Injuries in Avalanche Victims

In the Spring 2007 issue of High Altitude Medicine & Biology, published by the International Society for Mountain Medicine, there is an excellent article entitled Pattern and Severity of Injury in Avalanche Victims (Matthias Hohlreider et al, Volume 8, Number 1, page 56).

There is much discussion in the literature and at mountain medicine meetings about what types of injuries predominate, and the roles of specific anatomical injuries versus asphyxiation from burial under snow in deaths following entrapment of victims in an avalanche.

In this retrospective (looking backwards at medical records) study of avalanche victims who were brought to the University Hospital of Innsbruck, Austria between 1996 and 2005, some important observations were made. There were 105 victims with a total of 49 significant injuries. The limbs, spine, and chest were most commonly injured, but only 2 deaths out of the 36 deaths observed were attributed to injuries, both broken necks. One death was deemed due to hypothermia, and the remaining 33 deaths were felt to be due to asphyxia.

The authors point out that 100 to 150 people die in avalanche accidents each year in North America and Europe. If this study can be reasonably extrapolated to the entire population of avalanche victims, then this lends further support to the notion that rapid response and uncovering the victim (to allow him or her to breathe) is of paramount importance. Transceivers, devices to preserve the airway and provide oxygen, protective shields, and the like are critical adjuncts. While multiple-system trauma may certainly be noted in someone who has fallen roughly in unforgiving terrain composed of ice and boulders, the victim found alive and without an irreversible brain injury caused by oxygen deprivation has a decent chance of survival.

photo courtesy of Swiss Federal Institute for Snow and Avalanche Research Davos

Tags: avalanche, risk, mountaineering, injuries, physician, health, wilderness medicine, outdoor medicine, healthline

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Snakes of Medical Importance in India

With this post, I am going to begin to make regular use of the journal Wilderness & Environmental Medicine, published by the Wilderness Medical Society, in order to bring you cutting edge information. I will condense and translate from articles of interest, so that the knowledge presented can be disseminated beyond the health care providers who are subscribers to the journal. In subsequent posts, I will offer summaries from other important medical journals, such as High Altitude Medicine & Biology, the New England Journal of Medicine, and so forth.

In Wilderness & Environmental Medicine, 18, 2-9 (2007) appears an article entitled Snakes of Medical Importance in India: Is the Concept of the "Big 4" Still Relevant and Useful? by Drs. Ian Simpson and Robert Norris. In this article, they point out that snakebites continue to be a major medical concern in India, but little rigorous epidemiology to support exactly which snakes are the culprits for the majority of envenomations. This is a significant issue, as it has been estimated by the World Health Organization that there may be as many as 50,000 snakebite deaths per year in India.

Traditionally, the snakes of medical importance have been listed as the Indian cobra Naja naja, the common krait Bungarus caeruleus, the Russell's viper Daboia russelii, and the saw-scaled viper Echis carinatus. However, the observation that the hump-nosed pit viper Hypnale hypnale is commonly misidentified as the saw-scaled viper leads the authors to conclude that the hump-nosed pit viper is of medical significance and perhaps should be included in current efforts to develop and refine antivenoms used to treat victims of venomous snakebites. This is particularly important given the fact that the antivenom currently used in India to treat snakebite victims does not appear to be particularly effective against the bite of the hump-nosed pit viper.

The authors further note that hospitals can be a rich source of epidemiological data in order to identify other species of snakes that may be causing severe injuries and death. In North America, we teach snake bite victims to capture and transport venomous snakes with extreme caution, if at all, in order to avoid additional bites. It would appear that in India, it may be more important for biting snakes to be captured and identified, in order for clinicians and snakebite experts to better understand the clinical syndromes associated with the bites of specific snakes, and to better prepare life and limb saving antivenom products.

photo of hump-nosed viper courtesy of Ian Simpson and the Wilderness Medical Society

Tags: snake bite, snakebite, venomous snakebite, antivenom, India, viper, wilderness medicine, outdoor medicine, healthline

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Thank You to Med Valley High for Grand Rounds

Thank you to Med Valley High for including my post about the hazards of Irukandji jellyfish 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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New Recommendations for Tetanus Prophylaxis in Wound Management

In medical parlance, “prophylaxis” refers to the process (usually by vaccination [immunization] or administration of a protective drug [such as is done to prevent an infection, such as malaria]) whereby an adverse medical condition, such as an infection or blood clot formation, is prevented. So,”tetanus prophylaxis” refers to the situation where a person is given an injection or series of injections to prevent infection with the bacterium Clostridium tetani, the causative agent of a tetanus infection. Because infection with tetanus can be very serious and even life-threatening, it is important for each of us to have active immunity.

The Immunization Branch or the State of California Department of Health Services recently released a new recommendation for tetanus prophylaxis in wound management. This was necessary because of the increasing prevalence of pertussis (“whooping cough”) in our communities, which necessitates that greater attention be paid to preventing this disease, which is caused by the bacterium Bordetella pertussis.

From this point forward, it is recommended that adolescents and adults who require tetanus toxoid vaccine for wound management should receive a single dose of Tdap (tetanus, reduced diphtheria, and acellular pertussis) vaccine instead of Td (tetanus, diptheria) vaccine.

Healthcare workers who have direct patient contact are also recommended by the Centers for Disease Control (CDC) to get a dose of Tdap vaccine to protect themselves, their families, and their patients.

Health care providers need to be aware of which vaccines are licensed for which age groups:

1. Tdap (tetanus, diphtheria, pertussis): ADACEL® (sanofi pasteur) ages 11-64 years; Boostrix® (GlaxoSmithKline) ages 10-18 years
2. DTaP (diphtheria, tetanus, pertussis): DAPTACEL® (sanofi pasteur) ages 6 weeks to 7 years; TRIPEDIA® (sanofi pasteur) ages 6 weeks to 7 years; Infanrix® (GlaxoSmithKline) ages 6 weeks to 7 years; Pediarix® (GlaxoSmithKline) ages 6 weeks to 7 years
3. Td (tetanus, diphtheria): Td (sanofi pasteur) ages 7 years and older

One obvious question is which vaccine should be used for children between the ages of 7 years and 10 years? It is probably best to use the DTaP vaccine for this age group, even though no vaccine is licensed for this age group, and either Tdap or DTaP would likely induce the proper immunities.

Tags: tetanus immunization, tetanus, tetanus shot, medical, physician, health, wilderness medicine, outdoor medicine, healthline

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Wounded by a Horseshoe Crab

I am a member of a few list groups related to wilderness medicine. One of these is a “venom list,” in which members share interesting observations meant to educate one another. A recent notice called attention to the fact that an unfortunate man had the skin over his abdomen pierced by the tail of a horseshoe crab. He claimed to have developed an infection and persistent burning pain attributed to an infection. The tails are not known to carry any kind of venom, but it is not uncommon for marine spine puncture wounds, such as the “prongs” on a Pacific lobster carapace, to cause pain out of proportion to the magnitude of the puncture wound. It would be interesting to learn if this particular victim had immediate pain, whether or not his wound has been evaluated for a persistent foreign body, and if he has an infection, the nature of the offending germ(s).

Until further notice, if someone is punctured by a marine animal spine, it’s worth a try to immerse the affected area in hot water to tolerance (45 degrees Centigrade or 113 degrees Fahrenheit) to see if that has any beneficial effect on reducing the pain.

photo courtesy of University of Delaware Graduate College of Marine Studies and the Sea Grant College Program

Tags: horseshoe crab, crab, marine infection, medical, physician, health, wilderness medicine, outdoor medicine, healthline

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Thank You to Fat Doctor for Grand Rounds

Thank you to Fat Doctor for including my post about a novel ear drying device 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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Irukandji and Kate Hudson

If you've been following the movie news, you may have noticed that Kate Hudson was in Australia recently, filming a romantic action feature entitled "Fool's Gold." According to reports, the production was halted because Irukandji (Carukia barnesii) jellyfish were found in the waters that were slated for swimming scenes with Hudson and her co-star Matthew McConaughey. This stirred up quite a bit of press, with much speculation about why the jellyfish were in these waters, whether or not anyone had actually been stung, and what might have happened if anyone had become injured. I have no opinion about these matters, but there is certainly no doubt that the Irukandji is capable of a inflicting painful and powerful sting.

From the 5th edition of the textbook Wilderness Medicine, here is some information:


Carukia barnesii, the jellyfish known as “Irukandji,” is a small (1/2 to 1 inch across the bell) translucent jellyfish with four thin tentacles (2 to 3 1/2 inches in length at rest, and up to 30 inches extended) found off the coast of northern Australia in both inshore and open waters. Most stings occur near shore and during the afternoon. Because the jellyfish tend to aggregate, victims often present in clusters. Furthermore, victims can be stung inside stinger resistant enclosures when the mesh is small (approximately 1 inch diagonally). After causing a severe immediate skin reaction characterized by pain and redness, the venom may induce restlessness, muscle pain and spasm, severe lower back pain, lower leg pain, abdominal pain, breathing difficulty (including painful breathing), headache, shivering, tremors, nausea, and vomiting, which progress to profound weakness and collapse. Generally the discomfort remits in 6 to 24 hours; however, it occasionally recurs.

In a severe case, there can be intense abdominal and chest pain, a sensation of chest tightness, pale skin or bluish coloration in the fingers and toes, repeated vomiting, sweating, dangerously high blood pressure,rapid heartbeat, fluid in the lungs, brain swelling, and heart failure.

Although the systemic syndrome can be quite distinctive, there can be minimal skin signs of envenomation.

Although residents of Irukandji-endemic areas are often aware that stinger-resistant enclosures do not prevent entry of the smaller jellyfish, many tourists, particularly those from countries other than Australia, are not aware.

An Irukandji-like syndrome has been reported in South Florida divers, but the jellyfish species was not identified.

photo of Kate Hudson in Hawaii from www.jaunted.com

Tags: Carukia barnesii, Irukandji, jellyfish, Kate Hudson, physician, health, wilderness medicine, outdoor medicine, healthline

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More on Submersion Incidents and Drowning Prevention

After I posted recently on submersion incidents, I read an excellent commentary in the Spring 2007 issue of Brain Waves (ThinkFirst Canada's official newsletter) on residential pool safety by Claude Goulet, Ph.D., who is a Professor in the Department of Physical Education at the Universite Laval. He answered a question about safety and security measures to be taken upon installation of a home pool, many of which are applicable to water safety in a wilderness setting as well:

1. The most effective measure is to block access to the pool when it is not supervised.
2. Adhere to all local regulations dealing with pool safety.
3. For any pool deeper than 1.5 ft, block access to the pool with a fence or non-retractable, four-sided barrier at least 4 feet high, with a self-closing and self-latching gate.
4. Surround any inflatable pool with a four-sided fence.
5. Chain link fences can be scaled, so should not be used, regardless of the size of the openings in the links.
6. Any pool connected to a house by a deck must be surrounded on four sides by a proper barrier.
7. Pool alarms, gate alarms, pool covers, and other devices should not be considered substitutes for proper isolating fences and gates.
8. Position the pool filter unit so that it cannot serve as a step by which the fence can be scaled.
9. Do not leave toys or other objects attractive to children in a pool after swimming hours.
10. Swimming skills and lessons should not be considered an absolute drowning prevention measure, especially with children younger than 5 years of age.
11. Children in and around a pool must always be supervised by an adult.
12. Arm band floating devices are not an effective drowning prevention measure for children.
13. Do not allow diving into a pool of shallow depth, particularly less than 8 feet in depth.
14. At least one person supervising children in a pool should know water rescue and basic first aid and cardiopulmonary resuscitation (CPR).

Tags: near drowning, swimming pool safety, pool, drowning, physician, health, wilderness medicine, outdoor medicine, healthline

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Wilderness Medicine Conference

"Come all who need rest and light, bending and breaking with over work, leave your profits and losses and metallic dividends and come..." John Muir, 1874

The Wilderness Medical Society (WMS) has just announced its 23rd Annual Meeting, which will be held at Snowmass at Aspen, Colorado July 21-25, 2007. This is a fantastic setting for what promises to be a wonderful continuing medical education session for doctors, allied health professionals, and all others who will attend.

With superlative lectures, workshops, and outdoor activities, the meeting will be one of the best ever created by the WMS. The Advanced Wilderness Life Support (AWLS) and Toxicology in the Wilderness pre-conference programs are specifically designed to support WMS members in accruing credits toward their Fellowship in the Academy of Wilderness Medicine.

The faculty includes many of the most experienced wilderness medicine professionals and terrific lecturers, including Peter Hackett, Sheryl Olson, Bob Norris, Brad Bennett, Jolie Bookspan, Howard Donner, Luanne Freer, Peter Kummerfeldt, Mel Otten, Phil Rasori, Will Smith, and many others. Some of the optional workshops include GPS navigation, improvised splinting, litters and packaging, medical volunteering in developing countries, photographing wildlife and wild places, and surviving the unexpected night out. Research abstract presentations, special interest group meetings, and constant opportunities to mingle with faculty and attendees are additional highlights of this specially informative and entertaining meeting.

Mark Plotkin, Ph.D., who is President of the Amazon Conservation Team and author of the wonderful books Tales of a Shaman's Apprentice and Medicine Quest, will deliver a special evening presentation entitled "Maps, Midwives, and Medicine Men: Using GIS and Ancient Healing Wisdom to Save the Amazon in Six Dimensions."

Please take the opportunity to peruse the entire program at the conference website. It will be my pleasure to greet many of you in Snowmass this summer.

Tags: Wilderness Medical Society, WMS, CME, continuing medical education, physician, health, wilderness medicine, outdoor medicine, healthline

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Sahara™ DryEar Warm Air Ear Dryer

I just returned from Maui, where I participated as a teacher at the Stanford Symposium on Emergency Medicine 2007. At the end of my presentation on wilderness medicine, I was approached by a doctor who showed me a medical device - The Sahara™ DryEar warm air ear dryer. This small, portable device, which is on the market, was designed by an otolaryngologist (“ear, nose, and throat [ENT]” physician), Dr. Hamilton P. Collins, to prevent and treat ear disorders by drying the ear canal. The airflow from this sophisticated device runs for 80 seconds at a comfortable temperature and dries the outer ear canal. The device has a customized computer chip that directs a heater and fan to regulate the flow of warm air into the ear canal.

Divers and swimmers often trap water in the external ear canal, which can lead to inflammation and infection of the skin that lines the canal. This is known in medical terminology as otitis externa, commonly known as “swimmer’s ear.” A case of swimmer’s ear can easily ruin a vacation or dive trip, and can progress to a much more serious infection. The key to prevention is drying the external ear canal, which is often done by either instilling a few drops of rubbing alcohol, and/or by acidifying the canal, commonly done with a drop or two of household vinegar. The latter maneuver inhibits the growth of bacteria that cause the infectious component of otitis externa. The beauty of the DryEar™ device is that it safely evaporates water that has accumulated in the external ear canal, obviating the need for any further maneuver.

Each DryEar™ comes with five interchangeable, color-coded earpieces: blue, green, purple, pink and yellow. The different colors are designed so that different persons can have his or her own earpiece. The earpieces are designed to exhaust the airflow from the ear canal along with the evaporating moisture. In most cases, all the moisture trapped in the ear will evaporate in an 80 second application. If the user feels that water is still trapped in the canal, the cycle may be repeated.

The DryEar™ is equipped with a rechargeable lithium ion battery similar to those found in cell phones. The DryEar™ can run 50 times before requiring a recharge. The device is not waterproof, so one must take care when carrying it near the water, and it should be stored in a safe, dry location.

The manufacturer states that the device can be used if the eardrum is perforated. This seems reasonable, as when the device is turned on, the gentle stream of air is barely perceptible. Furthermore, the warm air seems to be of a temperature that should not induce dizziness from being too hot or cold.

Tags: Sahara DryEar, otitis externa, ear infection, swimmer's ear, physician, health, wilderness medicine, outdoor medicine, healthline

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Thank You to Dr. Keagirl for Grand Rounds

Thank you to Dr. Keagirl for including my post about drowning prevention in Grand Rounds, this week hosted at Dr. Keagirl's Urostream: Random Thoughts and Rants from Your Friendly Urologist. 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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Wilderness Medicine, 5th Edition

The 5th edition of the textbook Wilderness Medicine has just been released by Elsevier. I'm very pleased with the book, and hope that it is met with the same enthusiasm as have been previous editions. I am enormously grateful to the contributors, countless readers, and everyone who has offered me useful suggestions about ways to improve the book.

Over a period of nearly 25 years, Wilderness Medicine has become the leading text source of expert advice on handling health problems that occur in remote areas, extreme environments, and the great outdoors. Furthermore, it has served to define and expand the field of wilderness medicine. It is the only book that covers the entire field.

Wilderness Medicine explains how to manage everything from frostbite to infection by marine microbes and situations stemming from natural disasters to diverse injuries, such as bites, stings, poisonous plant exposures, and animal attacks. It includes vital, comprehensive treatment information that health care providers and rescuers cannot find in standard medical texts but will absolutely need during a medical crisis.

In addition to coverage of topics such as hypothermia, reptile bites, poisonous mushroom ingestion, and other essential wilderness medicine topics, this book includes new information on volcanic eruptions, extreme sports, wilderness cardiology, aerospace medicine, mental health in the wilderness, and tactical combat casualty care, among others. The book also describes how to meet the unique needs of specific patient populations, such as children, women, elders, the disabled, and people with chronic medical conditions. In addition, it addresses vital aspects of search and rescue, gear, navigation, nutrition, and survival.

Wilderness Medicine, 5th edition (ISBN: 978-0-323-03228-5) is 2336 pages long with 2100 illustrations, 1950 in full color. The complete table of contents and description of the book can be found at the Elsevier website. One hundred fifty-seven experts from medicine, government, education, research, industry, and the military, among other fields, contributed. An accompanying DVD-ROM carries the references, as well as duplicates the illustrations.

Persons who will find Wilderness Medicine essential include physicians, nurses, paramedics, EMTs, outdoor enthusiasts and adventure travelers, wilderness expedition leaders, the military, firefighters, search-and-rescuers, explorers in all environments (such as divers, alpinists, backpackers, etc.), and anyone interested in health care issues related to the outdoors. The coverage spans the globe with detailed descriptions of the environment, causes, diagnosis, treatment, and prevention.

I hope you enjoy the book, and find it informative and helpful as you pursue your passions for adventure, medicine, and the outdoors.

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

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