Running the Sahara, Part 5

by Jeffrey S. Peterson, MD

Contrary to what one would think, because of our government and military-security escorts in Libya, we were likely the safest we had been in all six “Running the Sahara” countries. Amazingly, the runners continued to pound out consecutive, 50-mile days.

Like the Niger Army solders, however, our new escorts also needed medical assistance, although at first—before I could provide treatment—they would ask me to show them the protocol in my Field Guide to Wilderness Medicine, by Paul Auerbach, MD. Eventually, trust was gained, and once again I was providing sutures, antibiotics, diabetes treatment, joint wraps, and—as always—treatment for eczema and more plantar warts, the latter which seemed to be a regional epidemic.

In Libya, while continuing to treat the runners' severe tendinitis, the psychological stresses created by 80-some successive days of extreme exertion and sleep-deprivation now reared their hydra heads. One was bottoming out psychologically. Another—the worst of the tendinitis sufferers— was worried about being left behind and wondered briefly about quitting. And the other member of the trio, after nearly quitting in Niger, had virtually retreated, talking to no one. This led to a fracturing of the running team’s dynamic, and soon the three were running on opposite shoulders of the roads, with one alone on one side and two runners on the other. Still, every day they continued further.

Six weeks later, by the time the runners had reached the Egyptian border, their bodies and systems were near full collapse. Tendinitis was now rampant, each of the three runners were now actively asking for strong pain medication that I had brought along in reserve for the last two days or for any severe injuries such as fractures and life-threatening emergencies.

Egypt brought with it a greater population density and far more crowded roads (meaning more vehicle threat to the runners). In addition, it had a robust security presence that implied a greater threat to us, as Egypt has seen aggressive anti-Western attacks on visitors in recent years.

For several weeks, the runners had been debating the possibility of running non-stop for the last week, treating the final, Egyptian segment as one long seven-day push. While the runners kept suggesting this scenario, Chuck and I felt they neither had the strength nor endurance left to treat the Egypt leg like an Adventure/Endurance Race, going 24 hours a day to the finish in a predicted time of seven or eight days. Additionally, we questioned whether the support crew also had the physical or psychological reserves to provide round-the-clock care. Thankfully, family and friends of the runners arrived to provide support, and generously and selflessly pitched in.

This support was doubly important, because the runners were near both physical and psychological collapse. Two men also continued to have gastrointestinal problems, and had been receiving intravenous hydration every few days for weeks. This gastro-intestinal condition also had left them with chronic diarrhea and abdominal fullness that made it difficult for them to ingest enough oral liquids to stay hydrated.

As they entered Egypt, one runner had blisters on his feet, but was responding well to care. Another runner, who had preferred self-care of his foot blisters throughout the trip, had developed a severe blister on the ball of his left foot. Within 48 hours of running a stepped-up schedule of 100-kilometer days, the blister on the ball of his left foot developed into a severe abscess with cellulitis, which covered the entire sole of his foot. I insisted on placing him on antibiotics, which he had previously refused.

More in Part 6…

photo by Jeff Peterson

Tags: Sahara,running,desert, Running the Sahara, Jeff Peterson, adventure race, wilderness medicine, outdoor medicine, healthline

Labels: adventure, endurance, Jeff Peterson, running, Sahara, Sahara desert

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Thank You to Rickety Contrivances of Doing Good

Thank you to Susan Palwick of Rickety Contrivances of Doing Good for publishing my post about a memorable moment with a diabetic patient at the latest edition of Grand Rounds. Grand Rounds is a weekly compilation of posts related to health care compiled by a host, who goes to great effort to create an interesting collection for readers.

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A Memorable Moment

Please allow me to deviate from my usual theme and share something with you that I wrote for the summer 2007 issue of Dartmouth Medicine Magazine. Laura Stephenson Carter asked me to provide a personal experience in the field of emergency medicine. I provided a tale excerpted from a book that I one day hope to publish about my experiences as a medical student and doctor.

A young woman came to the ER at Dartmouth suffering from astronomically high blood sugar and dehydration. Her breath had a strong fruity odor and she was hyperventilating. She was a "brittle" juvenile onset diabetic—meaning her disease was difficult to control and she often had to be hospitalized to bring her glucose level under control. Despite repeated admonitions from her endocrinologist, she frequently violated her diet and drug regimen. It wasn't that she was rebellious. She just wanted to live like a normal person and was having too much fun to pay attention to the directives. But the severity of her disease was going to ruin her eyes, kidneys, and heart before she reached middle age.

Like many interns before me, I sought an explanation from her. "You know that you're killing yourself. Why don't you take your insulin like you're supposed to? Why do you drink so much?"

"Because I'm a human being, or haven't you noticed?" Wink, wink. She was attractive, but the disease was taking its toll. She had scars from poorly healing skin ulcers, and her complexion was sallow. "Besides," she added, "I'm going to die, one way or another. I prefer to enjoy life."

My inexperience with chronically ill patients made me stupid. "But you're cutting years off your life," I told her.

It was her turn to educate me. "Oh, you doctors," she grinned. "You don't know so much. If I listened to you, I wouldn't eat anything I like, go outside, or have sex. What would be left? Work? This hospital?" The more she spoke, the more I liked her. "You know, I'm going out with a doctor," she said. "He's really cute. He never tries to tell me what to do. I just want to feel good. Can't you see that? It's my life." She wiped her eyes, then smiled and asked, "So, do I have to stay?"

"I'm afraid so. Your blood sugar is over 600 and you have ketones in your blood. You know what that means."

"Sure do. Okay, get me out of here quick. But I'll only stay if I get to eat cake," she asserted.

"What?"

As sick as she was, she was mischievous. "I know what you're gonna do. I don't want that ADA diet," she said, referring to the guidelines put out by the American Diabetes Association. "It's like eating cardboard. I want to eat cake."

"The food here stinks," I said. "You can have cake when you go home. I'm not allowed to give it to you."

"Then sign me outta here. No cake, no deal."

I thought about it for a moment. We were going to be replacing her body fluids and electrolytes with aggressive IV therapy and infusing her with repeated doses of insulin. We didn't have any chance to change her attitude, which was all that stood between her and despair.

"Cake it is."

"I don't really have a boyfriend," she said. "Are you interested?"

I walked from the room, laughing and shaking my head. I found out later that she wound up dating a medical student.

Hope isn't just about total success or failure, or about living or dying. It's about gradations of success, about things working out a little bit better than they might have. Hope is about a child suffering less pain or a wound healing with a smaller scar. It's about chest pain not being a heart attack or being a smaller one. At the very least, it's what I mean when I say, to every patient, "I hope you feel better."

There's always room for hope. Attitude counts for a lot in life, but never more than when it gives you strength during difficult times. In my opinion, being sick in the ER qualifies as hard times. In these moments of misery, you must strive to be strong.

As a patient, you should realize that it's much easier for a doctor to care for you when you are trying to get well, when you are making your best effort to understand your situation and to cooperate in the approach that your doctor has chosen to return you to good health. Everyone roots for a trooper. When you are either passive or negative, your doctor may misinterpret your mood as meaning that you don't care that much or even that you are angry.

In most of what any of us do, there is probably a desired outcome. When you walk on the beach, you hope for majestic waves, breaching whales, and magnificent sunsets. When you take a test, you hope for a good score. When you sleep, you hope for peaceful rest devoid of interruption. Think of any situation in which you are a participant, and you hope for something. Even when you have no expectation of achieving what you hope for, you are still hoping. That's a good thing, because it usually means that you care about what happens.

When you give up hope, it should be because you have come to peace, even if in surrender. If someone with you is giving up hope, then try to bring him or her to peace so that the ending is not a failure. And once you have accepted something as being in your past, then begin as quickly as possible to hope again.

Tags: diabetes,emergency medicine,hope,wilderness medicine, outdoor medicine, healthline

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Update on Methicillin-Resistant Staphylococcus Aureus (MRSA)

I have written two previous posts related to infections caused by methicillin-resistant Staphylococcus aureus (MRSA). Because MRSA infection is such an important topic in medicine, it is time for an update. In the July, 2007 issue of The New England Journal of Medicine, there is an excellent article entitled "Skin and Soft-Tissue Infections Caused by Methicillin-Resistant Staphylococcus aureus" (New Engl J Med 2007;357:380-90), authored by Robert S. Daum, M.D., C.M.

Here is some important information from the article:

MRSA refers to bacteria of the Staphylococcus aureus species that are resistant to all currently available "beta-lactam" antibiotics, including penicillins and cephalosporins (such as cephalexin, or "Keflex"). These resistant bacteria originally appeared in hospitals, but have now appeared in the community, caused by new strains of resistant microbes. The community-associated MRSA strains appear to be susceptible to the antibiotic clindamycin, but this is not absolute.

Reports suggest that the new community-associated strains may be easily transmitted between humans, including within the settings of households, military installations, and among athletes. Current epidemiology suggests that MRSA infections are on the rise.

Skin and soft-tissue infections represent most of the clinical manifestations of community-associated MRSA. These infections often become necrotic, with severe tissue breakdown, and may be incorrectly attributed to spider or insect bites. They often lead to abscess formation.

Treatment regimens are in evolution. One approach is to use topical antibacterial therapy for superficial skin infections. This is done with bacitracin, alone or in combination with polymyxin and neomycin. Other therapies are topical mupirocin (Bactroban) or the new drug retapamulin (Altabax). However, any of these therapies may prove to be ineffective.

For oral (outpatient) drug treatment, beta-lactam antibiotics should not be considered reliable as presumptive therapy for community-acquired skin and soft-tissue infections. In other words, if a person develops a significant skin or soft tissue infection, it is no longer sufficient to administer a drug like dicloxacillin or cephalexin, because of the risk of MRSA infection. A drug to treat MRSA infection must be included in the prescription. Such drugs include clindamycin, trimethoprim-sulfamethoxazole, or a tetracycline; however, it should be noted that the absolute effectiveness of these drugs for community-acquired MRSA infection has not been rigorously evaluated or compared in clinical trials. It should also be noted that these drugs have their own set of side effects, such as diarrhea caused by the bacteria Clostridium difficile as a side effect of clindamycin therapy. Furthermore, the percentage of isolates of MRSA that is becoming resistant to clindamycin is rising.

If trimethoprim-sulfamethoxazole or a tetracycline is prescribed because of suspicion for a MRSA infection, it is prudent to add a beta-lactam antibiotic to cover possible infection with group A streptococci.

Trimethoprim-sulfamethoxazole used alone for MRSA has met with mixed results. Doxycycline or minocycline should not be considered to be automatically effective substitutes for tetracycline. Rifampin is sometimes used in combination with trimethoprim-sulfamethoxazole or doxycycline to treat MRSA infection, but this is not based on scientific data.

Linezolid, which is a fairly new antibiotic, is active against almost all community-associated MRSA strains, as well as against group A streptococci. The reasons that it is not automatically prescribed are high cost, lack of routine availability, possible side effect of lowerering blood cell counts, and desire to avoid overuse that would lead to bacterial resistance.

Fluoroquinolone antibiotics, such as ciprofloxacin (Cipro), should not be used to treat skin and soft-tissue infections caused by community-acquired MRSA, because of bacterial resistance.

Limiting the spread of MRSA is very important. Some recommendations include:

1. Cover all draining wounds with clean bandages.
2. Wash hands frequently, particularly after contact with a (potentially) contaminated wound.
3. Launder clothing after contact with a contaminated area on the skin.
4. Bathe regularly with use of soap.
5. Avoid sharing items that may become contaminated by contact with wounds or skin bacteria.
6. Clean sports equipment with agents that are effective against MRSA: detergent or disinfectant registered by the EPA, such as quarternary ammonium compounds or a solution of dilute bleach).

photo courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention

Tags: MRSA,methicillin-resistant Staphylococcus aureus, wilderness medicine, outdoor medicine, healthline

Labels: methicillin-resistant Staphylococcus aureus, MRSA

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Thank You to Med-Source for Grand Rounds

Thank you to Med-Source for publishing my post about the proper management of an eye injury at the latest edition of Grand Rounds. Grand Rounds is a weekly compilation of posts related to health care compiled by a host, who goes to great effort to create an interesting collection for readers. This week's rendition is very well done.

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Running the Sahara, Part 4

by Jeffrey S. Peterson, MD

In Agadez, Niger—roughly the center of the journey—the runners were doing magnificently, still logging their usual mileage with little in the way of great difficulty beyond the fact they were running two marathons a day. It had become a rare day when they didn’t get in their 80 kilometers, and the need for medical care was present, but not terribly demanding.

Because we were now headed on a more northward track toward Libya, we picked up an 18-man Army of Niger attachment to provide security, owing to smuggling and rebel activity in the region. The security detail members had many of their own physical problems, and I was more than happy to provide medical care to them, out of respect to the hard lives they lead. Their diet was minimal, and their clothing not completely suited to the boiling temperatures of the day and the freezing cold nights. Across the group, I treated everything from broken teeth to cutaneous anthrax, eczema, stomach ulcers, conjunctivitis, and plantar warts. They kept me busy, but more than returned my care by keeping us safe from bandits.

A week-long sandstorm buffeted the group, and because the runners were now starting to run a long, gradual, uphill grade for hundreds of miles off-road and overland, guided by GPS with all of the running across deep and soft sand, tendinitis became a serious issue for two of the runners. To treat this more-severe pain, Chuck Dale increased his concentration of massage to the affected areas, while I began to prescribe short bursts of prednisone at different times.

As we exited Niger for Libya—being released from the country at the guard station at Madama, which has since been assaulted by rebel troops with 13 casualties and 47 hostages taken—we entered Libya, a wealthy and oil-rich nation where good, flat, smooth roads stretch to every border.

Before we could enter Libya, so that the runners could enjoy the firmer footing of paved roads, two things happened. As we approached the border-guard station at Toumou, we heard on the BBC World Service radio program that six Bulgarian nurses and a Palestinian doctor had been sentenced to death (for a second time) in Benghazi, for allegedly “infecting” several hundred Libyan children with HIV. There was clearly a lot of internal national politics about this, but it didn’t make our group, as foreigners - and especially me as a health-care provider - feel any safer.

Then, literally at the border guard station, as I was finishing my treatment of the Niger Army soldiers before they returned to their base, I was informed that one of the Libyan guards was sick and required medical attention. Given the fact that I’d just listened to the BBC, the prospect of this made my heart race and stomach churn, and tightened several other muscles in my body…to say the least.

Fortunately, the guard had severe bronchitis trending toward pneumonia, which would respond to an inhaler and the antibiotics we were carrying. For this, I was rewarded with a glass of screamingly hot, sugary, and mint-infused tea, and a firm and sincere thank-you handshake.

More in Part 5…

photo by Jeff Peterson

Tags: Sahara,running,desert, Running the Sahara, Jeff Peterson, adventure race, wilderness medicine, outdoor medicine, healthline

Labels: adventure, endurance, Jeff Peterson, running, Sahara, Sahara desert

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A Close Call

Kids will be kids, no matter how much you warn them about potential catastrophes. One came close recently, despite my admonition to be smart and keep his head down. The young man needed to travel a short distance over a remote road and wanted to ride standing in the bed of a pickup truck. The speed was going to be well under 5 miles per hour and there was no chance of a collision, but I was worried about low-hanging branches, a bad pothole or tree root in the pathway, or some other unforeseen hazard. Despite my caution, the boy's father said it was OK for him to ride in the back, which would have been all right 999 times out of 1000.

Except for this time. The poor boy looked away from the direction of travel for a brief moment, and when he turned around to face forward, caught a tree limb across his forehead. He immediately felt severe pain in his eye, and began to shout in distress. It was obvious that he had been struck in the eyeball. When I saw him a few moments later, he was miserable and crying crocodile tears.

I was able to quickly determine that he didn't have a ruptured "globe" (eyeball), and he was begging for relief, so I put a few drops of ophthalmic anesthetic solution into his eye, which made the pain go away quickly. After I pulled his lids back, I was able to achieve fairly good visualization of the surface of his eye. There was one small fleck of tree bark under his upper lid, but otherwise, his eye was free of foreign material. While the surface of his eye remained numb from the anesthetic, I rinsed it carefully with some disinfected water. He was a lucky fellow, because all he had done was to suffer a few small scratches on the white of his eye. If he had not had the great reflexes of youth and been able to duck a bit prior to impact, he easily could have sustained a much worse injury.

What if that had happened? If an eyeball is perforated, there will be a combination of loss of vision (ranging from hazy vision to blindness), pain, excessive tearing, a dilated pupil, and visible blood in the eye. If that is the case, do not attempt to rinse out the wound vigorously; remove obvious dirt and debris without placing any pressure on the eye. Close the eyelid gently and cover the eye with a protective shield. This can be fashioned by cutting gauze pads or soft cloth to the proper size, or by fashioning a doughnut-shaped shield with a cloth, cravat bandage, or shirt. Another good way to keep pressure off the eye is to cut an eye-sized hole in a stack of gauze pads and place the stack over the eye, taping or wrapping it in place. An eye shield can also be improvised by cutting off the bottom 2 in (5 cm) of a paper cup and taping it over the eye. Metal or plastic pre-shaped eye shields can be carried.

Do not exert pressure on the eyeball, because this can increase the damage. Instruct the victim to keep both eyes closed, and start him on oral ciprofloxacin, penicillin, cephalexin, or erythromycin. Seek immediate medical attention.

If the surface of the eye is merely scratched (abraded), then a corneal (clear part of the eye) or conjunctival (membrane over the white part of the eye) abrasion may have occurred. This will be painful because exposure of sensitive nerves to air is sufficient to provoke a significant pain response. If a corneal abrasion is felt to have occurred, the eye can be treated with topical antibiotic solution and the victim provided with sunglasses if the eye(s) has become sensitive to light. It is no longer deemed absolutely necessary to put a patch over an eye that has suffered a corneal abrasion. However, if the pain is relieved significantly by having the eye closed, this can be accomplished by gently taping a patch over the closed eye or by keeping the lids shut with a piece of tape gently applied over the lids. After 24 hours, the patch or tape should be removed to be certain that there is no underlying infection (which should not be patched) and to see if sufficient healing has occurred to allow the victim to tolerate an unpatched eye.

Tags: eye,eye injury,wilderness medicine, outdoor medicine, healthline

Labels: eye, eye injury

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Tips from the International Society of Travel Medicine

The International Society of Travel Medicine (ISTM) is the premier medical organization devoted to travel medicine. The organization wisely recognizes that it has an educational responsibility to laypersons at least as large as its mission for health care professionals. ISTM publishes two sets of tips (annotated by me) that are worthy of mention:

Tips for Healthy Travel

Before the Trip:

1. Seek consultation with a travel medicine specialist (or other travel-savvy health care provider) at least one month prior to travel.
2. Ask about special vaccines that are recommended for specific destinations. Be familiar with current Centers for Disease Control (CDC) recommendations.
3. Carry a first aid kit containing regular and special medication for the trip, and keep it in your hand luggage. Carry prescriptions for replacement medications, should these become necessary.
4. Procure evacuation and travel insurance to cover health emergencies while abroad.

During the Trip:

1. Take precautions against malaria when visiting areas at risk. Prevent mosquito bites using insect repellents, bed nets, proper clothing, etc. Take anti-malarial medications as advised.
2. Road safety is essential. Always wear your safety belt when in a car, a helmet when on a bicycle, motorcycle, or moped, and avoid driving at night or on dangerous narrow roads.
3. Abstain from casual sex or practice safe sex with condoms to prevent HIV and other sexually transmitted diseases.
4. Verify and consume safe water and food. Drink properly disinfected water. Carry medications to self-treat diarrhea and know how to use them.
5. Minimize excessive sun exposure and wear an effective sunscreen.
6. Do not handle or provoke animals, both domestic and wild. Animal bites, licks, or scratches can transmit rabies virus. Seek immediate care if bitten.

After the Trip:

1. If you develop fever during or after a trip, seek competent medical help.
2. Be certain to continue anti-malaria medications after your trip if advised by the prescribing physician.

The Responsible Traveler

1. Be informed. Study the history, geography, and people (culture) of other societies before you embark on your journey.
2. Be open-minded an patient. Understand that other cultures do not necessarily beat to the cadence or rhythm of your personal native country.
3. Be respectful. Show all people gratitude and respect. Adhere to local customs in your dress, speech, greetings, behavior in sacred or religious locations, and in displays of affection.
4. Avoid exploitation. Promote the local economy. Avoid condoning or contributing to local exploitation (low salaries, overwork, child abuse, sex) of indigenous peoples.
5. Protect the environment. Conserve food and water, and do not litter or damage sites. Do not remove natural objects for the purpose of any personal collection. If you pack it in, pack it out.
6. Leave a good impression. The experiences of those who follow you will in large part be determined by your behavior.

photo by Brenda Tiernan

Tags: healthy travel, responsible travel, tips, medical, travel medicine, ISTM, wilderness medicine, outdoor medicine, healthlineLabels: travel medicine

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Running the Sahara, Part 3

by Jeffrey S. Peterson, MD

By the time our expedition left Mauritania, it had become a daily experience to return to camp from both the morning and evening legs of the run, and find between five and 10 nomads, who had often arrived on camels, awaiting me in hopes of medical treatment. Word travels fast in the Sahara.

The run clearly now had momentum, and we literally flew through Mali. Our team was traveling eastward near the Mali/Niger border when John Davidson, the driver of our supply truck, radioed us that he had been stopped by a Tuareg woman, who'd run out of her tent carrying a baby as he'd passed through the camp. The baby had some pretty awful looking burns on its feet, John said.

We turned back to rendezvous with the supply truck. The baby, perhaps a year old and now held by its father - a Tuareg in traditional blue bubu robes and head-wrap - was horribly burned on its feet and shins. It had been burned by an overturned pot of boiling water. The water, the father explained, was from a nearby well, and they had been boiling it render it potable. The accident had happened four days earlier. Becausee of the lack of clean water, the severity of the burns, and the blowing sand, the burns were now covered in scaly, sandy, and pus-laden scabs. The burns with blisters had progressed into abscesses surrounded by cellulitis. My first thought was that this was one sick kid and likely to become even worse without aggressive management of the abscesses and treatment of the spreading infection.

I quickly went to work, creating a work area on a sheet, and had the baby's father sit with him. I then began to clean the baby's burns. It was too slow. The baby, uncomfortable with this strange man helping him, began to shriek and cry. Realizing this would take far too long, I dumped some light saline solution into a disinfected bucket, put povidone-iodine into the water, and decided to place both of the baby's feet and shins in it simultaneously to wash them. The baby, however, seeing a tub of red water (probably not all that different from the one that had burned it) began screaming bloody murder. Eventually, through a bit of manhandling, the feet went into the bucket, and the child calmed down. Forty minutes later, I could debride the dead skin (which had to be peeled off the baby's lower legs and toes), clean the wounds on both feet, and get them treated with ointments and covered with gauze.

I then gave the boy multiple intramuscular injections of two antibiotics and a tetanus shot. Through an interpreter, I showed the father how to clean and treat the wounds two to three times per day and administer the oral antibiotics that his son would need to take for two weeks. However, I still wanted to monitor the child's progress for a day or two. After 20 minutes of heated debate about whether John and I would stay behind to monitor the child's status, the father ended the discussion by saying “I'm an intelligent man, you have shown me this, I can do it. Please go with my thanks.” Realizing that we had done what we could for the child and that we were obligated to respect the father's wishes, we continued on and caught up with the runners.

A few days later, having crossed into Niger, our camp was entered by some local Tuareg herdspeople, this time four young girls. They said that their mother had given birth during the past two weeks, but was still so sick and weak she was having trouble nursing. She was becoming more dehydrated every day and could not keep any fluids down. We traveled the mile distance to the family’s camp, where I was required to obtain permission to enter from the male owner of the camp. Once granted access, I learned that the victim was subsisting on nearly-spoiled camel’s milk. Using an English-speaking Tuareg guide from our camp, I took her history and then—after politely explaining to both the male and female adults what I might be able to offer as help—was granted permission to perform a brief exam.

The woman was suffering not only from severe dehydration, but endometritis, which is a severe, post-delivery infection of the reproductive organs requiring very strong antibiotics for treatment. I returned to the camp, treated her with a battery of four antibiotics, plus some powerful anti-nausea medicine, and multiple liters of Gatorade. By the next morning, when I returned to check on her, her status had turned around. She was nursing the baby normally, and her color and skin tone had returned.

More in Part 4…

photo by Jeff Peterson

Tags: Sahara,running,desert, Running the Sahara, Jeff Peterson, adventure race, wilderness medicine, outdoor medicine, healthline

Labels: adventure, endurance, Jeff Peterson, running, Sahara, Sahara desert

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Thank You to Eye on DNA for Grand Rounds

Thank you to Dr. Hsien-Hsien Lei at Eye on DNA for publishing a guest post by Dr. Jeff Peterson entitled "Running the Sahara" and my post about tuberculosis at the latest edition of Grand Rounds. Grand Rounds is a weekly compilation of posts related to health care compiled by a host, who goes to great effort to create an interesting collection for readers. This week's version is terrific, and reflects a great deal of effort.

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Thank You to Health Business Blog for Grand Rounds

Thank you to David E. Williams of MedPharma Partners at Health Business Blog for publishing my post about the annual meeting of the Wilderness Medical Society. Grand Rounds is a weekly compilation of posts related to health care compiled by a host, who goes to great effort to create an interesting collection for readers.

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Celox™ Hemostatic Granules

Lately, I've been publishing more posts than usual about products. The reason for this is that I have noticed a large number of innovative new ideas worthy of mention. Many times, I am made aware of the products by seeing them on display at a medical meeting, but sometimes I am contacted by the inventors, manufacturers, or distributors, or by a person who has noticed something new or used it successfully. I think it's important to bring these to your attention, so that you can try them out (if you wish) and form your own opinion.

Celox (hemostatic granules) is a new high performance hemostatic material that has been created to control high-volume arterial bleeding. Composed of a proprietary marine biopolymer (including Chitosan), it is is poured as a granular mixture into a bleeding wound, where it helps to facilitate blood clot formation without causing any tissue damage. It is felt to do this by aggregating negatively-charged red blood cells, which are attracted to the positively-charged granules. According to promotional material distributed by Sam Medical Products, the granules assist a clot to form within minutes without generating any heat, burning sensation, or rigid structure formation within the wound. A gelled mass formed by excess granules protects the clot and is easy to remove.

Chitosan is manufactured by chemical modification of chitin , which is the structural element in the exoskeleton ("external" skeleton) of crustaceans (crabs, shrimp, and so forth). It carries a positive charge, wherein lies its value for this particular application. Chitosan is not known to commonly invoke an allergic reaction, and can be sterilized. Notably, it is present in other products designed to control bleeding from wounds, such as bandages marketed by HemCon Medical Technologies Inc.

Celox™ works in hypothermic conditions and also on blood that has been heparinized (e.g., a person being treated with this category of "blood thinner" or, presumably, with enoxaparin [Lovenox]). There is no mention of whether or not it has been or would be expected to be effective if a victim is currently taking warfarin (Coumadin), which is a very common anticoagulant.

To apply Celox™, one pours the granules from a sterilized, sealed packet (15 grams or 35 grams) into the wound and then holds them in place with a gauze bandage for five minutes. A compression bandage, such as an elasticized wrap, is then wrapped over the gauze-covered wound and the victim is brought to medical care.

image courtesy of www.popsci.com

Tags: Celox, bleeding, hemorrhage, health, wilderness medicine, outdoor medicine, healthline

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Running the Sahara, Part 2

by Jeffrey S. Peterson, MD

Despite having on-the-ground assistance from the scientists at the Gatorade Sports Science Institute (who had joined us for the first seven days), I was reminded that there was no way anyone was able to physically train to run 4,300 miles at a pace of roughly two marathons a day; the training for that alone would begin tearing down an athlete. In our case, each individual athlete was either going to complete the run, or he wasn’t.

It was in Mauritania, despite vigilant hygiene on our part—including frequent use of alcohol hand wash, drinking only bottled water, triply-rinsed food utensils, and well-cooked and boiled food—that our team developed a significant and long-lasting outbreak of gastroenteritis, resulting in yet more dehydration. The malady would dog us for a month, circulating several times through the camp. Each bout of gastroenteritis and dehydration was treated with oral antibiotics and intravenous boluses of normal saline. It was during this time that, despite rigorous hygiene, I finally succumbed to the infection myself. Given the fact that there was no medical provider to start an intravenous drip and administer care to me, Chuck Dale offered to do the best he could with what I could teach him. Having taught many medical students previously, I had no problem with the mechanics of starting the IV. The only problem was that I had to teach him to do it on me and I felt horrible. Chuck was allowed three tries to get the IV into my vein. Being a fast learner, Chuck amazingly hit the vein perfectly on the third attempt. After aggressive hydration and rest, I was back on my feet and ready to take care of the runners and crew once again.

Having grown used to the incredible physical demands of each day—and staying constantly watchful of hydration issues—we now began a stretch of weeks characterized by remarkable progress. The runners had an amazing ability to adapt their strides to respond to repetitive stress injuries, and at the first sign of a developing problem, they would change their shoes as the initial bulwark against further injury.

Early hands-on intervention by trainer and massage therapist Chuck Dale included deep tissue massage and trigger point manipulation. In addition, a step-wise approach (modulated to the injury) of oral ibuprofen, acetaminophen, and topical lidocaine patches over ibuprofen cream —kept more complex repetitive motion damage at bay. Due to the knowledge and experience of the runners, plus the work of Chuck Dale and me, the runners didn’t experience any profound over-use and repetitive stress injuries until the last few days of their run.

Most of Mauritania was crossed on the Trans-Mauritanian Highway, a treacherous thoroughfare with narrow shoulder and speeding vehicles with drivers unaccustomed to hosting a trio of runners along its apron. Many close calls were witnessed on the road. For instance, at one point, Charlie Engle’s elbow was side-swiped by a passing vehicle, reinforcing the dangerousness of the route.

More in Part III…

photo by Jeff Peterson

Tags: Sahara,running,desert, Running the Sahara, Jeff Peterson, adventure race, wilderness medicine, outdoor medicine, healthline

Labels: adventure, endurance, Jeff Peterson, running, Sahara, Sahara desert

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