A New Year's Resolution

This past weekend, I was speaking with a ski patroller friend, who told me that the ski season has started, and he's already taking people off the hill because they're drunk. Today in a totally different environment, I spoke with a lifeguard, who commented that he is seeing an increasing number of water rescues related to beer drinking on the beach. Taken together, these comments spell out a common recipe for disaster.

At the risk of sounding like a prohibitionist, let me take the position that alcohol has no place in the backcountry or in the midst of adventure sports. By that, I mean that drinking alcohol while engaging in any outdoor activity for which there is an element of risk related to decision-making, physical coordination or dexterity, mental alertness, and/or strength and conditioning is a poor choice. There is no benefit of alcohol that supercedes its potential deleterious effects.

For adolescents with limited experience of being "under the influence," the problems are confounded by even worse judgment. I know this to be true both as a physician and parent. Consider the following:

1. Alcohol-related automobile accidents are a leading cause of death. In the wilderness, alcohol figures prominently in drownings, boating accidents, falls, injuries from firearms, snowmobile accidents, skiing mishaps, and so forth.
2. Children model much of their drinking behavior from their parents. They are under constant pressure from their parents to drink alcoholic beverages.
3. By example, in the State of California, there is a "zero tolerance law," which in essence means that consumption of one-half a can or bottle of beer would put a teenager over the legal maximum blood alcohol level of 0.01% for a driver under the age of 21 years.
4. Alcohol markedly reduces inhibitions and leads to bad decisions about operating machinery, handling sharp objects (e.g., knives), staying on trails, handling burning objects, sexual promiscuity, getting into arguments that lead to physical altercations, and so forth.
5. A parent who provides alcohol or who permits it to be consumed by an underage individual is subject to severe financial penalties, and in certain circumstances, a criminal conviction.

At the end of the day, safely situated at the campground or at home and with no intention of being in a boat, negotiating a trail, or surviving a winter storm, I am delighted to sit safely distant from the campfire or fireplace and consume a single bottle of beer or glass of wine. I do this knowing that I do not place others or myself at risk because of my choice of beverage. My children and their friends will to some extent model their behavior after mine, so I must choose wisely. Without parental supervision, they would be all too delighted to contemplate making a poor choice.

Since it will soon be New Year's eve, I would be remiss if I didn't wish everyone "Happy New Year," with the admonition that if your celebration includes alcoholic beverages, please stay off the slopes and ice, and away from dangerous bodies of water. Hand the keys to the car, snowmobile, or boat to someone who is sober, and live to enjoy another day.

Tags: alcohol, drinking, medical, physician, health, wilderness medicine, outdoor medicine, healthline

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Thank You to Blogborygmi for Grand Rounds

Thank you to blogborygmi for including my post about hypothermia 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.

As we begin the new year, I want to express my gratitude in advance to the persons who make the extra effort to bring together medical bloggers and their posts in a way that makes it easier for everyone to access interesting medical information, updates, reports, philosophy, and musings. I'm continually impressed by the interest and enthusiasm of bloggers who share their time and knowledge with others.

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Happy Holidays

During the holidays, I pause to give thanks to the people who have meant so much to me in my efforts to support wilderness medicine.

First and foremost, there is my family. They continue to set an example for how their father should behave and guide his efforts. Second, there are my friends. My lifelong friends, be they experts in wilderness medicine, founders and keepers of the Wilderness Medical Society, co-workers in the Emergency Department at Stanford, or my neighbors, acquaintances, and traveling companions, are precious, and I realize that these relationships are more important than any peak I could possibly climb. Third, there are you, the readers - people who are curious, engaged, interested, and fascinated by the outdoors, medicine, and the world around you.

Last but not least, thanks to all of the wonderful people at Healthline, who allow me to maintain this blog and share my thoughts with you.







To all, happy and healthy holidays. I hope that 2007 brings you great adventures. More than that, I pray for the people of this planet to respect and love one another, and begin to apply reason and compassion to bringing an end to famine, pestilence, disease, and conflict.

Tags: holidays, happy holidays, medical, physician, health, wilderness medicine, outdoor medicine, healthline

photos by Paul Auerbach

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Human Hibernation

There is a report from Japan of a 35 year old man who became separated from his climbing party on Mount Rokko and was lost for 23 days. He is said to have been found with a core temperature of 71 degrees Fahrenheit, and to have been resuscitated and then doctored/nursed back to his normal pre-hypothermic condition, at least with regard to brain functioin. That he survived at all has been cited by some as a miracle, indeed, to perhaps represent an episode of "human hibernation." Is this possible?

We know that hypothermia creates a physiological situation that has been likened to a "metabolic icebox," in that the requirements for energy are greatly lessened in comparison to what is needed by someone for normal-temperature biological activities. When a person has a markedly lowered body temperature, he or she doesn't need as much oxygen (so can survive with a lower rate of breathing), sugar supply to the brain and other vital organs (so can supply with a lower heart rate and blood pressure), and so forth. So, in some sense, hypothermia can be protective, so long as its deleterious effects, such as tissue damage (frostbite), abnormal heart rhythms (which can be fatal), and other ill effects do not predominate.

What we know about Mitsutaka Uchikoshi, the climber in question, is that he separated from his friends and was found 23 days later, hypothermic, but not damaged so badly that he couldn't fully recover. He claims to have been unconscious for 20 or 21 days, but does that mean that this is actually what happened? Perhaps he wandered for many days in a confused state from moderately severe hypothermia before he actually lapsed into unconsciousness. Perhaps he was only truly severely hypothermic for a brief period of time.

The reports support the fact that he was severely hypothermic, but the true duration of his period of hypothermia is not fully known. As has been noted by at least one other observer, it is easy to hypothesize how he might have survived a period of 23 days without food, but surviving that period without any water is less plausible. However, as we know from Aron Ralston and others who have excellent documentation for feats of human endurance that would have not been survived by others, there are many exceptions to our accepted notions. Perhaps this is such a case.

Tags: hibernation, hypothermia, wilderness medicine, outdoor medicine, healthline

photo by Mathias Schar

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First Climber Found

One of the three climbers lost on Mt. Hood has been found, perished in a snow cave high on the mountain. He succumbed to hypothermia, which represents the second such tragedy in as many weeks, with perhaps more to follow.

As for all such situations, our hearts go out to the family and friends of the climber found and those still missing.

In the northern hemisphere, it is now winter, and so hypothermia and frostbite become serious medical concerns to a greater degree than during other seasons. What follows is a brief primer on the effects of hypothermia:

Heat is lost from the body to the environment by direct contact (conduction), air movement (convection), infrared energy emission (radiation), the conversion of liquid (sweat) to a gas (evaporation), and the exhalation of heated air from the lungs (respiration). The rate of heat loss via conduction is increased 5-fold in wet clothes and at least 25-fold in cold-water immersion. Windchill refers to the increase in the rate of heat loss (convection) that would occur when a victim is exposed to moving air.

During prolonged exposure to severe cold environmental temperatures, shivering is abolished after a few hours of exposure, because of exhaustion and depletion of muscle energy supplies. When a victim loses the ability to shiver, the cooling process becomes quite rapid. Normal skin temperature in cool weather is 90 to 93° F (32.2 to 33.9° C); this can drop to 70 to 73° F (21.1 to 22.8° C) before core cooling begins. Accidental hypothermia occurs when there is an unintentional decrease of 3.6° F (2° C) from the normal core body temperature of 98.6 to 99.9° F (32.7 to 37.7° C). Thus, hypothermia is felt to occur when the core temperature is at or below 95° F (35° C); mild hypothermia transitions to moderate hypothermia as the core body temperature descends from 95° F (35° C) to 90° F (32.2° C); severe hypothermia is defined as a core body temperature of less than 90° F (32.2° C).


The progression of hypothermia leads to predictable physiologic responses, which roughly correspond to different body temperatures. Although not invariable, the signs and symptoms are as follows:

95 to 98.6° F (35 to 37° C). Sensation of cold; shivering; increased heart rate; urge to urinate; slight incoordination in hand movements; increased respiratory rate; increased reflexes (leg jerk when the knee is tapped); red face.

90 to 95° F (32.2 to 35° C). Increased muscular incoordination; stumbling gait; decreased or absent shivering; weakness; apathy, drowsiness, and/or confusion; slurred speech.

85 to 90° F (29.4 to 32.2° C). Loss of shivering; confusion progressing to coma; inability to walk or follow commands; paradoxical undressing (inappropriate behavior); complaints of loss of vision; decreased respiratory rate; decreased reflexes.

Below 86° F (30° C). Rigid muscles; decreased blood pressure, heart rate, and respirations; dilated pupils; appearance of death. The victim no longer can control his body temperature and rapidly cools to the surrounding environmental temperature.

The first principle of therapy is to suspect hypothermia. Any person who is found in a cold environment should be suspected of suffering from hypothermia. In the absence of obvious hypothermia, the most likely clue to a hypothermic state is altered mental status. The winter hiker who gradually loses interest and lags behind the group (“Just leave me behind—I’ll catch up”), who dresses inappropriately for the weather or begins to undress, or who begins to stumble and make inappropriate remarks should be immediately evaluated for low body temperature. A hypothermic individual may become anxious, repeat himself, or even become delusional. Never leave a victim of even mild hypothermia to fend for himself.

If a hypothermic victim is improperly transported or rewarmed, the process may precipitate ventricular fibrillation, in which the heart does not contract, but quivers in such a fashion as to be unable to pump blood. The burden of rescue is to transport and rewarm the victim in a way that does not precipitate ventricular fibrillation.

The following general rules of therapy apply to all cases:

1. Handle all victims gently. Rough handling can cause the heart to fibrillate (cause a cardiac arrest).

2. If necessary, protect the airway and cervical spine.

3. Prevent the victim from becoming any colder. Provide a shelter. Remove all his wet clothing and replace it with dry clothing. Don’t give away all of your clothing, however, or you may become hypothermic. Replace wet clothing with sleeping bags, insulated pads, bubble wrap, blankets, or even newspaper. The “blizzard pack” from Blizzard Protection Systems, Ltd. can be used to provide protection from the elements. The Pro-Tech Extreme bag or vest, SPACE brand emergency bag, SPACE brand all-weather blanket, or SPACE brand emergency blanket, all from MPI Outdoors, are other options for this purpose.

Cover the victim’s head and neck. Insulate the victim from above and below with blankets. Do not change blankets unless necessary to keep the victim dry. If possible, put him in a sleeping bag sandwiched between two warm rescuers. But remember that in this situation, no heat is really contributed by the bag itself. Do not count on a sleeping bag to be adequately prewarmed by a normothermic rescuer’s body heat. Another technique is to blow warm air into the bag with the victim. Hot water in bottles, well insulated with clothing to prevent skin burns, may be placed next to the victim in areas of high heat transfer, such as the neck, chest wall, and groin.

4. Do not attempt to warm the victim by vigorous exercise, rubbing the arms and legs, or immersing in warm water. This is “rough handling” and can cause the heart to fibrillate if the victim is severely hypothermic.

5. Seek assistance as soon as possible.

Mild Hypothermia

The victim of mild hypothermia is awake, can answer questions intelligently, and complains of feeling cold. He may or may not be shivering.

Prevent the victim from becoming any colder. Get him out of the wind and into a shelter. If necessary, build a fire or ignite a stove for added warmth. Gently remove wet items of clothing and replace them with dry garments. If no dry replacements are available, the clothed victim should be covered with a waterproof tarp or poncho to prevent evaporative heat loss. Cover the head, neck, hands, and feet. Insulate the victim above and below with blankets. If the victim is coherent and can swallow without difficulty, encourage the ingestion of warm sweetened fluids. Avoid heavily caffeinated beverages. If a dry sleeping bag is available, one or more rescuers should climb in with the victim and share body heat. Do not apply commercial heat packs, hot-water-filled canteens, or hot rocks directly to the skin; they must be wrapped in blankets or towels to avoid serious burns.

Moderate Hypothermia

The victim of moderate hypothermia has become apathetic and mildly confused, wishes to be left behind, and is uncooperative. Speech is often slurred, and logic is on the wane. The victim rapidly becomes uncoordinated and clumsy, often stumbling. He has ceased to shiver, and shows signs of muscle stiffness. Unless you have a thermometer to measure this victim’s temperature, you must assume that he is severely hypothermic or will soon become so. Follow the directions for mild hypothermia, with the added caution that it is best not to allow this victim to walk about until he is fully alert; in addition, do not give him fluids to drink until he becomes wide awake and understands what is going on sufficiently allow purposeful swallowing in order to prevent choking on the ingested liquids.

Severe Hypothermia

Depending on the body temperature, a victim who appears to be asleep may be in a complete coma. Below 86° F (30° C), humans become poikilothermic like a snake, and take on the temperature of the environment.

Examine the victim carefully and gently for signs of life. Listen closely near the nose and mouth and examine chest movement for spontaneous breathing. Feel at the groin (femoral artery) and neck (carotid artery) for a weak and/or slow pulse.

If the victim shows any signs of life (movement, pulse, respirations), do not initiate the chest compressions of CPR. If the victim is breathing regularly, even at a subnormal rate, then his heart is beating. Because hypothermia is protective, the victim does not require a “normal” heart rate, respiratory rate, and blood pressure. Pumping on the chest unnecessarily is “rough handling,” and may induce ventricular fibrillation.

If the victim is breathing at a rate of less than 6 to 7 breaths per minute, you should begin mouth-to-mouth breathing to achieve an overall rate of 12 to 13 breaths per minute.

If help is on the way (within 2 hours) and there are no signs of life whatsoever, or if you are in doubt (about whether the victim is hypothermic, for instance), you should begin standard CPR. If possible, continue CPR until the victim reaches the hospital. Rescue breathing should take priority over chest compressions, particularly in the victim of cold-water immersion. There have been documented cases of “miraculous” recoveries from complete cardiopulmonary arrest associated with environmental hypothermia after prolonged resuscitation, presumably because of the protective effect of the cold. Remember, “no one is dead until he is warm and dead.” However, all of these victims were ultimately resurrected in the hospital, after they had been fully rewarmed.

A victim of severe hypothermia can rarely be rewarmed in the field. If a hypothermic victim suffers what you determine to be a cardiac arrest in the wilderness, transport should be the first priority. If enough rescuers are present to allow CPR and simultaneous transport, then do both. If you are the only person present, do not bother with CPR, because you will not be able to resuscitate the victim until he is rewarmed. Your only hope is that the victim is in a cold-protected state (“metabolic icebox”) and that you can extricate him (as gently as possible!) to sophisticated medical attention.

In any case of severe hypothermia, transport should be undertaken as soon as possible. Take care to cover the victim with dry blankets and to handle him as gently as possible. Rapid rewarming or restoration of circulation will release cold acid-laden blood from the limbs back to the core organs, which may cause a profound deterioration of the victim.

Prevention of Hypothermia

1. Carry adequate food and thermal wear, such as Thermax, Capilene, and/or polypropylene (“polypro”) or wool undergarments. Anticipate the worst possible weather conditions. Dress in layers so that you can adjust clothing for overcooling, overheating, perspiration, and external moisture. Use a foundation layer to wick moisture from the body to outer layers. The first layer (such as CoolMax) should keep the skin cool and dry (to avoid perspiration). Add an insulation layer to provide incremental warmth. For shirts, use wool, fleece, Capilene, or polypropylene. Consider a turtleneck or neck gaiter. For pants, wear wool or pile, with a fly. Carry windproof and waterproof outer garments, mittens or gloves (with glove liners), socks, and a hat. In very cold weather, up to 70% of generated heat may be lost by radiation from the uncovered head. Boots should be large enough to accommodate a pair of polypropylene socks (“liner socks”) plus at least one pair of heavy wool socks without cramping the toes.

2. Stay dry. Avoid sweating.

3. Keep hands and feet dry. This is important to avoid frostbite as well. For the feet, aluminum chlorohydrate–containing antiperspirant sprayed onto the skin can help to control sweating. Dr. Murray Hamlet recommends doing this three times a week for the first week of winter, then once a week after that. Avoid leather boots that become soaked with moisture and do not dry out easily.

4. Do not exhaust yourself in cold weather. Do not sit down in the snow or on the ice without insulation beneath you.

5. Seek shelter in times of extreme cold and high winds. Don’t sit on cold rocks or metal. Insulate yourself from the ground with a pad, backpack, log, or tree limb. Carry a properly rated (for the cold) sleeping bag stuffed with Hollofil II, Quallofil, or down. Insulate hands and feet well, even when you are in your sleeping bag, which should be fluffed up prior to entry. Do not enter a sleeping bag if you are wet without drying off first if possible.

6. Do not become dehydrated. In the cold, dehydration is caused by evaporation from the respiratory tree, increased urination, and inadequate fluid intake. Drink at least 3 to 4 quarts (liters) of fluid daily. During extreme exercise, drink at least 5 to 6 quarts per day. Ingesting snow is an inefficient way to replace water, because it worsens hypothermia. Drink cold water from a stream in preference to eating snow. Do not skip meals. Do not consume alcoholic beverages in cold weather. They cause an initial sensation of warmth because of dilation of superficial skin blood vessels, but this same effect contributes markedly to heat loss. At night, fill a canteen or Nalgene water container with at least 1 quart (liter) of water, and sleep with it to keep it from freezing.

7. Consume adequate calories.

Tags: hypothermia, search and rescue, Mount Hood, Mt. Hood, wilderness medicine, outdoor medicine, healthline

photo of Makalu by Chris Pizzo

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Search on Mount Hood

As I write this post, three climbers on Mt. Hood are still missing, last heard from six days ago when one called on his cell phone. Weather conditions are easing a bit, but the going remains difficult, as even expert mountaineers are being turned back by the conditions. Search and rescue personnel are being assisted by helicopters in attempts to locate the missing men.

It is possible that the climbers are still alive, but with each passing day, the odds diminish that they will be found in good condition. From the phone message on December 10, it is likely that the men split up, with the caller inside a snow cave and the other two attempting to descend to seek help. It is a grim situation, to be sure.

I have read commentary about who bears the responsibility for rescue, including the finances. With the exception of Colorado, Utah, and Oregon, which have state laws that allow victims to be billed for the expense, search and rescue (SAR) is provided for free by agencies that specialize in emergency response. There are arguments, pro and con, about the wisdom of billing for SAR: proponents of billing argue that persons would be less likely to take foolish risks if they knew they would be responsible for the SAR bill; opponents of billing hypothesize that a person might not ask for help when needed if he or she became worried about the payment.

The costs for SAR in hostile environmental conditions are not trivial, and go beyond mere dollars. Every time a helicopter is launched, the crew is placed at risk. Rescuers who ski through avalanche country looking for lost persons occasionally get caught in a slide. We are all familiar with tales of heroes drowned who attempted to pull people from icy water or swift currents. Risk is part of the activity, and definitely part of the aftermath of an adventure gone awry.

Having been involved with wilderness medicine for a long time, I know it is way too soon to rush to judgement. We do not know the precise circumstances that led to this particular episode, other than that three climbers got caught in bad weather. At this moment, it doesn't matter whether or not they made mistakes or could have avoided the situation. The fact is, they need help. Do we deny medical care and hundreds of thousands of dollars of resources to persons who smoke cartons of cigarettes and are stricken with lung cancer? How much money do we spend on persons who are addicted to drugs and alcohol? If you eat four cheeseburgers and drink ten Cokes a day, should we leave you alone in the parking lot when you have your heart attack? Let's stop the foolish talk about whether or not there should be a search, and who should pay for it. Rescuers should keep on searching until the men are found, or it becomes pointless to search any longer.

Tags: search and rescue, Mount Hood , Mt. Hood, wilderness medicine, outdoor medicine, healthline

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Great White Shark Attack

A great white shark attack was reported this past Sunday from Dillon Beach, California, which is northwest of San Francisco. A surfer had his board struck, and fortunately suffered only a couple of skin nicks. It certainly could have been far worse, so this surfer was very lucky.

White shark attacks are most common in the waters of southern Australia, the south coast of South Africa, the middle Atlantic coast of North America, and the American Pacific coast north of Point Conception, California. Attacks by great white sharks, which reach a length of nearly 20 ft (6 m) (making it the largest predatory shark), off the coast of northern California have led to the designation of a “red (or bloody) triangle” bordered on the north by Point Reyes and Tomales Bay, through the Farallon Islands to the west, and down south to Año Nuevo and Point Sur facing the Monterey Bay.

It is difficult to generalize about shark attacks on humans. Most attacks likely occur as cases of mistaken identity in which the shark misinterprets the splashing of humans at or near the water surface as the activity of normal prey items. Less commonly, attacks may be direct feeding events where large sharks simply perceive the human as appropriate sized and demonstrating appropriate behavior patterns.

The great white shark attains maturity at a length of approximately 2.5 m (8.2 ft). It is a man-attacker, but not always a man-eater. This statement reflects the observation that this highly feared animal usually releases its victim following a single “inquisitory” bite, a behavior it also employs on floating pieces of Styrofoam, surfboards, and marine mammals it does not consume, such as sea otters. Humans may survive and avoid consumption by having the ability to retreat to boats or surfboards prior to return of the shark, a luxury unavailable to the white shark’s normal prey. The great white shark has only recently been closely observed in the wild and is thus the subject of much speculation about predation strategies. The feared trait of the great white sharks is that they initiate contact with humans. Their unpredictable nature ranges from a seemingly docile approach to a research boat to a powerful attack on a surface sea lion. Breath-hold diver behavior and the similarity of the silhouette of a contemporary surfboard to that of a surface seal may be responsible for attacks on humans. Most attacks on humans occur at the water’s surface.

It has been noted that some great white sharks remain in one vicinity for a few days, so after an attack, it is probably best to stay out of the water in that location for at least a week, unless there is some compelling reason to risk encountering the same predator.

Tags: great white shark, shark attack , shark, wilderness medicine, outdoor medicine, healthline

photo by Carl Roessler

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Grand Rounds, Vol. 3 No. 12

Thank you to Anxiety, Addiction and Depression Treatments for including my post about the James Kim tragedy 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. I am continually impressed by the great efforts made by the editors of this weekly event to be inclusive and informative.

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Choosing a Backpack

It’s holiday season, and many people purchase outdoor recreation supplies as gifts for family and friends. Flashlights, canteens, tents, sleeping bags – there is an endless assortment of cool gear to be found at favorite stores and websites. Most of these products can be chosen without an eye to medical considerations, but a few should be properly fitted to the recipient and require some knowledge about features and their implications for ease of use and safety.

Backpacks are the quintessential symbol of trekking and mountaineering. A well-fitted, sturdy and durable backpack gives the user the freedom of the hills. Along with hiking boots, a backpack is essential for any sort of expedition in which someone is responsible for carrying his or her supplies. What is less well known is that a poorly fitted backpack can contribute to significant back pain, inefficient travel, or even the ruin of a trip. A backpack that weighs on its carrier can cause muscle spasm, sore neck and shoulders, numbness and tingling in the hands and fingers, sore hips, and irritated skin.

What features are important in a backpack that fits properly, distributes weight evenly and across the correct body parts, and will withstand extremes of environment? They are, in no particular order:

1. Proper size. It fits the torso closely, in particular the upper part of the body. When the padded waist strap is tightened, the weight of the pack should be distributed evenly across the hips.
2. The shoulder straps should be wide and well padded, to avoid compressing the front of the shoulders and armpits. They should be easily loosened and tightened. There should be a connecting strap that can be opened, closed and adjusted traversing the front of the chest attached to and between the shoulder straps.
3. Adjustable straps to fine-tune the tightness of the waist strap and the proximity of the pack to the back of the wearer are desirable.
4. Multiple compartments allow rational storage, ease of finding carried items, and more even weight distribution than possible with a single-compartment pack. Side pockets, top pockets, tie-down loops, an adjustable top cover, and other features to partition objects into discrete locations while protecting them from the elements are all good to have.
5. The pack should be designed so that it can be donned from a sitting or standing position, using the legs for stabilization. If it can only be put on by hoisting it and slinging it across the back, muscle strain is inevitable.
6. For a child-carrier pack, be certain that it is designed so that an active child can't easily self-extricate and wind up dangling or on the ground.

It is tempting to pick out a backpack for someone, wrap it up, and share in the pleasure when they reveal the gift. But remember, many times you will have picked out the incorrect size, fit, color, or whatever. Always purchase from a seller that has a reasonable return policy, because a backpack is a very personal item. You want to allow the recipient of your thoughtfulness to be able to make a trade if that results in the best possible person-pack match.

Tags: backpack, pack, medical, physician, health, wilderness medicine, outdoor medicine, healthline

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A Winter Tragedy

The practice of wilderness medicine is unfortunately frequently necessitated by tragic events and circumstances. We are all enormously saddened to learn of the death of James Kim, whose recovery was announced today. Mr. Kim succumbed to the cold Pacific Northwest environment, after he became lost searching for help and a rescue of his family, which became lost, then snowbound and stranded in a harsh environment. His wife and daughters, who remained with their vehicle, survived.

In my view, Mr. and Mrs. Kim are heroes - he for attempting to seek rescue for his family, and she for keeping her young daughters alive.

To assist others, I will summarize the advice of Warren Bowman, M.D., a good friend and former National Medical Advisor to both the National Ski Patrol System and the National Association for Search and Rescue, and his co-author Peter Kummerfeldt of Outdoor Safe, adapted from their chapter on wilderness survival in the forthcoming 5th edition of the textbook Wilderness Medicine.

Travelers should always plan for the unusual and unexpected. Tools include familiarity with weather forecasts, strategizing worst-case scenarios, carrying emergency items, avoiding solo travel, and leaving notice of the projected route and expected time of return. With good planning, deteriorating weather or a forced unexpected night outdoors might then become more of an inconvenience than a life-threatening ordeal. While we usually consider a life-or-death situation due to the elements to be associated with a remote expedition or natural disaster, the fate of James Kim highlights that even a drive home in a seemingly normal situation can turn ugly in a hurry.

Winter storm preparedness is essential for anyone who drives a motor vehicle in snow country. One must always be aware of the possibility of spending an unplanned night out in a vehicle. Causes include bad weather, breakdown, having an accident, running out of fuel, becoming lost, and getting stuck. Winter driving is especially hazardous because of the dangers of driving on snow or ice, losing visibility and orientation, fewer people on the road from whom to receive assistance, and the threats of frostbite and hypothermia. Accepting the possibility of trouble, carrying a vehicle survival kit (see below), and giving some thought to survival strategies will help prevent a night out in your car from deteriorating into a life-threatening experience.

Most travelers dress to arrive at a destination and not to survive a night out; in other words, they dress "to arrive, not to survive." A vehicle survival kit (listed below) should include extra clothing, blankets or sleeping bags, food, water, signaling equipment, and communications equipment (cell phone, citizen's band radio, etc.). It is also always better to stay with the vehicle, which provides significant protection and which is more visible to rescuers than a person on foot. Most laypersons are not experienced trail-blazing in wilderness environments, and particularly when landmarks are obscured by rain or snow, and darkness and cold weather conspire to alter orientation and judgement.

In cold weather, and especially for long-distance travel, drivers should keep their vehicles in the best possible mechanical condition. Drivers should use winter-grade oil, the proper amount of radiator antifreeze, deicer fluid for the fuel tank, and antifreezing solution in the windshield-cleaning fluid. Windshield wiper blades that are becoming worn should be replaced and special snow-and-ice resistant blades used when available. A combination snow brush and ice scraper should be carried. A can of deicer is useful for frozen door locks and wiper blades. Snow tires, preferably studded (illegal in some states), are desirable, but even with special tires and/or 4-wheel drive, chains should be carried. All-wheel drive or four-wheel drive is optimal, and front-wheel drive superior to rear-wheel drive. The battery should be kept charged, the exhaust system free of leaks, and the gas tank full ("drive on the upper half of your tank.").

Despite best efforts, you may become stranded or lost. If that happens, tie a brightly colored piece of cloth (such as a length of surveyor's tape) to the antenna. At night, leave the inside dome light illuminated so that it may be seen by snowplow drivers and rescuers. Headlights use too much current, so use the dome light. If necessary for heat, the standard recommendation has been that the motor and heater can be run for 2 minutes each hour (after checking to see if that exhaust pipe is free of snow). However, a more recent recommendation is that since it takes more gasoline to start a cold engine than a warm one, one should initially turn the heat up all the way and run the car engine until the inside is comfortable. Then, shut off the engine and wait until it becomes uncomfortably cold inside the car (which could be 10 to 30 minutes depending on outside temperature). The engine, however, will still be "warm." Start the engine again and run the heater until the occupants feel warm. Keep repeating this process.

Keep the tailpipe free from snow pack. Carbon monoxide (CO) poisoning can be a threat, so do not go to sleep inside the car with the engine running; if the engine is running, keep a downwind window cracked 1 to 2 inches in case there is a CO leak into the interior of the vehicle. A reusable CO detector is a wise addition to the survival kit. One or two large candles ("fat Christmas candle" size) should be carried to provide heat and light if the gasoline supply runs out, since two lit candles can raise the interior temperature well above freezing. However, resources should be used sparingly because you are never sure how long you will be stranded. In the situation of the Kim family, they were alone for more than a week.

Foresight enough to include heavy clothing and blankets or sleeping bags in the cold-weather vehicle survival kit is better than relying excessively on external heat generation. Do not smoke tobacco products or drink alcohol. If you have to exit the vehicle in a snowstorm, put on additional windproof clothing and snow goggles, and tie a lifeline to yourself and the door handle before moving away from the vehicle.

You must decide whether to wait for rescue or attempt to walk out under your own power. If rescue is possible, it is almost always better to remain in a snug shelter and conserve your strength. If you decide to leave, you must effectively mark your trail, in order to aid rescuers and enable you to return to the site if necessary. Travel should never be attempted in severe or extremely cold weather, or in deep snow without snowshoes or skis. If no chance of rescue exists, prepare as best possible, wait for good weather, and then travel in the most logical direction.

The best way for a lost or stranded person to aid potential rescuers is to do everything possible to draw attention to his or her location. Most modern rescues utilize ground parties, helicopters, and fixed wing aircraft. Besides radios, cell phones, and other electronic equipment, signaling devices are either auditory or visual. Three of anything is a universal distress signal: three whistle blasts, three horn blasts, three fires. The most effective auditory device is a whistle. Blowing a whistle is less tiring than shouting, and the distinctive sound can be heard farther than a human voice. An effective visual ground-to-air signal device is a glass signal mirror with a sighting device, which can be seen up to 10 miles away but requires sunlight. Special rescue beacons are available and can be carried as emergency equipment. These include strobe lights, laser signal lights, special beacons with both signaling and GPS capability, and personal locator beacons (PLBs).

Smoke is easily seen by day and a fire or flashlight by night. On a cloudy day, black smoke is more visible than white; the reverse is true on a sunny day. White smoke stands out well against a green forest background but not against snow. Black smoke can be produced by burning parts of a vehicle, such as rubber or oil, and white smoke by adding green vegetation to a fire. The lost person who anticipates an air search should keep a fire going with large supplies of dry, burnable material (wood and brush) and have a large pile of cut green vegetation close-by. When an aircraft is heard, the dry materials are placed on the fire, allowed to flare, and then armloads of the green vegetation are piled on top. This produces lots of smoke and a hot thermal updraft to carry it aloft.

Vehicle Cold Weather Survival Kit:

1. Sleeping bag or two blankets for each occupant
2. Extra winter clothing, including gloves, boots and snow goggles, for each occupant
3. Emergency food
4. Metal cup
5. Waterproof matches
6. Long-burning candles, at least two
7. First-aid kit
8. Spare doses of personal medications
9. Swiss army knife or Leatherman-type multi-tool
10. Three 3-lb empty coffee cans with lids, for melting snow or sanitary purposes
11. Toilet paper
12. Cell phone and/or citizen's band radio, with chargers
13. Portable radio receiver, with spare batteries
14. Flashlight with extra batteries and bulb
15. Battery booster cables and/or car battery recharging unit (plugs into cigarette lighter)
16. Extra quart of automobile oil (place some in hubcap and burn for emergency smoke signal)
17. Tire chains
18. Jack and spare tire
19. Road flares
20. Snow shovel
21. Windshield scraper and brush
22. Tow strap or chain
23. Small sack of sand or cat litter
24. Two plastic gallon drinking water jugs, full
25. Tool kit
26. Gas line deicer
27. Flagging, such as surveyor's tape (tie to top of radio antenna for signal)
28. Duct tape
29. Notebook and pencil/marker
30. Long rope (e.g. clothesline) to act as safety rope if you leave car in blizzard
31. Carbon monoxide detector
32. Ax
33. Saw
34. Full tank of gas

In this holiday season, we are all especially sensitive about the fragility of the human condition, and the good fortune to be at peace in our homes. My heartfelt condolences go out to the family and friends of James Kim.

Tags: James Kim , winter storm preparedness, survival, hypothermia, exposure, wilderness medicine, outdoor medicine, healthline

photo by Paul Auerbach

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The United States Lifeguard Standards Coalition

The United States Lifeguard Standards Coalition (USLSC) is a collaborative effort of the American Red Cross, the United States Lifesaving Association, and the YMCA of the USA. These are leading nonprofit groups that are members of the International Life Saving Federation, and all contribute to setting standards for lifeguards.

The USLSC is embarking on a process to research, identify, and promote evidence-based standards for lifeguarding and water rescue. As for medicine in general, evidence-based methods and standards are essential to support rational and defensible activities by rescuers and health care providers.

Because many lifeguarding techniques, skills, and protocols are based on historical accounts and empirical observations and opinions, often without scientific support, this process is an excellent idea. Lack of scientific evidence does not necessarily make any particular recommendation incorrect, but eventually, it is important to have data to support activities and interventions that directly impact health and safety. Furthermore, we have learned that tried and true methods and medical dogma are often changed considerably once comprehensive data are thoroughly reviewed.

The process is going to be a review of the lifeguarding literature. Because there will undoubtedly be much discussion and perhaps arguments, the process will encourage collaboration, but also include conflict management procedures. Many organizations and disciplines will be represented, including nonprofit professional and technical organizations, scientific researchers, and government agencies.

Many of us are eager to learn the outcome of the reviews and discussions. The desired results are evidence-based standards for the most effective lifeguarding and water rescue skills. Another product of these deliberations will be identification of areas in which evidence is lacking, in order to promote necessary research. The final guidelines and evidence review will be made public and distributed without charge.

Having participated in many panels in which there have been lively debate about the best way to handle certain wilderness medicine situations, such as resuscitation from severe hypothermia, frostbite, high altitude illness, snake bites, and the like, I anticipate that there should be quite a bit of back-and-forth during the upcoming sessions. The medical literature is replete with opinions about rescue, resuscitation, and the management of submersed victims, so it will certainly be the same for these groups. When their work is done, I will have more to report.

Tags: United States Lifesaving Association, American Red Cross, YMCA, physician, health, wilderness medicine, outdoor medicine, healthline

photo by Mike Sherrard

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Thank You to Emily DeVoto, Ph.D. at Grand Rounds

Thank you to Emily DeVoto, Ph.D. at "The Antidote: Counterspin for Health Care and Health News" for including my post about the killer whale incident 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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Alligator Attack

When I was a 4th year medical student at Duke, I completed an elective rotation in pediatric surgery at Shands Hospital at the University of Florida in Gainesville. It was an outstanding experience, working with some of the most dedicated and innovative pediatric surgeons in America.

The work hours were long – our typical day began at 5:30 AM, when we made rounds on our patients, and then extended nearly to midnight with all of the activities in the operating room, on the wards, in the E.R., and in the outpatient clinic. So, the only times I was able to leave the medical center to catch a workout was in the darkness. Since my method of exercise was to jog, running at night wasn’t so bad, since the daylight sun and heat combined with often stifling humidity to make exercising pretty miserable. At night, it was just warm, not steaming hot, so I could tolerate it.

I jogged around “Gator Lake,” a small body of water that was home to real live alligators. They weren’t shy, so everyone kept a watch out for them, like joggers around Jenny Lake in Grand Teton National Park do for bears. There were tales of pets and people who had encountered ‘gators in these parts, and came out on the losing end. Every so often, a wandering reptile met an untimely end at the hands of local animal control enforcement.

This past week, a naked man was reported to have been caught by a large alligator that nearly severed the victim’s arm. According to the press, the man had been wading in Lake Parker in Lakeland, Florida during the same hours when I used to do my jogging. The difference is that he may have been under the influence of an illicit drug, and he entered the water.

Here is information about crocodiles and alligators:

Crocodiles (genus Crocodylus) and alligators (genus Alligator) can be ferocious aquatic reptiles. Considered to be less sluggish than alligators, crocodiles may attack and severely injure a human. C. porosus, which ranges over an extensive geographic area, including India, Sri Lanka, southern China, the Malay Archipelago, Palau, the Solomon Islands, and northern Australia, has been claimed to be a prolific man-eater. Black caimans (Melanosuchus niger), prevalent in South America, have attacked humans. Estimates of human fatalities may be exaggerated based on isolated reports of atrocities committed by this beast. An adult crocodile devours prey much larger in size than a human. According to one report, the stomach of an Australian estuarine crocodile contained the remains of an aborigine and a 4-gallon drum containing two blankets. At a length greater than 20 feet (6 m) and a weight exceeding 2500 lb (1,136 kg), the crocodile can travel in water at a speed of 20 mph (32 km/h) and can charge a short distance over land at 10.6 mph (17 km/h). The enormous jaws and canine teeth can bite with sufficient force to sever an outboard boat propeller. However, the teeth are not well suited for tearing apart or chewing, so most prey is crushed into size and form suitable for swallowing and consumption. Some prey items are killed and allowed to rot, which makes them easier to swallow. Most crocodiles are content to eat fish, turtles, kangaroos, and wild pigs. However, feeding in freshwater rivers and adjacent land have introduced them to cows, horses, and humans, who are attacked when they cross rivers, catch fish, draw water, or work in the fields. The majority of attacks occur on persons swimming or wading in shallow water at twilight or at night. A crocodile attacks by grasping its prey in its powerful jaws and dragging it underwater, where it drowns and dismembers it with head shaking and a constant twirling motion (“death rolls”).

The American alligator Alligator mississippiensis most commonly attacks in the water but will also attack on land. These attacks seem to be motivated by feeding. Most alligator attacks in the U.S. seem to be on swimmers, waders, or fishermen. During the period 1948-2003, there were 326 alligator attacks resulting in 13 deaths in Florida.

When approached by an alligator, it is important to prevent the animal from opening its mouth, as the muscles elevating the jaw are relatively weak in comparison to the enormous crushing force obtained by closing the jaw. It is also important to avoid the powerful, lashing tail. The most important advice is to keep a safe distance at all times, and never intentionally put yourself in harm's way with any wild animal.

Tags: alligator attack, alligator, crocodile, physician, health, wilderness medicine, outdoor medicine, healthline

photo by Paul Auerbach

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