CDC Concussion Management Tool

The Centers for Disease Control (CDC) has a tool kit posted on the Internet designed to assist clinicians with recognition and management of persons suffering from concussion. Given the number of minor and major head injuries that occur each year in outdoor settings, this is a very important topic. The tool kit is useful and well-prepared information.

Entitled "Heads Up: Brain Injury in Your Practice," the information and tools include a booklet with information on diagnosis and management of mild traumatic brain injuries, an Acute Concussion Evaluation patient assessment tool, a care plan to help guide a patient's recovery, fact sheets in English and Spanish on preventing concussion, a palm card for on-field management of sports-related concussion, and more.

I'm beginning to work on a revision of my book Medicine for the Outdoors, and will include the following information, and more, on head injuries:

One method to categorize victims of head injury is to consider them to be divided into two groups, according to whether or not they have lost consciousness. If a victim has not lost consciousness, this implies a lesser injury, but like everything in medicine, is not infallible. If someone has lost consciousness, even for a few seconds, the red flag is up for a potentially serious injury. Always be aware that the dazed or unconscious victim cannot protect his airway; you must be vigilant in your observation. The most common dangerous complication of head injury is obstruction of the airway with the tongue, blood, or vomitus. The most common associated serious injury is a broken neck.

Loss of Consciousness

If a person struck in the head has lost consciousness, he has suffered at least a concussion. The following signs and symptoms are commonly associated with a concussion: unaware of what happened; confusion; loss of memory; loss of consciousness; headache or sensation of pressure in the head; dizziness; balance problems; nausea; vomiting; feeling “foggy,” “dazed,” or “stunned;” visual problems (e.g., seeing stars or flashing lights, or seeing double); hearing problems (e.g., ringing in the ears); irritability or emotional changes; slowness or fatigue; inability to follow directions or slow to answer questions; easily distracted or poor concentration; inappropriate emotioinal behavior; glassy-eyed or vacant starting; slurred speech; seizure.

1. Protect the airway and cervical spine.

2. If the victim wakes up after no more than a minute or two and quickly regains his normal mental status and physical abilities, he has probably suffered a minor injury—so long as there is no relapse into unconsciousness or persistent lethargy, nausea or vomiting, or severe headache. If the victim is far from help, he should undertake no vigorous activity and be kept under close observation for at least 24 hours. Normal sleep should be interrupted every 2 to 3 hours to briefly ensure that his condition has not deteriorated. Confusion or amnesia for the event that caused the blackout is not uncommon and not necessarily serious, so long as the confusion does not persist for more than 30 minutes. Because a serious brain injury may not become apparent for hours, the wilderness traveler who has been "knocked out" should not venture farther from civilization for 24 hours. If headache and/or nausea persist beyond 2 to 3 hours, or if the victim seems in any way altered with respect to mental status, the victim should begin to make his way (assisted by rescuers) to medical care.

If the injury is minor and evacuation is not undertaken, advance the victim’s activity as follows: no activity and complete rest until without symptoms; next, light walking without any heavy lifting or resistance activity; next, mild exercise with slight resistance; finally, full activity. Do not progress beyond one “level” each 24 hour period.

3. If the victim wakes up and is at first completely normal, only to become drowsy or disoriented, or lapses back into unconsciousness (typically, after 30 to 60 minutes of normal behavior), he should be evacuated and rushed to a hospital. This may indicate bleeding from an artery inside the skull, causing an expanding blood clot (epidural hematoma) that compresses the brain. Frequently, the unconscious victim with an epidural hematoma will be noted to have one pupil significantly larger than the other.

4. If the victim awakens but has a severe headache, bleeding from the ears or nose with no obvious external injury to those organs, clear fluid draining from the ear or nose, unequal-sized or poorly reactive (do not constrict promptly upon exposure to bright light) pupils, weakness, bruising behind the ears or under the eyes, vomiting, or persistent drowsiness, he might have a skull fracture. Such signs mandate immediate evacuation to a medical facility.

5. If the victim suffers a seizure after a head injury, no matter how brief, he should be transported to a medical facility.

6. If the victim does not wake up promptly after a head injury (unconscious for more than 10 minutes), has bleeding from an ear, has unequal or nonreactive (do not constrict to bright light) pupils, has clear fluid from the nose, has a profound headache, is weak in an arm or leg, is disoriented, or has a fluctuating level of consciousness (normal one minute, drowsy the next), he may have suffered a significant brain injury and should be immediately rushed to a medical facility. Because there is a high incidence of associated neck injuries, any person with a serious head injury should have his cervical spine immobilized. Head injuries often cause vomiting. Therefore, be prepared to turn the victim on his side so that he doesn’t choke.


Tags: concussion, CDC, health, wilderness medicine, outdoor medicine, healthline

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Thank You to Wandering Visitor for Grand Rounds

Thank you to Wandering Visitor for including my post about Derek Abraham in this week's Grand Rounds. Derek was an incredible young man who touched many lives and brightened the days of his family, friends, and acquaintances. In his loss, we are all drawn closer to the things that are truly important, and hopefully, will be more inclined to make the world a better place. Derek would certainly have done that for each of us.

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Rifaximin for Traveler’s Diarrhea

Although there are many causes of infectious diarrhea that affects travelers, “traveler’s diarrhea” (TD) is generally considered to be caused predominately by the bacteria Escherichia coli (E. coli), as well as sometimes by Shigella species, Campylobacter jejuni, Salmonella species, and a few other bacteria. A number of antibiotics are prescribed to treat TD, with the most common being ciprofloxacin (Cipro).

In 2001 in the journal Clinical Infectious Diseases volume 33, pages 1807-1815, Dr. Herbert DuPont and his coauthors reported the results of a study that compared rifaximin (now marketed as Xifaxan) to ciprofloxacin for the treatment of TD. Paraphrasing the abstract that preceded the full study report, 187 adult subjects including students from the U.S. in Mexico or international tourists in Jamaica received (in a random fashion, so as not to bias the results) either rifaximin (400 mg by mouth twice a day) or ciprofloxacin (500 mg by mouth twice a day) for 3 days. The results indicated that the two antibiotics were equivalent in their effect with respect to clinical improvement within the first 24 hours, failure to respond to treatment, cure, and adverse events (which were low and similar in each group). The investigators reached the conclusion that rifaximin is a safe and effective alternative to ciprofloxacin for treatment of TD.

Rifaximin is a poorly-absorbed antibiotic, which means that the drug remains in the gastrointestinal (GI) tract of the person who consumes it, and has its beneficial effect by eradicating the bacteria within the GI tract that cause diarrhea without the antibiotic being absorbed to any significant degree into the bloodstream. According to Dr. Robert Steffen, this may be very important from a number of perspectives. First, the drug appears potent and well tolerated for treating TD. Since it is not absorbed, it would not be expected to be effective against other infections, such as urinary tract or respiratory, where absorption is important. Used selectively against TD, rifaximin might allow ciprofloxacin and other similar drugs of the fluoroquinolone class to be reserved for other infections and thus used with less frequency, which might lower the incidence of the development of bacteria resistant to this very important class of drugs. More work needs to be done to prove that a poorly-absorbed drug like rifaximin is safe in pregnant women and children, which would make therapy easier.

The manufacturer (Salix Pharmaceuticals, Inc.) expresses the following safety considerations: Rifaximin is indicated for the treatment of patients (greater than or equal to 12 years of age) with traveler’s diarrhea caused by noninvasive strains of Escherichia coli. It should not be used in patients with diarrhea complicated by fever or blood in the stool or diarrhea due to infectious agents other than E. coli. It should be discontinued if diarrhea symptoms worsen or persist for more than 24 to 48 hours, at which time alternative antibiotic therapy should be considered. The drug is not approved for use in pregnancy.

Tags: infectious diarrhea , rifaximin, traveler’s diarrhea, medical, travel medicine, health, wilderness medicine, outdoor medicine, healthline Permalink | 1 Comments| Email Post

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SteriPEN™

From the aspect of preventing illness and avoiding disruption of an adventure, water disinfection is perhaps the most important skill for the wilderness and foreign traveler. Infectious diarrhea is rapidly debilitating and is a guaranteed loss of activity for 24 to 48 hours, minimum, unless you can recognize the early symptoms and treat aggressively with an effective antibiotic.

The SteriPEN™ carries the promotional byline of “safe drinking water anywhere.” Distributed by Traveler’s Supply, Inc., this unique hand-held water purifier that uses ultraviolet light (UVL) is advertised to fit into most plastic consumer water bottles as well as other types of containers up to 32 ounces (1 liter). It operates on 4 AA batteries, with nickel-metal-hydride or lithium batteries recommended. According to the distributor, only 48 seconds of exposure to the UVL is required to disinfect 16 ounces (1/2 liter) of water and 90 seconds for 32 ounces (1 liter). The claim is that the device is effective against common outdoor and household pathogens, as well as less common micro-organisms, to include bacteria, viruses, and protozoa. The test results are found at an Internet link provided by the company. According to the product literature, the SteriPEN™ meets U.S. Environmental Protection Agency standards for microbiological water purifiers.

A filter can be used to remove particulates from the water prior to UV treatment. At the current time, the selling price of SteriPEN™ Classic Handheld Water Purifier is $68.97 U.S.

Here are a few more details, provided by Traveler’s Supply, Inc. UVL works for water disinfection by destroying the DNA of microbes. This keeps the germs from reproducing, which is necessary in order for them to make a person ill. The light emitted by the SteriPEN™ device is in the UV-C range, of wavelength 254 nanometers. This wavelength is germicidal (kills germs) by causing adjacent thymine base nucleotides in DNA to bond together, which prevents them from being properly recognized (“read”) in the replication process, which is necessary for DNA to allow a micro-organism to reproduce. Thus, the germ(s) is rendered harmless. Used as directed, the UVL exposure is of no consequence, as this wavelength of UVL does not pass through most materials (e.g., glass, metal, ceramic, and nearly all plastics). Furthermore, the underside of the air/water surface in a water container acts as a reflector for UV-C. So, if the SteriPEN™ lamp is completely immersed in water and used according to the instructions, the UV-C is contained and does not pose any health risk to the user. For additional safety, the SteriPEN is equipped with water sensors and will not operate unless the lamp is under water. The SteriPEN™ contains a microcomputer that controls operation time, according to information it receives from integrated temperature sensors and user indication of the volume of water to be disinfected. During use, the device should be used to gently stir the water. It is intended for use in clear water, so cloudy water must be filtered or otherwise made clear prior to using the SteriPEN™. Disposable lithium or rechargeable AA nickel metal hydride batteries will provide many more disinfection cycles than will alkaline batteries. The latter are better in a cold weather situation.

I’m very eager to try out this device. In the wilderness, I drink boiled water or water that I disinfect with chemicals. It would be terrific to drink disinfected water without the iodine taste, and also to avoid burdening my body with the chemicals used to disinfect water. Combined with a filter to remove large particulates and clarify the water, this promises to be an excellent solution for water disinfection.


Tags: water disinfection, ultraviolet light, SteriPEN, water, physician, health, wilderness medicine, outdoor medicine, healthline

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Three Cups of Tea

As we approach the 4th of July, we reflect upon our remarkable country and the freedoms we enjoy. Many of us often take these for granted, but it has been with great sacrifices and extreme efforts that our way of life has been created and maintained. Independence Day is not a universal holiday, sadly, because there are still many places in the world where the essentials of life, truth, equality, and justice are superceded by governments, religions, and human shortcomings that do not support human rights. Many of these places are visited by outdoor adventurers. Sometimes, men and women who intend only to pass through in their quest to meet a personal challenge become drawn to a greater purpose.

Wilderness medicine and adventure attracts men and women of action, many of whom are very sensitive to the people and social issues of the countries they explore. It is difficult to ignore the plight of locals, frequently in "third world" countries, who are far less fortunate than the wealthy, well-educated, and extensively equipped alpinists, divers, and eco-tourists who come to their lands for fulfillment and to accomplish their own missions. When one steps back and witnesses the hospitality and generosity of people who possess far less than we do, and who are in need of health care, food, shelter, and the basic items of existence that we take for granted, it can be a stimulus for wanting to make things better.

Visionaries and missionaries (in the true sense of the word) come in all forms and varieties. One needn't have attained the summit of Mt. Everest or discovered the Titanic to realize that the world will only sustain itself and become a better place for future generations if we are able to make remarkable and sustainable efforts to improve the lot in life of those who are less fortunate. The most profound tool we have to initiate change is education.

Greg Mortenson, a mountaineer who came to understand his calling while climbing in the Karakoram mountains of Pakistan, has written a book (with David Oliver Relin) about his experiences. Entitled Three Cups of Tea, it is, in the words of Tom Browaw, "Thrilling...proof that one ordinary person, with the right combination of character and determination, really can change the world."

Mortenson was the recipient of routine (by local standards), yet extraordinary (by his standards), kindness in an impoverished Pakistani village after his failed attempt to climb K2. During his stay with the villagers, he came to understand how centrally important it was to their future, and in particular that of women, that a school be built. He had the will power and improvisational skills to extrapolate that need into a much larger project to build schools across an entire region, and in so doing, promote the most logical solution to a problem that cuts across all socioeconomic issues. In the process, he was assisted by timely benefactors, who recognized the greatness in this man far ahead of his track record. From his determination and ability to move people in the direction of progress, Mortenson founded the Central Asia Institute, for which he continues to serve as Director.

The book is a fast (because it is a "page-turner") and fascinating read. Anyone who has struggled with a local bureaucracy, needed to grease the palms of greedy officials, or cajoled local bullies in order to complete a project will identify with the universal themes of sweet-talking, surreptitious methods, good luck, and bravado necessary to be successful. Mortenson's mission was pure, which helped, but he spares no credit in explaining how the efforts of many people were necessary for him to get his first bridge, and then first school, built. The principles of perseverance would apply equally well to any similar project in a foreign land, be it the building of a hospital or the initiation of a conservation effort. Good work must be appreciated and supported, or it will take twice as long at three times the cost.

Three Cups of Tea is a case study in contrasts - between East and West, wealth and poverty, men and women, poor explorers and wealthy philanthropists, and local values and political storm. It is the essence of accomplished explorers that they are able to improvise, so that what one learns on belay when an anchor has slipped is applicable to what one must do when a load of lumber is on the verge of being hijacked. Rugged individuals are often great at being leaders and achieving heroic feats, while the qualities necessary to build and support a team are not ingrained by genes or schooling. Greg Mortenson pulled it off, and with the assistance of a wonderful and patient wife, went way beyond. He has created something larger than himself. It will be extremely interesting, and vital to the people and country he has served, to see where he takes it from here. As documentation of the remarkable progress made to date, Three Cups of Tea is a tale of great importance, and very well told. On this upcoming 4th of July, we should be proud to have Americans like Greg in our midst.

Tags: Three Cups of Tea, Greg Mortenson, Pakistan, Central Asia Institute, health, wilderness medicine, outdoor medicine, healthline

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Derek Abraham

Too often, I learn about a tragedy that happened outdoors. When I am able, I try to use it to help others avoid a similar circumstance or teach them how to help someone in distress. But truthfully, sometimes the events are cruel and make no sense. When that happens, all I can do is step back and wonder, why?

I am overwhelmed today with sadness at the death of Derek Abraham, and write these words because it helps me, and perhaps will help others, to cope with his loss. I am too close to this inspirational young man and his family to make an effort to teach. I just want to remind us that each and every person has a story and deserves to be honored for the positive things they do to make life better for others. Derek certainly deserves that honor.

I have known Derek and his family since he was a small child. This past Tuesday, he graduated from Los Altos High School. I attended his graduation ceremony, because my daughter is in his graduating class. Derek was a wonderful young man – outgoing, kind, athletic, musical, compassionate, and community-minded – all attributes he nurtured with the assistance of his parents and similarly-talented brother. Derek’s father, who has been a pillar of our community with his leadership in Boy Scouts, was preparing to stand by his side this month as Derek received his Eagle Award, and his mother recently accompanied Derek and the Main Street Singers of Los Altos High School to Scandinavia on a singing tour. Derek was the focal point of friendships, activities, and adventure.

Derek’s death was a freak accident. He and his best friend, also a terrific young man whom I have had the pleasure of coaching on the wrestling team, were kiteboarding at Panther Beach near Santa Cruz. Derek was caught by a gust of wind and before he could react, was suddenly dashed into the rocks, sustaining an unsurvivable injury. His companions called for help and tried to resuscitate him, but nothing could be done to save him. I received a call from my daughter as soon as she learned of the accident and was preparing to rush to his location when she called me back, sobbing, and told me that he didn’t make it.

We all loved Derek, and we love his family. The community, and in particular his classmates and friends, have rallied around the Abrahams to offer condolences and support, but right now, we are at a loss. I practice emergency medicine for a living, and am usually strong, but today, I am not so tough. We should be the ones providing strength, but it comes mostly from Derek’s family. Yesterday, I listened to his father tell the students that they should take a lesson from Derek and “not live their lives in a box.” That is true, of course. It is impossible to be a diver, climber, backpacker, mountain biker, or kiteboarder without exposing yourself to the elements, dangerous situations, and unforeseen events. But, logic fails, I’m not practicing what I preach – I just don’t feel any better. Parents all understand. We want our children to live longer than us. My heart goes out to the Abrahams, and to every family that loses someone before their time. We will go on, but there is emptiness in our hearts. Derek, it was a blessing to know you.

photo by Lauren Auerbach

postscript - There is a nice article about Derek in the Mercury News that reflects upon what an upbeat and terrific young man he was.

Tags: Derek Abraham, kiteboard,health, wilderness medicine, outdoor medicine, healthline

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ZeroWet

One of the hazards of cleaning wounds in the wilderness (or in the urban setting) is splashing the irrigation (cleaning) water, because the spray can transfer body fluids (containing infectious viruses, bacteria, etc.) onto the rescuer. In this day of hepatitis, human immunodeficiency virus infection, and other worrisome diseases, it is always prudent to shield oneself properly. This includes wearing eyeglasses or goggles, latex (or non-latex) surgical gloves ("rubber" or "vinyl" gloves), and otherwise preventing your victim's body fluids from contacting your moist mucous membranes (e.g., lining of the mouth, the eyes, etc.) or entering into any significant opening in your skin (e.g., scrape, puncture wound, open cut).

An excellent device that we use in the E.R. for this purpose, and which is equally useful in the wilderness, is the ZEROWET SPLASHIELD, available through ZEROWET, Inc. of Palos Verdes Peninsula, California. A fellow emergency physician and friend, Dr. Keith Stamler, had the brilliant idea to invent this product.

When you attach the SPLASHSHIELD to a syringe, it allows you to squirt water or saline (salt) solution into a wound at a pressure of 8 to 12 pounds per square inch, which is optimal for removing dirt and debris without pushing them deeper into the delicate and vulnerable human tissues. The SPLASHIELD, which is shaped like a cup, captures the splash, and therefore prevents the rescuer from becoming contaminated with errantly directed splashed fluid, blood, and other body fluids. The new SUPERSHIELD product can be attached to a 20 milliliter or larger syringe for the same purpose, and used to directly draw up irrigant into the syringe (without detaching the shield), as well as function as a shield. So, it effectively replaces the SPLASHIELD, because it has more functionality (you have to detach the SPLASHIELD from the irrigating syringe in order to refill the syringe).

Remember, "the solution to pollution is dilution." When I travel in the backcountry, I carry a couple of plastic syringes (size 20 to 35 milliliters) and a few SPLASHIELDS or SUPERSHIELDS, so that I can be prepared to adequately rinse a couple of wounds. I use the cleanest water available, which is usually filtered and/or disinfected drinking water. This is far better than the technique of using a plastic drinking bottle with a narrow tip or with a hole pierced through the top, because the drinking bottle method does not generate sufficient pressure when compared to the syringe technique.

Tags: wound irrigation, ZEROWET, SPLASHIELD, SUPERSHIELD, physician, health, wilderness medicine, outdoor medicine, healthline

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Thank You to Val Jones, M.D. for Grand Rounds

Thank you to Dr. Val & The Voice of Reason for including my post about how to avoid bear attacks 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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Swelling at Altitude

What is the swelling of the face, hands, and feet that sometimes occurs with trekking at high altitude? Is it serious? Should it be treated with diuretics ("water pills," that mobilize fluid from the body and increase urination)?

This problem is more frequently seen in women. If I were to hear that a woman suffered from this sort of swelling on a trek to high altitude, I would ask the following questions: 1) How old are you? If you still are having menstrual periods, do you have swelling on a regular basis at a particular point in your cycle? 2) Do you have any chronic illnesses, disease, or other medical conditions? 3) Were you taking any new medications when you noticed an episode of swelling? 4) Do you take any medications on a regular basis? 5) Have you ever had any heart conditions, particularly a heart attack or heart failure ("congestive heart failure")? 6) At what altitude were you hiking? 7) Were you carrying a backpack? If so, how heavy was it? 8) Is the swelling confined to your legs and feet? 9) Did the swelling resolve spontaneously? did you treat this swelling? How did you treat it? Was the treatment successful?

Swelling of the arms and face may be due to exercise, or to a combination of exercise and a tightly-strapped (onto the carrying individual) backpack that decreases the return of fluid through the veins and lymphatic system. Sometimes an imbalance of fluid and electrolytes can contribute to swelling. Heath failure can cause swelling(more common in the legs and feet), as can the side effects of certain drugs.Some women retain flud at certain times during their menstrual cycles. Unless the fluid retained in the face and arms causes a physical problem, such as difficult vision from puffiness around the eyes, or difficulty using fingers for fine manipulations, making an active attempt to get rid of the fluid is probably not necessary. Diuretics ("fluid pills") that increase urination will remove water from the body, but may cause dehydration, particularly during times of great exertion.

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

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When Nature Calls

I recently delivered a lecture on wilderness medicine (shark attack, actually) at the International Society of Travel Medicine (ISTM) meeting in Vancouver. This was a terrific gathering with many superb lectures, poster presentations, and spontaneous discussions between experts and old friends. For persons interested in travel medicine, this meeting is indispensable for its educational content, exhibits, and comaraderie.

In perusing the exhibits, I was drawn to a number of exciting new products that have direct application to the outdoor environment. One of the best items I saw is the whiz freedom, which is advertised as the world's first hydrophobic (repels water), anti-bacterial, and ecofriendly urine director. This is a device for women, designed to fit over the pudendal region so that urination can be accomplished when standing or sitting outdoors (or indoors) in such a manner that the urine stream is captured and directed away from the body.

The device is lightweight and completely collapsible, so that it is easily carried. When wet, it repels all liquid, so can be very easily shaken dry. It is constructed from medical-grade, latex-free, antibacterial plastic, and is machine washable. The distributor is JBOL Limited of Oxford, United Kingdom.

There are other products on the market that are intended for the same purpose, such as the "Lady J." I can't vouch for any of these by virtue of personal use, but can certainly remark that the whiz freedom has an excellent design (the outflow spout-fluid director is longer than that of the Lady J) and based upon its convenience and apparent durability, would be my first recommendation for a woman who wishes to use such a device in order to improve sanitation or her options for peeing in the wilderness.

Tags: whiz freedom, urination, female hygiene, pee, physician, health, wilderness medicine, outdoor medicine, healthline

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Thank You to InsideSurgery for Grand Rounds

Thank you to InsideSurgery for including my post about how to "de-skunk" a dog 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 would especially like to commend the author of InsideSurgery for his sensitive comments about the June 4, 2007 airplane accident involving members of a transplant team from the University of Michigan.

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Bears on the Prowl

A black bear walks into a doctor’s office. A Yellowstone grizzly (brown) bear mauls a park visitor. What is the common theme? According to Luanne Freer, M.D., who is a world-renowned authority on wild animal behavior and attacks, it’s a likely combination of two factors – habituation of these wild animals because of human encounters and lack of human understanding of just how hazardous and unpredictable these animals can be.

At a recent meeting of the International Society of Travel Medicine, I had the privilege of lecturing in a session alongside Dr. Freer, who shared some very important observations with the audience. The information that is perhaps most important from a bear behavior perspective is that a sow with a cub is always dangerous, because the urge to protect her young makes her ferocious in any situation. The evolutionary reason for this is that the sow must protect her cubs from the male grizzly bear, which will kill cubs for the purpose of inducing the sow to once again mate in order to bear more young. In the case of the most recent attack in Yellowstone, a sow and cub were surprised by the victim, who was taking photographs of bears. Photographers are notorious for approaching wild animals too closely.

According to Dr. Steve French, who authored the chapter of bear behavior and attacks in the 5th edition of the textbook Wilderness Medicine, here are the rules for avoiding a bear attack in the wilderness:

1. Do not provoke animals. Do not corner or provoke a bear.
2. Never approach an animal when it is with young.
3. Do not disturb a feeding animal. Do not explore into its feeding territory or disrupt mating patterns.
4. In bear country, hang all food off the ground in trees away from the campsite. Never keep food or captured game inside a tent. Use proper food storage to keep food away from bears. Cook at a site away from the sleeping area. Do not sleep in clothes worn while cooking or eating.
5. Make noise when hiking, particularly on narrow paths or through tall grass. If you confront a brown (grizzly) bear, avoid eye contact and try to slowly back away. If you confront a black bear, shout, yell, throw rocks or sticks, or do whatever you can to frighten off the animal.
6. If attacked by a bear, do not try to outrun it - you can’t. Cover your head and the back of your neck with your arms and curl into a fetal position or lay flat on the ground, face down, in order to protect your abdomen. If you are wearing a backpack, keep it on for additional protection. Use your elbows to cover your face if a bear turns you over. After a bear attack, remain on the ground until you are certain that the bear has left the area. More than one victim has successfully protected himself during the initial attack, only to arise too soon (before the bear has lost interest and left the area) and be mauled during the second attack.

photo of black bear by Tim Floyd

Tags: bear attack, bear, wild animal, prevention, physician, health, wilderness medicine, outdoor medicine, healthline

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