Outdoor Ed Community

Classroom Medicine

Tod Schimelpfenig — Mon, 07 May 2012 22:52:00 GMT

I recently sat through a wilderness medicine class by a well-meaning instructor who, despite decent credentials, had never cared for anyone in the wilderness. This is just after reading a poorly crafted wilderness medicine text. Instead of listening to the talk I made a list of things that drive me nuts in wilderness medicine education.

At the top of the list is classroom medicine. These are tools, techniques and advice that work in a clean, controlled world and fail in the reality of the field. Years ago we taught, I taught, not to apply warmth to a severely hypothermic patient because they were in "a stable metabolic icebox." Then I knelt next to my first severely hypothermic patient and the shallowness of this advice was clear. I had no illusions I would warm this patient in the field, but not applying heat to stabilize his temperature made no sense. I read advice to keep frozen feet frozen all night by keeping the foot outside a sleeping bag. This fell to the axe of reality when I stared at my own frozen foot in a tent on a cold winter's night. We used to think tourniquets implied amputation and that open chest wounds need to be sealed with three-sided dressings to allow air to escape. This classroom advice did not survive the test of the battlefield. If your skepticism meter is pegging over words of dubious wisdom, ask the instructor if he has ever done this to a real patient. You'll be surprised how often the honest answer is no.

High on my list are inaccurate statements of frequency. If I believed all the tales of drama I hear from someone who heard from someone who heard, I would not leave home without an auto- injector of epinephrine in a hip holster, locked and loaded. If I believed the NOLS incident data history, solid enough to generate multiple medical papers, I can argue that anaphylaxis is rare in the wilderness. But I won't make that argument. A snapshot is not the entire picture. Data is often a matter of context. We don't know the true incidence of anaphylaxis, or many other ailments, in the outdoors. Statements of frequency need to be viewed with healthy skepticism.

In the same vein I recently read that the risk of a lawsuit from reducing a dislocation in the field is high. Based on what cases or data? I've heard outdoor experts say that the most common injury on NOLS courses is a laceration from slicing cheese. The real answer, sprains and strains, is easily accessible in the published literature. When you see or hear numbers, ask for the source, and ask for the conflicting evidence. If the educator is worth his salt he will tell you the breadth of science on this question and why he choose to believe this particular study. Consider any unreferenced number to be junk.

I'm also skeptical of resumes, credentials and endorsements. Resumes can be exercises in creative writing, exaggerating or underselling experience. Credentials often tell us of educational accomplishments, not experience. Endorsements might be earned, but they can also be purchased-- a source of income for an organization willing to sell their name. These badges don't tell us whether the person has ever seen a patient, seen a patient in the wilderness, spent much time in the wilderness or whether they have ever had to make a real decision in the field.

In my upper echelon of molar grinders are statements of absolutes. These often reveal inexperience, not expertise, and as William Osler MD said "are made at the expense of a clean conscience." There isn't an “accepted” splint. There are splints that are crafted based on available resources and splinting principles. There is no single evacuation plan. There is only what we create based on sound plans, sound assessments and sound judgments. There are many lists of classic signs and symptoms, there is rarely a classic patient.

Last, but not least, is the phrase "our curriculum is evidence-based." This is an intriguing statement since quality evidence in first aid is rare, and in wilderness first aid it is almost non-existent. I prefer to say "evidence-informed." It acknowledges that our choices are a blend of science, experience and opinion.

Am I a curmudgeon? Probably. Am I innocent of these sins? Probably not. But I am aware. I'm trying to be virtuous and I do have the good fortune of being surrounded by colleagues who enjoy calling me to task when I slip.

Take care

Tod Schimelpfenig

Curriculum Director

NOLS Wilderness Medicine Institute

May 2012

Do you inform pre-orientation students that they must follow college policies while traveling off-campus?

Brent Bell — Thu, 03 May 2012 14:45:14 GMT

Another listserve I monitor (National Orientation Directors Association) has started a discussion regarding policies. How are students informed that they are expected to follow college policies while on a pre-orientation trip away from campus? Although this is not confusing to most program directors, it may be confusing to participants?

I wonder about student led programs that perceive a bit of distance from the administration, is it clear that college policies apply during trips in the summer?

I am hoping to hear how others inform students and if their are any stories to learn from. It is one detail that you may want to include with your paperwork distributed to incoming students.

Brent

Introducing The Curriculum Project

Rick Curtis — Sun, 15 Apr 2012 04:18:00 GMT

I just got back from this spring's OOPS Conference (Outdoor Orientation Symposium) hosted as the Association for Experiential Education AEE new England Regional Conference). OOPS is an annual event that brings together student leaders and program directors and staff from college outdoor orienation programs.

Brent Bell, Professor from the University of New Hampshire and the leading researcher on outdoor orientation programs again served as conference convener. Brent's opening presentation was on his ongoing research project - The Neighborhood Project - the goal of which is to identify adn track the various outdoor orientation programs in North America to understand the range of programs and to ascertain what are the key elements that make programs successful and, as a corollary, what factors cause programs to fail/be discontinued.

During the discussion period of Brent's talk and throughout the other presentations during the day, one factor emerged as the key reason for program success - CURRICULUM. Good curriculum is what creates, builds and maintains successful programs.

Based on the understanding, those of us in the outdoor orientation field are coming together to create a corollary to The Neighborhood Project that we are calling The Curriculum Project.

The goal of The Curriculum Project is to gather curriculum and successful practices from all of the existing outdoor orientation programs on the OutdoorEd.com Outdoor Orientation Community site so that all of us can benefit from the individual expertise of our peer programs. It's simple to do. Go to the Files Tab and upload files you want to share.

For specific guidelines on the types of files we can take, see the general Submissions Information page.

Start Posting Now. Strong Curriculum means Strong Programs

The Outdoor & Adventure Orientation Program Census 2012

Rick Curtis — Mon, 09 Apr 2012 02:24:54 GMT

Dear orientation program representative,

The following survey collects information on adventure orientation programs, such as outdoor orientation, camp-based, service, academic, and arts based orientation programs. The term adventure orientation is defined in a recent paper (Vlamis, Bell, & Gass 2011) as an orientation using novel experiences and challenges combined with reflective activities to meet the goals of student orientation.

The first census of such programs was completed in 2006 with a 98% participation rate. This census updates the 2006 study and will be used to verify adventure orientation program trends and complete an accurate account of adventure orientation program practices. This survey will help form a deeper understanding of the 200+ programs in the USA and Canada. This survey focuses on program features and operation; it does not ask for information about individuals. All information will be used in aggregate. The research will not be reported in a manner to identify individual program practices.

This survey is comprehensive. It will take most people 20-30 minutes to complete up to a maximum of 57 questions (where the total number will depend on the response path taken). We understand that directors of adventure-based orientation programs are busy people, and we appreciate your time responding to this research. If you would prefer to take the survey by phone instead, please email the researchers (emails are listed below).

If you have any questions about the survey, please contact us. We (the research team) appreciate your participation. The cooperation of the "neighborhood" is an outstanding feature of adventure orientation programs.

https://docs.google.com/spreadsheet/viewform?formkey=dFhITkN1Vjl3ODFTR0pvNU5hcDlVUmc6MQ#gid=0

Sincerely,

Dr. Brent Bell
UNH Outdoor Education
bbell@unh.edu

David Starbuck, Ph.D. ABD
UNH Outdoor Education
David.Starbuck@gordon.edu

Patricia Chan
Graduate student in outdoor education at UNH
patriciagchan@gmail.com

Ibuprofen and Altitude Illness

Tod Schimelpfenig — Mon, 26 Mar 2012 16:42:00 GMT

I've been receiving emails about the recent online publication of a study in the Annals of Emergency Medicine titled “Ibuprofen Prevents Altitude Illness: A Randomized Controlled Trial for Prevention of Altitude Illness With Nonsteroidal Anti-inflammatories.” the study was highlighted by several of the health blogs and newspapers.

Eighty-six study participants took either ibuprofen 600 mg or placebo three times a day, beginning 6 hours prior to ascent from 4,100 feet (1,240 meters) to 12, 570 feet (3,810 m) in the White Mountains of California. The study looked at the incidence and severity of acute mountain sickness (AMS) as measured by the Lake Louise Questionnaire AMS score.

The ideal way to prevent AMS is to ascend slowly and acclimatize. Some folks don't want to do this, others may not be able to do it, and some folks still need assistance from medications. The standard has been acetazolamide (Diamox) which is well studied and received an endorsement in the recent WMS Consensus Guidelines for Prevention and Treatment of Altitude Illness.

Acetazolamide (Diamox) works by stimulating breathing, which facilitates acclimatization. We don't know how ibuprofen, an anti-inflammatory medication, works in AMS treatment. It might dampen an inflammatory component to AMS. This remains an active area of research.

In the recent study 69% of the people taking placebo and 43% of the ibuprofen group developed AMS. The severity of the AMS score was less in the ibuprofen group, but it did not meet the predetermined level of significance the authors hoped for.

Ibuprofen is appealing because it is non-prescription and readily available. Both medications have their side effects - pick your poison. This study suggest ibuprofen might work faster than acetazolamide, which should be started the day prior to ascent.

I don't think this study knocks acetazolamide (Diamox) from the altitude medication podium. I'm always skeptical of the latest and greatest drug for altitude illness. They come and they go. We need to see this work replicated, controlled for ascent profile, dehydration and other causes of headache and compared head-to-head with acetazolamide.

In the meantime , given no contraindications or adverse side effects,it is reasonable to use Ibuprofen as a non-prescription medication for prevention of AMS symptoms. If you have a history of AMS talk with your doctor about your choice of medication. Acetazolamide, with it's proven effect on acclimatization, and it's ability to smooth out erratic breathing during sleep,might be a better choice for you.

New Book: Outdoor Program Administration: Principles and Practices

Rick Curtis — Mon, 19 Mar 2012 02:42:00 GMT

A new book has just come out from Human Kinetics Publishing from the Association of Outdoor Recreation and Education (AORE) that adds to the growing list of text books that focus on outdoor education and is a great reference title for any professional's library. The editors, Mat Epeldring and Geoff Harrison have brought together experts from across the industry to explain administering outdoor programs from the inside out. Available from Amazon.com and Human Kinetics.

[Full disclosure - the authors included a graphic on risk management and decision making from one of my lectures. I did not receive any compensation for the use of my material.]

About the Author:

The Association of Outdoor Recreation and Education (AORE) provides opportunities for professionals and students in the field of outdoor recreation and education. AORE’s mission is to exchange information; promote the preservation and conservation of the natural environment; and address issues common to college, university, community, military, and other not-for-profit outdoor recreation and education programs.

Geoff Harrison, MS, has been working in the field of health and recreation for over 20 years and has been fostering student and staff development at Boise State University since 1998. Geoff serves as the associate director of education and recreation at Boise State University, where he oversees multiple programs and service areas, department partnerships, and initiatives. He also serves as an adjunct faculty for the department of kinesiology. Prior to his work at Boise State, Geoff worked in the fields of publishing, event promotion, and domestic and international adventure travel.

Geoff has served the Association of Outdoor Recreation and Education as a committee chair, board member, conference host, and interim national director. In 2010, Geoff was the recipient of the Association of Outdoor Recreation and Education’s Jim Rennie Leadership Award.

Mat Erpelding, MA, has been working in the field of physical education and outdoor leadership for over 15 years. Currently, he teaches at the College of Western Idaho in the physical education department and at Boise State University in the leadership studies minor. Additionally, Mat guides mountain climbers and teaches courses for the American Alpine Institute and teaches wilderness medicine courses for the Wilderness Medicine Training Center. Before making the transition to outdoor education, Mat worked as a developmental therapist and in the mental health industry.

Mat is a past president of the Association of Outdoor Recreation and Education and served on committees and the board of directors and as a conference host. In 2006, Mat was the recipient of the Association of Outdoor Recreation and Education’s Jim Rennie Leadership Award, and in 2010 he received the Instructor of the Year Award from the Wilderness Education Association.

Mat and Geoff co-own Experiential Adventures LLC. They provide training and consulting services to organizations that foster leadership development, help organizations manage change, develop positive organizational cultures that promote success, and build professionalism in outdoor programs through trainings and certifications.

From the Publisher:

Outdoor recreation programming is a growing and diverse field that requires administrators to be ready to work in complex and multidisciplinary environments. Outdoor Program Administration: Principles and Practices will help both seasoned and new administrators—as well as students and emerging professionals—flourish in various settings, including university, military, government, commercial, and nonprofit organizations.

You’ll learn the best contemporary administrative strategies and practices from veteran professionals from the Association of Outdoor Recreation and Education (AORE). The AORE authors provide extensive coverage of all aspects of administrative duties and responsibilities from a diverse organizational setting.

Outdoor Program Administration: Principles and Practices guides you in developing and sustaining programs in outdoor recreation settings across public, private, and nonprofit sectors. You will reap the benefits of the experience shared by the AORE authors, who also provide questions and critical thinking exercises that will enhance the materials and deepen your understanding.

This reference explores all the issues pertinent to being a successful outdoor program administrator. The book has four sections: Outdoor Program Foundations, Program Design and Implementation, Staffing Considerations, and Facilities and Programs. Topics you’ll delve into include

designing and developing programs;
risk management and legal considerations;
budgeting and financial operations;
marketing and land access (permits);
environmental stewardship;
staff recruitment, supervision, training, and assessment; and
management of indoor climbing walls and challenge courses.

Outdoor Program Administration: Principles and Practices presents material that will help you improve your administrative skills and enhance the programs you oversee. As such, it’s an essential book for your professional library.

Contents

Preface

Part I. Outdoor Program Foundations

Chapter 1. The Outdoor Program Administrator
Geoff Harrison, MS, and Mat Erpelding, MA
Outdoor Program Administration Defined
Outdoor Program Administrator Defined
Skill Sets for Outdoor Program Administrators
Administrative Competence
Acquiring Skills
Professional Maintenance
Administrative Challenges
Summary

Chapter 2. History of Outdoor Recreation in the United States: An Outdoor Program Administrator’s Perspective
Steven P. Guthrie, PhD, Bryan J. Cavins, EdD, and Jerome Gabriel, MEd
The Beginnings of Environmentalism and Outdoor Recreation: 1825 to 1880
The Beginnings of a Profession: 1880 to 1920
National Environmental Consciousness and Outdoor Recreation Evolves: 1920s to 1960s
Adventure Programming Emerges: 1960s to 1990
Outdoor Adventure Programming Today (1990 to Present)
Summary

Chapter 3. Dimensions of Outdoor Recreation Programs
Todd Bauch, MEd, and Steve Hutton, MA
Three Service Sectors of Outdoor Recreation Programs
Common Programmatic Types
Common Facilities or Resources of Outdoor Programs
Outdoor Program Administrative Structures and Models
Summary

Chapter 4. The Future of Outdoor Program Administration
Laurlyn K. Harmon, PhD, and Susan L. Johnson, MS
Evolving Participant Characteristics
Staffing
Professionalization of the Field: Standards, Certifications, Accreditation
Youth and the Outdoors
Technology and the Outdoors
Sustainability
Collaborations and Partnerships
Outcome Assessment
Summary

Part II. Program Design and Implementation

Chapter 5. Administrative Risk Management
Mat Erpelding, MA, and Geoff Harrison, MS
Terms and Definitions of Risk Management
Creating a Comprehensive Risk-Management Plan
Summary

Chapter 6. Designing and Developing Outdoor Recreation and Education Programs
Todd Miner, EdD, and Heidi Erpelding-Welch, MS
Vision
Mission Statement
Strategic Plan
Sustainability
Dealing With Change: Evolve to Survive and Thrive
Summary

Chapter 7. Legal Considerations in Outdoor Recreation
Brent Wilson, JD, and Tracey Knutson, JD
Negligence
Legal Definition (Elements) of Negligence
Negligence and Related Theories of Liability
Defenses Against Negligence
Role of Insurance in Legal Liability Matters
Summary

Chapter 8. Budgeting and Financial Operations of Outdoor Programs
Tim J. Moore, MS, and Geoff Harrison, MS
Budget Components
Budget-Development Strategies
Forecasting Expenses and Revenue
Summary

Chapter 9. Marketing Outdoor Programs
Geoff Harrison, MS, and John McIntosh, PhD
Marketing Basics
Identifying the Market
Marketing Mix
Developing a Marketing Plan
Branding
Marketing Methods
Summary

Chapter 10. Access and Permitting for Use of Public Lands
Rachel M. Peters, MA
Outdoor Programs on Public Lands
Permitting Defined
Management Agencies and Regulations
Permitting Tips
Summary

Chapter 11. Environmental Stewardship
Whitney Ward, PhD, and Will Hobbs, PhD
History of Environmental Stewardship in the United States
Major Impacts of Recreation Today
Applied Environmental Stewardship
Integration of Environmental Stewardship and Recreation
Summary

Chapter 12. Developing Policies, Procedures, and Guidelines for Outdoor Programs
Mat Erpelding, MA, Curt Howell, MA, and Brien Sheedy, MA
Characteristics of Quality Policy, Procedure, and Guideline Documents
Considerations Specific to Developing Policies and Procedures
Developing Administrative Policies and Procedures
Developing Field Policies and Procedures
Summary

Part III. Staffing Considerations

Chapter 13. Staff Recruitment and Supervision
Jeff Turner, PhD, and Leigh Jackson-Magennis, MEd
Human Resource Planning
Staff Selection
Staff Supervision
Summary

Chapter 14. Staff Training
Bruce Saxman, MA, and Tom Stuessy, PhD
Needs Assessment
Staff-Training Progression
Mentoring
Staff-Training Assessment
Mechanisms for Training Assessment and Evaluation of Staff
Staff-Training Designs: Integrated Training Model
Activity-Specific Training
Staff Appraisal
Summary

Chapter 15. Staff Assessment
Jenny Kafsky, PhD, and Mark Wagstaff, EdD
The Basics and Purpose of Staff Assessment
An Effective Environment for Assessment
Assessment Criteria
Assessment Tools
An Effective Assessment System
Summary

Part IV. Facilities and Programs

Chapter 16. Rental Operations
Rob Jones, MS
Planning
Purchasing
Rental Center Operations
Summary

Chapter 17. Indoor Climbing Walls
John Bicknell, MA, and Guy deBrun, MS
History of Artificial Climbing Walls
Climbing Wall Facilities and Construction
Climbing Wall Activities
Climbing Wall Management
Summary

Chapter 18. Challenge Course Management
Christina Carter Thompson, MS, and Adam Bondeson, BA
Challenge Terms
History
Challenge Course Program Design and Outcomes
Primary Influences on Challenge Programming
Challenge Course Facilities
Designing and Choosing a Course
Bidding Process
Building Process
The Challenge Course Administrator
Organizational Support and Resources
Summary

Chapter 19. Land-Based Programming
Curt Howell, MA
Incident Prevention and Incident Response
Cost Analyses
Determining Learning Outcomes
Risk Management
Backpacking
Climbing
Caving Programs
Mountaineering
Ski Programs
Cycling
Summary

Chapter 20. Water-Based Programming
Chris Stec, BS, and Geoff Harrison, MS
Incident Prevention and Incident Response: Needs Assessment
Water-Based Programming: Flat Water
Water-Based Programming: Moving-Water and Whitewater Venues
Water-Based Programming: Open Water
Summary

Chapter 21. Special Events Programming
Brent Anslinger, BS, and Amy Anslinger, BS
Special Event Options
Risk Management for Special Events and Competitions
Assessing and Planning for Your Event
Staffing
Managing the Event
Developing Timelines for Successful Events
Putting the Planning Into Motion
Summary

References and Resources
Index
About the Editors
About the Contributors

Audiences

Reference for outdoor program professionals in university, military, nonprofit, and other settings and for outdoor professional employers. Text for college and university students.

Risk-taking Behavior and Helmet Use in Skiers

Paul Auerbach — Tue, 28 Feb 2012 02:48:03 GMT

by Paul Auerbach, M.D.

The general consensus in the medical community regarding helmet use and skiing (also snowboarding) is that helmets should be worn to prevent or lessen head injuries related to falls and collisions. While a helmet may not significantly lessen deceleration forces upon the brain incurred by a sudden stop at high speed, they almost certainly somewhat soften the blow and are useful to prevent skull fractures. As they become standard equipment for recreational skiing, we will learn more about the psychology associated with their use.

“Risk-taking Behavior in Skiing Among Helmet Wearers and Nonwearers” is an original research article by Lana Ruži?, MD, PhD and Anton Tudor, MD, PhD in a recent issue of Wilderness & Environmental Medicine (22, 291-296, 2011). The objective of the study was to examine differences in on-the-snow ski behavior between helmet wearers and non-wearers. Using a survey taken of 710 skiers, the predictive power for risk-taking behavior was tested for gender, age, educational level, level of skiing, years of skiing, and helmet usage. Independent predictors for overall risk could be correlated with younger age (less than 35 years of age), male gender, higher skiing level, and helmet usage. Significantly higher risk was assessed for male helmet wearers, while this was not seen to be significant for female helmet wearers. The group found to be most prone to risk-taking behavior was the male occasional helmet wearers

It has been shown previously that male skiers generally take more risks than do female skiers. It is new information that wearing a helmet appears to increase risk-taking behavior, perhaps even further, in young males. What should we make of this? Perhaps wearing a helmet contributes to a feeling of invincibility, or creates an impression in the user that regardless of behavior, a helmet will be protective. Skiers and snowboarders should be made to understand that the benefits of wearing a helmet might possibly be neutralized by risky behavior. Risk profiles for high-speed impacts decline with age, but that should not obviate the need for a helmet. The elder brain is less tolerant of injury, and there is a higher likelihood that a significant blow to the head will result in bleeding within the skull.

Perhaps the largest elephant in the room is the notion I have heard offered by some that if one is not wearing a helmet, he or she is more likely to ski with caution, in order to avoid a collision or fall. This sounds good, but has never been proven. Furthermore, despite all best intentions, collisions occur because skiers catch an edge, are impacted by a colliding skier, slip on ice, or due to a myriad other reasons to precipitously strike the ground or a foreign object with their heads. The takeaway here is that a helmet is not a license to throw away caution, but it appears that this may be the interpretation by young, male skiers. We need to inform them otherwise.

Reposted with permission from the Medicine for the Outdoors Blog

'Brain Buckets' - A Climber's Best Friend?

Rick Curtis — Mon, 13 Feb 2012 05:24:00 GMT

I am dating myself, but when I started rock climbing, almost everyone wore helmets. It was as essential a piece of gear as your harness and shoes. But in the decades that followed, helmets became passe. Part of that change had to do with climbing styles and style (fashion) in climbing. Some comes from a misunderstanding of risk and people assuming that helmets are only to protect you from rockfall (no rockfall means no helmet needed). But it's not that simple, let me tell you my friend Dan's story.

Dan was lead climbing in the Gunks in New York in the late 80's and he was wearing a helmet. In part that's because he was an EMT and in medical school and he valued his brain. Dan took a lead fall and pendulumed, smacking the side of his helmet against the rock (no rock fall here). He hit so hard that his 1980's (heavy) fiberglass helmet cracked and Dan hung in the air unconscious for 20 minutes while his belayer held him in place, unable to lower him and other climbers initiated a rescue. For those of you with first aid training, he had a Traumatic Brain Injury (TBI) and was immediately transported to the local ER. He regained consciousness on the way and was treated and eventually released. But his medical problems didn't stop there. He had significant short term memory loss for the next 6 months. If you told him that you had a bagel for lunch and then asked him what you had for lunch, he couldn't remember. It was pretty hard being a medical student when you can't remember what your patients tell you from moment to moment. He also had double vision in one eye from retinal damage due to the impact. When he looked straight ahead with his right eye he saw double but if he looked down his vision was normal. He ended up having surgery to cut and resew the muscles in his right eye so that the right eyeball was 'tilted' up. Then when he looked straight forward he was looking out of the bottom of his eye and could see normally. Dan was convinced that without a helmet he would have died or had permanent extensive brain damage. I've continued to wear a helmet ever since.

Helmets are not just for rock fall, they're also for falls on rock. Some climbing areas are know for loose rock so people wear helmets there and not in other places. But falls on rock are a lot more common and it's not just lead falls. Inverted falls can happen in lead and sport and can easily result in head impact. We now know a lot more about TBI in sports thanks to research on football, hockey, soccer and boxing injuries. Repeated small TBIs can lead to permanent damage just as a dramatic high impact whipper like Dan's can. Traumatic Brain Injury is serious business so any climber needs to keep both of those things in mind when making the decision about wearing a helmet. Helmet technology has come so far in the last five years with lighter designs that the excuses about it being too heavy no longer hold water.

There's a Facebook photo that recent caused a lot of controversy, a single mother climbing with a toddler on her back with lots of people saying it was irresponsible. What I found most irresponsible is that the woman and her belayer both had helmets on but the toddler didn't. Both adults considered the hazard of climbing required a helmet but the toddler had no such protection. Crazy if you ask me.

The British Mountaineering Council (BMC) is running a helmet safety campaign to educate climbers about helmet use and I applaud them for this effort. You can read more about their campaign along with guides to helmets at the following sites:

Yes, I wear a helmet biking, whitewater kayaking, Telemark skiing and climbing. Brain buckets may have once been a derogatory term, but thanks to Dan's lesson, I value my brain and am happy to keep it safe in a bucket, especially now that they are so stylin'.

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 95 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 due 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 happening in the field and that helped me make decision.

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.

Seventh 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. Eighth 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.

Ninth Lesson Learned - Have an intermediate 'Rallying Point' 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. Tenth 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.

Eleventh 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. Twelfth 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 have a great set of colleagues who I could call on and they all came to my aid. Thirteenth 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 - have good weather software
Seventh Lesson Learned - you've got communication out, how's your communication in?
Eighth Lesson Learned - have an Evac Location for each day of the trip.
Ninth Lesson Learned - have an intermediate 'Rallying Point'
Tenth Lesson Learned - have a great relationship with your transportation provider - build it ahead of time.
Eleventh Lesson Learned - have good transportation software.
Twelfth Lesson Learned - develop your campus network ahead of time.
Thirteenth 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