The Mountain Dispatch. A Newsletter of the International Mountain Medicine Center

Transcription

1 The Mountain Dispatch Summer 2016 A Newsletter of the International Mountain Medicine Center

2 This Summer in the Mountains Welcom e t o t he first edit ion of I nt ernat ional Mount ain Medicine Cent er's newslet t er! Join us for excit ing program updat es and t hought provoking art icles on m ount ain em ergency m edicine & rescue. I M M C FACULTY Direct or - Jason Wi lli am s Medical Direct or - Dr. Jenna Whit e Medical Direct or - Dr. Darryl M aci as Medical Direct or - Dr. Aaron Rei lly Facult y - Dane Abruzzo Facult y - Dr. Joe Alcock Facult y - Ti m Henley Facult y - Dr. Hans Hurt Facult y - Pet e LeBlanc Facult y - Trevor M ayschak NEWSLETTER CONTRI BUTORS Jason Wi lli am s is t he Direct or of t he I MMC Dr. Jenna Whit e is an at t ending Em ergency Medicine Physician at UNM, DiMM holder, and Medical Direct or for t he UNM EMS Consort ium 's Reach & Treat Team and for Cibola Search & Rescue Trevor M ayschak is facult y for t he I MMC, DiMM holder, Param edic, and SAR provider at Grand Canyon Nat ional Park Dane Abruzzo is facult y for t he I MMC, DiMM holder, Param edic, and first year m edical st udent at UNM NEWSLETTER DEADLI NE The Mount ain Dispat ch is a sem iannual newslet t er released every sum m er and wint er. I f you would like t o cont ribut e t o t he newslet t er, your subm ission m ust be received by Oct ober 1st for t he wint er edit ion or by March 1st for t he sum m er edit ion. READ THI S DI SCLAI M ER! The I nt ernat ional Mount ain Medicine Cent er and it s facult y, cont ribut ing aut hors, and t he affiliat e ent it ies shall not be liable or responsible for t he advice or safet y of any t echniques described in t his newslet t er. I t is t he responsibilit y of t he m edical provider or rescuer t o invest igat e t echnical and m edical t echniques and evaluat e t hem for safet y, effect iveness, and applicabilit y. Reliance on any inform at ion provided by t his newslet t er is solely at your own risk. Universit y of New Mexico Int ernat ional Mount ain Medicine Cent er MSC Universit y of New Mexico Albuquerque, NM ht t p:/ / em ed.unm.edu/ im m c/ index.ht m l hsc-im m c@salud.unm.edu 2

3 Sum m er 2016 FEATUREDTHISQUARTER The Di plom a i n M ount ai n M edi ci ne, A Facult y I nsi der's Perspect i ve - 4 Facult y m em ber, Dane Abruzzo t akes a look back at t he m ost recent Diplom a in Mount ain Medicine courses and shares som e excit ing updat es. Collaborat i on wi t h t he Uni versi t y of I nsubri a, I t aly - 6 Jason William s t alks about an excit ing collaborat ion wit h a Mast ers in Mount ain Medicine program based out of I t aly. Nut s & Bolt s - I nsi de Bolt Corrosi on - 9 Facult y m em ber Trevor Mayschak t akes us inside t he m yst erious workings of bolt ed rock clim bing anchors. Learn how t o ident ify properly placed bolt s and what bolt corrosion is all about. Treat m ent of M assi ve Hem orrhage i n t he Aust ere Envi ronm ent - 13 Facult y m em ber Dr. Jenna Whit e discusses current pract ice used t o cont rol m assive hem orrhage and it s im plicat ions in ext rem e environm ent s. Hem ost at ic agent s, TXA, and m ore! Upcom i ng Courses & Event s - 15 Whet her you are a prospect ive st udent or a cont ribut ing facult y m em ber, check out our upcom ing courses and event s! Dane Abruzzo sets the ropes for students to practice single-rescuer pick-off techniques Front Cover: An Airforce Blackhawk flies overhead on a SAR m ission in t he Sandia Mount ains 3

4 AFACULTYINSIDER'SPERSPECTIVE: THE DIPLOMAINMOUNTAINMEDICINEUPDATE Dane Abruzzo The Diploma in Mountain Medicine continues to make up the core of what we do here at the UNM International Mountain Medicine Center. When we?re not out in the Sandia Mountains helping students rig for a litter haul, we?re likely in the office escaping the Albuquerque summer heat and covering a whiteboard with ideas for new lectures, collaborative opportunities, or convoluted technical rescue problems. Truthfully we spend the entire year planning and prepping for this singular behemoth of a program and do so for a really important reason; we strongly believe the diploma holds the potential to change the face of rescue in the U.S. So, what shape-shifting face-lift are we looking for? We believe that rescue teams across the U.S. need to evolve by excelling both as thoughtful rope rescue technicians and as advanced wilderness medical providers. In order for this evolution to take place across the nation, we need a strong base of leaders. These leaders model the integration of quality medical care with elite, non-medical mountain skills, and demonstrate the capacity to medically manage remote emergencies while also addressing technical rescue problems and mountain hazards. We envision that the graduates of our DiMM programs become these leaders and return to their respective corners of the U.S. to stimulate a ground-up progression of our discipline. We have been graduating these leaders from our program since Just last year, 22 students successfully earned their Diplomas in Mountain Medicine. 2015/2016 also marked a major milestone in the evolution of our curricular options, with the completion of our first ever Online + Seminar format of the curriculum. Historically, our courses were embedded within the traditional Drs. Hans Hurt & Keit h Azevedo are blast ed by spindrift from t he rot or wash of Colorado's Flight For Life B3 helicopt er while conduct ing an avalanche beacon search out side Silvert on, Colorado 4

5 SILVERTON Colorado The Flight For Life helicopter crew poses with our Winter DiMM class in front of their Astar helicopter. Flight For Life has collaborated with Silverton EMS and the local SAR teams to provide rapid response for avalanche rescues. semester based structure of UNM and catered primarily to in-house Bachelors of Science in EMS students. Our Online/Seminar format enabled us to cast our net a bit wider, helping to attract practicing medical professionals often with time-crunched schedules. The condensed, 9 day summer and winter field sessions help students find the time off from work, and the self-paced online curriculum offers didactics whenever they decide it?s convenient, with around 70 hours of AMA Category 1, UNM CME approved credits to boot. As an added benefit, this format helped to diversify our classes, by bringing in out-of-staters from Connecticut, Colorado, and North Carolina. Our Winter 2016/2017 course is looking particularly diverse, with Florida, Arizona, Tennessee, Illinois, Chile and Australia represented. What?s the most important insider knowledge to have about the UNM DiMM program? We are all about progression. We find inspiration for growth via our own professional development as well as through collaborations with other leaders in mountain rescue, research, and wilderness medicine education. Here are few examples of progression and collaboration from 2015/2016. In October, Dr. Aaron Reilly, along with supporting in-house Emergency Medicine residents/dimm students, provided medical direction at the Trans-Pecos Ultra in Big Bend, Texas. In January, our Winter DiMM crew joined Silverton EMS, Silverton Avalanche School, and Flight For Life Colorado in the San Juan Mountains for an interagency avalanche rescue simulation. We also had two fantastic mountain medicine leaders visit our Summer DiMM course in May. First, Dr. George Rodway, president-elect of the UIAA Medical Commission and co-director of the WMS DiMM program, flew in to participate in the first few days of coursework and gave an inspiring presentation on real-world opportunities for DiMM graduates. Later, Dr. Alan Oram, IFMGA Mountain Guide and Medical Advisor to the American Mountain Guides Association (AMGA), drove down from the Tetons to participate in the back half of the course at the Enchanted Tower near Datil, NM. After cruising some world-class sport climbs on the tower, he then demonstrated the AMGA rescue drill, which utilizes standard climbing equipment only to rescue injured clients from multi-pitch rock climbs. From my perspective, discovering and fostering these collaborations is the most exciting part of being on the faculty side of the table at the IMMC. Our DiMM program has a solid track record of converting students to colleagues and outside professionals to collaborators, which propels us farther forward each year. What am I looking forward to in 2017? The ideas and challenges that none of us have thought up yet. - DiMM participant Dr. Thomas Kinsley comes down the third pitch of Big-T in the Sandia Mountains during the 9 day summer seminar 5

6 I n October of 2015 the University of New Mexico collaborated with the University of I nsubria, located in Verase, I taly to hold a joint conference in Albuquerque, NM on Mountain Emergency Medicine with practical sessions held at the Grand Canyon, Arizona Collaboration with the University of I nsubria, I taly Jason Williams It was a chance encounter 6,000 miles away from Albuquerque, NM, that led to a remarkable collaboration and cultural exchange. In the summer of 2014 I walked into a room at the World Congress on Mountain Emergency Medicine held at the European Research Academy in Bolzano, Italy. I sat next to a lively Italian thoracic surgeon by the name of Dr. Luigi Festi. It turned out that Dr. Festi ran a Masters degree Diploma in Mountain Medicine program in Italy. We shared stories of our classes, the mountains, and fathomed the potential of collaboration between respective programs. Light-heartedly, I told Luigi that he should bring his students to New Mexico for a week. To my surprise, without hesitation, he said,?yes, we will come to New Mexico. I think we will come in October, and I will bring all 19 students.? You can imagine my shock! Oct ober 5t h t o Oct ober 11t h, 2015 Nineteen physicians from Italy, Slovakia, Chile, Brazil, and the Netherlands came together in New Mexico for a week of conference and practical training in Mountain Emergency Medicine. After a hand full of trips to the Albuquerque International Sunport, the group assembled on Monday at the UNM Department of Emergency Medicine for an afternoon of lectures. The timing of the trip was fortuitous as many participants saw the sky filled with hot air balloons that were flying as a part of the Albuquerque International Balloon Fiesta. On Wednesday morning we packed the vans and headed out to the Grand Canyon National Park. Our existing collaborations with Grand Canyon National Park Emergency Services made this a prime destination to conduct practical exercises, ranging from utilizing an istat for heat related illnesses to high angle rescue scenarios to a 6

7 helicopter med-evac demonstration. After three days at the Grand Canyon we returned to Albuquerque where we ended the week with a flight up the Sandia Peak Tramway and rock climbed on cool limestone at 10,000 feet. In the end we left feeling grateful to host such an exceptional group. Memories of early morning trips to the balloon fiesta, engaging lectures, hot hikes in the Canyon, exhausting rope rescue scenarios, sunsets on the South Rim, and ear-to-ear smiles will forever be in our minds. Photos & video do these days justice: March 2016 The Alps - the birthplace of modern mountain emergency rescue. At some point every climber and rescuer should take a pilgrimage to this beautiful land. Riding on the coat tails of Dr. Festi, in March of 2016 Dr. Darryl Macias and I traveled to Italy and France where we instructed and participated in a continuation of the University of Insubria Masters in Mountain Medicine program. It was great to be back in Europe, but seeing the same 19 students that traveled to New Mexico almost a year earlier was incredible. We began our travels at the University of Insubria in Verase, Italy just a half hour outside Milan. Luigi gave us a tour of the campus and hospital including their state of the art surgical suites. 7

8 MILAN, ITALY Jason Williams and Darryl Macias present at the Milan City Hall at the Mountcity conference on Safety in the M ountains Standing outside the University we saw the Alps calling in the distance. We gathered in a bus and headed to Chamonix, France, which sits on the Italian and French borders. The two countries literally separated by the highest peak in the Alps, Monte Bianco, (Italian) aka Mont Blanc (French). In Chamonix, we conducted lectures at the Training Institute on Mountain Medicine Research and went for an afternoon ski. Dr. Buddha Basnyat, President of the International Society for Mountain Medicine, joined us for the travels and gave several thought provoking lectures along the way. On the Italian side of Monte Bianco, the next day in Courmayer we participated in lectures and practical sessions at the Mountain Foundation, a non-profit group dedicated to safety in the mountains. On the last day, back in Milan, we gave a lecture at the Mountcity festival, an annual festival in Milan dedicated to mountain culture. The theme there was on safety in the mountains. The Europeans certainly have learned how to balance adventure and exploration with safety and prevention. The continuation of this cooperation has marked a milestone in international collaborations for the IMMC. We anticipate this is just the first of many opportunities to engage other leaders of mountain medicine from around the world, sharing ideas and pushing the standards for medicine and rescue in the mountains. - Off-Piste skiing the Vallee Blanche (White Valley), Chamonix, France 8

9 NUTS&BOLTS July, 2016 I nside Bolt Corrosion Trevor M ayschak Tonsai Tower Photo: Jory Hanselman Some will recognize Koh Phi Phi as one of the locations devastated by the Indian Ocean tsunami that took place in December of Considered to be the world?s deadliest tsunami, the natural disaster left over 230,000 dead across Southeast Asia [1]. Just over 10 years later, the island located in the Andaman Sea off of the Southern coast of Thailand barely shows evidence of the catastrophe. It was here that my climbing partner and I set out for some sunrise sport climbing. The limestone cliffs of the Tonsai Tower stood before us, mildly illuminated by the morning glow as the sun crept above the horizon. Hoping to get off the ground before the crab-eating macaques awoke to harass us, we roped up. 9

10 NUTS&BOLTS: I nside Bolt Corrosion We opted for a moderate two-pitch climb that ended with a comfortable belay in a shallow cave. Upon starting up the second pitch, we found the climb to have two bolt lines side-by-side. The right-most line was composed of what appeared to be properly recessed ring bolts, very slightly corroded, with the sworn by RE-500 red Hilti glue. The left hand line sported what appeared to be a stainless steel U-bolt, no visible corrosion, held in by an unrecognized adhesive. Unsure of what to clip and what not to clip, we opted to bail from the climb in favor of mimosas on the beach. Confusing parallel lines of bolts on the 2nd pitch of Stir Fried Water (6b) The Problem In the 1990?s, climbers in Thailand observed failure of stainless steel expansion bolts under body weight alone. These failures were especially concerning given that some bolts were failing after less than one year of being placed. Metallurgist Mike Shelton traveled to Thailand to lend his expertise to the issue and suggested that the primary issue was the material of the bolt [2]. Further investigation revealed that a process known as Stress Corrosion Cracking (SCC) was at the root of the problem. The expansion bolts that are so near and dear to our climbing hearts in the continental US are the prime candidates for SCC. Stainless steel, regardless of the grade, retains inherent stresses within the metal that take place during the manufacturing process. When the bolt is put under constant tension, as is the case with expansion bolts, the bolt is made especially vulnerable to corrosive conditions [3]. The fluctuating humidity, high ambient temperatures, and presence of chloride from the seawater make the magnesium-rich limestone cliffs of Southern Thailand the prime environment for SCC. To make matters worse, this type of corrosion typically occurs at the rock/metal interface, hiding it from view of the unsuspecting climber. For all intents and purposes, clipping expansion bolts in this environment could be considered on par with the risks of free solo rock climbing with an added false sense of security. The Solut ion To avoid the issues of SCC, fixed protection would need to avoid a number of the aforementioned factors. Climbers began to use glue-in (resin) bolts. This afforded a couple of advantages. First, glue-in bolts are held in by an adhesive, thus avoiding the tensile stresses that are inherent with expansion bolts. Second, the adhesives used for glue-in bolts could create a water-tight seal around the bolt, allowing for less of the corrosive chemicals to contact the metal. This latter aspect is particularly true when using an epoxy resin, such as the waterproof red glue produced by Hilti. All of that being said, 10

11 A display at Tonsai Basecamp shows the various types of bolts that are found throughout the area. The three bolts on the left are made of titanium whereas the rest are various types of steel. Note that many of the bolts do not have any identifying information on them Photo: Trevor M ayschak NUTS&BOLTS: I nside Bolt Corrosion stainless steel glue-ins are still at risk for corrosion. As such, the climbing community has adopted the use of titanium glue-in bolts. Accelerated corrosion testing at the University of Colorado showed that a 316 stainless steel hanger would crack in under 5 hours, whereas a titanium bolt under similar conditions would remain unaffected for 28 days. A large rebolting effort called the Thaitanium Project has undertaken the task of replacing all of the old stainless steel bolts, expansion and glue-ins alike, with titanium glue-in bolts. Lim it at ions Although this is a good solution, there are a few limitations that should be recognized. Glue-in bolts are inherently more challenging to place than expansion bolts and have a greater potential for error. Take, for example, an area in Railay known as Duncan?s Boot. This area of the Phra Nang Peninsula sports a number of Petzl glue-ins that, to the naked eye, may look solid. Unfortunately, the individual that bolted Slow Pull-Testing of glue-in bolts. Top: Hole blown out with blower. Failure at 10.4 kn. Middle: Hole blown out with compressed air at 8 bar. Failure at 15.3 kn. Bottom: Hole blown, brushed, and blown with blower. Failure at 34.7 kn. [ 5] these climbs used a 10mm drill bit for the 10mm bolts. A glue-in bolt of 10mm diameter requires a hole of at least 12mm in diameter to accommodate the glue; otherwise, the glue will be pushed out upon insertion of the bolt, leaving very little adhesive in place [4]. Another error in the glue-in process is cleaning out the bolt hole. According to Lightner Jr., the individuals that rebolted a climb called Kratoy in the Muai Thai area failed to follow the manufacturer?s recommendations for cleaning the bolt holes. Slow pull-testing of glue-in bolts has shown that bolt holes cleaned out by a blower have a pull-out force of 10.4 kn compared to 34.7 kn for those that are blown out, brushed, and blown out again [5]. In addition to the number of errors that can occur when the bolts are placed, recognizing what makes a good glue-in bolt can be extremely challenging. The majority of bolts do not identify the the manufacturer or the material 11

12 used. Considering that corrosion oftentimes takes place out of sight, identifying weak bolts can be anything but intuitive. The Bot t om Line A local guide deep-water soloing, no bolts necessary! Photo: Trevor M ayschak It might be tempting to think that these issues are far from home, especially if you live in a region of the states as dry as the Southwest. It?s important to recognize that the type of bolt corrosion that occurs in Thailand happens all over the world. Areas such as Thailand, Italy, and Greece certainly have a higher risk of bolt corrosion, but this type of corrosion occurs even in the driest of climates, albeit at a slower rate. The UIAA recently released a document outlining a number of variables that play into bolt corrosion, from environmental factors to the grade of the metal used [6]. It should also be known that a similar type of corrosion can occur when the alloys used between the hanger and the bolt are different. Known as galvanic corrosion, the electric potential between two dissimilar metals can cause rapid corrosion to occur. This is most common when a stainless steel hanger is placed on a zinc-plated bolt [7]. This type of corrosion occurs out of sight at the bolt/hanger interface, making it challenging to identify. At the end of the day, climbers need to recognize that the potential for bolt failure is always present. Never put yourself in a situation where you?re relying on a single bolt. When traveling to climb, chat with the local guides and look into up-to-date guidebooks to get the beta on safe climbs. And if you're ever in doubt, just don?t climb it. - 12

13 MEDICINEREVIEW Recognizing someone with a life-threatening hemorrhagic injury in the austere environment is critical to ensuring that individual?s survival, and quick decision-making and treatment is essential. Injuries that are visible externally are easiest to spot, and are usually more effectively treated in the field setting. Common external injuries that are sources of major bleeding include large lacerations to the face and scalp, open fractures of long bones, traumatic extremity amputations, and soft tissue wounds deep enough to damage veins and arteries. If the location of the injury allows, applying direct pressure to the wound is recommended. If this is successful in controlling bleeding, a pressure dressing can be an effective means of maintaining direct pressure on the wound continuously in order to facilitate extrication and evacuation. This Summer, 2016 Treatment of Massive Hemorrhage in the Austere Environment Jenna White, MD, DiMM An example of the various styles of tourniquets and hemostatic gauze that are available. It is imperative to be familiar with the devices that one decides to carry as well as the pro's and con's of each. may not be possible in the case of large extremity injuries or fractures. In these instances, a tourniquet should be applied proximal to the injury. While a tourniquet can be improvised, a manufactured tourniquet designed for this purpose is recommended and should be carried by anyone spending time in a remote setting. If application of a tourniquet does not stop the bleeding, then a second tourniquet should be applied. Once applied, tourniquets should not be removed. Prompt extrication and evacuation is essential. Internal injuries can also cause hemorrhaging, but are more difficult to recognize in the austere environment. These injuries require rescuers to make a presumptive diagnosis based on the subject?s mechanism of injury, chief complaint, and vital sign instability. A patient with suspected internal bleeding must be promptly extricated and evacuated. In the meantime, the patient must be kept warm and protected from the elements. In multi-system control, control external sources of bleeding. Ensuring that the patient is oxygenating and ventilating appropriately is key. This may mean performing other interventions such as needle decompression of a suspected pneumothorax, or performing airway 13

14 management. If it's possible that the patient has suffered a pelvic facture, a pelvic binder should be prophylactically applied. Limiting IV fluid resuscitation will help prevent the patient?s clotting factors from becoming diluted. Auxiliary treatments for the patient with significant bleeding include topical hemostatic agents and tranexamic acid. Topical hemostatic agents are helpful in the management of soft tissue injury with significant bleeding. Tranexamic acid can be administered in the setting of many different sources of life-threatening hemorrhage, but must be administered within the first 3 hours after injury, and requires IV access. No matter the type of injury or source of hemorrhage, the injured subject requires swift action on the part of the rescue team to prevent morbidity and potentially mortality. - Di M M st u d en t s at t h e Gran d Can yon Nat i on al Park assess a si m u l at ed p at i en t 14

15 Upcoming Courses & Events WILDERNESS FIRSTAID July 20, 2016 Locat i on: Si lver Ci t y, NM Using our hybrid form at, t his class com bines 8 hours of online, self-paced cont ent wit h 8 hours of in- class pract ical t raining. Graduat es will receive a Wilderness First Aid cert ificat ion, valid for 2 years. Course fee: $175 7 TH WORLDCONGRESSOF MOUNTAIN& WILDERNESS MEDICINE July 30 - Aug. 4, 2016 Locat i on: Telluri de, CO From advanced m edical care t o m ount ain rescue best pract ices, t his conference will hold lect ures and workshops t aught by leading expert s in fields of wilderness m edicine and m ount ain rescue. This collaborat ion bet ween t he I nt ernat ional Societ y for Mount ain Medicine and t he Wilderness Medical Societ y is sure t o be a great opport unit y t o learn about what 's on t he cut t ing- edge. Our facult y will be providing workshops on backcount ry ult rasound as well as t echnical rescue/ m edical sim ulat ion. Visit s.org for m ore inform at ion! DIPLOMAINMOUNTAINMEDICINE- FALLSEMESTER Aug Dec. 16, 2016 Locat i on: Albuquerque, NM This fall sem est er, learn how t o adapat your m edical t raining t o t he m ount ain set t ing and com plet e t he first half t he Diplom a in Mount ain Medicine. Open t o param edics, nurses, m idlevels, and physicians, st udent s m ay enroll for eit her 9 college credit hours or m ay pay for cert ificat e only. Classes will be held regularly every Thursday from 1-4pm wit h t he occasional weekend t rip t o different locat ions t hroughout t he sout hwest. Cont act us for m ore inform at ion! WILDERNESSFIRSTRESPONDER Sept. 6 - Oct. 29, 2016 Locat i on: Albuquerque, NM Using our hybrid form at, t his class com bines 40 hours of online, self-paced cont ent wit h 40 hours of in- class pract ical t raining. Pract ical sessions will t ake place on Tuesday & Thursday evenings from 6:15 t o 8:45 on UNM Nort h Cam pus and in Open Space areas of Albuquerque. Graduat es will receive a 2- year Wilderness First Responder cert ificat ion and will be eligible t o license as a First Responder wit hin t he st at e of New Mexico and nat ionally as well. No previous m edical t raining needed! Course fee: $575 WILDERNESSFIRSTRESPONDER- REFRESHER Nov. 12, 2016 Locat i on: Albuquerque, NM Join us t o renew your Wilderness First Responder cert ificat ion! This course com bines 16 hours of online cont ent wit h an 8 hour in- class pract ical session t o t rain WFRs in current best pract ices at t he basic life support level. Addit ionally, t his course awards licensed EMS providers wit h 24 hrs of cont inuing educat ion t o renew t heir licenses. Course fee: $200 WILDERNESSFIRSTAID, WILDERNESS FIRSTRESPONDER, & WILDERNESSEMT UPGRADECOURSES Spring 2017, Dat es TBA Locat i on: Albuquerque, NM Wilderness Medicine courses of all level will be held t hroughout t he spring. Let us know if you're int erest ed so t hat we can keep you up t o dat e as we finalize t he schedule! DIPLOMAINMOUNTAINMEDICINE- SUMMERSEMINAR May 6-14, 2017 Locat i on: Albuquerque, NM Our sem inar form at of t he Diplom a in Mount ain Medicine is designed m edical providers t hat would like t o acquire a DiMM from out afar. The sum m er sem inar com plet es half of t he program wit h 25 hours of online cont ent followed by a 9 day pract icum t hroughout New Mexico. This course is filling up fast, so subm it an applicat ion t oday! Course fee: varies wit h level of licensure DIPLOMAINMOUNTAINMEDICINE- WINTERSEMINAR Jan 28 - Feb 5, 2017 Our upcom ing wint er sem inar is already full! Cont act us for t he pot ent ial t o be wait list ed or t o obt ain 2018 wint er sem inar st art dat es. NEEDACLASS?? Are you a m em ber of a group looking for wilderness m edical or rescue t raining? Be it a recreat ional group or SAR t eam, our facult y can provide t ailored courses t o m eet your specific needs. Cont act us t o discuss opt ions! FOR MORE DETAILS ON OUR COURSES, VISIT OUR WEBSITE HERE! 15

16 REFERENCES Nuts & Bolts 1. Osborne, Hannah. "2004 Indian Ocean Earthquake and Tsunami: Facts about the Boxing Day Disaster." International Business Times RSS. N.p., 22 Dec Web. 08 June Schmitz, Elke, and Wee Changrua. Rock Climbing in Thailand. S.l.: Schmitz, Print. 3. Haden, Francis. "Bolt Systems." Francishaden.com. N.p., Web. 24 June Lightner, Sam. Thailand: A Climbing Guide. Seattle, WA: Mountaineers, Print. 5. "Glue-in Bolt Design." Glue-in Bolt Design. N.p., n.d. Web. 10 June Watch Your Anchor! Corrosion and Stress Corrosion Cracking Failure of Climbing Anchors. N.p.: International Climbing and Mountaineering Federation, Dec PDF. 7. Haas, Jason. "Bolt Basics: What Every Climber Should Know Climbing." Bolt Basics: What Every Climber Should Know. Access Fund, n.d. Web. 12 June Pract ice what you preach... Safe rappel t echnique com ing off of Sour Mash, Red Rocks, Nevada Back Cover: DiMM part icipant s com ing up t he Rut t er after clim bing t he 4 pit ch Ram p rout e in t he Sandia Mount ains University of New Mexico International Mountain Medicine Center MSC University of New Mexico Albuquerque, NM hsc-immc@salud.unm.edu 16

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