Tick Attachment Sites

The first issue of Volume 19 of the journal Wilderness & Environmental Medicine has just been published. It contains some very interesting information, some of which I will share with you in this and another post.

In an article entitled "Tick Attachment Sites," Abdulkadir Gunduz and his colleagues looked at the location of attached ticks in 67 patients who presented to their emergency department with a history of tick bites. They noted that 20% of the ticks were attached to regions of the body that patients could not themselves visualize. Since it is important to remove attached ticks before they become embedded, and as soon as possible to minimize the transfer of infectious agents or toxic (salivary) fluids, this highlights the need for a full body inspection of any person who has recently traveled in endemic (for ticks) country.

In Turkey, there is concern for transmission of fatal cases of Crimean-Congo hemorrhagic fever from the tick genus Hyalomma, while in the U.S., we are more familiar with the genera Amblyoma, Dermacentor, and Ixodes, and the disorders of Lyme disease, Rocky Mountain spotted fever, ehrlichiosis, and tick paralysis.

In this particular study, the most common tick attachment sites were the lower limbs, follwed by the lower abdomen and genital region, then the back (at the level of the chest), and the buttocks. Given that most people would not be able to spot a tick, which may be very tiny if in a juvenile form, in some of these (and other) locations, it is prudent if traveling through tick country to have someone you trust perform a "tick check," or use a mirror if one is available. If a tick appears to be attached and cannot be removed by the human host in its entirely, then he or she should get assistance for its removal.

photo of tick courtesy of www.lymediseaseaction.org.uk

Preview the 25th Anniversary & Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 25-30, 2008.

Tags: tick attachment, tick, wilderness medicine, outdoor medicine, healthline

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Hospitalito Atitlan 5

Towards the end of my week at the Hospitalito, one of the staff members asked me to speak with the parents of a teenager who had suffered an electrical injury in the past few days. The young boy had climbed onto a roof in pursuit of a kicked soccer ball. The young man was sweating, and he recalled wearing a wet tee-shirt. The ball had come to rest near the business end of a power-supplying transformer. The boy’s head came sufficiently close to the transformer to cause it to discharge an arc directly onto the top of his head. The youth was rendered immediately unconscious and thrown by the force of the current. He remembered climbing up onto the roof and waking up in an ambulance, but nothing in between. The errant power discharge tripped the breakers, or he might have been killed.

Although it was his misfortune to have been struck by the electricity, he was incredibly lucky with respect to his landing spot. The perimeter of the roof was ringed by a raised concrete edge with embedded chunks of sharp glass, placed to deter intruders. There were only a few small sections of the edge without glass, and he landed face down in one of them, or he might have been impaled and shredded. His friends called for help and he was rushed to emergency care, from where he was transferred to a hospital. According to his parents’ report, he was managed very well, as the doctors considered injuries to his brain, bones and muscles, kidneys, and heart. Again, luck prevailed, as his only serious injuries appeared to be burns.

The burn pattern was a hybrid between what one would expect to see with a lightning strike and an industrial injury. That is, the electricity entered via the top of his head, appeared to flash over his body, and exited via his legs. He suffered first and second degree burns on his scalp, across his chest, and down the front and back of his legs. The current followed what was probably the pattern of superficial moisture on his body. However, they did not have the typical “ferning” or “punctuate (flower-like)” configuration of a lightning strike, but appeared more like scald burns. So, he suffered a “flashover phenomenon,” but with a lesser voltage than would have been incurred by a lightning strike. He also did not suffer other common sequelae of a lightning strike, such as ruptured eardrums, visual changes, or significant amnesia.

I examined this very nice young man a few days after he left the hospital. The burns on his body were doing nicely, except for some deeper second degree burns on the backs of his legs. These needed to be treated more aggressively with topical moisturizing cream to decrease dessication and increase pliability, and to allow the initiation of physical therapy (gradual stretching) to prevent his muscles from forming contractures. Both the youth and his father were very gracious, and gave me permission to take photographs for the purposes of this description and teaching. In a few weeks, I fully expect his soccer career to resume.

Preview the 25th Anniversary & Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 25-30, 2008.

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

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Thank You to monash medical student for Grand Rounds

Thank you to monash medical student for including my post about the upcoming 25th Anniversary & Annual Meeting of the Wilderness Medical Society in 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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Picaridin-Based Insect Repellent

There is a plethora of insect repellents on the market. Many of the newer repellents are intended to replace DEET (N,N diethyl-m-toluamide), which is an excellent and reliable repellent, but which carries a distinctive odor, can dissolve certain fabrics, and has been associated with rare reports of toxicity when used in high concentrations. Newer insect repellent choices include picaridin, which is advertised to be odorless, nontoxic, and non-injurious to clothing and tents. Wanting to give it a try, I carried a bottle of Cutter Advanced Insect Repellent (With Picaridin!) on a fishing trip this past summer to British Columbia. The main component in this product is picaridin 7%.

In previous years, I have relied upon DEET, namely, DEET PLUS Composite Insect Repellent Lotion from Sawyer Products, which contains as its main component 17.5% DEET, and which has always been very effective. I have been using this product for years, because I continue to replenish my first aid kid from a supply I obtained nearly a decade ago. Despite this period of time, the repellent continues to perform very well and with no apparent decrease in its effectiveness.

The Cutter Advanced Insect Repellent with picaridin was easy to apply and, as advertised, was colorless and odorless. However, in my subjective, one-person observation, it wasn't as effective against the mosquitoes at our camp as was DEET. I took care to carefully apply the picaridin-containing spray to the exposed skin on my forearms, hands, face, neck, and legs, but found that I continued to be bitten by mosquitoes. The spray worked to a certain degree, as I did receive as many bites as I suffered without using the spray, but on many occasions, I needed to add the DEET Plus lotion in order to keep the mosquitoes off my skin. Furthermore, when I used DEET Plus alone instead of the picaridin spray, the former seemed to be much more effective.

Does this mean that there is no role for picaridin? Not at all. It certainly lessened the number of mosquito bites, and it is true that it is easy to apply and sports the physical characteristics as advertised. However, I have heard from a few others that their experience with picaridin has been the same, namely, that it seems to be less effective when the mosquitoes are plentiful and/or voracious, and that if an application is not perfect (e.g., a patch of skin is not treated), the mosquitoes are not repelled by picaridin in the vicinity (e.g., on treated skin) to the same degree that they might be if DEET had been used.

My recommendation at this time is that picaridin has a place as a mosquito repellent, but the user should be aware that if there is a serious concern about mosquito bites (e.g., with transmission of disease, such as West Nile virus or malaria), one should still be utilizing a DEET-containing product, use mosquito netting, pre-treat clothing with permethrin, and so forth.

PLEASE remember to preview the 25th Anniversary & Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 25-30, 2008.

Tags: insect repellent,picaridin, DEET, mosquito, insect bite, wilderness medicine, outdoor medicine, healthline

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25th Anniversary & Annual Meeting of the Wilderness Medical Society

It is a great pleasure to announce the 25th Anniversary and Annual Meeting of the Wilderness Medical Society. It's hard to believe that it has been 25 years since I collaborated with Ed Geehr, M.D. and Ken Kizer, M.D. to create the WMS. "Combining Your Profession With Your Passion" has been the theme since the beginning, and the meeting this summer is no exception. You can register and learn more about the meeting at the WMS website, specifically at the link to the meeting.

The meeting will be held in Snowmass, Colorado, and will feature up to 49.5 continuing medical education (CME) and 46.25 Fellowship of the Academy of Wilderness Medicine (FAWM) credit hours for participants, including lectures, skills instruction, 49 different workshops, special evening presentations, and a WMS 25th anniversary gala celebration. The Wilderness Medicine Skills Practicum will be presented by the Wilderness Medicine Institute (WMI) of the National Outdoor Leadership School (NOLS), and Military Medicine Lessons: Applications in a Wilderness Environment will be another, additional special pre-conference session.

The evening events are outstanding, and include "The Arctic National Wildlife Refuge" featuring National Geographic Society grantee Jonathan Waterman, "What's Your Everest? - Combining Your Profession with Your Passion" featuring Dr. Luanne Freer, "Public and Global Health Issues in 2008: A Surgeon General's Perspective" featuring Richard H. Carmona, M.D., the 17th Surgeon General of the United States, and the WMS 25th Anniversary Celebration with reception, silent auction, dinner and awards, and the first-ever "Wilderness Ball."

The faculty for the meeting is a "Who's Who" of wilderness medicine, including Howard Backer, Brad Bennett, Jolie Bookspan, Michael Callahan,Tom DeLoughery, Lance Ferguson, Peter Hackett, Gordon Giesbrecht, Colin Grissom, Eric Johnson, Lee Kaplan, Peter Kummerfeldt, Jay Lemery, Mel Otten, Phil Rasori, Brownie Schoene, Joe Serra, Chris Van Tilburg, and many others.

Please make plans to join us as we celebrate the 25th anniversary of the WMS with one of the year's outstanding meetings. I look forward to seeing many of you in Snowmass.

Tags: Wilderness Medical Society, WMS, wilderness medicine, outdoor medicine, healthline

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Thank You to Polite Dissent for Grand Rounds

Thank you to Polite Dissent for including my post about providing pain management in suboptimal settings in 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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Pain Management in Difficult Situations

A reader writes: "I just came back from an elective in Nepal in orthopedics. A lot of what you describe (about Guatemala) sounds eerily familiar... especially what you mentioned about pain management. If the situation in Guatamela is anything like it was in Nepal, I think it's not that they're more stoic there... they tolerate the pain because there is no choice. And I think that tolerate is probably the wrong word... I'm sure it has the same negative effects on a patient there as it would here. In Nepal, we didn't always have anesthesiologists or a GP with us, and ortho surgeons are not allowed to administer procedural sedation. Strictly speaking, they're not supposed to do bier blocks or nerve blocks either. Which meant that we ended up doing a lot of closed reductions without any anesthetic. I can't imagine how the patients felt, but I have to say that I was just horrified. I wonder if you had similar feelings, and if so, how did you deal with them?"

Whenever a health care provider doesn’t have the equipment or drugs needed to optimally manage a patient, he or she must make due with what is available. Sometimes this means that you can manage the problem fully, but sometimes it is only possible to achieve a less-than-desired result. I am a bit surprised that the orthopedic surgeons were not allowed to administer local or regional anesthesia, because they are usually trained to do so. In any event, if no one was available to provide significant pain management, then one would have to decide how best to proceed – allow the victim to endure the persistent pain and possible adverse outcome of a nonreduced fracture, or proceed with a painful intervention and know that as soon as the bones were properly aligned, the pain would rapidly diminish. I have been in that situation many times, most often on the athletic field, where a quick reduction (usually of a dislocation) is momentarily painful, but solves the situation.

There are other techniques that sometimes diminish pain for the victim. Ice packs properly applied make a difference, as can emotional distraction. Still, without “real” pain medicine, moving a broken bone really hurts. I’ve been there myself with a fracture-dislocation of my ankle, and the narcotic injection was most appreciated.

When I wrote that the patients were more stoic, I did not mean to imply that they didn’t feel the pain. Many of these persons do not have easy access to medical care or the copious number of pharmaceuticals (including pain medication) that we expect in the U.S. So, they are indeed more stoic, complain less, and are more accepting of a delay to therapy and relief than are most persons in our culture. Given their attitude, the pressure is even greater on the providers to work diligently to make these patients more comfortable, because they may not be fully expressing their true needs.

How do I feel when I’m caring for someone and I can’t do everything I would like to do? If I think the outcome will be acceptable, I live with it. If things are going poorly, I get frustrated, unhappy, and sometimes angry (at the situation, or even myself, for not being able to improve the situation). But I always do my best to hide any negative emotions from the patient, family, bystanders, and other health care providers. Much of the time when I practice medicine, I am in charge, and if I “lose it,” nobody benefits.

Tags: Guatemala, pain, wilderness medicine, outdoor medicine, healthline

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Question About a Bee Sting

A reader writes: "I was stung by bee on the palm of my hand and forefinger 6 weeks ago. My palm remains inflamed and swollen, which worsens as the day progresses; all joints remain tender. I have a small pebble-like knot under the skin approx 1/4" to 1/2" from where I was stung. I have been to 6 different doctors without receiving much explanation. I recently saw a hand specialist who diagnosed "trigger finger" brought on by the bee sting. Anyone ever heard of this? Is it possible that the tip of the stinger remained inside and migrated a bit from the sting site? Could the hard place be tissue forming around the stinger that may have remained inside? An E.R. nurse practitioner says it is possible that the stinger remains inside, however, my treating doctor says no way possible."

There are a number of possibilities here, related to the pathophysiology of a bee sting. Depending on the species of bee, part or all of the stinger may have been present in the wound immediately after the sting. For instance, a honeybee often leaves the stinger and attached venom sac in the wound. Sometimes the stinger is easily visible, revealed as a tiny dark splinter or speck. Other times, it is impossible to see without magnification. So, unless the sting site was very carefully inspected under magnification and no stinger seen, something may have remained in the wound. This is not usually the case, but it happens.

Bee venom contains a number of components that cause pain, redness, and swelling, all of which can be part of the initial toxic envenomation and subsequent inflammatory response. Depending upon how close the sting was to a tendon (and its sheath, within which it slides), it could have caused tenosynovitis, which could cause persistent pain on motion, and ultimately lead to some contraction of the finger, which might be diagnosed as a “trigger finger.”

The formation of a knot might represent inflammatory tissue solidifying into a scar around the initial puncture wound, which would be more likely if there was a residual “foreign body.” The remaining material doesn’t need to be a huge piece – even a microscopic speck is enough to fuel the process. The material under the skin would not migrate to a different location, unless it was within an open tract, which is highly unlikely. So, is it possible that a fragment of the stinger is still within the tissue? The answer is yes. It might be visible using an enhanced ultrasound technique, so that might be worth a try.

Tags: bee, bee sting, wilderness medicine, outdoor medicine, healthline

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Thank You to Canadian Medicine for Grand Rounds

Thank you to Canadian Medicine for including my post about caring for a patient in Guatemala with a lip lesion 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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Hospitalito Atitlan 4

In a clinical setting such as that at the Hospitalito Atitlan, one is often required to participate in activities that would be referred to a specialist in a better resourced environment. We had the option to send patients on a two hour drive to a general surgeon, or a few hours away to obtain a CT scan, or four hours to Guatemala City hospitals, but there was no easy access to the diversity
of specialty referrals available here in the U.S. To see a dermatologist, rheumatologist, neurologist, etc. might mean months of delay and certainly, expenses beyond the means of most of the patients who came to the Hospitalito seeking care and advice. So, the medical practitioners at the Hospitalito continue to try as best possible to deal with problems locally, develop a culture of health awareness, and establish continuity with their patients. This is often not easy in a situation where the advice of a elder relative might carry as much or more weight than that of a trained physician, or the patient is simultaneously under the care of a traditional healer with a differing approach to solving the problem. Sometimes the Hospitalito represented the place to go after other prolonged attempts to remedy a situation had failed. This sometimes contributed to a condition or disease being in an advanced state upon presentation to the medical staff at the Hospitalito. Chronic hip pain might be a femur fracture of many years’ duration allowed to heal without intervention, and shortness of breath be lung cancer or complication of end-stage kidney failure. In those situations, comfort care was all that could be offered.

Other times, interventions could be made, and the outcomes beneficial and quite acceptable. One cheerful gentleman visited us because of a growth upon his lip. He didn’t remember any trauma or incident that initiated the growth, but it was continuing to enlarge and bothering him a great deal, particularly when he ate and drank. He was hopeful that we could fix the problem for him.

The lesion bled at slight touch, and seemed to be a bit crumbly in consistency, with the appearance of a pyogenic granuloma, which is a benign (noncancerous) growth that is well endowed with very tiny blood vessels – hence the bleeding. They often erode internally (to the lesion) – hence the consistency – but rarely invade surrounding tissue. Sometimes they become infected, but don’t seem to be caused by infections. A treatment often deployed in the U.S. is obliteration using a pulsed dye laser, but of course, that was not an option for us. So, we elected to go with the tried and true method of excision and then cauterization of the base, to eliminate any remnants of granulomatous tissue in the base from which might spring a recurrence.

We explained what we wished to do for our patient and he consented to the minor surgery. After taking him to our small operating room, we cleaned the granula and surrounding skin carefully with povidone-iodine disinfectant, then used a small injection of numbing medicine into his lip. We discovered a small string tied around the granuloma, which was an attempt by someone to remove the lesion by strangulating it at its base. While this was not a therapy that would be successful, it didn’t worsen the situation, and actually gave us a tag that we could use to apply traction to the lesion as we excised it from underneath. We sharply dissected the granuloma from his lip, and put it in a container to be sent off for a definitive pathologic examination, to be certain that it was what we thought it to be, and not a skin cancer. After the granuloma was removed, we cauterized the (bleeding) base to its margins, and applied a sterile dressing. If we were successful in zapping all the culprit tissue, the growth will not recur, the scar will be tiny, and the problem solved.

photo of Hospitalito Atitlan courtesy of Jennifer Jaggi

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

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Hitting Your Head

A reader writes: "Can you tell me what type of head injuries you can have if you were standing, then fell and hit the side of your head on a table on the way to the floor?

I have dizziness and when I look down to get something out of my pocket, for example, I get very dizzy and it is a lot harder for me to write this because my hands are weak. Can you tell me what you think I have?"

With the usual caveat that I am not trying to practice medicine over the Internet without the benefit of a full history and physical examination, this question is important, both for persons indoors and outdoors, because falls occur in all settings. First, one must ask if the victim was knocked unconscious during the event, in which case the diagnosis of concussion must be considered. Second, whenever someone strikes his or her head, the rescuer must assume that there may also be a neck injury. I would be particularly worried about that possibility in this circumstance, given the report of weakness in the hands, which might represent a spinal cord or nerve root injury, along with a possible bony spine or ligamentous injury.

The dizziness presents another set of possibilities, including concussion, contused (bruised) brain, blood clot within or outside the surface of the brain, and/or skull fracture. The dizziness and other symptoms might also be due to something entirely unrelated to the fall.

So, my advice is for this correspondent to be thoroughly evaluated by a physician trained to recognize the problems associated with head, spine, and nerve root injuries possibly associated with a fall.

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

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Thank You to ChronicBabe for Grand Rounds

Thank you to Jenni Prokopy of ChronicBabe for including my post about caring for a patient 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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Hospitalito Atitlan 3

The man appeared at the entrance to the emergency room (literally, a small room) at the Hospitalito after having been delivered in a tuk-tuk (pronounced “took took”), a three wheeled taxi popular in many of the small villages surrounding Lake Atitlan. These small conveyances were usually driven by teenagers, and sometimes piloted by children as young as 8 years of age, so on more than one occasion, I nearly got picked off walking the streets on my way home from the hospital at the end of the day, particularly during the busy evening hours.

Instead of arriving at the hospital by ambulance, with his neck immobilized in a restraining, protective cervical spine collar, oxygen administered through a facemask or nasal prongs, and an intravenous catheter in place through which to provide fluid and pain medications, this man was a passenger in a little cramped vehicle powered by the same sort of engine one would find in a riding lawn mower. He had fallen off a roof approximately 15 feet straight onto his head. He was obviously in agony, complaining of pain in his neck and back. He was also having difficulty breathing, his chest hurt, and he was dizzy.

The man couldn’t recall the moment of impact when he had struck the ground or if he had been knocked unconscious, but he was making sense at the moment, which was important, since there was no CT (computed tomography) scan to image his brain. A physical exam showed that he could move, and had normal sensation and reflexes, in both arms and legs, which was good given that he had severe neck pain and a mechanism of injury from which he could have easily broken his neck. When I listened to his chest with my stethoscope, it seemed like he had diminished breath sounds on the right side, which might be indicative of a collapsed lung. I examined his chest and felt along every rib. He wasn’t tender on his chest wall, but he was hurting badly in his mid-back, and complained about tenderness when I felt his spine in his mid-thoracic region. So now, in addition to a possible concussion and broken neck, and perhaps a collapsed lung, I was worried about a spinal fracture. His abdomen (“belly”), pelvis, and legs looked to be OK.

With our limited x-ray capabilities, we settled for a chest x-ray, three views of his cervical spine (neck), and two views of his thoracic spine. The chest film showed that his diaphragm was elevated on the right side, so his lung volume was possibly diminished, but there were lung markings all the way out to the periphery of his chest. If he had a collapsed lung, it was a small collapse. I didn’t see any obvious broken ribs. The neck films were terrific, and the technician shot a perfect odontoid view, a direct result of his success learning the technique earlier in the week. I was very concerned to see that three cervical vertebrae might be compressed. It was impossible to tell if this was a new finding (e.g., because of the fall) or “old” degenerative change, so we kept him in the cervical collar that we had placed when we first examined him. With administered oxygen, his oxygen saturation was acceptable, so there was no rush to pursue a collapsed lung or need to place a chest tube. The lateral x-ray of his spine showed a probable compression fracture of one of his vertebrae, which accounted for his pain. The film was a bit underexposed, so it was difficult for me to interpret, until the technician showed me his method for viewing such an x-ray without having to shoot another. He rolled up the paper x-ray jacket in which the film was destined to be stored, and we examined the film through the tube, which eliminated all ambient light and highlighted the details. With a much better look at the film, if fortunately looked to be a “stable” injury, but a broken bone in a man’s back really hurts.

With an adequate supply of pain medications, the ability to do the necessary CT scans to delineate the nature of the possible cervical spine and definite thoracic spine injuries, and further imaging and close observation for the possible collapsed lung, we might have been able to keep this patient, but these modalities were not available to us in Santiago. So we packaged him as best possible, and sent him to a more fully equipped facility in Guatemala City, where he could receive a further evaluation and the ongoing care that he deserved.

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

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