More Fire Advice

This is my third day of watching the Black Crater fire near Sisters, Oregon. Yesterday, thick plumes of orange smoke rose from the pine forests not far from our location. The darker smoke indicated new, more oily fuel burning, from the pitch (resin) in the trees. At night, we could see reflections from the flames; this past afternoon, the flames themselves were visible from a distance of approximately 8 miles. Today, whiter smoke is rising from areas burning from drier fuel with a less intense burn, but it is dangerous nonetheless. It is windier than usual for this time of year, which spreads the fire and makes it much more dangerous for firefighters and local residents. Many people have their cars packed with irreplaceable possessions, because if the order comes to evacuate, there is no time to collect belongings – you have to get out as fast as possible. It is impressive listening to large airplanes dropping dropping water and chemicals on the fire.

When a fire is burning in your vicinity, the air quality is often markedly diminished. At times, you can taste the smoke and find ash drifting into your hair. It is not the time to be exercising, and certainly not a time to be backpacking or riding mountain trails that might be engulfed in the fire line. Persons with chronic obstructive pulmonary disease (COPD), asthma, congestive heart failure, or any other cardiopulmonary condition in which oxygen supply is critical need to be very cautious, and remain indoors in an air-filtered, air-conditioned environment if possible. If the smoke becomes momentarily overwhelming, a cool and wet cloth held over the mouth and nose through which to breathe can be helpful. Sometimes a surgical mask can help, but the best thing to do is to avoid the smoke. Persons with asthma or any other form of “reactive airway” disease need to be similarly cautious and be certain to carry bronchodilator medications with them at all times.

For everyone else, there is an attraction to get close to fires, to observe them or take photographs. For your safety and the safety of rescuers, please don’t do this. Fire behavior is unpredictable. A wind direction shift and/or increase in wind velocity can move a fire toward you much faster than you can move away from it. Know your escape routes and stay close to them.

Tags: fire, wild fire, forest fire, Black Crater fire, wilderness medicine, outdoor medicine, healthline

photo by Paul Auerbach

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Wildfire Lookout Situations

As I write this, I am near the Black Crater fire near Sisters, Oregon, which is growing by 1/4 acre per jump. The air is thick with smoke in the area, and so persons with chronic lung disease, including asthma, are advised to stay indoors or move away from the smoke. Three years ago we were evacuated by another fire that ripped into Black Butte, and now we are perhaps facing that possibility again.

2006 is already a record-breaking year for wildfires in the U.S. The numbers are on track to witness perhaps more than twice the 10-year average in terms of number of acres burned. The situation is more serious in the western states, but with the heat wave that has been affecting the rest of the nation, fires are a big hazard in many parts of the country.


There is much dry fuel ready to ignite. I just returned from a visit to the interior in British Columbia, where I saw enormous expanses of clear-cutting interspersed with the remnants of fires triggered by lightning. In addition, insects, mostly beetles, have cut huge swaths through the forests, so that as many trees are brown and dead as are green and alive. It is only a matter of time until raging fires clean out the deadwood in preparation for natural renewal or reforestation.

If you’re camping or traveling through fire country, be alert for the following high-risk conditions:

1. Drought conditions, including low humidity, high air temperature, and gusty winds
2. Areas rich with abundant fuel, such as dead grass, pine needles, shrubs, and dead and fallen trees
3. Travel through gullies or canyons, or along steep slopes where wind and fuel can rapidly advance a fire
4. Recent fires in the vicinity
5. A smoke-filled situation in which you cannot judge the location of a fire
6. Rugged terrain in fire-vulnerable country, so that escape would be difficult

Tags: wild fire, forest fire, outdoor medicine, wilderness medicine, healthline

photo by Paul Auerbach

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The Wind in Your Hair

My kayaker buddies just told me the tale of a fellow who smacked his head on a big river rock when trying to execute an Eskimo roll on a gnarly rapid in North Carolina. He wound up with about a hundred stitches, and was lucky that he didn't bleed to death.

When I recently watched a professional mountain bike race in Colorado, I noted that all riders were required to wear a helmet. There was no option for the competitors to ride without a helmet. To my knowledge, none of them complained. Even though the race was on a very stable course, there was little chance for collision, and the speeds were relatively low by racing standards, all of the riders understood that accidents happen, and so they dutifully wore their head protection.

I asked a few of them whether they found the helmets cumbersome or an imposition. “Are you nuts, man?” one rider responded. He unstrapped his helmet and showed me a scar that wound around from the middle of his hairline in the front behind his left ear and back into the hair on his neck. “Check this out. I got this zipper when I patched out on some mud and skidded off the pavement and into a big hunk of granite. Popped my head like a big ripe peach. Got over a hundred stitches. The doc told me that if I was wearing a helmet, I’d have gone home with just a Band-Aid.” He replaced his helmet. “I’d wear this thing to bed if it fit on the pillow.”

Pittsburgh Steelers quarterback Ben Roethlisberger is the luckiest man on Earth. By all accounts, he recognizes that luck saved his life. He should spend the rest of his career as a poster person for wearing a motorcycle helmet.

I can’t imagine how anyone can consider it a personal freedom to sustain a severe injury because they choose to ride a bicycle, motorcycle, all terrain vehicle, horse, or any other conveyance capable of throwing a person to the ground without a helmet.

Rock climbers and snowboarders should wear them as well. I've participated in the rescue of an unhelmeted climber who lost the top part of his head from rockfall, who would have suffered only a glancing blow to plastic if he had been wearing a helmet. All wilderness medicine doctors can tell you stories about whitewater fatalities that occurred when unfortunate people flipped out of rafts or rolled their kayaks in rock-laden swiftwater, to meet their demise from cracked skulls and unconsciousness that led to drowning. Ski patrollers around the world have pulled too many victims from tree wells, who knocked themselves unconscious by colliding with these immoveable obstructions.

Who suffers because of unnecessary medical catastrophes? The victim, the families, taxpayers – everyone bears part of the burden. It is not an act of freedom or bravery to challenge a boulder or the pavement with your head. It is an act of foolishness.

Tags: head injury, helmet, outdoor medicine, wilderness medicine, healthline

photo by Paul Auerbach

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Wilderness Medicine in Snowmass

The Wilderness Medical Society (WMS) is holding its Annual Meeting from July 22-26 in Snowmass, Colorado. I'm attending this continuing medical education (CME) meeting, and it's terrific. In addition to presentations from doctors and other medical professionals on such topics as "Causes and Prevention of Wilderness Accidents," "Exercise Physiology and Extreme Environments," "Chronic Medical Conditions and the Wilderness Traveler," "Avian Flu Update," and "Psychological Response to Wilderness Injury and Crises," there are awesome evening programs about mountain rescue doctors, the New Orleans rescue efforts, and a walk across Siberia.

I had the privilege to teach as an instructor of an Advanced Wilderness Life Support (AWLS) program, which is a practical approach to the treatment of injuries and illnesses experienced at a distance from traditional medical assistance. It is a certification program about which I will write more in a future post.

The comaraderie and enthusiasm are awesome, and it's a wonderful opportunity for me to learn the latest and greatest, and catch up with my wilderness medicine friends. Snowmass is gorgeous, and what little free time we have is spent hiking and mountain biking on the trails that wind around Snowmass and Aspen. With a little luck, we'll find a few hours to visit the Maroon Bells, and hopefully not have to use any of our wilderness medicine expertise.

Tags: Wilderness Medical Society, CME, outdoor medicine, wilderness medicine, healthline

photo by Paul Auerbach

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West Nile Virus

The County of Santa Clara (California) Public Health Department reports that 5 pools of mosquitoes were found within the county infected with West Nile Virus (WNV) the week of July 3, and that at least 24 dead birds have tested positive for WNV. So, the WNV season is in full swing. WNV has also been reported from many other counties in the state, and will likely begin its seasonal upswing across the western U.S.

WNV is an arbovirus endemic in Africa, Europe, Asia, and the Middle East that established its presence in the U.S. beginning in 1999. It has since spread to be found in most states. It is transmitted to humans by the bite of an infected mosquito. While much of the clinical WNV activity is noted in summer and autumn, it is certainly possible to acquire the disease in winter from the bite of an infected mosquito. The four top species of wild birds affected by WNV are American crows, Western scrub-jays, yellow-billed magpies, and Steller's jays. Mosquitoes bite the birds and thus acquire the virus.

Most (80%) people infected with WNV never realize that they have had the disease, because they remain without symptoms. 20% of infected people develop West Nile fever, and less than 1% of people infected develop severe medical illness, including meningitis and/or encephalitis (characterized by seizures, loss of vision, and disorientation) or paralysis. Death is uncommon.

West Nile fever incubates in a human for 3 to 14 days after the bite of an infected (with WNV) mosquito, and is usually characterized as a mild illness lasting for 3 to 6 days. However, it can be more severe, with fatigue as a residual symptom lasting for up to a month. Symptoms include fever, fatigue, headache, muscle aches, and skin rash (chest, stomach, or back). Lymph glands (nodes) may become swollen.

WNV infection does not appear to spread from human to human. There are blood tests for WNV infection. These measure antibodies to the virus, and show positive in most infected people within 8 days of the onset of symptoms. However, they may initially be "negative" and need to be repeated at a later date. Treatment for West Nile fever is based upon symptoms - there is no antidote. For severe WNV disease, there are studies looking at specific drugs to combat the virus.

Prevention is essential. First and foremost, that means preventing mosquito bites. Here are some recommendations:

1. Do not maintain standing water that serves as a breeding ground for mosquitoes, which lay eggs in the water. Drain or dump all standing water on a weekly basis. This includes water as shallow as one inch deep, as may be found in flower pots, planter bases, old tires, child pools, etc.
2. Be sure that all doors and windows have tight-fitting screens. Repair any holes or rips, and if possible, treat screens and door jambs with mosquito control products.
3. Most bites occur at dawn and dusk, so limit outdoor activities during these times.
4. Use effective insect repellents, such as those containing DEET (N,N-diethyl-m-toluamide) or picaridin (KBR 3023). Use repellents according to the manufacturer's labeled instructions, and reapply frequently, particularly if you swim or become sweaty.
5. Wear clothing designed to cover your arms and legs, including long sleeves and pants.

Tags: West Nile Virus, mosquito, outdoor medicine, wilderness medicine, healthline

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Another Day, Another Disaster

It seems that each day brings a new natural disaster, the most recent being the tsunami that flooded Java in Indonesia. The tsunami was spawned by an undersea earthquake of Richter magnitude 7.1 beneath the Indian Ocean, which created a 6-foot wave that crashed onto the beach. Once again, a popular resort area was struck, and beachgoers fled inland to escape the approaching water.

At the mercy of hurricanes, tornadoes, floods, earthquakes, forest fires, blizzards, and the like, we have learned that Mother Nature holds the upper hand at will. In the response to these events, what appears to be the most practical medical knowledge is right up the alley of wilderness medicine - improvisation and clinical care under austere conditions. When the power is gone, supplies are unavailable, and rescuers must tend to overwhelming numbers of victims, it is the seasoned wilderness medicine doctor who very often can negotiate his or her way through the chaos to helping the greatest number of victims. In the case of the tsunami, the immediate issues are drowning and trauma. In the aftermath, there will be some issues with infectious diseases. But the most important issues will be food, water, waste disposal, shelter, transportation, communication, and maintenance of a lawful, orderly societal structure. At times like this, we are expected not only to be doctors, but to be truck drivers, cooks, mechanics, engineers, and social workers. Sometimes the medicine is easy, but keeping up morale and maintaining a positive outlook are quite difficult.

Tags: tsunami, disaster, outdoor medicine, wilderness medicine, healthline

photo courtesy Centers for Disease Control

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Heat Wave

It’s very hot across the U.S. right now, and my emergency doctor friends report that they’re caring for many patients struck down with heat-related illnesses, including fainting, heat exhaustion, and heat stroke. Unlike cold weather, which can sometimes be forgiving, hot weather is devastating, because humans are not able to tolerate body temperatures much above 104 to 105 degrees Fahrenheit.

I wrote recently about beating the heat, but it bears mentioning again. For weather like this, particularly when it’s humid as well, here are recommendations that may keep you from crossing the boundary from just feeling hot into serious medical illness:

1. Stay well hydrated. Thirst may not be an adequate indicator of how much water you need to drink, so be sure to keep up with your fluid losses by drinking enough so that you have to urinate often. If your urine is dark in color, then you are likely dehydrated, so keep drinking. Unless your doctor tells you otherwise, supplement water with an electrolyte-containing beverage, such as Gatorade.
2. Curtail heavy exercise when it is hot, and particularly when it is humid. Above 75% humidity, you will have difficulty evaporating sweat, so your natural cooling mechanism is impeded.
3. Wear a broad-brimmed hat in the sun. Better yet, stay out of the sun.
4. When you feel hot, immediately seek a cooler location.
5. Don’t bundle yourself in hot clothing in the heat. Don’t try to lose water weight as part of any weight loss program.
6. Avoid alcohol and other beverages that act as diuretics.
7. If you are supervising children, athletes, or laborers in the heat, pay close attention to their behaviors. Anyone who seems overly tired, confused, or inappropriate may be on the verge of serious heat illness. Get them to a cool location, have them shed articles of clothing, and begin to lower their body temperature.
8. The second leading cause of death, after head injuries, in athletes is heat stroke. It is cruel and unnecessary, and particularly dangerous, to withhold water from athletes during practice and games. Furthermore, they are at great risk for overheating when exercising while wearing occlusive uniforms, hats, and helmets. Provide frequent water breaks and rest periods for all athletes.

Tags: heat wave, hydration, outdoor medicine, wilderness medicine, healthline

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Preventing Blisters

Blisters are the bane of hikers. Last October, a group of us hiked the Inca Trail to Machu Picchu, and blisters nearly knocked a couple of my companions off the trail. The most common causes of blister formation are improperly fitted footwear, new (stiff) footwear, and the physical forces of pressure, rubbing, moisture, and heat. We had all of that as we negotiated long days on hot, dusty, and rocky trails. The time to treat a blister is before you get it, when you just begin to notice the irritation, and perhaps only have reddened skin (a “hot spot”). Before the fluid-filled blister develops, you still have a chance to prevent it. That can be done with a commercial bandage (like the ingenious Blist-O-Ban bandage shown above in the photo); a donut of Molefoam or Moleskin with a piece of Spenco 2nd Skin hydrogel positioned in the hole of the donut; or a padded bandage covered with tape. The best way I have found to avoid blisters is to wear a pair of thin liner socks underneath my hiking socks, so that the friction occurs between the two sock layers, rather than between the sock and the foot.

Tags: blisters, hiking, trekking, foot care, wilderness medicine, outdoor medicine, healthline

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Removing a Fishhook

Fishing is fun, but not when you catch yourself. If a fishhook enters the skin, gently wash the skin surrounding the entry point with soap and water, or at least give it a rinse to remove dirt, slime, or bait. Apply gentle pressure along the curve toward the point while pulling on the hook. If the hook is not easily removed, this means that the barb is caught in the tissue. There are then two ways to remove the hook.

The first method is to push the point through the skin. This is done by firmly gripping the shank of the hook with a pliers and pushing the hook until the barb is completely through the skin. Cut off the shaft or the barb, taking care to cover the area with a free hand to prevent the detached barb from flying into someone’s eye, and then pull the remainder of the hook out of the skin. Do not ever attempt this method if the hook is anywhere near the eye. In that case, try to keep the hook from moving, and seek immediate medical attention.

The second method of hook removal is the “string-pull” or “press and yank” technique. Tie a shoelace, thick fishing line, or other unbreakable string to the bend in the hook. Push the shank of the hook down (toward the embedded barb) in a direction that will disengage the barb. Then, use the string to yank the hook from the skin in a snapping motion. Take care that the flying hook does not impale anyone nearby – also wear eye protection or look away when you pull on the string to remove the hook. As above, do not attempt this method if the hook is anywhere near the eye.

Always wear eyeglasses when you are fishing, so that a flying line doesn’t throw a hook into your eye. If you are in a situation where you can fish with a barbless hook, that may make it more difficult to land a fish, but it will definitely make it very easy to remove the hook if you put it into someone.

Tags: fishing, fishhook, wilderness medicine, outdoor medicine, healthline

photo by Paul Auerbach

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Ice it Down

Athletes know it and do it, and so should you. If you are going to be vigorous on your feet, with your knees, with your shoulders, or any muscle group or joint, inflammation is your nemesis. So, to counteract the irritation, fluid collections, swelling, and pain, I highly recommend using ice and pressure within an hour or two of the exercise. In sports medicine, athletes are advised to do this after a significant (e.g., swollen and painful) joint injury, like a wrist or ankle sprain, and the method of RICE (rest, ice, compression, and elevation) works pretty well. If ice works for a dramatic injury, why not for something less pronounced, but nonetheless significant?

You can prolong the longevity of your joints by applying a firm or slightly compressed bag of ice or commercial cold pack for 20 minutes at a time, taking care to insulate the skin from direct ice application in order to avoid creating a frostbite injury. This should be done after exercise, and continued until the recipient reports pain relief, or even a bit of numbness in the skin. After a baseball player pitches a game, he or she ices the shoulder and elbow. If you are a rock climber and develop sore wrists, forearms, and elbows, it is perfectly reasonable to try a regular post-exercise icing routine. Hikers would do well to ice their knees, feet, and perhaps calves and ankles. It is easier on your system to rely upon ice and rest than a mixture of anti-inflammatory drugs and pain medicine.

Tags: ice, hiking, inflammation, wilderness medicine, outdoor medicine, healthline

photo by Paul Auerbach

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Water Safety

The summer news is already featuring some tragic deaths of youngsters who have drowned. Drowning is a leading cause of death in young people, for many reasons, most of them related to lack of supervision, and the inquisitive and risk-taking behaviors of infants, children, and teenagers. As I mentioned in a previous post, outdoor injury prevention is the name of the game. Once a submersion (under water) event has occurred and the victim is seriously ill, it is sadly often too late for rescuers and doctors to do anything that makes a big difference in survival and clinical outcome.

Here are important methods of prevention in the summer when young people will be around water:

1. Supervise all young children when they are swimming or near bodies of water.
2. Have all swimming pools properly fenced to prevent improper entry.
3. Keep the level of water in swimming pools high enough to the edge of the pool so that a person who struggles to the side can slide his or her body up over the edge and out of the water.
4. Insist that life jackets be worn whenever someone is on a boat, kayak or jet-ski; water-skiing; white-water rafting; or in any other circumstance in which they may be tossed into deep or swiftly-moving water. Maintain a lookout or lifeguard for all swimmers, water skiers, and other persons in the water.
5. Insist on helmet use for all kayakers and white-water rafters.
6. Do not allow diving into known or suspected shallow water, such as from rock ledges (lakes and quarries), rope swings, or diving boards.
7. Do not allow the use of alcohol or recreational drugs near the water.
8. Do not allow horseplay on boats, docks, or far out in a lake or ocean.
9. Do not assume that swimming lessons confer protection upon young children. They still must be closely observed and supervised.
10. Always swim or surf in pairs or groups.

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

photo by Paul Auerbach

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Use a Sunscreen

When it comes to sun (ultraviolet radiation, or “UVR”) exposure, there is no such thing as a “safe tan.” Sunburn, skin aging (including age spots and leathery skin), wrinkles, and skin cancers are excellent reasons to seek protection from harmful rays and to minimize ultraviolet exposure when recreating in the outdoors. As an avid skier, fisherman, and hiker, I can attest to how difficult it is to avoid the sun, and how important it is to protect my skin. I have suffered numerous sunburns, I’m getting older, my forehead has not been smoothed by Botox, and I have had a few pre-cancerous lesions frozen with liquid nitrogen by my dermatologist or carved out of my body by a plastic surgeon. Had I used sunscreens properly, particularly in my youth, I could have avoided most of these interventions.

Suncreens come in liquid sprays, lotions, and creams. They either absorb UVR, act as barriers to it, or reflect light. People have different skin types, depending on their tendency to burn or tan, but they all need protection. The “sun protection factor,” or SPF, of a particular sunscreen, indicates the degree of protection. For example, a sunscreen with SPF 15 confers protection such that it would require 15 times the UVR exposure to produce a sunburn in a person with protected skin as opposed to unprotected (by the sunscreen) skin. This assumes a liberal and complete application, which rarely occurs. Therefore, to be safe, use a sunscreen of at least SPF 30, and reapply it at intervals of no more than every 3 to 4 hours. If you are sweating or swimming, you need to reapply more often.

Tags: sunscreen, sunburn, SPF, outdoor medicine, wilderness medicine, healthline

photo by Paul Auerbach

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Outdoor Injury Prevention

Emergency physicians are pretty good at taking care of people, but we’d much more prefer that people not suffer enough to need our attention. In the outdoors, and certainly when you are off in a remote wilderness area, injury prevention is critically important. Every story of rescue and survival begins with a description of how the victim got into trouble in the first place. In all too many episodes, the accident or illness was avoidable. Here are some familiar mishaps (and possible consequences):

1. I skied out of bounds and became lost. I was forced to spend the night outdoors without a shelter. (Four of my toes suffered severe frostbite and were amputated.)
2. I decided to ride my mountain bike without wearing a helmet. I hit an exposed tree root, misapplied the front brake, and flew over the handlebars. (When I awoke with a concussion, I discovered that my shoulder was dislocated.)
3. I drank a few beers before I saw a snake slithering through the tall grass. When I reached over to grab it, the fangs were in my wrist before I could jump away. (After 48 hours in the intensive care unit receiving antivenin, my doctor says that I should be able to retain part of the function in my hand.)
4. When I began my hike up the butte, the sky was blue. When the clouds darkened and I heard thunder, I thought it would pass quickly, so I kept on climbing. I don’t remember anything between the flash and when they put me in the ambulance. (My hearing will likely be impaired for at least a few months while the hole in my eardrum heals up.)
5. Roping up the last few hundred meters of the glacier, I forgot to use my sunglasses. That night, my eyelids swelled shut and my vision was hopelessly blurred. (I sat our the remainder of the ascent, and missed the summit day.)
6. The last thing I remember about that afternoon was jumping off the cliff into the quarry. Everybody except me dove feet first. (I will be in this wheelchair for the rest of my life.)

We need all the advantages we can have. It doesn’t pay to take chances, even if the thrills are huge. One poor choice – one risky crossing across an avalanche runout, one tumble onto the sharp coral in tumultuous surf, one ill-fated white-water run without a helmet – and life as you know it changes forever.

Tags: injury, injury prevention, wilderness medicine, outdoor medicine, healthline

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Turning an Ankle

The July 4th weekend is a great chance to get outside and work on conditioning. I was hoping for a great jog on the trails around Folsom Lake, but was stymied by something that happens to me every couple of years, even when I’m paying attention. Running downhill on a narrow path, I stepped on a softball-sized rock protruding from the hard ground, and twisted my left ankle. It was the classic turn, inverting my foot (inward rotation) and “rolling” over the outside of my foot. I heard the all-too-familiar crunch and felt the small ligaments tear, with immediate pain on both the outside and inside of my ankle. I still had two miles to go to get back to my starting point. It was slow going, but I continued, because I knew that the pain would grow worse and the pain increase within the hour.

No doubt, I nailed my anterior inferior tibiofibular and anterior talofibular ligaments, which help anchor the bones of my ankle in place. These are the most commonly injured, but there are seven other ligaments in the ankle complex that might have also been strained.

The immediate therapy is RICE: rest, ice, compression and elevation. As soon as I could, I iced my ankle, using a bag of frozen edamame (soy beans) from Trader Joe’s. I was off to watch my son play baseball, so I carried a bag of ice to apply off and on for the next few hours. Still, it turns out that I have a fair amount of swelling, so it will be a couple of weeks at least before I can test my ankle jogging again.

To complete the therapeutic advice, for the next two days, I will wear a walking splint (left over from an ankle fracture/dislocation four years ago – but that’s another story) for a couple of days so that I can work in the E.R., then begin using intermittent heat applications to assist in comfort and resolution of the swelling. Most of all, I need to be patient, because ligaments take weeks to heal, and it’s important that they heal “tight and strong.”

Tags: ankle, ankle sprain, jogging, wilderness medicine, outdoor medicine, healthline

photo by Paul Auerbach

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