From the Chair
Eric A. Weiss, MD, FACEP
First and foremost, I would like to express my appreciation and gratitude to Carl Heine, MD, for establishing and leading the Section of Wilderness Medicine during the past two years. Carl drew up the operational guidelines and brought to fruition what has now become the fastest growing section in ACEP. In recognition of this achievement, the Section of Wilderness Medicine received the "Promoting Section Membership Award" at ACEP’s Scientific Assembly in Chicago that is given to the section with the largest jump in membership from one year to the next. In just two years, the Wilderness Medicine Section gained 326 members, a statistic that reflects the growing interest and enthusiasm of emergency physicians in the exciting field of Wilderness Medicine. We are all indebted to Carl’s service, motivation and inspiration.
The Section of Wilderness Medicine is chartered by the Board of Directors of the American College of Emergency Physicians to provide a forum in which members of the College with a special interest or expertise in Wilderness Medicine can develop a knowledge base, share information, and serve as a resource to ACEP and external organizations.
The section is uniquely positioned to become a partner with the growing interest in emergency medicine-based Wilderness Medicine Fellowships. Together, we can help to better define the mission and goals of Wilderness Medicine Fellowships and to standardize the curriculum and expand the opportunities for research and electives.
One concept that has been suggested is the creation of a committee to oversee Fellowships and to facilitate the development of an exit exam and an accreditation process. An important part of this goal involves seeking your viewpoints and suggestions. Commensurate with this, I will circulate a survey to the Section members in the very near future. This survey will be one component of a strategic and tactical planning process that will enable us to make significant strides and better prepare for the months and years ahead.
Our section shares many common interests and overlaps with other ACEP sections including International Emergency Medicine, Rural Emergency Medicine, Tactical Emergency Medicine, EMS-Prehospital Care, and Disaster Medicine. Our leadership will work to develop partnerships with these other sections and bring our organization’s considerable talent and experience to bear on any shared problems or issues.
Our section in particular shares many common threads with the medical ramifications of international travel and global health. The health of travelers and of local inhabitants of developing countries is inextricably related through the transmission of infectious diseases. Diarrhea infections, malaria, and other endemic infections that may attack wilderness travelers to developing countries are of paramount importance to our members. Many wilderness and expedition physicians who travel to these areas also provide care to the local population. Practicing medicine in developing countries shares similarities with providing care in the wilderness, including the need to improvise, because of limited supplies and diagnostic capabilities.
And finally, without the wilderness, there cannot be wilderness medicine. Population and economic pressures have resulted in encroachment and degradation of wilderness areas, deforestation, and environmental depredation of the water and air. Our interest in wilderness medicine in part stems from our love of the wilderness. For many of us, it is a vital component of our health and well-being. Because of our love of the wilderness, we all share some conservation ideals. I would like to suggest that we expand our mission to include matters that deal with environmental protection and the effects of environmental depredation on human health. I believe that it is a vital part of our quintessential goal to integrate our love of the wilderness with our medical careers.
Whatever your current level of involvement with the section, I invite you to increase it and play an important role today in creating the wilderness medicine field of tomorrow. I encourage feedback and suggestions for ways to improve my service to the section, and for ways to foster its success.
Back to Top
Past Chair’s Report
Carlton Heine, MD, PhD
We held a successful annual business meeting for the section during Scientific Assembly in Chicago. At that meeting, Eric Weiss was elected chair, Grant Lipman was chosen chair-elect and Michael Caudell was elected secretary. And I happily assumed the position of past chair. We also approved the revisions to the section operational guidelines. I can also report that our section has some strong links with the ACEP Board of Directors. The incoming president-elect, Angela Gardner, is a member of the section with a long standing interest in wilderness medicine and, in spite of an overly packed schedule during SA, stayed for our entire business meeting. Our board liaison is Andrew Bern, which is significant because he was instrumental in helping ACEP start the section system and has been very involved with all aspects of running sections for the College. Now all we need is some section business or project that needs board approval. Suggestions are welcome.
Our section photo contest was again a big hit at the Medical Humanities Section art show in the Exhibit Hall. A beautiful photograph of a slot canyon by Nici Singletary was selected as the winner and will be posted on our Web site. Again, it was hard to select only one winner as there were many very beautiful pictures submitted. Thank you to the members who submitted their work.
Much of the discussion at the meeting centered around how we in the College can assist the growing number of academic fellowships develop, and ways that we can help emergency medicine residents and medical students with an interest in wilderness medicine. There are now four post-residency fellowships in wilderness medicine and an article in this newsletter presents the current group of fellows in those diverse programs. Your section leaders again met with leaders from the Wilderness Medical Society and have been working on teaching tools for residents and medical students interested in learning more about our specialty.
Another accomplishment for the section at the meeting was the presentation of the award for the section with the most increase in membership. It is very clear to me that there is a very strong interest in wilderness medicine among emergency physicians and creating this section was long overdue.
Back to Top
The State of Wilderness Medicine Fellowships
In the two years since the inception of ACEP’s Wilderness Medicine Section, the number of fellowships offering specialized training in the United States has tripled. Is this a timely coincidence, an educational tipping point, or a Fibonacci sequence of events worthy of the next Dan Brown novel? Time will tell. Regardless, it is an exciting time on the educational front. The personalities and pursuits of this year’s fellows are as diverse as the subject matter. Hopefully this will lead to a cross pollination between the programs, to share in ongoing projects, and enable us to both further define as well as standardize the fellowship training of wilderness medicine. Here is an introduction to the fellows, their backgrounds, and goals.
- Grant Lipman, Chair-elect
Massachusetts General Hospital
Tracy Cushing, MD, is the inaugural fellow of the Massachusetts General Hospital (MGH) Wilderness Medicine Fellowship (Harvard Medical School). Dr. Cushing attended medical school at New York University and trained at the Harvard Affiliated Emergency Medicine Residency. She earned her MPH from the Harvard School of Public Health. As a resident, Dr. Cushing participated in event medicine for adventure races and marathons, and helped lead a 28-day "Medicine in the Wild" course for medical students.
Fellowship Goals: High altitude medicine. She will serve as a volunteer physician at the Himalayan Rescue Association’s Pheriche clinic during the Spring of 2009. Pursuing research on pulmonary artery pressure responses to acetazolamide and dexamethasone. She is also pursuing her PADI dive certification this year, and serving as the chair of the international committee of the Wilderness Medical Society.
University of Utah
Matthew Hamonko, MD, is one of two Wilderness Medicine/EMS Fellows at University of Utah and currently completing a MPH from the University of Utah. Dr. Hamonko received his MD from the University of Pittsburgh and his emergency medicine training at Resurrection Medical Center in Chicago, Illinois. He also participated in research at Harvard Medical School and the Mount Desert Island Marine Biology Laboratory.
Fellowship Goals: Research interests include the pre-hospital use of continuous positive airway pressure for acute cardiogenic pulmonary edema, acute head injury secondary to skiing and snowboarding accidents, in-flight airway management by air-medical personnel and the analysis of injuries and medical illnesses occurring during N.O.L.S. courses. Dr. Hamonko is organizing the first MedWar adventure race in the western United States, and is serving as assistant editor of Wilderness Medicine Magazine.
Marion McDevitt, DO, is a board-certified emergency physician also pursuing her MPH while a Wilderness Medicine/EMS Fellow at University of Utah. Dr. McDevitt went to medical school at University of Health Sciences in Kansas City, Missouri and completed her emergency medicine training at Michigan State University. After residency, Dr. McDevitt practiced emergency medicine in Fairbanks, Alaska.
Fellowship Goals: Interests include avalanche, hypothermia, and cold injury research. She will be working with Park City Resort Mountain Ski Patrol, as well as collaborating with the N.O.L.S. Wilderness Medicine institute analyzing injury patterns sustained during wilderness courses.
UCSF Fresno
Brian Horan, DO, is a recent graduate of the UCSF Fresno emergency medicine program and the first Wilderness Medicine Fellow at UCSF Fresno. He came to California from the Midwest, and a love of hiking, biking, climbing, scuba, surfing, camping, and skiing led to his creating and pursuing a fellowship in wilderness medicine.
Fellowship Goals: Create plans for the new fellowship while working with the Park Medic Program, National Parks, local EMS and sheriff's search and rescue, and local ski patrol. Dr. Horan wants to refine UCSF’s wilderness medicine medical student course, while possibly adding a second course. Dr. Horan plans to attend wilderness medicine conferences in the winter, and plans a tropical medicine trip in the spring.
Stanford University
Jay Sharp, MD, is the current Wilderness Medicine Fellow at Stanford University Hospital. Dr. Sharp is board certified in emergency medicine, having trained at the University of Illinois-Chicago College of Medicine and worked as assistant professor at Loyola. In Chicago, he lectured on wilderness medicine for ACEP board review courses and decided to pursue more formal training out West.
Fellowship Goals: Dr. Sharp hopes to focus special attention on search and rescue and dive medicine. He plans to spend time training with Bay Area Search and Rescue, Teton County SAR, learn dive medicine in Honduras, and is serving as a member of the medical team on Racing the Planet’s ultra-endurance race across the Atacama Desert of Chile in March 2009. Dr. Sharp plans to do research in the field of medical student training, and hopes to use the knowledge gained during this year to further educate fellow physicians, residents, and medical students in wilderness medicine.
Back to Top
2008 Section Meeting Minutes
If you would like to review the minutes from the section’s 2008 annual meeting, they are available both on the section Web page at www.ACEP.org and also posted as a resource in the Section’s social networking page.
Back to Top
Connect with Other Section Members with New Online Tools
ACEP proudly introduces social networking to ACEP.org. Section members are assigned to a specific private group where you can connect with your wilderness medicine colleagues, discuss important EM issues, and share documents and photos. Like Facebook and MySpace, there are also several public groups open to all ACEP members, and include topics such as resident physicians, clinicians, and challenging cases. To get started, visit www.ACEP.org and log in – your public and private groups will be available under MyACEP.
Back to Top
Winter Wilderness Medicine Conferences
There are three wilderness medicine conferences offered this winter that may interest members.
The National Conference on Wilderness Medicine is sponsored and accredited by the American College of Emergency Physicians and is approved for 23 hours of ACEP Category 1 credits.
There are two locations:
Big Sky, Montana -- Feb. 7-11, 2009
Snowbird/Alta, Utah -- Feb. 25-March 1, 2009
Members of the ACEP Section of Wilderness Medicine will receive 25% off the registration fee at one of these ACEP-accredited meetings. Call 888-995-3088 to register, and let them know that you are an ACEP Wilderness Medicine Section member, or visit www.wilderness-medicine.com.
The Wilderness Medical Society will hold its Winter Wilderness & Mountain Medicine Meeting at The Canyons, Park City, Utah from Feb. 20-25, 2009. The conference is accredited by the Wilderness Medical Society for 22.25 Category 1 credits. Register online at www.wms.org or call 801-990-2988.
Back to Top
Adventure for Good
Jim Barr
President, Track & Trail Adventures
An adventure travel company has partnered with the Wilderness Medical Society to assist in establishing a research-based endowment fund for society members.
Track & Trail Adventures is an adventure travel company amassing top-notch faculty to develop engaging, accredited curriculum paired with a legendary adventure. The endowment fund allows members to take their involvement in providing enhanced medical treatment a step further, explained Track & Trail Adventures medical advisor, Dr. Jonathan Theoret.
Wilderness Medical Society (WMS) CEO, Loren Greenway, said the relationship is a "win-win for everyone."
"This new affiliation satisfies the continuing medical education component, and helps fund research," he said. "Our mission is education, research and wilderness practice. In providing medical education in an auspicious environment, it satisfies one of our core reasons for existence."
One upcoming opportunity reflects some recent research. Statistics show that an ever-increasing number of snow-minded adventurers are being lured into the backcountry each ski season. Those who are not trained in terrain assessment and avalanche dangers can end up in the emergency department of their hospital, or worse yet, in its intensive care unit.
"We recently concluded a risk assessment survey and what was found is surprising," said John Kelly, Operations Manager for the Canadian Avalanche Association. "One out of 10 individuals dropping under a resort’s boundary line to get at that tempting powder run accepts the risk of a major incident or death as a result of their quest for fresh tracks."
Track & Trail Adventures, in association with the WMS, the American College of Emergency Physicians, Northern Escape Heli-Skiing, and faculty (including Stanford’s Dr. Grant Lipman), are hosting a very unique opportunity in April 2009 titled "Wilderness Medicine Updates for the Backcountry."
This five-day educational adventure blends accredited CME with heli-accessed skiing or snowboarding. CME credits are earned, not just through traditional educational presentations on hypothermia and backcountry orthopedics, but through workshops in the field that will help understand the procedures in avalanche rescue, terrain assessment and patient management in the wild. These life lessons are not unique to avalanche situations, but can also be applied to anyone who deals with any winter exposure trauma.
"To blend didactic education in a real world environment is a great thing. Normally you receive the education in one place and those real-world experiences in another, but to put them together allows for substantial professional development opportunities," Mr. Greenway said.
Track & Trail Adventures also is proud to partner with the WMS, Berg Adventures International (a leading expedition producer), and Everest Base Camp physicians Luanne Freer and Eric Johnson, to produce another unique adventure travel educational opportunity.
Dr. Freer, featured in the 2006 BBC documentary Everest ER, has dedicated the last five spring climbing seasons to working at Everest Base Camp, managing a wave of climbers suffering from a number of ailments, including hypothermia and altitude sickness. Drs. Johnson and Freer, both former WMS presidents, will be joined by Wally Berg, a four-time Everest summiter and National Geographic photographer, to present a series of educational sessions on route to Everest Base Camp in October 2009.
Conference delegates spend two nights at Everest Base Camp with a working expedition, listening to war stories from Everest veterans about what it takes to make it to the top and conduct successful rescues.
These and all upcoming Track & Trail medical adventures will benefit the new WMS endowment fund. "We have three research awards annually which help with investigations into wilderness medical projects. We then publish society members’ findings in various publications. This new relationship helps further those interests," Mr. Greenway said.
For details, visit Track & Trail Adventures’ Web site at www.tandtadventures.com and watch for them in Park City at the WMS Winter Meeting.
Back to Top
Table Rock Rescue
Seth Hawkins, MD, FACEP
Morganton, North Carolina
It was in the last 5 minutes of my EMS office hours that the pager sprang to life. As an emergency physician, I have very little call responsibility, so my pager is usually a plastic annoyance that gets in the way when I’m negotiating close seating in restaurants. However, when it does erupt into an insistent cacophony of beeps, it usually represents an emergency for our wilderness EMS rescue team and pre-empts anything else that is going on. At those times my world shrinks to its iridescent screen, which may suddenly dictate the remainder of my day.
This time it read, "Hiker - fallen on climb at Table Rock - Spec Ops medics needed." Spec Ops is our EMS Special Operations program, which certifies a select group of paramedics to perform technical rescue and wilderness medical interventions. They perform about 60 missions a year, and as the oldest EMS-based wilderness rescue service in North Carolina, have built up a reputation that has continued to attract some of the best medics in the region. I, on the other hand, represent a new addition as a medical director, and as a physician might be a help or a hindrance. I suspect that, in their minds, the jury is still out.
It is hard to serve both paramedics and patients adequately during an ED shift, so I dedicate a few hours a month – "office hours" -- to sitting in our county Emergency Operations Center (EOC), exclusively available to paramedics. These office hours were just wrapping up, so I figured I could make it to this mission. I walked over to the dispatch center at the other end of our building to find out the details before I headed out. Sometimes these calls end up being a stuck coon dog (no joke, our most recent call) or a standby, and the pages can be cryptic. A little early investigation can sometimes prevent later frustration, such as finding I’ve responded to a miscoded call for a patient with a stubbed toe and no gas money to get to the hospital.
Thoughts like this preoccupied my mind as I heard the office door close behind me. Damn! Rookie move. At this hour of the day the doors of the EOC lock behind you and I had no key to get in. My jump bag, including climbing helmet and gear, were now locked in my office. I’d have to go without them. Rookie move!
The dispatchers, who (in our basement facility) are buried in a subterranean cave like high-tech gnomes, monitoring and directing the day-lit action aboveground, confirmed that it was in fact a "real" call. A hiker had fallen on Table Rock Mountain, tumbling down one of the climbing routes and coming to rest on Lightning Ledge, about halfway down. I formally checked in with them as a responder and jogged out to my car.
Emergency response to a wilderness scene is always somewhat strange. There’s an initial spurt of urgency, but usually a long and relatively uneventful trek to get to the impromptu command center, let alone the patient. Even driving with lights and sirens, it is at least a 30-minute drive up to the Linville Gorge Wilderness Area and Table Rock Mountain. Half that drive is on the treacherous hairpin-turns of gravel logging roads. It is a testimony to the restraint of wilderness rescuers that there are so few crashes among responders on these roads.
The gravel slapped my SUV’s undercarriage and my emergency lights turned the green leaves into fall colors as I flung myself through the woods. My mind drifted to what brought me here. This road was like so many others that had led, one onto the other, toward a dream that there could be such a thing as a wilderness physician. A love of the outdoors, early training and volunteer work as a rural EMT before I’d even considered medical school, and an authentic impulse to help people in distress had pointed me toward medical school. As with so many medical students, only mentors, role models, and continued dreams about what I wanted to do with my degree pulled me through dark times in my medical training, when it seemed I’d lost my way. And, driving up the dirt road to Table Rock, I still wasn’t sure that I had yet arrived, or that this dream of serving patients in the wilderness as a doctor was even feasible.
About half an hour later I pulled into the parking lot command center. Few people appreciate the logistics that go into a rescue of this sort. The patient had hiked up one of the back trails to the summit and was walking near the climbing routes on the other side when she stumbled and fell. In an urban system, an ambulance would have come, splinted anything that hurt, treated her pain (or not, if you believe the literature!), and transported her to the hospital. They’d be back in service in 30 minutes. Move that stumble to a remote rock climbing ledge and the same initial mechanism of injury in this case led to a tumble down a rock face and an extraordinarily complex multidisciplinary operation ultimately involving 8 agencies, more than 6 hours, and more than 50 providers spread out across the wilderness area.
When I arrived, the command team was sorting out resources and the patient’s status. I walked over to Sean,* the incident commander.
"Oh hey, doc," he said distractedly. "Good to see you. The patient’s a girl who fell off the top of Table Rock onto Lightning Ledge. There’s a friend up there now who was able to talk to her. The patient thinks she lost consciousness but doesn’t seem to be bleeding and her back hurts. We’ll need to decide whether she stays there or goes down tonight."
This is one of the hardest roles for a wilderness command physician. Emergency physicians are trained to direct paramedics from a distance and make decisions about patient care over the radio. However, this type of care almost always assumes the patient is or will be shortly en route to a hospital. In this case, the underlying question Sean was implying was whether she would spend the night on the ledge and whether we should call for a helicopter.
The sun was going down, and technical high-angle rescues are orders of magnitude more difficult -- and dangerous -- by headlamp. If the patient was stable, there was really no reason a medic couldn’t rappel down to her with food, water, and sleeping bags, and spend the night until the sun came up. Of course if she had a head injury that was worsening, this could be a fatal decision. One year earlier, our team had performed a helicopter nighttime high-angle pickoff – the first ever in North Carolina – and this could be an option, as well. But nighttime helicopter operations could be even more dangerous than a technical lowering operation, and a crash would be enormously catastrophic in all sorts of ways. We put together all the clinical reports we could get, and decided to send in a team and bring her down as soon as possible without a helicopter.
But even the simple act of putting together a response team can be complex. In the post-9/11 world, "typing" emergency resources has gained even more emphasis. Resource typing describes, before they are deployed, what a given resource (people, teams, equipment) can do, where they can do it, and what they can do it with. Despite this growing emphasis, a grab bag of operatives show up on most large wilderness medical operations. The challenge to an incident commander of a large multiagency operation is to put together functional teams using individuals whose background may not be completely known.
Comprehensive resource typing has not reached all rural areas, and to complicate matters further, wilderness medicine is notoriously unregulated and in many ways lacks standards and universal terminology. In cases of specialized rescue, usually personnel are needed from multiple jurisdictions, and when they show up, you hope their home agency has sent the right folks (or that they sent them at all and the responders are not just overly ambitious "civilians" with a scanner). I like to joke that resource typing in a wilderness EMS operation often amounts to looking at the stickers on a responder’s car, but this is an exaggeration. Somewhat.
We all signed in and met each other (me having to bum equipment off whoever I could because mine was locked away in the office), and put together a response plan. One guy, after telling everyone frequently and insistently that he was a former Army Ranger, began hopping from one foot to another as if he desperately needed to pee.
"Let’s go, let’s go, let’s go, let’s go," he began chanting in an irritated fashion. He was not alone. One of the premier wilderness experiential education schools is in our county and often responds to missions with us, and we frequently depend on them for technical assistance during high-angle rescues. Their climbing instructors are some of the best in the country. But there is still a disconnect between their style of climbing, which values speed, simplicity and self-rescue, and a formal rescue operation, which privileges safety and organizational control. They couldn’t understand why we didn’t just immediately rappel down to the patient and lower her down.
Mr. Former Army Ranger apparently agreed.
It wasn’t until we were hiking into the woods, and got close enough to him, that we could smell the unmistakable reek of alcohol. His behavior suddenly made sense in a terrible way. He was discreetly and rapidly removed from the insertion team. Goes to show -- formal resource typing can only go so far. Ultimately, it is a dynamic art of on-scene size-up, not a cold detached review of certifications. Like medicine, Incident Command is an art, as well as a science.
Our modified insertion team continued the hike up to the site where the patient had fallen off the edge. Len,* a tall, strapping paramedic with a frank and infectious enthusiasm for wilderness medicine and rescue, had thrown our backboard onto his shoulder, and refused to allow anyone to help him. The rest of us stretched out behind him. It felt like any other hike until we suddenly cleared the woods and stepped out into a breathtaking vista.
The sun was setting over the Linville Gorge skyline and the Pisgah National Forest beyond was painted in various shades of purple and blue. The outlines of the team in front of me were suddenly cast in silhouette against a backdrop that has stunned human beings since they first explored these ancient Smoky Mountains. In the front was the tall outline of Len and the backboard, with responders in uniform spread out behind him.
I swallowed hard with that sudden insight that hits you all once, not in stages, but as if God is smacking you in the face, saying, "Look where you are, you dummy! Look at what you’re doing!" I was a doctor, I was hiking along the spine of a gorgeous ridge, with specialized rescuers I had helped train, to come to the aid of an injured hiker. It had happened. I had come to the place I had been dreaming of, and headed toward, since before medical school. I had arrived.
Epilogue
Hours later, Len and I laid back against the now-cool rocks at the top of the climb. We had remained at the top while two other team members had gone down to the patient, tied her in to a basket, and lowered her to the ground. It was now midnight and the bright moon had helped the operation. The patient turned out to be cheerful and brave, and her injuries did not seem as severe as we worried at first they might be. The most eventful moment had been when the lowering line popped off an entanglement and the medic and patient dropped a few feet. I’ve been in that situation myself, and any sensation of free fall, even a "few feet" in reality, feels like your life is over. The medic on the line got, you might say, a little high-pitched in his lowering instructions, but otherwise handled it quite well. When the patient got to the hospital, no significant injuries were found, just strains and bruises.
This was a great example of how an event that is completely routine on an overnight shift in an ED becomes far more significant simply by changing medical management to a remote site with limited accessibility, no lighting, essentially no egress, and no staff or equipment except what you hike in. It is also a great example that the actual medical care is often (but not always!) the least complicated part of a wilderness medical evacuation. This is partly why wilderness EMS personnel sometimes struggle to gain the appreciation of those who provide subsequent patient care -- the patient’s medical condition is often unremarkable, and the rest of the environmental context is hard to express to a hospital-based provider. To them, it’s just another minor patient with strains and bruises.
Three of us stayed at the top of the cliff, monitoring the anchors, while the patient was lowered and taken out. We were relaxing into that peculiar post-mission zone where you talk about everything and nothing, and just let the emotions wash off you until you feel absolutely clean and whole. We had a panoramic view of the entire valley, and I could see my town twinkling in the distance. I imagined I could see the lights of my hospital, where I would be starting a shift in just a few hours. I knew that later on this morning, I would step out into the ambulance bay, walk toward the helipad, and stare out at the South Mountains. Of course, I would still apply in the ED all the skill and compassion I could muster, but I would know my dream job – my heart – had been left up here in the mountains, where my meandering, joyful, painful path had finally delivered me. I had arrived.
*All names have been changed
Back to Top
This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.
