult of the challenging
operating environment.
I think that in the UnitedStates we would probably see a
different pattern of traumaticversus medical causes of injury,
and here's why there are notvery many professional rescue
operations in the United Statesoutside of the National Park
(07:35):
Service.
The majority of people involvedin search and rescue are
volunteers, so theirconditioning may actually be
much less than those who areconducting 10,000 rescue
operations annually.
Accordingly, I would expect tosee a higher degree of medical
and environmental related causesof illness in an American
(07:56):
rescue population, or in anypopulation where it is
predominantly volunteers who areproviding care.
So I thank Dr Milani at all fortheir interesting article, and
the quick review that we'veprovided you here is just
touching on some of what they'vediscussed in this article.
If you want more, look inVolume 81, Number 6, that's June
(08:17):
2023 in the Annals of EmergencyMedicine.
Now let's move on to talk aboutdiarrhea in the returning
traveler.
A friend of mine went on a longweekend trip to Mexico City a
(08:39):
few months ago, which he saidwas like a vibrant and verdant,
slightly rough around the edgesvariant of Paris.
One night he had a marvelouscourse meal at a top 50
restaurant, and the followingnight he ate tacos and watched
some luchador wrestling.
That night he fell happilyasleep, only to be rudely
awakened by a stomach and knotsand overwhelming nausea For the
(09:03):
following week.
Even though he returned to theUS, he had persistent abdominal
cramping and diarrhea.
He asked me whether he shouldconsider antibiotics, so I
thought it was time for arefresh on the subject.
First, some background.
Traveller's diarrhea is definedby the presence of multiple
loose stools in the context oftravel, accompanied by either
(09:26):
abdominal pain and cramping,fever, blood in the stool or
nausea and vomiting.
The problem of diarrhea in aquote returning traveler is not
uncommon.
Of those who spend at least twoweeks in a developing country,
somewhere around 20-60% willexperience some kind of
diarrheal illness.
The less developed the country,the higher the risk of illness.
(09:50):
The management and diagnosis oftraveler's diarrhea is pretty
different depending on whetherit's acute or persistent.
Acute, in this case we mean tobe less than two weeks in
duration, and persistent isanything of longer duration.
Acute Traveller's Diarrhea themajority of cases of Traveller's
(10:11):
Diarrhea in the acute phase arecaused by self-limiting
bacterial infections.
Organisms include Salmonella,shigella, campylobacter E coli
and Plesiamonas, among others.
Viruses Norovirus among them,account for around a third of
cases, and parasites, mostlyGiardia and Entomibia, account
(10:32):
for the remainder Low.
Diagnostics have advancedsignificantly in recent years,
with PCR panels quicklyreplacing stool culture and
microscopy.
The actual usefulness of thistesting is unclear and generally
there's no need for testingBecause of bacterial
predominance.
Acute diarrhea does oftenrespond to antibiotic therapy.
(10:53):
Cyprophyloxacin is the classicmedication for treatment of
Traveller's Diarrhea.
However, fluoroquine aloneresistance is on the rise and
azithromycin is a strongalternative.
Still, because most cases areself-limited, because some are
due to viruses, and becauseantibiotics can cause their own
slew of GI problems, there's noreal indication for treatment.
(11:17):
Additionally, if there's bloodin the stool or fever,
antibiotics are contraindicatedas they can cause complications
when treating enterohemorrhagicE coli, also known as e-HEC,
causing such problems ashemolytic uremic syndrome and
kidney failure.
An alternative to antibioticsis to treat the diarrhea itself
(11:37):
with Loparamide, an opioidmedication that's poorly
absorbed in the gut, which thusmakes it possible for use for
its side effect, which isconstipation.
Loparamide is alsocontraindicated in bloody
diarrhea or diarrhea with fever,as these symptoms suggest a
toxin-forming bacteria, and inthese cases it's better out than
(11:57):
in.
Dosing for Loparamide is a 4mgoral loading dose and then 2mg
PO for each loose stool, to amaximum of 16mg per day in
adults.
Persistent Traveller's Diarrhea.
This is a deep, deep hole, nopun intended.
There are essentially threemain causes of persistent
(12:20):
diarrhea, which is anythingaround 14 days or longer.
The first is a persistentinfection or a secondary
infection after an initialinfection.
Some infectious causes areresponsible for longer courses
of illness, namely parasiteslike GRD-iasis, which should be
strongly suspected and testedfor in any diarrhea lasting
(12:42):
longer than 14 days.
The second is what's calledpost-infectious phenomena.
Some infections can cause gutdysregulation and subsequently,
difficulty digesting fructose,lactose and other food compounds
.
This is also something that canresult from taking antibiotics
and another reason to thinkcarefully before using them.
Third is underlying GI disease.
(13:07):
Interestingly, underlyingchronic GI diseases can be
unmasked by an acute diarrhealinfection, including celiac,
spru, crohn's disease andulcerative colitis.
There are even some theoriesthat inflammation in the setting
of diarrhea can lead to theinitiation or development of
these diseases.
Back to the case.
Would antibiotics work for myfriend?
(13:29):
Perhaps, if he is one of thepredominance of cases caused by
bacteria, but his diarrhea islikely to resolve on its own,
antibiotics could cause theirown problems, including a
malabsorptive syndrome or Cdifficile infection.
Sure, if he continues to havediarrhea beyond 14 days, then
(13:49):
things get more interesting andthere might be a reason to start
thinking harder and consideringsome testing, mostly for
parasites like Giardia.
In the meantime, I'll try someLeParamide.
Did I say that?
Yeah, this patient is me.
(14:14):
Thank you, as always, forlistening to Wilderness Medicine
Updates.
I always appreciate yourattention and time, and if you
have a friend, a relative, afellow resident, a fellow, a
paramedic, a nurse who you thinkwould benefit from listening to
(14:37):
this podcast, please do shareit.
As always, reviews on iTunesare much appreciated, as that
helps to get this podcast out.
I hope you enjoyed this video.
If you did, please like, shareand subscribe to my channel and,
as always, reviews on iTunesare much appreciated, as that
helps to get this podcast out tomore people like yourselves.
(14:58):
Finally, if you happen tolisten to the last Fast Push
episode, number 2.1, calledSafety Third and you were one of
the lucky people who got theoriginal version in which my
voice sounded like a chipmunkthanks for your patience
Something went totally sidewaysin post-processing there and
thanks to my dad, jeff, whopointed that out to me so I
(15:19):
could fix that and get that backout to you all.
This is a learning curve for meand I hope you don't mind the
ride.
So, as always, don't hesitateto reach out at WildMedUpdates
on Twitter or reach out to me atWildernessMedicineUpdates at
gmailcom with any questions,episodes you'd like to hear,
feedback or thoughts.
(15:39):
Until next time, stay fit, stayfocused and have fun.
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