Outdoor Ed Community

Skier Intentionally Triggers Huge Avalanche in Teton Backcountry

Rick Curtis — Mon, 30 Jan 2012 02:49:00 GMT

I just got back from skiing at Jackson Hole last week. Like much of the west the snow pack has been really low all winter. Jackson Hole only had a 44 inch (old) base when I arrived. Starting with the day I arrived (Wednesday, January 18) the snow started falling and in a series of storms over 55 inches fell over the next five days. With an old base it created what the Bridger-Teton Avalanche Center rated as "Considerable Avalanche Danger."

On returning to the east coast I read about a significant avalanche in the Teton Backcountry on Mt. Taylor. This slide has created a significant buzz in the backcountry skiing blogosphere since it was intentionally triggered by a professional guide who the made a ski cut above a popular line, intending to release an small avalanche and make the slope safer for him and his party. "The huge slide ran 2,600 vertical feet and took out previous tracks and part of the uphill track. It crossed Coal Creek and ran up over the opposite slope and left a 30-foot-deep deposit of snow and debris. No one was injured in the incident, but search and rescue teams responded to make sure no one was buried or carried." Truly a killer avalanche if anyone had been it it's path. The skier who triggered the avalanche skied down the slope with his beacon on to see if anyone was caught in the slide. Search and Rescue teams also responded to the slide but no one was caught in it.

You'll see a broad range of comments online at TetonAT.com with points of view from "this is no big deal" to "hugely irresponsible behavior." I encourage you to browse the comments and you'll see the range of attitudes some of which espose responsible decision-making and others who suggest that 'what you do is your own business.' Some of these I found just plan scary and I hope I am never downslope from people who think the latter.

One point that I want to make here is that the decisions that we make in the backcountry, don't just affect us and our group. Although no one was hurt in this avalanche, other groups could have been below resulting in potentially catastrophic results. One common risk management error is "the expert on his/her own turf" which could be one explanation for this behavior. Being in "our element" sometimes blinds us to the potential risks and the fact that one has skied an area "1,000 times" doesn't somehow make you safer. Sure, site knowledge like slide paths, previous avalanche history and stability are all pieces of data, but not a license to make decisions that put other people at serious risk.

http://www.jhnewsandguide.com/article.php?art_id=8177

http://www.tetonvalleynews.net/news/massive-slide-on-taylor-highlights-avalanche-danger/article_9e5a2fdc-47b2-11e1-9ce0-001871e3ce6c.html

(Please visit the site to view this video)

Lightning Safety Awareness

Paul Auerbach — Wed, 25 Jan 2012 16:42:00 GMT

by Paul Auerbach

This post relates information learned in a recent issue (Volume 22, Number 3, 2011) of the journal Wilderness & Environmental Medicine, published by the Wilderness Medical Society.

In an article entitled “Lightning Safety Awareness of Visitors in Three California National Parks” by Lori Weichenthal et al, the authors set out to assess the level of lightning safety awareness among visitors at three national parks in the Sierra Nevada Mountains of California.

Having recently enjoyed a wonderful trip to Yosemite National Park (one of the study sites) and gotten caught in a powerful thunderstorm replete with multiple lightning strikes and wind-driven sheets of rain and icy hail, this is timely for me and very important for anyone who spends time outdoors.

There were no surprises in the conclusions derived from this study, but the investigation reinforces the notion that we don’t recall all that we need to know, or may have never fully understood lightning safety in the first place.

For instance, while participants in the national parks knew that lightning is more likely to strike in the afternoon, they were not aware of the dangers of seeking shelter in a small cave or group huddling. Few people understood proper body position, and other than avoiding metal objects or isolated tall trees, the respondents had too many errors (in my opinion) with respect to advice such as avoiding water or thick groves of trees. The authors appropriately concluded that there exist many educational opportunities, which can take many forms, including trailhead awareness placards, park visitor pamphlets, public service announcements, and national park web site education portals.

Here is some information on lightning avoidance from the 5^th edition of the book Medicine for the Outdoors:

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 many 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 before 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.

More Lightning Safety Resources on OutdoorEd.com

Lightning Resources

Wilderness Medicine - 6th Edition released

Rick Curtis — Mon, 09 Jan 2012 02:25:00 GMT

I want to let everyone know about the release of the 6th Edition of Wilderness Medicine, the premiere textbook on the subject, edited by our frequent contributor Dr. Paul Auerbach. There are not too many books out there that I personally consider as "classics" in our field (titles like Mountaineering: The Freedom of the Hills comes to mind), for wilderness medicine, this book is a classic. I've used previous editions of this book for teaching first aid and it was one of my core reference books when writing the first aid chapter in The Backpacker's Field Manual. I'm really excited to see this new edition and that there will be an ebook version. At over 2,300 pages it's no wonder that this textbook is widely referred to as "The Bible of Wilderness Medicine."

This is one book that I recommend that every serious outdoor program have on the shelf as the ultimate reference guide. It covers every conceivable aspect of wilderness medicine in articles written by experts from around the world. What makes this book stand out is the combination of the breadth of coverage and its great readability. I try and keep current on wilderness medicine issues, but as a non-physician, reading things like the New England Journal of Medicine often leaves me scratching my head at the super-technical things that I don't have the background for. This textbook, written for both medical professionals and non-medical provides a great balance. Don't let the price tag deter you, any textbook of this magnitude is worth every penny. The book is available from the publisher Elsevier.com as well as on Amazon.com in hardcover and Kindle format and at Barnes and Noble in hardcover and Nook format.

From the Publisher:

"Quickly and decisively manage any medical emergency you encounter in the great outdoors with Wilderness Medicine! World-renowned authority and author, Dr. Paul Auerbach, and a team of experts offer proven, practical, visual guidance for effectively diagnosing and treating the full range of emergencies and health problems encountered in situations where time and resources are scarce. Every day, more and more people are venturing into the wilderness and extreme environments, or are victims of horrific natural disasters...and many are unprepared for the dangers and aftermath that come with these episodes. Whether these victims are stranded on mountaintops, lost in the desert, injured on a remote bike path, or ill far out at sea, this indispensable resource--now with online access at www.expertconsult.com for greater accessibility and portability-- equips rescuers and health care professionals to effectively address and prevent injury and illness in the wilderness!

From Paul Auerbach:

I’m thrilled to let you know that the 6th edition of the textbook Wilderness Medicine, for which I serve as Editor, is now available. The book is the culmination of more than three years’ work, and the publisher (Elsevier) has done a terrific job with the layout. The book contains 114 chapters, including a tremendous amount of information new to this edition.

This is the big reference book for medical and rescue professionals, educators, scientists, explorers, and others with wilderness medicine interests and activities. The depth of topic coverage underlies much of my other writing. The contributors have gone the extra mile to update their previous work, make new contributions, and do their best to create a comprehensive, encyclopedic work. I’m grateful to have had the opportunity to mold this edition, and am particularly pleased that the publisher allowed me to add chapters on matters related to wilderness preservation. I hope you find it an informative, useful, and fascinating book.

Here’s the Table of Contents:

PART 1 - Mountain Medicine

High-Altitude Medicine and Physiology
Avalanches
Lightning Injuries

PART 2 - Cold and Heat

Thermoregulation
Accidental Hypothermia
Immersion Into Cold Water
Nonfreezing Cold-Induced Injuries
Frostbite
Polar Medicine
Pathophysiology of Heat-Related Illnesses
Clinical Management of Heat-Related Illnesses

PART 3 - Burns, Fire, and Radiation

Wildland Fires: Dangers and Survival
Emergency Care of the Burned Victim
Exposure to Radiation From the Sun
Volcanic Eruptions, Hazards, and Mitigation

PART 4 - Injuries and Medical Interventions

Injury Prevention: Decision Making, Safety, and Accident Avoidance
Principles of Pain Management
Taping and Bandaging
Splints and Slings
Emergency Airway Management
Wilderness Trauma and Surgical Emergencies
Wound Management
Improvised Medicine in the Wilderness
Hunting and Fishing Injuries
Tactical Medicine
Combat and Casualty Care
Wilderness Orthopedics
The Eye in the Wilderness
Foot Problems and Care
Wilderness Dentistry
Management of Facial Injuries
Wilderness Cardiology
Wilderness Neurology
Chronic Diseases and Wilderness Activities
Mental Health in the Wilderness

PART 5 - Rescue and Survival

Wilderness Emergency Medical Services and Response Systems
Search and Rescue
Technical Rescue, Self-Rescue, and Evacuation
Litters and Carries
Helicopter Rescue and Aeromedical Transport
Essentials of Wilderness Survival
Principles of Meteorology and Weather Prediction
Jungle Travel and Survival
Desert Travel and Survival
Whitewater Medicine and Rescue
Caving and Cave Rescue

PART 6 - Animals, Insects, and Zoonoses

Protection from Blood-Feeding Arthropods
Mosquitoes and Mosquito-Borne Diseases
Malaria
Arthropod Envenomation and Parasitism
Tick-Borne Diseases
Spider Bites
Scorpion Envenomation
Bites by Venomous Reptiles in Canada, the United States, and Mexico
Envenoming and Injuries by Venomous and Nonvenomous Reptiles Worldwide
Bites and Injuries Inflicted by Wild and Domestic Animals
Bear Behavior and Attacks
Alligator and Crocodile Attacks
Wilderness-Acquired Zoonoses
Rabies
Emergency Veterinary Medicine

PART 7 - Plants

Seasonal and Acute Allergic Reactions
Plant-Induced Dermatitis
Toxic Plant Ingestions
Toxic Mushroom Ingestions
Ethnobotany: Plant-Derived Medical Therapy

PART 8 - Food and Water

Field Water Disinfection
Infectious Diarrhea From Wilderness and Foreign Travel
Nutrition, Malnutrition, and Starvation
Dehydration, Rehydration, and Hyperhydration
Living Off the Land
Seafood Toxidromes
Seafood Allergies

PART 9 - Marine Medicine

A Brief Introduction to Oceanography
Submersion Injuries and Drowning
Emergency Oxygen Administration
Diving Medicine
Hyperbaric Medicine
Injuries From Nonvenomous Aquatic Animals
Envenomation by Aquatic Invertebrates
Envenomation by Aquatic Vertebrates
Aquatic Skin Disorders
Safety and Survival at Sea

PART 10 - Travel, Environmental Hazards, and Disasters

Travel Medicine
Non-North American Travel and Exotic Diseases
Natural Disaster Management
Expedition Medicine
Global Humanitarian Medicine and Disaster Relief
Natural and Human-Made Hazards: Disaster Risk Management Issues

PART 11 - Equipment and Special Knowledge

Global Crimes, Incarceration, and Quarantine
Wilderness Preparation, Equipment, and Medical Supplies
Ultrasound and Telemedicine in the Wilderness
Outdoor Clothing for the Wilderness Professional
Nonmedical Backcountry Equipment for Wilderness Professionals
Ropes and Knot Tying
Wilderness Navigation Techniques and Communication Methods

PART 12 - Special Populations and Considerations

Training for Wilderness Adventure
Exercise, Conditioning, and Performance Training
Children in the Wilderness
Women in the Wilderness
Elders in the Wilderness
Persons With Special Needs and Disabilities
Wilderness and Endurance Events
Ranch and Rodeo Medicine
Wilderness Medicine Education
Medical Liability and Wilderness Emergencies
The Ethics of Wilderness Medicine
Native American Healing

PART 13 - The Wilderness

The Changing Environment
Biodiversity and Human Health
Health Implications of Environmental Change
Wilderness Management and Preservation
Leave No Trace
Space Medicine: The New Frontier
Appendix - Drug Stability in the Wilderness

INDEX

The hard copy book and e-reader versions both come with access to Elsevier’s expertconsult.com

Epinephrine for Out-of-Hospital Treatment of Anaphylaxis

Paul Auerbach — Sun, 18 Dec 2011 17:11:00 GMT

by Paul Auerbach, M.D.

For management of a serious (even life-threatening) allergic reaction, I have been teaching adults to administer epinephrine (adrenaline) by injection for years. This can be a lifesaving intervention. The Emergency Medical Services (EMS) community now concurs that EMS personnel should be trained to recognize a serious allergic reaction and be allowed to administer epinephrine. In a recent issue of the journal Prehospital Emergency Care (2011;15:570-576), there is an article by Jacobsen and Millin entitled "The Use of Epinephrine for Out-of-Hospital Treatment of Anaphylaxis: Resource Document for the National Association of EMS Physicians Position Statement" that details the use of epinephrine for this purpose.

The major new thrust of this document is to highlight the fact that the intramuscular (IM, directly into the muscle) injection route of administration is preferred, rather than the traditional primary recommendation to inject into the tissue space just under the skin layers ("subcutaneous"). This is because injection into the muscle tissue results in smoother and more reliable drug absorption, with higher peak therapeutic levels of the drug achieved sooner than with subcutaneous injection. The lateral thigh is often used for the IM injection; the outer upper arm is most commonly used for the subcutaneous injection. In an "autoinjector pen" used to administer epinephrine (often referred to by the brand name “EpiPen”), the needle may not be long enough to reach the muscle tissue of a large and/or obese person. However, if the epinephrine is injected into the subcutaneous tissue, it will in all likelihood still be effective, albeit perhaps not as quickly following the injection.

Here is advice about how to give epinephrine for a severe allergic reaction:

Administer aqueous epinephrine (adrenaline) 1:1,000 in an intramuscular or subcutaneous injection (depending on the depth obtained by the needle). The adult dose is 0.3 to 0.5 mL; the pediatric dose is 0.01 mL/kg of body weight, not to exceed a total dose of 0.3 mL. For weight estimation, 1 kg equals 2.2 lb. The drug is available in preloaded syringes in certain allergy kits, which include the EpiPen autoinjector and EpiPen Jr. autoinjector, the Twinject autoinjector (0.3 mg or 0.15 mg doses; 2 doses per unit), and the Ana-Kit. Instructions for use accompany the kits. The EpiPen and Twinject epinephrine products are generally easier for laypeople to use, because they require less dexterity to accomplish injection with them. The Twinject autoinjector and Ana-Kit syringe are configured with enough epinephrine for a second (repeat) dose, which is sometimes necessary. The Twinject is a true autoinjector for the first dose; the second dose is delivered as a routine injection from a concealed syringe and needle.

For dosing purposes, the EpiPen and Twinject 0.3 mg autoinjector should be used for adults and children over 66 lb (30 kg) in weight. Children 66 lb and under should be injected with the EpiPen Jr. or Twinject 0.15 mg autoinjector.

Take particular care to handle preloaded syringes properly, to avoid inadvertent injection into a finger or toe. Do not intentionally inject epinephrine into the buttocks or a vein. Epinephrine should not be exposed to heat or sun, but does not need to be kept refrigerated. If clear (liquid) epinephrine turns brown, it should be discarded. When administering an injection, never share needles between people.

Reposted with permission from the Medicine for the Outdoors Blog

Ski Helmets and Reaction Time

Paul Auerbach — Sun, 11 Dec 2011 17:08:00 GMT

by Paul Auerbach, M.D.

Ski season is upon us. Many experts (including myself) are of the opinion that helmets should be worn by all downhill skiers and snowboarders to help prevent head injuries. One of the “con” arguments proposed by some persons who object to wearing helmets is that they interfere with skiing in such a way as to perhaps make it more dangerous. In their opinion, this might occur by obscuring peripheral vision or diminishing the perception of sound. A very important article entitled article entitled “Do Ski Helmets Affect Reaction Time to Peripheral Stimuli?” (Wilderness & Environmental Medicine:22,148-150,2011) has recently been published by Gerhard Ruedl and colleagues from the Department of Sports Science at the University of Innsbruck in Austria.

The investigators sought to determine whether or not ski helmet use affects reaction time to peripheral stimuli. They used the Compensatory-Tracking-Test (CTT) in a laboratory situation to study 10 men and 10 women during four conditions in a randomized order: wearing a ski cap, wearing a ski helmet, wearing a ski cap and goggles, and wearing a ski helmet and goggles.

The CTT is performed by using a video projector that projects on a screen. The subjects being studied are seated at a table and instructed to respond to visual stimuli that appear on the screen, notably including the periphery of vision. The results were interesting. The lowest (quickest) mean reaction time (approximately 477 milliseconds) was noted for persons wearing only a ski cap. This was not statistically significantly different from the mean reaction time noted for persons wearing a ski helmet (approximately 478 milliseconds). The persons wearing both the goggles and cap or helmet had longer mean reaction times (514 milliseconds and 498 milliseconds, respectively). Note that all of these times are around one-half second.

What are the take-aways from this study? First, it is important to note that this is a simulation that involved only one measure—peripheral vision. It did not take into account the influence of sound. It was not a field experiment, so the influences of extraneous factors were not included. Such factors might be sounds (e.g., ski and wind noise, talking, etc.), thickness of helmet or design of goggles, ambient weather (e.g., sunshine or cloud cover), speed of travel on skis and snowboard, and so forth. However, it somewhat counters the notion that wearing a helmet per se diminishes reaction time to external visual stimuli, regardless of the situation. Furthermore, in a very controlled setting, the differences in reaction time are very, very small—approximately 30 milliseconds (30/1000 of a second), which would not seem to be a huge factor in causing ski accidents. So, while more studies need to be somehow accomplished in more realistic field settings, this is a good start to dispelling the automatic notion that wearing protective helmets is harmful to skiers wishing to avoid the sorts of accidents that cause head injuries.

Reposted with permission from the Medicine for the Outdoors Blog

Wilderness Medical Society Practice Guidelines for Frostbite

Paul Auerbach — Sun, 04 Dec 2011 17:08:00 GMT

by Paul Auerbach, M.D.

Led by Scott McIntosh, MD and his colleagues, the Wilderness Medical Society has published "Practice Guidelines for the Prevention and Treatment of Frostbite" (Wild Environ Med 2011:22;156-166). These guidelines are intended to provide clinicians about best evidence-based practices, and were derived from the deliberations of an expert panel, of which I was a member. The guidelines present the main prophylactic and therapeutic modalities for frostbite and provide recommendations for their roles in patient management. The guidelines also provide suggested approaches to prevention and management of each disorder that incorporate the recommendations.

In outline format, here is what can be found in these guidelines:

Introduction
Methods
Pathophysiology of Frostbite
Classification of Frostbite
Prevention
Field Treatment and Secondary Prevention
- Scenario 1: The Frozen Part Has the Potential of Re-freezing and Will Not Be Actively Thawed
- Scenario 2: The Frozen Part Can Be Kept Thawed and Warm With Minimal Risk of Refreezing Until Evacuation is Completed
Immediate Medical Therapy – Hospital (or High Level Field Clinic)
Other Post-Thaw Medical Therapy
Conclusions
Disclosure
References

The science and medicine of frostbite and other cold-induced injuries are not without discussion, opinions, and some controversy. These Practice Guidelines are an excellent beginning point for persons interested in the topic.

Read it Online

Read the Journal Article online at Wilderness & Environmental Medicine Journal.

Reposted with permission from the Medicine for the Outdoors Blog

Stinging Nettles

Paul Auerbach — Mon, 21 Nov 2011 05:18:47 GMT

by Paul Auerbach, M.D.

Hikers often brush up against injurious plants, such as poison oak or thorny shrubs. One particularly vexing plant is the “ubiquitous weed, Urtica dioica,” commonly known as stinging nettles. As described in an article entitled “Mechanism of Action of Stinging Nettles” (Wilderness & Environmental Medicine:22,136-139,2011) by Alexander Cummings and Michael Olsen, direct contact exposure to the weed causes immediate stinging and burning sensation on the skin. The authors exposed mouse skin to the plants and looked at this skin using an electron microscope. They found smooth nettle spicules that had pierced the skin surface, a few of which retained their bases, which appeared empty of liquid contents. The authors concluded that the mechanism of action of stinging nettles skin reaction was both biochemical and mechanical, likely caused by impalement of spicules into the skin.

Spicules of a stinging nettle, photo courtesy of Randy A. Nonenmacher (CC BY 3.0)The spicules are present as small “hairs” that are found on the stem and undersides of the leaves of the plant. Even light touch against the plant can cause a reaction, which is often characterized as instantaneous burning, itching, and sometimes a slight swelling of the skin. The nettles have been found to contain biologically active chemicals, which might account for part or all of the reaction. This current study shows that spicules, in whole or in part, are retained in the skin. To what extent the mechanical effect of spicule retention contributes to the reaction is yet to be determined, but it is certainly possible that there is such a mechanical effect.

It is not known if removing spicules soon after they enter the skin might be helpful, but it seems logical to make the attempt. There aren’t great ways to do this, because the spicules are so tiny and numerous. It is possible that a peeling method, in which the sticky side of adhesive tape is applied to the skin and then removed, might be helpful. It is certainly worth a try, if someone encounters stinging nettles and can rapidly get their hands on some tape (e.g., is carrying it with them).

Reposted with permission from the Medicine for the Outdoors Blog

Sawyer Squeeze Water Filtration System

Paul Auerbach — Mon, 31 Oct 2011 03:44:00 GMT

by Paul Auerbach, M.D.

As most of you know, I am sometimes sent outdoor health equipment and supplies to evaluate. I’ve recently received a few items worthy of mention.

Sawyer Squeeze Water Filtration SystemFirst, there is the Sawyer Products ‘Squeeze’ Water Filtration System. Advertised to be able to endure filtering 1 million gallons of water for the purpose of water disinfection/purification, this 0.1 micron filter is rated to be able to remove sediment, bacteria, protozoa, and cysts from water. It uses an in-line series of a bag (to contain the unfiltered water: 3 bags are supplied in sizes of one each at 32 ounces, 16 ounces, and 12 ounces) connected to a filter that simply screws onto a fitting at one end of the bag. The water is then squeezed through the hollow fiber-containing filter and exits the system through a discharge port similar to the pop-up closure top found on many water bottles, such as those used by cyclists.

It is easy to use, extremely lightweight, and convenient to pack and carry. The kit comes with a 60 milliliter syringe to be used to backwash (clean) the filter should it become less efficient, because it is becoming clogged with whatever has been removed from the water by the unit. You can learn more about this product and others from Sawyer Products at www.sawyer.com.

Reposted with permission from the Medicine for the Outdoors Blog

Comparing New Agents Used to Control Bleeding

Paul Auerbach — Sun, 16 Oct 2011 21:29:00 GMT

by Paul Auerbach, M.D.

Once of the major recent advances in trauma care has been the evolution of topical substances that can be applied to wounds in order to limit or stop hemorrhage (bleeding). This is very important in wilderness medicine, because uncontrolled bleeding is a leading cause of death from injuries. When the bleeding site can be approached in such a manner as to stop the bleeding, then something very valuable may possibly be done for the patient.

In article entitled “Comparison of Celox-A, ChitoFlex, WoundStat, and Combat Gauze Hemostatic Agents Versus Standard Gauze Dressing in Control of Hemorrhage in a Swine Model of Penetrating Trauma,” Lanny Littlejohn, MD and colleagues used an animal model of a complex groin injury with a small penetrating wound, followed by completely cutting the femoral artery and vein, to determine whether there was any benefit to one or another hemostatic (stops bleeding) agent in comparison to each other and to standard gauze dressing. To cut to the chase (no pun intended), the results showed that no difference was found among the agents with respect to initial cessation of bleeding, rebleeding, and survival. In this study, WoundStat was inferior with respect to initial cessation of bleeding and survival when compared to Celox-A.

The authors point out how important it is to control severe bleeding early in the course of a patient’s therapy, because at a certain point, bleeding leads to organ failure and a vicious cycle of severe acid-base imbalances, more bleeding, and the complications that might occur from blood transfusions. The different hemostatic agents, be they free granules poured into a wound or gauze impregnated with active substances, need to be readily available, easy to deploy, effective in a short period of time, not painful, and without complications. There are more than a few agents that fit the bill, so it’s important to be objective about the pros and cons of each agent. In this study, it was confirmed that they all work roughly equally effectively, so the choice often comes down to comfort of the user with a particular product and personal preferences.

What was surprising as an outcome in the study was the observation that a standard (nonmedicated) gauze dressing was as effective as any of the hemostatic agents. That contradicts some of the current rhetoric that I have heard at medical meetings from experts on wound care, who are beginning to swear by the use of hemostatic agents. If it is true that there are circumstances in which hemostatic agents do not add any benefit to the clinical process of stopping or limiting bleeding, we need to know, so that we don’t waste precious time and money deploying these agents. Obviously, if these agents are beneficial, we need to know about that as well.

A practical observation of this particular study was that a rolled, impregnated (with hemostatic agent) gauze introduced into a bleeding wound should first be unrolled prior to application, to avoid creating a congealed mass of gauze and blood that cannot be properly manipulated and positioned within the confines of the wound.

Reposted with permission from the Medicine for the Outdoors Blog

A Proposed New Conference Model for Outdoor Education

Jay Roberts — Mon, 03 Oct 2011 21:05:00 GMT

I have posted here previously about my views on the current conference structure/environment in outdoor/experiential education but now I would like to propose a specific way forward in the hopes that it might get some folks talking and (just maybe) get the folks with AORE/AEE/WRMC/WEA talking with one another. As the previous sentence reveals, we have a veritable mess of organizations and conference associations for such a small field. While to some degree "diversity is strength" I believe in this particular case it is not. While I do not have current numbers at my fingertips, I would hazard that none of these conferences has attendance over 1,000 and many/most hover between 250-800. I also know, from conversations with folks at the various associations, that budgets are very, very tight. Given this backdrop, does it make sense to have not 1, not 2, but at least 3 different associations and conferences happening around the same time year after year? I don't believe it does.

In my perfect world, we would simply merge at least AEE and AORE into one, larger association and all would be right for the world. For anyone that knows the history of these two "cultures" I would say that my hopes for such a merger are slim at best. But, there are other creative ways forward! I suggest that each year the three conferences (AEE, AORE, WRMC) come together at the same location for their conferences. Participants could then sign up for "packages" that would consist of various "tracks" and/or Special Interest Groups. Cost sharing would consist of a set conference fee plus additional fees for the various tracks signed up for. Many conferences have similar set-ups.

The advantages to this are numerous. All associations would save on conference hosting costs as we could share costs among larger organizations. Vendors would be thrilled with more potential customers and we would likely get higher vendor participation and advertising potential. With more people, we would have better bargaining power with catering, hotels, etc. Imagine a conference titled "International Conference on Outdoor and Experiential Educational" or something of the like that drew 1500-2000 attendees rather than several hundred. Students, vendors, scholars, practitioners could all attend because this would be the ONE conference to attend, to network, and to learn and grow professionally.

It's time to change the paradigm. It's time to think boldly so that we can better serve our constituencies. Are there issues? Sure. But you cannot tell me those are not petty compared with the benefits of a larger gathering of folks. We can make it work. Isn't that, after all, one of the educational tenets we claim to espouse in this field-- collaboration, creativity, and cooperation?

A Perfect Storm - Lessons Learned from Hurricane Irene & Tropical Storm Lee

Rick Curtis — Mon, 03 Oct 2011 02:47:00 GMT

This year took me by surprise, as I know it did for many of my colleagues and it was all about water. First came Hurricane Irene and then Tropical Storm Lee. Each September the Outdoor Action Program at Princeton University sends out over 1,000 students (800 freshmen and over 200 trip leaders) on our six-day outdoor orientation program. This year we had 97 trip groups out. This is the single largest program in the country; that is no one else sends out as many people at once as we do. In this post, for my friends and colleagues, I want to share my Lessons Learned, some old, some new about relocating over 1,000 students from a weather calamity in hopes that it is beneficial for your program..

In order to handle the logistics and the need for emergency response, I've built an extensive backend logistical structure (See Running Mega Programs 1 and Mega Programs 2 and Mega Programs 3 for more information). For each busload of students in the field we have at least one Support Team stationed nearby. This is a pair of students in a minivan staying in a motel near the trip area. They provide transports for minor medical issues, drop off water for groups in dry periods and resupply groups with equipment. Trip groups carry satellite or cell phones (depending on their location) to call out in the event of an emergency and they turn on their phones at 12:00 PM and 6:00 PM so that we can contact them if there is an issue. On campus we have a fully operational Command Center with a group of over a dozen volunteers who staff banks off phones, laptops, a large TV monitor hooked to a laptop, access to online trip routes, and participant lists and map boards of each area. This structure has served us well over may years.

This year was something different altogether. September is hurricane season so with our trips stretching from Virginia up to Vermont I am always tracking storms developing out in the Atlantic because of the potential for impacting our trips. So when Hurricane Irene approached the east coast at the end of August, I was on alert even though it was scheduled to hit New Jersey on Sunday, August 28 and our trips didn't leave until Sunday, September 4. Well Irene did hit and caused a shutdown of a number of our pre-trip training events since air and train transportation was significantly disrupted on the east coast for several days. Sunday brought tropical storm force winds and heavy rain to New Jersey leading to major power outages and significant flooding. It had already been an incredible wet summer in the east so the ground was already saturated before Hurricane Irene hit.

That's my First Lesson Learned--it's not just the big weather event like the hurricane, it's also the rest of the weather context that's been in play for the previous weeks or months. As you look ahead to your program planning, keep an eye on the meta-weather picture over the last month or more. Has it been an exceptional wet period? Has a drought been in place for months or longer? These longer time scale weather events can play a big role. In New Jersey, for example, the ground saturation was so bad with the wet summer that when Irene hit large trees were toppled over from the roots from a combination of super-saturated soil that could no longer support the root system and high winds that simply pushed the trees over. Earlier this summer a sixteen-year-old died on another organization's summer wilderness program in the Wind River Range when a dead tree toppled as students were hanging a bear bag. Certainly in the past I wouldn't have thought to warn my leaders about trees simply toppling over from saturated soil, but with this mega-saturation event, it was a real possibility - Second Lesson Learned - mega-weather events bring up new safety risks that may be outside of our normal "risk radar." While flooded streams and dangerous river crossings were in my mind all the time, I now add toppling trees to the list.

While Hurricane Irene cleared out of New Jersey on Monday, August 29 much of the state was in transportation gridlock until Tuesday, August 30. Downed trees and powerlines, flooded roads, closed airports brought transportation to a near standstill. As Monday wore on I began reviewing our status and checking the storm's impact on the various trip areas we were sending trips to. As I watched the news about how badly Vermont had been hit by the storm and the incredibly flooding and road damage I started thinking about our busload of students heading up there and began tracking down road closure information. Third Lesson Learned - the National 511 System. The Department of Transportation has a national 511 information system set up to provide realtime traffic information including road closures. Each state's Department of Transportation manages and implements their own online system. Start with www.fhwa.dot.gov/trafficinfo/index.htm. You can then drill down by state and it will link you to the State 511 Website. So I looked at Vermont and saw Rt. 9, one of our major trail access roads to the Appalachian Trail - closed to to flooding damage. I also used a free Website Sigalert.com. By default it is city-based but you can pick a nearby city and then scroll the map to see road closures and problems.

Emails from colleagues in college outdoor programs like John Abbott at the University of Vermont and contacts with the Green Mountain rangers brought the bad news, the Green Mountain National Forest in Vermont was closed with a $10,000 fine for entering. So five trips cancelled on Monday, August 28. The news went from bad to worse. Flooding and catastrophic road damage in the Catskills resulted in the closure of the entire Catskills Park - 12 trips gone. Major flooding on the Delaware River washed away most of the riverside campgrounds. The National Park Service closed the Delaware River Corridor and all trails in the Delaware Water Gap National Recreation area - 13 trips gone. The Housatonic River in Connecticut flooded washing out sections of the Appalachian Trail in the southern part of the state (5 trips gone). Seven Lakes Drive in Harriman State Park in New York had was damaged by flooding, the park was accessible from the northern entrance but officials decided to close the park - 5 more trips gone. All told we lost 40 trip routes in about 48 hours and had to replan trips to new locations in just 5 days. [For the record what I was dealing with was an inconvenience as compared to the personal tragedy, loss of life and property that victims of these storms had to endure.]

Fourth Lesson Learned - after a major weather event or national disaster, local officials have to allocate their resources sparingly. When they are stressed to the max just rescuing people from their homes, probably the last thing they want to add in is having to do Search & Rescue efforts on college outdoor orientation programs (or any other organized group) in the backcountry. So park closures can be due to major road closures in the area as well as damage to the park itself.

Fifth Lesson Learned - have more trips in your back pocket than you need. Earlier in the summer we had been scouting an area we used about 10 years ago. during the summer we decided that the 8 routes weren't as good as the ones we had on the books so we didn't use it. We ended up bringing this area and other old trip areas back online. There were pluses and minuses to this approach. I had some familiarity with these areas but in the extremely short time span we had to bring these areas online, there wasn't time to fully develop emergency site plans (so later we had to do it on the fly).

After all this trip reshuffling the weather cleared, all our freshmen arrived and our trips departed campus on Sunday, September 4, a beautiful sunny day. Once they all got dropped off by bus on Sunday, I took my first small sigh of the week. They are on the trail. So now I and the Command Center staff needed to stay attentive and handle whatever came our way over the next five days. I continued to watch the weather carefully. Sixth Lesson Learned - have a good online weather site/service. I've been using Accuweather Premium for years. It costs $80/year and some might say why pay when you can get it for free. Well, great radar, good 15 day forecasts and the ability to save 10 trip regions to quickly see weather in that area is worth it for me. I'm also tracking things on my iPad and Lightning Finder is a great app to keep realtime track of cloud to ground lightning strikes. I was watching what was

I had heard about Tropical Storm Lee down in the Gulf but I didn't pay it too much attention since it was hitting Texas and Louisiana, way too far away for me on Saturday, September 2. Well, Lee had other plans. looking at radar on Sunday night I began to see a huge swath of rain heading north and east into the Mid-Atlantic and New England like a freight train that wasn't stopping. I knew the ground was already super-saturated so flash floods popped into my head.

Sixth Lesson Learned - you've got communication out, how's your communication in? As I said, all our groups carry sat or cell phones and we have a time to have your phone on. Part of this is to be able to communicate to our groups in a natural or national emergency or if there is some family emergency for one of the students (which we've had like a death in the family). I also have implemented a database system for automatically sending text messages out to all those phones. [It combines a database of all the phone numbers in Microsoft Access, along with some easy database programming and a third party software program called Total Access Emailer which does email merges from an Access Database.] This whole thing can be sent up to send out text messages which is what I did on Sunday night. I texted that there was significant rain coming and that people needed to be aware of potential flooding and check their weather radios for local details (all the groups carry a NOAA Weather Radio). One problem, that text went out on Sunday night, but phones didn't go on until noon on Monday. So from here on in our groups will turn on their phones first thing in the morning as well as noon and six to see if there is a text. By the way, lots of times a text message will go through when a voice call won't so having text message capability IN and OUT is key.

Here's what I was looking at on the radar. Scary looking isn't it. The first image is the storm track. The second shows the rainfall totals. It rained so much they had to restart the color shading at green.

Rain started slowly on Monday and was forecast to come down 4-6 inches a day for 3 days. On Monday the flash flood watches and warning started popping up for Tuesday. I looked at the pattern and made a big decision, bring people out. At first that started with Pennsylvania and Maryland tow areas right in the "eye" of Lee, then I expanded it to include Virginia and then Connecticut and Massachusetts as the storm move north and east. I sent a text telling groups that we were going to pick them up and relocate them, basically a precautionary evac. Seventh Lesson Learned - have an Evac Location for each day of the trip. If you have to pull everyone out of an area, it's a huge transportation issue. You want to have a spot on each days trip route where you know you can easily pick people up. If conditions are not dangerous, it's better for people to hike/paddle/bike whatever to those locations rather than have them pop out randomly on the trail someplace. Keep in mind that the leaders are the one experiencing the actual field conditions so they need to make the decision about whether your planned Evac point is viable, or will they have to cross three flood-swollen creeks to get there. I had Evac locations for all of our longstanding trips, but not for many of the ones we just replanned, so we did it on the fly for those areas.

Eighth Lesson Learned - where do you go when you have to leave? I've known this one for a long time so it wasn't as much a new lesson for me, more of an 'I told you so.' For the areas that we've been using regularly for the past ten years we have identified in each region a relocation/evacuation rallying point--a state park with camping, an outdoor education center with cabins, etc. Someplace where we could move groups as an intermediate site in case of a major weather event. I had these lined up for our longstanding routes, but didn't get those worked out for the 40 replacement routes. Why is this important? You'll see. Many of the places that our trips go are 5 or more hours from New Jersey. Something I've known for years is that bus drivers are limited by Department of Transportation regulations from driving more than 10 straight hours. So a number of our bus driver who dropped groups off on Sunday, had to stay in a motel Sunday night since they couldn't drive back the same day. Well, that also meant that in order to pick up all our waterlogged groups they could not drive from New Jersey, pick the groups up and get back to New Jersey on the same day. That meant we had to relocate 1,000 people to an intermediate site and then bring them back the next day. That's the reason for knowing where these "rally points" are ahead of time. For example, in Shenandoah National Park, we moved everyone to Big Meadows Campground in the park. So do the research and have these locations tagged ahead of time. Talk to the camps, state parks, rangers, etc. and ask them if the could handle 50 people or however many in an emergency evac. Then you just have to activate this emergency relocation plan.

So we got our people out to their intermediate sites. It was a challenge because I had 22 buses reserved for Friday, the day the trips were supposed to return and suddenly I called our bus company and asked for 22 buses on Wednesday. Ninth Lesson Learned - have a great relationship with your transportation provider - build it ahead of time. We have a really good relationship with our bus company Coach USA. Because they are in the business of keeping their buses on the road, they didn't have 22 buses and drivers. Just 9 they could give us with 24 hours notice (remember the 10 hour driver rule?). So I took the nine buses and worked out a way to have them drive out, pick up all the groups and ferry them to the closest state park, motel, etc. and then go back and get another load and got it all done in under the 10-hour driver limit. Being able to talk directly to Zarco the bus dispatcher was key.

Tenth Lesson Learned - have good transportation software. There are lots of products out there - online like Google Maps or software products like Microsoft Streets and Trips (which I use). None are perfect, especially when you are dealing with buses since consumer software ignores things like bridge weights and overpass heights, but they are better than nothing. Since I already had all my original bus drop-off points saved out in Microsoft Streets it was a fairly quick job to run directions for the drivers to go from Evac pickup locations 1, 2 and 3 to the motel and then back to locations 4, 5 and 6. It saved me hours of time trying to communicate with the bus dispatcher when I could just email him a PDF of the bus pickups. There are software products built for commercial trucking fleets that do know things like bridges and overpasses and route trucks (and buses) around them. Next year I'll sign up for a 30 day free trial of PC*Miler|Web and see how that works for bus directions.

So we got over 1,000 people relocated to intermediate motels and campsites (no don't ask me about how much this all cost). We got a second wave of buses out to join the 9 buses and we got everyone back to campus, dry and happy on Wednesday and Thursday. I have so many people to thanks for pulling this off and getting everyone back safety. The tremendous student leaders who used great judgment to keep things under control. Our Support Teams in the field who did an epic job of picking up groups and getting them to buses. To the superb Command Center Team who stayed on the phones for 16+ hours a day working all the pickups. To all the administrators and staff at Princeton who figured out how to feed people when then got back to campus and came up with fun activities for our groups to do so they could continue to function in their small groups until the scheduled end of the program. Eleventh Lesson Learned - develop your campus network ahead of time. So when BIG things happen you have the relationships built to get the help you need. Thirty years of being at Princeton means that I had a create set of people who I could call on and they all came to my aid. Twelfth Lesson Learned - what is your campus emergency response plan and how does your trip fit into that? Like many campuses Princeton has an Emergency Response Team (ERT) to deal with some major campus calamity, a dorm fire, school shooting etc. Know what that plan is and talk to those people to know when, if your program is dealing with a major event, that event hits the threshold to initiate the college's ERT. They can get things done that you can't simply by virtue of their being activated and having mega resources at their disposal. Last Lesson Learned - have a great staff team - Leaders, Command Center and Support. It makes all the difference.

I don't want to make it sound like these trips were terrible. On the contrary, while my week was terrible, the students bonding incredibly well. They had enough challenges to bring them together, not so much that it broke them apart. Making the decision to start to pull the trips out, knowing that it could not be all done in 24 hours, meant that we did get them out before conditions got really bad. Like I said the leaders did a great job and when I saw all the students in the main campus auditorium on Thursday night they were totally pumped about their experience. As I've said, it was the best possible outcome from a bad situation. We successfully achieved the goals of our outdoor orientation program.

And I finally got some sleep. Here are my Lessons Learned. Pop yours in the Comments Section or contact me about submitting a Blog entry.

First Lesson Learned--it's not just the big weather event like the hurricane, it's also the rest of the weather context.
Second Lesson Learned - mega-weather events bring up new safety risks.
Third Lesson Learned - the National 511 System.
Fourth Lesson Learned - after a major weather event or national disaster, local officials have to allocate their resources sparingly.
Fifth Lesson Learned - have more trips in your back pocket than you need.
Sixth Lesson Learned - you've got communication out, how's your communication in?
Seventh Lesson Learned - have an Evac Location for each day of the trip.
Eighth Lesson Learned - where do you go when you have to leave?
Ninth Lesson Learned - have a great relationship with your transportation provider - build it ahead of time.
Tenth Lesson Learned - have good transportation software.
Eleventh Lesson Learned - develop your campus network ahead of time.
Twelfth Lesson Learned - what is your campus emergency response plan and how does your trip fit into that?
Final Lesson Learned - have a great staff team - Leaders, Command Center and Support

In the Wake of Hurricane Irene – Methods of Water Disinfection

Paul Auerbach — Tue, 13 Sep 2011 02:06:39 GMT

by Paul Auerbach, M.D.

In the wake of Hurricane Irene, many people will be without electrical power for days. If they need to disinfect water to obtain drinking water, the following are some techniques that may be used:

Water disinfection is the treatment of water with chemicals, boiling, or filtration in order to remove agents of infectious disease, such as bacteria and cysts. The principal offending agents in contaminated water or on unwashed food that cause illness and diarrhea are the bacteria Salmonella, Shigella, E. coli, and Campylobacter, and the flagellate protozoan Giardia lamblia.

All containers should be wiped clean to remove external moisture and dirt. If the water to be disinfected is cloudy or dirty, it should be allowed to rest for several hours in order for large particles to settle to the bottom. The top portion can be poured off—if possible, it should be poured through a filter or fine cloth.

Coagulation and flocculation techniques can remove smaller suspended particles: Add a pinch of alum (an aluminum salt) to a gallon (3.8 liters) of water and mix well, then stir occasionally for 60 minutes. Allow the water to rest while the aggregated particles settle, then pour off the upper (and hopefully clearer) part through a paper filter (such as a laboratory-grade filter with a pore size of 20 to 30 microns).

Water may be disinfected by any of the following methods:

1. Boil the water.

At sea level, when water has been boiled for a few minutes, it can be considered to have been disinfected. Giardia cysts are instantly killed in water heated to 158° F (70° C). To play it safe, keep boiling it for a few minutes at this temperature to kill off all bacteria and most viruses. Hepatitis A virus requires a full minute of boiling to assure inactivation. To provide a wide margin of safety, boil the water for three minutes.

Time and temperature have an inverse relationship with respect to water disinfection: The higher the temperature, the less time is required, and vice versa. For instance, pasteurization of food products can occur at a lower temperature (158° F, or 70° C) if 30 minutes at this temperature are allowed. Sterilization (killing of all microorganisms) occurs after five to 10 minutes of boiling at sea level.

2. Use a halogen, such as iodine or chlorine, as a chemical disinfectant.

The rate at which halogens kill microorganisms depends upon the concentration (measured in mg per liter, or parts per million [ppm], which are equivalent) of halogen and time allowed for disinfection. At a given water temperature and pH, contact time is inversely related to concentration. Thus, you double the contact time if half the concentration of halogen is present. Decreased (cold) water temperature or cloudy (more organic material) water requires a longer contact time or higher halogen concentration. Halogens can create an unpleasant taste if the concentration exceeds four mg/liter. They can lose effectiveness after prolonged exposure to moisture, heat, or air, and may be corrosive or stain clothing. In general, to improve taste, use a lower concentration of halogen for a longer contact time. Eight mg/liter (or ppm) is considered the concentration of iodine effective for water disinfection in room-temperature, clear water. A pregnant woman or a person with thyroid disease or iodine allergy should consult a physician before using any iodine compound for water disinfection.

Water disinfection tablets, such as Potable Aqua® (see below) and other iodine- and chlorine-based products may be used inside plastic hydration bladders, such as those found in the CamelBak®. While they may discolor the plastic, they do not degrade it.

Add one tablet of fresh tetraglycine hydroperiodide (Potable Aqua®, Globaline, Coughlan’s, EDWGT) to one quart (liter) of water and allow the water to stand for 15 minutes. If the water is cloudy, use two tablets. If the water is cold, allow one hour after adding the tablets before drinking. Each tablet releases approximately 8 mg/liter of iodine. Do not leave an open bottle exposed to high heat and/or humidity. Potable Aqua Plus includes oxidizing tablets to remove the iodine taste after disinfection.

Add to 1 quart (liter) of water:

water	clear	cloudy
warm (>15° C, 59° F)	1 tab for 15 minutes	2 tabs for 30 minutes
cold	1 tab for 60 minutes	2 tabs for 60 minutes

After adequate time for disinfection has elapsed, add a few grains of sodium thiosulfate per quart (liter) of water; this kills the iodine taste. Ascorbic acid (vitamin C) is also effective. Any fruit flavorings that contain vitamin C should be mixed in after full time for disinfection has elapsed. Granular activated charcoal removes organic material, chemicals, and radioactive particles by adsorption, but does not remove all microorganisms, and thus cannot be relied upon to disinfect water. Rather, it should be used to improve taste and clarity. Use it after water has been properly disinfected.

Zinc metal reduces free chlorine or iodine in solution through a chemical reaction. A wand of zinc bristles stirred into a quart (liter) of water for 4 minutes will remove 10 mg/liter of residual chlorine.

Because a 50-tablet bottle of tetraglycine hydroperiodide contains only 0.4 g of iodine (1/50 the lethal dose), the tablet method is very safe. If you use military surplus iodine tablets, they should be steel gray in color and not crumble when pinched by two fingers; discard older, crumbled tablets. Also, no matter what chemical disinfection system you use, allow disinfected water to seep around the cap and threads of your canteen or water bottle, in order to disinfect them.

Another method is to add 8 to 10 drops (0.5 ml in each drop) of standard 2 percent iodine tincture per quart (liter) of water and allow it to stand for 15 minutes. Use a dropper for measurement. If the water is not at least 68° F (20° C), this technique may not eliminate Giardia. If the water is cold, allow it to stand for 1 hour before drinking. If you have extra time and do not like the iodine taste, use four to five drops of iodine and allow the water to stand for 8 hours or overnight. Five drops of tincture of iodine disperses to approximately 4 mg/liter.

add to 1 quart (liter) of water:

water	clear	cloudy
warm (>15° C, 59° F)	5 drops for 15 minutes	10 drops for 30 minutes
cold	5 drops for 60 minutes	10 drops for 60 minutes

Another iodine product that can be used to disinfect water, but has not definitively been proven effective for this purpose, is 10 percent povidone iodine (Betadine) solution (not “scrub”):

add to 1 quart (liter) of water:

water	clear	cloudy
warm (>15° C, 59° F)	8 drops for 15 minutes	16 drops for 30 minutes
cold	8 drops for 60 minutes	16 drops for 60 minutes

Another method is to fill a 1 oz (30 ml) glass bottle with iodine crystals (U.S. Pharmacopoeia [USP] grade, resublimed: 2 to 8 grams), then fill the bottle with water. The bottle should have a paper-lined Bakelite cap. Warm the water to 68 to 77° F (20 to 25° C). Shake vigorously, then allow the crystals to settle to the bottom for 1 hour. This will create a saturated solution of iodine. As a crude measure, pour at least half of this liquid (not the remaining crystals), or approximately 12.5 to 15 ml, through a fine filter (such as Teflon) into a quart (liter) of water and allow it to stand for 30 minutes. If the water temperature is not at least 68° F (20° C), this technique may not eliminate Giardia. The crystals may be reused up to 1,000 times. Two grams (0.07 oz) of iodine represents a potentially lethal dose if ingested, so it is absolutely essential to keep the iodine crystals out of the hands of children. A commercial iodine crystal system that can be reused to disinfect up to 2,000 quarts (liters) of drinking water is sold as Polar Pure Water Disinfectant.

If one capful from a 2 oz (59 ml) bottle equals approximately 2.5 ml, then using a saturated solution prepared from iodine crystals in water:

add to 1 quart (liter) of water:

water	clear	cloudy
warm (>15° C, 59° F)	5 capfuls for 15 minutes	10 capfuls for 30 minutes
cold	5 capfuls for 60 minutes	10 capfuls for 60 minutes

An alcohol-iodine solution can be prepared by adding 8 g of iodine crystals to 100 ml of 95 percent ethanol. The resulting supernatant yields 8 mg iodine per 0.1 ml. To add to water, measure with an eyedropper:

add to 1 quart (liter) of water:

water	clear	cloudy
warm (>15° C, 59° F)	0.1 ml for 15 minutes	0.2 ml for 30 minutes
cold	0.1 ml for 60 minutes	0.2 ml for 60 minutes

3. Filter the water through a category-three (as set for purification by the Environmental Protection Agency) water treatment device.

Manufacturers who sell representative devices are the Mountain Safety Research, Katadyn, AquaRain Filter Systems, General Ecology Inc., Recovery Engineering, Timberline, Stearns Outdoors Inc., McNett, and Sawyer Products. The Sawyer Point Zero Two™ water filter, with a 0.02 micron filter, is rated to remove viruses. This product is available with a bucket adapter kit, or can be fitted to four liter bags or a special water bottle.

If the filter doesn’t come with a “prefilter” (nylon mesh or screen) to remove large particles, pour the water through filter paper (like coffee filter paper) or fine cheesecloth. This helps keep your expensive water filter from clogging up, allows it to work more efficiently, and will improve the appearance and taste of the water.

4. Use halazone prodcuts to disinfect water.

Halazone (a mixture of monochloraminobenzoic and dichloraminobenzoic acids) or other chlorine (bleach) products have been considered less effective for field water disinfection. Halazone has been characterized as losing 75 percent of activity after two days’ continuous exposure to air with high heat and humidity; having a shelf life of six months; and decreasing potency by 50 percent after storage above 104° F (40° C). Therefore, you should obtain a new bottle every three to six months.

Each Halazone tablet releases 2.3 to 2.5 mg/liter of chlorine. To disinfect water:

add to 1 quart (liter) of water:

water

clear

cloudy

warm (>15° C, 59° F)

5 tablets for 15 minutes

2.5 tablets for 30 minutes

7 tablets for 15 minutes

5 tablets for 30 minutes

cold

5 tablets for 60 minutes

7 tablets for 60 minutes

Liquid bleach (hypochlorite solution; household bleach, usually 5.25 percent) can be used to disinfect water via chlorination. There should be a faint smell or taste of chlorine before drinking.

For 5.25 percent bleach, add to 1 quart (liter) of water:

water	clear	cloudy
warm (>15° C, 59° F)	2 drops (0.1 ml) for 30 minutes	4 drops (0.2 ml) for 30 minutes
cold	2 drops (0.1 ml) for 60 minutes	4 drops (0.2 ml) for 60 minutes

For 1 percent bleach, add to 1 quart (liter) of water:

water	clear	cloudy
warm (>15° C, 59° F)	10 drops (0.5 ml) for 30 minutes	20 drops (1 ml) for 30 minutes
cold	10 drops (0.5 ml) for 60 minutes	20 drops (1 ml) for 60 minutes

5. Superchlorination and dechlorination.

Superchlorination followed by dechlorination is an effective technique. This is a more complicated method that requires understanding and experience. Add 27 g or more of calcium hypochlorite crystals to a gallon (3.8 liters) of water to attain a chlorine concentration of 27 to 30 parts per million. After the requisite disinfection time (10 to 30 minutes), add six drops of concentrated (30 percent, caustic) hydrogen peroxide to dechlorinate the water. The chemical reaction produces calcium chloride (which remains in solution), water, and oxygen.

6. Aquamira® water treatment.

Aquamira® water treatment uses stabilized 2 percent chlorine dioxide combined with an activator (5 percent food grade phosphoric acid) to improve the taste of water. One kit can be used to treat more than 120 liters of water. Mix 7 drops of the two bottles together, and let sit 5 minutes, then pour the contents into 1 quart of water. Oxygen is released in a highly active form to kill odor-causing bacteria. The process takes approximately 20 minutes.

7. The SteriPEN™

The SteriPEN™ carries the promotional byline of “safe drinking water anywhere.” Distributed by Traveler’s Supply, Inc., this unique hand-held water purifier that uses ultraviolet light (UVL) is advertised to fit into most plastic consumer water bottles as well as other types of containers up to 32 ounces (1 liter). It operates on 4 AA batteries, with nickel-metal-hydride or lithium batteries recommended. According to the distributor, only 48 seconds of exposure to the UVL is required to disinfect 16 ounces (1/2 liter) of water and 90 seconds for 32 ounces (1 liter). The claim is that the device is effective against common outdoor and household pathogens, as well as less common micro-organisms, to include bacteria, viruses, and protozoa. The test results are found at an Internet link provided by the company. According to the product literature, the SteriPEN™ meets U.S. Environmental Protection Agency standards for microbiological water purifiers. A filter can be used to remove particulates from the water prior to UV treatment.

UVL works for water disinfection by destroying the DNA of microbes. This keeps the germs from reproducing, which is necessary in order for them to make a person ill. The light emitted by the SteriPEN™ device is in the UV-C range, of wavelength 254 nanometers. This wavelength is germicidal (kills germs) by causing adjacent thymine base nucleotides in DNA to bond together, which prevents them from being properly recognized (“read”) in the replication process, which is necessary for DNA to allow a micro-organism to reproduce. Thus, the germ(s) is rendered harmless. Used as directed, the UVL exposure is of no consequence, as this wavelength of UVL does not pass through most materials (e.g., glass, metal, ceramic, and nearly all plastics). Furthermore, the underside of the air/water surface in a water container acts as a reflector for UV-C. So, if the SteriPEN™ lamp is completely immersed in water and used according to the instructions, the UV-C is contained and does not pose any health risk to the user. For additional safety, the SteriPEN is equipped with water sensors and will not operate unless the lamp is under water. The SteriPEN™ contains a microcomputer that controls operation time, according to information it receives from integrated temperature sensors and user indication of the volume of water to be disinfected. During use, the device should be used to gently stir the water. It is intended for use in clear water, so cloudy water must be filtered or otherwise made clear prior to using the SteriPEN™. Disposable lithium or rechargeable AA nickel metal hydride batteries will provide many more disinfection cycles than will alkaline batteries. The latter are better in a cold weather situation.

The Role of the Routine Physical Examination in Young People

Paul Auerbach — Mon, 29 Aug 2011 11:20:00 GMT

by Paul Auerbach, M.D.

Increasing numbers of young people participate in outdoor activities, including strenuous competitive athletics. In so doing, they subject their bodies to stresses that are more intense and prolonged than those presented by a largely sedentary life. Every story of a sudden death in a young person is a tragedy, and usually accompanied by commentary pondering the role and utility of pre-activity screening. Could the death have been prevented? What was the physiological condition of the deceased? Could the collapse, often attributed to a heart problem, have been predicted? Was there an examination or evaluation that might have indicated that the deceased was at greater risk, or should have been held out of the activity? These are all important questions, with no simple answers.

Sudden collapse and cardiac arrest in a young person seems wrong. It shouldn’t happen. It is a parent’s worst nightmare. Similar horrors occur on the freeway when a teenage driver is killed, or at the beach when a surfer is tossed in a monster wave and drowned. We know a great deal about injury prevention; much of our teaching and experience points to errors in judgment. But the situation is different when the seemingly healthy slumps to the ground without a pulse. That person has been taken by surprise in a cruel act of fate.

Sometimes we learn that the victim had a congenital or acquired heart abnormality, such as idiopathic hypertrophic subaortic stenosis, a seizure disorder, or a propensity to abnormal heart rhythms. A young person may be walking around with an inflamed heart muscle after apparently recovering from a viral infection, and not know until it is too late that his or her heart is operating at a greatly reduced capacity, such that heart failure is just around the corner. The young person with a brain aneurysm is in great shape until the dilated blood vessel bursts and leaks a lethal torrent into the confined space within the skull.

A large proportion of sudden adverse health events—whether a first serious attack of ketoacidosis associated with diabetes, a stroke in a person with a brain aneurysm, or cardiac arrest in a person with a potentially lethal heart rhythm disorder—come without any antecedent event or other warning. To what degree should apparently healthy persons be screened for the possibility of an occult problem?

Warning Signs

To begin with, the child should receive a prompt physical examination if there is a chronic problem with any of the following:

fainting spells
frequent urination
fatigue out of proportion to the activity
weight loss
shortness of breath
palpitations (particularly with an irregular pulse)
chest pain

The doctor will screen for heart problems and other abnormalities. Routine parameters of good health, such as appropriate pulse rate, blood pressure, ease of breathing and breath sounds, and ideal body mass and total weight are essential. Similarly, routine laboratory testing, such as blood counts, urinalysis, blood glucose, and essential electrolytes establish what is hopefully a normal baseline for the participant.

What is “Extra”?

An electrocardiogram (ECG, EKG – “heart tracing”) is not usually part of a basic physical examination in youth. The test will detect arrhythmias and certain structural abnormalities of the heart. An echocardiogram bounces sound waves off the heart and determines anatomy and function. Combined with the ECG, an ultrasound becomes a very reasonable heart screening regimen for persons of all ages.

Exercise-associated events, such as dizziness, fainting or chest pain, should be examined with an ECG and echocardiogram, and perhaps a stress test (“treadmill”). Further testing is guided by the results of these three examinations.

What is the Value of “Family History?”

Certain congenital conditions and many medical disorders have a basis in genetics. Knowing whether or not your father or mother had heart problems is useful to help determine your risk, but in my opinion, a “negative” family history does not rule out the need for a physical examination and proper testing. The person who collapses with a heart attack may be the first one in the family to do so.

What Are the Controversies in Testing?

False Positive Results

There is always a possibility that the results of a test deemed positive for a problem are in fact incorrect—there is not a problem, so the test is “false positive.” If the false positive rate is high, then there will be too much unnecessary follow-up testing, and, furthermore, persons may be precluded from activities when they are perfectly normal.

Cost

How many lives are saved for what total dollar amount? How much is it worth to society to save a small number of athletes who, without screening, might go on to collapse and die? Finally, what is the quality of “mass screening?” Do we rush through the exams and make mistakes with the interpretations because we don’t have a high index of suspicion combined with a hasty effort?

Final Words

My recommendation, which is entirely based on opinion, is that a healthy child, who has received all the normal examinations and healthcare, should have a comprehensive physical examination prior to undertaking a new and very strenuous activity (be it on the playing field, underwater, or climbing a mountain). A baseline EKG is good for people to have in their possession for future medical reference, provided that it will be safely stored, and not misplaced or lost. If there is any suggestion of a heart problem by virtue of history or exam, or if there is a significant family history of heart abnormalities, an echocardiogram should be obtained.

reposted with permission from the Medicine for the Outdoors Blog

Fatal Bear Attack

Paul Auerbach — Mon, 22 Aug 2011 04:42:00 GMT

by Paul Auerbach, M.D.

By now, most everyone is familiar with the tragic circumstances in which a visitor on a trail in Yellowstone National Park on July 6, 2011 surprised a brown (grizzly) bear with cubs, provoking a fatal attack. Fortunately, events like this are rare. At the same time, they are also predictable by virtue of our understanding of bear behavior, particularly in the wildland-urban interface. It was not the victim’s fault, and our hearts go out to his family and friends. For the benefit of others who will backpack and explore in bear country here is an excerpt about avoidance of hazardous animals, in particular bears, adapted from the book Medicine for the Outdoors:

Avoidance of Hazardous Animals

Most wild animal encounters can be avoided with caution and a little common sense. Follow these rules:

1. Do not surprise or otherwise provoke animals. Unless they are apex predators, starving, senile, or ill, most animals will not attack humans without provocation. Do not corner or provoke a carnivore. Do not tease animals. Do not approach an animal when it is with young. If you are a photographer approaching a wild animal that may become provoked and charge, do not come any closer to the animal than 100 yards distance. Some experts say that you should attempt to stay even further away from bears.

2. Do not disturb a feeding animal. Do not explore into its feeding territory, approach during rut, or disrupt mating patterns.

3. Do not separate fighting animals using your bare hands. If possible, drive animals apart using a long stick or club.

4. In bear country, make your presence known by calling out, clapping your hands, or otherwise making noise, particularly when approaching streams and blind spots on the trail. If you are a jogger on a trail, you may approach a bear more rapidly than it has time to flee, so it is best to stay off trails frequented by bears if you are traveling at a brisk pace.

5. Hang all food off the ground in trees away from the campsite. Never keep food or captured game inside a tent. Use proper food storage to keep food away from bears. Cook at a site away from the sleeping area. Do not sleep in clothes worn while cooking or eating.

6. Make noise when hiking, particularly on narrow paths or through tall grass. Walk slowly. If you confront a brown (grizzly) bear, avoid eye contact and try to slowly back away. If you confront a black bear, shout, yell, throw rocks or sticks, or do whatever you can to frighten off the animal.

7. If attacked by a bear, do not try to outrun it; you can’t. If you are carrying pepper spray (at least one percent capsaicin or capsaicinoids) in a canister intended for use against a bear (“bear pepper spray” that meets EPA standards; a spray distance of 25 feet under optimum conditions, minimum spray duration of six seconds, minimum net content of 7.9 ounces or 2.25 grams), use it if you have time. Personal defensive spray, such as Mace, will likely not work because the canister shoots a relatively thin stream and the substance is not sufficiently potent. Carry the spray where it is obvious and can be immediately deployed. It should be on a holster on your waist or chest, not in the bottom of your pack. Show your companions its location.

8. If you are attacked by a bear and not carrying bear pepper spray, cover your head and the back of your neck with your arms and curl into a fetal position or lay flat on the ground, face down, to protect your abdomen. If you are wearing a backpack, keep it on for additional protection. Use your elbows to cover your face if a bear turns you over. After a bear attack, remain on the ground until you are certain that the bear has left the area. More than one victim has successfully protected himself during the initial attack, only to arise too soon (before the bear has lost interest and left the area) and be mauled during the second attack.

5. Never leave a small child alone with an animal, regardless of the animal’s demeanor.

6. Do not pet or feed animals.

reposted with permission from the Medicine for the Outdoors Blog

The Science of Experiential Learning

Jay Roberts — Fri, 29 Jul 2011 18:15:00 GMT

A recent editorial in Nature argues for more experiential, informal curriculum for students in science classes. The editorial titled: “Learning in the Wild” makes the point that informal learning environments are often much more powerful and longer lasting in transfer than formal classroom curricula. They go on to note: “Indeed, researchers say, the personal and idiosyncratic nature of informal science education is precisely what makes it powerful. The question that plagues classroom science — why is this relevant? — never even arises.”

Experiential methodology is getting a little more attention these days as we learn more about how the brain functions in various learning contexts and states. The Nature editorial cites the 2009 report from the National Academies on how people learn in informal settings which can be found here. The National Academies Press also released a very useful text simply titled How People Learn in 2000 that represents a rigorous scientific approach to the issue and summarizes key findings from neuroscience and related studies. Not surprisingly to those of us who advocate for experiential education, these reports support experiential learning methodologies. It would be well worth your time to read these as it is difficult to find rigorous, evidence-based studies of experiential education from such well-regarded sources (e.g. the National Academy of Science). Here is a short-list of findings from the 2000 report:

1. You must work with and address pre-existing knowledge in learners

2. Active learning is a key component to “meta-cognition”

3. Depth of learning is more important than “superficial coverage” of topics

4. Learning is influenced by context. Therefore, attention must be paid to the social aspects of learning

For those who support experiential education, these findings ought to look and sound familiar. They speak to the heart of the experiential educational philosophy and approach. That our “hunches” are now finding support in empirical science is heartening. Here is hoping there are policy makers, school officials, and “curriculum specialists” out there reading more about the science of learning. In the meantime, for the outdoor and experiential educators out there: take heart because the National Academy of Sciences has got your back!

Tragedy in the Tetons

Rick Curtis — Sun, 24 Jul 2011 18:08:00 GMT

On July 18, 2011 tragedy struck in the Tetons. A 16-year old participant on an outdoor education program sponsored backpacking trip was killed by a falling tree. According to the Chicago Sun-Times:

"The Teton County Sheriff’s Office received a satellite telephone call at 2:45 p.m. July 18 from Wilderness Ventures, a commercial backpacking company in Jackson Hole, Wyo., that Burns was struck by a falling tree and severely injured. Burns was approximately 66 feet away from the base of the tree helping to set up camp, when other group members attempted to hang food in a “bear bag” in the dead 75-foot tree. Burns, who was kneeling down tending to camp equipment when she was struck, never regained consciousness, witnesses said."

This is the official press release from the Teton County Sheriff's Office:

"On Monday July 18, 2011 at 2:45 PM, The Teton County Sheriff's Office Dispatch center received a call on a satellite telephone from a commercial backpacking company stating that a girl in their group had been struck by a falling tree and was severely injured.

While setting up camp approximately four (4) miles due east of the Turpin Meadow trailhead in the Teton Wilderness, a sixteen-year-old female member of a backpacking group was struck by a falling tree when the tree uprooted as group members were attempting to hang food in a "bear bag" in the tree. The girl, Elizabeth Burns of Lake Forest, Illinois, was tending to camp chores when the approximately 75 foot dead tree struck her. She was approximately 66 feet from the base of the tree. The tree was approximately 24" in diameter at the base and 9" in diameter where it hit her. She was kneeling down tending to camp equipment when she was struck.

A helicopter from the Teton Interagency group was flown to the site with Grand Teton Park Search and Rescue members aboard to render aid. According to people at the scene, she never regained consciousness after being struck. The girl was pronounced dead at the scene at 1635 hours. She suffered numerous injuries but the suspected cause of death was blunt force trauma to the head.

The remaining members of the backcountry camping group hiked out with the assistance of the park rangers to the Togwotee Mountain Lodge where they were met by crisis counselors from Grand Teton National Park. The Togwotee Mountain Lodge provided lodging for the rest of the group for the night."

Our condolences go out to the family and fiends of the victim and to all those involved in the program.

This incident is sadly reminiscent of a tree branch death in Australia that took place on a high school camping trip run by an outdoor education program in Victoria in August 2005.

These incidents are a stark reminder of some of the 'less visible' hazards in the outdoors.I experienced this some years ago on a backpacking trip through our program when a group hung a bear bag on a branch late at night. In the dark it wasn't clear to the group that the branch was dead. As the bear bag was hauled up the branch broke hitting one of the participants in the head resulting in a scalp laceration. To compound the incident the dead branch contained a bees nest and when the branch hit the ground and broke open a hive of angry bees emerged and several participants got stung. Luckily there were no serious injuries from this. Analysis of the incident led us to implement new bear bagging protocols.

Dead branches or dead trees can be the result of blights or infections such as the Mountain Pine Beetle which has killed huge stands of trees in the American West. I urge everyone to be vigilant in assessing this hazard. Here are a few important resources to help you assess these hazards for your program.

How to Recognize Hazardous Defects in Trees (PDF) - Pamphlet by the U.S. Forest Service
Preventing death and serious injury from falling trees and branches (PDF) by Andrew Brookes, Australian Journal of Outdoor Education, 11(2), 50-59, 2007
Protocols for Assessing Tree Safety (PDF) by Andrew Brookes, Australian Journal of Outdoor Education, 11(2), 50-59, 2007

Andrew Brookes, a professor at the School of Outdoor Education and Environment,La Trobe University, Bendigo, Australia in identifies the following factors to consider when assessing the hazards associated with trees:

Assessing trees:

Tree health
- Is the tree alive or dead?
- Are there dead branches or other visible signs of ill-health – dead leaves or twigs at the end of branches?
- Are there visible signs of rot or fungal attack on the trunk?
- Are there dead or sagging branches?
- Are there signs of ageing?
- Are there signs of coppicing or epicormic regrowth? (Branches that have grown following damage or stress might
  be more weakly attached than branches that form part of a tree's original structure)
Tree structure
- Is the tree balanced or leaning? Is any lean due to damage?
- Assess the size and relative weight.
- Are there structural weaknesses such as co-dominant forks with included bark2?
- Are there visible signs of damage to roots, trunk, or branches, such as wounds, cracks, or bulges?
  Does any damage observed compromise structure (for example root damage on one side, or loss of branches on one side)?
- Has the soil been softened by rain?
- Is the soil cracked or bulging?
- Are there any loose branches suspended in the canopy?
Assessing location
- What areas are at risk from falling branches?
- What areas are at risk from the whole tree falling? (Distance estimation)
- Is the tree particularly susceptible to wind loading from any particular direction?
- Does the tree have a large "sail" area (wind load)?
- Have tracks, clearing, or other works changed the way the tree has grown, or altered wind loads?
Weather
- What is the forecast
  - Rain softening the ground
  - Snow or ice loading
  - Wind loading
  - Rain loadings on canopy
  - Wind direction
- What previous weather events might have affected trees
  - Long dry spells
  - Sodden ground

When You Break or Lose A Tooth

Paul Auerbach — Sun, 17 Jul 2011 18:05:00 GMT

by Paul Auerbach, M.D.

Sometimes when a person falls or is struck in the mouth, a tooth is broken or knocked out. If a tooth is cracked (with the root still present and in place), there is little for the victim to do other than keep his mouth clean and avoid contact with extremes of temperature. If air, saliva, the tongue, or temperature change coming into contact with an exposed nerve causes intolerable pain, a temporary cap (shield) can be created by mixing melted paraffin (candle wax) with a few strands of cotton. When the mixture begins to harden but can still be easily molded, press a wad onto the tooth, using the teeth on either side as anchors. If you are carrying emergency dental supplies, a cap can be fashioned from Cavit™ or IRM®.

If a tooth is broken or a crown falls off, apply a little eugenol to the tooth for immediate pain control. For a displaced crown, press it back onto the tooth and see if the crown will hold without cement. If not, apply a dab of Cavit™ and use it as a fastener, scraping away the excess. If all else fails, cover the tooth with paraffin or dental wax.

If a tooth is shifted out of its normal position, but is still embedded in the gum, it may need to be repositioned. If the tooth appears to be longer or off to one side, use a gloved hand, firmly grasp the tooth, and move it into proper alignment. If the tooth has been pushed into the gum and appears to be too short, do not move the tooth.

If a tooth is knocked cleanly out of the socket, it can sometimes be replaced successfully if the victim can reach a dentist within the first hour. After two hours, there is little hope for salvage of that particular tooth. The best treatment for a tooth that has been out of the socket for 15 minutes or less is to gently rinse it clean (do not scrub the root of the tooth, because that will injure the periodontal ligament) and reinsert it with firm pressure into the socket to the level of the adjacent tooth. Try to splint the tooth in place with a paraffin bridge or a cap to the adjacent tooth. A better material for this purpose is Express Putty, which hardens within four minutes after equal amounts of the putty base and catalyst are mixed.

The best storage solution for a tooth that will be carried to a dentist is pH (acid–base) balanced (Hank’s balanced salt solution) and accompanied by a cushion to prevent injury to the microscopic ligament cells that hold the tooth in place and must reattach for the tooth to “take.” The Save-A-Tooth® or EMT Toothsaver™ storage device is recommended.

Alternately, the tooth can be placed in a container and covered with a small amount of cool, pasteurized whole milk (not yogurt, low-fat milk, or powdered milk) for transport. Do not carry the tooth on a dry cloth or paper. Do not soak the tooth in tap water. A tooth can also be rinsed and carried by the victim in the space between his lower lip and lower gum (taking care not to swallow the tooth), although saliva is not particularly good for the periodontal ligament. Do not place a tooth back into the socket unless an antibiotic (e.g., penicillin 500 mg four times a day for two weeks) can be administered to avoid an infection, and tetanus toxoid given if necessary.

Once the tooth is replaced, it can be splinted to an adjacent tooth or teeth by cutting a small piece of plastic and using something like tissue glue (Dermabond), if you have it in the first aid kit, to anchor the splint to the front of the teeth (Ann Emerg Med 2011;57:375-377). If it will be a few days until you are back to civilization, have the victim follow a soft diet, brush the teeth gently after eating, and use mouthwash twice a day.

If the socket of a broken or lost tooth continues to bleed, apply direct pressure by having the victim bite on a gauze pack for 30 minutes. If there is a large blood clot, remove it, then apply pressure. Keep the head elevated. Avoid rinsing, spitting, tooth brushing, and tobacco use for 24 hours. Gentle rinses with warm salt water can be started after that time period. If the bleeding does not stop after several hours, biting on a dry tea bag (tannic acid) may help. “Dry socket” may occur two to four days after a tooth is lost. This is characterized by pain, foul odor, and a bad taste. Inspection of the tooth socket may show exposed bone. Treatment is gentle saltwater rinses followed by packing with a strip of eugenol-soaked gauze. The pack should be changed every one to two days until the symptoms are relieved, which may take up to 10 days. During this period, do not ingest alcohol or carbonated beverages.

reposted with permission from the Medicine for the Outdoors Blog

Wilderness Medical Society Frostbite Treatment Practice Guidelines

Tod Schimelpfenig — Sun, 19 Jun 2011 17:57:00 GMT

It's summer somewhere; snowing in the Wind Rivers today.

The Wilderness Medical Society has released the second in a series of consensus practice guidelines on topics in wilderness medicine. This paper, guidelines for the prevention and treatment of frostbite, is the work of an expert panel convened at the 2010 Annual Winter Meeting of the WMS in Park City, Utah. The paper addresses both field and hospital treatment, describes the quality of evidence supporting the recommendations and the risk/benefit questions.

The paper is available at http://www.wemjournal.org/article/S1080-6032%2811%2900077-9/fulltext.

Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Frostbite.
Wilderness & Environmental Medicine, 22, 156–166 (2011)

Wilderness Medical Society Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness

Rick Curtis — Sun, 12 Jun 2011 17:25:00 GMT

To provide guidance to clinicians about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the prevention and treatment of acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE). These guidelines present the main prophylactic and therapeutic modalities for each disorder and provide recommendations for their roles in disease management. Recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches to the prevention and management of each disorder that incorporate these recommendations.

You can read the full version of the Guidelines online.

Mouth-to-Mouth Breathing Versus Mask-Assisted Breathing

Paul Auerbach — Mon, 06 Jun 2011 02:19:00 GMT

by Paul Auerbach, M.D.
reposted with permission from the Medicine for the Outdoors Blog

When a person performs cardiopulmonary (heart and lung) resuscitation (CPR), it is sometimes recommended to provide rescue breathing. This is certainly the case when the primary cause of the victim’s difficulty relates to failure to breathe adequately, such as with a drowning episode. When CPR first arrived on the landscape, laypersons were trained to perform mouth-to-mouth breathing (for adults) or mouth-to-mouth and nose breathing (for infants and small children).

Following growing concern about transmission of diseases from blood and body fluids, laypersons were introduced to using masks or something similar to allow them to provide breathing assistance (“artificial respiration,” “artificial ventilation,” “rescue breathing,” etc.) to non-breathing persons. Masks have been used for decades by professional rescuers for ventilating patients, often in conjunction with the use of bags in a “bag-valve-mask” configuration. The valve between the mask and bag provides for one-way flow and prevents the backwash of vomitus, blood, liquid from the lungs, or other fluids that might diminish the effectiveness of the technique.

A number of excellent masks and face shields are available on the market for rescuers to be able to (relatively) safely blow air into a victim’s lungs. One example is the NuMask, which is very useful and definitely indicated for personal (rescuer) protection. However, the NuMask requires some practice to use successfully. The masks typically used by professional rescuers require training and a strong set of hands (sometimes two sets of hands, depending on the situation and facial anatomy of the victim) to obtain a proper mask seal that can be maintained during rescue breathing using a bag.

Current advice to laypeople who might be called upon to provide rescue breathing is to carry and utilize a shield or shielding mask. I recently read a report from Reuters in which it was commented that a “small study suggests that lifeguards may perform better with direct mouth-to-mouth breathing.” For the study reported by this news agency, trained lifeguards performed CPR on mannequins using each of three breathing techniques – mouth-to-mouth, pocket mask, and bag-valve-mask. In this study, using visible chest rise in the mannequin, the lifeguards were successful 91 percent of the time with mouth-to-mouth, 79 percent of the time with pocket masks and 59 percent of the time with bag-valve-mask setups.

This announcement makes perfect sense to me, because I have performed all three techniques. With mouth-to-mouth breathing, the seal is created in a dynamic fashion by using the rescuer’s pliable lips to create a firm (as airtight as possible) closure over the victim’s mouth. This may be aesthetically displeasing, but it is effective and efficient. One knows exactly how firmly to press, and can change the lip (seal) position instantly to achieve the best seal possible. At the other end of the spectrum is the bag-valve-mask apparatus, which requires fairly precise placement, and is influenced by the victim’s facial anatomy, hair, and slippery factors like oral secretions, sweat, exogenous water, blood, and vomited gastric contents. Furthermore, it requires a reasonable amount of grip strength, sufficiently large hands, and good technique to achieve and maintain the seal. Somewhere in the middle is the smaller “pocket” rescue mask or shield, which usually fits fairly easily onto the victim and is easy to hold in place while the rescuer blows into it.

It is important to observe, as did Reuters, that this study could not be used to infer any direct effect on survivor outcome, either morbidity or mortality, because it was performed on mannequins, not on real victims. Other factors should be considered besides chest rise, such as the fact that supplemental oxygen can be administered using a port into the bag-valve-mask apparatus, as well as knowing how long it takes for a rescuer to become fatigued, thereby rendering any technique less effective or ineffective.

Given the risks associated with disease transmission (which is estimated, but not definitively measured, in the literature), we cannot infer that the improvement in effect with mouth-to-mouth over the other techniques would argue for a change in recommendations. They would, however, certainly emphasize the importance of proper training and maintenance of skills. Learning a technique one time does not solve anyone’s educational needs over the long term. Refreshers are essential to sharpen your skills to function well in an emergency situation.

Brief Introduction to Search and Rescue

Paul Auerbach — Mon, 16 May 2011 02:55:00 GMT

by Paul Auerbach, M.D.
reposted with permission from the Medicine for the Outdoors Blog

Finding lost persons in the wilderness is, unfortunately, increasingly necessary as greater numbers of persons explore in the outdoors. Beyond the need to find explorers in remote environments, there is the common situation of a young child wandering off into the woods, or an elder with dementia becoming disoriented from failing to remember their path. Persons who perform search and rescue (“SAR”) are commonly volunteers with superb orienteering skills and admirable dedication to helping out at a moment’s notice in difficult situations. Dr. Aaron Billin gave a wonderful lecture entitled “Search and Rescue Theory” at the 2010 Wilderness Medical Society annual meeting. Here is just a very small amount of what we learned.

SAR Techniques

There are many definitions of SAR, generally revolving around assisting and retrieving persons in distress, providing for their initial medical and other needs, and delivering them to a place of safety. Depending on the terrain, weather, time of day, and so forth, this can be a very daunting task that requires numerous individuals, teamwork and expensive resources.

SAR types include mountain rescue, combat rescue, air-sea rescue, ground rescue, and urban rescue. Essential SAR skills include wilderness survival and improvisation, wilderness first aid, high angle rescue, low angle rescue, ice rescue, mountaineering rescue, swift water rescue, cave rescue, use of search dogs, horse-mounted rescue, dive rescue, and person tracking. Contemporary SAR participants sometimes use modern technologies, including global positioning systems (GPS), emergency locating beacons (including aircraft emergency locator transmitters [ELT], watercraft emergency position indicating beacons [EPIRB] and handheld personal locator beacons [PLB]), satellite-based locating and positioning systems, sonar, thermal imaging, and night vision apparatus. The techniques employed to find lost persons include profiling and behavior, evidence handling, “hasty teams,” grid searches, and lost person containment.

In SAR, one common technique is to attempt to construct a profile of the lost person to use to predict his or her behavior. It is even possible to use mathematical models to determine how best to go about searches for these persons.

When a person is lost, the lost person questionnaire attempts to record the source of information, name and address of the lost person, physical description, trip plans, clothing type, point last seen, outdoor experience, habits and personality, health and general condition, equipment carried, contacts that the lost person would make if possible, what actions have been taken, and family concerns. All of these are potentially useful to help locate and care for the lost person.

Search Urgency

Search urgency is determined by a number of factors, including age, medical condition, number of lost persons, experience, weather, equipment, terrain and hazards, and so forth. Each of these offers information, both for an individual’s situation, and to predict the likelihood of a difficult situation and the possibility of a successful outcome. For instance, it is known that children ages one to three years may have no concept of being lost, have no navigational skills or sense of direction, will tend to wander aimlessly, and may lie down and go to sleep. Children ages three to six years are more mobile, have a concept of being lost and try to return to a familiar place, may become lost by pursuing interests or attractions, look for a place to sleep when tired, and may have been instructed to avoid strangers. Children ages six to 12 years may become confused in a strange environment, may intentionally run away for personal reasons, may not answer when called, and are provoked by darkness to accept help. Elders may suffer from dementia or senility, be hard of hearing, are often easily distracted, are oriented to past environments rather than the present, and might overextend themselves. Mentally challenged individuals of all ages behave much like children ages six to 12 years, often do not respond to their name, may hide because they are frightened or seeking shelter, may remain or hide for days in the same location, and often do not make an effort to help themselves. Despondent persons usually seek solitude, generally will not respond to searchers, are usually within sight and sound of civilization, and tend to be found near prominent locations (e.g., lake, hill, scenic vista).

Why SAR Is Needed

When hikers become lost or overdue on their return, it is often because they have lost the trail, fallen behind and become disoriented, or become ill or injured. Hunters may become lost because in pursuit of game, they have dropped their attention on navigation, overextended themselves in terms of terrain and darkness, or are unprepared for inclement weather. Fishermen get into trouble by having accidents, including those related to boating. Climbers run afoul of weather, falling debris, and avalanches. Skiers go out of bounds, suffer accidents, or stay out late as the day descends into disorienting darkness.

Organizations with information and training on SAR include the National Search and Rescue School, National Association for Search and Rescue, Mountain Rescue Association.

Comfort Zone: Model or metaphor?

Rick Curtis — Mon, 09 May 2011 03:33:00 GMT

I found this research paper from the Australian Journal of Outdoor Education by Mike Brown of the University of Waikato and wanted to share it. Mike presents a very interesting perspective on the Comfort Zone in outdoor education programming.

ABSTRACT: The comfort zone model is widespread within adventure education literature. It is based on the belief that when placed in a stressful situation people will respond by overcoming their fear and therefore grow as individuals. This model is often presented to participants prior to activities with a highly perceived sense of risk and challenge which arouses strong emotional and physical responses to novel tasks (e.g., ropes courses or rock climbing activities). Students are encouraged to think about ‘stretching themselves’ by moving outside their comfort zone, to expand their preconceived limits and by inference learn (and become better people). This paper explores theories from cognitive and social psychology, based on the work of Piaget and Festinger respectively, that underpin the comfort zone model. The perpetuation of this model which uses risk to promote
situations of disequilibrium/dissonance does not find strong support in educational literature. It is therefore suggested that the comfort zone model be reframed as a metaphor, for possible discussion post activity, rather than being used as a model to underpin programming and pedagogy in adventure education settings.

You can read the PDF online.

The State of Outdoor Recreation in the United States

Rick Curtis — Mon, 02 May 2011 02:51:00 GMT

Each year the Outdoor Industry Foundation releases it's Outdoor Recreation Participation Topline Report which presents an assessment of the level of participation in outdoor sporting activities in the United States. Monitoring these trends are key for outdoor programs to stay focused on what activities are of major interest to different population groups.

Unlike many other sports, outdoor participation among Americans has remained remarkably stable over the last several years - demonstrating impressive resiliency during challenging economic times. According to The Outdoor Foundation's topline report, the rate of participation in outdoor recreation in the United States remained solid in 2010 and at the same level seen in 2008. Nearly half of Americans ages 6 and older, or 137.9 million individuals, participated in at least one outdoor activity in 2010, making 10.1 billion outdoor outings, according to the 2011 Outdoor Recreation Participation Topline Report. The research shows significant increases in adventure sports such as kayaking, backcountry camping and climbing as well as slight increases in youth participation among those individuals ages 13 - 24.

Published annually by The Outdoor Foundation, the 2011 Outdoor Recreation Participation Topline Report 2011 is derived from 40,000 online interviews conducted in January 2011/early February 2011. Respondents came from a nationwide sample of individuals and households from the U.S. Online Panel operated by Synovate. A total of 15,086 individual and 23,656 household surveys were completed. The total panel has over 1 million members and is maintained to be representative of the U.S. population. Over-sampling of ethnic groups took place to boost response from typically under-responding groups.

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The Fully Stocked First Aid Kit

Paul Auerbach — Mon, 18 Apr 2011 13:30:00 GMT

by Paul Auerbach, M.D.
reposted with permission from the Medicine for the Outdoors Blog

[Outdoor Ed Note: What goes into a good backcountry first aid kit is always a balancing act between size of group, length and remoteness of trip, first aid expertise, type of environment and potential environmental hazards, weight and cost. Our contributing blogger Dr. Paul Auerbach, author of numerous wilderness first aid books including Medicine in in the Outdoors, goes over his exhaustive list of first aid supplies from his book. While you may not carry all of this stuff, it's a fantastically thorough list to work from as you pare down to what would be appropriate for your program.]

As a reminder of what a layperson might need to consider carrying in order to be prepared to assist a person outdoors in need of medical attention, here is a list that appears in the 5^th edition of Medicine for the Outdoors.. From this list, one would select the desired items:

General Supplies

medical guidebook
first-aid report form
pencil or pen with small notepad
steel sewing needle
paper clip
safety pins
needle-nose pliers with wire cutter
sharp folding knife
disposable scalpels (#11 and/or #12 blades)
paramedic or EMT shears (scissors)
Swiss Army® knife or Leatherman®-type tool
seam ripper
sharp-pointed surgical scissors
bandage scissors
splinter forceps (tweezers)
standard oral thermometer: digital, mercury, or alcohol
low-reading hypothermia thermometer
wooden tongue depressors (“tongue blades”)
rolled duct tape (3 in x 1 yd, or 91 cm)
1/8- to 1/4-inch-diameter braided nylon cord (minimum 10 ft, or 3 m)
water bottle (such as Nalgene® 1/2 to 1 liter)
blue “baby bulb” or “turkey baster” suction device
waterproof flashlight (such as Pelican® MityLite™)
headlamp (and spare batteries) – preferably with floodlight and flash settings, able to withstand moisture and temperature extremes
CYALUME® fluorescent light sticks
CPR mouth barrier or pocket mask (such as a Microshield® X-L Mouth Barrier™ or NuMask® Pocket CPR Kit)
sterile (hypoallergenic or latex) surgical gloves; if you are allergic to latex, bring other (such as nonlatex synthetic) nonpermeable gloves
signal mirror
magnifier
waterproof matches
fine-mesh head net or travel tent to repel insects
Oral Rehydration Salts or Cera Lyte 70 oral electrolyte powder
rubber cement
urine pregnancy test

Wound Care—Preparations and dressings

elastic bandages (Band-Aid® or Coverlet®), assorted sizes (strip, knuckle, and broad); cloth with adhesive is preferable
Band-Aid® Liquid Bandage
butterfly bandages
adhesive strips for wound closure (Steri-Strip™ or Cover-Strip® II), assorted sizes (such as 1/4 in x 4 in, 1/8 in x 3 in, 1/2 in x 4 in), reinforced (plain or impregnated with an antimicrobial) or elastic
3 in x 3 in or 4 in x 4 in sterile gauze pads (packets of 2 to 5) (such as Nu-Gauze® highly absorbent)
5 in x 9 in or 8 in x 10 in sterile gauze (“trauma”) pads (packets of 2 to 5)
nonstick sterile bandages (Telfa), assorted sizes
1 in, 2 in, 3 in, and 4 in rolled conforming gauze (C-wrap or Elastomull®)
1 in x 10 yd (9.1 m) rolled cloth adhesive tape
1 in x 10 yd (9.1 m) rolled paper or silk (hypoallergenic) adhesive tape
1 in x 10 yd (9.1 m) rolled waterproof adhesive tape
1/2 in x 10 yd (9.1 m) rolled waterproof adhesive tape
Blist-O-Ban® blister bandages (assorted sizes)
Molefoam (41/8 in x 33/8 in)
Moleskin Plus (41/8 in x 33/8 in)
Spenco®® 2nd Skin® (1.5 in x 2 in, 3 in x 4 in, 3 in x 6.5 in) and Spenco® Adhesive Knit Bandage (3 in x 5 in)
Aquaphor moist nonadherent (petrolatum-impregnated) dressing (3 in x 3 in)
Hydrogel occlusive absorbent dressing (4 in x 4 in x 1/4 in)
Tegaderm® transparent wound dressing (also comes in combination with a Steri-Strip™ in a Wound Closure System)
liquid soap
sterile disposable surgical scrub brush
cotton-tipped swabs or applicators, sterile, 2 per package
safety razor
syringe (10 ml to 60 ml) and 18-gauge intravenous catheter (plastic portion), for wound irrigation (do not use plastic disposable syringes to administer oral medications, as the small caps can dislodge and inadvertently eject into the patient’s throat.)
Zerowet Splashield or Supershield (2)
tincture of benzoin, bottle or swabsticks
benzalkonium chloride 1:750 solution (Zephiran)
povidone iodine 10% solution (Betadine), 1 oz bottle or swabsticks
suture material (nonabsorbable monfilament nylon on curved needle, suture sizes 3/0 and 4/0; consider sizes 2/0 (thicker) and 5/0 (finer)
stainless-steel needle driver
disposable skin stapler (15 staples)
disposable staple remover
tissue glue

Splinting and Sling Material

cravat cloth (triangular bandage)
2 in, 3 in, and 4 in elastic wrap (Ace)
4 1/4 in x 36 in SAM® Splints (2)
aluminum finger splints
Kendrick® femur traction device

Eye Medications and Dressings

prepackaged individual sterile oval eye pads
prepackaged eye bandages (Coverlet® Eye Occlusor)
metal or plastic eye shield
sterile eyewash, 1 oz (30 ml)
contact lens remover (or mini-marshmallows)
ofloxacin, moxifloxacin or gatifloxacin eye drops
oxymetazoline hydrochloride 0.025% eye drops

Dental Supplies

oil of cloves (eugenol), 3.5 ml
Cavit™, 7 g tube
Intermediate Restorative Material (IRM®)
Express Putty
zinc oxide powder
dental floss
mouth mirror
paraffin (dental wax) stick
wooden spatulas
cotton (rolls and pellets)

Topical Skin Preparations

hydrocortisone cream, ointment, or lotion (0.5 to 1%)
potent corticosteroid ointment
bacitracin ointment
mupirocin ointment
mupirocin calcium 2% cream
bacitracin-neomycin polymyxin B sulphate ointment
miconazole nitrate 2% antifungal cream
silver sulfadiazine 1% (Silvadene) cream
insect repellent
sunscreen lotion or cream
lip balm or sunscreen
sunblock
Adolph’s meat tenderizer (unseasoned)
Kenalog in Orabase (oral adhesive steroid for canker [mouth] sores), 5 g container
aloe vera gel
hemorrhoidal ointment with pramoxine 1%

Nonprescription Medications

buffered aspirin, 325 mg tablets
ibuprofen, 200 mg tablets
acetaminophen, 325 mg tablets
antacid
decongestant (such as pseudoephedrine) tablets
decongestant (such as oxymetazoline) nasal spray
loperamide (Imodium A-D), 2 mg caplets
Glutose™ (glucose) gel tube
stool softener (such as docusate calcium, 240 mg gel caps)
caffeine, 200 mg tablets (to stay awake for survival purposes, such as during a rescue)

Prescription Medications

Select from this list, and from information throughout this book, what you feel you might need; the drugs listed are for example.

Pain medication(s): e.g., hydrocodone 5 mg with acetaminophen 500 mg
Asthma medication(s); e.g., metered-dose bronchodilator (albuterol)
Allergy medication(s): e.g., epinephrine (injectable) and prednisone, 10 mg tablets
Antibiotics: e.g,
penicillin V potassium, 250 mg tablets
azithromycin, 250 mg tablets
dicloxacillin, 250 mg tablets
ampicillin, 250 mg tablets
amoxicillin-clavulanate, 500 mg tablets
erythromycin, 250 mg tablets
cephalexin, 250 mg tablets
ciprofloxacin, 500 mg tablets
tetracycline, 500 mg tablets; or doxycycline, 100 mg tablets
trimethoprim-sulfamethoxazole, double-strength tablets
prochlorperazine (Compazine) suppositories, 25 mg
promethazine (Phenergan) suppositories, 25 mg

Allergy Kit

allergy kit with injectable epinephrine (EpiPen® auto-injector [0.3 mg] and EpiPen® Jr. auto-injector [0.15 mg]; or Twinject® 0.3 or 0.15 mg auto-injector)
diphenhydramine, 25 mg capsules

For Forest and Mountain Environments

water disinfection equipment or chemicals (such as Potable Aqua tablets or Polar Pure iodine crystals)
calamine lotion
SPACE® Emergency Blanket (2 oz, 56 in x 84 in) (alternatives include Pro-Tech Extreme bag or vest, SPACE® brand emergency bag, SPACE® brand all-weather blanket)
hypothermia thermometer
hyperthermia thermometer
whistle
acetazolamide (Diamox), 250 mg tablets
dexamethasone (Decadron), 4 mg tablets
nifedipine (Adalat CC), extended-release 30 preparation
powdered electrolyte beverage mix (Oral Rehydration Salts)
instant chemical cold pack(s)
hand warmer (mechanical or chemical)
Kendrick® Traction Device (leg splint)

For Aquatic Environments

waterproof dry bag or hard case (such as Pelican Case, Storm Case, or OtterBox), to carry first-aid supplies
motion sickness medicine
acetic acid (vinegar) 5%
isopropyl alcohol 40%
hydrogen peroxide
VoSol otic solution
Ofloxacin 0.3% ear drops
Safe Sea® Sunblock with Jellyfish Sting Protective Lotion

A sole supplier, such as Rescue Essentials, will be unlikely to have everything you need for every situation, but it is a good place to begin to get a handle on what is available and what the cost is to consumers. Remember: allow yourself enough lead time prior to any outdoor adventure in order to gather your belongings and to be properly prepared.

Australian Study shows ongoing outdoor education program multiplies life effectiveness skills

Rick Curtis — Mon, 11 Apr 2011 13:16:00 GMT

A recent Australian study shows teenagers exposed to outdoor education programs develop real life skills that give them a huge advantage over others as they transition into adult life.The study, commissioned by Cranbrook School in Sydney, is the first to follow a group of students who attend four Outward Bound courses as part of their mandatory high school curriculum from Year 7 to 10. "It shows young people taken from the comfort of their homes learn to be self reliant fast in wilderness conditions. They also learn to take responsibility, work in teams, and accept the consequences of their own actions. Their life skills grow with every year, and by their final outdoor experience they are significantly more confident, capable and stable than students who did not participate. They are also far better prepared to initiate, motivate, and lead in later life." The study, led by Dr. James Neill from the University of Canberra, used a variety of measures to assess changes in leadership and other social skills impacted by an ongoing Outward Bound experience.

Experts agree than any outdoor education is better than none. Similar research techniques have been used to measure the effect of short courses – some less than a week - provided by others in the industry – all of which show students developing positive life skills. The Cranbrook Study shows that the benefits are multiplied if students take part in more than one outdoor education course throughout their school years.

You can download a PDF copy of the full report from Outward Bound Australia.