Wilderness Medicine

Wilderness Risk Management Conference - 15 years later

Tod Schimelpfenig — Tue, 30 Sep 2008 02:07:00 GMT

Fifteen years ago I opened the first WRMC in a large tent at the NOLS base in Conway Washington.   Today, amid the beautiful fall colors in Grand Teton National Park, I was looking at my notes from that presentation

Opening remarks WRMC 1994. Current Issues.
- Today the public demands more from wilderness educators, and we demand more of ourselves. This is still true. We wrestle to find the balance between risk management and adventure, worry whether we can make our programs too safe, and ask where we cross the line between risk management and program integrity. At some point, in order to sail, the ship needs to leave the harbor.
- We feel, either perceived or real, pressures from our litigious society and its seeming reluctance to accept responsibility for its actions. This is still true.
- We ask more of our staff in terms of their technical ability, experience and training. This is still true.
- We wrestle with the impact of technology in the traditional wilderness experience. In 1994 I didn’t imagine the communication, information, navigation technology available to us today. Nor did I anticipate how people have grown to expect these, to take them for granted as part of the wilderness experience. There are now field staff who have never worked in the pre-sat phone and GPS era.
- We try to explain our programs to people who seem more and more disconnected from wilderness. This was before we worried about children who did not even go outside.

Where have we gone in 15 years?
Industry-wide dialogue on risk management was, and is a goal in the formation of this committee and this conference.   We’re more knowledgeable. Our risk management practices are better.   We have better lines of communication. We have more resources; in people, information and experience.

Yet the issues are in many ways the same. I could say the same things today that I said in 1994. They remain relevant.

What I didn’t say then, but wish I had, is that we can develop risk management systems and programs, have sound training and support materials and good lines of communication, but ultimately, our ability to be present when a staff person and a participant are engaged in a real time decision is limited. Lets keep this focus on the person in the field making the decisions, the person at the sharp end of the rope, with their hands on the tiller and their eyes on the terrain and weather.   For this ultimately is the core of risk management in our programs and our most valuable tool.   It still comes down to the competence and judgment of our people in the field - and this is a good thing.

Rabies Vaccine Shortage

Outdoor Ed — Thu, 25 Sep 2008 03:08:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

The American College of Emergency Physicians has just alerted emergency physicians that because of a shortage of rabies vaccine, they need to obtain a confirmation code from their state health department before ordering doses of the vaccine for post-exposure prophylaxis.

Here is some information about rabies:

Rabies virus infection occurs more frequently in wild than in domestic animals. In some foreign countries where immunization of animals is infrequently practiced, the risk is great even in domesticated animals. The virus is carried in saliva and is transmitted by bite or lick (if the skin is broken). It has been transmitted by bats in caves either by aerosolized saliva or undetected bites. Raccoons, dogs, cats, foxes, coyotes, skunks, wolves, bats, woodchucks, and groundhogs are the most common carriers. Rabies has not been reported in bears. Although rabbits, hares, mice, squirrels, chipmunks, rats, guinea pigs, and ferrets may be rabid, they are rarely involved in the transmission of rabies to humans. Domestic animals such as cattle, horses, and sheep become infected in regions where skunk or raccoon rabies is found. In developing countries in Asia, Africa, and South and Central America, dogs are the most common carriers.

Animals with rabies show abnormal behavior. In the “furious” phase, they are hyperactive, may have a fever, are overtly aggressive, and salivate excessively. With “dumb” rabies, they appear tired, lack coordination, and may become paralyzed.

Because of rabies risk, all wild animal bites or scratches, and bites or scratches of unregistered or strangely behaving cats and dogs, should be reported to the appropriate public health authority. If the animal is a pet with otherwise normal behavior, it should be observed for 10 days. If the animal is rabid, it will become very ill or die during that time, and its brain tissue can be analyzed for the presence of rabies. If the animal is a pet with unusual behavior, or a captured high-risk wild animal, it should be killed and examined. If it is a high-risk animal and cannot be captured, it must be presumed to be rabid.

Immediately scrub an animal bite wound or a wound that has been licked by a potentially rabid animal vigorously with soap and water. If benzalkonium chloride 1% (Zephiran); 10% povidone iodine (Betadine) solution (less effective); or, in a pinch, Bactine (benzalkonium 0.13%) antiseptic is available, one of these should be used to irrigate and deeply swab the wound, since they may kill rabies virus.

The standard instructions in times of plentiful rabies vaccine supply are:

If rabies is a consideration, the victim should seek the assistance of a physician, who will determine the need for postexposure rabies vaccination (a series of five injections) and injection of antirabies serum (human rabies immune globulin; as much as possible is injected around the bite wound, and the remainder intramuscularly). A person who has been previously immunized against rabies still needs two booster doses of rabies vaccine after high-risk contact with a rabid animal. In countries (Africa, Asia) where rabies in very prevalent in dogs and cats, the vaccination status of the biting animal should be ignored, because the vaccination may not have occurred or may have been ineffective. Begin vaccination and then discontinue after 10 days if the animal is observed to remain healthy during that time period.

Preexposure vaccination against rabies should be administered to people at high risk of exposure (animal handlers, cavers, hunters, and trappers in rabies-endemic areas, along with travelers to certain foreign countries). This is given as a series of three intramuscular injections over 28 days, although a newer 1 week schedule for the injections appears to be quite effective. An intradermal regimen can be used for immunization, but this technique may result in lower antibody level.

The incubation period of rabies ranges from 9 days to more than 1 year, but is usually between 2 and 16 weeks. The first symptoms are fatigue, weakness, anxiety, irritability, fever, headache, nausea and vomiting, sore throat, abdominal pain, and loss of appetite. Some victims complain of numbness and tingling where they were initially bitten. After a few days to 2 weeks, the virus shows its devastating effect upon the nervous system, with symptoms of increased agitation, hyperactivity, seizures, hallucinations, uncontrollable behavior, and inability to drink (hydrophobia) due to muscle spasms in the throat. This constellation is called “furious rabies.” With “dumb” rabies, a person becomes progressively weak, uncoordinated, and paralyzed. Unfortunately, rabies is virtually always fatal, with the terminal events being one or more of coma, respiratory failure, seizures, abnormal heart rhythms, paralysis, and pneumonia.

To avoid rabies, be certain that all pets and livestock are properly vaccinated, do not feed or handle wild animals, do not feed or touch stray animals, avoid sick or strange-acting animals, keep garbage and food (including feed for animals) covered and away from wild animals, do not keep wild animals as pets, do not touch or pick up dead animals, and do not handle bats.

With the current vaccine shortage, the protocol for post-exposure vaccination has been modified. Complete details are found at the CDC website dedicated to information about rabies. To emphasize some of the information:

As of August 29, 2008, Sanofi Pasteur in coordination with the Centers for Disease Control and Prevention (CDC) will resume shipping IMOVAX® Rabies, Rabies Vaccine for post-exposure prophylaxis only. Novartis Vaccines will no longer be shipping supplies of RabAvert®.

For a physician to obtain IMOVAX rabies vaccine, he or she must first contact the appropriate Rabies State Health Official so that a risk-assessment can be conducted for the suspected exposure. If the Official determines that post-exposure prophylaxis is required, the inquiring physician will be provided with a pass code to place on the Sanofi Pasteur Rabies Post-Exposure Form. The form must be filled out in its entirety, including the required physician’s signature and pass code provided by the Rabies State Health Official. Sanofi Pasteur may be contacted at 1-800-VACCINE to obtain the required form.

Vaccine availability for pre-exposure vaccination continues to be limited, and will be distributed on approval from state and federal public health authorities for those first responders with a critical need and in consideration of available supplies. These measures will allow responsible management of currently limited supplies of this vaccine for individuals at highest risk of exposure.

Why is there an interruption in supply?

Starting in June 2007, Sanofi Pasteur began renovating its IMOVAX Rabies vaccine production facility in France to maintain compliance with the most current requirements from FDA and the French regulatory body. Prior to these renovations, Sanofi Pasteur established an inventory based on historical levels of sales and projected market demand. The facility is scheduled to be approved and operational by mid-to-late 2009. Until the facility is operational, Sanofi Pasteur has a finite amount of IMOVAX Rabies vaccine.

After the renovations began, Novartis, the other supplier of rabies vaccine for the United States, was unable to meet projected rabies vaccine supplies. Since early 2008, Novartis has been supplying its rabies vaccine, RabAvert, for post-exposure use only. Consequently, Sanofi Pasteur has been supplying nearly all of the market for rabies vaccine. The increase in demand for IMOVAX is outpacing the company’s historical levels of supply.

Persons at increased risk for rabies exposure should take appropriate precautions to avoid rabies exposure. Vaccine is available for pre-exposure prophylaxis, and providers should consult with their local or state public health department to ensure appropriate use of such prophylaxis. General rabies awareness and prevention messages should be emphasized to avoid exposure (e.g., avoid wildlife contact, vaccinate pets/livestock, capture/observe/test exposing animal, etc.).

Lightning Precautions

Outdoor Ed — Tue, 09 Sep 2008 03:41:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

Spring, summer (peak season), and autumn are the seasons during which we witness most thunderstorms, and during which people and animals are struck by lightning. The National Oceanic and Atmospheric Administration indicates that approximately 50 Americans are struck and killed each year by lightning.

One of the world's experts on lightning injuries is Dr. Mary Ann Cooper, who is Professor of Emergency Medicine and Director of the Lightning Injury Research Program at the University of Illinois at Chicago. This year, Dr. Cooper was the recipient of the Research Award from the Wilderness Medical Society at its annual scientific meeting held in Snowmass, Colorado. She is also senior author of the chapter on lightning injuries in the textbook Wilderness Medicine.

As Dr. Cooper has noted, most people seriously underestimate the risk of being struck and do not know when or where to take shelter. NOAA data indicate that of persons struck and killed by lightning, 25 percent were standing under a tree and 25 percent occurred on or near the water. It is logical that nearly all persons killed by lightning are struck outdoors, so it is very important that everyone who might be caught in a thunderstorm be able to make a rapid assessment of the risk, and seek the best shelter or protective positioning possible. This is a personal responsibility for most, and a very important skill for group leaders.

Here is some information intended to help you understand the behavior of lightning in order to improve avoidance techniques:

1. Lightning strikes the earth at least 100 times per second during an estimated 3,000 thunderstorms per day. Fortunately, the odds of being struck by lightning are not very great. The wise traveler respects thunderstorms and seeks shelter at all times during a lightning storm.

2. Thunder, which is always present with lightning, is attributed to the nearly explosive expansion of air heated and ionized by the stroke of lightning. To estimate the approximate distance in miles from your location to the lightning strike, time the difference in seconds between the flash of light and the onset of the thunder, and divide by five.

3. Lightning can injure a person in five ways:

A. Direct hit, which most often occurs in the open.
B. Splash, which occurs when lightning hits another object (tree, building). The current seeks the path of least resistance, and may jump to a human. Splashes may occur from person to person, or from a metal fence.
C. Contact, when a person is holding on to a conductive material that is hit or splashed by lightning.
D. Step (stride) voltage (or ground current), when lightning hits the ground or an object nearby. The current spreads like waves in a pond.
E. Blunt injury, which occurs from the victim’s own muscle contractions and/or from the explosive force of the shock wave produced by the lightning strike. These can combine to cause the victim to be thrown, sometimes a considerable distance.

4. When lightning strikes a person directly, splashes at him from a tree or building, or is conducted along the ground, it usually largely flows around the outside of the body (flashover phenomenon), which causes a unique constellation of signs and symptoms. The victim is frequently thrown, clothes may be burned or torn (“exploded” off by the instantaneous conversion of sweat to steam), metallic objects (such as belt buckles) may be heated, and shoes removed. The victim often undergoes severe muscle contractions—sufficient to dislocate limbs. In most cases, the person struck is confused and rendered temporarily blind and/or deaf. In some cases, there are linear (11/2 to 2 in, or 1.3 to 5 cm, wide, following areas of heavy sweat concentration), “feathered” (fernlike; keraunographism; Lichtenberg’s flowers—cutaneous imprints from electron showers that track over the skin), or “sunburst” patterns of punctate burns over the skin, loss of consciousness, ruptured eardrums, and inability to breathe. Occasionally, the victim ceases breathing and suffers a cardiac arrest. Seizures or direct brain damage may occur. Eye injuries occur in half of victims.

5. A victim struck by lightning may not remember the flash or thunder, or even recognize that he has been hit. The confusion, muscle aches, body tingling, and amnesia can last for days. With a more severe case, the skin may be mottled, the legs and/or arms may be paralyzed, and it may be difficult to locate a pulse in the radial (wrist) artery, because the muscles in the wall of the artery are in spasm. First-, second-, or third-degree skin burns may be present. Broken bones are not uncommon.
If a person is found confused, burned, or collapsed in the vicinity of a thunderstorm, consider the possibility that he was struck by lightning. The victim is not “electrified” or “charged”—you will not be jolted or stunned if you touch him.

6. If you are in the vicinity of a thunderstorm, seek shelter for the victim and yourself. Lightning can strike twice in the same place!

Lightning Avoidance

1. Know the weather patterns for your area. Don’t travel in times of high thunderstorm risk. Avoid being outdoors during a thunderstorm. Carry a radio to monitor weather reports. Lightning can lash out from 10 miles in front of a storm cloud, in seemingly clear weather. If you calculate (see above) that a nearby lightning strike is within 3 miles (5 km) of your location, anticipate that the next strike will be in your immediate area. The “30-30 rule” specifies that if you see lightning and count less than 30 seconds prior to hearing thunder, seek shelter immediately. Since thunder is rarely heard from more than 10 miles away, if you hear thunder, it is best to curtail activities and seek shelter from lightning. Do not resume activities outdoors for at least 30 minutes after the lightning is seen and the last thunder heard.

2. If a storm enters your area, immediately seek shelter. Enter a hard-roofed auto or large building, if possible. Tents and convertible autos offer essentially no protection from lightning. Tent poles are lightning rods. Metal sheds are dangerous because of the risk of side splashes. Indoors, stay away from windows, open doors, fireplaces, and large metal fixtures. Inside a building, avoid plumbing fixtures, telephones, and other appliances attached by metal to the outside of the building.

3. Do not carry a lightning rod, such as a fishing pole or golf club. Avoid tall objects, such as ski lifts and power lines. Avoid being near boat masts or flagpoles. Do not seek refuge near power lines or tall metal structures. If you are in a boat, try to get out of the water. If you are swimming in the water, get out. Do not stand near a metal boat. Insulate yourself from ground current by crouching on a sleeping pad, backpack, or coiled rope.

4. Move off ridges and summits. Thunderstorms tend to occur in the afternoon, so attempt to summit early and be heading back down by noon. In the woods, avoid the tallest trees (stay at a distance from the tree that’s at least equal to the tree’s height) or hilltops. Shelter yourself in a stand of smaller trees. Avoid clearings—you become the tallest tree. Don’t stay at or near the top of a peak or ridge. Avoid cave entrances. In the open, crouch down or roll into a ball.

5. Stay in your car. If it is a convertible, huddle on the ground at least 50 yards (46 m) from the vehicle.

6. If you are part of a group of people, spread the group out so that everyone isn’t struck by a single discharge.

7. If your hair stands on end, you hear high-pitched or crackling noises, or see a blue halo (St. Elmo’s fire) around objects, there is electrical activity near you that precedes a lightning strike. If you can’t get away from the area immediately, crouch down on the balls of your feet and keep your head down. Don’t touch the ground with your hands.

8. The StrikeAlert Personal Lightning Detector (Outdoor Technologies, Inc.) is the size and configuration of a pager and uses an audible warning and LED display to show the wearer how far away lightning is striking and if a storm is approaching or leaving.

Handwashing, Giardia and old Tales

Tod Schimelpfenig — Wed, 27 Aug 2008 16:18:00 GMT

Once there was a time, days of freedom and ignorance vaguely remembered as the 70’s, when we didn’t worry about wilderness water quality. We drank when and where we pleased. Yes, there was a tale of backpackers in Utah who became ill with “beaver fever” caused by Giardia, but we tried to ignore this challenge to our assumptions. The die was cast, however, and discussions began over whether we needed to disinfect the water.

Physician and outdoor educator Thomas Welch wrote an editorial on water disinfection in the Journal of Wilderness and Environmental Medicine 2004. He points out that this classic 1976 Utah incident of Giardia caused diarrhea, which brought this protozoa to our attention and probably sparked the water disinfection era, looks in hindsight like a hygiene, not a water disinfection problem. Other groups using the same area didn’t get sick, cysts could not be isolated from the water, and the patients all became ill at the same time, and with a short incubation period, suggesting this was not a waterborne protozoa illness.

Giardia’s reputation is enhanced by an association bias. People go camping, get diarrhea and assume the source was the water. This perception is encouraged when the diagnosis of Giardia is based on a history of a recent camping trip, but without testing. The patient leaves believing they may have Giardia, when in fact there is often no proof. They leave thinking it was the water they drank, when the cause of the illness may have been hand-to-mouth transmission. They might need a lecture about hand washing from their health care provider, along with the advice to be more diligent with water disinfection.

The editorial makes the point that water disinfection is not a substitute for hand washing or alcohol-based hand cleaners.

Someday we may have the science to give us a better sense of when we need to disinfect water. Until then, routine water disinfection has low health risks and is prudent. And hygiene, especially hand washing, is vital for avoiding illness on a wilderness trip.

Welch, TR. Evidence-based medicine in the wilderness: The Safety of Backcountry Water. 2004. Wilderness Environ Med. 15:235-237.

Summer Health Tips

Outdoor Ed — Sun, 03 Aug 2008 18:03:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

I was recently invited by Revolution Health to offer their readers a few summer safety tips to beat the "silent summer spoilers." The following is a modified version of what was presented, with the notation that these afflictions are not so silent, and can certainly ruin your vacation or outdoor adventure.

Sunburn can be brutal. The best way to avoid sunburn is to stay out of direct sunlight. If possible, stay in the shade, and wear sun-protective clothing. Use a sunblock that is effective against both ultraviolet A (UVA) and UVB rays. It is an increasingly prevailing opinion that UVA is more damaging than previously thought.

Be certain to obtain a good application (at least an ounce or two for a "normal" sized adult), and reapply the sunscreen often, particularly if you are sweating or spending time in the water (scuba diving, surfing, swimming, etc.). If you are taking medication, know if it might make your skin more sensitive to sunlight.

Pay attention to your surroundings. High altitude, wind, and sun reflecting off the surface of water, sand, or gravel add to UV exposure. Don't forget to protect your eyes with sunglasses rated to block nearly 100% of UV radiation. If you decide to use insect repellent containing DEET (N,N-diethyl-m-toluamide) as well as a sunscreen, be advised that the combination might reduce the effectiveness of the sunscreen. If you are using two separate products (sunscreen and insect repellen), in general, it is best to apply the sunscreen first, allow it to absorb into the skin for 20 to 30 minutes, then apply the insect repellent, in order to maximize the effect of the repellent. If you are going to be in water where you might come in contact with stinging jellyfish, consider using Safe Sea sunblock with jellyfish sting protective lotion incorporated into the product.

A mild sunburn without blistering can be treated with cool compresses, showers or baths, a non-sensitizing skin moisturizer lotion, and aspirin or a nonsteroidal anti-inflammatory drug (e.g., ibuprofen) to decrease inflammation. A sunburn, even first degree, that is so extensive that it causes the victim to suffer chills, nausea and vomiting, weakness, and diarrhea, may require oral rehydration and bedrest. If blisters are present, this indicates second-degree burns, which sometimes must be treated with topical antiseptic ointment, bandages, and more extensive medical care. You certainly wish to avoid this situation. The skin bubbling and peeling that follow a first degree sunburn are superficial and do not result in fluid loss, and rarely lead to infection, but the skin should be kept clean and moisturized to prevent any complications. Anyone with a severe sunburn of any sort should be examined for dehydration.

Blisters are the bane of hikers and trekkers, and often of persons wearing new sandals, particularly if the feet are dirty and dusty, as the grit and grime serve as agents of abrasion. Break in andy new shoes, boots, flip-flops and sandals before walking any distance in them. Keep your feet clean and dry. When walking in boots, wear a thin pair of liner socks under your regular socks, so that the friction is between the socks, not between the boots and your feet. Cushion any reddened "hot spot" or cover it with a BlistOBan® bandage before a fluid-filled blister appears. If you do get a blister:

Fasten a "donut"-shaped foam pad to the perimeter of the affected area. Cover the affected area ("donut hole") with a fitted hydrogel (e.g., Spenco 2nd Skin®) pad, and then place tape over the foam and hydrogel. Watch for signs of infection, which include cloudy fluid or pus within the blister, or red streaks emanating from the edges of the blister into the surrounding skin. If the blister appears infected, use a disinfected or carefully cleaned needle to create a small puncture at the edge of the blister, and drain it. Cover the open wound with antiseptic ointment, and apply a sterile dressing.

Sprains and strains are common ailments in the summertime due to increased outdoor activity. The most common sprain involves the ankle. In the event of a sprain, use the "RICE" technique. RICE stands for "rest, ice, compression, elevation." Try to rest the joint. Elevate the affected body part and apply ice packs intermittently (e.g., 15 minutes on, 15 minutes off) as much as is practical for the next 24 hours. If the skin becomes reddened and painful from the application of ice, ease off to avoid a cold injury (e.g., frostbite) to the tissues. Mild compression with a wrap may provide some pain relief. If you need to keep walking, tape, bandage or splint the joint for support.

Once a joint is weakened by a strain or sprain, re-injury is common. Take precautions by using a mechanical ankle support (e.g., brace and high-top shoes or boots) and/or a walking stick over rocky terrain. It takes a full 6 to 8 weeks to recover from a mild ankle sprain, and 3 to 6 months to recover from a severe sprain.

Gastroenteric problems are common in the summer. Traveler's diarrhea, commonly caused by the bacteria E. coli, is often due to water or food contamination. Failure to wash or "gel" hands or to properly prepare food are likely the most common errors that lead to diarrhea. Water disinfection techniques include heating, addition of chemicals, filtration, or application of UV light. It is important to carry redundant water disinfection systems, so that if a unit (e.g., filter) is lost or damaged, you have backup. Avoid drinking beverages with ice, unless you can be absolutely certain that the ice was prepared from properly disinfected water.

Tick and mosquito bites can result in serious, even fatal, infections. So, be certain to protect yourself. If circumstances permit, wear light-colored pants tucked into socks and paired with a long sleeve shirt. Wear a head net or use a bed net when needed. Use insect repellent(s). Permethrin is applied to clothing, while DEET or picaridin is applied to exposed skin. Perform regular "tick checks" of the entire body (especially the scalp, groin and armpits), and immediately remove ticks. When attempting to remove a tick, do not twist it, touch it with a hot object such as a hot match head, or attempt to suffocate or kill it with petrolatum (petroleum jelly), mineral oil, kerosene, stove fuel, etc. These techniques might cause the tick to struggle and regurgitate potentially infectious agents into your bloodstream.

Finally, learn to recognize poison ivy, oak, and sumac. If you become exposed to their resin, immediately wash it off with soap and water or with a specialized scrub (e.g., Tecnu or Zanfel) within 30 minutes if possible. To treat a rash from poison ivy, oak or sumac, you may soothe the affected skin with calamine lotion and also consider the following measures: apply a topical anesthetic, such as praxomine HCl 1%; soak in a tepid (not hot) bath supplemented with baking soda or Aveeno (contains oatmeal proteins); consider taking an antihistamine medication, which helps control itching and acts as a sedative. Consult a physician if the reaction is severe. Prescription treatment (such as corticosteroid therapy) may be required.

The resins from plants can remain on clothes, fabrics, backpacks, tents, pet fur and elsewhere for long periods of time, so be certain to wash these carefully to prevent further exposure to the resin. Once the rash appears, you are not contagious, and you cannot spread the rash by scratching. However, you can open up blisters and make the affected skin vulnerable to secondary infection.

image courtesy of w3.ouhsc.edu

Epinephrine Roundtable

Tod Schimelpfenig — Mon, 28 Jul 2008 20:19:00 GMT

Last evening I sat on a roundtable discussion on the the use of epinephrine in the backcountry at the 25th Anniversary and Annual Meeting of the Wilderness Medical Society.

Dave Johnson MD from Wilderness Medical Associates was the initiative on this project. The panel, moderated by Jay Lemery MD, included Dr Johnson, myself, Flavio Gaudio MD from Cornell, attorney Frances Mock, Carl Weil and Joanne Vitanza MD from Versus Pharmaceuticals (the Twinject people).

Highlights from the discussion include:

It’s difficult to know how common anaphylaxis is, both in the city, and the backcountry. Definitions vary and hinder reporting. The incidence of this rare, but deadly reaction is probably influenced by where and when program operates; some places have more bee and wasp stings, for example.

Data collection has been a disappointment. There have been several efforts over the years, but no compelling reason, other than AEE accreditation, for outdoor programs to submit data to a common database. This epinephrine argument is a clear example of where diligence in data collection would be of value.

In the absence of solid numbers our perceptions are influenced by the emotional hook of anaphylaxis.   Tales of patients with severe allergic responses saved with epinephrine circulate in the industry, yet documented accounts are elusive.     NOLS, for example, has only 2 incidents in the past 24 years where epinephrine was used for anaphylaxis (and no incidents where epinephrine was indicated and not administered). The 1998-2005 WRMC data set, which includes 960,000 program days of back-country experience, has no incidents of anaphylaxis. Dave Johnson, based on his experience, thinks these numbers are a low cohort.   I can’t disagree, the evidence does not allow us to draw conclusions about frequency.

We want to be prepared to treat this problem, yet worry that a layperson administering epinephrine to another person may not be supported by law.   Frances spoke to the legal dilemma of the law being behind the current medical standard of care.   Dave Johnson notes that the “horse is out of the barn” and the law will change to support layperson use of epinephrine, it may just take some time.

There may be an expectation by parents and clients, driven by the attention to food allergies in the media, that the person in charge should be able to manage anaphylaxis, yet the legal support for epinephrine use by laypeople as a first aid skill, while improving, remains inconsistent state by state.

A few states give Good Samaritan support to people administering epinephrine in an emergency. Some states mandate training for camp counselors. Some states have clear training requirements, others leave training to the equivalent of local medical control (e.g., physician, nurse practitioner). Some states include school bus drivers on the list for training, others do not allow EMT’s to initiate epinephrine treatment in the field (which of course, seems silly).

There are a number of advocacy groups supporting administration of epinephrine in anaphylaxis by well-trained first responders (school teachers, coaches, nurses, bus drivers, etc.). These include the Food Allergy & Anaphylaxis Network and medical organizations such as the American Academy of Allergy, Asthma and Immunology, American Academy of Pediatrics, the American Medical Association), the Red Cross and the American Heart Association in the 2005 First Aid Guidelines. We hope our roundtable discussion leads to a similar statement of support by the Wilderness Medical Society for layperson use of epinephrine in the wilderness.

National Estimates of Outdoor Recreational Injuries

Outdoor Ed — Sat, 26 Jul 2008 16:44:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

In Volume 19, Number 2 (2008) of the journal Wilderness & Environmental Medicine appears an original research article entitled "National Estimates of Outdoor Recreational Injuries Treated in Emergency Departments, United States, 2004-2005," authored by Adrian H. Flores and his associates from the Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia. This article was the beneficiary of multiple press releases, and so there has already been a fair amount of discussion regarding its findings. Because I was briefly quoted regarding this article by the Associated Press, I have received a fair number of inquiries about its significance.

This article is the first to provide national estimates of nonfatal outdoor recreational injuries treated in 63 U.S. emergency departments (EDs). The data were gathered using the National Electronic Injury Surveillance Survey System - All Injury Program. In this way, national estimates of outdoor recreational injuries were calculated, and activities leading to injury, demographic characteristics, principal diagnoses, and primary body parts affected were described.

Averaged across the study years, an estimated 212,708 persons were treated each year in U.S. EDs for outdoor recreational injuries. Males accounted for 68.2% of the injuries, but the rates of injury did not take into consideration that males have higher rates of participation in outdoor recreation. The lower limb, upper limb, and head and neck region were the most commonly injured body regions. Fractures and sprains or strains were the most common diagnoses. For all injuries, the leading causes were falls, being struck by or against an object, and overexertion. In this study, the 10- to 19-year old and 20- to 29-year old ages groups accounted for the greatest percentage of injuries. Snowboarding, sledding, and hiking were the leading activities associated with outdoor recreational injuries.

What can be learned from this study? Much of what was documented is fairly well appreciated already, and confirms our suspicions about who suffers what type of injuries. As with any type of epidemiological research, the devil is in the details. For instance, to understand about how to make use of the information about injuries in snowboarders, it would be necessary to understand what happened during each event - did the accident occur at the beginning of the day (? icy terrain or deep powder) or at the end of the day (? participant tired, evolving icy conditions, impending darkness); was the snowboarder wearing protective equipment (? wrist guards, leash, helmet); was the snowboarder experienced (? beginner, intermediate, expert), etc. To understand how to make use of the information about injuries in hikers, it would be important to know the nature of the terrain, the skill-strength-experience of the hiker, the environmental conditions, type of footgear, use of a walking stick, etc. The premise is that with some reasonable degree of detail, we can draw conclusions about how better to prevent accidents and injuries. The name of the game is injury prevention.

One cannot remove all risks from outdoor recreational activities, but a reasonable goal would be to remove all unnecessary risks. If a deeper analysis of this study reveals that injured boaters were all driving above a certain speed, we can perhaps conclude something from that and perhaps make recommendations. If a greater percentage of the head-injured among the study persons were without helmets than the participating population at large, then we can perhaps make a recommendation. This is a nice study that will hopefully inspire others to look with greater depth at specific areas of outdoor recreation in order to identify patterns that can lead to more effective injury prevention.

image courtesy of www.ABC-OF-SNOWBOARDING.com

Preview the 25th Anniversary & Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 25-30, 2008.

Splinting

Tod Schimelpfenig — Sat, 12 Jul 2008 19:35:00 GMT

A recent edition of an urban EMT magazine has an article on splinting that opens with a tale of a patient being transported with an un-splinted ankle fracture, and a reference to a study where only 25% of patients with extremity fractures had their injuries splinted before arrival at the ER, and fewer had RICE therapy applied in the field to help manage pain. I’m not sure how representative the sample population of this study may be (it didn't clearly separate isolated injuries from urgent multiple trauma patients), but it is consistent with my experience that splinting does not receive the same attention in urban EMS that we give it in wilderness medicine.

One of the comments on the web version of this article said that most ambulance patients are on backboards, which serve as a splint. I disagree. Just the other day I took over care of a patient with an un-splinted open tib-fib fracture. This first response crew also thought the backboard was plenty of splint, and were focused on applying the gadgetry of modern EMS; electrodes, pulse ox, automatic BP cuff, IV. I splinted the leg.

Because we can care for patients for hours or days, and transport patients in difficult conditions, wilderness medicine providers know the value of a sound splint: padded, but not bulky or heavy; rigid; adjustable; with fingers/toes accessible for assessment; with the joints above and below long bone injuries and the bones above and below a joint injury immobilized. We know a splint can stabilize an injury and prevent further damage, and that combined with RICE, can be helpful in pain management.

This is basic first aid. It’s an important skill that is much appreciated in the wilderness but sadly sometimes a lost art in the urban world.

Tomatoes and Salmonella

Outdoor Ed — Tue, 08 Jul 2008 03:15:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

Let's just say that people who like to be outdoors are often the same people who like to eat tomatoes. Tomatoes are a staple food at cookouts, on backpacking trips when fresh food is carried, for lunch and dinner on the river, etc. Nothing tastes better than a homegrown beef tomato sprinkled lightly with a bit of salt and pepper, and perhaps a touch of balsamic vinegar.

Over the past few weeks, we were informed that now we all needed to be extra careful, because we were supposedly in the midst of a multi-state (U.S.) outbreak of infections caused by Salmonella serotype Saintpaul, attributed to consumption of raw tomatoes, and in particular, red plum, red Roma, or round red tomatoes.

Thirty-two states and the District of Columbia were said to have reported infections to the Centers for Disease Control, via the identification of Salmonella strains from ill persons routed for identification through the State health departments. The reports were presumedly linked to tomatoes - consumed at home or in restaurants. There was no definitive link to tomatoes consumed "in the wild" - and none to my knowledge on an expedition. Now it appears that these Salmonella infections may not have originated with tomatoes after all, but from some unknown carrier(s) of the bacteria. We are not yet even sure if the contaminated food was produce, but that is a possibility. If it was not tomatoes, perhaps it was something served with tomatoes, or a food product made with tomatoes, such as salsa. If it was salsa, then it could have been any of the other ingredients, such as green onions, cilantro, or jalapeño peppers.

If there are contaminated tomatoes, or any other vegetable, meat, or other food product(s) in circulation, sooner or later, someone will get become sick after eating the product during a picnic or an outdoor trip. In retrospect, and for the purpose of avoiding future illness, it is very important to note that we do not have information about how the culprit tomatoes were supposedly handled prior to consumption - were they washed, and if so, in what manner? I don't imagine that we will ever learn these details, particularly if the very origins of the reported illnesses are in doubt.

So, that leads us back to a general discussion of infection with Salmonella, which is a very real cause of diarrheal illness. There are multiple species of Salmonella, including Salmonella typhi, which causes typhoid fever. The bacteria normally reside in the intestinal tracts of humans and other animals, including birds. The most well known causes of Salmonella food poisoning are contaminated beef, poultry, milk, and eggs. Salmonella food poisoning (infection), usually caused by S. typhimurium or S. enteritidis, typically causes diarrhea (loose and watery stools, usually without blood), fever, and abdominal cramping 12 to 72 hours after incubation of the infection. Untreated with an antibiotic, the illness usually lasts from 4 to 7 days. The infection may spread and cause the victim to become seriously ill, or rarely, to die. On occasion, persons with Salmonella infection develop a post-infection syndrome of painful joints, irritated eyes, and pain on urination.

For gastroenteritis, antibiotic therapy is usually not indicated, because it does not shorten the duration of the disease. Furthermore, antimotility drugs, such as loperamide (Imodium), are not recommended, because they may prolong contact time of the bacteria in the bowel, and prolong or worsen the illness. However, antibiotics are often recommended for Salmonella gastroenteritis in infants younger than 3 months, infants younger than 12 months with temperatures higher than 102.2°F (39°C), and persons with certain blood disorders, HIV infection or other cause of immunosuppression (e.g., diabetes or chronic steroid therapy), cancer, or chronic gastrointestinal illness. The recommended antibiotics for such individuals include ampicillin, amoxicillin, trimethoprim-sulfamethoxazole, cefotaxime, ciprofloxacin, and ceftriaxone, among others.

So far, in this current Salmonella outbreak, there have been no directly-attributable deaths reported, but at least 53 persons have been hospitalized. Overall, the number of afflicted persons is likely greater than that reported, because many people who develop diarrhea don't seek medical care and/or obtain a stool culture.

The Food and Drug Administration (FDA) has been advising consumers in the U.S. to be cautious, and to choose for consumption cherry tomatoes, grape tomatoes, tomatoes sold with the vine attached, homegrown tomatoes (more reason to "go organic"), and to avoid red plum, red Roma, and round red tomatoes unless they come from reliable sources. Of course, much as one needs to avoid contaminated ice in beverages, one should be aware that if tomatoes are the culprits, then raw tomatoes used to prepare sauces, salsa, cold soups, and other food products can carry Salmonella. Ditto for lettuce or any raw fruit or vegetable. The truth is that right now, we don't know precisely what to avoid.

Here are additional precautionary measures that place emphasis on food handling and preparation:

1. Within 2 hours of use, refrigerate or discard cut, peeled, or cooked fruits and vegeatables.
2. Do not purchase bruised or damaged fruits or vegetables.
3. Wash all vegetables and fruits thoroughly under running water. If you are camping, use properly disinfected water. Soaking vegetables and fruits with a skin or "peel" in an iodinated disinfecting solution, then rinsing with disinfected water to remove the residual iodine (and improve the taste) is a common practice in some third world restaurants.
4. Keep raw produce for consumption separate from raw meats and seafood.
5. Wash all cutting boards and surfaces, dishes, utensils, and counter tops with soap and hot water in between handling different types of food products.
6. One might consider peeling tomatoes, but there is not yet evidence that this makes a difference in diminishing the number of infections, which may not be caused by the tomatoes anyway.

The U.S. Department of Agriculture has an excellent Fact Sheet entitled "Salmonella Questions and Answers."

In summary, the recent reports of Salmonella infection, while perhaps attributable to tomatoes, may well have been created by an alternative source(s). The rules for safe food handling and avoidance of food-borne infection apply to all foods, not just tomatoes.

image of "Tennessee tomatoes go camping" courtesy of blackstarjewelry's photostream

Laceration Repair in the Wilderness

Outdoor Ed — Wed, 25 Jun 2008 02:16:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

.
I'm delighted to present another guest post from Jeremy Joslin, M.D., entitled "Laceration Repair in the Wilderness":

The Scenario

It always happens by accident. You're using your new, lightweight pack saw to collect downed wood for an evening fire when the saw slips and slices into the back of your left thumb. Blood flows immediately, and you feel a rush of pain up your hand. You're four days' hike from civilization and the cut looks like it needs stitches.

Let the first aid begin. You apply pressure and the bleeding stops. After irrigating the wound with clean water, you reach into your pack to find your sewing kit and sutures. But should you really be stiching up this cut?

The answer doesn't necessarily hinge solely on your training. I've discussed this subject with emergency physicians who repair lacerations daily, as well as with first responders who learned from their grandmothers that if they could sew cloth, they could sew skin. My personal opinion is that people should take great pause before sewing a laceration outside of a medical exam room. In my mind, the decision about whether or not to sew a wound in the field is related to the issue of "wound appropriateness."

Wound appropriateness takes both wound size and cleanliness into account. A small wound that remains contaminated with dirt and debris shouldn't be closed because the closure would trap all the necessary ingredients for an infection. On the other hand, a small wound that's fairly clean probably doesn't need stitches anyway - perhaps not even in the Emergency Department! An article (1) reviewed this particular topic and came to the conclusion that uncomplicated lacerations less than 2 cm (just under an inch) didn't heal better or ultimately appear better when sutured (stitched) compared to when they were left unsutured. A small, debris-filled wound should be cleaned with water that is disinfected enough to drink, and then left open to heal or closed (e.g., skin edges brought together) with an adhesive bandage (strips).

My preferred technique for caring for small wounds is to clean them thoroughly, then use skin (tissue) glue to make the initial closure, after which I cover the entire wound with a piece of gauze and duct tape or with Tegaderm (a thin, clear, plastic adhesive covering) for protection. Some people have used "super glue" to close wounds, but this is not recommended for several reasons. Any laceration can be sutured by a physician in a delayed fashion upon your return, if such a repair is necessary for cosmetic or other reasons.

Any large wound needs to be examined with three things in mind:

How contaminated is the wound?
How much will the wound bleed?
Are there any other structures involved?

Every large wound will have different answers to these questions, which is where clinical acumen comes into play. Always prioritize control of blood loss, and consider closing the wound(s) loosely with stitches if this is the only way to staunch the bleeding. If the wound is deep, there may be damage to structures beneath the skin, such as tendons, ligaments, and/or nerves, any of which may require formal wound care not possible in the outdoors. Therefore, consider evacuation for all large wounds. While evacuating, the wound should be covered and compressed with a clean bandage.

(1) Emergency Medicine Journal 2007;24:217-218; doi:10.1136/emj.2007.046813

image courtesy of St. David's Healthcare

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Disinfect, or drink?

Tod Schimelpfenig — Wed, 11 Jun 2008 22:11:00 GMT

We all need to drink water in the backcountry, but do we need to disinfect it? The latest edition of the Journal of Wilderness and Environmental Medicine (Vol 19, Num 2) has an article looking at risk factors for contaminated water in the Sierra Nevada.1

The article extends physician Robert Derlet’s and pathology researcher James Carlson’s previous research into a 5 year study of the prevalence of coliforms (a marker for fecal contamination) in wilderness water. They found, as suspected, that coliform prevalence varied by the land use patterns of humans and domesticated animals. Pack animals and cattle grazing areas had a high probability of coliform presence. In areas that were frequented only by backpackers, there was significantly less risk. This, of course, makes perfect intuitive sense. Previously, their research showed that waterways below roads, popular trails and well-used cattle grazing areas often show the presence of harmful bacteria, while pristine sites have less risk.

Despite all the trail head warnings, rhetoric and water treatment product information, scientific evidence about the relationship between drinking untreated surface water in North American wilderness and intestinal illness is scanty.

This research echoes a theme in other research and editorials. If you want to read more I’ve included a short bibliography at the end of this blog.

Many an outdoor leader has questioned the assumption that all non-tap water needs to be disinfected. This research suggests it may not, but it’s not the end of the story. There is still much we could learn about wilderness water quality and how it may vary by season, mountain range, soil and other variables. The decision to disinfect water remains a balance between the risk of illness and consequences to our health, and the side effects of the disease’s treatment, with concerns over the health effects of chemical disinfection of water.

What do I do? When working for NOLS I treat all my wilderness water (and some urban water as well). I respect the school’s position, and, believing, if used wisely, the risk to my health from chemical disinfectants is low, I have better things to do than argue this question.

On my personal time I occasionally make use of the educated guess and I will quaff apparently pristine alpine water like a mountain man of old while I exalt in the freedom of the hills - but mostly I disinfect my water.

Tod

June 08

1. Robert W. Derlet, MD; K. Ali Ger; John R. Richards, MD; James R. Carlson, PhD Risk Factors for Coliform Bacteria in Backcountry Lakes and Streams in the Sierra Nevada Mountains: A 5-Year Study. Wilderness and Environmental Medicine, 19, 82 90 (2008)

Welch, TP. Risk of giardiasis from consumption of wilderness water in North America: a systematic review of epidemiologic data. 2000. Int. J. Infect. Dis. 4(2):100-103.

Welch, TR, Welch, TP. Giardiasis as a threat to backpackers in the United States: a survey of state health departments. 1995.

Derlet, RW, Carlson, JR, Nonponen, MN. Coliform and pathologic bacteria in Sierra Nevada national forest wilderness area lakes and streams. 2004. Wilderness Environ Med;15(4):245-9.

Derlet, RW, Carlson. An analysis of wilderness water in Kings Canyon, Sequoia, and Yosemite national parks for coliform and pathologic bacteria. 2004. Wilderness Environ Med;15(4):238-44.

Wilderness Environ Med. May;6(2):162-6. Craun, GF, Calderon, RL, Craun, MF. Outbreaks associated with recreational water I the United States. 2005. Int. J. Environ. Health Res. Aug;15(4):243-262.

"Backcountry Water Quality: Technologies, Trends and Paranoia?," by Ron Silflow & Ryan Jordan. BackpackingLight.com. http://www.backpackinglight.com/cgibin/backpackinglight/backcountry_water_quality_technologies_trends_paranoia.html, 09/20/2006.

How Safe is the Water? Backpacker December 1996.

Treatment Principles

Tod Schimelpfenig — Fri, 06 Jun 2008 19:50:00 GMT

In Dr. Jerome Groopman’s “How Doctors Think” there is a tale of medical students from two different schools being told that two entirely different approaches to a problem are the gold standard. As they started to practice medicine they realized that, in fact, there were several approaches to this problem. Their education would have served them better, they observed, if it had prepared them for the uncertainty inherent in medicine, and encouraged them to keep an open mind.

In both urban pre-hospital and wilderness medicine there are areas where experts argue best practices. Femur traction splints, MAST pants, the value of IV’s, lights and sirens and air transport are only a few of the urban practices that are taken for granted, yet are controversial. On the wilderness side we also debate traction splints, and tourniquets, pressure immobilization bandages for Elapid snakebite, whether we should “clear a spine”, reduce a dislocation, or straighten a fracture.

This can cause uncertainty in the WFR, well-trained but with limited experience, who is challenged by someone with a different approach to a problem. Do I really know my stuff? Might I harm the patient? As well, the WFR may be making a medical decision in the context of all the variables inherent in wilderness leadership: terrain, weather, unknown evacuation support, unreliable communication and their responsibilities to the rest of their expedition members.

One of the aspirations of NOLS Founder Paul Petzoldt was to develop leaders with judgment; the ability to reason in the midst of uncertainty.

We all know people who are dogmatic preachers - confident and passionate that their technique or knowledge is the final word. Yet, you know the saying, “If you step in dogma, your shoes stink.”

There can be many ways to solve a problem, many of them workable, none of them perfect. Without flexibility and breath of understanding our judgment may be limited. Teaching one way to manage a problem might be educationally sound for a beginner, but it could leave the wilderness leader, on their own and reasoning in uncertaintly, with limited options.

To be an effective WFR you need to know how to manage a problem and make a decision based on treatment principles, which you can adapt to the situation at hand. Novices need cookbooks, with treatment principles that are sound recipes. It’s our job, both in wilderness medicine and wilderness education, to show students recipes that work, and to help them be a thinking cook.

Tod

June 2008

Immersion Foot

Tod Schimelpfenig — Thu, 15 May 2008 22:38:00 GMT

The view from my window is of the eastern slope of the Wind River Range. The high country gleams white with snow. The lower slopes are green with spring, or white with snow, depending on the day, or sometimes the hour. My hike last weekend was a combination of snowshoeing in wet snow and slopping through mud, conditions ripe for a non-freezing cold injury such as immersion foot.

Most people don’t know this injury, because like I did last weekend, they go home at night. It’s the multi-day hikers, the soldiers and others who stay outdoors in wet and cold who are at risk.

In immersion foot, like frostbite, blood vessels constrict in response to cold and damp. In this case it’s cold enough to impair circulation, but not to freeze tissue. Cells are deprived of oxygen and nutrients.   Nerves are especially sensitive, which accounts for the numbness, pins and needles sensations, itching and pain that often announce the injury.

In the field it’s common to see cool pale extremities, numbness or tingling, itching and mild swelling. It’s less common to see the textbook appearance of cold, swollen, numb, cyanotic and mottled skin, or the warm, swollen, red and painful skin that surprises the camper after they take their first warm shower.

There isn’t much we can do to treat this in the field. We need to recognize it, keep the foot dry and warm and go see the doctor. The pain can be awful and difficult to manage with medications. Severe cases result in tissue loss. Moderate cases can be painful and sensitive for weeks, months and even years.

We used to think sleeping with warm dry feet prevented injury, no matter how cold they were during the day.   This is probably true in many cases, but I’ve seen immersion foot develop over a day and in a cold multi-hour river crossing. There must be individual susceptibility issues. As well, this day may be the tipping point after several days of exposure. An afternoon of lapsed attention that unravels days of diligent prevention.

Footwear isn’t a panacea, although today’s plastic boots are a godsend compared to the leather we used to wear.   You can get a non-freezing cold injury from sweat-dampened socks, neoprene socks and other vapor barrier systems, as well as with supergaitors and snowpack boots. It happens to novices and experts, in summer and winter, in the deserts and mountains, and even in the jungle. It’s a consequence of how cool and damp your extremities are, no matter what you wear on your feet.

The adage that “cold injuries are a leadership challenge long before they are a medical problem” is certainly true. Prevention starts by looking at your feet, and the feet of those you lead. Don’t assume.   This injury surprises people.

The prevention toolbox is deep with advice: wool or synthetic socks; keeping the body warm; massaging the feet twice a day; sleeping with dry and warm feet; drying wet socks against your skin; warming you feet during the day; keeping your feet out of water or mud as much as possible; watching carefully and reacting promptly if you experience numbness or tingling; keeping footwear loose to allow for circulation.

I’ve tried vapor barrier, and anti-perspirants for my sweaty feet, with mixed success. I’m partial to changing my socks in the middle of the day, which makes me look at my feet. They surprised me once years ago. I’m sure they can do it again. I don’t tolerate numb toes, and my threshold for dealing with cold toes is low. Changing my socks gives my students permission to do the same and shows that cold, damp socks is not a sign of toughness, rather, it’s a bad habit.

Take care

Tod

Sea Bather’s Rash

Outdoor Ed — Mon, 05 May 2008 01:09:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

From the month of May through September, oceangoers along the U.S. Gulf coast need to be concerned about a particular form of skin rash caused by tiny jellyfish. As the summer season progresses, this can also become a problem along the entire eastern seaboard. I've been afflicted while scuba diving in Cozumel, Mexico, and the episodes can be much more than a minor annoyance. Indeed, the intensity with which some people react to these particular stings was an impetus for the development of Safe Sea, a jellyfish sting inhibitor product for which I participated in the design of clinical trials.

Sea bather’s eruption, often misnamed "sea lice" (which are true crustacean parasites upon fish), occurs in seawater and more often involves bathing-suit-covered areas of the skin, rather than exposed areas. The skin rash distribution is very similar to that from seaweed dermatitis, but no seaweed is found on the skin. The cause is stings from the nematocysts (stinging cells) of thimble jellyfish, such as Linuche unguiculata, and the larval forms of certain anemones. The victim may notice a tingling sensation under the bathing suit (breasts, groin, cuffs of wet suits) while still in the water, which is made much worse if he takes a freshwater rinse (shower) while still wearing the suit. The rash usually consists of red bumps, which may become dense and confluent. Itching is severe and may become painful.

Treatment is often not optimal, because application of vinegar or rubbing alcohol to stop the envenomation may not be very effective. An agent that may work better is a solution of papain (such as unseasoned meat tenderizer), which may be applied using a mildly abrasive pad, although a good outcome is not guaranteed. After the decontamination with any agent and a thorough freshwater rinse, apply hydrocortisone lotion 1% twice a day to treat the inflammatory component of the skin reaction. If the reaction is severe, the victim may suffer from headache, fever, chills, weakness, vomiting, itchy eyes, and burning on urination, and should be treated with oral prednisone as if he suffered from poison oak. Topical calamine lotion with 1% menthol may be soothing.

Prevention is obviously quite important. If you are able to obtain the product, cover exposed skin areas with Safe Sea. This includes at least a few inches underneath the cuffs of wet suits or Lycra-type "stinger suits" that are equipped with elastic cuffs at the wrists and ankles, and sometimes around the neck. If you only wear a normal bathing suit, which does not have tight cuffs, the tiny creatures can easily wash onto your skin underneath the suit, where they can wreak havoc. So, if you are concerned about the possibility of seabather's eruption, you must also apply the Safe Sea underneath your bathing suit. If there are "thimbles" (jellyfish) visible in the water, it is best to stay out. If you are swimming in apparently uninfested water and begin to feel a tingling sensation on your skin, then the "swarm" may be moving into your location and you should exit the ocean.

Preview the 25th Anniversary & Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 25-30, 2008.

Hands-Only CPR

Tod Schimelpfenig — Tue, 01 Apr 2008 20:47:00 GMT

I imagine you have heard of or seen the media splash today on “Hands-only” CPR.   It’s not an April’s Fools Joke.   It stems from a press release by the American Heart Association (AHA) yesterday (Mar 31) that in turn reflects the position of their Emergency Cardiovascular Care (ECC) Committee.   You can read the complete scientific article on this in Circulation at http://circ.ahajournals.org.

While this shocks some folks like a runaway defibrillator, if you follow the research trends on CPR it’s not a surprise. The science for some time has questioned the value of rescue breathing (mouth to mouth/mask) for people who don’t suffer cardiac arrest secondary to hypoxia. In 2005, the AHA almost took this step, but instead wrote “Laypersons should be encouraged to do compression-only CPR if they are unable or unwilling to provide rescue breaths, although the best method of CPR is still compressions coordinated with ventilations.”   In addition, the AHA Guidelines have recommended compression only CPR for dispatcher-assisted instructions for untrained bystanders.

This new change was supported by evidence published from several recent large studies, which looked at hundreds of incidents of bystander CPR on cardiac arrest victims. None of the studies demonstrated a negative impact on survival when ventilations were omitted from the bystanders’ actions.

The AHA states that Hands-Only CPR should not be used for infants or children (who tend to have cardiac arrests secondary to hypoxia), for adults whose cardiac arrest is from respiratory causes (like drug overdose or drowning), or for an un-witnessed cardiac arrest (where ventilations may benefit the victim who has not been breathing for several minutes).

Hands-only CPR is designed for a witnessed collapse on an adult when there is immediate access to an EMS system. The two key points in the training are 1) Call 911 and 2) start compressions (hard, fast, uninterrupted).

The AHA ECC committee isn’t recommending abandoning ventilations and compressions. They ideally want people prepared to manage all types of cardiac arrests.   The recommendation and press release is accompanied by a “Call to Action”.   The AHA is addressing the low rate of bystander CPR, which may be due to fear of disease from rescue breathing and fear of performing CPR incorrectly.

WMI doesn’t plan to change our CPR curriculum. We will describe this technique and it's rationale for our students. Hypoxia is a possible cause of cardiac arrests in the wilderness (drowning, avalanche burial). As well, wilderness CPR does not have access to 911 and AED’s, and rescue breathing is an important adjunct to chest compressions.   For our context, ventilation and compressions are an important skill.