Killer Whale "Attack"

The news media reports that Kasatka, a female killer whale, injured a trainer during a show at SeaWorld Adventure Park in San Diego. It took hold of his foot in its mouth and pulled him underwater twice, rather than release him so that he could emerge from the water and jump off the whale's nose.

This is not the first time that a performing killer whale has been uncooperative with a trainer during a performance. In a highly publicized previous event, a whale turned on its trainer in apparent pursuit, presumably agitated and with possible intent to cause harm by repetitive battering behavior.

As has been learned repeatedly with other wild animals that have been raised in captivity, tamed, trained, or otherwise been domesticated to a degree sufficient to perform with humans, unpredictable events occur.

The killer whale, Orcinus orca, is probably not a ferocious killer of humans. The largest of the living mammalian dolphins, these magnificent animals grow to 33 feet and 10 tons and are found in all oceans. They usually travel in pods of up to 40 individuals. Swift and enormously powerful creatures, they feed on squid, fish, birds, seals, walruses, and other whales. Their powerful jaws are equipped with cone-shaped teeth directed back into the throat, designed to grasp and hold food. The killer whale can generate enough crushing power to bite a seal or porpoise in two with a single snap.

In captivity, killer whales are playful creatures and seem intelligent, without the primal behavior of sharks. However, as reflected by this most recent and other incidents, they can occasionally become aggressive.

Although killer whales are believed not to prey on humans, they should be regarded with respect and at a distance in their natural habitat.

Tags: killer whale, whale, medical, physician, health, wilderness medicine, outdoor medicine, healthline

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Thank You to Grand Rounds at Notes from Dr. RW

Thank you to R.W. Donnell at Notes from Dr. RW for including my post about safety factors when eating produce in this week’s Grand Rounds. Grand Rounds is a weekly hosted event where a medical blogger recommends notable posts of the prior week from other medical bloggers.

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Speaking the Language

When someone practices wilderness medicine, it is often the case that he or she is in a foreign country. To interact with the indigenous people, appreciate the culture, and treat patients, it is a huge advantage to be able to speak the local language. How many of us speak a non-native (to us) language? If you are an American, do you speak Spanish, Nepali, Russian, or French? If so, are you fluent, or merely capable of asking for the bathroom and directions to the train station?

Think about the complexities of medical conversation in your native tongue. Doctors struggle to avoid “medi-speak,” so that their patients can understand them. Now try to do this in another language. Not only do you need to speak Norwegian; you need to speak medical Norwegian. The subtleties of any language are magnified when one is trying to deal with an ill person, who may mumble or speak in brief phrases.

An interpreter is essential. I am definitely at a disadvantage, and often embarrassed, when I cannot speak in the language of my guides, porters, assistants, and companions. In the most successful clinics run by volunteers in lands where they do not speak the language, skilled interpreters and medical assistants are essential to the success of the operation, and therefore to the health of the patients. The wilderness is a tough enough place without having to guess what someone is saying.

Tags: language, language barrier, interpreter, wilderness medicine, outdoor medicine, healthline

photo by Brenda Tiernan

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Tips for Avoiding Food-Borne Illness

There has been a great deal of press lately about contamination of food and in particular, fresh produce. The focus has been on Escherichia coli ("E. coli") and Salmonella typhimurium ("Salmonella") infections, but there are many other bacteria, such as Campylobacter, Shigella, and Vibrio species, that also cause debilitating gastroenteric infections.

The U.S. Food and Drug Administration (FDA) recently advised consumers about how to reduce the risk of foodborne illness from fresh produce. The advice is superb, and so I will use it as the foundation of a more comprehensive approach to produce handling and preparation that takes into account the realities of wilderness and foreign adventure travel. The italicized advice is the original offered by the FDA. The non-italicized comments that follow are mine:

Buying Tips for Fresh Produce

1. Purchase food that is not bruised or damaged. Penetrating wounds to the food that can introduce bacteria through the surface are probably worse than a bruise, unless the latter is extensive and indicates a large volume of underlying rot.
2. When selecting fresh cut produce - such as a watermelon or bagged mixed salad greens - choose only those items that are refrigerated or surrounded by ice. This is practical in an urban market, but not likely an option in an outdoor market or from street vendors. If you are trekking, you will be carrying your produce without refrigeration, so will be avoiding most items intended for raw consumption, unless they can tolerate prolonged periods of lack of refrigeration without decomposition. As you can see from the photo, you will have many opportunities to buy fruit and vegetables that has been peeled. If you look closely at the photograph, you will notice that the fruit is covered with insects, whose tiny feet spread germs.
3. Bag fresh fruits and vegetables separately from meat, poultry and seafood products when packing them to take home from the market. This is a great recommendation. Abide by it.

Storage Tips for Fresh Produce

1. Certain perishable fresh fruits and vegetables (like strawberries, lettuce, herbs, and mushrooms) can be best maintained by storing in a clean refrigerator at a temperature of 40 degrees F or below. If your're not sure whether an item should be refrigerated to maintain quality, ask your grocer. Don't carry these. They are high risk under the best of circumstances.
2. All produce that is purchased pre-cut or peeled should be refrigerated within two hours to maintain both quality and safety. Again, don't buy or carry pre-cut or peeled fruits or vegetables.
3. Keep your refrigerator set at 40 degrees F or below. Use a refrigerator thermometer to check. What if it's cold outside? Is that equivalent to refrigeration? The answer is, only if the environmental temperature is constant and within the accepted ranges for domestic refrigeration, from a safety perspective. If your food freezes or becomes too warm, it is at risk for destruction and/or contamination. Coolers with ice maintained at proper temperature are acceptable, but do not mitigate the other forces of improper hygiene, like introduction of dirt (e.g., bacteria).

Preparation Tips for Fresh Produce

1. Many precut, bagged produce items like lettuce are pre-washed. If so, it will be stated on the packaging. This pre-washed, bagged produce can be used without further washing. You shouldn't be carrying this sort of item in the backcountry.
2. As an extra measure of caution, you can wash the produce again, just before you use it. Precut or prewashed produce in open bags should be washed before using. This seems to conflict with the advice immediately above. If you have clean hands and reliably disinfected water, it seems like a better recommendation than the one above. However, remember that most of the pre-washed items are quite safe, so you need to be sure that you aren't taking a good situation and making it worse.
3. Begin with clean hands. Wash your hands for 20 seconds with warm water and soap before and after preparing fresh produce. Amen! Do this before handling any food. Hand sanitizer is an alternative to soap and water. Remember, it is important to wash hands even if handling something that will be emerging from a wrapper, like an energy bar, if there is a chance that you will touch the food before it passes your lips.
4. Cut any damaged or bruised areas on fresh fruits and vegetables before preparing and/or eating. Produce that looks rotten should be discarded. This is an excellent suggestion. Use a clean knife to do the cutting. When you cook meat and produce, you should thoroughly clean the cooking implements (e.g., knife, cutting board) if they have been used for handling meat before they are used for preparing produce.
5. All unpackaged fruits and vegetables, as well as those packaged and not marked pre-washed, should be thoroughly washed before eating. This includes produce grown conventionally or organically at home, or produce that is purchased from a grocery store or farmer's market. Wash fruits and vegetables under running water just before eating, cutting or cooking. You likely won't have running water, so use disinfected water intended for this purpose.
6. Even if you plan to peel the produce before eating, it is still important to wash it first. This is because you don't want to drag microscopic infectious organisms that you cannot see with the naked eye from the surface down into the part of the food that you intend to eat.
7. Washing fruits and vegetables with soap or detergent or using commercial produce washes is not recommended. This is because the residue of these products, when not completed removed from the food, can be toxic and make you ill.
8. Scrub firm produce, such as melons and cucumbers, with a clean produce brush. Mechanical forces greatly improve your ability to remove infectious micro-organisms.
9. Drying produce with a clean cloth or paper towel may further reduce bacteria that may be present. This is from the mechanical effect and from removing any surface moisture that may continue to carry infectious bacteria, viruses, and/or cysts.

Tags: food-borne illness, food safety, medical, physician, health, wilderness medicine, outdoor medicine, healthline


photo by Paul Auerbach

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Patterns of Injuries and Illnesses in the Wilderness

As participants and health care providers, we are familiar with certain types of injuries and illnesses, such as animal bites, falls, drownings, frostbite, malaria, and so forth. Epidemiologists study the patterns of things, and so with a reasonable population size (in order to attain statistical significance, putting trust in the numbers), can offer us observations that might lead to methods of prevention and treatment. Since anecdotal opinions abound in medicine, and in particular, in wilderness medicine, it is very important to be fact-based when possible, so as to base recommendations upon real, verifiable, and reproducible data.

It is common to discuss incidence (of events) and risks associated with these events. For instance, how often do climbers fall? What happens when they fall? What injuries do they incur? What influences whether or not a climber will fall, and if a fall occurs, what influences the type and severity of injuries? Are certain climbing techniques or maneuvers more or less dangerous? What about the correlation with time of day, season, and weather conditions? Climber experience? You get the picture - determining what causes an event, and then determining what might prevent or mitigate the event are important factors in determing outcomes, and essential to the practice of medicine in the wilderness.

In the most recent issue (Volume 17, Number 3, 2006) of Wilderness & Environmental Medicine, the official journal of the Wilderness Medical Society, there are a few articles that approach some of these issues. In the article, "Pattern of Injury and Illness During Expedition-Length Adventure Races," Dr. Kyle McLaughlin and co-authors evaluated the 2003 Subaru Primal Quest Expedition Length Adventure Race held in Lake Tahoe, California. The event was held over 10 days, and generated 356 patient encounters and 406 illnesses and injuries. The most common problems were skin and soft tissue injuries, predominately blisters. I didn't find anything surprising or unexpected in this report, so the general recommendation to anticipate skin and soft tissue problems, minor orthopedic ailments (e.g., sprains and strains), and an assortment of other issues (bee sting, snake bite, diarrhea, upper respiratory infection, etc.) seems like common sense.

Another article in the same issue yielded a bit of a surprise for me. Entitled "Back Pain in Whitewater Rafting Guides," the article by David Jackson and co-authors was an attempt to quantify rates of back pain among whitewater guides and to look for correlations between the presence of back pain and specific activities associated with guiding. After evaluating 390 returned survey forms (of 2510 distributed), the authors concluded that the rates of back pain among whitewater rafting guides appeared to be similar to the general population. I would have expected a higher incidence of back pain, but perhaps the reason for this is that the guide population is younger (for sure) and in better shape (highly likely) than me! Events correlated with back pain in this analysis included stacking 5 or more inflated boats, as was loading and unloading rafts in general. No mention was made of prolonged periods in the sitting position, such as occurs during a long stretch of floating, but again, the respondents were presumably young and less commonly sufferers of chronic lumbar disk problems than older riders.

Although lifting techniques were not specifically studied, the authors offered suggestions for outfitters to decrease the incidence of back pain among their guides:

1. All guides be taught and reminded how to life heavy objects, including advice to utilize a deep knee bend, keep the weight close to the torso, minimize rotation or twisting while lifting, and conduct lifts with a controlled, measured pace.
2. Special attention should be paid to overhead lifts, with additional persons added to minimize the per-person load, and good communication emphasized.
3. When throwing rafts overhead, if the raft falls off the stack, all participants should get out of the way and let the raft fall to the ground, rather than trying to catch it.
4. Use a mechanical lift and hoist system if available.
5. Allow guides to take sufficient time off to rest during the rafting season, and in particular if they are suffering from back pain.

Two other articles of interest in the same issue are "Injuries at the 2005 World Championships in Rock Climbing" and "Spinal Injuries in Scottish Mountaineers."

Tags: injury prevention, illness prevention, whitewater, rafting, back pain, wilderness medicine, outdoor medicine, healthline

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Sea Lion Bites

It seems that this is the week for aquatic animals to be irascible. A California sea lion has bitten at least 14 swimmers in the water of San Francisco's Aquatic Park Lagoon. While none of these bites has been serious, the prospect of being attacked and bitten has driven many enthusiasts from the water. According to reports, the animal appears to be watching victims from the shore. When the swimmers enter the water, the marine mammal follows and then makes its move to bump and bite them. The bites are nips, but carry an infection risk. Accordingly, the victims have been advised to take antibiotics. However, the San Francisco Department of Public Health has not recommended immunization against rabies.

The animal's behavior is not readily explained, as it does not appear to be defending a mate or any offspring. It is perhaps exhibiting territorial behavior, or as some have suggested, might be under the effects of toxic algae.

Sea lions and seals are usually mild-mannered mammals except during the mating season, when the males may become aggressive, and the breeding season, when both genders attack in defense of their newborn pups. Divers and swimmers should avoid ill-tempered and abnormally aggressive animals. There is nothing unique about the clinical aspects of these injuries, except for the post-bite infections.

“Seal finger” (also called "spekk finger" or "blubber finger") follows a bite wound from a seal or from contact of even a minor skin wound with a seal’s mouth or pelt. It has traditionally been an occupational hazard of seal hunters, but has now been noted in aquarium workers and persons trying to save seals. One case was attributed to a polar bear (which may or may not have eaten a seal) bite. The affliction is characterized by an incubation period of 1 to 15 (typically, 4) days, followed by painful swelling of the digit, with or without destructive joint involvement. As the lesion worsens, the skin becomes taut and shiny, while the entire hand may swell and take on a brownish violet hue. It is quite possible to have involvement of adjacent fingers. It is common for the affliction to run a protracted course.

Current thinking focuses upon Mycoplasma species as the inciting cause. Infection with Erysipelothrix rhusiopathiae is in the differential diagnosis, but usually is characterized by a more reddened and sharply-bordered rash spread amongst multiple fingers.

Tetracycline is the recommended therapy. Certain other antibiotics, such as ciprofloxacin, may be useful if tetracycline is not available. Preventive measures washing all wounds as soon as possible vigorously with soap and water.

Tags: sea lion, animal bite, wilderness medicine, outdoor medicine, healthline

photo by Paul Auerbach

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Shark Attack

A shark attack occurred on November 11, 2006 in the ocean off the coast of Maui, specifically in Kama’ole Beach Park II in Kihei. Despite the rarity of such attacks, this event attracted the usual amount of media attention and speculation as to causation. It was the fourth attack recorded this year in Hawaii. Although all of the sharks in these attacks were not definitively identified, they are presumed to likely be tiger sharks, which frequent the islands and are known to be man attackers.

As reported in the press, the victim was caught 30 to 40 feet offshore and bitten a single time in a “hit and run” attack. He pushed the shark away while kicking at it, and the animal fortunately left the scene without a visible return visit.

Other types of shark attacks are “bump and run” and “sneak attack.” In the former, the shark bumps up against its victim prior to a bite attempt. It is possible that this represents an attempt by the animal to assess the defensive response of its victim, or perhaps even to wound the victim with a blunt blow and exposure to the abrasive sandpaper-like skin of the shark. The latter refers to attacks where the shark is not seen prior to the attack, most commonly when it approaches the victim from behind or below.

Because I enjoy diving with sharks, I have had many encounters with them underwater, some of them frightening. To emphasize shark attack avoidance recommendation #11 below, I will never forget putting my heart in my throat during a dive in Micronesia, when we were traveling from Truk Lagoon to Ponape. One afternoon, I was photographing schooling dolphins, which were swimming in a vortex underneath me in blue open water. I was alone at the surface, equipped only with mask, fins, and snorkel, because dolphins are usually frightened by the harsh noise generated by breathing through a scuba regulator, and will generally not approach divers underwater. As I looked down through these friendly fish, I was surprised to see a solitary reef shark enter the scene. At first, the denizen swam slowly below the bottom of the school of dolphins, and I thought it was going to pass through them and move away into deeper water. However, it began to swim erratically and to ascend in a circular pattern, in a fashion that indicated agitation and perhaps agression. The dolphins did nothing to impede its approach. I lifted my face out of the water and motioned to a companion nearby, who sat in a small two-person boat 25 yards distant, awaiting my return. He waved back, interpreting my gesture as a greeting. I then shouted loudly and made it clear to him that I needed him to bring the boat - quickly! He arrived at my side at precisely the moment that the shark made a quick move up at me. I pushed my heavy metal camera housing between me and the shark, and somehow launched my body up out of the water and into the boat without ever touching the side of the boat. So much for being protected by Flipper and friends...

So, from personal experience, avoidance of shark attacks is key. The following advice is intended to assist ocean-goers from being bitten by a shark:

1. Avoid shark-infested water, particularly at dusk and at night
2. Do not wander too far from shore; heed posted warnings
3. Do not swim through schools of bait fish
4. Do not swim with domestic animals in shark waters
5. Swim in groups; pay attention to your companions
6. Avoid turbid water, drop-offs, deep channels, and sanitation waste outlets
7. Do not bleed in the water
8. Avoid shiny metal adornments and brightly colored swimwear
9. Do not carry tethered (dead or injured) fish
10. Be alert for sharks when fish act erratically
11. Porpoises do not preclude the presence of sharks
12. Do not tease or corner a shark
13. Do not panic or splash at the surface

Tags: shark attack, injury prevention, shark, Maui, wilderness medicine, outdoor medicine, healthline

photo by Paul Auerbach

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Thank you to Grand Rounds at "the rumors were true"

Thank you to topher at "the rumors were true" for including my post about religious pilgrims at high altitude in this week’s Grand Rounds. Grand Rounds is a weekly hosted event where a medical blogger recommends notable posts of the prior week from other medical bloggers.

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General Approach to Medications

Better life through pharmaceuticals, or so it seems. As a wilderness medicine doctor, indeed as a physician in general, I receive many questions about medications. Without dwelling on any particular drug, there is a general approach to the use of medications that seems sensible to me. Over-the-counter (“OTC”) medications are often sufficient for simple medical problems (like minor skin irritations or symptomatic relief of diarrhea), but fall short for serious problems (like an allergic reaction or rapidly progressive infection caused by bacteria. For instance, for a severe allergic reaction, you may need epinephrine (also known as adrenalin) in injectable form, and for the infection, you may need an antibiotic(s). Both of these categories of drug require a doctor’s prescription, at least in the U.S.

In my opinion, an excellent way to acquire these medications is to bring a list of what you intend to carry to your personal physician. Explain that the medications are being used to supply a medical kit, and ask your doctor to explain each medication to you in terms of indication(s), dose, duration of administration, and side effects. Be certain to learn if a drug is part of a particular “class” of drugs. For instance, acetazolamide (Diamox) is used to prevent and treat acute mountain sickness is a “sulfa” drug, so a person allergic to that class of drugs should probably be advised to not use it. If your doctor doesn’t have time to provide the explanations, then obtain this information from a pharmacist. Write everything down. Don’t carry medications if you don’t understand what they are and their appropriate use. Also, you should know the shelf life of each medication, so that the drugs can be replaced when they are outdated. Furthermore, you should know which drugs lose potency in extreme temperatures, if you will be exploring in very hot or cold environments. Finally, encourage each member of your traveling party to carry his or her own prescription medications, and to inform you where they are kept so that you will have ready access in a medical emergency.

Tags: first aid kit, medications, medical, physician, health, wilderness medicine, outdoor medicine, healthline

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The Pilgrim at High Altitude

The fall issue of High Altitude Medicine & Biology, the official journal of the International Society for Mountain Medicine, is opened with an insightful editorial by Buddha Basnyat, M.D., a long-time friend who resides in Kathmandu, Nepal. Entitled “The Pilgrim at Altitude,” the discussion focuses on the observation that many pilgrims ascending mountains for religious purposes are stricken with mountain sickness, and may die without fanfare, in contrast to highly-publicized incidents among recreational and professional mountain climbers, such as those attempting to summit Mt. Everest.

As commented upon by Basnyat, thousands of religious pilgrims seek to visit the abode of the gods, often at altitudes above 4300 meters. If they become ill with acute mountain sickness, they may not turn back, and so develop high altitude pulmonary and/or cerebral edema. Worse still, others might ascend by helicopter, essentially eliminating any chance for acclimatization to the high altitude.

Unfortunately, scant or no records are kept, so the true incidence of illness is unknown. Undoubtedly, many thousands of visitors to Mount Kailash at 6714 meters have been struck down or even succumbed to high altitude illness. Victims are often elders, and may be misdiagnosed with altitude illness. Some may even feel privileged to die in the shadows of such a holy place.

Doctors of the Himalayan Rescue Association are doing what they can to be available during predictable congregations in Nepal (such as at the Gosainkunda lakeside north of Kathmandu during the August full-moon gathering), but it is impossible to be everywhere in the Himalayas, so education efforts are critical.

I highly recommend High Altitude Medicine & Biology to all physicians and researchers interested in the physiology of high altitude. In this same issue (Volume 7, Number 3, 2006), there is a wealth of fascinating information, including a case report by Susi Kreimler and coauthors about the successful treatment of severe acute mountain sickness and apparent correction of excessive pulmonary hypertension with dexamethasone in a young girl. One case is not proof of cause and effect, but it is intriguing to hypothesize a benefit, which hopefully can be corroborated (or disproven) in the future.

Tags: high altitude, religious pilgrim, medical, physician, health, wilderness medicine, outdoor medicine, healthline

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Thank you to Grand Rounds at MSSPNexus Blog

Thank you to MSSPNexus Blog for including my post about waking up after a head injury in this week’s Grand Rounds. Grand Rounds is a weekly hosted event where a medical blogger recommends notable posts of the prior week from other medical bloggers.

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Essential Vaccinations for Children

Much is written in the wilderness medicine literature about vaccinations (shots given to boost the immune system in order to prevent disease) for travelers. Diseases such as yellow fever, Japanese encephalitis, and typhoid can be prevented to some degree by adequate immunization. However, we must never forget that less exotic diseases are also present worldwide, including in the U.S., and that these diseases cause "unnecessary" health problems, in the sense that proper immunization against them, mostly in childhood, would prevent their occurrence.

Here is a list of immunizations (vaccines) that are essential in childhood. These should be administered under the supervision of a pediatrician or other qualifed health care professional:

1) Hepatitis B (virus) beginning at birth
2) Polio (virus) beginning at age 2 months
3) Haemophilus influenza type b, or "Hib" beginning at age 2 months
4) Diphtheria, tetanus, and pertussis (whooping cough) [all bacteria], or "DTaP" beginning at age 2 months
5) Pneumococcus (bacteria) beginning at age 2 months
6) Measles, mumps, and rubella (German measles) [all viruses], or "MMR," beginning at age 1 year
7) Varicella (chicken pox) virus beginning at age 1 year
8) Hepatitis A (virus) beginning at age 1 year
9) Meningococcus (to prevent illness, particularly meningitis, from the bacteria Neisseria meningitidis) for children at age 11-12 years. This vaccine (Menactra, Sanofi Pasteur, Inc., a tetravalent meningococcal polysaccaride-protein conjugate) was in short supply until recently, but is now available in adequate supplies for routine vaccination of all recommended groups, including children aged 11-12 years, and if not previously vaccinated, adolescents at high school entry (at approximately age 15 years), college freshmen living in dormitories, and other persons at increased risk for meningococcal disease
10) Human papilloma virus (to prevent cervical cancer) for girls at age 11-12 years

In addition, influenza vaccine may be administered beginning at age 6 months. At age 5 years (and until the age of 49 years), the intransally administered, live, attenuated influenza vaccine is an acceptable alternative to the intramuscular trivalent inactivated influenza vaccine.

Tags: childhood vaccines, vaccines, immunizations, medical, physician, health, wilderness medicine, outdoor medicine, healthline

photo courtesy World Health Organization

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Waking Up After a Head Injury

A reader writes (about Head Injuries): "My son once fell on his head...and cried all the way home. When we got home he fell asleep from exhaustion....what does sleeping after a fall do?"

It is commonly taught that after someone has sustained a head injury with loss of consciousness (implying a concussion), that he or she should be kept awake. It is also taught that if the victim falls asleep, he should be awakened regularly, presumably to demonstrate that he can be woken up, and has not worsened or lapsed into a coma.

Where does this advice come from? Before the advent of computed tomography (CT) scans and magnetic resonance imaging (MRI), doctors could not easily get a radiographic look at the brain to determine if there was brain swelling or bleeding into or around the brain. A plain ("routine") X-ray of the skull only shows the bone. While it is important to see "the box," it's more important to see what is inside of it (e.g., the brain) - hence the importance of the CT and MRI technologies. So, prior to CT and MRI, many diagnoses were really estimates of what was going on inside the skull, not definite determinations. In order to determine if a victim of head injury was worsening, someone would need to perform a neurological examination ("neuro check") and keep track of the victim's mental and physical status. The frequency of these checks was fairly arbitrary, but sometimes would be as frequent as every 15 to 30 minutes. In most cases, once every hour or so would suffice. That would necessitate waking a sleeping patient.

Somehow, the concept that it was necessary to awaken a patient in order to perform a neuro check got transformed into the presumption that going to sleep was a bad thing to do after one suffered a head injury. That is not true. Sleeping in and of itself has no influence on the progression of the head injury. Furthermore, some persons who have suffered a concussion (or worse) become sleepy. If they fall asleep, they will not worsen because they fall asleep. If they worsen, it is part of the progression of the head injury, not related in any way to sleep. You cannot keep someone awake forever, because they need sleep to rest.

So, if you are in a situation where you are assessing someone who has suffered a head injury to determine their neurological status, you need to set reasonable intervals at which to perform the examinations. There is no magic number, but if you are concerned that someone is worsening, at least once an hour seems reasonable. Signs of worsening following a blow to the head include nausea and vomiting, blurred vision, increasing headache, and/or any change in mental status (e.g., declining alertness, ability to converse, or ability to follow commands; increasing confusion; or decreasing level of consciousness). If someone seems more sleepy than usual after a head injury, particularly if it is a child, perhaps difficult to assess and compounded with exhaustion, it is better to be safe than sorry. Bring that person to medical attention as soon as possible.

Tags: head injuries, concussion, medical, physician, health, wilderness medicine, outdoor medicine, healthline

photo by Paul Auerbach

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