Prevention of Submersion (Near-Drowning) Incidents

As we approach summer, more people, particularly youths, will be in the water, in the wilderness, and in resort and urban locations. Swimming is an essential part of summer camps, trips to the coast, floating down rivers, kayaking, scuba diving – indeed, much of life at the beach, at the lake, and in the pool. Sadly, there will be many avoidable and unavoidable accidents, and victims will be submersed and drown.

Many factors contribute to submersion incidents. These include poor judgment, inability to swim, fatigue in rough waters, panic, drug and alcohol abuse, and many others. Surprisingly, what is not so well known by the general public or consistently promulgated are the rules and suggestions by which submersion incidents might be avoided. The following is advice for anyone who is going to be near the water or who is responsible for others who will be vulnerable to a submersion episode:

1. Learn to swim. This is most important for children and teenagers, who are frequently in the water and often place themselves in precarious situations. It is also important for adults, particularly those who may need to self-rescue, such as surf swimmers, scuba divers, and river rafters. However, do not let swimming lessons create a false sense of security, particularly with children. Small children who learn to swim do not necessarily have the physical strength and decision-making abilities to support themselves in a critical rescue situation. If you would supervise a child who doesn’t know how to swim, continue to supervise him or her if they do know how to swim. Toddlers are at greatest risk for near-drowning.
2. Do not tolerate horseplay in or around the water. This includes diving from heights into shallow water or water of unknown depth.
3. Avoid solo swimming; use the buddy system, so that someone is always on the alert to help a companion in need.
4. It is never safe to cross thin ice; one should be particularly careful during the spring thaw.
5. Alcohol and recreational drugs have no place anywhere near the water. It takes only a brief lapse of common sense to ruin a person’s life forever.
6. Surround all pools and swimming areas, where possible, with fences. Maintain the water level in a pool as high as possible (e.g., close to the ground surface) to allow a person who reaches the edge to pull himself out.
7. Never place non-swimmers in high-risk situations: small sailboats, whitewater rafts, inflatable kayaks, and the like.
8. When boating or rafting, always wear a properly rated life vest (jacket) with a snug fit and a head flotation collar.
9. In a kayak or raft traversing whitewater, wear a proper helmet.
10. Know your limits. Feats of endurance and demonstrations of bravado in dangerous rapids or surf are foolhardy.
11. Learn how to properly cross flowing streams of natural water. Do not attempt to cross a flowing stream where the water is above your knees.
12. Be prepared for a flash flood. In times of unusually heavy rainfall, stay away from natural streambeds, arroyos, and other drainage channels. Use a map to determine your elevation and stay off low ground or the very bottom of a hill. Know the location of high ground and how to get there in a hurry. Absolutely avoid flooded areas and unnecessary stream and river crossings.
13. Abandon a stalled vehicle in a flood area.

photo by John Mickey

Tags: submersion incident, drowning, near-drowning, prevention, physician, health, wilderness medicine, outdoor medicine, healthline

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Thank you to Stuart Henochowicz, M.D. for Grand Rounds

Thank you to Stuart Henochowicz, M.D., M.B.A., for including my post about rattlesnake bites in Grand Rounds, this week hosted at Medviews. 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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Mountain and Wilderness Medicine World Congress 2007

The Mountain & Wilderness Medicine World Congress 2007 has just been announced by the
Wilderness Medical Society (WMS) and the International Society for Mountain Medicine (ISMM). This event will be a landmark event for both organizations, because this is the first time that the United Kingdom has hosted such an ambitious joint meeting between the two entities. I'm very fortunate to have been invited to deliver the keynote presentation, which will be entitled "Wilderness Medicine: Are you ready for anything?"

Other sessions will deal with high altitude physiology and illnesses, cliff rescue, swift water rescue, wilderness casualty scenarios, hazardous encounters at sea and on land, exercise and training at high altitude, venomous bites and stings, wild animal attacks, hypothermia, mountain medicine, solar radiation, frostbite, lightning strike, water disinfection, mountain guides and porters, and many others. There will be research paper presentations and workshops as well. The program is one of the most comprehensive I have seen in quite some time, and the hosts promise that the social activities will rival the medical education.

Dr. Charles Clarke, one of the world's foremost authorities on mountain medicine, is the Conference Chairman. He will be assisted in running this program by Dr. Eric Johnson, President of the WMS, and Dr. Jim Milledge, President of the ISSM. These fellows are the legends, and the lecturers they have lined up are some of the biggest names and most informative and entertaining educators in the field. If you can't tell, I'm stoked! This should be a great meeting.

Tags: Mountain and Wilderness Medicine, mountaineering, ISMM, WMS, health, wilderness medicine, outdoor medicine, healthline

photo by Mathias Schar

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Rattlesnake Country

A good friend of mine just took off on his annual outing to Texas, where he hunts for snakes with his friends, mostly at night (because that’s when the snakes are out in the open and moving around). After all these years, he finally asked me what he should do if bitten by a snake, particularly if he was far from care. Here’s my answer:

If you’re by yourself several miles or more from help, try first to identify the snake, taking care to not get bitten again in the process. If it is venomous or you think it’s venomous, then the best place for you to be is in a hospital where a doctor can administer antivenom if that treatment becomes necessary. For North American snakebites, the only likely field first aid therapies are immobilization of the bitten part, such as a splint and sling for a bitten hand or forearm. Suction devices, such as The Extractor, or “cut and suck” devices, such as razor blade-rubber suction cup combinations, have not been proven efficacious. An ice pack gently applied won’t do any harm, but immersion into a bath of ice water might compound the snakebite injury with frostbite.

If you need to walk to get to medical attention, then a splint on your leg may be impractical. Don’t waste time making a fancy arm splint – a sling will do. I would begin to walk, not run, toward help. If you travel for a few hours and nothing happens other than a bit of pain and swelling, you are probably going to do fine (unless the bite is from a Mojave rattlesnake or venomous coral snake, in which case severe medical manifestations can be delayed by a few hours in onset). Staying put and sweating it out doesn’t really accomplish anything and basically puts your outcome in the hands of fate. If you are so far from help that walking for a few hours isn’t going to accomplish anything, then you might wish to stay where you are and conserve your strength. Remember, if there is any chance that an envenomation is significant, seek medical attention as soon as possible, so that antivenom can be administered under the guidance of a qualified health care professional.

Tags: rattlesnake bite, snakebite, medical, snake bite, health, wilderness medicine, outdoor medicine, healthline

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Thank You to Blog, MD for Grand Rounds

Thank you to Samuel Blackman, M.D. for including my post about antibiotics for a trip to Nepal in Grand Rounds, this week hosted at Blog, MD. 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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Hiking at Altitude While Pregnant

If someone is pregnant and wishes to hike for a few days at high altitude, is this safe?

There is not a tremendous amount of information available about the effects of a brief sojourn to altitude during pregnancy. A significant decrease in the amount of oxygen available to the baby (fetus) would only be expected at extreme altitude or if the mother were to suffer from high altitude pulmonary edema (fluid in the lungs), a severe asthma attack, or something else that would serously affect her ability to breathe and transfer oxygen into her bloodstream. If a woman has a complicated preganancy in which her obstetrician has advised caution or restrictions beyond those associated with a normal pregnancy, she should probably not hike higher than an altitude of 12,000 feet. If for any reason a pregnant woman suffers from high blood pressure, she may be at increased risk for suffering preeclampsia (a very serious affliction in which accelerated high blood pressure is associated with premature labor), although this has not been proven definitely (this caution derives from the observation that pregnancy-induced high blood pressure is more common in women who live at high altitude than in "lowland" women).

A real risk is that of being remote from medical care, if your journey will take a pregnant woman into the wilderness where she cannot seek immediate attention should she need to do so. It would probably be wise for any pregnant woman to visit her obstetrician immediately prior to any extended or unusual travels in order to be certain that all is well with her pregnancy.

Tags: high altitude, hiking, medical, pregnancy, health, wilderness medicine, outdoor medicine, healthline

photo by Terry Johnson

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Thank You to Bertalan Meskó at ScienceRoll for Grand Rounds

Thank you to Bertalan Meskó, a fourth year medical student at the University of Debrecen, Hungary for including my post about how to properly remove a tick in this week’s Grand Rounds. Grand Rounds, this week hosted at ScienceRoll, is a weekly hosted event where a medical blogger recommends notable posts of the prior week from other medical bloggers. In this compilation, the host included a few funny medical satire video clips, which bring a knowing smile.

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Antibiotics for a Trip to Nepal

As I mentioned in some of my first few posts, I had the good fortune to travel to Everest Base Camp in Nepal. In response to those posts and in the past, I was asked to comment on what antibiotics should be carried in a first aid kit.

First, what I am about to say is not a prescription for specific medical advice for a condition. It is, rather, a suggested list of drugs that might be carried to deal with infections that are often encountered during a trek in Nepal.

For a complete list of what to carry in a first-aid kit, see the section on First-Aid kits in the book Medicine for the Outdoors. With respect to antibiotics, you will need to get prescriptions for these from a physician or other health care provider licensed to write prescriptions. Be certain to explain any known allergies or bad reactions you have had to drugs in the past, and have the use of all medications explained to you prior to your travel, including side effects and interactions with other drugs or substances (such as metronidazole with alcohol).

The antibiotics I would recommend are:

1. Ciprofloxacin for infectious (bacterial) diarrhea. Given the incidence of certain bacteria that are resistant to ciprofloxacin, it is also wise now to also carry azithromycin (see #3).
2. Ampicillin or amoxicillin-clavulanate or something similar for sinus infection, skin infection, or ear infection.
3. Azithromycin for bronchitis, pneumonia, or serious throat infection.
4. Trimethoprim-sulfamethoxazole or doxycycline for methicillin-resistant Staphylococcus aureus (MRSA) infection.
5. Metronidazole or something else effective against Giardia lamblia and for dental infections.

Tags: antibiotics, Nepal, medical, physician, health, wilderness medicine, outdoor medicine, healthline

photo by Terry Johnson

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Avalanche Injuries

It was recently reported that a man buried by an avalanche for nearly 8 hours survived after being found with an avalanche probe. According to the victim, he was buried face up 4 feet below the surface of the snow. If he survived, there is no other conclusion to draw other than that he had sufficient air to breathe and was able to tolerate a drop in his core body temperature.

As noted by Knox Williams and his co-authors in the dealing with avalanches in the forthcoming 5th edition of the textbook Wilderness Medicine, avalanche deaths have increased in the U.S. each decade since 1950. From 1950 to 2004, 716 people died in avalanches. The average age of all victims was 30 years. The youngest was 6 years; the oldest, 67 years.

The man described in the first paragraph above was snowmobiling when he was caught in the snow slide. Most victims are pursuing some form of recreation at the time of their accident, with climbers, backcountry skiers, and snowmobilers heading the list. Miscellaneous recreation includes sledders and persons playing in the snow, campers, and even an unlucky ski kayaker. Among non-recreation groups, avalanches strike houses (residents), highways (motorists and plow drivers), and the workplace (ski patrollers and others whose jobs put them at risk).

Some of the factors that influence a buried victim’s chances for survival are time buried, depth buried, clues on the surface (to facilitate location of the victim and rescue), rescue equipment, injury, ability to fight the avalanche, body position, snow density, presence of air (breathing) pocket and size of air pocket, and luck. A victim who is uninjured and able to fight on the downhill ride usually has a better chance of ending up only partly buried, or if completely buried, a better chance of creating an air pocket for breathing. A victim who is severely injured or knocked unconscious is like a rag doll being rolled, flipped, and twisted. Being trapped in an avalanche is a life-and-death struggle, with the upper hand going to those who fight the hardest.

Avalanches kill in two ways. First, serious injury is always possible in a tumble down an avalanche path. Trees, rocks, cliffs, and the wrenching action of snow in motion can do horrible things to the human body. Second, snow burial causes asphyxiation (either obstructed airway or exhausted oxygen supply). A very small percentage of avalanche victims succumb to hypothermia, probably because they succumb to injuries or asphyxia before they have a chance to become sufficiently hypothermic to expire.

The problem of breathing in an avalanche does not start with being buried. A victim swept down in the churning snow has an extraordinarily hard time breathing. Inhaled snow clogs the mouth and nose; asphyxiation occurs quickly if the victim is buried with the airway already blocked. Snow that was light and airy when a skier carved turns in it becomes viselike in its new form.

Snow sets up hard and solid after an avalanche. It is almost impossible for victims to dig themselves out, even if buried less than a foot deep. Hard debris makes recovery very difficult in the absence of a sturdy shovel. The pressure of the snow in a burial of several feet sometimes is so great that the victim is unable to expand his or her chest to draw a breath. Warm exhaled breath freezes on the snow around the face, eventually forming an ice lens that cuts off all airflow.

Another factor that affects survival is the position of the victim’s head; that is, whether they were buried face up or face down. The most favorable position is face up. Data from a limited number of burials show the victim is twice as likely to survive if buried face up rather than face down. If buried face up, an air pocket forms around the face as the back of the head melts into the snow; if buried face down, an air pocket cannot form as the face melts into the snow.

A completely buried victim has a poor chance of survival. Survival is interrelated with both time and depth of burial. Survival probabilities diminish with increasing burial depth. To date, no one in the U.S. who has been buried deeper than 2.1 m (7 feet) has been recovered alive.

Time is the true enemy of the buried victim. In the first 15 minutes, more persons are found alive than dead. At 30 minutes, an equal number are found dead and alive. After 30 minutes, more are found dead than alive and the survival rate continues to diminish. In favorable circumstances, buried victims can live for several hours beneath the snow; therefore rescuers should never abandon a search prematurely. In 2003, two snowshoers caught near Washington’s Mt. Baker survived burials of 22 and 24 hours. Such long survival times are a reminder that no rescue should be abandoned prematurely on the thought that the victim is dead.

Tags: avalanche burial, avalanche, medical, survival, wilderness medicine, outdoor medicine, healthline

photo by Colin Grissom

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Tick Removal

After reading my last blog about acquiring Lyme disease from a (presumed) tick bite, a few people have asked me, what is the correct way to remove a tick if it is embedded in a person or pet? With a rising incidence of tick-borne diseases, it’s important to know the answer to this question.

The correct way to remove a tick is to grasp it close to its mouthparts with tweezers or with your fingernails (cover your fingers with tissue paper, gloves, or a thin cloth) and pull it out with a slow and steady motion. There are also V-shaped tick removal devices that are designed to slide between the tick and the skin to trap the tick and allow it to be pulled free. Don’t twist the tick. Don’t touch the tick with a hot object (e.g., extinguished match head) or cover it with anything that will cause it to struggle, since that might cause the tick to regurgitate infectious fluid into the bite site. If the tick head is buried in the skin, you can apply permethrin (Permanone insect repellent), which is an insecticide, using a cotton swab, to the upper and lower body surfaces of the tick. After about 10 minutes, the tick will relax and you can pull it free. After you remove a tick, look for remaining parts, and scrape them free with a knife edge or needle. Then wash the area well and apply a dab of antiseptic (e.g., bacitracin) ointment. If the area swells a bit, this is not necessarily worrisome, since ticks have salivary substances that cause a bit of a skin reaction, which may last for a week or two. However, if an infection develops or if the lump doesn’t go away, seek medical attention.

Tags: tick removal, tick, medical, physician, health, wilderness medicine, outdoor medicine, healthline

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Thank You to GruntDoc for Grand Rounds

Thank you to GruntDoc for including my post about erythema migrans and Lyme disease 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. This week marked the 4th time that GruntDoc hosted the event, which is remarkable. As always, this takes a great deal of effort and is much appreciated.

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"A Diagnostic Dilemma" Update

On September 17, I wrote a post entitled "A Diagnostic Dilemma," in which I described a friend who had developed an illness that we attributed to an insect bite, species undetermined. It was a possible spider bite, but the differential diagnosis included tick bite, and even the possibility of Lyme disease.

As it turns out, his blood tests for Lyme disease have come back positive, so the rash portrayed here and in the original blog is most likely a true case of erythema migrans (also sometimes called erythema chronicum migrans), which is the hallmark presentation for an early localized infection with Borrelia burgdorferi, the causative infectious organism of Lyme disease.

The ability of patients to remember a tick bite varies, frequently by species of tick, as some bites are more painful than others. Early localized disease typically begins as a localized erythema migrans rash or lesion, which occurs 7 to 10 days (range, 3 to 32 days) after a tick bite. It has been stated that 75 to 90% of patients with Lyme disease will develop an erythema migrans lesion.

Erythema migrans may appear anywhere on the body, but usually occurs at or near the site of the tick bite. In cases with a single erythema migrans lesion, the most common sites (in order of descending frequency, which likely reflects the propensity of a tick to land and bite) include the head and neck region, arms and legs, back (as was the case with this particular victim), abdomen, armpits, groin, and chest.

The erythema migrans rash is variable in size, ranging from two centimeters to over 60 centimeters in diameter, and is usually in a circular pattern. To meet the Centers for Disease Control (CDC) case definition of Lyme disease, the lesion must be at least 5 cm. It usually begins as a red flat spot or bump, with an area of central clearing that becomes more apparent as the lesion expands in size. The central portion of the rash may become inflamed and lumpy. The borders, which are usually bright red, may expand as much as one centimeter a day. These borders are usually flat, although rarely they may be raised or inflamed. Occasionally, there are multiple, alternating concentric rings of redness and central clearing, a rash pattern referred to as “bulls-eye.” The rash is often warm to the touch.

The lesions sometimes are difficult to differentiate from local immune reactions to tick salivary proteins, and are sometimes confused with secondary bacterial infections. In contrast, local allergic reactions usually occur within hours of the tick bite and are very itchy. Secondary infections typically occur within a few days of the tick bite and lack the central clearing and rapid expansion.

Patients often describe the lesion as burning, but may also report itching or pain. Children may develop fevers to 104ºF (40ºC), although low grade fevers are more common in adults. Constitutional symptoms, such as fatigue and muscle aching, may also be present.

Erythema migrans fades after an average of 3 to 4 weeks (range, 1 to 14 weeks) without treatment; with antibiotics, the lesion resolves after several days and seldom comes back. Although erythema migrans lesions resolve without treatment, untreated patients are at risk for developing more severe Lyme disease.

Tags: Lyme disease, tick, erythema migrans, ECM, health, wilderness medicine, outdoor medicine, healthline

photo by Paul Auerbach

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