Wilderness Medicine

Wilderness First Aid Scope of Practice Update

Tod Schimelpfenig — Fri, 12 Mar 2010 21:08:00 GMT

Folks

This is an update on the wilderness first aid scope of practice process and documents.

Our group of colleagues have been working steadily on these documents.We have circulated several drafts of the Wilderness First Aid (WFA) Scope of Practice document, considered the feedback we have received and are close to a final draft. We’ve also been working on a Wilderness First Responder Scope (WFR) of Practice document and have a solid working draft which the providers are reviewing.We hope to post this for review later this spring.

One of the challenges we face is balancing the needs of a large spectrum of students, from outdoor trip leaders to camp staff and non-institutional outdoor recreationists, with the length of the course and our ability to deliver the material effectively. A WFA is a basic and introductory course in wilderness medicine, yet we’ve been asked to teach GPS and survival skills, detailed emergency plans, improvised litters, and a wide variety of medical topics. The elder hostel argues for cardiac curriculum, the therapeutic program for mental health curriculum, the ocean-based program for marine toxins, the high latitude program for more on cold injury. Folks up north don’t want to hear about heat illness and folks down south don’t want to hear about frostbite.

Choices must be made. As we develop each SOP document, we consider the available medical evidence, input from a variety of sources including practitioners, educators, and consumers, and our collective experience as guides, trip leaders, medical providers and professional medical educators.

We have had many collegial and interesting discussions on what should or should not be included in the scope of practice of a WFA .It is easy to reach consensus on the majority of the content. We spend most of our time on the question of what should be core and what can be an elective skill or topic. There is a need to balance a clear minimum standard for this credential while providing some flexibility to meet individual program needs.

I’m excited that the Wilderness Medical Society (WMS) will consider publishing the scope of practice documents in a consensus position statement on wilderness medicine courses for laypeople. The WMS is writing a series of position statements on important issues in wilderness medicine. The first consensus statement, on altitude illness, will be published in the next edition of the Wilderness and Environmental Medicine Journal. A statement on frostbite treatment is also being developed. Tony Islas MD, incoming WMS President, has offered the WMS as a place to support periodic, perhaps annual or biannual, gatherings of wilderness medicine providers to discuss common issues and revise these documents as needed. I think this is an excellent forum for us to publish our work and continue our conversations. The consensus position statement brings the weight of the society to bear on this question, and it's very appropriate.

A copy of the most current WFA SOP is attached (see the attachment link below). We are still open to comments.

Take Care,

Tod Schimelpfenig
Curriculum Director
Wilderness Medicine Institute of NOLS

Tick-Borne Illness

Paul Auerbach — Sat, 06 Mar 2010 22:02:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

This is the next post based upon a presentation given at the Wilderness Medical Society Annual Meeting held in Snowmass, Colorado from July 24-29, 2009. The presentation was entitled “Lessons Re-learned: The US Army’s Experience with Tick –Borne Illness.” It was delivered by John Westhoff, MD, who is a Fellow of the American College of Emergency Physicians.

Dr. Westhoff made a number of great points, in a session that mentioned Rocky Mountain spotted fever, ehrlichiosis, Lyme disease, tularemia, Q fever, and southern tick-associated rash illness (STARI).

A case presentation format was used to highlight the varied way and severity in which some of these disorders can present to clinicians. For instance, a case was described in which the victim was a 49 year old with a 24 hour history of headache and chills, mildly elevated blood pressure – pulse – respirations – temperature – white blood cell count, and was initially given the diagnosis of sinusitis. One day later, the patient was seen with persistent problems, and informed of a working diagnosis of viral syndrome. Three days later, the patient had developed subjective numbness in the hands and feet, and still had a progressive low grade fever, but the white blood cell count had dropped to normal. The working diagnosis was still viral syndrome. On the fourth visit, the victim underwent a spinal tap (lumbar puncture) and was admitted to the hospital. A skin rash developed and blood testing revealed that the patient suffered from ehrlichiosis, from which there was a full recovery.

Ehrlichiosis can be severe. Dr. Westhoff described another case, in which a young man who initially presented with fever and chills and not much more deteriorated over three days sufficiently to be admitted to the hospital, and died after 8 days in the hospital, again with a diagnosis of ehrlichiosis. During his illness, he suffered from skin rash, muscle pain, high fever, infiltrates (consistent with pneumonia) in his lungs, low blood counts, and severe systemic infection with multi-organ failure. Ticks were found in his groin.

Human ehrlichiosis (there is also a canine form) is present in two forms, one caused by a rickettsial organism known as Ehrlichia chaffeensis, which is spread by Amblyomma americanum tick bites, and the other caused by the rickettsial organisms E. phagocytophila and E. equi, spread by Ixodes tick bites. Infection is usually acquired by a person who inhabits a rural environment. The average incubation period after a bite is approximately 7 to 10 days. The victims, who are more commonly middle-aged adults than children and young adults, complain of a flu-like syndrome with high fever, chills, fatigue, headache, muscle aches, vomiting, and a variety of skin rashes, which can be punctate, bumpy, like tiny bruises, or broad and reddened. A victim often has decreased counts of various types of blood cells, as well as liver dysfunction. The treatment is tetracycline 500 mg four times a day, or doxycycline 100 mg twice a day, for 10 days. The few children who have been diagnosed with ehrlichiosis have been treated with doxycycline 3 mg per kg of body weight in two divided doses per day. Untreated or treated after a delay in diagnosis, up to 15% of victims can develop severe infections, kidney failure, bleeding disorders, seizures, and/or coma.

Human anaplasmosis, which was formerly called human granulocytic ehrlichiosis, is caused by infection of white blood cells by a bacterium named Anaplasma phagocytophilum. Like ehrlichiosis, anaplasmosis is disseminated by bites of Ixodes ticks, the blacklegged tick (I. scapularis) in the Northeast and upper Midwest, and the western blacklegged tick (I. pacificus) on the West Coast. Infected persons have the onset of illness 5 to 21 days after a bite with symptoms of fever, headache, fatigue, and muscle aches, which may progress to more serious illness affecting the kidneys, central nervous system, lungs, and blood system. The treatment is the same as for ehrlichiosis.

We also learned about Rocky Mountain spotted fever (RMSF), which is most commonly seen during the months of April to September, when ticks and humans are most frequently in contact. The disease carries an incubation period of 5 to 10 days, and classically presents with fever (flu-like illness), typical rash 2 to 5 days after the fever, and a history of tick bite. Treatment is usually with doxycycline 100 mg by mouth every 12 hours (4 mg/kg/day for persons under the weight of 45 kg) for 10 days. Chloramphenicol is used for pregnant patients.

After a further discussion of features of ehrlichiosis and Lyme disease and brief discussion of tularemia, Q-fever, and STARI, the bulk of the remainder of the session was devoted to the most important topic – namely, prevention of tick-borne illnesses. The key features noted were personal skin inspection to locate and remove ticks, heightened awareness during tick season, use of appropriate insect repellents, such as DEET (33% controlled release lotion), permethrin treatment of clothing, proper wearing of clothing (long sleeves, tucked in shirts and pants), and so forth. It was emphasized that permethrin treatment of clothing is much more effective than is DEET treatment of clothing.

If you decide to apply permethrin spray to clothing, be certain to do the following:

1) Follow manufacturer’s instructions closely. Do not exceed recommended spraying times.
2) Treat clothing only. Do not apply to skin.
3) Apply the permethrin in a well-ventilated outdoor area, protected from the wind.
4) Only spray the permethrin on the outer surface of clothing and shoes.
5) In a concentration of 0.5%, it can be sprayed on both sides of clothing to lightly moisten the outer surface of the clothing item; it is not necessary to have the clothing soaked through (saturated).
6) Be certain to apply completely cover socks, trouser cuffs and shirt cuffs, where insects may attempt to crawl or fly through openings to your skin.
7) Hang treated clothing outdoors and allow to dry for at least 2 to 4 hours in non-humid conditions and for at least 4 hours in humid conditions.
8) Treat clothing no more often than every 2 weeks.
9) Launder treated clothing separately from other clothing at least once before re-treating.
10) Assume that your treated clothing is effective for repellency for 2 weeks or more. Wear it only when you need to repel insects and arthropods. Store it in a separate impermeable (to permethrin) bag when not in use.

Pain Management in Children for Broken Bones

Paul Auerbach — Mon, 08 Feb 2010 04:24:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

Pain management is a hot topic in medicine in general and certainly in medicine for the outdoors. Injuries in particular, and many illnesses, cause pain, which in turn causes the victim to suffer. To a great extent, pain is subjective, but regardless of whether your pain is a "1" or a "10," it can be disabling and even dangerous, particularly if it causes you to be distracted in a situation of risk (e.g., climbing, swimming, walking along a ridgeline).

Broken bones usually hurt a great deal. It's commonly believed that the pain is always of a severity to require the administration of "strong" pain medicine, notably, something containing a narcotic compound. This may not be true. In an article (Annals of Emergency Medicine 2009;54:553-560) entitled "A Randomized Clinical Trial of Ibuprofen Versus Acetaminophen With Codeine for Acute Pediatric Arm Fracture Pain," Amy Drendel, MD and colleagues compared the treatment of pain in children with arm fractures by using ibuprofen in a dose of 10 milligrams per kilogram (2.2 pounds) of body weight versus acetaminophen with codeine in a dose of 1 milligram per kilogram (based on the codeine component of the medication). The children were assessed for three days after discharge from an emergency department. Two hundred forty four patients were analyzed in this study.

The authors concluded that ibuprofen was at least as effective as acetaminophen with codeine for children ages 4 to 18 years with arm fractures treated as outpatients. What is also very interesting is that the children receiving ibuprofen had significantly fewer adverse effects, and both the children and their parents were more satisfied with ibuprofen. The proportion of children who had any function (play, sleep, eating, school) affected by pain was significantly lower for the ibuprofen group.

What to make of all this? The known side medication side effects measured were nausea, vomiting, drowsiness, dizziness, and constipation. Ibuprofen appears to be clearly superior in this study population. This is an eye opener for me, because I am a bit surprised (and now enlightened) by the data. I would have expected these broken bones to require more potent pain medication (e.g., a narcotic), but I see that this is not necessarily the case. In the future, I will recommend ibuprofen (if there is no contraindication) as an initial medication for many more types of pain situations, and wait to see if a more potent "rescue drug" is necessary only as needed, rather than as first choice. If remaining alert and fully functional in an outdoor setting is a priority, this makes double sense.

Proper Hydration at High Altitude

Paul Auerbach — Mon, 01 Feb 2010 02:19:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

The standard dictum when advising persons who travel to high altitude, and thus expose themselves to a lower atmospheric oxygen concentration, is to stay "well hydrated," which translates into drinking sufficient liquid that they urinate frequently, with urine color being light (not concentrated). However, this recommendation has heretofore never been based on science, just on presumption and medical common sense. So, it is with great interest that I read an article in the current issue of Wilderness & Environmental Medicine, entitled "Hydration and the Physiological Responses to Acute Normobaric Hypoxia," authored by Alan Richardson, Peter Watt and Neil Maxwell (Wilderness & Environmental Medicine 20, 212-220 (2009).

The objective of the study was to identify how hydration status, above and below normal hydration levels, affects physiological responses and onset of acute mountain sickness (AMS) symptoms during acute normobaric (normal atmospheric pressure - equivalent to that at sea level) hypoxia (lowered concentration of oxygen in the air). In this study, eight males subjects completed intermittent walking tests in the condition noted after controlled normal hydration (euhydration), hyperhydration (too much water) and hypohydration (dehydration - too little water) protocols. During the measurement period of approximately 2 hours' exposure, heart rate, core body temperature, peripheral arterial blood oxygen saturation, urine osmolality (a measure of concentration and thus the state of hydration), and self-reported AMS scores were obtained.

The observations and analysis showed that the different states of hydration had a significant effect on all of these parameters, and that hydration state above (hyper-) and below (hypo-) normal hydration had detrimental consequences on physiological strain and onset of acute mountain sickness symptoms under the conditions studied.

This is very important work, and will undoubtedly spur further investigation. We are fairly familiar with the concept of hypohydration, which leads to dehydration and all of its deleterious effects upon performance and body functions. However, in the setting of high altitude, we are less familiar with hyperhydration (too much water), because we don't encounter it very often, unless it is induced by a doctor- or rescuer-led intervention. We suspect that fluid retention in general, when it occurs for whatever reason, may contribute to the accumulation of fluid in the brain (AMS) or perhaps even the lungs (high altitude pulmonary edema), but this has never been proven. The worsening of headache in this study (as a presumptive symptom of AMS and perhaps harbinger of fluid accumulation in the brain) in the hyperhydration group is a bold word of caution to us to attempt to achieve normal hydration, and nothing more, with our fluid replacement strategies. How best to do this? At the current time, the best we have in the field is maintaining urine color, specific gravity and/or osmolality (signs of urine concentration and thus state of hydration) at preferred values. However, with the advent of technologies such as that offered by Cantimer, we may soon have other methods by which to guide fluid administration, as thirst in and of itself is notoriously not sufficiently precise for this purpose.

SAM Splint versus Philadelphia Collar

Paul Auerbach — Mon, 25 Jan 2010 01:41:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

In an issue of Wilderness and Environmental Medicine (Volume 20, Number 2, 2009), Todd McGrath and Crystal Murphy have written an article entitled “Comparison of a SAM Splint-Molded Cervical Collar with a Philadelphia Collar.” The objective of this study was to compare the effectiveness of a SAM Splint molded into a cervical collar with that of a Philadelphia collar (commonly used by paramedics and others to hold a neck motionless during transport after an accident) at limiting movement of the cervical spine (neck) in a variety of common predicted directions of motion.

Healthy volunteers participated in the study. A goniometer was used to measure degrees of maximal extension (bending the neck backwards) and lateral motion (left and right) with each type of collar. After data analysis, it was concluded that the results of this study suggest that the SAM Splint, when molded into a cervical collar, is as effective as the Philadelphia collar at limiting movement of the cervical spine.

This is good news for rescuers, backpackers, athletic medical responders and others who have occasion to splint an injured or potentially injured neck in the field. I have used SAM Splints to fashion cervical collars for many years, because my observations were that it could be quickly configured into a reliable and functional splint for this purpose, so it is nice to have my suspicions confirmed. There is certainly nothing wrong with using a (preferably, lightweight) Philadelphia collar or other similar pre-molded appliance to maintain a neck motionless when necessary. The general considerations will be space, weight, ease of use, and adaptability to a variety of patient sizes and conditions. Furthermore, it cannot be overemphasized that if you wish to use a SAM Splint or any other rescue product in the outdoors for which operator skill and experience are required, you should take the time to practice beforehand in a controlled and non-frenetic environment.

Frozen Autoinjectors and Armpits

Tod Schimelpfenig — Sun, 17 Jan 2010 22:05:00 GMT

I recently exchanged emails with a fellow who asked if it was acceptable to freeze the auto-injector in his first aid kit. I told him of course not, you may not have time to thaw the medication. Now curious, I intentionally froze four expired EpiPens® on a minus 22ºF night and timed how long it took to thaw the auto-injectors in my armpit.

The first one mechanically fired with a normal amount of pressure while frozen, the needle extended, but no liquid was ejected. When opened the epinephrine was frozen and there were no obvious cracks in the tubex. I then thawed the remaining three EpiPens® in my left armpit (97ºF via our household mercury thermometer).

At 3 minutes I discharged the second EpiPen®, but only a little bit dribbled out of the needle. I opened this EpiPen® and found the epinephrine still frozen.

At 4 minutes I discharged the third EpiPen® and I saw a stream of liquid, but it seemed less than expected. The epinephrine in this unit was partially thawed.

At 5 minutes I discharged the last EpiPen® and observed a decent steam of liquid and upon opening, found the remaining epinephrine liquid.

Likewise I froze an ampule of epinephrine. This was thawed after 3 minutes under my armpit. The ampule was not cracked. Several years ago we did the same test on one of the older “AnaGuard” syringes and it took 5 minutes to thaw completely.

So there you have it, backyard science to support the common sense practice of keeping a liquid emergency medication thawed and ready to use. It makes no sense to tempt fate and hope you can thaw your medication in time. Keep it close to your body in cold weather.

There is a second question here, will frozen and thawed epinephrine work? If it was frozen and thawed, and I needed it, and it was not discolored with precipitates floating around, I'd use it. According to the UIAA Medical Commission, yes, it will be biologically active. However, freeze-thaw is not the best situation and will accelerate the deterioration of the medication. It can also crack the ampule or syringe and affect sterility of the product.

Take care

Tod

Kupper, Th. Milledge, J. Basnyat, B. Hillebrandt, D. Schoffl, V The Effect of Extremes of Temperature on Drugs. Consensus Statement of the UIAA Medical Commission Vol 10 2008

Posterior Cruciate Ligament Injury

Paul Auerbach — Mon, 11 Jan 2010 04:31:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

We're in ski season and so a few unfortunate individuals will suffer few knee injuries. A while back, a reader asked me to describe an uncommon injury, which is a torn posterior cruciate ligament (PCL).

This injury usually occurs during a fall. As you can see from the drawing, the PCL keeps the lower leg bone (tibia) from moving too far back in relation to the upper leg bone (femur). If a sudden unnatural force is applied, usually a direct blow to the front of the lower leg near the knee while the knee is bent, the tibia is jammed backwards and the PCL may be torn. In the skiing situation, this usually happens during a fall and a tumble, when someone strikes an immovable object, or when the knee is bent or "twisted" and struck forcefully from the side.

The immediate sensation is pain, and there may be a feeling of instability to the knee, particularly when trying to walk or change levels (e.g., walk over the snowpack or on stairs). When the injury occurs, there usually is not the "pop" sensation noted with an anterior cruciate ligament tear. However, the knee will almost always swell, because there is bleeding into the knee joint and/or soft tissue swelling.

The diagnosis may be surmised by taking a good history and understanding the mechanism of injury, performing a physical examination to determine what elicits pain and instability (commonly, the "posterior drawer test"), and these days, most often by magnetic resonance imaging (MRI). Sometimes an x-ray is taken prior to the MRI to determine whether or not there is a broken bone, but the x-ray does not show the structure and integrity of the ligaments and cartilage within the knee.

Until you can see your doctor, you should apply ice packs a few times a day for 15 minutes to help diminish pain and swelling, and avoid weight bearing. Use crutches if you have them. A broadly-applied (mid calf to mid thigh) pressure wrap may help diminish pain and increase stability, but take care to not apply it too tightly. If you decide to take pain medication, avoid aspirin-containing products (to diminish bleeding). If you have a knee brace (usually from a previous injury or as a preventative appliance for certain sports, wear it to provide extra stability.

Whether or not you will need surgery depends on the magnitude of the tear and the degree to which you respond to rehabilitation. Small tears are sometimes treated "conservatively" without surgery and can be rehabilitated under the guidance of an experienced physical therapist. If the knee does not improve or if the tear is sufficiently extensive initially, surgery may be recommended to replace the PCL with a graft.

drawing courtesy of www.zimmer.co.nz

Canadian C-Spine Rule

Paul Auerbach — Sun, 13 Dec 2009 19:18:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

Christian Vaillancourt, MD and his colleagues recently published an article in the journal Annals of Emergency Medicine (2009;54:663-671) entitled "The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics." This rule was originally developed for "clinical clearance" (e.g., without the use of x-rays) of persons with possible cervical spine fracture (broken neck) in alert and stable trauma patients by qualified persons (generally, emergency physicians) in a health care setting (such as an emergency department). This particular study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing important cervical spine injuries.

The Rule, properly applied to an awake and alert injured person for which there is a concern for a cervical spine injury, provides the following direction:

1. If a person has a high-risk factor (age greater than or equal to 65 years; a dangerous mechanism of injury [a fall from an elevation greater than or equal to 3 feet; fall down 5 or more stairs; direct blow to top of head, such as a diving board accident; motor vehicle accident characterized by high speed, rollover or passenger ejection; motorized recreational vehicle accident; bicycle collision]; or numbness/tingling in an arm or leg), then neck immobilization and x-rays are indicated.

2. If the victim is not able to actively rotate his or her neck, under their own power and without assistance, 45 degrees to the left and right without causing pain, then neck immobilization and x-rays are indicated. If the victim is completely without pain at rest and on active range of motion of the neck, then it is unlikely that an unstable fracture is present.

3. Low-risk accident factors that allow safe assessment of range of motion of the neck include simple rear-end motor vehicle collision (excludes being pushed into oncoming traffic, being hit by a bus or large truck, rollover, or hit at high speed by a vehicle); person is capable of a sitting position; person is ambulatory (e.g., walking); delayed onset of neck pain; and absence of posterior or anterior pain on examining (e.g., pressing upon) the neck. If the accident is deemed to be low-risk, then the victim is asked to attempt rotation of his or her neck under their own power and without assistance. See number 2 above.

What does this mean for the layperson who is practicing medicine in the outdoors? It provides a very reasonable approach to deciding who might be safely examined and when to apply a cervical spine immobilization technique. The overall goal is to not move someone's neck if he or she might have an unstable fracture, where movement could jeopardize the integrity of the spinal cord. Clinical judgment and intuition serve important roles, because it truly is best to always err on the side of "better safe than sorry." However, if the victim is low risk from all perspectives, it allows the rescuers more comfort in moving the victim or allowing self-extrication from a difficult situation or hostile environment.

Helmets for Active Sports

Paul Auerbach — Mon, 07 Dec 2009 04:51:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

The National Highway Traffic Safety Administration reported an analysis of motorcycle helmet use in fatal crashes. What was discovered is not surprising - namely, that in states in which there is not a state helmet law, the odds of a rider in a single-vehicle (e.g., the motorcycle) crash wearing a helmet was 72% less than in states with a helmet law. So, absent a law, people are not particularly inclined to wear a helmet.

One needs to couple this information with the facts about the benefits of wearing motorcycle helmets. First, motorcyle fatalities and fatality rates are increasing at a time when motorcycle riding is becoming more popular. Second, the average age of motorcycle fatalities has moved up to 39 years, from 30 years nearly 20 years ago, probably because the age of motorcycle riders has increased. Third, motorcycles expose the drivers more directly to lethal forces than do enclosed vehicles. Helmets are essential to prevent brain injuries and deaths.

What are the arguments against wearing helmets? Some argue that motorcycle helmets are heavy and therefore increase neck and spinal cord injuries. The opposite has been shown to be true. Some opponents claim that motorcycle helmets impair the driver's ability to hear and see. These senses have been studied in the context of motorcycle activity and do not appear to be impaired, and in certain circumstances, may be improved. The argument that motorcycle helmets are only effective up to a speed of 15 miles per hour is not entirely true. Many head injuries follow glancing blows, not high speed direct impacts. It is true that a helmet can not be effective against a tremendous blow, but it is better than nothing.

Many argue that there is a freedom of choice issue at play. If you knew that you were going to be struck on the head during a particular ride, would you choose to wear a helmet? Probably, you would. The problem is that no one is able to predict the day or moment of their accident and head injury. Few people believe that anything bad will ever happen to them.

Motorcycle helmets are a surrogate for helmets in all situations of risk in which there is a reasonable likelihood of being struck on the head and injuring the scalp, skull, and/or brain. What are those situations? In the water, it is the kayaker who is at risk for being flipped onto a rock or getting caught in a strainer. Knocked unconscious in the water, he is drowned. For the rock climber, it is being struck by falling rocks, swinging into a rock face, or suffering a fall. For the horseback rider, it is coming off the horse. For the motorcycle or ATV rider, or bicyclist, it is crashing and striking one's head. For the skier, it is falling, crashing, or being struck by a ski or snowboard.

One gives up very little (nothing, really) and gains everything by wearing a helmet in the appropriate circumstances. Freedom of choice is a selfish concept when one considers that the head-injured victim forces loved ones or society to provide care and the financial resources to manage the injury and rehabilitation, and sadly, support for the disabled person, who might have avoided most of the injury by wearing a helmet.

There is no excuse for not wearing a helmet approved for high risk (for head injury) situations. It is no different than wearing a seat belt in a car or washing your hands before you eat. Prevention is the name of the game. Having cared for many people with devastating head injuries, most of which would have been trivial or absent if a helmet had been worn, I can only hope that we do what it takes to mandate helmet use in every reasonable situation for which they would be of benefit. That is a necessary and appropriate use of the law.

Helmets & Snowsports

In the most recent issue of the journal Wilderness & Environmental Medicine, published by the Wilderness Medical Society, there is an article entitled "Skiing and Snowboarding Head Injuries in 2 Areas of the United States," authored by Mark Greve, MD and colleagues (Wilderness and Environmental Medicine 10:234-238, 2009). The objective of their research was to explore the use of helmets in skiers and snowboarders injured at ski runs and terrain parks in Colorado and the northeast U.S. and to examine differences in head injury severity in terrain parks as compared to ski runs. The study was done by reviewing emergency department records of injured skiers at nine medical facilities in Colorado, New York and Vermont. Eligible patients were skiers and snowboarders who sustained a head injury.

Most of the injuries occurred when the victim hit her or her head on the snow; fewer occurred when the skiers or boarders were involved in collisions with other skiers or fixed objects. Only 37.1% of the victims were wearing helmets. There were significantly fewer instances of loss of consciousness in fall events in the Colorado group; significantly lower incidence of loss of consciousness in fall events in helmet users who struck fixed objects; and a higher incidence of skiers colliding with fixed objects in the Northeast. Even when controlling for helmet use, there were significantly more head injuries in terrain parks.

What does this all mean? Obviously, the study sample is small, but the big takeaway for me is that helmet use makes sense. Why are there more injuries in terrain parks? Perhaps this represents the mechanics of falls when snowboarding, as opposed to skiing, or perhaps it indicates a higher degree of risk (for a head injury) with this sport, either because of the mechanics, degree of risk (e.g., aerial maneuvers, jumps, etc.), speed for the terrain, or propensity to hit a fixed object. It seems like helmet use is a very logical, and perhaps even necessary, way to prevent head injuries, certainly while snowboarding, and probably while skiing.

Wilderness Emergency Medical Services

Paul Auerbach — Sun, 29 Nov 2009 03:40:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

I am frequently asked to write articles for magazines, chapters for textbooks, and commentaries for journals. Almost always, these are published, but sometimes a publishing project will fall through. Such is the case with a book entitled "Prehospital Care - Pearls and Pitfalls," edited by two longstanding emergency physician friends. Since their book is not going to be published, they have given me permission to use my contribution as I see fit in other venues, so please allow me to make the readers of this blog the beneficiaries. With a big thanks to my co-author, Dr. Laurie Kates, here goes:

WILDERNESS EMERGENCY MEDICAL SERVICES

1. What is wilderness medicine?

According to the Wilderness Medical Society (WMS): “Wilderness medicine focuses on medical problems and treatment in remote areas. It includes aspects of physiology, clinical medicine, preventive medicine, and public health.” For the purpose of emergency medical services (EMS) personnel, there are four qualities that define wilderness medicine:

• An austere environment
• Prolonged time to definitive care requiring modifications to traditional pre-hospital protocols
• Integration of rescue and medical skills
• Environmental threats

2. What is the difference between wilderness EMS and urban EMS?

Rapid response, stabilization and transfer to an advanced care facility comprise the focus of traditional urban EMS training systems. The physical remoteness, environmental exposure, challenging geography and often extended periods of time required for a rescue and stabilization require special training and define wilderness EMS. Traditionally, urban EMS is reactive and protocol driven, whereas wilderness EMS requires improvisation, innovation and extended protocols. In urban EMS, patient extrication is typically the responsibility of Fire Department personnel,who hand off patients to EMS providers, who begin providing medical care. In wilderness EMS, patient extrication is often technically difficult and time-intensive, requiring simultaneous administration of medical care by providers skilled in both medical and rescue skills.

3. How are wilderness emergency medical technicians (WEMTs) different from regular EMTs?

The Department of Transportation (DOT) is responsible for creating EMT curricula. The National Registry of Emergency Medical Technicians was inaugurated in 1970 to serve as a national certifying body for EMTs. Standardized tests are used to certify and recertify EMTs at the state level or into the National Registry of EMTs. There is no national standard or formal certification exam for WEMT designation. The WEMT curriculum is based on the DOT EMT curriculum and establishes an approach to emergency care in wilderness settings and is based on the recommendations of the Wilderness Medical Society, the Wilderness EMS Institute (WEMSI), the National Association of Search and Rescue (NASAR), the National Ski Patrol, the National Outdoor Leadership School (NOLS) and several other groups. Typically, a WEMT course includes 45-100 hours of classroom didactic time, 10 hours of emergency department time, and an additional 48 to 80 hours of clinical training as opposed to non-wilderness EMT courses, which require approximately 120 hours of classroom and ambulance ride-along time. WEMT courses include a minimum of 22 hours of training on medical conditions related to environmental conditions. In contrast, the typical EMT course includes only 3-10 hours addressing environmental emergencies. Other unique aspects of the WEMT curriculum include added training on extended patient care, rescue techniques, special equipment, and in providing care for injuries unique to the remote outdoors.

4. What procedures can be performed by WEMTs?

The procedures performed by a WEMT are determined by both the state protocols under which a WEMT practices, as well as his or her level of training. As there is no national standard for WEMT training, different states and health care systems have a variety of policies regarding what health care providers may and may not do given their levels of training. It is the responsibility of all health care providers to know the standard of care for their level of training, what procedures may be performed, and the protocols and policies of their system. Key elements in WEMT training include technical skills and authority, depending on the system in which they are working, to perform the following:

•Airway management, including endotracheal intubation.
•Needle thoracostomy for tension pneumothoraces
•Shock management, including intravenous therapy
•Use of military antishock trousers (MAST), although this is experiencing decreased use and popularity.
•Oxygen administration.
•Medication administration, including epinephrine for allergic reactions; antibiotics for certain circumstances; acetazolamide, nifedipine, and furosemide for altitude sickness; and pain medications for injuries.
•Field rewarming techniques.
•Field reduction and splinting of fractures and dislocations.

5. What employment opportunities and experiences are available for WEMTs?

Wilderness EMT skills are useful for anyone who spends a substantial amount of time in wilderness areas, but can also open new opportunities for employment. Some possibilities include:

• National and state park ranger, such as the ParkMedic program in Yosemite National Park
• Adventure travel
• Search and rescue
• Forest Service worker
• Disaster medicine/relief work
• Work in rural/wilderness areas
• Military

6. Are standards for wilderness (e.g., mountain, water) rescue teams different around the world?

Wilderness rescue teams vary tremendously around the world. In the United States, most teams are volunteer, with a wide range of qualifications and skills from first aid to paramedic, and are under the jurisdication of national parks, state parks, or county sheriffs. In Canada, mountain rescue teams are coordinated by the military. In Europe, most teams are staffed with full-time physicians and paramedics. In many of the most remote areas of the world, there is no organized system of wilderness emergency care, so travelers and expeditions are required to be self-sufficient.

7. What questions must be answered when assembling a team for a rescue?

Wilderness rescue requires coordinated and thorough preparation with consideration to the following:

ENVIRONMENT/GEOGRAPHY

•What time of day is it and will it be? (Are you prepared for a night rescue?)
•What are the anticipated weather (environmental) conditions, and are you prepared for them?
•Is a helicopter, boat, or other specialized rescue vehicle(s) needed or available?
•Is the weather acceptable for air rescue?

VICTIMS

•How long ago did the accident occur?
•What is the number of victims?
•What are their injuries?
•How many people are in the victim’s party?
•How well prepared are they?
•Does anyone in the party have medical experience or training?

RESCUE PERSONNEL

•Do you have a location, or is this a search and rescue?
•Is a “hasty” team (a smaller, less equipped team sent ahead to provide initial care or to search and rescue while the main team prepares and follows) needed? If so, has it been deployed yet?
•Are all team members prepared?

ARE THE RESCUERS AT SIGNIFICANT RISK?

•Are all team members trained for this type of rescue?
•Who is on the medical team?
•Who is on the evacuation team? Is the number of team members adequate? (For instance, 16 to 20 litter carriers are typically necessary for a ground evacuation of 1 to 3 miles over level terrain).
•Is the team equipment organized and divided up adequately?
•How urgent is the situation?
•Will multiple agencies be involved?
•Are communications coordinated between the different agencies?

8. Who is responsible for search and rescue?

•Search and rescue (SAR) is the responsibility of national and state parks, sheriffs, state conservation offices, or other government agencies, depending on the location and jurisdiction. National and state parks do not have a “duty to rescue.” In addition, there is sometimes significant controversy about when rescue missions should be attempted and who should pay for them. The prevailing opinion is that a call for help cannot ethically be dismissed.

•As mentioned in question 4, most rescues are done by volunteer groups.
•90% of mountain rescues are done by foot.
•95% of rescues are performed without physicians present.
•Only Yosemite and Grand Teton National Parks use helicopters extensively.
•Only Denali National Park uses fixed-wing aircraft extensively and helicopters occasionally.
•Only Yosemite, Grand Teton, and Mount Rainier National Parks have rangers specifically trained in technical rescues, advanced medical care, and helicopter operations.
•Many backcountry and climbing areas are outside parks. Rescues in these areas are by local fire and rescue departments, with or without the benefit of special training or technical skills.

9. What special knowledge is needed for searches and rescues (e.g., mountain, high angle, cave, ocean)?

•Understanding equipment (ropes, slings, carabiners, harnesses, helmets, litters, litter harnesses, haul systems, personal flotation devices, throw rings and bags, and litter patient packaging equipment) used in SAR operations, including their maintenance and care.
•Basic radio communication and signaling.
•Basic helicopter and fixed wing operation and procedures.
•Understanding search and rescue procedures.
•Knowledge of the Incident Command System and its use in SAR.
•Basic rope handling and knot tying skills.
•Advanced skills as needed for specific circumstances, including water SAR, white-water rescue, avalanche SAR, technical or vertical (rock) techniques, or cave training.
•Interpersonal skills and the ability to deal with field death and inform family and friends of deaths.

10. What are some examples of scenarios likely to require “extended” rescue and emergency care?

Mountain, wilderness, rural, white-water, air-sea, cave, and avalanche rescue, as well as expedition and disaster medicine and most search and rescue missions. The terms “extended rescue” and “extended emergency care” refer to medical care and rescue efforts beyond the first, or “golden,” hour.

11. What government agencies are responsible for search and rescue?

Federal SAR activities are either under the supervision of the United States Air Force (for inland regions), Aerospace Rescue and Recovery Service (responsible for federal aircraft incidents) or the United States Coast Guard (supervises coastal regions and all maritime and ocean searches). At the state level, there is significant variety in SAR supervision, because it is often under the jurisdiction of law enforcement agencies. All states have legislation that provides support to local governments during emergencies. During a nationally declared disaster, the Federal Emergency Management Agency (FEMA) assumes responsibility for SAR activities. The Department of Health and Human Services runs the National Disaster Management System (NDMS), which develops Disaster Medical Assistance Teams (DMAT) that can be rapidly deployed to nationally declared disaster areas.

12. What are the four phases of SAR?

•Locate.
•Access.
•Stabilize.
•Transport.

13. How many SAR missions occur each year in the United States?

Specific numbers are not reported. It is estimated that more than 100,000 SAR missions occur annually.

14. What are factors that may cause someone to need to be rescued (and therefore, to require the services of a WEMT)?

Any one, or a combination, of the following, may produce a situation that results in the need to be rescued, stabilized, and treated.

•Improper clothing or footgear.
•Fatigue.
•Dehydration.
•Hypo- or hyperthermia.
•Overextension of abilities.
•Lack of physical conditioning.
•Inadequate food.
•Inadequate planning.
•Inadequate leadership.
•Itinerary confusion.
•Inadequate recognition of environmental, physical, or mental factors.
•Inadequate preparation for weather conditions.
•Lack of navigational proficiency (getting lost).
•“Invincible” mind-set.
•Bad luck resulting in injury, illness, or exposure to an adverse environmental condition or event.

15. Is an EMS provider on a trip liable for care rendered during that trip?

The question is, “Is the provider acting as a designated health care provider, or is the provider merely a person on the trip who happens to be an EMS provider?” If the provider is the latter, then he or she is not duty bound to assist others in need. If he chooses to help, he is not invariably protected from liability by a Good Samaritan Law. While a Good Samaritan Law provides protection for medical personnel assisting within the scope of their skills, voluntarily, at an emergency scene, it is important to note that the provider is held to the full capabilities commensurate with his training. If an EMS provider is acting as the trip medical support, then he is liable to provide care at the accepted standard of care. In addition, because EMTs and almost all EMS providers act under a physician’s license, the doctor under whom the EMT is working is also liable for his or her actions.

16. What are some unique ethical dilemmas associated with wilderness EMS?

•How much risk will you accept for yourself and your team when planning SAR (e.g., going out in a snowstorm looking for a child) and treating victims in the wilderness?
•If a rescuer becomes injured, who will you treat first? The original victim or the rescuer?
•If a limited amount of supplies is available, who gets treated?
•How will the care affect others in the group (e.g., leaving scuba divers in the water in order to deliver a diver with decompression sickness to a hyperbaric chamber)?
•In a remote and prolonged care situation, how do the relationships of people in the group affect their choices for care and decisions regarding the group?

More so than in urban situations, a serious emergency in a wilderness area stresses many unique aspects of relationships and decision-making capabilities. From a survivalist point of view, it is necessary to take care of rescuers and teammates before caring for victims. Many potential circumstances can influence this decision. So, one must think about potential circumstances in advance and plan appropriate ways to incorporate a productive reaction to insure the survival and optimal outcome for rescuers, the team, and patients.

17. Where can I get more information about wilderness medicine and wilderness EMS?

WILDERNESS MEDICINE ORGANIZATIONS

•The Wilderness Medical Society, P.O. Box 2463, Indianapolis, IN 46206; (317) 631-1745
•The International Society of Mountain Medicine
•The International Society of Travel Medicine
•The Divers Alert Network

SEARCH AND RESCUE ORGANIZATIONS

•The Mountain Rescue Association
•The National Association for Search and Rescue
•The National Ski Patrol
WILDERNESS EMT TRAINING PROGRAMS

•The Wilderness Emergency Medical Services Institute
•The National Outdoor Leadership School, Wilderness Medicine Institute

There are many companies and colleges that offer WEMT courses. Check in your region for programs near you.

Pearls and Pitfalls

1. Wilderness EMT (WEMT) designation requires specialized training in rescue techniques, use of special equipment, and extended patient care in remote areas.
2. WEMT’s must work very closely with all search and rescue (SAR) personnel to ensure the safety of the patient and all team members.
3. The four phases of SAR are locate, access, stabilize and transport.
4. A unique ethical dilemma for the WEMT is how much personal risk is acceptable to accomplish the rescue.

BIBLIOGRAPHY

1. Auerbach PS (editor). Wilderness Medicine, 5th ed. Philadelphia, Mosby Elsevier, 2007.
1. Cooper DC, LaValla PH, Stoffel RC: Search and rescue. In Auerbach PS (ed): Wilderness Medicine, 5th ed. Philadelphia, Mosby Elsevier 2007, p. 708.
2. Langer CS: Medical liability and wilderness emergencies. In Auerbach PS (ed): Wilderness Medicine5th ed. Philadelphia, Mosby Elsevier 2007, p 2163.
3. Hubbell FR: Wilderness emergency medical and response systems. In Auerbach PS (ed): Wilderness Medicine 5th ed. Philadelphia, Mosby Elsevier 2007, p 694.
4. Iserson KV: Ethics of wilderness medicine. In Auerbach PS (ed): Wilderness Medicine 5th ed. Philadelphia, Mosby Elsevier 2007, p 2170.
5. Johnson, L. An introduction to mountain search and rescue. Emerg Med Clin N Am 22 (2004): p. 511
6. Klainer PH: Prehospital emergency medical services. In Harwood-Nuss AL, Linden CH, Luten RC, et al (eds): The Clinical Practice of Emergency Medicine, 2nd ed. Philadelphia, Lippincott-Raven, 1996, p. 1517
7. Russell, M.F. Wilderness emergency medical services systems. Emerg Med Clin N Am 22 (2004): p. 561
8. Sholl, JM and E.P. Curcio. An Introduction to wilderness medicine. Emerg Med Clin N Am 22 (2004): p. 265

photo courtesy National Outdoor Leadership School (NOLS)

Evidence-Based Management of Wilderness Injuries

Paul Auerbach — Mon, 23 Nov 2009 00:47:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

This is the next post based upon a presentation given at the Wilderness Medical Society Annual Meeting held in Snowmass, Colorado from July 24-29, 2009. The presentation was entitled “Evidence-based Management of Wilderness Trauma with Case Studies from Vermont Search & Rescue.” It was delivered by Tim Burdick, MD, who is a Fellow of the Academy of Wilderness Medicine, Assistant Professor of Family Medicine at the University of Vermont College of Medicine, Medical Officer for Stowe Mountain Rescue, and Medical Team Manager for FEMA Urban Search & Rescue Massachusetts Tasks Force 1.

There are clinical decision rules (or “tools”) used by physicians in order to control the number of tests (such as x-rays) they use to determine whether or not patients have specific injuries. The purpose of such rules is to avoid unnecessary testing, which can add to undesirable consequences, such as additional expense and radiation exposure. In the wilderness, the purpose of decision rules is to determine the likelihood of diagnosis, who might need an evacuation, and when it is advisable to continue or discontinue a trip.

Dr. Burdick noted that there are evidence-based clinical tools for ankle and midfoot fractures, cervical spine (neck) fractures, shoulder dislocations, and detection of fractures (broken bones) using a tuning fork.

The Ottawa ankle decision rules for the use of x-rays to determine the presence or absence of an ankle fracture were determined in patients who had mostly twisted their ankles, rather than fallen. According to these rules, an ankle fracture might exist if (1) the patient complains of pain near either malleolus AND (2) can’t bear weight for a distance of four steps OR suffers bony tenderness (when you press) in either malleolus. As it turns out, the test has a positive predictive value (e.g., when the test is positive the patient has a fracture) of 17% and a negative predictive value (e.g., when the test is negative the patient does not have a fracture) of virtually 100%.

There is something similar for neck fractures. For a blunt injury (e.g., not a stab wound, or “penetrating” injury), here are a set of criteria for which a patient should be evaluated:

1. Patient is alert and reliable
2. Patient is not intoxicated
3. There is no painful, distracting (from the examination) injury (such as a broken leg)
4. There is no focal abnormal neurological finding (such as weakness in the grip strength of a hand, or abnormal deep tendon reflex)
5. There is no midline cervical spine (neck) tenderness when the neck is examined

If all of these conditions were met by a good examination, then according to the medical literature, then only 2 out of 4307 persons initially complaining of neck pain turned out to have a broken neck.

What about dislocated shoulders? The usual admonition against attempting to reduce a shoulder dislocation prior to obtaining x-rays is to avoid tugging on a broken arm, in the event that a fracture-dislocation is present. It appears that there is a greater risk of fracture-dislocation if the victim’s age is less than 40 years and the mechanism involves “substantial force” (e.g., motor vehicle accident, assault, sports injury, or a fall from a distance greater than the victim’s personal height); or in a victim age 40 years or greater, if there is bruising around the humerus (long “upper” bone of the arm) or if the dislocation is the first for the victim. However, given all of this, it is still not clear that attempting the relocation of a dislocated shoulder that happens to be associated with an undetected fracture of the humerus is a big problem, unless one applies extreme force in the attempt and significantly worsens the break. Certainly, putting a shoulder back in place and allowing the victim greater mobility, reducing pain, and perhaps creating a situation that enables self-extrication can be extremely important.

Can someone use a tuning fork to diagnose a longbone fracture? The concept is that sound is conducted through intact bone and joints better than through broken bone. The technique is to place a vibrating tuning fork of a bony prominence beyond (distal to) the suspected fracture and then to listen with a stethoscope over a bony prominence in front of (proximal to) the suspected fracture. Sound conduction is compared between identical exams of the injured and contralateral (uninjured) limb. Decreased conduction (appreciation of sound transmittance) would indicate a possible fracure. One brief analysis of this concept in 1987, utilizing a 128 hertz tuning fork and stethoscope, indicated that it might be useful, improving the detection of fractures by a few percentage points.

Wilderness First Aid Scope of Practice

Tod Schimelpfenig — Fri, 30 Oct 2009 19:13:00 GMT

The concept of consistency in the content of Wilderness First Aid (WFA) and Wilderness First Responder (WFR) programs is receiving much attention. Some folks seem to think there is chaos among the various providers with people teaching widely varying practices. I’m not so sure this is the case.

I’ve been talking with David Johnson MD of Wilderness Medical Associates for several years on this question of curriculum consistency. We decided last winter that it was time to move forward on this question and to approach this project by first defining the Scope of Practice (SOP) for WFA and WFR. Scope of Practice is medical jargon for a job description, a statement about what a WFA or WFR should be able to do, and not do. This seems a logical place to start.

We do not feel it is our place to dictate standards to the industry. Rather, we’ve drafted a document with input from peer groups including Aerie, SOLO, Wilderness Medicine Training Center, Wilderness Medicine Outfitters, Landmark Learning and Desert Mountain Medicine. Together we’ve trained over 150,000 WFA students since 2000.

Most of this was straightforward and it was easy to reach agreement. The challenging issues revolve around the total amount of content we think can reasonably fit in a 16 hour program without eroding overall skill retention, and questions on what skills and decisions are appropriate for a WFA.

The attachment below (pdf) is the consensus document, posted to allow a wider audience a chance for input.

Our next step will be to send it to the Wilderness Medical Society’s Education committee for their consideration as part of their charge to develop standard WFA and WFR curriculum.

As you can see, we agree it is time to take another step toward consistency in the WFA and WFR programs, so the consumer, often an outdoor program hiring a trip leader, knows what a credential implies. If you work in outdoor programs and want to participate please send your comments to Dr. Johnson and myself.

Heat-related Illnesses

Paul Auerbach — Mon, 12 Oct 2009 01:43:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

This is the next post based upon a presentation given at the Wilderness Medical Society Annual Meeting held in Snowmass, Colorado from July 24-29, 2009. The presentation was entitled “Heat Related Illnesses.” It was delivered by Flavio Gaudio, M.D. from Weill Medical College of Cornell University. Dr. Gaudio is a very enthusiastic and articulate physician with great expertise in wilderness medicine.

Dr. Gaudio covered the topics of thermoregulation and heat dissipation, acute heat stress and acclimatization, impaired thermoregulation, and specific heat related illnesses. Thermoregulation for humans is essentially the balance of heat load (generation or external source addition) with heat loss. The act of being alive (basal metabolism) at rest generates about 75 kilocalories of energy per hour, which undissipated would create a human temperature rise of approximately 1 degree Celsius (approximately 9/5 degrees Fahrenheit) per hour. The optimal temperature for human metabolism is between 36 and 37.5 degrees C (96 and 99 degrees F).

Humans shed heat by radiation, evaporation, conduction, convection and respiration. For radiation to be maximally effective, blood flow to the skin must increase. When this occurs, there is a compensatory decrease in blood flow to certain internal organs. Convective heat loss in humans occurs by sweating, which requires evaporation to be effective. Therefore, sweating becomes ineffective with high relative humidity (greater than 75%). The scalp, face and torso have more sweat glands than do the lower limbs. A very important fact is that a limiting factor for evaporation as a cooling mechanism for humans is the gastrointestinal tract, which can only absorb about a liter per hour of liquid. Taking your shirt off to allow sweat to evaporate is generally a good thing, with the following possible exceptions: (1) in strong sunlight, (2) in the absence of any cooling breeze when there is a high solar load (of heat) and (3) if skin is highly pigmented, and would therefore absorb more heat than non-pigmented skin.

Hats should be worn to reduce solar load, but be aware that they may decrease evaporative cooling. So, wear your lightweight hat in the hot sun, but remove it when you are in the shade or if there is a brisk breeze to promote evaporation. And you are sweating.

Acclimatization to heat generally occurs over 1 to 2 weeks, but may take longer, particularly if exposure is intermittent and inadequate for the purpose. Among many changes, it is interesting to note that acclimatized sweat glands have increased sweat capacity and conserve sodium (so the sweat is more dilute).

Pay particular attention to elders and infants, and persons with predisposing medical conditions, such as obesity, kidney disease, diabetes, cystic fibrosis, scleroderma, and Alzheimer’s dementia. Many drugs, both prescription and illicit, may impair heat dissipation.

Fluid replacement strategies for heat cramps, which are generally felt to be caused by water-without-electrolytes replacement, are numerous, but generally center around “sports beverages.” A good natural concoction is ½ liter orange juice combined with ½ liter of water and ½ to 1 teaspoon of table salt. This provides water, fructose, sodium, potassium, chloride, vitamins C and B6, thiamine and folate.

Heat edema (fluid retention and swelling) involves the hands and feet of persons during the first few days of heat exposure. Treatment is rest, elevation of the affected body parts and support hose for the legs and feet. Heat syncope (fainting) is caused by a brief drop in blood pressure associated with some combination of dehydration, dilation of blood vessels in the skin, drug effects, slow heart rate, and pooling of blood in the lower limbs during periods of standing. If there is no other obvious cause of swelling, heat edema may be treated with rest, elevation of the swollen legs and feet and support hose.

Heat syncope is caused by a brief drop in blood pressure and therefore in the pressure of blood delivered to the brain. It may come on quickly, and is usually seen early during an episode of heat exposure. Dehydration is a contributor, as are the effects of certain drugs. The treatment is to replenish fluids.

When someone suffers heat exhaustion, which may lead to full-blown heat stroke, the length of heat exposure has been longer than that which causes heat syncope. Physical findings occur weakness, fatigue, normal to mildly elevated body temperature, rapid heart rate and breathing, thirst, decreased urine output, low blood pressure and altered mental status (listlessness, agitation or confusion). The latter is very important. Anyone who is in the heat and acting abnormally is suffering from heat illness until proven otherwise. Additional physical findings include nausea, vomiting, headache and muscle cramping. Skin signs may be variable and show skin that is sweaty or dry, and hot and flushed or cool and clammy.

Heat stroke is a situation of extreme heat exhaustion with a failure to be able to control body temperature. This is life-threatening and is associated with a body temperature in excess of 40 degrees Centigrade (104 degrees Fahrenheit), severe neurologic signs (delirium, coma, seizures), and injury to many organ systems, such as the liver, gastrointestinal tract, kidneys and heart. It is essential to cool the victim as soon as possible.

Charles Houston MD

Tod Schimelpfenig — Thu, 01 Oct 2009 17:28:00 GMT

Charles S. Houston MD passed away on September 27^that the age of 96. We have lost a great presence in wilderness medicine and mountaineering.

You may recognize Dr. Houston as the author of Going Higher: Oxygen, Man, and Mountains, the wonderful layperson textbook on altitude illness. You may not know of his technical paper in the New England Journal of Medicine that first described High Altitude Pulmonary Edema, his life of research in altitude physiology on Mt Logan in the Yukon, his succession of publications and international forums on hypoxia. Dr. Houston was a mentor to many in the field of wilderness medicine. I loved to listen to him speak about medicine, sharing his thoughtful insights into physiology and treatment, and his compassionate approach to his patients. I’m saddened to know these moments are now in the past.

You might also recognize Dr. Houston's extensive early climbs in Alaska and the Himalayas, including 1st ascents of Mt. Foraker in 1934 and Nanda Devi in 1936 and an exploratory trip to K2 in 1938 where they almost reached the summit. The 1953 K2 expedition is legendary for the heroic descent through storm during which his team would not abandon an ill companion, at great risk to their lives. Reinhold Messner said of this expedition, “I have great respect for the Americans and the way they failed in 1953. They were decent. They were strong. And they failed in the most beautiful way you can imagine.” Read K2 the Savage Mountain, or watch the documentary film "Brotherhood of the Rope" for a tale of a style of expeditioning we can’t help but admire, and should not forget.

Nutrition Needs for Rescuers and the Rescued

Paul Auerbach — Tue, 29 Sep 2009 13:06:00 GMT

by Paul Auerbach, M.D.

reposted with permission from the Medicine for the Outdoors Blog

This is the next post based upon a presentation given at the Wilderness Medical Society Annual Meeting held in Snowmass, Colorado from July 24-29, 2009. The presentation was entitled “Special Nutrition Needs for the Rescued (and the Rescuer!).” It was delivered by Eldon “Wayne” Askew, PhD from the University of Utah. The objectives of the presentation were to emphasize the medical and psychological importance of providing proper nourishment to rescued individuals, highlight some frequently encountered medical situations involving rescue for which clinical nutrition should be considered as part of treatment and stabilization of the rescued individual, and discuss expedition food planning for persons with medical conditions and for rescuers.

Here were some key points:

1. Plan ahead. Everyone is likely to be hungry. This may seem like a simple recommendation, but adequate planning in all aspects of an expedition is often not achieved.
2. Even if persons are not hungry, they will need nourishment of strength.
3. Food and drink can be emotionally reassuring
4. If victims have their energy stores “refueled,” they may be able to participate in their own rescues.
5. Do not count on a few food bars to maintain you. You may be out longer than you anticipate, food and water supply may not be feasible, you may need to share your supplies, and you have an obligation to be adequately fed and hydrated in order to maintain your performance.
6. If a victim is capable of eating and drinking, he or she should consume at least 30 grams of carbohydrate every 30 minutes to put off exhaustion. This is necessary to keep blood glucose sufficiently high to contribute to continued exertion.

By some estimates, 6% of the population suffers from some form of diabetes. If a person is on medication to lower blood sugar, that puts him or her at particular risk for a hypoglycemic (low blood sugar) reaction, so close observation is always necessary. Type I diabetics, who are insulin dependent, are most at risk, so heightened vigilance for this group is important. Trip leaders or other persons responsible for medical care should be informed about who suffers from diabetes, and should carry a glucose meter (“glucometer”). The medically trained person will carry insulin, injectable glucose, and perhaps glucagon for injection. Dr. Askew made the very important point that glucagon should not be expected to work with hypoglycemic persons who are also experiencing starvation, adrenal gland insufficiency or chronic hypoglycemia (low blood sugar), because these conditions are associated with an inability of the liver to produce glucose sufficiently in response to glucagon. These individuals need oral or injected glucose.

Blood sugar levels over 200 milligrams per deciliter (mg/dL) are too high, at 60 to 140 mg/dL are acceptable, and below 60 mg/dL are too low. These are general numbers. Some persons may exhibit signs and symptoms of hypoglycemia at levels above 60 mg/dL. Common symptoms of low blood sugar are shakiness, hunger, sweating, sudden moodiness or behavior changes, confusion, headache, pale skin color, dizziness and fatigue. Common symptoms of high blood sugar are thirst, vomiting, blurred vision , fainting, feeling ill, and fatigue. There is some overlap, but in general low blood sugar is rapid in onset, and high blood sugar develops more gradually.

If someone is suspected or proven to be hypoglycemic, then initially feed them 15 grams of sugar or carbohydrate, followed by small meals or snacks every 3 hours. Food sources that are roughly equivalent to 15 grams of carbohydrate are a slice of bread, a banana, 2 tablespoons of raisins, 1/3 cup of dry milk, 2 small cookies, a small granola bar, 8 ounces of sports beverage, a tablespoon of honey, or 4 restaurant packets of jelly.

Dr. Askew then discussed food allergies. The foods that most commonly cause serious allergic reactions are eggs, milk, fish, shellfish, nuts, soy, and wheat. Manifestations of a serious food allergy are hives, itching, swelling of the lips/face/tongue and throat/elsewhere, wheezing, difficulty breathing, nasal congestion, abdominal pain, diarrhea, nausea/vomiting, and/or dizziness/lightheadedness/fainting. When this occurs, treatment for a severe allergic reaction is necessary. To treat an allergic reaction from any cause, it is optimal to have injectable epinephrine and oral antihistamines.

Other topics covered included dehydration and rehydration, low serum sodium, and the importance of adequate food energy to performance. The last discussion merits more detailed mention, because it is so frequently underestimated.

If a person does not eat adequate food, with the extreme being no food at all, he or she should anticipate being uncomfortable from hunger, and having difficulty concentrating, anxiety, loss of body weight, decreased endurance, weakness, nutritional deficiencies leading to tissue and organ system deterioration, and perhaps collapse and death from starvation.

The situation may occur where a rescuer needs to feed a starving person who has been rescued. The general approach should be to:

1. Resolve any life threatening injuries or medical conditions.
2. Be certain that the person has functioning kidneys. This may be difficult for a layperson to determine, particularly in the field. If the person is still urinating, for the purposes of immediate care, you should proceed to offer food and drink. If the person is so “dry” that he has not urinated for 24 hours or more, then proceed with caution, observing for fluid retention. Approximately 10 milliliters of oral fluid per kilogram of body weight per hour consumed every 2 to 3 hours should initiate urination within 24 hours. An acceptable basic fluid for dehydration is to add the following to each liter: 3 grams potassium chloride, 1 gm sodium chloride, 4 gm calcium gluconate, and 50 gm glucose or sucrose. An alternative is to offer a dilute electrolyte solution (e.g., Gatorade diluted in half).
3. Slowly feed small portions of a food that is relatively high in fat (e.g., bacon, eggs, nuts, banana chips).
4. DO NOT permit the person to gorge on fluid or food. The sudden sensation of profound fullness may cause nausea and vomiting, which are detrimental.

Thanks so much, Dr. Askew, for making the outdoors a safer place!