How to Choose the Right Life Jacket

The U.S. Coast Guard produces and distributes a number of helpful informational pieces (pamphlets) intended to improved water safety and to decrease morbidity and mortality in the water. Two of these are very germane as we enter the summer season, and so I am going to repeat the content here in separate posts – the first entitled “How to Choose the Right Life Jacket,” and the second entitled “Paddle Safe! Have Fun!”

How to Choose the Right Life Jacket

Fact: One-half of all recreational boating fatalities happen in calm water, close to shore and due to drowning. In most cases, life jackets are not worn. When an unexpected emergency happens, there is usually not time to don a stowed life jacket.

If a life jacket fits properly, it will help keep your head above water. If it is too large, the jacket will ride up around the face. If it is too small, it will not keep the wearer afloat.

Always try on a life jacket for proper size and fit. First, check the label. Next:

1. Make sure that the jacket is properly fastened.
2. Hold your arms straight up over your head. Have someone grasp the tops of the arm openings on the jacket and gently pull up. Be sure that there is no excess room above the openings and that the jacket does not ride up over your chin or face.
3. For the best fit, try the life jacket in shallow water under safe and supervised conditions.

Auto Inflatable life jackets inflate automatically upon immersion or with manual activation. Manual inflatable life jackets only inflate upon manual activation. Both types of jackets require regular maintenance, and are not recommended for children under the age of 16 years or for non-swimmers. They are not for sports, such as whitewater paddling, where immersion is expected, because they will inflate and may interfere with the activity. They may turn the unconscious wearer face up.

Belt pack inflatable life jackets must be placed over the head after inflation, and should not be expected to turn the unconscious wearer face up.

Vest type life jackets require little maintenance, are good for non-swimmers, provide good flotation, are less bulky than offshore vests, and may turn the unconscious wearer face up.

There are children’s life jackets, both vest type and hybrid inflatables. The most important feature of these is a proper fit. You should not count on an adult-size life jacket to properly fit and protect a child.

Flotation aids, whether in vest type or abbreviated style, assist with flotation, but should not be relied upon to turn the unconscious wearer face up.

Other jackets combine features and fit appropriate to their intended use, such as waterskiing, hunting, rafting, whitewater paddling, and so forth. The “offshore vest” type of lifejacket is intended for boating offshore, open water, and coastal cruising. It offers the most flotation, may help prevent hypothermia, is bulky, and is designed to turn an unconscious person face up.

Please be aware of the U.S. Coast Guard life jacket requirements for recreational vessels:

1. A wearable life jacket for each person must be aboard.
2. The life jackets must be U.S. Coast Guard approved, the proper size for the intended wearer, in good and serviceable condition, and properly stowed (e.g., readily accessible).
3. When a vessel is underway with children under the age of 13 years, the children must be wearing a life jacket unless they are below deck or in an enclosed cabin. This requirement may vary by state.

Preview the Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 24-29, 2009.

Tags: life jacket, water safety, drowning, wilderness medicine, outdoor medicine, healthline

Labels: life jacket, U.S. Coast Guard, water safety

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More MRSA

"Community acquired" (that is, not acquired in the hospital, which would be "hospital acquired") methicillin-resistant Staphylococcus aureus (MRSA) infections have not likely come about because germs that have evolved bacterial resistance by residing within hospitals have spread into the community. Rather, this bacterial resistance to methicillin appears to have arisen independently. The "community" now absolutely needs to be considered to include the outdoor community. Hikers, kayakers, divers, climbers and all other outdoors persons who share equipment or mingle with the general population are susceptible. From a reference entitled "Diagnosis MRSA - The Clinical Challenge of Multidrug-Resistant Infections," authored by Peter DeBlieux and colleagues and published as a supplement to ACEP NEWS, comes some useful observations.

Skin and soft tissue infections are among the most common infections caused by bacteria that can develop resistance to bacteria. Persons at particular risk for such infections include males, certain geographies, time of year (during warmer months), and affliction with diabetes. Many of the infections are abscesses, in which there is a pus pocket that can be drained by making an incision. Such treatment is in fact important to help control the spread of MRSA infections, presumably by helping to cure the abscess(es).

The current thinking is that in the setting of an "uncomplicated" skin and soft tissue infection (e.g., no involvement of deep tissues, minor clinically: simple abscess, impetigo, pimple, or superficial cellulitis), incision and drainage of small, localized abscesses can be curative. However, this is not an absolute, so many physicians are of the opinion that adding an effective antibiotic is useful. Until we have more information, it remains the clinical judgment of the treating physician about whether or not to prescribe an effective antibiotic, such as trimethoprim-sulfamethoxazole.

In complicated infections, which involve deeper skin structures (such as infected tissue ulcers, rapidly progressive infections, diabetic foot infections involving MRSA), antibiotics are deemed to be essential. The oral antibiotics that are felt to be effective against MRSA are clindamycin, trimethoprim-sulfamethoxazole, doxycycline, minocycline, linezolid, and rifampin. The injectable antibiotics that are felt to be effective against MRSA are vancomycin, clindamycin, daptomycin, tigecycline, linezolid, and quinupristin-dalfopristin. Notably, the fluroquinolone category of drugs, which includes ciprofloxacin, is not recommended as an effective treatment for community acquired MRSA infection. The same holds true for the macrolide category, which includes erythromycin, as well as cephalexin, penicillin, and dicloxacillin.

To prevent the spread of MRSA, wounds should be kept covered with clean, dry bandages; hands washed with soap and water or an effective hand sanitizer after each dressing change; close contacts instructed to bathe regularly; no sharing be allowed of bedding, towels, washcloths, bar soap, razors, and so forth.

image courtesy of www.mrsatreatments.com

Preview the Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 24-29, 2009.

Tags: MRSA, Staphylococcus aureus, infection, wilderness medicine, outdoor medicine, healthline

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You are Brilliant, and the Earth is Hiring

An acquaintance of mine, a physician who is dedicated to environmental preservation, suggested that I read the following address, which was delivered by Paul Hawken. For persons who are fervent about the wilderness and what it will take to ensure its existence, it is worth reading.

Paul Hawken is a renowned entrepreneur, visionary environmental activist, and author of many books, most recently Blessed Unrest: How the Largest Movement in the World Came into Being and Why No One Saw It Coming. He delivered this speech as part of the ceremony during which he was presented with an honorary doctorate of humane letters by University of Portland President Father Bill Beauchamp, C. S.C., on May 3, 2009.

"You are brilliant, and the earth is hiring."

When I was invited to give this speech, I was asked if I could give a simple short talk that was "direct, naked, taut, honest, passionate, lean, shivering, startling, and graceful". Boy, no pressure there. But let's begin with the startling part. Hey, Class of 2009: you are going to have to figure out what it means to be a human being on Earth at a time when every living system is declining, and the rate of decline is accelerating. Kind of a mind-boggling situation - but not one peer-reviewed paper published in the last thirty years can refute that statement.

Basically, the earth needs a new operating system, you are the programmers, and we need it within a few decades. This planet came with a set of operating instructions, but we seem to have misplaced them. Important rules, like "don't poison the water, soil, or air," and "don't let the earth get overcrowded," and "don't touch the thermostat," have been broken.

Buckminster Fuller said that spaceship Earth was so ingeniously designed that no one has a clue that we are on one, flying through the universe at a million miles per hour, with no need for seatbelts, lots of room in coach, and really good food - but all that is changing.

There is invisible writing on the back of the diploma you will receive, and in case you didn't bring lemon juice to decode it, I can tell you what it says: YOU ARE BRILLIANT, AND THE EARTH IS HIRING. The earth couldn't afford to send any recruiters or limos to your school. It sent you rain, sunsets, ripe cherries, night blooming jasmine, and that unbelievably cute person you are dating. Take the hint.

And here's the deal: Forget that this task of planet-saving is not possible in the time required. Don't be put off by people who know what is not possible. Do what needs to be done, and check to see if it was impossible only after you are done.

When asked if I am pessimistic or optimistic about the future, my answer is always the same: If you look at the science about what is happening on Earth and aren't pessimistic, you don't understand data. But if you meet the people who are working to restore this earth and the lives of the poor, and you aren't optimistic, you haven't got a pulse. What I see everywhere in the world are ordinary people willing to confront despair, power, and incalculable odds in order to restore some semblance of grace, justice, and beauty to this world.

The poet Adrienne Rich wrote, "So much has been destroyed I have cast my lot with those who, age after age, perversely, with no extraordinary power, reconstitute the world. " There could be no better description.

Humanity is coalescing. It is reconstituting the world, and the action is taking place in schoolrooms, farms, jungles, villages, campuses, companies, refuge camps, deserts, fisheries, and slums. You join a multitude of caring people. No one knows how many groups and organizations are working on the most salient issues of our day: climate change, poverty, deforestation, peace, water, hunger, conservation, human rights, and more.

This is the largest movement the world has ever seen. Rather than control, it seeks connection. Rather than dominance, it strives to disperse concentrations of power. Like Mercy Corps, it works behind the scenes and gets the job done. Large as it is, no one knows the true size of this movement. It provides hope, support, and meaning to billions of people in the world. Its clout resides in idea, not in force. It is made up of teachers, children, peasants, businesspeople, rappers, organic farmers, nuns, artists, government workers, fisherfolk, engineers, students, incorrigible writers, weeping Muslims, concerned mothers, poets, doctors without borders, grieving Christians, street musicians, the President of the United States of America, and as the writer David James Duncan would say, the Creator, the One who loves us all in such a huge way.

There is a rabbinical teaching that says if the world is ending and the Messiah arrives, first plant a tree, and then see if the story is true. Inspiration is not garnered from the litanies of what may befall us; it resides in humanity's willingness to restore, redress, reform, rebuild, recover, re-imagine, and reconsider. "One day you finally knew what you had to do, and began, though the voices around you kept shouting their bad advice," is Mary Oliver's description of moving away from the profane toward a deep sense of connectedness to the living world.

Millions of people are working on behalf of strangers, even if the evening news is usually about the death of strangers. This kindness of strangers has religious, even mythic origins, and very specific eighteenth-century roots. Abolitionists were the first people to create a national and global movement to defend the rights of those they did not know. Until that time, no group had filed a grievance except on behalf of itself.

The founders of this movement were largely unknown - Granville Clark, Thomas Clarkson, Josiah Wedgwood - and their goal was ridiculous on the face of it: at that time three out of four people in the world were enslaved. Enslaving each other was what human beings had done for ages. And the abolitionist movement was greeted with incredulity. Conservative spokesmen ridiculed the abolitionists as liberals, progressives, do-gooders, meddlers, and activists. They were told they would ruin the economy and drive England into poverty.

But for the first time in history a group of people organized themselves to help people they would never know, from whom they would never receive direct or indirect benefit. . And today tens of millions of people do this every day. It is called the world of non-profits, civil society, schools, social entrepreneurship, and non-governmental organizations, of companies who place social and environmental justice at the top of their strategic goals. The scope and scale of this effort is unparalleled in history. The living world is not "out there" somewhere, but in your heart.

What do we know about life? In the words of biologist Janine Benyus, life creates the conditions that are conducive to life. I can think of no better motto for a future economy. We have tens of thousands of abandoned homes without people and tens of thousands of abandoned people without homes. We have failed bankers advising failed regulators on how to save failed assets. Think about this: we are the only species on this planet without full employment. Brilliant. We have an economy that tells us that it is cheaper to destroy earth in real time than to renew, restore, and sustain it. You can print money to bail out a bank but you can't print life to bail out a planet. At present we are stealing the future, selling it in the present, and calling it gross domestic product.

We can just as easily have an economy that is based on healing the future instead of stealing it. We can either create assets for the future or take the assets of the future. One is called restoration and the other exploitation. And whenever we exploit the earth we exploit people and cause untold suffering. Working for the earth is not a way to get rich, it is a way to be rich.

The first living cell came into being nearly 40 million centuries ago, and its direct descendants are in all of our bloodstreams. Literally you are breathing molecules this very second that were inhaled by Moses, Mother Teresa, and Bono. We are vastly interconnected. Our fates are inseparable.

We are here because the dream of every cell is to become two cells. In each of you are one quadrillion cells, 90 percent of which are not human cells. Your body is a community, and without those other microorganisms you would perish in hours. Each human cell has 400 billion molecules conducting millions of processes between trillions of atoms. The total cellular activity in one human body is staggering: one septillion actions at any one moment, a one with twenty-four zeros after it. In a millisecond, our body has undergone ten times more processes than there are stars in the universe - exactly what Charles Darwin foretold when he said science would discover that each living creature was a "little universe, formed of a host of self-propagating organisms, inconceivably minute and as numerous as the stars of heaven. " So I have two questions for you all: First, can you feel your body? Stop for a moment. Feel your body. One septillion activities going on simultaneously, and your body does this so well you are free to ignore it, and wonder instead when
this speech will end.

Second question: who is in charge of your body? Who is managing those molecules? Hopefully not a political party. Life is creating the conditions that are conducive to life inside you, just as in all of nature.

What I want you to imagine is that collectively humanity is evincing a deep innate wisdom in coming together to heal the wounds and insults of the past. Ralph Waldo Emerson once asked what we would do if the stars only came out once every thousand years. No one would sleep that night, of course. The world would become religious overnight. We would be ecstatic, delirious, made rapturous by the glory of God. Instead the stars come out every night, and we watch television.

This extraordinary time when we are globally aware of each other and the multiple dangers that threaten civilization has never happened, not in a thousand years, not in ten thousand years. Each of us is as complex and beautiful as all the stars in the universe. We have done great things and we have gone way off course in terms of honoring creation.

You are graduating to the most amazing, challenging, stupefying challenge ever bequested to any generation. The generations before you failed. They didn't stay up all night. They got distracted and lost sight of the fact that life is a miracle every moment of your existence.

Nature beckons you to be on her side. You couldn't ask for a better boss.

The most unrealistic person in the world is the cynic, not the dreamer. Hopefulness only makes sense when it doesn't make sense to be hopeful.

This is your century. Take it and run as if your life depends on it.

Preview the Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 24-29, 2009.

Tags: Paul Hawken, conservation, environment, wilderness medicine, outdoor medicine, healthline

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Ciguatera and Sex

Ciguatera fish poisoning involves a large number of tropical and semitropical bottom-feeding fish that dine on plants or smaller fish that have accumulated toxins from certain microscopic dinoflagellates. Therefore, the larger the fish, the greater the toxicity. The ciguatoxin-carrying fish most commonly ingested include the barracuda, jack, grouper, and snapper. Symptoms, which usually begin 15 to 30 minutes after the victim eats the contaminated fish, include abdominal pain, nausea, vomiting, diarrhea, tongue and throat numbness, tooth pain, difficulty walking, blurred vision, skin rash, itching, tearing of the eyes, weakness, twitching muscles, incoordination, difficulty sleeping, and occasional difficulty in breathing. A classic sign of ciguatera intoxication is the reversal of hot and cold sensation (hot liquids seem cold and vice versa), which may reflect general hypersensitivity to temperature. Unfortunately, the symptoms persist in varying severity for weeks to months. Victims can become severely ill, with heart problems, low blood pressure, deficiencies of the central and peripheral nervous systems, and generalized collapse. Anyone who displays symptoms of ciguatera fish poisoning should be seen promptly by a physician.

It was reported this spring that ciguatera fish poisoning has been linked to pain during sexual intercourse. Despite the sensational coverage that this announcement received by the press, the phenomenon has been known for quite some time. It is indeed a fact that a person affected by ciguatera fish poisoning may suffer symptoms of pain during sex. These symptoms include painful ejaculation in men, and a burning sensation during and after (for up to 3 hours) intercourse. What was interesting about this most recent report, which was generated by observations made in North Carolina, was quantification of the duration of the uncomfortable symptoms. One male reported that his symptoms lasted a week, and two of the women said that they were affected for a month. The fish implicated in this particular cluster of cases was amberjack.

Treatment for ciguatera fish poisoning is for the most part supportive, although certain drugs are beginning to prove useful for aspects of the syndrome. An example is intravenous mannitol for abnormal nervous system behavior or abnormal heart rhythms. These therapies must be undertaken by a physician. Prochlorperazine may be useful for vomiting; hydroxyzine or cool showers may be useful for itching. There are chemical tests (such as Cigua-Check® Fish Poison Test Kit) to determine the presence of ciguatoxins in fish, but there is not yet a specific antidote.

Preview the Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 24-29, 2009.

Tags: ciguatera, ciguatera fish poisoning, painful sex, wilderness medicine, outdoor medicine, healthline

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Deer Tick Encephalitis

A fatal case of deer tick encephalitis (inflammation of the brain) was recently reported by Norma Tavakoli and colleagues in the New England Journal of Medicine (N Engl J Med 2009;360:2099-107).

Deer tick virus is a member of the tickborne encephalitis group of flaviviruses. It is closely related to Powassan virus. While infection with tickborne encephalitis virus may be asymptomatic or mild, it can be quite devastating, leading to meningitis, encephalitis, and, we now know, death. Other flaviviruses that cause human diseases are West Nile virus, St. Louis encephalitis virus, dengue (fever) virus, and yellow fever virus. These are commonly transmitted by mosquitoes.

This case emphasizes that deer tick-borne diseases, such as deer tick encephalitis, babesiosis, anaplasmosis, and Lyme disease, can be serious, life-threatening illnesses. Persons who frequent the outdoors should take appropriate precautions via proper clothing, insect repellent, and skin inspection, to avoid tick bites. Since nymphal deer ticks capable of transmitting disease can be quite small (1.5 mm in diameter), it is understandable how they might be missed on a casual skin or hair-covered area inspection. Furthermore, unless there is a local reaction, a bite may go unnoticed. It is therefore crucial to bathe and scrub vigorously at frequent intervals when in “tick country,” and to engage the assistance of a companion to visually inspect any body areas in which you suspect the presence of a tick.

image courtesy of www.bioweb.uwlax.edu

Preview the Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 24-29, 2009.

Tags: encephalitis, deer tick, deer tick encephalitis, wilderness medicine, outdoor medicine, healthline

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