Hospitalito Atitlan 2008

I am spending a week working at the Hospitalito Atitlan in Santiago, Atitlan (state of Solola) in the highlands of Guatemala. I have visited the hospital twice in the past (2007 and 2006), but never before worked as a clinician at the hospital. The building is a temporary solution that must serve the people here until such time as a new hospital can be built to replace the structure that was destroyed in the mudslides associated with the hurricane in October of 2005.

Santiago is a busy small city of very friendly and industrious persons, although it appears to have become more intense and less relaxed than it was a year ago. In the morning, the air is dense with smoke from wood fires used for heat and cooking. Not surprisingly, many of the local people suffer from pulmonary diseases associated with exposure to this smoke.

The purpose of my visit is to learn better how this hospital can be supported with doctors, staff, and money. A new hospital is being planned, but construction cannot accelerate until there are more resources identified.

The patients are certainly in need and very appreciative. The volunteers and paid staff are phenomenal in their dedication and rapidly improving expertise. My participation in just the first few days has been filled with moments of improvisation, because the supplies are limited and decision making must take into account conservation of supplies, the expense to the patients, the relative inability to easily obtain tests we take for granted in the U.S., and the wishes of the patients and families. It is a collaborative process, and I am hindered somewhat by my inability to speak Spanish or Tz'utujil, the Mayan language spoken in this region.

The patient mix is varied - the first day saw a mixture of obstetrics, neonatology, trauma (tuk tuk accidents are quite common, as these three-wheeled taxis are driven by individuals as young as 8 years of age), infectious disease, an acute urological emergency, lung problems, and much more. My wilderness medicine training has helped in at least a few situations, and as is often the case, duct tape is quite valuable.

I can't say enough about how important it is for local medical facilities like this to be successful. This hospital provides an extraordinary service to the Santiago residents and other inhabitants of this locale, and it is clearly understood that for this to be a long term success, it needs to be based upon the recurring expertise and efforts of the community and Guatemalan physicians. I will collect more of my experiences and my thoughts at the end of this experience, and write more.

Back to work...

photo by Kathy Roach

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Treatment for Burns

1. Remove the victim from the source of the burn. If his clothing is on fire, roll him on the ground or smother him in a blanket to extinguish the flames. If the victim has been burned with chemicals, gallons of water should be used to wash off the harmful agents. If the eyes are involved, they should be irrigated copiously. Phosphorus ignites upon contact with air, so any phosphorus in contact with the skin must be kept covered with water. Do not attempt to neutralize acid burns with alkaline solutions or vice versa; the resultant chemical reaction may liberate heat and worsen the injury. Stick to irrigation with water. If clothing remains stuck to the skin and does not fall away with irrigation, do not tear the clothing away. Cut around it.

2. Evaluate the airway. Look for evidence of an inhalation injury: burns of the face and mouth, singed nasal hairs, soot in the mouth, swollen tongue, drooling and difficulty in swallowing saliva, muffled voice, coarse or difficult breathing, coughing, and wheezing. If it appears that an inhalation injury has occurred, administer oxygen by face mask at a flow rate of 5 to 10 liters per minute, and transport the victim to a hospital as quickly as possible.

3. Examine the victim for other injuries. Unless the airway is involved or the victim is horribly burned, the burn injury will not be immediately life threatening. In your eagerness to treat the burn, don’t overlook a serious injury such as a broken neck. Control all bleeding and attend to broken bones before applying burn dressings.

4. Treat the burn:

First-degree: A first degree burn, such as a mild to moderate sunburn, may be treated with cool, wet compresses. If the burn is acquired suddenly (as when a child grabs a hot rock), immediate application of very cold water (not solid ice) may help limit the extent of the tissue damage. Oral administration of an anti-inflammatory drug, such as aspirin or ibuprofen, may provide considerable relief. For severe sunburn (“lobster body”), the administration of oral prednisone in a rapid taper (80 mg the first day, 60 mg the second, 40 mg the third, 20 mg the fourth, 10 mg the fifth) may be extremely helpful. Corticosteroids should always be taken with the understanding that a rare side effect is serious deterioration of the head (“ball” of the ball-and-socket joint) of the femur, the long bone of the thigh.

Topical corticosteroid creams or ointments are of no benefit in treating a burn wound. Anesthetic sprays that contain benzocaine work for a few hours, but may induce allergic reactions. They should be used sparingly. If no blisters are present, a moisturizing cream (such as Vaseline Intensive Care) will help soothe the skin. Aloe vera gel or lotion seems to promote resolution of extensive first-degree burns. Burnaid first-aid burn gel (Rye Pharmaceuticals), which also comes in an impregnated dressing, contains 2 to 4% melaleuca oil and is advertised to provide relief from the pain of minor burns and scalds.

Second-degree: A second-degree burn should be irrigated gently to remove all loose dirt and skin. This should be done with the cleanest cool water available. Never apply ice directly to a burn; this may cause more extensive tissue damage. Cool compresses may be used for pain relief.

After the wound is clean and dry, cover it with a soft, bulky dressing made of gauze or cloth bandages, taking care to keep the dressing snug but not tight. If antiseptic cream such as silver sulfadiazine (Silvadene) is available, it should be applied under the dressing. An alternative is mupirocin ointment or cream, or bacitracin ointment. A nonadherent dressing layer directly over the antiseptic is easier to change than coarse gauze. Another excellent covering is Spenco 2nd Skin underneath an absorbent sterile dressing. Spenco 2nd Skin is an inert hydrogel composed of water and polyethylene oxide. It absorbs fluids (so long as it doesn’t dry out), which “wicks” serum and secretions away from the wound and promotes wound healing. Other occlusive hydrogel-type dressings are NU-GEL (preserved polyvinyl pyrrolidone in water) and Hydrogel, which can absorb up to 21/2 times its weight in exuded (from the wound) fluids. Yet another covering for a burn is a layer of petrolatum-impregnated Aquaphor gauze under a dry (absorbent) gauze dressing.

Do not apply butter, lanolin, vitamin E cream, or any steroid preparation to a burn. These can all inhibit wound healing, and may facilitate infections with increased scarring.

Dressings should be changed each day to readjust for swelling and to check for signs of infection. Be certain to keep burned arms and legs elevated as best possible, to minimize swelling and pain.

Blisters should not be opened, unless they are obviously infected and contain pus (this will generally not occur until 24 to 48 hours after the burn injury). If a blister remains filled with clear fluid, it is an excellent covering for the wound and will minimize fluid loss and infection. There is no rush to remove charred skin from a burn wound. As the wound matures and dressings are changed, gentle scrubbing will lift off dead tissue.

A victim with large areas of second-degree burns may need to be treated for shock.

Third-degree: A third-degree burn should be irrigated gently and covered with antiseptic cream or ointment or Spenco 2nd Skin, and a dry sterile dressing.

If a first-degree burn involves more than 20% of the body surface area and the victim suffers from fever, chills, or vomiting, a physician evaluation is required. If a second-degree burn involves a significant portion of the face, eyes, hands, feet, genitals, or an area greater than 5% of the total body surface area, a physician evaluation is required. Body surface area can be estimated using the “rule of nines.” For an adult, each upper limb equals 9% of total body surface area (TBSA), each lower limb equals 18%, the anterior and posterior trunk equal 18% each, the head and neck combined equal 9%, and the genital/groin area (perineum) equals 1%. For a small child, each upper limb equals 9% of TBSA, each lower limb equals 14%, the anterior and posterior trunk equal 18% each, the head and neck combined equal 18%, and the perineum equals 1%. Another method to estimate involved body surface area is the “palm of hand” rule: The surface area of the victim’s palm without the fingers represents approximately 1 to 1.5% of his TBSA. All third-degree burns are serious and should be seen by a physician.

Wet versus Dry Dressings

If the burn surface area is small (less than 10% of total body surface area), then cool, moist dressings (not ice) may be used to initially cover the burn wound. These often provide greater pain relief than do dry dressings. If the surface area involved is large, however, dry, nonadherent dressings should be used, in order to avoid overcooling the victim and introducing hypothermia. Because the skin is the major thermoregulatory organ of the body, it is difficult for an extensively burned victim to control his body temperature, so great care must be taken when wetting down such a person. If the victim begins to shiver, the cooling is too extreme.

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Avalanche Safety Practices in Utah

We are finally in the midst of repeated major snowfalls in the Sierra of northern California. Given the large accumulations here and in other mountain ranges, such as the Wasatch Range of Utah, avalanches are inevitable. One may not head for the slopes at a ski resort thinking about avalanche hazard, but it is wise to do so. This is highlighted in an article that appears in the 4th issue of Volume 18 of the journal Wilderness & Environmental Medicine, which has recently been published.

Natalie Silverton, M.D. and her colleagues from the Division of Emergency Medicine at the University of Utah commented in an article entitled "Avalanche Safety Practices in Utah." They utilized a survey of 353 winter backcountry users to determine the percentage of participants in a variety of categories with respect to whether they were carrying avalanche transceivers, shovels, probes, or AvaLungs; whether or not they had taken an avalanche safety course; and whether they were traveling solo or with a partner(s). Interviewees were backcountry skiers, snowboarders, snowshoers, snowmobilers, and out-of-bounds resort skiers/snowboarders traveling in the Wasatch and Uinta Mountains of Utah during the winter of 2005-06.

The results are revealing and make sense. Backcountry skiers showed the highest level of avalanche preparedness, with 98% carrying avalanche transceivers, 98% carrying shovels, 77% carrying probes, 86% having taken an avalanche safety course, and 88% carrying out minimum safety practices. Out-of-bounds snowboarders were the least prepared, with only 9% carrying avalanche transceivers, 9% carrying shovels, 7% carrying probes, 33% having taken an avalanche safety course, and 2% carrying out minimum safety practices. The authors concluded, "There are significant differences in the avalanche safety practices of backcountry travelers in Utah. Backcountry skiers and snowboarders were the most prepared, while snowmobilers, snowshoers, and out-of-bounds skiers/snowboarders were relatively less prepared."

Unless the demographics and attitudes of the respondents for this survey are remarkably different from those of similar populations that utilize the winter backcountry, this very useful demonstration points us in the direction of where best to apply outdoor safety education campaigns. If snowmobilers, snowshoers, and out-of-bounds skiers/snowboarders are least well prepared to survive an avalanche, if they can be persuaded to be better prepared, that might result in fewer future personal tragedies.

"Fresh Frosting, Wasatch Mountains, Utah" by David Whitten at www.davidwhittenphoto.com

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Meat Tenderizer for a Jellyfish Sting

Anonymous has left a new comment on your post "Myths to Debunk":

"What about meat tenderizer for a jellyfish sting? I know that hot water works well as it causes the venom proteins to refold, but the usual folk treatment for Man 'o War stings here in Texas is a paste of meat tenderizer or to rub the area with a slice of fresh papaya or pineapple."

Great question. There are numerous remedies that have been recommended as effective against different "jellyfish" stings, but not many that have been tested scientifically in clinical trials. Furthermore, I have seen opinions change based on anecdotes and observation of just a few patients.

Here are some of the substances and methods that have been recommended for immediate treatment (not prevention) of jellyfish-type (e.g., jellyfish, Portuguese man-of-war, hydroid, fire coral, and others) stings, and my current understanding of what we know (or feel) about them:

1. Vinegar (household variety of white vinegar, which is acetic acid 5.0%, is recommended for stings from a box-jellyfish (Chironex fleckeri) and for many other stinging species. It seems to be a good all-purpose decontaminant. It can be cut 50% with water or isopropyl alcohol (see below) and retain its beneficial effect.

2. Isopropyl ("rubbing") alcohol has been observed by many users and practitioners to be effective against may stinging species. However, in at least one laboratory experiment, stinging cells (nematocysts) from jellyfish were observed under the microscope when flooded with isopropyl alcohol, and seen to "fire" their stinging apparatus. However, the meaning of this observation cannot be precisely determined, because it is not known whether the firing occurred with sufficient force to cause an envenomation (had the stinging cells been on a live tentacle placed against human skin), or even whether it was an agonal (occurring in the act of destruction of the stinging cells) activity caused by the alcohol. So far as I know, it has not been reported clinically that application of isopropyl alcohol worsens the sting of any marine creature. If anyone is aware of such a circumstance, please let me know.

3. Meat tenderizer. Most of these products contain papain, which breaks down proteins. This is perhaps the reason why an application of meat tenderizer is effective in diminishing the discomfort associated with the sting of a marine creature. However, one must take care to not leave meat tenderizer on sensitive skin for too long (e.g., longer than 10 to 15 minutes), because it can cause an irritating reaction in and of itself. Furthermore, I have heard from a few users that if the seasoned form of tenderizer is used, it may increase the irritation or even cause stinging with the initial application. The sensitive skin of infants and babies, and facial skin at all ages, may be more prone to an adverse skin irritation from application of papain. With regard to using application of fresh papaya fruit, I have heard that recommendation before. I don't know anything about the use of pineapple.

4. Other substances reputed to be of value are household ammonia, and lemon or lime juice. It's possible that the change in acid-base balance (pH) is what causes this effect, or perhaps it is some denaturation (destruction or inactivation) of protein or other components of venom.

5. Application of fresh water (e.g., tap water) has received mixed reviews. It is fairly well accepted that gentle application (e.g., pouring water without pressure or gentle rinsing under a tap) of fresh water worsens the situation, because fresh water is hypotonic (e.g., contains a lower concentration of salts) than sea water, and causes the stinging cells to "fire" and discharge their stinging apparatus, thus worsening the envenomation and pain. On the other hand, lifeguards in various locations have reported that the brisk spray from a shower or garden hose can be helpful. This is perhaps because the mechanical effect of the spray actually removes stinging cells and supercedes the deleterious effect of the hypotonic water. Application of cold packs, moist or dry, has received mixed reviews. The latest recommendation, which emanates from experts in Australia and other Indo-Pacific regions, is that application of hot water to tolerance can be helpful to treat a sting.

6. Solvents (e.g., acetone) are generally not useful and perhaps dangerous, both because of direct skin irritation and potential absorption of toxic chemicals through the skin.

7. The "pressure immobilization technique" was formerly recommended for stings of the Indo-Pacific box jellyfish (Chironex fleckeri), but has been removed from any formal recommendations, as it does not appear to be helpful, and may actually even be harmful.

One important point bears mention, which is that no topical decontaminant is foolproof, so it is absolutely essential to remember that prevention is extremely important. Whether one chooses to stay out of the water when stinging creatures are expected to be in the vicinity, wears a wet suit or "stinger suit," uses a topical sunscreen-jellyfish sting inhibitor, such as Safe Sea, or some other maneuver, it is much better to not be stung in the first place than to hope for success with any given treatment.

Tags: jellyfish,jellyfish sting, marine sting, wilderness medicine, outdoor medicine, healthline

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Thank You to SHARPBRAINS for Grand Rounds

Thank you to SHARPBRAINS for including my post about general first aid principles within this week's 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 compile an interesting collection for readers.

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Cause of Death in Avalanche Fatalities

There are many excellent and informative articles in the 4th issue of Volume 18 of the journal Wilderness & Environmental Medicine. One that is particularly interesting is entitled, "Causes of Death in Avalanche Victims."

Scott McIntosh, M.D. and his co-authors from the University of Utah in Salt Lake City reviewed records from the Utah Avalanche Center and the medical examiner that covered the time period from the 1989-90 to 2005-06 winter seasons. The records were reviewed to identify accident circumstances, autopsy findings, and causes of death.

From reviewing 46 avalanche deaths, it was determined that 85.7% of deaths were due to asphyxiation, 8.9% were due to a combination of asphyxiation and injuries (trauma), and 5.4% were due to injuries alone. Head injuries were common in persons killed solely by injuries.

The conclusion was straightforward and has been corroborated often anecdotally by avalanche rescue experts - namely, that avalanche deaths (in this case, in Utah) result from asphyxia (suffocation leading to lack of oxygen in the brain and body). Therefore, most victims are alive for a period of time in the post-avalanche period and have the potential for live recovery until they succumb to asphyxia. According to the authors, rescue strategies that employ rapid recovery as well as techniques that prolong survival while a person is buried provide the best means for improving outcomes.

Colin Grissom, M.D. (a good friend, the President-elect of the Wilderness Medical Society, and a co-author on the article discussed in this particular post) and I discussed this a bit last October in Aviemore, Scotland at the WMS-ISMM World Congress. Based on our discussion, I have initiated a project to evaluate the practicality of design of a novel avalanche survival device. It is not an easy project, but one worthy of effort, given the dismal fate of most persons who become entombed in the unyielding snow that smothers them within the debris of an avalanche. We are not yet close to success, but we are still at it.

photo courtesy of Richard L. Armstrong

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General First-Aid Principles

The following is adapted from Medicine for the Outdoors:

In all first-aid situations, the rescuer must remain calm. If you panic, you may lose control of the victim, as well as of yourself. To establish authority, speak and act calmly and purposefully. Allow the victim to discuss the incident, his (or her) situation, and his fears. If you can involve the victim in his rescue and treatment, it is often good for morale. Try not to be judgmental and save criticism for after the event. Avoid laying any blame on people; they may get hurt emotionally or become argumentative as a result. When communicating with a victim and bystanders, remember that you are not only caring for the victim, but in many ways, for family and friends. It is important to communicate frequently, honestly, and in a manner that is reassuring and inspires cooperation and hope.

1. Do not endanger additional inexperienced rescuers. If you cannot get to the victim easily, send for help. Approach all victims safely; don’t allow the sense of urgency to transform a sensible rescue into a series of risky, or even foolhardy, maneuvers. If it appears that the victim is too ill to be moved, set up camp and create a shelter immediately. In all cases, protect the victim from the elements from above and below.

2. If you have paper and a writing instrument, record your observations. If you send someone for help, have him carry a piece of paper that states the victim or victims’ location, the nature of the emergency, the number of people needing help, the condition of the victim(s), what is being done to treat the victim(s), and any specific environmental conditions or physical obstacles. Accident report forms are available from organizations such as The Mountaineers.

3. Always assume the worst. Assume that each victim you encounter has a broken neck or a heart attack until proven otherwise. Always be conservative in your treatments and recommendations for further evaluation or rescue.

4. Never move a seriously injured victim unless he is in danger from the environment or needs to be moved for medical reasons. Don’t encourage a victim to get up and “shake it off” until you have examined him as fully as possible for a potentially serious problem. If you must remain in a wilderness location for a prolonged period of time caring for a victim, remember to attend to the basic survival requirements, which include air (oxygen) for breathing, shelter, water, food, psychological support, and human waste disposal.

5. Don't administer medicines or perform procedures if you are not sure what you are doing. The good Samaritan has certain legal protections for his actions so long as he operates within prudent limits and takes reasonable care. A good rule to follow is primum non nocere: “First of all, do no harm.” If you are not certain what to do and the situation isn’t worsening, don’t interfere. Explain to the victim that you are not a physician, but will do your best to get him through whatever crisis he has encountered, to the best of your knowledge and ability. If you encounter a victim who may be seriously ill, seek an expert opinion as soon as possible. Even if your treatment seems successful, it is wise to consult a physician if you would have ordinarily done so.

6. Listen carefully to the patient. The story of what happened and the medical history can be extremely important in making swift and appropriate medical decisions. Let the victim tell you what happened in his or her own words, and try not to interrupt unless it is important. If a victim has a sprained ankle, a comprehensive discussion may not be necessary, but if it is appropriate, try to elicit the following:

Current illness: What happened? When did it happen? Why did it happen? If the victim is suffering pain, describe its location, time of onset, whether it came on suddenly or gradually, whether it comes and goes, its quality (dull, sharp, cramping, etc.), how it is made worse or relieved, and whether the victim has suffered anything similar before (and if so, whether there was a medical diagnosis). Have the victim describe all symptoms, such as nausea, vomiting, diarrhea, blurred vision, shortness of breath, fatigue, cough, etc.

Prior illnesses and preexisting conditions: Have the victim describe any previous illness (heart attack, asthma, pneumonia, meningitis, etc.) and any current conditions (diabetes, anemia, abnormal heart rhythms, etc.) and how they have been and are currently being treated.

Surgeries: Have the victim list any surgical operations, such as appendectomy or knee surgery.

Allergies: This includes allergies to food, plants, insects, and medication(s) and the nature of the allergic reaction(s).

Immunizations, exposure to communicable diseases, foreign travel, recent dietary history: Any of these may be appropriate if the victim is perhaps suffering from an infectious disease, including food poisoning or toxic ingestion.

Review of systems: This is a comprehensive questioning of each organ system to determine if the victim has or has ever had symptoms referable to each system:

Head: headache, dizziness
Eyes: blurred vision, double vision, decreased vision, discharge, pain
Ears: decreased hearing, ringing in the ears, discharge from the ears, pain
Nose: nosebleeds, difficulty breathing, nasal discharge, sinus infection
Throat: sore throat, foreign body sensation, tonsillitis, hoarseness or difficulty talking, painful swallowing, difficulty swallowing
Dental: tooth loss, abscess, dentures
Neck: pain, decreased range of motion, arthritis
General: fever, chills, weakness, unintentional weight loss or gain, dizziness, history of intravenous drug use
Chest(lungs): difficulty breathing, shortness of breath, wheezing, cough (productive of sputum or nonproductive), coughing blood, history of tobacco use
Heart: palpitations, chest pressure-like sensation, chest pain
Abdomen: pain, mass
Gastrointestinal: nausea, vomiting (describe what is vomited), diarrhea (describe consistency), red blood in stools or dark black stools, yellow skin (jaundice), perianal itching, constipation, excessive gas, bloating, belching
Hematologic/immune: anemia, frequent infections, exposure to HIV
Genitourinary: change in frequency of voiding, painful urination, discolored or malodorous urine, back pain, blood in urine, history of sexual contacts, penile or vaginal discharge, date and character of last menstrual period (normal, abnormal), vaginal bleeding
Neurologic: seizure, weakness in any body part, numbness or tingling of any body part, difficulty with coordination or walking, difficulty with speech or comprehension, fainting
Muscular: muscle cramps, weakness, incoordination, pain
Psychiatric: abnormal thinking, hallucinations (visual or auditory), desire to hurt self or others, inappropriate crying or laughing, depression

Tags: first aid,wilderness medicine, outdoor medicine, healthline

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Ginkgo biloba for Prevention of Acute Mountain Sickness

The fourth issue of Volume 18 of the journal Wilderness & Environmental Medicine has recently been published. The lead article is entitled "Ginkgo biloba Decreases Acute Mountain Sickness in People Ascending to High Altitude at Ollague (3696 m) in Northern Chile," authored by Fernando A. Moraga and his associates.

The article describes a study, the objective of which was to determine the effect of Ginkgo biloba in preventing acute mountain sickness (AMS) at an altitude of 3696 meters (12,126 feet) in participants without high-altitude experience. Thirty-six persons who reside at sea level were transported by ground transportation over 8.5 hours to an altitude of 3696 meters. The study participants were divided into three equal groups of 12 persons each. One group received Ginkgo biloba in a dose of 80 milligrams every 12 hours by mouth, one group received acetazolamide (Diamox, a drug commonly used to hasten acclimatization to altitude or to treat AMS) in a dose of 250 milligrams every 12 hours by mouth, and the final group received a placebo (e.g., no active drug). Each group began its treatment 24 hours before ascending and continued treatment during the 3-day stay at altitude. A standard Lake Louise Questionnaire was administered to determine the Self-Report Score, which is an accepted method for determining the presence and degree of AMS. In addition, selected physiological measurements were taken.

The results are the most compelling data to date supporting the efficacy of Ginkgo biloba in prevention of AMS. The group taking the Ginkgo biloba had no increase in their AMS score (which is remarkable), while the acetazolamide and placebo groups showed increases of 36% and 54%, respectively. The authors concluded that their study provides evidence supporting the use of Gingko biloba in the prevention of AMS, demonstrating that 24 hours of pretreatment with Gingko biloba and subsequent maintenance during exposure to high altitude are sufficient to reduce the incidence of AMS in participants with no previous high-altitude experience.

No doubt, others will attempt to replicate this investigation. If the results are corroborated, then Ginkgo biloba may prove to be a very useful adjunct in the prevention and treament of AMS.

Ginkgo biloba plant image courtesy of www.artofbonsai.org

Tags: Ginkgo biloba ,AMS, altitude, acetazolamide, high altitude, wilderness medicine, outdoor medicine, healthline

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Thank You to pathtalk.org for Grand Rounds

Thank you to Trent McBride of pathtalk.org for including my post about tiger attack within this week's 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 compile an interesting collection for readers.

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Tiger Attack

The recent attack by a captive tiger upon three men at the San Francisco Zoo is a reminder that captive "big cats," no matter how seemingly domesticated, remain wild and unpredictable animals.

My good friend Luanne Freer, M.D., discussed tiger attacks in her chapter on wild animals in the textbook Wilderness Medicine. With some editing, here is what she had to say about the strength and ferocity of a tiger attack:

"Over the last 5 centuries, an estimated 1 million people have been eaten by tigers. In the 19th century, the tigers’ toll in India averaged 2000 victims per year. Man-eating tigers in India between 1906 and 1941 ate an estimated 125 persons each, and one was reported to have killed 436 persons. From 1930 to 1940, the annual number never dropped below 1300. In the late 1940s, the rate of humans killed dropped to about 800 per year, where it remains.

An adult tiger is so powerful that the human victim is often killed instantly. It is not unusual for a limb to be severed with a single bite. A swiping blow to the human head is of sufficient force to cause a skull fracture. Like many big cats, a tiger typically strikes without warning from behind, biting the head and neck and often shaking its head violently to sever the victim’s spinal cord. Tigers are a major threat to the lives of humans in the cats’ native regions. Although the number of tigers in the world is dwindling rapidly, they are still the number one animal killer of humans.

Man killing almost invariably results from stress (wounds or old age) or lack of
habitat and natural prey that forces the animal to prey on humans. A tiger subsisting solely on human meat would have to kill approximately 60 adults a year, and documented cases in selected regions have approached this rate over periods of up to eight years. However, unlike lions, tigers are not thought to become exclusive man eaters. Some tigers have become opportunistic man eaters in lieu of plentiful natural prey, and tiger biologists hypothesize that these animals have become unafraid of man."

In addition to the extraordinary trauma that can be inflicted by a tiger, lion, or other large cat, there is the complication of infection from germs prevalent on the teeth and claws of these animals. Notable among these infections is that caused by Pasteurella multocida. The astute clinician will be aware of the potential for a P. multocida infection following a tiger attack, and treat the victim with an appropriate antibiotic(s), such as ciprofloxacin, cefuroxime, or cefoxitin, to attempt to avoid the onset of an infection.

Portrait of the Tiger by LeRoy Neiman

Tags: tiger attack, tiger, Pasteurella multocida, wilderness medicine, outdoor medicine, healthline

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A Week on the Hill

I just returned from spending a few days on the slopes as a member of the doctor patrol at a downhill ski resort in the Sierra Nevada mountain range in the state of California. The patrol is a volunteer activity in which the doctor(s) assists the ski patrollers with medical issues when summoned to a scene or the first aid room. Because there hasn't been a tremendous amount of snowfall quite yet, the resort was not as crowded as usual during the holidays, which was good from an injury perspective.

However, people still get hurt, because there were falls and collisions. In discussing each days' events with the highly experienced and attentive ski patrol members, they had some interesting observations. With regard to injuries on the slopes, technology is both friend and foe. While new equipment, such as improved boots and bindings, helps prevent orthopedic injuries, the ever-improving skis and snowboards allow skiers of lesser abilities (and frequently less experience) to attempt steeper slopes and more difficult terrain. This puts them into situations where experience and judgment might combine to help avoid injuries. People who take only a few ski or snowboarding lessons leave their instructors to attempt double black diamond inclines on their own, and they are not prepared to handle them.

Peer pressure is definitely a factor, much more so for the younger crowd. In the midst of a minor blizzard and temporary "white-out," I observed three young men strip to the waist and ski, sans jackets and helmets, onto a busy slope so that they could get a picture for their friends. They weren't breaking any rules - just testing Darwin's Law.

I am completely convinced that the major contributor to injuries is speed. The faster that people ski or snowboard, the more likely that a fall or collision will result in a significant injury. Machine-groomed steep slopes are common, and high-speed lifts deliver people to the top efficiently. This puts greater numbers of individuals on these steep slopes at any given time, which contributes to falls and collisions. As one learns to drive defensively, one should ski defensively. This may take away some of the thrill, but it is the sensible thing to do.

The number one way to prevent injuries is to ski under control, and this is, unfortunately, less often the rule when people ski or board too fast. It seems as if many skiers and snowboarders have lost respect for the mountain and forces of nature, or never properly appreciate them in the first place. High winds, particularly on ridges, may make the terrain icy, and this leads to loss of control and accidents. People ski in conditions for which they are not prepared, such as white-outs and deep powder in boundary areas, which leads to lost persons and tales of survival.

In terms of equipment, the best insurance policy is a helmet. There is no question that helmets prevent or diminish head injuries. In my activities this season as a member of the doctor patrol, I have already cared for too many individuals who suffered concussions that would have been prevented had they been wearing helmets. There’s no explanation, including that of personal freedom, that I can support, to argue against helmet use. They are advised for skiers at any age and level of experience.

So, enjoy the slopes, but ski or snowboard safely and do your best to participate within your personal limits. When you take on more challenging terrain, try to do so under optimal conditions in the presence of persons who can assist you should you get in over your head, become injured, or otherwise require a rescue.

Tags: skiing,snowboarding, speed, wilderness medicine, outdoor medicine, healthline

Labels: helmet, ski, skiing, snowboard, snowboarding, speed

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Thank You to Other Things Amanzi for Grand Rounds

Thank you to other things amanzi for including my post about speeds associated with skiing and snowboarding within this week's 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 compile an interesting collection for readers. This week's edition is accompanied by beautiful photographs from South Africa.

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Many Reasons To Be Thankful - A Pledge for 2008

The outdoor and wilderness medicine communities have many opportunities to view the world from unique perspectives. Daniel Mazur of www.summitclimb.com shared with me an observation he received from a member of the Mount Everest Foundation that we have many reasons to be thankful. Here is what was observed about what is eaten in one week by families around the globe:


Italy: The Manzo family of Sicily
Food expenditure for one week: 214.36 euros or $260.11


Germany: The Melander family of Bargteheide
Food expenditure for one week: 375.39 euros or $500.07


United States: The Revis family of North Carolina
Food expenditure for one week $341.98


Mexico: The Casales family of Cuernavaca
Food expenditure for one week: 1,862.78 Mexican pesos or $189.09


Poland: The Sobczynscy family of Konstancin-Jeziorna
Food expenditure for one week: 582.48 zlotys or $151.27


Egypt: The Ahmed family of Cairo
Food expenditure for one week: 387.85 Egyptian pounds or $68.53


Ecuador: The Ayme family of Tingo
Food expenditure for one week: $31.55


Bhutan: The Namgay family of Shingkhey Village
Food expenditure for one week: 224.93 ngultrum or $5.03


Chad: The Aboubakar family of Breidjing Camp
Food expenditure for one week: 685 CFA francs or $1.23

For 2008, let us all pledge to commit some portion of our time, energy, financial resources, and love to making the world a better place.

Tags: 2008, wilderness medicine, outdoor medicine, healthline

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