Shark Attack Tragedy

I don’t have the complete details, but from what I know about sharks, it was bound to happen. An Austrian diver in the presence of intentionally attracted (with bait to feed) sharks was bitten by a bull shark and bled to death in Bahamian waters. Of course, our hearts go out to the victim, family, and friends. I also feel badly for the proprietor of this adventure, who certainly would never have intended for something like this to happen. No doubt, there will be finger pointing, recrimination, incredible remorse, and possible litigation.

Shark attraction and feeding for the benefit of viewing diver audiences have been going on for decades. The only safe way to do this is to have the divers observe the animals from within the confines of impenetrable (to sharks) cages, not in open water. The owners of the businesses that promote shark diving wouldn’t have been providing this service if they thought it was exceedingly dangerous. But as we all observed with the tragic stingray puncture to Steve Irwin’s heart, undersea creatures are often swift, strong, wild and above all, unpredictable, animals. Sharks should should never be considered domesticated or safe because they have been in the presence of humans. Their fight, flight, and other defensive mechanisms are guided by primitive and highly conditioned responses intended to promote their survival. They are, plain and simple, predators. When they are feeding, they are considered to be more prone to bite humans. Standard shark avoidance advice is to stay away from sharks during intense feeding activities, to avoid being mistaken for intended prey.

Sharks are fast swimmers endowed with remarkable sensory systems, and when they become disturbed, especially in the feeding mode, there is very little that a human can do to evade an attack. The usual admonition is to seek protection from behind and the sides if possible when a shark swims in an “agitated” fashion, which is what you would expect during provoked feeding of a group of sharks attracted by blood and chum in the water.

It is hard to tell what this will mean for guided shark feeding experiences. Given that it appears to be the case that this victim was bitten by a shark that was within a group being fed for show, my future recommendations are set. Although some might argue that it may still be all right to arrange out-of-cage shark feeding experiences with "less dangerous" species, I don't recommend it. Although certain sharks have less propensity to attack humans, these same animals have sharp teeth and are capable of creating severe bite wounds. It is impossible as a doctor who gets consulted about the clinical manifestations of shark attacks to advise it is acceptable for people to intentionally be in open water in the presence of a group or school of feeding sharks, particularly if they exhibit aggressive behavior.

photograph of bull shark by Howard Hall

Tags: shark, shark attack,wilderness medicine, outdoor medicine, healthline

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Thank You to ScienceRoll for Grand Rounds

Thank you to Berci Meskó of ScienceRoll for including my post about caring for an infant at the Hospitalito Atitlan 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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Epinephrine for Allergic Reactions

A reader posed a question in response to my post about killer bees in New Orleans:

"I have a question regarding the proper use of epinephrine in wilderness medicine situations. In my recent wilderness first responder (WFR) recertification, we were told that if epinephrine is required, the protocol is to administer one dose, then give an oral antihistamine. Before the oral medication has time to work, another does of epinephrine will (might) be required. The point was that TWO doses (minimally) of epinephrine should be packed for each individual with severe allergies on a wilderness trip. This is NOT what I was taught in my initial certification - there, we were taught that one dose is enough. I believe in always being on the safe side in packing meds, but is a second dose of epinephrine always necessary?"

The answer is that most of the time, one dose of epinephrine injected subcutaneously or into muscle tissue (intramuscularly) will be sufficient to handle an allergic reaction. However, it is unpredictable. So, sometimes a second dose of epinephrine is necessary. My recommendation is to carry two doses, because there is absolutely no harm in being prepared.

The premise of the Twinject product is that it provides for two doses of epinephrine in a single unit package, as opposed to the EpiPen, which only provides for a single dose. Both products can be lifesavers.

Tags: epinephrine,allergic reaction, Twinject, wilderness medicine, outdoor medicine, healthline

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Hospitalito Atitlan 2

Each day working at the Hospitalito Atitlan brought new challenges. At every opportunity, the staff rose to the occasion. They were resourceful to the maximum, and by the end of the week, I fully realized that I had received much more of an education than I had contributed.

A young mother brought her 10 day old baby to us because it was feeding poorly, with little interest in breast-feeding. The infant weighed only 2 kilograms (4.4 pounds), was breathing shallowly and rapidly, had a weak pulse, rapid heart rate, poor cry, was jaundiced (yellow in skin coloration), had an obviously infected eye covered with swollen eyelids draining pus, and had a low body temperature. The tiny child was clearly dehydrated and hypothermic, which are often signs of sepsis (an overwhelming systemic infection). If the source of the infection was the child's eye, then a likely culprit would be the bacterium Chlamydia trachomatis, for which we did not have a rapid test available. If the baby had a Chlamydia eye infection, there was a good chance that it also had pneumonia caused by the same organism. We took a chest X-ray, which did not show a pneumonia, but that might have been because of the dehydration, which would not allow hydration of the infected lung tissue, and so prevent it from "blossoming" in appearance on the radiograph.

It was our impression that this child was in a very precarious situation. Indeed, if the visit to the Hospitalito had been delayed a few more hours, the child might have died. First and foremost, the child needed to receive life-saving fluid. Its inability to feed made it essential for us to place an intravenous catheter for fluid administration. I searched the tiny arms and didn't see anything that looked like a vein. I was fearful that we might need to perform a "cut-down," an incision through the skin to find a vein that we might cannulate, but one of the young Guatemalan technicians who performed many tasks at the Hospitalito gently caressed and patted the baby's arm, then slid a tiny catheter into a vein that none of us could see, and only he could feel. It was an awesome, and for this child lifesaving, performance.

We administered fluid, but realized that this child also needed nutrition. Another staff member suggested that she place a tiny feeding tube through the child's nose and into its stomach, through which we could push small amounts of breast milk provided by the mother. This was done, and now we could begin to give the child nourishment. Two antibiotics were given through the IV, and a third (necessary for the eye infection) was given through the feeding tube. To warm the child, we bundled it in blankets, and had the mother hold it close to her body. We had the option to transfer the child to Guatemala City, but decided that it was in too critical a condition to send on a four hour car ride without constant medical observation. It was going to survive at our Hospitalito, or not make it.

Fortunately, the child did not stop breathing. By the next morning, the infant offered small sucking gestures, and began to weakly breastfeed. It grew stronger over the next couple of days, and survived what I hope will be its closest call with death. Only time will tell what effects this episode will have on the child's development.

In America, we live in a relative haven where there is a neonatal intensive care unit around every corner. Mothers for the most part enjoy excellent prenatal care, and it is relatively rare for an infant to be in such a dire condition before it is brought to medical attention. That is not the norm in many other parts of the world, where infant morbidity and morality are much higher, and accepted as a fact of life. It is a worthy cause indeed to address the inequities that exist because of lack of education and finances, and differing social and moral values. All doctors should spend time thinking about these things.

Tags: Hospitalito Atitlan, Guatemala , wilderness medicine, outdoor medicine, healthline

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Thank You to Daily Interview for Grand Rounds

Thank you to Daily Interview for including my post about caring for an accident victim in Guatemala 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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Amputation

Amputation is detachment of a body part, such as an ear, finger, or foot. It is usually associated with a serious force or crushing injury, such as an animal bite. The immediate threats to life are bleeding and shock.

If a body part is detached, apply firm pressure to the site of the bleeding where the tissue loss has occurred. Manage any serious bleeding. Cover the wound with the cleanest available bandage, then wrap firmly. Do not attempt to reattach the detached body part. If a digit is hanging on by a small “bridge” of skin or muscle, attempt to bandage it without completing the separation.

If the body part can be easily recovered and the victim can be brought to a hospital within 6 hours of the injury, do the following:

1. Gently rinse the body part if the cut end is contaminated with dirt.

2. Wrap the body part in clean cloth or gauze and keep the covering moist. The ideal solution is saline (not ocean water, because of infection risk), if that is available; if not, fresh water will do. Do not immerse the part in a bag of water; merely keep the covering moist. Keep the body part cool by placing it on ice after wrapping it securely in a bandage, cloth, or towel. To avoid a frostbite injury, do not apply ice directly to the body part or immerse it in ice water.

3. Bring the body part with the victim to the hospital.

The application of a tourniquet to stop bleeding is essentially a decision to sacrifice the limb in order to preserve life. If any salvageable part of the limb is still attached, do not apply a tourniquet to stop bleeding until you have exhausted all pressure techniques. If the limb is completely severed and the bleeding is torrential, a tourniquet may be applied until the muscular walls of the arteries constrict and bleeding can be controlled by direct pressure. Tie a cloth or rope circumferentially an inch or two above the wound and tighten it just enough to allow direct pressure to stop the bleeding. After 5 to 10 minutes, loosen the tourniquet briefly to see if the bleeding can be controlled with pressure techniques alone.

Tags: amputation,wilderness medicine, outdoor medicine, healthline

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A Week at Hospitalito Atitlan

I’ve just completed a week working at the Hospitalito Atitlan in Santiago, Atitlan, state of Solola in the highlands of Guatemala. I decided to spend this clinical week prior to lecturing for the 3rd consecutive year at Tropical Medicine 101, a continuing medical education course for physicians interested in that topic.

In addition to serving as a doctor and seeing patients at the hospital, I was able to evaluate the experience for its value as a service and educational opportunity for the emergency medicine residents (in training) and post-residency fellows in emergency medicine at Stanford University. After having spent time working at the Hospitalito, there is no question about it – this would be a phenomenal opportunity for these highly motivated doctors.

It is difficult to express in words all of my experiences, thoughts, and emotions from the week, so I will limit my writing to expressing just a portion. Foremost, I am grateful for having had the opportunity to spend time at the hospital. Second, I was very impressed by the doctors and staff – all were dedicated, hard working, collegial, and open to both teaching and learning. Third, Guatemala is a beautiful country, and the people in the Atitlan region deserve the support of their government and whatever resources can be mustered from philanthropic efforts. Finally, there is still much to be done, so I hope to be back.

I operated under the handicap of not speaking Spanish or the local Mayan language, Tz'utujil, which is a situation that I must rectify in order to be more effective in the future. Still, I was surrounded by both Spanish-speaking and Tz'utujil-speaking physicians and assistants (technicians, nurses, nursing students, and volunteers), who assisted me with their linguistic expertise and understanding of local culture and customs.

We saw a wide variety of patients, with many different conditions, diseases, and social situations. In some circumstances, the medicine was straightforward, but in others, we were hampered by lack of specific drugs and/or equipment. As opposed to what we enjoy in the United States, there was no immediate specialist backup – no neurosurgeon, plastic surgeon, cardiologist, dermatologist, and so on and so forth. A transfer meant that the patient would need to travel by ambulance under the care of the local “bomberos,” who could not accompish anything more than transportation. The closest hospital was in Solola (a rugged, bumpy ride one hour away), but all that could be accomplished by a transfer to that facility was perhaps a more rapid trip to the operating room in the event of something like non-cardiac trauma or appendicitis. Individuals requiring hospitalization for something particularly severe, complicated, undiagnosed, or needing specialty care (e.g., a complicated pregnancy) needed to be transferred to Guatemala City, four hours away over winding roads. There is currently no capability for "routine" helicopter evacuation.

Local healers, bonesetters, midwives, and family members figure prominently in the medical culture and decision making. The patients are not necessarily accepting of the advice offered by western practitioners, although this is improving. On more than one occasion, a dozen or more people would gather to pray (loudly) outside the door to the small emergency room (literally, a room) in support of a friend or family member being treated inside.

To a patient, everyone I treated was gracious and grateful. I was never arguing, but spent a great deal of time explaining, which is something I wish I had more time to do in my U.S.-based emergency medicine practice. What was particularly rewarding was the repeated opportunities to teach and even better, to be taught. There was a lot of sharing of information, and the patients were the beneficiaries of multiple opinions.

A few patients and episodes exemplify the clinical diversity we encountered, the remarkable learning process, and how we were able to sprinkle our practice with improvisation. In a series of posts, I will describe some of these.

An enormous commotion and the squeal of automotive brakes announced the arrival of the victim of a bicycle accident. The young man was riding down a hill when his front wheel locked or he struck a large rock (I lost the details of the event in translation), throwing him over the handlebars. According to bystanders, he landed on his head and shoulder, directly onto the pavement. He had not been wearing a helmet. I ran out the door to witness him in the back of a small pickup trunk, blood oozing from the left side of his scalp, while he moaned loudly, obviously in a great deal of pain. There were a few people in the back of the pickup truck pulling at his arms to unload him, which made him scream in agony, because he had a badly broken collarbone. I reached into the back of the pickup, and with the assistance of my physician and medical student colleagues at the Hospitalito, replaced the friends and family with more knowing hands. We held his neck steady, slid him onto a gurney, and wheeled him into the small room that served as the emergency department.

The patient was yelling constantly, more so when anyone tried to move him. I am accustomed to evaluating and treating victims of trauma, more so than the Hospitalito crew in Guatemala, so I was able to tell from a rapid assessment (basically, running my hands over the victim’s body, looking at him carefully, and deciding rapidly that he did not have a major head, chest, abdomen, or long bone injury) that everything would be OK from a medical perspective, but that I sure needed to calm down both the patient, his friends, and those attending the patient. I was able to do that fairly quickly, and then completed a full head-to-toe examination of the patient, which revealed that he had a small cut and large abrasion on the side of his head, a completely broken left collarbone, and some tenderness posteriorly over the vertebrae of his neck. Since his chest was clear, abdomen nontender and soft, and I could find no other indication of a significant injury, the neck tenderness was of greatest concern. Because he had fallen and struck his head, I needed to be as certain as possible that he had not broken his neck.

Our x-ray capabilities consisted of a single portable machine, which was housed in the same area as the small laboratory, so we needed to bring the patient to that location, which meant wheeling him out of the E.R., in full view of family, friends, and bystanders. I wished to give him pain medications, but the supply of narcotics had dwindled to two doses, which needed to be reserved in the event of a caesarian section (“C-section"). Since three C-sections had been performed the previous week, and two pregnant women had recently presented with eclampsia (life-threatening elevation in blood pressure associated with pregnancy that often necessitates emergency childbirth), I could not use up the narcotics. So, I made due with an injection of a less potent pain medication and a couple of relatively weak pain pills. People in Guatemala are often very stoic, and tolerate much more pain than do people in the U.S. and other privileged countries.

The x-ray technician was the same young man who managed the small laboratory. He was always cheerful, and like everyone who worked regularly at the Hospitalito, was able to multi-task without difficulty. However, he had never before needed to take one special x-ray, an “odontoid view” of the cervical spine, in which the 1st two cervical vertebrae (“C1” and “C2”) are visualized, to be certain that there is not a “hangman’s fracture," or other injury at this spinal level, which could become catastrophic if present and the neck manipulated. His first two attempts at this x-ray were failures, because the films were “underpenetrated,” that is, much too light and blurred in appearance, so that the details of the spine could not be visualized. He worked with me to narrow the field of view exposed to radiation and to turn up the intensity of the beam, and on the third try, got it perfect. It was a moment of triumph, made all the more so by the fact that the next time I called upon him to shoot the same view on another patient, he produced a perfect image and a smile bright enough to light up the entire room.

In ordering tests, be they blood tests, x-rays, or others, it was important to remember that the cost of these tests to the patients, on a relative basis, was much greater than they would have been to you or me. For instance, the cost of an x-ray might represent three day’s pay for the patient. So, we always tried to be as cost effective as possible, so that we did not spend our patients’ money just to make ourselves feel better. It was, and should always be, about what is in the patients’ best interest, balancing safety with financial and social considerations. In the U.S., and many other countries, the risk for being sued for malpractice forces overutilization, which is something we did not encounter, thank goodness. This was a very refreshing aspect of the practice. I was overwhelmed by the grace and gratitude of the patients, staff, and doctors.

The x-rays did not reveal any broken bones in the young man’s neck, but we were easily able to appreciate his shattered collarbone on these same x-rays. Because his only areas of tenderness below his collarbone were scattered abrasions on his hands, hips, and knees, and because his chest was clear, he was breathing easily, his blood pressure and pulse were normal, and his abdomen, hips, and the remainder of his spine were without tenderness, we did not obtain additional x-rays. We were without sufficiently potent pain medication to manage him overnight, so he was transferred to a hospital in Guatemala City, via a local ambulance driven by volunteers. As is often the case, we would only receive follow-up on his clinical course after he or a family member returned home to report on his progress.

Tags: Hospitalito Atitlan, Guatemala, wilderness medicine, outdoor medicine, healthline

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Winter Issue of High Altitude Medicine & Biology

The Winter 2007 issue of High Altitude Medicine & Biology, the official publication of the International Society for Mountain Medicine, has just been published. This is an excellent journal, entirely devoted to matters associated with physiology and events at high altitude. Here is an overview of some of what one will find in the current issue:

In the lead editorial, there is comment about the fact that the International Federation of Association Football (FIFA) [soccer in the U.S.] had banned international matches at altitudes over 2500 m (8202 ft). It is hypothesized that the rationale for the ban may have been to protect some of the South American football giants, such as Argentina and Brazil, whose teams would be disadvantage if their games were played so high above sea level. Because of protests from countries, like Ecuador and Bolivia, with major cities (and teams) at high altitude, the ban was loosened a bit to allow games up to 3000 m (9842 ft) and in La Paz, Bolivia.

A paper that was the product of the Caudwell Xtreme Everest Research Group identified a specific gene configuration that appeared to have been associated with successful ascent to extreme high altitude. It is interesting to note that this particular gene configuration may also be associated with lowered mortality from acute respiratory distress syndrome and a better response to other medical situations that might in part be related to low oxygen in tissues.

Another investigation measured optic nerve sheath diameter as a surrogate for the presence of increased intracranial pressure (e.g., pressure within the skull, which suggests brain swelling, called high altitude cerebral edema [HACE]), and showed that high altitude pulmonary edema (HAPE, or fluid in the lungs) was associated with increased intracranial pressure. Although HAPE and HACE are currently felt to have different pathophysiological causes, there may be more of a relationship between the two than has previously been appreciated.

Tags: ISMM,optic nerve, soccer, wilderness medicine, outdoor medicine, healthline

Labels: Caudwell Xtreme Everest, cerebral edema, FIFA, football, HACE, high altitude cerebral edema, optic nerve, soccer

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Shock

Shock is a condition in which the blood supply (which carries oxygen and nutrients) to various organs of the body is insufficient to meet metabolic demands. The signs and symptoms are restlessness, low blood pressure, weak and rapid (thready) pulse, altered mental status (restlessness, anxiety, confusion), moist and cool (clammy) skin, rapid shallow breathing, inability to control urination and bowel movements, nausea, and profound weakness. It is a life-threatening condition and may follow a large number of inciting events. Causes of shock include severe internal or external bleeding (25 to 30% acute loss of an adult’s total blood volume, equivalent to 1.5 to 2 liters out of 6 liters), overwhelming infection, burns, dehydration, heart attack or disease, hormonal insufficiency, hypoglycemia, hypothermia, hyperthermia, allergic reaction, drug overdose, and spinal cord injury (loss of sympathetic nervous system support allows blood vessels to dilate as they lose tone).

Shock is a true emergency. Unfortunately, there is little that the rescuer can do in the field. The management of shock includes the following:

1. Position the victim on his back, with the legs elevated about 30 degrees (8 to 12 in or 20 to 30 cm), in order to encourage blood in the leg veins to return to the central circulation (heart) and head (brain) (figure 31). Do not elevate the legs if the victim has a severe head injury, difficulty breathing, a broken leg, neck or back injury, or if such a maneuver causes any pain. If the victim is short of breath because of heart failure, he may be more comfortable in the sitting position.

2. Keep the victim covered and warm. Remove him from harsh weather conditions. Remember to insulate him from below. If insufficient bundling is available, lie next to the victim to share body heat. Take special care to keep his head, neck, and hands covered.

3. Administer oxygen at a flow rate of 10 liters per minute by mask.

4. Control any obvious sources of external bleeding. Splint all broken bones.

5. If the victim is diabetic, consider a hypoglycemic reaction. If the victim is conscious and can purposefully swallow, administer Glutose paste or a sugar-sweetened liquid by mouth in small sips. Otherwise, do not give the victim anything to eat or drink unless he is alert and thirsty or hungry. If the victim is in shock because of diarrhea and dehydration, attempt to initiate oral fluid intake.

6. If the victim has been stung by an insect or appears to be suffering an allergic reaction, treat the allergic reaction.

7. Transport the victim to a hospital as rapidly as possible.

image courtesy of http://library.thinkquest.org

Tags: shock, wilderness medicine, outdoor medicine, healthline

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Migraine Headache

Migraine headache is generally more severe than an "ordinary" or tension headache. Migraine is defined as episodic attacks of headache lasting 4 to 72 hours and characterized by at least two of the following: moderate to severe intensity, one-sided pain, throbbing, and worsening with movement. In addition, there is nausea or vomiting (which may be treated with metoclopramide [Reglan] 10 mg by mouth or with ondansetron [Zofran] 4 mg oral dissolving tablet), and aversion to light or sound. Migraine headache is caused by painful dilation of small arteries in the head. Migraine headaches have many variations, which may include stuffy or runny nose and weakness of an arm or leg. Some people experience an “aura” prior to the “classic” migraine headache, in which they may smell strange odors or see flashing lights. Others develop "tunnel vision", which is diminished peripheral vision. The headaches are characterized as excruciating, pounding, or explosive. Occasionally they will respond to nonsteroidal anti-inflammatory medications ("NSAIDs"), such as ibuprofen, but migraine sufferers often require stronger pain medications and sometimes may need to be treated with narcotics.

Specific anti-migraine medications include the “triptans,” such as sumatriptan (Imitrex) and zolmitriptan (Zomig). These medications should be given as early as possible in the course of the headache to achieve maximal effectiveness. Other medicines that are effective include propranolol or metoprolol (both "beta-blockers"), amitriptyline, methysergide, flunarizine, and prochlorperazine (Compazine) given with diphenhydramine (Benadryl). Ergotamine drugs (such as dihydroergotamine mesylate [Migranal] nasal spray) directly constrict arteries; these should only be used under the direct supervision of a physician, since they may worsen the effects of certain types of migraines. If an oxygen tank is available, the victim may achieve some relief by breathing 10 liters per minute by face mask. An elderly person with a severe migraine should seek immediate medical attention, because sometimes what appears to be a migraine headache may actually be a stroke.

A migraine headache may be precipitated by lack of sleep, high altitude, emotional stress, cyclical hormone changes, noxious odors, and certain ingested substances (such as caffeine and monosodium glutamate). Therefore, the migraine sufferer should seek to obtain regular sleep (go to bed and wake up at the same times every day), rest, and meals (do not skip or delay); limit caffeine consumption to the equivalent of two cups or coffee or two 12-ounce sodas per day; avoid tobacco products; avoid known personal triggers (e.g., red wine); practice relaxation techniques; and strive to maintain fitness through regular exercise and dietary discretion.

molecular diagram of sumatriptan courtesy of www.3dchem.com

Tags: headache, migraine headache, wilderness medicine, outdoor medicine, healthline

Labels: headache, migraine, migraine headache

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