Thank You to Musings From A Distractible Mind for Grand Rounds

Thank you to Musings from a Distractible Mind for publishing my post about rules for outdoor sports injury prevention in the latest edition of Grand Rounds. Grand Rounds is a weekly compilation of posts related to health care compiled by a host, who makes a great effort to create an interesting collection for readers. This week's presentation is very creative. Great job!

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Outdoor Sports Injury Prevention

Outdoor recreation is the fastest growing category of recreation in the U.S., and perhaps worldwide. In addition to hiking, trekking, backbacking, camping, fishing, hunting, skiing, swimming, boating, scuba diving, and all of the other outdoor recreational activities with which we are familiar can be added sports activities, some of which include competitions. So, when you consider surfing, windsurfing,mountain biking, rock climbing, adventure races, triathlons, marathons, and all of the assorted activities that are perpetrated outdoors, outdoor sports is a huge category.

Each activity has a set of rules for injury prevention. For instance, if you are a scuba diver, there are unique concerns for which you must be aware, such as how long you spend underwater and at what depth, rapidly you ascend from the depth, which marine animals to avoid, and so forth. There isn't enough space in this individual post to consider every activity, but there is certainly room for a list of generalities, which are the foundation upon which are built the specific considerations of injury prevention.

Here is a list of injury prevention recommendations for outdoor sports, whether they be recreational or competitive:

1. Be prepared. The Boy Scouts (and Girl Scouts) have it right. There is no substitute for preparedness. Adherence to this basic rule will prevent or ease the majority of mishaps that occur in the wild. Proper education prior to situations of risk allows you to cope in a purposeful fashion, rather than in a state of fear and panic.

2. Prior to undertaking a trip where you will be far from formal medical assistance, it is wise to attend to any obvious medical problems. If you have not done so within the past 6 months, visit a dentist. Make certain that all of your immunizations are up to date.

3. Use common sense. Many accidents occur because people ignore warning signs or don’t anticipate problems. Swimmers are stung by jellyfish outside protective net enclosures; nonswimmers drown while participating in hazardous whitewater rafting adventures.

4. Pay heed to rangers, posted warnings, weather reports, and the experience of seasoned guides. For instance, in hot and dry weather, know the specific fire risks, and take no chances.

5. Prepare for situations of risk by developing your skills in less challenging conditions.

6. Wear recommended personal safety equipment, such as a flotation jacket, safety harness, or climbing helmet.

7. Do not tolerate horseplay in dangerous settings.

8. Many health hazards of wilderness travel, such as falls, can be avoided by a reasonable degree of strength and endurance, which can only be acquired by conditioning. Every expedition member should begin from a state of maximum fitness.

9. Other health hazards, such as temperature extremes and high-altitude disorders, can in certain circumstances be avoided by acclimatization to the environment. Acclimatization is a physiological adaptation that is often different from, and may be unrelated to, physical fitness.

10. Be prepared for foul-weather conditions. Always assume that you will be forced to spend an unexpected night outdoors. Carry warm clothing and waterproof rain gear. 11. Break in all footwear, and take care to pad rough edges and exposed seams.

11. Prepare a trip plan (itinerary) and record it in a location (trailhead, ranger station, marina, or the like) where someone will recognize when a person or party is overdue and potentially lost or in trouble.

12. Make sure that children wear an item of bright clothing and carry a whistle that they know to blow if they are frightened or lost. If you carry a radio, know how to tune in to a weather information channel.

13. In most stories of miraculous ocean or wildland survival, the first chapter includes the account of how the victim lost his way. All wilderness travelers should carry maps, be proficient with compass routing, understand how to signal for help, and know in advance where they intend to explore.

14. People with specific medical disabilities, such as chronic severe lung disease, may be advised by a physician to avoid certain stressful environments, such as high altitude.

15. Anyone who undertakes vigorous physical activity should consume adequate calories in a well-balanced diet. A debilitating weight-reduction program should not be continued in the wilderness, where a rescue might depend on extraordinary effort and endurance.

16. To avoid dehydration and exhaustion, take adequate time to eat, drink, and rest. Most adult males require 3,000 to 5,000 food calories each day in order to sustain heavy physical exertion. Women require 2,000 to 3,500 calories. A nutritious diet can easily be maintained with proper planning. Don’t plan to live off the land unless you are a survival expert.

17. Fluid requirements have been well worked out for all levels of exercise. Most people underestimate their fluid requirements. Encourage frequent rest stops and water breaks. If natural sources of drinkable water (springs, wells, ice-melt runoff) will not be encountered, you should carry at least a 48-hour supply. Carry supplies for water disinfection.

18. Use the buddy system. Don't enter a remote area without a companion, or better, a few companions.

photo by Lanny Johnson

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

Labels: injuries, injury prevention, sports, sports injuries

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Nasal Influenza Vaccine for Younger Children and 2007 Updates

The fall, winter, and spring are terrific for outdoor activities, but they are also the peak seasons in the U.S. for being exposed to the influenza virus. Young children and elders are particularly prone to severe infections and the attendant complications. It has been suggested that a nasal vaccine (sprayed into the nose), such as FluMist, containing a weakened form of the live virus, provides better protection against influenza than does an intramuscular injection of inactivated (“killed”) virus, currently provided as trivalent inactivated vaccine (TIV).

The U.S. Food and Drug Administration has just approved expanding the population for use of FluMist to include children between the ages of 2 and 5 years. Previously, the lower age limit was felt to be 5 years of age. In the clinical study cited by the FDA to support their new recommendation, it was observed that children under the age of 2 years had an increased risk for wheezing and hospitalization.

As with certain other immunizations, there can be side effects, which in the case of FluMist include runny nose and/or nasal congestion, as well as fever in children ages 2 to 6 years. It should not be used in any person who suffers from asthma or in children under the age of 5 years with recurrent wheezing.

For 2007, here are important updates on current recommendations for immunization:

1. The trivalent inactivated vaccine (TIV) is supplied as a 0.5 milliliter dose containing 15 micrograms each of A/Solomon Islands/3/2006 (H1N1)-like, A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia2506/2004-like antigen. Trade names for this vaccine are Fluzone and Fluvirin.
2. Two doses of TIV administered at least 1 month apart are recommended for children aged 6 months to 8 years who are receiving TIV for the first time. Those who only received one dose in their first year should receive two doses the following year.
3. For FluMist, two doses administered at least 6 weeks apart are recommended for children aged 2 to 8 years who are receiving this vaccine for the first time. Those who received only 1 dose in their first year of vaccination should receive 2 doses in the following year.

Tags: influenza vaccine, influenza, flu, wilderness medicine, outdoor medicine, healthline

Labels: flu, FluMist, influenza, vaccination, vaccine

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Thank You to Kevin, M.D. for Grand Rounds

Thank you to Kevin, M.D. for publishing my post about pre-existing neurological conditions at high altitude in the latest edition of Grand Rounds. Grand Rounds is a weekly compilation of posts related to health care compiled by a host, who makes a great effort to create an interesting collection for readers.

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Going To High Altitude with a Preexisting Neurological Condition

"Going High with Preexisting Neurological Conditions" is an article written by Ralf Baumgartner, Adrian Siegel, and my good friend Peter Hackett that appeared in Volume 8, Number 2 (2007) of the journal High Altitude Medicine & Biology, published by the International Society for Mountain Medicine.

A very common question of wilderness medicine physicians is whether a person can engage in certain activities and/or travel in a particular environment, depending on their state of health and medical history. Given the number of persons with preexisting conditions, especially those who are part of a growing senior population, these are very important considerations. Whether a person has diabetes, rheumatoid arthritis, sickle cell anemia, or any other of thousands of conditions, it is important to understand what situations are felt to be safe, and what situations are felt to be risky.

Paraphrasing the abstract and article, here is what I learned from Baumgartner et. al.:

There are potential impacts of high altitude exposure on persons with preexisting neurological conditions who normally reside at low altitude. These conditions include permanent and transient lack of oxygen to (portions of) the brain (e.g., stroke, transient ischemic attack [TIA, or stroke "warning"]), occlusive cerebral artery disease (e.g., atherosclerosis of the cerebral arteries), central venous thrombosis (clotted large veins in the brain), abnormal blood vessels within the skull (e.g., aneurysms), multiple sclerosis, space-occupying lesions within the skull (e.g., benign and malignant tumors), dementia, movement disorders, migraine and other headaches, and epilepsy (seizures).

A very important point made early in the article is that much of what is stated is that the recommendations are made mostly from review of case reports (clinical anecdotes), rather than from "controlled" clinical trials, in which there are large, statistically significant numbers of patients who have been observed and studied.

Preexisting neurological conditions are stable or unstable. If they are unstable, they are worsening or improving. Patients with unstable conditions should not travel to high altitude, because resultant low blood oxygen levels may impair or prevent recovery from the condition.

For starters, here is a listing of absolute and relative contraindications for ascent to high altitude:

Absolute contraindications for active (e.g., trekking or climbing) or passive (e.g., motorized vehicle transport) ascent:

1. "Unstable" (progressive, recovering, or fluctuating) condition
2. High risk for a repeat stroke
3. TIA within the past 90 days

Absolute contraindication for active ascent:

1. Residual deficit, either central (e.g., from a stroke), or peripheral (e.g., from multiple sclerosis or severe diabetic neuropathy); these persons may consider passive ascent.

Relative contraindications for active or passive ascent:

1. Severe narrowing or occlusion of a cerebral artery
2. Space-occupying lesion (e.g., brain tumor)
3. Poorly controlled seizure disorder
4. Cerebral aneurysm (dilated blood vessel that might leak or burst)

Here are a few more recommendations from the article:

Stroke and TIA

There are some data from the military to suggest that long-term residence at altitude might increase risk for stroke, but there is no evidence yet to suggest a risk to a short-term traveler. There are factors pro and con, and some thought that inactivity, dehydration, cold, and increased red blood cell count (in response to low oxygen at altitude) may contribute to an increased risk for stroke, but no statistics to support the thesis. Fairly well accepted is the notion that persons who have suffered a stroke are at increased risk for suffering a second stroke. Any persons who has suffered a stroke should consult with his or her physician to determine whether or not a high altitude sojourn should be allowed, and if so, if anti-platelet (anti-blood clotting) therapy with an agent such as aspirin, should be initiated. Persons who have suffered a TIA have a 25% risk of suffering a stroke, another TIA, heart disease, or a major cardiovascular/cerebrovascular incident with the next 90 days. This suggests that they not travel to high altitude during this time period.

Occlusive Cerebral Artery Disease (narrowed or otherwise occluded cerebral artery)

Severe occlusive cerebral artery disease is considered to be a worrisome situation, since an increase in cerebral blood flow is an important adjustment to the diminished oxygen available at high altitude. It is possible that a person would be at increased rish for a situation of low oxygen delivered to the brain and thus a propensity for altitude illness.

Hemorrhage Within the Skull and Blood Vessel Malformations

There is no good study to offer data about the risk of bleeding into or around the brain at high altitude. While high altitude-related blood pressure changes might increase the pressure within blood vessels and therefore the risk of aneurysmal rupture, there are not data. High altitude increases the fragility of very small blood vessels, which theoretically could increase the risk for bleeding.

Multiple Sclerosis

There is no evidence that high altitude in and of itself causes problems for persons with multiple sclerosis.

Intracranial (within the skull) Space-Occupying Lesions

If such a lesion is known to be cancer and is causing neurological symptoms, the person should not travel to high altitude. If the lesion is not cancer (e.g., it is "benign"), caution is warranted, because it is not entirely known which lesions are prone to expansion and thereby inciting neurological symptoms.

Dementia

Persons with dementia be watched very closely for increase in impairment.

Pre-existing Migraine and Other Headaches

The presence of pre-existing headaches is not a contraindication for a trip to high altitude. Clinicians working at high altitude have noted that altitude can be a trigger for migraine headache.

Seizures (Epilepsy)

Rapid ascent to high altitude may predispose to increased frequency of seizures. Gradual ascent may not pose the same risk. To date, there is not evidence that there is an increase in frequency or severity of seizures when anti-seizure medications are contiued at high altitude.

photo by Mathias Schar

Tags: neurological, stroke, high altitude, TIA, headache, migraine headache, seizure, epilepsy, wilderness medicine, outdoor medicine, healthline

Labels: epilepsy, headache, high altitude, high altitude medicine, migraine, migraine headache, multiple sclerosis, neurological conditions, neurology, seizure, stroke, TIA, transient ischemic attack

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Beware the Triggerfish

Wilderness Medicine is a colorful magazine published quarterly by the Wilderness Medical Society, and features society news, editorials, announcments, and interesting articles by members and others with an interest in wilderness medicine. While it is written predominately at the health care provider level, the prose is often quite understandable for layperson readers and usually very entertaining. The Summer, 2007 issue is no exception, including such interesting pieces as "Reach Out: Things That Fly, Slither, Drop, and Crawl," "Fit to be Wild: Backpacking Without Back Pain," "Rabies Considerations for Travelers," and "Off the Beaten Path: The Best Little Clinic in the Amazon."

One accounting that I really enjoyed is entitled "Beware the Vicious Triggerfish!" by Yvonne Lanelli. It is the account of an attack (bite on the leg) by a triggerfish upon a diver off Sipadan Island in Borneo. The knowledgeable explanation for this attack was offered by a local divemaster, who remarked that triggerfish are known to nest and guard their eggs during periods of the full moon.

Triggerfish may be gregarious or unimposing, but during mating season (and during the full moon) the females of at least two species (Pseudobalistes fuscus and the larger Balistoides viridescens) can become extremely territorial in guarding their nests and thus aggressive, inflicting painful bites. The strong jaws each carry eight long, protruding, and chisel-like teeth in an outer row, backed by an inner row of six teeth. Usually the fish “bites and runs,” but the orange-striped triggerfish Balistoides undulatus has been reported to bite and not release. It is common to have to strike the fish in some manner to get it to release. In the Gilbert Islands, a release technique is to bite the fish on the top of the head.

photo courtesy of www.islandgazette.net

Tags: triggerfish, bite,marine attack, wilderness medicine, outdoor medicine, healthline

Labels: fish bite, marine attack, triggerfish

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Thank You to "six until me" for Grand Rounds

Thank you to "six until me" for publishing my post about pufferfish poisoning in the latest edition of Grand Rounds. Grand Rounds is a weekly compilation of posts related to health care compiled by a host, who makes a great effort to create an interesting collection for readers.

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TRAVEL MEDICINE™

When I attended the International Society of Travel Medicine meeting in Vancouver, I was re-acquainted with TRAVEL MEDICINE™, a company with the purpose of disseminating information and selling products for safe travel. Founded by my friend Stuart Rose, M.D., this is a business extension spawned from the excellent book by Dr. Rose (now co-authored with Dr. Jay Keystone), entitled 2006/07 International Travel Health Guide, published by Mosby-Elsevier. From medical kits and insect repellents, to sunscreens and electrical adaptors, TRAVEL MEDICINE™ is designed to offer products needed by most travelers to make their journeys safe and comfortable.

What I particularly appreciate about the offering is that the products are high quality and have been vetted based upon the wisdom and experience of Dr. Rose. Some of these, such as permethrin clothing spray, are not easy to find in other retail outlets or catalogues. Ultrathon™ is a terrific insect repellent, and all of the major repellent classes, including picaridin and lemon eucalyptus, are represented. These are just an example of the comprehensive approach and convenience of this product listing.

Other terrific products include mosquito nets, water treatment (filtration and disinfection) supplies, sleeping bag liners, oral rehydration formula, binoculars, Safe Sea® jellyfish safe sunblock lotion, travel aids for jet lag and sleep, first aid kits, totes and pack-it containers, headlamps, electrical adaptors, first aid kits, emergency dental supplies, and many others.

Furthermore, one can purchase an SOS Global Traveler membership from International SOS™ at a 20% discount. This type of insurance is important for emergency assistance and evacuation when traveling abroad.

Tags: first aid supplies, repellent, supplies, medical, travel medicine, health, wilderness medicine, outdoor medicine, healthline

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Puffer Fish Poisoning in Thailand

A recent news report commented upon the fact that vendors in Thailand have been selling puffer fish meat and calling it salmon. According to a reporting physician in Thailand, this disguised (dyed in some cases) puffer fish meat has caused at least 15 deaths over the past year.

Certain puffers ("blowfish," "globefish," "swellfish," "porcupinefish," and so on) contain tetrodotoxin, one of the most potent poisons in nature. These fish are prepared as a delicacy (fugu) in Japan and elsewhere by specially trained and licensed chefs. People intentionally eat puffer fish for the culinary thrill, which when causing the sought-after effects, generates a set of minor, non-debilitating symptoms of what can become a very serious, even fatal, intoxication (see below).

The toxin is found in the entire fish (including the flesh, or "meat"), with greatest concentration in the liver, intestines, reproductive organs, and skin. After the victim has eaten the fish, symptoms can occur as quickly as 10 minutes later or be delayed by a few hours. These include numbness and tingling around the mouth, lightheadedness, drooling, sweating, vomiting, diarrhea, abdominal pain, weakness, difficulty walking, paralysis, difficulty breathing, and collapse. As noted above, this ingestion can be fatal. Tetrodotoxin is also found in other animals; for instance, it is the toxin responsible for the potentially lethal bite of the Indo-Pacific blue-ringed octopus.

If someone is suspected or known to be suffering from puffer poisoning, he or she should immediately be transported to a hospital. Pay attention to their ability to breathe, and assist breathing if necessary. This may necessitate using a bag-valve-mask device, or in the absence of a doctor or emergency medical technician, using mouth-to-mouth breathing, preferably with a barrier shield.

Unfortunately, there is no antidote for tetrodotoxin poisoning, and the victim will need sophisticated medical management until the toxin is eliminated from the body. Eating puffers, unless they are prepared by the most skilled chefs, is dietary Russian roulette. Persons should now, obviously, be extremely careful when purchasing fish from vendors in Thailand.

photo by Ken Kizer

Tags: pufferfish, poisoning,puffer fish, tetrodotoxin,wilderness medicine, outdoor medicine, healthline

Labels: poisoning, puffer, pufferfish, tetrodotoxin, Thailand

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Thank You to The Efficient MD for Grand Rounds

Thank you to The Efficient MD for publishing my post about the SteriPEN water disinfection method in the latest edition of Grand Rounds. Grand Rounds is a weekly compilation of posts related to health care compiled by a host, who makes a great effort to create an interesting collection for readers.

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Running the Sahara, Part 6

by Jeffrey S. Peterson, MD

As our entourage approached Cairo, it was decided that the running would be timed to enter the sprawling, polluted, and congested city at dawn. Thanks to police and army escorts, the run passed through the city without dangerous incident, despite dense auto and pedestrian traffic. In the city, we paused only a couple of times for brief rest, nutrition, and medical care (including once on a bridge spanning the Nile River, an experience that can only be described as surreal).

From there, we began the run’s last 36 hour leg down a four-lane toll road leading to the Red Sea. The runners had decided to run non-stop to the finish for the last 48 hours. Despite our hope that evenings and nights would be calm due to reduced traffic, we were sadly mistaken, and spent the night barely sharing the road with non-stop, speeding 18-wheel truck traffic; the roaring and booming passage of which not only buffeted everyone in its wash, but which also proved unnerving to the runners so close-by and unprotected.

By this point, all of the runners were on minimal doses of oral narcotics to deal with their pain and prednisone to lessen the severe tendonitis and general swelling that had become debilitating in each of them. This is not surprising, given the fact that they had run more than 4,000 miles in 110 days.

Overnight and into the next dawn, all three runners had nearly ceased communicating with one another, talking instead to family, friends, and supporters. One began to hallucinate and was frequently disoriented. Several times during the night, he lay down in the middle of the toll road in search of rest. After appropriate caffeine, hydration, and emotional support, he would continue on.

Athough the runners were within 25 to 30 feet of one another, they were in their own worlds; at times, they were disoriented and psychologically isolated. Miraculously, despite the near-misses, dangers, and craziness of the night, dawn arrived without a major incident. With daylight, the trucks left the toll road. As our escorts didn’t want to pay the tolls, they also departed, leaving our group alone on a virtually unused road. It had become abundantly clear, however, that two of the runners required some sleep if they were to finish the remaining 50 kilometers.

One of these men, however, was very concerned that were he to stop running and rest, he would be incapable of re-starting and once again gaining momentum. Consequently, he wanted to continue walking—making minimal progress—as he waited for the others to catch up.

It was decided by all three runners that two men would stop on the side of the road and rest for one to two hours, while the other proceeded on. This was calculated to be acceptable, given the extremely low pace being kept by the sole runner, who sported a painful abscess on his left foot. In all the stopping and starting, his determination to regain momentum was the only thing propelling him forward.

Prior to this period, it was clear that the road warrier's once angry-looking blister had turned into a very frank abscess draining purulent fluid. Severe pain associated with the affliction led to significant alteration in gait and stride, initiating an entirely new series of over-use injuries.

Perhaps it was attributable to disorientation, a desire to end the pain, end the run, or innate hyper-competitiveness, but before long our man began to pick up his pace. Soon, he was covering 15 kilometers an hour or more. After a quick calculation, I radioed a relay signal to the remaining (resting) runners through a unit of the film crew trailing us. They had overslept.

My apprehension and fear were replaced by jubilation when I looked in the rearview mirror and saw two small figures rapidly approaching from behind. We estimated that, in order to catch up, they covered 18 to 20 kilometers an hour. They rejoined their companion eight kilometers from the Red Sea. Upon reaching him, with wide grins on their faces, they said in unison, “Are you headed to the Red Sea?”

At this point, the runners were nearly totally spent, and covered the next few kilometers with a gradually slowing pace, spurred on by the watery finish line in sight. With merged support teams—African, Taiwanese, Canadian, and American—cheering them on, everyone stepped from their vehicles to walk the last three kilometers with the runners in support of finishing this epic run and journey. At the Red Sea, each runner dipped his hands, and after 111 days of every roadblock, logistical nightmare, and impediment imaginable, the expedition had succeeded. The physical achievement and psychological stamina were unrivaled in my eyes.

On February 20, 2007, just a few hours before sunset, it was complete. The remarkable runners had covered 6,920 kilometers (4,300 miles). Aside from the accomplishment of finishing, the expedition saved the lives of two, changed the lives of many, and in the future will hopefully improve the lives of countless, through its mission of supporting integrated sustainable water programs in Africa.

photo above by Jeff Peterson

Thanks, Jeff, for this fantastic series. You are a phenomenal storyteller, and we look forward to learning about your next adventure.

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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Too Hot

There are certain topics that will be appropriate to cover in regular cycles as posts to this blog, particularly if they are about situations where timely information might prevent a bad medical problem. Heat illness, and in particular heat stroke that leads to death, is one such problem. So, given the fact that at least 27 deaths have been reported in California due to this recent heat wave, I believe it is time to revisit the topic.

In our state, and across the nation, we seem to be witnessing higher temperatures during the summers than have historically been the norm. Whether or not this can be definitively attributed to global warming is a matter of debate, but the fact is that when people get too hot, they can rapidly become ill, and even die. Humans are not that well adapted for extremes of temperature. While cold can in certain circumstances be protective, heat is a destroyer. Humidity makes the situation worse, as it impedes evaporation of sweat, which is a major body cooling mechanism for humans. The National Weather Service has a heat index that roughly correlates air temperature and relative humidity to derive an "apparent temperature." At all temperatures, humidity makes the situation worse. For instance, at an air temperature of 85 degrees Fahrenheit, if the relative humidity is 80%, the apparent temperature is 97 degrees F. So, you must be extremely careful not to overdo it when the thermometer is rising. The most effective ways to avoid heat-related illnesses are to:

1. Stay well hydrated. Thirst is often not be an adequate indicator of how much water you need to drink, particularly when you are tired and during exertion. Be sure to keep up with your fluid losses by drinking enough so that you have to urinate often. If your urine is dark in color, then you are likely dehydrated, so keep drinking. You want your urine to be light-colored. Unless your doctor tells you otherwise, supplement water with an electrolyte-containing beverage, such as Gatorade. If the beverages you drink are a bit cool, they may be more palatable.
2. Curtail heavy exercise when it is hot, and particularly when it is humid. Above 75% humidity, you will have difficulty evaporating sweat, so your natural cooling mechanism is impeded.
3. Wear a broad-brimmed hat in the sun. Better yet, stay out of the sun.
4. When you feel hot, immediately seek a cooler location.
5. Don’t bundle yourself in hot clothing in the heat. Don’t try to lose water weight as part of any weight loss program.
6. Avoid alcohol and other beverages (such as tea and coffee) that act as diuretics.
7. If you are supervising children, athletes, or laborers in the heat, pay close attention to their behaviors. Anyone who seems overly tired, confused, or inappropriate may be on the verge of serious heat illness. Get them to a cool location, have them shed articles of clothing, and begin to lower their body temperature.
8. The second leading cause of death, after head injuries, in athletes is heat stroke. It is cruel and unnecessary, and particularly dangerous, to withhold water from athletes during practice and games. Furthermore, they are at great risk for overheating when exercising while wearing occlusive uniforms, hats, and helmets. Provide frequent water breaks and rest periods for all athletes.
9. Observe elders closely, particularly those who reside in dwellings without air conditioning.
10. Never leave a child or pet unattended in an automobile in the heat. The internal temperature of a car in the sunlight can rapidly rise to the point that the passengers are overwhelmed.
11. Be particularly vigilant if you are taking medications that affect your body’s ability to control its temperature. Have your pharmacist review all of your medications in order to let you know whether you are particularly vulnerable to the heat.

Tags: heat, heat illness, hydration, dehydration, heat wave, wilderness medicine, healthline

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Thank You to for Parallel Universes for Grand Rounds

Thank you to Parallel Universes for publishing my post about multiple uses for tissue glue in the latest edition of Grand Rounds. Grand Rounds is a weekly compilation of posts related to health care compiled by a host, who makes a great effort to create an interesting collection for readers.

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Tissue Glue, Fingers, and Float Tubes

When you are in the wilderness, it's good to carry supplies that can be used for multiple purposes. Duct tape is important for it's usual purposes, such as fixing a rip in a tent, but it can also be used as a wound closure strip or, in a pinch, to fashion a pair of emergency "sunglasses" for someone with a scratched cornea. We usually think of how non-medical supplies can used improvisationally for medical purposes, but the opposite holds true: there are occasions where the first aid kit comes in handy for non-medical purposes.

Here's how I killed two birds with one stone on a recent fishing trip. After instructing all the kids on the trip to be careful around the campfire, when chopping wood, and using sharp knives, I proceeded to stab myself deeply into the pad of my thumb when cleaning a fish. The wound bled freely, but wasn't spurting or gushing (e.g., no major blood vessel was involved), so I decided the finish the task at hand, then attend to my wound. After I was done with my chore, I washed the wound out vigorously with camp soap and disinfected water, because I am familiar with the sorts of infections one can acquire from bacteria that reside in the freshwater environment. Rather than achieve immediate closure tight closure with tape, I elected to pull the wound edges together only enough to stop the bleeding, and then applied bacitracin ointment and a bandage, so that I could give the cut a day to begin its healing process before attempting a more definitive closure.

The next morning, the cut looked clean, but after a day of fishing and repeated immersion in lake water, it was open and would clearly be a nagging nuisance for the remainder of my vacation, so I wanted to close it. Tape and bandages would work on dry land, but I had observed that even my super-sticky Coverlet® bandages worked themselves loose after a few hours of fishing and repeated immersion of my hand in the water to retrieve fish, handle them, and set them free after they were caught. So, I needed a better solution.

I always carry a few DERMABOND® ProPen (Ethicon, Inc.) applicators with me when I am traveling, so I carefully washed and rinsed my cut again, allowed it to air dry, and then glued it shut with the tissue glue. That worked like a charm, and the cut not only healed without incident, but the pliable and semi-transparent wound repair easily withstood three days of nearly constant soaking in the water. When I returned home, I easily peeled the remaining purple tissue glue off my finger.

While I was gluing my cut, one of my fishing buddies noticed me working on my hand, and asked for an explanation. His eyes lit up and he said, "I think you have a solution for me. The valve on my float tube has come loose. I got it to fit back together but I need something to keep it in place, and I can't find any epoxy cement. Do you think your stuff (the tissue glue) might work?" I had no idea, because I had never used DERMABOND® on anything other than people, but it was worth a try. Using the applicator, he applied a ring of the 2-octyl cyanoacrylate compound to the reassembled valve, taking care to avoid occluding the opening. It was the perfect viscosity to penetrate the connection. We let it dry, then applied one more coating for good measure.

It worked! So, my cut was fixed, and so was my friend's float tube. Of course, I'n not advocating that you consume precious medical supplies to fix your fishing gear, since a tube of Super Glue would be much less expensive, but it's nice to know what works. Furthermore, once you break the seal on a vial of DERMABOND®, it's a one-time use situation, because the vial that is now exposed to air will harden and need to be discarded, so you might as well figure out if you have anything else that needs to be glued before you throw the applicator in the garbage. After observing our success with the float tube, I touched up a few pinholes in my tent and one fraying tent seam, for good measure.

Tags: tissue glue,DERMABOND, cut, fishing, first aid, wilderness medicine, outdoor medicine, healthline

Labels: cut, DERMABOND, first aid, supplies, tissue glue, wound, wound closure

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