Lifeguard Situation in California

Here's a recent communication that originated with the Orange County (California) Register:

Wednesday, April 9, 2008
State lifeguard funding gets a reprieve. Public safety mandates staffing.
By FRED SWEGLES
The Orange County Register

Lifeguard service at area state beaches will be as robust as in years
past this spring and summer – but after Labor Day, all bets are off.

That's the message from Rich Hayden, acting sector superintendent for
San Clemente, Doheny and San Onofre State Beaches. The move follows a
Register news article that reported a warning from Hayden's
colleague, Steve Long, about dangerously low levels of lifeguard
staffing due to budget constraints.

"Steve Long's (warnings) in the Sun Post News and the Register did
set off some seismic shock waves up in Sacramento, as you might
imagine," Hayden told San Clemente parks commissioners Tuesday
night. "Action at the Sacramento level was very swift. Monies were
freed up and sent down to our district. We got some money that made
us whole, meaning that from now until the end of the fiscal year on
June 30 there will be no change in the state lifeguard service."

This applies to the entire South Coast District – San Onofre, San
Clemente, Doheny, Crystal Cove, Huntington Beach and Bolsa Chica
State Beaches, said Rich Rozzelle, district director.

"We are moving monies around from one pot to the other to put
lifeguards on the beach and maintain a level of service for public
safety," Hayden said.

He said the plan is to extend traditional levels of service through
the summer, although uncertainties surround a new state budget that
is due July 1. That budget may not be adopted until the fall, Hayden
said.

"Once we get a signed budget, I don't know … if it does come up that
we take a (forecasted) 50-percent cut." Hayden said. He spends 60
percent of his budget for seasonal lifeguards in July and August so
there would be consequences. "I'm going to have to find that money
someplace or ask for forgiveness at the end of the fiscal year.
That's the stark reality of it," he told the city.

City officials had voiced concerns and invited Hayden to appear
before the commission to discuss state lifeguarding scenarios
affecting San Clemente.

"State parks has gotten to a point where we're at critical mass,"
Hayden said. "We cannot take any more cuts."

He said the current park entry fees – $10 per car – are about as high
as users can take.

Parks commissioners voted 6-0 to encourage area residents to write
Gov. Schwarzenegger and state lawmakers to protest lifeguard cuts in
the new budget. Commissioners also asked San Clemente's city staff to
work closely with state parks to ensure there is ample protection on
state beaches bordering the city's beaches.

Residents can send e-mails to governor@governor.ca.gov

Contact the writer: fswegles@ocregister.com or 949-492-5127

Outdoor health and safety concerns are not immune from economic conditions. The public's opportunity to be kept safe requires money and manpower. Lifeguards, park rangers, road warning crews, firefighters, outdoor educators, and every other position imaginable require robust budgets and infrastructure, and in our current declining economy become vulnerable to fiscal constraints. As we can learn from the report above, advocates for safety are now required to be vocal up to the point of political lobbying, because it may no longer be safe to presume that health and safety will take priority over competing programs.

There are solutions to cut-backs, such as shifting resources and volunteers, but these may only be stop-gap and insufficient to replace the original services. It will be tragic to witness the curtailing of essential safety programs leading to increased injuries or even deaths. Of course, we all understand the hard choices presented by insufficient funding and that recreational safety may not be able to compete with other very appropriate public health initiatives, such as immunization programs.

So, given that we know that times may become tough, and that the definition of discretionary (e.g., non-essential) spending may be expanded, we should be prepared to make the case for our causes, and be prepared to find solutions should resources become limited. Safety and injury prevention in a problematic economy should be everyone's concern, beginning right now.

image of lifeguard courtesy of FreeFoto.com

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

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Thank You to Doc Gurley for Grand Rounds

Thank you to Doc Gurley for including my review of Sharkwater 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. Doc Gurley has certainly accomplished that feat in an entertaining and novel way this week! As a high school wrestling coach, I like his style...

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Sharkwater

The oceans are our greatest wilderness. On a recent trip to Hawaii, I was in an aquatic mood and watched the recently-released DVD entitled "Sharkwater." It is a very fine production that should be watched by every person interested in marine conservation, because it describes eloquently what is happening to one of the most important species on our planet.

The story line revolves around Rob Stewart's personal interest in sharks, beginning with a brief explanation of his interest in diving and underwater photography, and culminating in his current devotion to conservation and cinematography. The tale is fascinating, and will serve a great purpose in heightening awareness of the plight of sharks worldwide.

To being, I quote from the extensive website devoted to this production, education, and shark conservation:

"For filmmaker Rob Stewart, exploring sharks began as an underwater adventure. What it turned into was a beautiful and dangerous life journey into the balance of life on Earth.

Driven by passion fed from a lifelong fascination with sharks, Stewart debunks historical stereotypes and media depictions of sharks as bloodthirsty, man-eating monsters and reveals the reality of sharks as pillars in the evolution of the seas.


Filmed in visually stunning, high definition video, Sharkwater takes you into the most shark rich waters of the world, exposing the exploitation and corruption surrounding the world's shark populations in the marine reserves of Cocos Island, Costa Rica and the Galapagos Islands, Ecuador.

In an effort to protect sharks, Stewart teams up with renegade conservationist Paul Watson of the Sea Shepherd Conservation Society. Their unbelievable adventure together starts with a battle between the Sea Shepherd and shark poachers in Guatemala, resulting in pirate boat rammings, gunboat chases, mafia espionage, corrupt court systems and attempted murder charges, forcing them to flee for their lives.

Through it all, Stewart discovers these magnificent creatures have gone from predator to prey, and how despite surviving the earth's history of mass extinctions, they could easily be wiped out within a few years due to human greed."

Again, from the website, here are the listed awards already garnered by this movie:

Canada's Top TenToronto International Film Festival
People's Choice Atlantic International Film Festival
People's Choice Ft. Lauderdale International Film Festival
Best Documentary Ft. Lauderdale International Film Festival
Spirit of Independents AwardFt. Lauderdale International Film Festival
Special Jury Award Hawaii International Film Festival
Best Musical Composition France World Festival of Underwater Pictures
Prix Planete Thalassa France World Festival of Underwater Pictures
Best of the Festival Palm Springs International Film Festival
Best International Doc Beverly Hills Hi-Def Festival
Best HD Feature AFI Dallas International Film Festival
Audience Choice Award for Best FeatureGen Art Film Festival
Grand Jury Award for Best FeatureGen Art Film Festival
Peter Benchley Shark Conservation Award Shark Research Institute
Special Jury Award15 Short Film Festival – Charlotte, NC
Must-See Award (Category: Wake-Up Films)Telluride Mountain Film Festival
Hero of Conservation – Water Category Conservation for the Oceans Foundation
Top Ten Films Cambridge Film Festival
Jameson Audience Award for Best International Documentary Encounters South African Int’l Doc. Festival
Best Documentary Film - Nominee Critics Choice Awards
Animal Action Award International Fund for Animal Welfare
Best Documentary Directors Guild of Canada
Best Of The Festival Santa Barbara Ocean Film Festival
Best Sound - Nominee Golden Reel Awards
Best Documentary - Nominee Genie Awards
Best Environmental Film of 2008 National Ocean Film Festival Alliance

The story line in this DVD is compelling, and can be distilled down to two major concepts. First, indiscriminate and/or illegal fishing is devastating marine fish populations. Second, the harvesting of sharks solely for the purpose of finning to enable production of shark fin soup is an overwhelming destructive force in the animal kingdom. Upon these two insights, Stewart drapes the remainder of the video.

There are two moving statistics printed in black and white at the conclusion of the DVD. In the 89 minutes that it takes to view the production, fifteen thousand sharks are killed. Ninety percent of the world's shark population has been depleted by man, and the remainder is at risk. What will it take for us to stop the slaughter?

The video is punctuated by moments of great storytelling, mostly surrounding the high seas adventure organized by Paul Shepherd, who is a renowned warrior in the world of environmentalism. The exposure of an international consortium designed to decimate the world's shark population in order to serve unnecessary soup for profit is disturbing to the maximum.

There are a few moments in the DVD that seem out of place, and noncontributory to the major premise. A good example is the digression describing Shepherd's affliction with "flesh eating disease." The reenactment of his hospital stay is unrealistic and amateurish filmmaking, so I wish it had not been included. Fortunately, it is possible to overlook this awkward moment and focus upon much more important aspects of Sharkwater.


If the collective mentality of the fishing industry, governments, and regulatory agencies allows marine species slaughter on the scale portrayed in Sharkwater, we will see wholesale extinction of sharks and other marine animals in the next century, and perhaps in our lifetime. I'm afraid that similar situations exist with hundreds of species in the oceans and on land, and that there will soon be an entire library of film productions devoted to life as we knew it, rather than as we should know it. Watch Sharkwater soon, and see for yourself.

image of shark fins courtesy of www.sharktrust.org


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

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More Bee Story

Jeremy Joslin, MD has left a new comment on your post "Question About a Bee Sting":

"Thanks for posting this very interesting case. Your blog really helps me learn through cases that I don't ordinarily see.

Dr. Auerbach, do you think this could be a Type 4 hypersensitivity reaction alone which is causing the drawn-out symptoms? Like you said, the inflammatory mediators alone could be causing all of these symptoms simply by mere proximity to all the fine hand structures.

While special ultrasonography would be a useful first line modality, if it's not available do you think MRI would be able to define the "knot" and give a hint as to which soft-tissue structure it is associated with?

To me it doesn't seem very likely that such a minute penetration of the skin could violate the nerve sheath."

These are terrific questions. It is possible that this might be a prolonged hypersensitivity reaction, but I have not been made aware of a type 4 hypersensitivity reaction associated with a bee sting. I have, however, seen a reaction that was quite similar to serum sickness associated with multiple stings afflicting a single victim.

Magnetic resonance imaging (MRI) might be useful to define a foreign body, but I am not aware of its use for a bee stinger. The stinger would have to have penetrated quite deeply to warrant this modality, and in my experience, a retained stinger leaves a trailing end at the surface.

Violating a "nerve sheath" would not be the problem here, but rather a "reactive" inflammatory response affecting the nerve or a tendon sheath. It is not uncommon to have the introduction of an animal or plant toxin in the vicinity of a tendon, and to have it become inflamed.

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

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Thank You to Dr. Val and The Voice of Reason for Grand Rounds

Thank you to Dr. Val Jones of Dr. Val and The Voice of Reason for including my post about blisters 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. Dr. Jones has done a superb job, which is very much appreciated.

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Blisters

Blisters are the bane of hikers. These clear fluid- or blood-filled vesicles have probably ended more outings than all major illnesses combined. They can be prevented by keeping feet dry, wearing adequate and properly fitting socks, wearing thin liner socks (polypropylene or polyester) under heavier wool-blend hiking socks, breaking in footgear prior to the expedition, and padding all rough edges within hiking boots. If an area is known to rub, prevent a blister by applying a nonwrinkled layer of moleskin, Molefoam, or athletic tape over the skin before a “hot spot” develops. A terrific method to prevent a potential hot spot (e.g., area that will be rubbed, such as one's heel within a boot) or cover a non-blistered (prior to the appearance of a blister) hot spot is the Blist-O-Ban "bandage" from SAM Medical Products.

If a blister is caused by pressure (ill-fitting boots), you have a couple of choices. As mentioned above, prior to actual blister formation, you can protect or pad the area. Once a blister forms, the blister site can be padded with moleskin or other adhesive foam, so that rubbing no longer occurs, the blister should be ringed with a doughnut of padding and left intact. For a better cushion, a piece of Spenco 2nd Skin (an inert gel consisting of polyethylene oxide and water) can be laid into the doughnut hole and the entire area covered with a second layer of moleskin or an absorbent bandage, such as a Spenco adhesive knit bandage. If no such padding is available, if continued rubbing will rupture the blister, or if the blister interferes with walking, then you can drain it of fluid by using a “sterile” needle (heat a sewing needle to red hot and allow it to cool) to punch a small hole at its edge. If an antiseptic ointment, such as mupirocin or bacitracin, is available, it should be applied to the open wound underneath a sterile (or clean, if "sterile" is not available) dressing or bandage. If the blister appears infected, it should be unroofed entirely, an appropriate dressing and ointment applied, and the victim treated with dicloxacillin, erythromycin, or cephalexin for 5 days or until the skin appears normal. If the dressing (such as Curad Hydro Heal) keeps the blister slightly moist, it may be less prone to drying out and cracking.

Blisters or reddened skin may also be caused by an allergic (“contact”) reaction to chemicals such as formaldehyde or rubber. If a rash is confined to the soles of the feet (shoe inserts) or top of the feet (shoe tongue dye), suspect this problem. In this case, the footgear must be changed.

If a blister is caused by a thermal burn, it should be immediately immersed in cool or cold water (do not apply ice directly to the burn) for 10 to 15 minutes, in order to relieve pain and lessen the ultimate injury. Then dry the wound and apply a soft, sterile dressing. Unless there is a reason to suspect infection (cloudy fluid or pus, fever, redness and swelling beyond the blister edges, swollen lymph glands), burn blisters should be left intact. Opening an uninfected blister or sticking a needle into it risks introducing bacteria that can cause an infection. A topical antibacterial cream, such as silver sulfadiazine or mupirocin, or ointment such as mupirocin or bacitracin, should be applied if the blister is broken, or to prevent the dressing from sticking to the wound. Alternatively, apply a layer of Spenco 2nd Skin or Aquaphor gauze underneath a sterile gauze dressing.

photo of reddened foot courtesy of www.planet-x-bikes.com

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

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Jellyfish Question

A reader writes (paraphrased by me): “Here in Corpus Christi, today, while surfing, I practically picked up a large man-o-war while surfing. The burn is intense as I write. I felt severe pain immediately. I panicked in the water. The tentacles clung on to me. I felt pressure on my heart and my feet began to itch. It was a long trip for a remedy, but I finally rinsed the burning skin with vinegar, but I think this made the pain worse as I began to have more pain in my joints and chest. I have been hit by a man-o-war before but never like this. I have been taking Tylenol to help with the pain.”

The victim’s experience invokes many of the nuances of jellyfish sting syndromes. First, the pain is typically described as burning, and begins immediately after the tentacles with their microscopic stinging cells make contact with the skin. When the tentacles wrap around the wrist and/or hand, the pain can be sufficient to cause muscle spasm, so that the ability to grip an object is lost. The “pressure in the heart” described by the victim might have been chest discomfort from the toxin, the cause of which is poorly understood. If the victim was in the age category for coronary artery disease, angina may have been invoked, which would be quite worrisome. It is possible to have a heart attack precipitated by a jellyfish sting, but this is quite rare. Itching in the feet makes one think about an allergic reaction, which is certainly possible after a jellyfish sting.

The victim reports that when he rinsed his skin with vinegar, he continued to suffer pains in his chest and joints. The vinegar would only be expected to diminish the skin pain, if it is effective at all, but not to have an effect on any systemic manifestation of the envenomation. So, if any venom that had entered the victim’s circulation was causing chest pain, joint pain, or any other symptom, topical vinegar would not be expected to have an beneficial impact on those particular problems.

From the description, this sounds like a significant, severe envenomation. Jellyfish stings are not to be taken lightly. I wouldn’t be surprised if this victim develops a prominent inflammatory response, which would have an entirely different set of manifestations, and subsequent treatment.

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

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Thank You to Women's Health News for Grand Rounds

Thank you to Rachel Walden of Women's Health News for including my book review of Mountains Beyond Mountains 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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Mountains Beyond Mountains

With my busy schedule, I don't have much time to sit down and read, so when I am able to do that, it is precious for me. I've just finished Tracy Kidder's Mountains Beyond Mountains, subtitled "The Quest of Dr. Paul Farmer, A Man Who Would Cure the World."

For many of us in the field of wilderness medicine, and certainly for healthcare professionals involved with international medicine, travel to foreign (to the U.S.) countries is part of the profession. Furthermore, the situations in these countries is rarely like that in our highly privileged circumstances. As Dr. Paul Farmer discovered early in his career, there are enormous unmet needs everywhere, and particularly in "third world" countries, which suffer from combinations of poverty, civil disobedience, lawlessness, lack of food and shelter, endemic malnutrition, absence of access to healthcare, corrupt governments, and many other factors that contribute to the physical and emotional afflictions of mankind. It takes a special type of person to be dedicated to improving such situations. Indeed, it is usually all that a person can do to be a single provider caring for patients, let alone someone who takes on the responsibility to improve an entire healthcare delivery system.

In Mountains Beyond Mountains, Tracy Kidder follows Dr. Paul Farmer from his days as a medical student to his emergence as an internationally known figure in global health. It is written in a style that does not glorify Dr. Farmer or his calling in life. Rather, we are presented with some of the intricacies of his personality, not all of which are flattering. No human is perfect, and it is both instructive and refreshing to learn how a young man on a mission to bring modern healthcare to impoverished persons can transcend personal and professional difficulties to make a profound difference. One of my favorite expressions in life is, "If it were easy, everybody would be doing it." Dr. Paul Farmer aspired to tasks selected by few individuals, because they obligated him to sacrifice or postpone much of what we Westerners see as laudable social and financial outcomes. He realized at a tender age that one makes a difference by actually making a difference, not hypothesizing or pontificating about change.

Dr. Farmer has chosen to tackle difficult diseases, such as HIV and tuberculosis, because these are the scourges of the types of people to whom he has dedicated his efforts - the downtrodden, displaced, and incarcerated. In these populations reside reservoirs of potent, relentless infectious diseases that prey upon their weakened immune systems. In most countries, poor people do not have the resources to meet their daily nutritional requirements, let alone seek the guidance of professors in major medical centers. Having spent time as a volunteer in such countries, one becomes accustomed to both the nondemanding demeanor of the patients and their fatalism, born of reality, when faced with serious diseases and conditions. They understand that resources are limited, and are usually enormously grateful for whatever assistance they are given. It is always striking to travel from the U.S. to a place like Haiti or Guatemala and to witness the striking dichotomies in the lifestyles and resources for the "haves" and "have nots." I suspect that this will only grow worse as the world's population increases and unwieldy numbers of humans are forced to life in proximity on a declining land mass.

Tracy Kidder does an excellent job of portraying Dr. Farmer for what he is - an exceedingly talented and intelligent human being with a moral compass that points in the direction of compassion and progress. None of his remarkable work in places like Haiti and Russia came without sacrifice. As for most of us, his emotional and cultural frameworks were installed by his parents and his upbringing. The rest derives from the motivations and emotional framework that are unique to this fascinating and highly accomplished individual.

Here is what is written about Dr. Paul Farmer by the Brigham and Women's Hospital in Boston:

"Paul Farmer, M.D., Ph.D., Associate Chief of the Division of Social Medicine and Health Inequalities, is a physician-anthropologist who has worked in infectious disease control for nearly two decades. He is a co-founder of Partners In Health, an international charity organization that provides direct health care services and undertakes research and advocacy activities on behalf of those who are sick and living in poverty. Dr. Farmer is the Maude and Lillian Presley Professor of Medical Anthropology in the Department of Social Medicine at Harvard Medical School. He has been a visiting professor at institutions throughout the U.S. as well as in France, Canada, Peru, the Netherlands, Russia, and Central Asia.

Along with his colleagues at DSMHI and in the Program in Infectious Disease and Social Change at Harvard Medical School, Dr. Farmer has pioneered novel, community-based treatment strategies for infectious diseases (including HIV/AIDS and multidrug-resistant tuberculosis) in resource-poor settings. Author or co-author of over 100 scholarly publications, his research and writing stem in large part from work in Haiti, Peru, Russia, and Rwanda and from his clinical and teaching activities. He is the author of Pathologies of Power (University of California Press, 2003); Infections and Inequalities (University of California Press, 1998); The Uses of Haiti (Common Courage Press, 1994); and AIDS and Accusation (University of California Press, 1992). In addition, he is co-editor of Women, Poverty, and AIDS (Common Courage Press, 1996) and of The Global Impact of Drug-Resistant Tuberculosis (Harvard Medical School and Open Society Institute, 1999).

Among the numerous awards Dr. Farmer has received are the Jimmy and Rosalynn Carter Award for Humanitarian Contributions to the Health of Humankind from the National Foundation for Infectious Diseases, the Salk Institute Medal for Health and Humanity, the Duke University Humanitarian Award, the Margaret Mead Award from the American Anthropological Association, the American Medical Association’s International Physician (Nathan Davis) Award, and the Heinz Award for the Human Condition. In 1993, he was awarded a John D. and Catherine T. MacArthur Foundation 'genius award' in recognition of his work.

Dr. Farmer received his Bachelor’s degree in 1982 from Duke University, and his M.D. and Ph.D. (in Anthropology) simultaneously in 1990 from Harvard University."

I highly recommend Mountains Beyond Mountains for every medical student who intends to practice clinical medicine, and for persons who seek to understand what motivates persons like Dr. Paul Farmer to reach beyond the comforts of the U.S. to make the world a better place.


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

Tags: Mountains Beyond Mountains, Paul Farmer, wilderness medicine, outdoor medicine, healthline

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Multiple Bee Stings

A reader writes (about bee stings): "But what can be done for a victim stung many times, but who is not having an allergic reaction? I imagine this venom begins to become systemically dangerous after around 2-300 stings (assuming 500 is a lethal threshold)."

The most common cause for dangerously low blood pressure (shock) after a bee sting is an allergic reaction to the venom. The chance for this to happen is greater after multiple stings than after a single sting.

With multiple stings, the venom burden and its direct physiological effects may cause severe illness. Low blood pressure (hypotension), abnormal heart rhythms, difficulty breathing, abdominal pain, and nausea and vomiting may all be features of this sort of a reaction.

Treatment consists of administration of epinephrine by injection for the allergic reaction, and intravenous infusion of fluid to fill the cardiovascular system and reverse the low blood pressure. If the heart is beating in an abnormal rhythm, it may be necessary to administer drugs to normalize the rhythm.

If a complicated immune system reaction develops, then it may be necessary for a physician to prescribe a glucocorticoid ("steroid") medication to suppress the reaction.

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

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Thank You to Dr. Wes for Grand Rounds

Thank you to Dr. Wes for including my post about reflection on the Hospitalito Atitlan 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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Reflections on Hospitalito Atitlan

It has already been useful for me to take a step back and reflect upon my week in Santiago, Guatemala working at the Hospitalito Atitlan. My overwhelming impression is positive, for many reasons. Perhaps I was lucky, but without exception, the people I encountered were upbeat and made every effort to be productive. It is a challenging situation, but that does not deter the healthcare professionals and staff at the Hospitalito from seeking constant improvement, and working to better the situations of their patients. I did not encounter the negative attitudes and burnout that are generously sprinkled thoughout the U.S. healthcare system.

Before I arrived at the Hospitalito, I was nervous about the degree to which I might need to improvise, and how I would respond to practicing medicine without my customary supplies and support systems. No doubt, there were tests and specialists that would have been very nice to have, but on the other hand, I quickly discovered that I needed to become a better diagnostician, to think more, and to become less reliant upon the “shotgun approach” to testing to which we are so accustomed. There is indeed a certain lack of precision that leads to heightening of the senses in order to regain that diagnostic acumen, and even in a short week, I found myself looking and listening to my patients with a less hurried and more critical approach.

The faith and trust of the patients were remarkable. I did not encounter a single complaining patient. Was this because they had lower expectations or less medical knowledge? I don’t think so. I think it is because they are a people of “please” and “thank you,” who are grateful when they are assisted. When I walked home after work wearing hospital scrubs, everyone smiled and many greeted me. No one begged or tried to sell me anything. I was instantly accepted as part of the community, as a helper. In America, there are many people who appreciate their doctors, but these days, there seem to be just as many who have complaints.

I was disappointed, but not surprised, by the lack of environmental and public health awareness. Large portions of the over-fished lake are polluted, there is a constant haze of smoke from wood-burning fires, garbage is strewn in the community gardens, children are malnourished, prenatal care is inadequate, and there is little attention to many of the basic measures of hygiene, nutrition, and natural resource consumption that we all know to be the cornerstones of a healthy life for people and our planet. But I understand full well how food, clothing, and shelter take priority over conservation, and how education can only be effective if governments can put people into a situation where they are motivated to learn, and protected from harm while they learn. So, on the flip side, there are libraries, and community outreach efforts, and local citizens trying to better their communities.

I did not sense the tension between young and old people that exists in our country. Elders are respected, and are not uncomfortable wearing their traditional garments when surrounded by westernized youths sporting jeans and modern haircuts. I did not witness taunting, and saw very few law enforcement officers. While crime no doubt occurs, if there had been a significant number of assaults, we would have known about it. If there was an illicit drug culture, I did not encounter it. While there were many opportunities for the locals to have their way with me economically, largely because I do not speak Spanish, no one tried to take advantage.

Rebuilding the Hospitalito Atitlan is a worthy cause. With far fewer resources than would be implemented in an equivalent operation in the U.S., the new hospital will contribute to the health and welfare of a relatively larger population to an extraordinary degree. The people of this lake region deserve it, and it is my great hope that the Guatemalan government will support it, as hopefully will many good people of philanthropic intent.

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

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Zanfel™

Poison ivy (oak and sumac) season will soon arrive, and much will be written in the press about remedies for the itchy rash caused by exposure to urushiol, the resin found in these plants. In addition to the standard method of washing with soap and water, there are commercial products touted to facilitate physical removal of the oily resin, which theoretically reduces the exposure and lessens the skin reaction.

One such product is Zanfel™ Poison Ivy, Oak & Sumac Wash. Zanfel™ is sold in 1 ounce tubes, and is advertised to carry a 10 year shelf life. Instructions for use direct the user to:

1. Wet the affected area.
2. To treat a surface area of skin approximately the size of an adult hand or face, squeeze 1 and 1/2 inches of Zanfel™ from the tube into the palm of a hand. Do not use less than this amount.
3. Wet and rub both hands together for 10 seconds, working the Zanfel™ into a paste. This activates the ingredients.
4. Using both hands, rub the activated Zanfel™ onto the affected skin for 3 minutes or until there is no itching.
5. Rinse the area thoroughly with running water.
6. If itching returns, repeat the process.

The manufacturer states that Zanfel™ is "safe and effective during any stage of the allergic reaction," is "safe for face and genitals," and is "safe for children and pregnant or nursing women."

Zanfel™ is a soap mixture of ethoxylate and sodium lauroyl sarcosinate surfactants. When "activated" (worked into a paste that can be spread effectively on the skin), the soap is able to bind urushiol and thus allow it to be removed from the skin by rinsing.

Zanfel™ is unique with respect to poison ivy/oak/sumac remedies in that it is supposed to remove resin from the skin after the rash has appeared. In one study, this effect was present even at 144 hours post exposure. However, it seems logical that at some point post exposure, urushiol is no longer present in the skin and that the allergic contact dermatitis (manifested as redness, itching, swelling, and blisters), would not be lessened by Zanfel™, unless it has some direct anti-inflammatory properties. The exact duration of the period during which Zanfel™ would be expected to be effective has not been determined, but its effectiveness is likely greatest nearest the time of initial exposure to urushiol. It is possible that used within the first few hours of exposure, a reaction might be prevented.

It should be noted that relative to many other drugs and remedies on the market, there are few clinical studies using Zanfel™. While the data referenced by the company are supportive, it is possible that repeat or larger studies might be less conclusive. That having been said, there does not seem to be any harm in using this product, and there may be significant benefit. The user is cautioned that no therapy, including Zanfel™, is infallible, so that if a person suffers a serious reaction to poison ivy, oak, or sumac, physician attention may be necessary. The most potent treatment currently available is high-dose steroid administration, which should be done under the guidance of a medical professional, unless one is far from help (e.g., in the wilderness).

Anecdotally, a few of my medical colleagues have used Zanfel™, both for themselves and for patients, and have found it to be effective, in that they believe that the reaction to a known poison oak/ivy/sumac plant(s) has been lessened (in comparison to what they would have expected), and in some cases halted, after application of the product. Other providers, like myself, await their first opportunity to use Zanfel™.

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

Tags: Zanfel, poison oak, poison ivy, poison sumac, urushiol, wilderness medicine, outdoor medicine, healthline

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Thank You to GruntDoc for Grand Rounds

Thank you to GruntDoc for including my post about a young man with a high voltage electrical injury 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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