Chafing is Not Just for Babies

Out on the trail, on your bike, on a dive boat, and in many other outdoor situations, skin rashes are high on the list of disorders suffered by adventurers. For me, and many others, the earliest sign of too much sweating, dirty clothes, and something rubbing is chafing on the inside of my thighs.

Chafing is generally caused by the insides of the thighs rubbing together, and is worsened by moisture. Persons with heavy (especially fat) legs are more prone than are thin persons, although in times of high humidity or sweat- and grime-soaked clothing, chafing can afflict anyone. Other predisposing factors are irritating clothing (such as a coarse hemline on a pair of hiking shorts that terminates where the thighs rub together). Once you have initiated the rash by jogging in the heat, riding a rough bicycle heat, or wearing a tight neoprene wet suit for too long, minimal abrasion will cause it to fester and become more reddened and painful.

One potential solution is to wear nylon or other synthetic bicycle pants that are long enough to cover your entire thigh. These can be worn under hiking or running shorts. If you will have bare skin rubbing against bare skin, sometimes a thin layer of Vaseline helps to decrease friction and prevent chafing. There are also commercial products designed to allow skin to glide against other skin or clothing, in order to prevent chafing.

Since salt water or sweat absorbed into the liner of a pair of shorts or bathing suit will cause chafing, be certain to bathe or wash the areas that are irritated each day with soap and water. If chafing becomes itchy and extends into your groin, suspect a fungal infection.

Tags: skin rash, chafing, medical, physician, health, wilderness medicine, outdoor medicine, healthline

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Thank You to "from MEDSKOOL" for Grand Rounds

Thank you to "from MEDSKOOL" for including my post about the risks of climbing Mt. Everest 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 Memorial Day rendition is energetic and full of interesting posts.

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A Novel Method to De-Skunk a Dog

Any of you who is a dog owner or who has ever personally been sprayed by a skunk knows how awful that can be for all involved. The odor is brutal, and permeates everything in the vicinity. There are lots of folk remedies for "de-skunking" an animal, such as a bath in tomato juice or scrubbing with medicinal hydrogen peroxide, but I have just learned of a new technique that sounds like it is the solution for which we have all been waiting.

Dr. Rebecca Smith-Coggins, an emergency physician and remarkable outdoorsperson, is one of the smartest people I have encountered. Last week we were pondering different vintages of Turley wines, when she revealed that she had discovered the solution to de-skunking her pet dog. I don't know why she thought of this in the middle of our conversation about wine, but perhaps it was related to the odor of the vegetable medley we were being served at the time.


According to Dr. Smith-Coggins, the surprisingly effective product to neutralize skunk spray odor is Summer's Eve douche, manufactured by C.B. Fleet Company, Inc. Rebecca used 7 bottles to de-odorize her 70 pound dog. The method is to apply it directly to the fur and work it into the deeper layers by hand. For the dog's face, she used a washcloth with the solution to apply the product. Rebecca has used this technique successfully 4 times on her dog, who apparently isn't smart enough to figure out how to avoid getting sprayed by skunks.

For those of you with pets or who will personally become laden with skunk stink, if you try this technique, let us know how it works. If you have other "pearls" like this to share, let us hear about them.

Tags: skunk, douche, Summer's Eve, medical, physician, health, wilderness medicine, outdoor medicine, healthline

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Injury Patterns Among Canyoneers

Nearly everyone interested in wilderness medicine and many more people are familiar with the tail of survival written by Aron Ralston in his spellbinding book entitled Between a Rock and a Hard Place. Aron superbly details how he fell into difficulty, his brush with death, and how he was forced to amputate part of his arm in order to extricate himself from being pinned by a boulder in order to save his life. His story is one of the great adventure tails of our times.

Persons who explore in canyons face certain risks. In Wilderness & Environmental Medicine, 18, 16-19 (2007) appears an article entitled Injury Patterns and First Aid Training Among Canyoneers by Drs. Steven Stephanides and Taher Vohra. These doctors completed a web-based survey of canyoneers in order to ascertain injuries experienced or treated, first aid training, and whether or not first aid supplies were carried.

The authors received 38 responses. The group that responded did not require any evacuations, but identified the following as their most common medical problems, in descending order of frequency: cuts and scrapes, minor orthopedic issues (such as sprains and strains), encounters with cactus and other injurious plants, heat injury, hypothermia (it gets cold at night...), major orthopedic issues (such as broken bones), and falls. Most of the respondents were males, which probably indicates that gender's predilection for exploring narrow canyons along watercourses, and how the survey was distributed (primarily to two American and one Australian canyoneering interest e-groups).

No conclusions were drawn about first aid kits or training, but the frequencies of injuries reported are useful in order to allow canyoneers to better prepare for the medical issues they might encounter. To this list of potential situations should be added snakebite, insect stings, sun exposure, drowning, and animal bite.

photo of Aron Ralston courtesy of www.spirituallyfit.com

Tags: canyoneering, risk, injuries, medical, physician, health, wilderness medicine, outdoor medicine, healthline

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Wilderness Medicine in the News

Hardly a day goes by without a wilderness medicine story in the news. When I launched the AOL website the other day, here were three of the headlines: "Grizzly Bear Kills Moose in Couple's Driveway," "Doctor Finds Spiders in Boy's Ear," and "Black Death Found in Denver Squirrels." It seems like there's going to be a lot of outdoor news this year.

In future posts, I'll talk about bear avoidance and attacks, and infectious diseases such as plague, but for now, here's what you can do about a bug(s) in your ear:

1. Your primary goal is to get the insect to exit the ear canal before it causes any damage, such as would occur with a bite or sting. Therefore, the risk for a painful injury is obviously greater with an insect like a bee or wasp than with a non-toxic ant or tiny spider (if it's a relatively non-venomous species).
2. Another goal is to try to induce the insect to leave or to subdue it without causing it to struggle, which might cause it to bite or sting, or to move around in a fashion that causes great pain within the highly sensitive ear canal and against the eardrum.
3. A final goal is to do no harm - in other words, to try to not force the insect further into the ear or wedge it in such a fashion that it cannot be removed. Digging around in the ear with a cotton-tipped swab, paper clip, or other object that can gouge the external ear canal is not recommended.
4. An inanimate foreign body (a piece of corn, peanut, foxtail, stone, or the like) can be left in the ear until an ear specialist with special forceps can remove it. If a live creature (cockroach, bee) enters the external ear canal and causes pain that is intolerable, the ear should be filled with 2 to 4% liquid lidocaine (topical anesthetic), which will (slowly) numb the ear and drown the bug at the same time. If lidocaine is not available, mineral oil can be used, with the caution that it will frequently cause the insect to struggle, which may encourage a sting or bite and incredible temporary pain. Once the animal is dead (a few minutes), a gentle attempt should be made with small tweezers to remove it, if you can visualize part of the bug in order to grasp it. Don’t attempt this unless you can see part of the bug, however. Don’t push the bug in farther, or you might rupture the eardrum.
5. If you are going to be sleeping in a situation in which there is a high likelihood of a small crawling critter having access to your ears, then consider wearing earplugs (similar to those worn on airplanes or by hunters to suppress loud noises).

photo courtesy of Associated Press

Tags: foreign body, ear, insect, medical, physician, health, wilderness medicine, outdoor medicine, healthline

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Update on Antibiotics Prior to Dental Procedures

Wilderness dentistry is an art form, often improvised and rarely practiced in an optimal setting. Most health care professionals are not trained in dentistry and are therefore forced to improvise when faced with an injured or lost tooth, gum infection, lost crown, or other dental emergency. Furthermore, most first aid kits are not supplied with proper tools for managing dental problems unless a traveler has had the foresight to carry the necessary supplies and learn how to use them properly.

One traditional concept in dentistry has been that certain antibiotic coverage is necessary for persons with certain structural heart problems prior to certain dental manipulations. I was taught this in medical school, and dogma about this has not
changed until just recently. The American Heart Association (AHA) has released new recommendations that state that the use of antibiotics prior to dental procedures is rarely needed. This information is applicable to the wilderness as well as the urban setting.

The update states that giving antibiotics to patients prior to dental procedures is unlikely to prevent many cases of infective endocarditis [inflammation of the lining of the heart and its valves].

A specially appointed writing group sponsored by the AHA was created because of its collective expertise in prevention and treatment of infective endocarditis. This group, along with members representing the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics, concluded that the use of prophylactic (preventive) antibiotics should be restricted to patients at risk for infection, such as those with artificial heart valves or certain congenital heart defects.

According to the writing group, and as reported by Julie McKeel of the Duke Clinical Research Institute, antibiotic use should be reserved only for those people who would have the worst outcomes if they get infective endocarditis. The writing group concluded that "random bacteremia" (showers of bacteria released into the blood stream) resulting from routine daily activities, such as chewing food or tooth brushing, is far more likely to cause infective endocarditis than is bacteremia secondary to dental procedures. They did not, however, recommend that people take antibiotics whenever they eat or brush their teeth.

So, preventive antibiotics are now recommended for high-risk persons in which there will be manipulation of gum tissue, creation of cuts or perforations inside the mouth, or extensive dental worth around the periapical (near the base of the root) region of teeth. Such "high-risk" patients include recipients of heart transplants who have developed heart valve problems, as well as persons with:

• Prior infective endocarditis (infection of the heart valves)

• Artificial heart valves

• Unrepaired cyanotic ("blue coloration") congenital heart defects, including life-preserving shunts and conduits

• Congenital heart defects completely repaired with artificial material or a device, whether placed by surgery or by catheter intervention, during the first six months after the procedure

• Repaired congenital defects with residual defects at the site or adjacent to the site of an artificial patch or prosthetic device

Preventive antibiotics are no longer advised for persons with unrepaired "natural" mitral and aortic valve disease, rheumatic heart disease, or structural disorders like ventricular or atrial septal defects or hypertrophic cardiomyopathy (thickened heart wall muscle).

It is unlikely that lay persons will make the decision about when to apply these rules, but they are an important example of current information that needs to be disseminated to physicians so that they can provide good advice to people with disabilities who might venture into the wilderness.

image courtesy of www.clinica-dental-estrella

Tags: dental procedures, antibiotics, cardiac, prophylaxis, physician, health, wilderness medicine, outdoor medicine, healthline

Labels: antibiotics, dentistry, prophylaxis

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Risk versus Reward

Much has been written about the sixteen tragic deaths that occurred on Mt. Everest in 1996, including the excellent book Into Thin Air, by John Krakauer. in the most recent climbing year (2006), it appears that there were at least 15 deaths. Unlike 1996, in which 8 climbers died during one tragic storm, there was no single catastrophic event to account for all of these tragedies.

In wilderness medicine, we learn too often about the consequences of encounters with extreme environments. Man’s demise comes not only from sudden, unforeseeable events, like falling into a crevasse, but from more insidious and predictable medical difficulties, such as severe altitude illness. High altitude cerebral edema (excess fluid in the brain) and pulmonary edema (excess fluid in the lungs) are the nemeses of fit and experienced mountaineers, and all too common in inexperienced and under-qualified climbers. These days, it is not enough to climb Mt. Everest – one now seeks to climb for a record or distinction – most number of climbs, fastest climb without oxygen, oldest climber, youngest climber, first amputee climber, first climber from Montana who is a member of the Republican Party and who has graduated from Princeton – you get the picture. It is hard to fathom, but there are persons making summit attempts who have never before climbed another significant peak. In the guiding community, it is no secret that clients are sometimes literally hauled up the mountain for substantial sums of money. The result is, at least in part, that approximately 1 in 20 persons who climb to reach the summit of Mt. Everest perish during the attempt.

Adventurous men and women are entitled to be risk takers, but there is a boundary beyond which risk becomes foolish and perhaps unacceptable. Perhaps we hear too often, “No risk, no reward. No bet, no blue chips. No guts, no glory.” From a strictly medical perspective, it makes no sense to take people who are ill-equipped to encounter hardship at sea level in a controllable urban environment, and put them in a fight for their lives in extreme sub-zero temperatures at altitudes where one cannot survive for long without supplemental oxygen. Furthermore, many of the ill and wounded have never climbed even close to the altitudes at which they encounter misfortune on Mt. Everest. I believe in personal choice, but not when it will unnecessarily lead to limbs and lives lost.

If the climbing community and officials in Nepal and Tibet allow the routes up Mt. Everest to become highways open to anyone with the ability to afford a permit, not with any proven and relevant climbing experience, we can look forward to setting at least one new record on a regular basis – raising the number of persons maimed and killed in the attempt. Ocean divers must be educated, trained, and certified in order to be able to rent scuba tanks. Is it time to promote something comparable for persons who wish to climb extreme peaks?

Tags: high altitude, risk, mountaineering, medical, physician, health, wilderness medicine, outdoor medicine, healthline

photo by Mathias Schar

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MRSA on the Rocks

A while back, I wrote a post about methicillin-resistant Staphylococcus aureus (MRSA), the bacteria that causes extremely tenacious and problematic infections, usually by entering the human body through the skin. Many of this blog’s readers have offered comments, which indicates a high interest in the topic, because MRSA infections can be nasty and prolonged.

I was contacted a few months back by Janet Bergman, a rock, ice, and mountaineering instructor, who is also an emergency medical technician (EMT) and excellent writer. She asked me for a few quotes that she could use for an article she was preparing for the magazine Rock and Ice, a publication “built by climbers” for the climbing community. Her demeanor and approach were thoughtful and well-meaning, so I agreed to help out. I’m asked quite often to assist writers who prepare articles for lay media, and also by medical professionals writing for technical journals and textbooks. I’m always impressed by level-headed, rational, and thorough reporters who are not trying to sensationalize information, but to get it right. I’m very pleased to report that Janet Bergman wrote a terrific piece, from which I learned a great deal.

I urge you to read Janet’s article, entitled “It’s Not A Spider Bite,” beginning on page 78 in issue 159 (April 2007) of Rock and Ice. It begins, “Megan Day, a Boston-area climber, visited the doctor for the fourth time. It was last August and the painful, pus-filled red bump recurring on her leg and abdomen….on her ear, and it was almost the size of a golf ball.” In the paragraphs that follow, Berman goes on to describe community acquired MRSA, in terms of definitions, epidemiology relevant to climbers, clinical presentation, risk factors for transmitting the infection, economic impact, medical complications, treatment, and sensible prevention measures. She wisely consulted experts in the field, so her facts are current and spot on.

What I really like is that the magazine’s editors allowed her the word count and space to do justice to the topic. This is a rarity in many lay magazines, who want to deliver everything in sound bites, which hardly are sufficient for complicated medical topics.

MRSA infections are becoming increasingly common, and so the public needs to be aware of how best to protect themselves and the importance of prompt diagnosis and proper treatment. Janet Bergman has done a great service to the climbing community by advising them to:

1. Keep hands clean by washing thoroughly with soap and water or using an alcohol-based hand sanitizer.
2. Keep cuts and scrapes clean and covered with a bandage until healed.
3. Avoid contacts with other people’s wounds and bandages.
4. Avoid sharing personal items such as towels or razors.

Assume that MRSA is here to stay. If you are an athlete or adventurer, the last thing you want is to be laid low for months with a debilitating affliction that might have been avoided by personal hygiene measures.

Tags: MRSA, Rock and Ice, medical, physician, health, wilderness medicine, outdoor medicine, healthline

Labels: methicillin-resistant Staphylococcus aureus, MRSA

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There is a Limit

There is a story in the press about a 29-year old man from New Jersey who died a year ago from exhaustion and dehydration while participating in a wilderness survival adventure. According to reports, he exerted steadily for at least 10 hours in temperatures that at times exceeded 100 degrees Fahrenheit. Ed White of the Associated Press refers to the event as a "death march."

It is tragic that this man died, and made all the worse by the fact that he was accompanied by "expert" guides from the Boulder Outdoor Survival School who could have ended the exercise and administered water to the victim at any point. On May 7, 2007, it was announced that a law suit has been filed against BOSS.

I am not a jury or judge and admit that I do not have first hand knowledge of the specifics of what happened. The details will hopefully be revealed in court. If we have learned anything from the Duke lacrosse team fiasco, it should be that there is a presumption of innocence until all the facts are known.

However, from what has been reported, there may be a huge problem here. What sort of experts were these? If the accounts are accurate, what were they thinking to deny a struggling man a drink of water? If they were experts, what was their expertise? Did they know about heat illness, dehydration, exhaustion, and the obvious risk of pushing an inexperienced person beyond his physical and emotional limits? If they were wilderness survival experts responsible for the welfare of their clients, then they absolutely should have been educated about these topics. It makes no difference whether the victim was in shape or out of shape, signed a waiver form, or tried to wave them off. By eyewitness accounts, his mental status was altered, he fell repeatedly, and was no longer able to fend for himself. In this situation, there is a duty to rescue, and to say or think otherwise is untenable.

Forced dehydration has been abandoned as a conditioning technique by everyone who knows anything about its potential catastrophic effects. In sports, it is prohibited, and in the military, it is appropriately intensively monitored. Regardless of the outcome of the legal proceedings that are now attached to this incident, everyone should know clearly that severe dehydration can be rapidly fatal, and take every reasonable precaution to prevent an episode such as this.

I am saddened by this event, for the victim, for the family, and for all responsible persons who teach wilderness survival. David Buschow's death appears to have been unnecessary, and only serves the purpose, hopefully, of instructing others to not put themselves into a similar situation, either as victims or inadequate supervisors. There is risk in the wilderness, for sure, but there was no risk whatsoever to this man's companions had they chosen to do the proper thing and try to save his life with cooling, rest, and water.

Tags: death, dehydration, outdoor survival, David Buschow, Boulder Outdoor Survival School, health, wilderness medicine, outdoor medicine, healthline

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Thank You to The Blog That Ate Manhattan for Grand Rounds

Thank you to The Blog That Ate Manhattan for including my post with a book review of New Medicine: Complete Family Health Guide in 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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Outdoor Education Fatalities

An excellent paper analyzing outdoor education fatalities by A. Brookes was published in 2003 in the Australian Journal of Outdoor Education. One hundred fourteen fatal incidents were reviewed from the perspectives of supervision, first aid, and rescue. There were 2 homicides and seven deaths from natural causes. The accidental deaths included drowning in lakes or pools, drowning in moving water, drowning in open water, falls, falling objects, fire and lightning, hypothermia, and motor vehicle related.

The observations and conclusions were very revealing. Not many, if any fatal outcomes were contingent upon the quality of first aid provided, but better planning for a possible rescue could have saved lives. Fatalities that occurred under close supervision appeared to be unexpected or unpredictable; however it was not entirely clear which situations were unintentional errors versus which were intentional violations of recommended behaviors.

Supervision may deteriorate because of adverse conditions that contribute to an incident. For instance, if the weather grows bad, and everyone is focused upon self-preservation, or focus is lost, conditions are ripe for an incident. Supervision is a specific factor in swimming and other water-related fatalities. This is as much a function of spotting a person in distress as of preventing a lapse in judgment. Loose or absent supervision of teenage boys around moving water or steep drops has been and continues to be associated with fatalities. Bravado is suspected to be a risk factor. One conclusion is that tight supervision should be in place when youths are anywhere near steep ground or moving water.

Not surprisingly, fatalities due to falling objects were not consistently linked to supervision.

Rescues often involve split second decisions and very brief windows of opportunity. Therefore, rescue attempts may fail if a rescue has not been anticipated, with rescuers in place beforehand. The obvious example would be a situation of an overturned raft or kayak in swift water. Outside assistance should be sought early and aggressively. Emergency communication should be tested before it is needed.

photo copyright Rensselaer Polytechnic Institute and DJ Wagner

Tags: outdoor education, accidents, fatalities, medical, physician, health, wilderness medicine, outdoor medicine, healthline

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New Medicine - Complete Family Health Guide

Drs. David Peters and Kenneth Pelletier and their publisher, Dorling Kindersley Limited of Great Britain, have released the book New Medicine, subtitled Complete Family Health Guide into the U.S. The original publication date in the United Kingdom was 2005. The book is 512 pages in length, very well illustrated, and carries a retail price of $35 U.S.

New Medicine is a quite well written compendium of information intended to present, side-by-side, information that allows the reader to understand choices for therapy from both “western” (traditional) allopathic medicine and from “alternative” or “complementary” medicine. Combined, all of this medical knowledge generates an “integrated” approach to wellness, prevention, diagnosis, and treatment. This is a timely topic for medicine in general, and particularly germane to wilderness medicine. We are all fully aware that there are innumerable varieties of medicine practiced in remote regions worldwide, ranging from the herbalism and rituals of shamans to the sophisticated interventions that can be accomplished with the use of such tools as pulse oximeters, mobile surgical units, and portable hyperbaric chambers.

The world has suffered too long from lack of communication between “east” and “west” and can no longer afford to discount all reasonable approaches to acute and chronic debilitating conditions. It is rare that any faction has “the answer,” so we have much benefit to obtain if we can learn to integrate our knowledge and approaches to healing.

The book is divided into two sections. In the first section, there definitions, philosophical explanations, and general descriptions and introductory instructions that define the different types of medicine discussed in the disorder-specific topics that appear in the second section of the book. The chapters in the first section include well-being and health, conventional medicine, nutritional medicine, bodywork therapies, western herbal medicine, homeopathy, traditional Chinese medicine, acupuncture, environmental health, mind-body medicine, and psychological therapy. I found this portion of the book to be a refreshing overview of a general approach to practicing medicine. It more than serves its purpose of exposing a lay audience to the important principles and practices within each topic.

The second major section is entitled Disease & Disorders. It includes general advice & precautions, brain & nervous system, skin, eyes & ears, respiratory system, digestive & urinary systems, circulatory system, musculoskeletal system, hormonal system, women’s health, pregnancy & childbirth, men’s health, children’s health, mind & emotions, allergies & systemic disorders. It covers the 100 or so diseases and disorders most amenable to an integrated approach, as estimated by the editors. This is terrific stuff.

In a subsequent edition, I would love to see the book expanded to cover as many diseases and disorders as possible. Furthermore, it would be fascinating to see additional complementary approaches added from diverse cultures.

I am very favorably impressed by New Medicine and see a clear need for something like this at the doctor level. Given the vast amount of medical information available, it would be quite useful to have a reference source that puts a “New Medicine approach” Furthermore, I am convinced that personally taking some of their advice to heart would be instrumental in improving the health of anyone, including this reviewer.

Tags: New Medicine, family health guide, integrated medicine, alternative medicine, physician, health, wilderness medicine, outdoor medicine, healthline

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