Three Common Swimming and SCUBA Myths in the News Again

On Monday July 7, a news show Troubled Waters featured a story of two scuba divers who floated 19 hours overnight after they and their dive boat did not connect after a dive on the Great Barrier Reef in Australia.

In their television interview, the two divers told various points of the situation. Three of the concerns were common myths often repeated in scuba training.

1. They mentioned they experienced signs of hypothermia. Technically, not any chilling is hypothermia. Being uncomfortably cold does not mean you have hypothermia. Shivering and teeth chattering does not mean you have hypothermia. You can even become incapacitated by cold before becoming hypothermic. In informal conversation, the two terms of hypothermia and chilling are often used interchangeably.

2. The woman of the pair stated she had read in a book, which had a section about progression of hypothermia, that exercise is not good and can be counterproductive. They were worried that body movement would, "send blood to the muscles away from your core, and your organs" and for that reason, make them colder.

I have read the book they mention. It is a book of wonderful stories and great writing, interesting medicine, but the physiology is frequently off. As a physiologist, I notice these things. When I teach medical students in their classes, I often see that they do not want to learn physiology, they only want to learn what medicine to give and where to cut. I tell them that without understanding the reasons for how the body resulted in the situation in the first place, they will only repeat the mistakes of their teachers by giving medicines and cutting.

Back to the shivering divers floating all night, waiting for rescue. It is not always the case that exercise in the cold must only make you colder. Exercise in cold water can generate enough heat to match or surpass the large thermal drain, depending on water temperature, work load, duration of exposure, your body composition, what you are wearing, and other factors. It is true that exercise in cold water increases heat loss, but it is an important point that it does not mean that you will always cool. Whether you stay comfortable or get cold depends how much heat you keep and how much you lose. If you generate more heat than you lose, you will be warmer than when you started. When I worked on cold water immersion for the Navy, we studied body cooling in pilots downed in cold water, and how long they could survive (all volunteers, really they loved my studies). We also studied divers. Some divers sent for underwater missions during the Gulf War were overheating underwater and had to wear ice vests with their scuba gear.

3. The last myth is a popular one. I am a scuba instructor and have heard this one repeated often. The two divers mentioned that the woman of the pair was menstruating and that there were sharks in the water. The woman said, "I'm shark bait is what I'm thinking." Diver researcher Dr. Carl Edmonds found that Australia's shark attack tracking system reported nine times more shark attacks on men, even though there was an even number of male and female swimmers.

Menstrual blood does not attract sharks. Neither does menstrual blood attract grizzly bears during camping trips, cause wine to sour as stated in ancient religious writings, or cause wings to snap off airplanes, as pilots insisted in the 1920's. The term man-eating shark, for now, remains.

I explain these myths and more about swimming and diving physiology, underwater and in heat and cold, in the book Diving Physiology in Plain English.

Labels: cold, myths, scuba, swimming

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Regular Exercise Reduces Cold and Flu Incidence

A giant cold germ is pictured at left.

Studies first started to report the benefit of exercise to reduce incidence of colds when looking at recreational exercisers, who reported fewer colds once they began regular running. Later research on exercise, intensity, and the number of colds, found that people who exercised moderate on most days averaged one cold, while the less active group reported over four colds in the year. Related work shows that being a regular exerciser is also associated with quicker recovery from colds.

Moderate exercise also enhances immune function during the exercise and for a few hours following it. Specific research into mechanisms has found that moderate exercise speeds various immune-function cells through the body, and increases levels of the type of white blood cell called leukocytes that work to fight infection.

A 2006 randomized clinical trial found that "postmenopausal women who exercised regularly for a year had about half the risk of colds compared to those who did not work out routinely." The women in the exercise group also reduced body weight, body fat, and intra-abdominal fat from increasing their exercise level.

Too much intense exercise may lower immune function and predispose to some infectious illness shortly after the time of the exercise. The decrease seems to be temporary, similar to the increase seen around the time of moderate exercise. There is some concern that continual, intense exercise lowers immune function for longer periods. An example often offered for this is that during the Winter and Summer Olympic Games, clinicians report that "upper respiratory infections abound" and that "the most irksome troubles with athletes are infections." The situation may be more that high numbers of young people are concentrated in close quarters. Their high general health may mean that they are unlikely have other health disorders during the short period of the Games.

It is more likely that poor nutrition and insufficient rest, added to harsh, ongoing, strenuous work or exercise, decreases immune function, not just strenuous exercise alone.

Although cold and flu germs are reported to live better in the cool dry weather of fall and winter, if you are cold, caught in the rain or snow, or out in a draft, that does not make you more likely to fall prey to them. Immunology is not my field so I can only repeat what I've read. My understanding is that these germs are all around us most of the time. They are on surfaces all over our home, and workplace. Your immune system keeps them out or eats them if they try to invade (pictured to my level of understanding at right). They don't cause problems unless their number is too high and your immune system cannot deter them. I call germs the jerks of the world - they are always there and are harmless unless conditions let them under your skin with your defenses down.

Much attention is given to disinfecting yoga mats. Give attention to cleaning up your own strength against disease. Breathe. Exercise happy thoughts for good sleep. Don't eat junk food or junk drinks. Exercise in fun ways. Laugh. Take quick fun exercise breaks. Get enough exercise to sweat - your own sweat has antibiotic properties. Wash your hands. Get sunlight every day. Sit comfortably without slouching.

We need to start a new trend that Health is Contagious - Make Health Catching! Stand up and stretch. Do good deeds. Go now.

Labels: aging, cold, colds/flu/infectious, fix pain, performance enhancing modality, running

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Swimming and Pulmonary Edema Part II

In Monday's post, Katharine, an Ironman Triathlete, told of having pulmonary edema of swimming twice this year and asked if warm up or fluids were involved. US Open Water Swimming also interviewed me about pulmonary edema. Here are some things they asked.


1. What is pulmonary edema and why should swimmers know or be concerned about it?

Edema means too much fluid accumulation. Fluid suddenly fills the lungs. The left side of the heart is not pumping properly. It can cause you to have to stop a race. It can sometimes cause serious illness and death.

2. Is it more likely to occur in cold water?

It seems to be more likely in cold water. It has occurred in surface swimmers and scuba divers in both cold and warm water. Cold is only one of the several proposed causes.

Causes or contributors seem to be things that increase cardiac preload and afterload, including immersion in water, cold water, heavy exercise, negative pressure breathing (like breathing with a snorkel, and swimming with the chest below the surface and even the slight elevation of the head to breathe in), and drinking too much water or other fluids before swimming. Don't drink lots of water before swimming.

3. What are the signs and symptoms?

Unusually shortness of breath (not just fatigue) and coughing bloody froth. No chest pain.

With a stethoscope you can hear rales, an abnormal rattling breathing sound. Chest x-rays show the classic pattern of pulmonary edema. When blood oxygen in the arteries is checked, arterial O2 may be lowered.

4. Do wet suits provide any measure of protection against PE?

Difficult to say since it has occurred in people with and without wet suits. I haven't seen charts where the numbers of each predisposing possibility, like protective garments and temperature, were compared.

5. Can medical personnel easily detect PE?

Pulmonary edema is not subtle. The person is usually gasping and spitting pink froth, and asking for help with a worried look.

A swimmer who develops shortness of breath and cough in a race may have something else like exercise induced asthma.

6. What is the first aid if PE is suspected?

Get them out of the water. Sit them up to elevate the head, if conscious. Give them 100% oxygen by mask, and get them to the emergency facility.

7. If PE is untreated and the athlete continues to the race/swim, what could happen?

Depends how serious. Symptoms can resolve on their own or they can get worse. I wish I knew the future for them, but it's like other injuries. There have been deaths. We wonder how many people who suddenly went under were not drowning but developed pulmonary edema. We have no way yet to tell. Drowning also produces pulmonary edema (after the fact). Repeat cases of pulmonary edema can occur in the same person.

Interestingly, the frothing pulmonary edema occurs in racehorses after hard races. They are blowing bloody nose froth all over, but veterinarians have reassured me that the horses are fine. Any readers who are veterinarians, please tell me more. If a person is frothing, get help.

Labels: circulation, cold, fix pain, injury, pulmonary edema/oedema, swimming

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Swimming and Pulmonary Edema Part I

Reader Katharine asked:

"I am an Ironman Triathlete and have recently experienced symptoms of swimming induced pulmonary edema on two occasions this year and am trying to find as much information about this condition as possible. I have a background in swimming and have not experience this phenomena until recently. In both instances, my breathing became labored and fluid built up in my lungs during the early stages of a competitive triathlon swim.

"The most recent instance of what I suspect was 'SIPE' (Swimming Induced Pulmonary Edema) was on July 22nd at Ironman USA in Lake Placid. After the swim portion of the event, I had to be taken to the hospital as I was unable to breathe and was coughing up a 'pink frothy foam.' I felt normal within 24 hours and have still been able to continue to train as normal –initial ECG and Echo tests of my heart are normal, as well as a lung scan and x-rays of my lungs, throat and sinuses.

"The problem has only occurred in 2 out of 4 triathlon’s I have been in this year – and both instances occurred at approx. the 750m mark of an open water swim.

"It doesn't seem to be a common ailment so I’m trying to gather as much information on SIPE as possible from anyone who has studied it. I'm primarily trying to find out how to prevent it from happening. I am fine in training in the same 'open' cold water as I race it, so why is it happening on race day... Perhaps not enough of a swim 'warm-up' and an immediate elevation in HR... that along with added fluids in the days leading up to a long distance event such as an Ironman."

Warming up does not seem to be related to developing pulmonary edema. Why pulmonary edema can happen with swimming, what fluids have to do with it, and what to do, follow on Wednesday - click Swimming and Pulmonary Edema Part II .

Labels: circulation, cold, injury, pulmonary edema/oedema, swimming

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Fast Fitness - Healthier Sports Shake

A New Zealand swimmer asked for more sports nutrition. Here is Friday Fast Fitness - quick, good tasting sports shakes - cheaper and healthier than store-bought.

My father and grandfather, (and great-grandfather+) were Ice Swimmers. We all swam all year in open water including several over 20 miles (32km). My grandfather's sure-power recipe was an oily mixture (for future posts). When I raced competitively, I swam 5-7 miles a day, 35-40 miles a week (up to 64km/week). The coach pushed the common fad of eating Jello powder. As a vegetarian I skipped it, and watched other vogue sports food assumptions come and go. Best is real food.

Throw in a blender or other mixer:

• Clean water
• Peeled banana
• Peeled orange with the seeds
• Some of the well-washed orange peel
• Raw walnuts or other favorite
• Some cooked brown rice left from a meal
• Sweeten with raisins or a prune softened in clean water. Molasses optional. Adds many minerals.
• Cinnamon powder to level blood sugar

Tips:

• For the day of the event, you can substitute tea for the water.
• Experiment with amounts to get preferred consistency
• If you want a chocolate shake, add a scoop of unsweetened cocoa powder (unsweetened non-dutched baking cocoa). People with migraine can leave out the cocoa.
• Don't junk it up with milk, sugar, artificial sweeteners, commercial sports powders.
• If you use a juicer, put the solids and pulp back in, or you will be drinking sugar water and throwing away the point and the nutrition.
• Try different fruit - Persimmons, mangosteen, pineapple, melon, berries, your favorite. Raw red beets are an overlooked sweet fitness food good in shakes.
  
• For flavors, add a small slice of unpeeled ginger root, washed mint leaves.

Labels: cold, endurance, fast fitness, nutrition, performance enhancing modality, swimming

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Nutrition for Endurance Swim Training

"Dr. Ernie" is training to swim the Cook Strait of New Zealand. We met him in May in Sixteen Miles of Cold Water, learned about cold acclimatization with him in Getting Fitter in 50 Degrees, and did Better Stretches for Swimming with him in Cook Strait Update.

Dr.Ernie (blog name) writes,

"The water temp now (has risen to) 14 degrees Celsius (57F) and I had a robust swim this afternoon in Wellington Harbour (photo below right). Interestingly enough there was virtually no shivering. I'd swum for about an hour and a half in the pool earlier today.

"I was struck by the difference between pool and ocean swimming... technically I've improved tremendously in the pool over the past few weeks and my times have improved greatly. In the ocean it's much harder -- but I felt faster nonetheless.

"I am not a fast swimmer -- in fact, at this point I am still too slow to pass Phil's test -- but I can feel I'm making progress. I've been able to hold a pace of 2.5 km/hour for a few hours, and this has been an improvement from a measly 2 km/hour not very long ago. And I'll be up to 25 km/week by the end of this month (about 15.5 miles a week - longer and generally more work swimming than running).

"My plan is to increase weekly mileage to 40 km (approx 25 miles) per week by the end of November and then to make a push through to 50 km/week (about 31 miles) by the end of December -- the 'crunch' month. I'll attempt to renter the open waters by mid-November and begin reacclimatization to the cold. With luck and persistence, I'll be granted the privilege of attempting the Cook Strait swim.

"I met with Phil Rush -- the man who has crossed the Strait seven times (including a double-crossing) and who holds the world's record for a triple crossing of the English Channel. He will be piloting the support boat for my attempt, which will hopefully be in February 2008. His advice: swim, swim, swim… then be ready to take a 6-hour test in early January. In the test I will have to demonstrate that I can sustain at least a 3 km/hour pace for the 6 hours. He told me I'd have to figure out the kind of sustenance I'd need on my own, and he recommended that I not try to gain too much weight -- though he cautioned not to lose any from this point on. He also suggested that I procure the skills of a swim coach to refine technique (Fitness Fixer posts in progress on faster healthier stroke mechanics for swimming).

"Any advice on nutrition or cross-training would be appreciated. Because I also have a full-time job, time is tight and hours in the water are limited. I've experimented with a commercial product (name deleted) for multi-hour endurance activities that's easy on the stomach."

I am not a nutrient biochemistry or epidemiology researcher, so I can only report what I have read from others, which can inadvertently repeat and perpetuate wrong information incestuously (we all say so, it must be true). Following is a summary of what I believe and have seen from working with my patients and athletes:

• In general, good nutrition all year will give more benefit than eating special foods for an event, race, or hike.


• Processed packaged sports supplement foods cost far more than the ingredients, and you can get healthier ingredients, cheaper, and just as easily without commercial sports powders, bars, drinks, and other preparations.


• Many nutrients need to work in the original food containing other components that make each part work better. Some do not work, or have even been found to increase health risks when concentrated in vitamin and mineral supplements.
  


• In general, no commercial processed "sports food," no matter how engineered or marketed as effective for training, will give you the health of healthful real food. Whole foods, for example, a simple apple with the skin, contain combinations of nutritional and disease fighting chemicals that are not available in supplements.


• "Energy food" technically means it has calories. Extra calories alone will not enable you to build muscle or win a race.


• Increasingly, some "energy food" and drinks contain stimulant compounds. This practice is a foolhardy one to become accustomed to, building cycles of inability to focus, exercise, or feel well without them, and varying degrees of agitation with them, sleep difficulties, and various cardiovascular risks.


• Products with soy are usually unfermented soy. Unfermented soy contains enzyme inhibitors which block digestion, goitrogens which inhibit thyroid function, phytic acid, which blocks minerals like zinc and calcium, and estrogen-promoting compounds. Anyone with tendency to estrogen-dependent tumors or cancer, fibroids, cystic ovary and breast, or endometriosis will be better to avoid unfermented soy.


• Even if sugar water will extend endurance, it is still junk food, not healthy for the long term. Science Daily reports "Sports drinks face junk food label"


• Protein and carbohydrate together work better for training than sugar alone, however commercial processed powdered mixtures are still not the healthy choice over the long term.

This is all good news. You can eat good tasting food, that is quick to make, and cheaper and better for you than expensive commercial "sports food." Click the nutrition label under this post for suggestions, with more to come in future Fitness Fixer posts.

Don't worry that you have to eat engineered products to be able to win. You will win better in the long run without them.

Recipe follows in Fast Fitness - Healthier Sports Shake.

More on all these issues plus some Halloween treat suggestions - Is Your Health Food Unhealthful?

Labels: cold, endurance, nutrition, performance enhancing modality, readers inspiring story, swimming

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Exercise and Cancer

Regular physical exercise is documented to reduce risk of cancer. Exercise has also been found to increase survival in those with existing cancer, (JAMA and J Clin Oncol.) improving both number of years and quality of life.

Until recently (sometimes currently), cancer patients, along with heart patients and back pain sufferers were told to rest and stop activity. Inactivity creates new health problems and worsens existing health problems. Lack of regular exercise decreases strength, endurance, energy, blood sugar regulation, cellular repair (lengthy list here) and increases fatigue. Cancer treatments of radiation and chemotherapy do the same, and worse. This is called iatrogenic harm, which means injury or illness brought on by medical treatment. One medical report found that debilitating tiredness and loss of energy from cancer treatments can be more disruptive to the patient than the original pain of cancer. Another report called fatigue, "The most important consideration for the patient with cancer." Cancer fatigue can be a problem for months, even years, after treatments end.

Reader Dr. Zoe E., cancer survivor with personal experience writes:

"I don't think I'm quite ready for prime-time yet - but if I can be a source of encouragement to those trashed by chemo, I'm happy to be displayed.

"Yes, exercise helps if you can do it. Lots of people are lucky to experience low toxicity during chemo and are able to keep up their exercise programs or active life through treatment. Others are laid low and must stop treatment or are just trying to recover enough between treatments to continue them.

"While the Lance Armstrongs and Tony Snows of the world are inspirational, it would be a bad thing if the general population thought that people should be able to work and function during cancer treatment. Many, maybe most, can't and they shouldn't feel bad about it. Chemotherapy is as close to killing you as modern medicine gets."

Getting enough exercise to improve strength and quality of life doesn't only mean exhausting yourself or stopping your day to change clothes and go "do exercises." Some posts with ideas:
What is "Fitness as a Lifestyle?"
How Good Would You Look From 400 Squats a Day - Just Stop Unhealthy Bending
and
How Often Should You Be Healthy?

Dr Zoe sent an update the day before yesterday:

"I did the Relay for Life on Saturday (a fund raiser for the American Cancer Society). It's a 12-hour team event where you keep one person on the track for the full time. I did the Survivor's Lap and several more with lots of rest stops. I managed to hang out there for 4 hours before I got too pooped. No photos though, I'm even more camera shy than blog shy! You can draw a picture if you want."

One of the benefits of exercise is that your body produces more of an interesting compound called heat shock protein. Heat shock proteins (HSP) are families of proteins that do several things including accompanying and helping other proteins under stress (called chaperoning). Heat shock chaperones keep the other proteins neatly folded when they are being deformed by stress factors such as infection, ultraviolet light, starvation, heat, and other harsh conditions. Heat shock proteins help cell survival and are thought to mobilize immune function against infections and diseases. One of the big stressors of focus in heat shock study is cancer. Heat shock proteins have been investigated for their role in activating immune response to cancer, and in cancer vaccine research.

Molecular physiology isn't my research area, so I haven't done any work in it personally. I just read the work of others. Heat shock proteins are intensely fascinating to me for their role in exercise, in increasing tolerance to hot environments (interestingly, cold too), and other extreme challenges to the body. I hope to post more about it from the sports medicine meeting next week.

Get exercise that is healthy and fun, and as a normal part of how you bend and position your body in healthful ways during your day.

Labels: cancer, cold, heat, injury, performance enhancing modality, readers inspiring story

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Getting Fitter in 50 Degrees

The Cook Strait, separating the north and south islands of New Zealand, is cold. Reader Dr. Ernie, 52 years old, is training to swim the 26 kilometers across the strait next February. Sixteen Miles of Cold Water started telling about it.

Cold water can be uncomfortable, even incapacitating. Scuba divers wear wet suits in cold water, and dry suits in very cold water, not only for comfort, but safety. According to International Swimming Federation rules (Fédération Internationale de Natation (FINA), marathon swimmers cannot use wet suits to stay warm. English Channel swimmer Ted Erikson is reported to have said that "wearing a wet suit in a marathon swim is like completing the Tour de France on a moped."

Unofficial swimmers can wear whatever they want, but the idea of training in the cold is to improve your fitness by training several body systems so you can generate more heat and better prevent heat loss. The process of increasing resistance to cold injury through regular cold exposure during real conditions is called cold acclimatization. The International Union of Physiological Sciences distinguishes acclimatization in actual conditions, from acclimation, which is change produced in a laboratory.

To be able to swim in the cold, you need to train in the cold water, not just swim in a pool. The idea is not supposed to be to make yourself sick and weak from cold, but to train to become healthier. Dr. Ernie writes:

"Last Saturday I did an 8 km swim: two and a half hours total, out to Somes Island in the middle of the harbour, fortunately dodging the big and small ships with the help of friends in an accompanying dinghy. It was a most gorgeous day. And though tired on the following Sunday, I felt ready to start up again on Monday. It was a tremendous confidence and stamina builder. Today (Sat) after about half an hour in the pool I ventured out and swam about 40 minutes -- water colder, rainy.... but exhilarating. Pretty much a sprint all the way (I have to stay warm enough). We are in our autumn here and will be easing into winter in a few months.

"I feel as if my best chance to make it across Cook Strait is not going to involve miles and miles in the pool, but lots of time in the ocean, hence I'm trying to maximize that, trying to become more and more familiar with its changing moods. I love it and am reaching a tremendous comfort with it even in rough conditions (as this past week). I'd really like to keep up sea swimming through winter without a wetsuit -- the water might get as low as 10 Celsius (50 degrees F).... we'll see."

Read more on cold immersion and cold tolerance in "Diving Physiology in Plain English."

Labels: cold, performance enhancing modality, readers inspiring story, swimming

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Sixteen Miles of Cold Water

A physician in New Zealand wrote that he is preparing to swim Cook Strait, the body of water separating the north and south islands of New Zealand, next February. The Strait is 26 km wide (16 statute miles). It may take him anywhere from 8 to 15 hours to swim, depending on tides and other factors. Temperatures range from 14 to 19 degrees Celsius (52-66 F). Body grease is allowed for the crossing, but no wetsuit, just a regular bathing suit. He asked me to call him "Ernie."

Dr. Ernie is 6'2", approx. 190 lbs, on the lean side. He shivers easily. He asked for suggestions about acclimatizing to cold water swimming.

Cold acclimatization means increasing your ability to tolerate cold. Cold acclimatization occurs through regular exposure to cold. People developing cold acclimatization don't need to shiver so soon, and generate more heat without shivering. They may develop ability to both increase and decrease skin temperatures. In some circumstances, skin blood flow increases to keep extremities warm. In other cases, it decreases to reduce heat loss.

Tolerance to cold improves with physical conditioning. A fit person can tolerate a colder external environment and lower internal body temperature than an unfit person before shivering begins, and they can generate more internal heat through shivering. Increased muscle through physical training increases their ability to produce and store heat. Being physically fitter allows you to exercise at a higher intensity to generate more heat. Cold tolerance increases more with exercise in the cold than from exercise alone. For that reason, you need to get out and exercise in the cold.

Dr. Ernie writes, "I've kept up my schedule of working on technique in the pool and have been in Wellington Harbour at least 4 times weekly for 30 minute swims: the temp is about 14-15 Celsius and I can feel myself slowly able to tolerate the cold better -- much less shivering after I'm finished."

A nice fat layer helps maintain warmth and buoyancy for cold water swims. You don't want so much fat that you are slower or unhealthy. I mentioned to Dr. Ernie, that maybe he can stay lean to make the training more effective (difficult) now, then gain the fat closer to time of the crossing when he will want an easier ride.

Ideas? Encouragement? Comment below.

Information on cold immersion and cold tolerance is in "Diving Physiology in Plain English." Read the next update of Dr. Ernie's training for the Cook Straight in Getting Fitter in 50 Degrees.

Labels: cold, performance enhancing modality, readers inspiring story, swimming

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Wilderness Medical Elective

The Wilderness Medical Society will run the next wilderness medicine elective from February 5 to March 2, 2007, in the Smokey Mountains of Tennessee. Three of my students from last year, Neeta Abraham, Yvonne Chow, and Joey Brunkhorst, are pictured at left. I didn't do that to them. They were preparing for scenarios that simulate locating and rescuing injured adventurers.

I'll be at the elective again in February to teach three units of underwater physiology, scuba science, and diving medicine, some fun seminars in orthopedics, and a workshop on stretches that harm and how to change them to stretches that help. It's good for future doctors to know which of the traditional stretches and exercises are adding to injuries or are not effective, and what to do instead.

The wilderness elective is designed for 3rd and 4th year medical students, residents, and allied health profession students from accredited schools. The elective includes a 48 hour Wilderness First Responder Course and ends with a 4-day overnight field trek through the mountains, with the itinerary planned by the campers. In between are plenty of lectures, hands-on practice, and practice in outdoor rescue scenarios from first aid to advanced life support. It is directed by Dr. Tom Kessler, a wilderness medical society member, global doctor, volunteer physician for Native American reservations, exceptionally knowledgeable practitioner, and kind teacher with an on-target sense of humor.

The Wilderness Medical Society has extended the application deadline, which normally closes in August. Space is available for only 24 students. Check the WMS elective site for information, or e-mail Dr. Tom Kessler at tkphs@yahoo.com.

Labels: cold, education, hyperbaric

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