Thank You to edwinleap.com for Grand Rounds

Thank you to edwinleap.com for including my post about estimates of outdoor injuries 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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Creating A Defensible Space Against A Wildfire

California firefighters are still battling to contain innumerable wildfires estimated to be burning in the state. Depending on the weather, this number may grow. Hot, dry winds repeatedly worsen the situation, and if there is more lightning without compensating rainfall, we may witness one of the most destructive fire seasons in history.

Everyone now must consider how best to safeguard their homes and property against an encroaching wildfire. At the wildland-urban interface, human dwellings are juxtaposed against the wilderness. As opposed to the man-made fire breaks imposed by living in the city, there is often scant protection out "in the country." The recommendations that follow are applicable in an urban setting as well, but much more important in a wildland setting:

1. Use fire-resistant external construction materials, particularly for the roof, where embers may fall. Wooden shakes are highly flammable. keep the gutters clean of combustible materials.
2. Remove combustible materials from close proximity to the dwelling. This includes piles of wood, flammable refuse, leaf litter, dead limbs, and piles of slash. Dry underbrush within stands of trees close to a dwelling serves as tinder for a fire.
3. If landscaping is flammable, maintain it as far as possible from the dwelling, so that it does not provide an easy flame path to your home. The further that combustible landscaping is located from the at-risk buildings, the better. A recommended minimum distance is 30 to 50 feet. In addition, create paths and openings that allow firefighters easy access to the dwelling.
4. Keep all trees and shrubs pruned of dead limbs and leaves. Do not allow large trees, dead or alive, to overhang your home. Maintain a green lawn if the lawn is adjacent to your home. Do not allow grass to grow tall and become dry, so that it can easily burn.
5. To block embers from entering your home, use metal screens over vents and other openings. Otherwise, they can enter and ignite the inside of the dwelling.

Please check out the excellent information that can be found at www.firewise.org, the Truckee (California) Fire Protection District's web page, and http://www.firesafecouncilnevco.com/Publications/FSC_defensiblespace.pdf

image courtesy of Squaw Valley Public Service District

Tags: wildfire, fire precautions, defensible space, wilderness medicine, outdoor medicine, healthline

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Summer Tips

I was recently invited by Revolution Health to offer their readers a few summer safety tips to beat the "silent summer spoilers." The following is a modified version of what was presented, with the notation that these afflictions are not so silent, and can certainly ruin your vacation or outdoor adventure.

Sunburn can be brutal. The best way to avoid sunburn is to stay out of direct sunlight. If possible, stay in the shade, and wear sun-protective clothing. Use a sunblock that is effective against both ultraviolet A (UVA) and UVB rays. It is an increasingly prevailing opinion that UVA is more damaging than previously thought.

Be certain to obtain a good application (at least an ounce or two for a "normal" sized adult), and reapply the sunscreen often, particularly if you are sweating or spending time in the water (scuba diving, surfing, swimming, etc.). If you are taking medication, know if it might make your skin more sensitive to sunlight.

Pay attention to your surroundings. High altitude, wind, and sun reflecting off the surface of water, sand, or gravel add to UV exposure. Don't forget to protect your eyes with sunglasses rated to block nearly 100% of UV radiation. If you decide to use insect repellent containing DEET (N,N-diethyl-m-toluamide) as well as a sunscreen, be advised that the combination might reduce the effectiveness of the sunscreen. If you are using two separate products (sunscreen and insect repellen), in general, it is best to apply the sunscreen first, allow it to absorb into the skin for 20 to 30 minutes, then apply the insect repellent, in order to maximize the effect of the repellent. If you are going to be in water where you might come in contact with stinging jellyfish, consider using Safe Sea sunblock with jellyfish sting protective lotion incorporated into the product.

A mild sunburn without blistering can be treated with cool compresses, showers or baths, a non-sensitizing skin moisturizer lotion, and aspirin or a nonsteroidal anti-inflammatory drug (e.g., ibuprofen) to decrease inflammation. A sunburn, even first degree, that is so extensive that it causes the victim to suffer chills, nausea and vomiting, weakness, and diarrhea, may require oral rehydration and bedrest. If blisters are present, this indicates second-degree burns, which sometimes must be treated with topical antiseptic ointment, bandages, and more extensive medical care. You certainly wish to avoid this situation. The skin bubbling and peeling that follow a first degree sunburn are superficial and do not result in fluid loss, and rarely lead to infection, but the skin should be kept clean and moisturized to prevent any complications. Anyone with a severe sunburn of any sort should be examined for dehydration.

Blisters are the bane of hikers and trekkers, and often of persons wearing new sandals, particularly if the feet are dirty and dusty, as the grit and grime serve as agents of abrasion. Break in andy new shoes, boots, flip-flops and sandals before walking any distance in them. Keep your feet clean and dry. When walking in boots, wear a thin pair of liner socks under your regular socks, so that the friction is between the socks, not between the boots and your feet. Cushion any reddened "hot spot" or cover it with a BlistOBan® bandage before a fluid-filled blister appears. If you do get a blister:

Fasten a "donut"-shaped foam pad to the perimeter of the affected area. Cover the affected area ("donut hole") with a fitted hydrogel (e.g., Spenco 2nd Skin®) pad, and then place tape over the foam and hydrogel. Watch for signs of infection, which include cloudy fluid or pus within the blister, or red streaks emanating from the edges of the blister into the surrounding skin. If the blister appears infected, use a disinfected or carefully cleaned needle to create a small puncture at the edge of the blister, and drain it. Cover the open wound with antiseptic ointment, and apply a sterile dressing.

Sprains and strains are common ailments in the summertime due to increased outdoor activity. The most common sprain involves the ankle. In the event of a sprain, use the "RICE" technique. RICE stands for "rest, ice, compression, elevation." Try to rest the joint. Elevate the affected body part and apply ice packs intermittently (e.g., 15 minutes on, 15 minutes off) as much as is practical for the next 24 hours. If the skin becomes reddened and painful from the application of ice, ease off to avoid a cold injury (e.g., frostbite) to the tissues. Mild compression with a wrap may provide some pain relief. If you need to keep walking, tape, bandage or splint the joint for support.

Once a joint is weakened by a strain or sprain, re-injury is common. Take precautions by using a mechanical ankle support (e.g., brace and high-top shoes or boots) and/or a walking stick over rocky terrain. It takes a full 6 to 8 weeks to recover from a mild ankle sprain, and 3 to 6 months to recover from a severe sprain.

Gastroenteric problems are common in the summer. Traveler's diarrhea, commonly caused by the bacteria E. coli, is often due to water or food contamination. Failure to wash or "gel" hands or to properly prepare food are likely the most common errors that lead to diarrhea. Water disinfection techniques include heating, addition of chemicals, filtration, or application of UV light. It is important to carry redundant water disinfection systems, so that if a unit (e.g., filter) is lost or damaged, you have backup. Avoid drinking beverages with ice, unless you can be absolutely certain that the ice was prepared from properly disinfected water.

Tick and mosquito bites can result in serious, even fatal, infections. So, be certain to protect yourself. If circumstances permit, wear light-colored pants tucked into socks and paired with a long sleeve shirt. Wear a head net or use a bed net when needed. Use insect repellent(s). Permethrin is applied to clothing, while DEET or picaridin is applied to exposed skin. Perform regular "tick checks" of the entire body (especially the scalp, groin and armpits), and immediately remove ticks. When attempting to remove a tick, do not twist it, touch it with a hot object such as a hot match head, or attempt to suffocate or kill it with petrolatum (petroleum jelly), mineral oil, kerosene, stove fuel, etc. These techniques might cause the tick to struggle and regurgitate potentially infectious agents into your bloodstream.

Finally, learn to recognize poison ivy, oak, and sumac. If you become exposed to their resin, immediately wash it off with soap and water or with a specialized scrub (e.g., Tecnu or Zanfel) within 30 minutes if possible. To treat a rash from poison ivy, oak or sumac, you may soothe the affected skin with calamine lotion and also consider the following measures: apply a topical anesthetic, such as praxomine HCl 1%; soak in a tepid (not hot) bath supplemented with baking soda or Aveeno (contains oatmeal proteins); consider taking an antihistamine medication, which helps control itching and acts as a sedative. Consult a physician if the reaction is severe. Prescription treatment (such as corticosteroid therapy) may be required.

The resins from plants can remain on clothes, fabrics, backpacks, tents, pet fur and elsewhere for long periods of time, so be certain to wash these carefully to prevent further exposure to the resin. Once the rash appears, you are not contagious, and you cannot spread the rash by scratching. However, you can open up blisters and make the affected skin vulnerable to secondary infection.

image courtesy of w3.ouhsc.edu

Tags: sunburn, poison oak, insect+repellent, wilderness medicine, outdoor medicine, healthline

Labels: blisters, insect repellent, poison ivy, poison oak, sprain, strain, sunburn

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National Estimates of Outdoor Recreational Injuries

In Volume 19, Number 2 (2008) of the journal Wilderness & Environmental Medicine appears an original research article entitled "National Estimates of Outdoor Recreational Injuries Treated in Emergency Departments, United States, 2004-2005," authored by Adrian H. Flores and his associates from the Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia. This article was the beneficiary of multiple press releases, and so there has already been a fair amount of discussion regarding its findings. Because I was briefly quoted regarding this article by the Associated Press, I have received a fair number of inquiries about its significance.

This article is the first to provide national estimates of nonfatal outdoor recreational injuries treated in 63 U.S. emergency departments (EDs). The data were gathered using the National Electronic Injury Surveillance Survey System - All Injury Program. In this way, national estimates of outdoor recreational injuries were calculated, and activities leading to injury, demographic characteristics, principal diagnoses, and primary body parts affected were described.

Averaged across the study years, an estimated 212,708 persons were treated each year in U.S. EDs for outdoor recreational injuries. Males accounted for 68.2% of the injuries, but the rates of injury did not take into consideration that males have higher rates of participation in outdoor recreation. The lower limb, upper limb, and head and neck region were the most commonly injured body regions. Fractures and sprains or strains were the most common diagnoses. For all injuries, the leading causes were falls, being struck by or against an object, and overexertion. In this study, the 10- to 19-year old and 20- to 29-year old ages groups accounted for the greatest percentage of injuries. Snowboarding, sledding, and hiking were the leading activities associated with outdoor recreational injuries.

What can be learned from this study? Much of what was documented is fairly well appreciated already, and confirms our suspicions about who suffers what type of injuries. As with any type of epidemiological research, the devil is in the details. For instance, to understand about how to make use of the information about injuries in snowboarders, it would be necessary to understand what happened during each event - did the accident occur at the beginning of the day (? icy terrain or deep powder) or at the end of the day (? participant tired, evolving icy conditions, impending darkness); was the snowboarder wearing protective equipment (? wrist guards, leash, helmet); was the snowboarder experienced (? beginner, intermediate, expert), etc. To understand how to make use of the information about injuries in hikers, it would be important to know the nature of the terrain, the skill-strength-experience of the hiker, the environmental conditions, type of footgear, use of a walking stick, etc. The premise is that with some reasonable degree of detail, we can draw conclusions about how better to prevent accidents and injuries. The name of the game is injury prevention.

One cannot remove all risks from outdoor recreational activities, but a reasonable goal would be to remove all unnecessary risks. If a deeper analysis of this study reveals that injured boaters were all driving above a certain speed, we can perhaps conclude something from that and perhaps make recommendations. If a greater percentage of the head-injured among the study persons were without helmets than the participating population at large, then we can perhaps make a recommendation. This is a nice study that will hopefully inspire others to look with greater depth at specific areas of outdoor recreation in order to identify patterns that can lead to more effective injury prevention.

image courtesy of www.ABC-OF-SNOWBOARDING.com

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

Tags: injury, injury prevention, CDC, 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 MRSA infections in this week's edition of Grand Rounds, which is the 200th 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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MRSA Madness and Tomato Update

Methicillin-resistant Staphylococcus aureus (MRSA) is here to stay. Although it is most problematic in healthcare settings, particularly hospitals, it is present in the "community" as well, and therefore will become a consideration for outdoor and wilderness enthusiasts.

In mid-April (2008), the following press release appeared:

One in Every 20 Healthcare Workers Is (a) MRSA Carrier
By Michael Smith, North American Correspondent, MedPage Today

GENEVA, April 15 -- One in every 20 healthcare workers carries methicillin-resistant Staphylococcus aureus, researchers here said.

This study suggests that healthcare workers sometimes play a role in the transmission of MRSA. But the vast majority is without symptoms and only 5.1% have full-blown clinical infections, according to Stephan Harbarth, M.D., of the University Hospitals of Geneva, and Werner Albrich, M.D., of University Hospital Bern.

One implication is that screening efforts aimed at symptomatic infections are likely to miss a large proportion of colonized healthcare workers who might transmit the bacteria, they wrote in a literature review in the May issue of Lancet Infectious Diseases.

Instead, they said, "aggressive screening and eradication policies" should be used in an outbreak and in situations where MRSA has not reached highly endemic levels.

The researchers looked at 127 studies published from January 1980 through March 2006, and on the basis of the published evidence, they concluded that healthcare workers are usually vectors, rather than the main sources of MRSA transmission, implying that "good hand hygiene practices remain essential to control the spread of MRSA."

4.6% of approximately 33,000 health care workers were carrying MRSA, the researchers found - usually in the nose, although other sites were found. Most (94.9%) of the carriers had no symptoms. Risk factors included chronic skin diseases, poor hygiene practices, and having worked in countries with endemic MRSA.

"Our search revealed 18 studies with proven and 26 studies with likely transmission to patients from healthcare workers who were not clinically infected with MRSA, the researchers said. That finding suggested that a recent recommendation that screening efforts focus on healthcare workers with symptomatic infection is likely to miss the boat.

"Staphylococcal dispersal is mainly dependent on whether the person is a nasal carrier," they said, so that "screening of infected healthcare workers only will likely miss a large number of asymptomatic personnel capable of transmitting MRSA to patients. They added that MRSA screening - and treatment to eradicate colonies of the bacteria - "should always be part of a comprehensive infection control policy including staff education and emphasizing high compliance with hand hygiene and contact precautions."

It's also important to avoid "feelings of guilt or stigmatization" among those found to be colonized, they said. "In analogy to needle-stick injuries, MRSA carriage or infection in a healthcare worker should be considered an occupational hazard," they said.

MRSA has been around since the 1960s and 1970s, when S. aureus developed resistance to the types of "semi-synthetic" penicillin (such as methicillin) used to treat the infection. Because the antibiotic vancomycin has been fairly effective against MRSA, and because there are other antibiotics, such as daptomycin, liezolid, tigecycline, and developmental drugs, which are effective against MRSA, we do not have a germ run completely wild, but we definitely have an in-hospital surge in infections and increasing indications that MRSA is gradually increasing its prevalence outside of the hospital.

It has been estimated that the general population may carry MRSA on the skin or in the nose at a rate of anywhere from 1% to 30% of the group studied. However, it is important to point out that the real frequency in the community is unknown, so there is not yet a cause for panic, but rather, for rational recommendations, mostly around hand-washing, disinfection of common surfaces, and general hygiene.

For outdoor enthusiasts, the following risk factors apply:

1. High prevalence of MRSA in the local community
2. Recurrent skin disease
3. Crowded living conditions (e.g., military barracks)
4. Participation in contact sports (e.g., wrestling)
5. Member of Native American, Pacific Island, or Alaskan Native populations
6. Shaving of body hair
7. Sharing equipment that is in prolonged contact with skin (e.g., paddling jacket)

Ten years ago, when an abscess was drained in the emergency department, it was considered unnecessary to send a sample of the pus or discharge from a wound for a culture to determine which bacteria might be present. Today, it is much more reasonable to do this to determine the presence or absence of MRSA.

Personal hygiene is very important, particularly if you come in contact with infected skin. It is essential to do full hand-washing with soap and water, and also to consider utilizing disinfectant gel. If you use a disinfectant soap, be sure to allow sufficient contact time with the skin - up to 3 minutes is fine before rinsing, rather than a quick scrub and rinse. Clothes that are put through a hot cycle are generally safe - on the trail, try to use very hot water to wash clothing, of course taking care to avoid any skin burns.

Tomatoes and Salmonella Update

The FDA has announced that it has lifted its Salmonella warning on tomatoes. The agency advises that people at highest risk for the illness, including the immunocompromised and elders, should avoid raw jalapeno and serrano peppers. The message here is that no definitive food source culprit has been identified for this particular outbreak of Salmonella infections. I recommend that all people use prudent handling techniques whenever preparing and serving food.

image courtesy of www.cdc.gov

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

Tags: MRSA, methicillin-resistant Staphylococcus aureus, wilderness medicine, outdoor medicine, healthline

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Mumps Vaccination for Outdoor Travelers

Mumps (a viral infection) is making a comeback in the U.S. and other countries because of failure to vaccinate. It is not a trivial disease, particularly in adults, and is highly communicable. In children, mumps typically causes fever, headache, muscle aching, fatigue, loss of appetite, and swelling of salivary glands, in particular the parotid glands, which are located in the cheeks directly in front of the ears. In all age groups, patients suffer from fever and inflamed salivary glands, which causes the "chipmunk" appearance, as if the person was a small animal storing nuts in his or her cheeks. In male adults, mumps can cause inflammation of the testicles (orchitis), which can become quite painful and debilitating. In other cases, mumps can cause deafness and inflammation of the brain and sensitive tissues around the brain. It can also cause ovarian or breast inflammation, miscarriage, and deafness. The severity of infection tends to increase with age.

In an article entitled "Recent Resurgence of Mumps in the United States" (New England Journal of Medicine 2008;358:1580-9), Gustavo H. Dayan, M.D. and his co-authors describe that the largest mumps outbreak in two decades in the U.S. occurred in the year 2006. This was in a population that received the proper immunization regimen of two doses of vaccine. Their conclusions were that it may be necessary to develop a more effective mumps vaccine or to make a change(s) in mumps vaccination policy (e.g., institution of a recommendation for a third dose of vaccine).

Why did the incidence of mumps increase? Some factors cited by the authors include declining immunity, high population density and contact rates among college students, the possibility that the vaccine did not provide sufficient immunity against certain ("wild") strains of the virus, and that perhaps the virus was transmitted by persons with very mild ("subclinical") disease or vaccine-modified disease.

What does this mean for the wilderness or foreign traveler? Outbreaks have certainly occurred in other countries, such as Canada. For now, it is just a reminder that all childhood immunizations should be brought up to date prior to travel, because exposure to mumps and other normally childhood diseases may periodically be higher in countries outside the U.S.

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

Tags: mumps, immunizations, wilderness medicine, outdoor medicine, healthline

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The Adventurous Traveler's Guide to Health

I just received a copy of The Adventurous Traveler's Guide to Health by Christopher Sanford, M.D. Chris is a delightful, smart, and witty person, and is a true expert in travel and tropical medicine. He is a family practice physician and co-medical director of the Travel Clinic at Hall Health Center at the University of Washington. The book is published by the University of Washington Press and carries a retail price of $14.95 U.S.

At 220 pages, including the index, the book is a very handy size, of small dimensions, for carrying on a trip. At that size, it is not intended to be a comprehensive tome. Rather, it is a well-written and entertaining appetizer that covers a reasonable assortment of ailments and situations relevant to most travelers, whether or not they are experienced. There are questions and answers, and quite a few "pearls" of wisdom. Knowing Chris, I am not surprised that he has at times interjected a dry sense of humor, which is done tastefully and in a manner that does not detract from the medical content.

I wish that the book was more comprehensive, if it is really meant to serve the "adventurous" traveler as a guidebook. Presumably by choice, the topics covered are not particularly patterned. One very brief chapter, entitled "Really, Really Nasty Diseases and Other Threats That Are Really, Really Rare, Thank God," contains mention only of cholera, Chagas' disease, kuru, the candiru fish, volcanoes, and being eaten by a lion. It consumes 4 pages. In my view, this precious real estate would have been better used to provide actionable information for true adventurers.

So, the book is interesting and easy to read - I enjoyed it, really - but I would recommend it as an introduction to whet the appetite of the reader for further information, not as a guide to be carried as a medical reference for the myriad medical situations that a traveler might encounter. Therefore, I think a more appropriate title would be "Health Matters to Be Considered Prior to Travel." It is a noble effort, and worth the price of admission.

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

Tags: travel, travel medicine, The Adventurous Traveler's Guide To Health, wilderness medicine, outdoor medicine, healthline

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Thank You to The Blog that Ate Manhattan for Grand Rounds

Thank you to The Blog that Ate Manhattan for including my post about Salmonella infections 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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Outdoor Medicine and the Environment 3

In followup to my previous two posts on this topic:

There are several potential methods for physicians and other healthcare professionals to increase awareness and involvement with environmental issues. First, there should be courses at every level on the relationship of environmental issues to human health. To cover the principles of environmental science and related medical issues, these courses should include information on atmosphere and climate; global climate change; the relationship of climate change and weather to disease vectors and transmission; the effect of climate change on the biology and afflictions of humans, plants, and animals; methods for assessing climate-related health effects; ecology and the environment; biodiversity and human health; natural environmental hazards; causes and effects of environmental contaminants; food and water science; and the causes and effects of population growth. Courses should be prepared and reviewed for accuracy and objectivity by authoritative environmental scientists and educators, in collaboration with medical professionals.

Medical societies and special interest groups, specialty organizations, and research institutes should whenever possible engage experts to summarize the best evidence about the effects of environmental change on health and medical conditions. This continuous process should foster exchange of views that takes into account medical, social, geopolitical, economic, and cultural issues. It goes without saying that the opinions that emanate from the medical profession, or any other profession for that matter, should be science-based to the greatest degree possible. Whenever new evidence emerges, current views may need to be modified as they relate to both the environment and health implications. I think it would be terrific if medical organizations would review their missions, and determine to what extent they are willing to disseminate environmental education material to their membership. Medical organizations should encourage members to become environmentally aware, and consider creating reports and multimedia presentations on global environmental health for delivery to medical professionals, students of medicine, business, government, and the general public.

Persons with special medical knowledge should investigate environmental organizations and consider supporting them with their special expertise. When appropriate, healthcare professionals can develop specific initiatives in collaboration with environmental professionals. Moreover, medical professionals should all learn about companies that truly use environmentally sound practices in their business efforts and consider supporting them. It may not make a big difference to the environment, but if for no other reason than to begin to establish a trend, hospitals and health care practices should make reasonable efforts to become green in ways that promote effective patient care while limiting the negative effect on the environment of providing that care.

And what about the wilderness medicine community? What can a person learn and do who wants to be healthy in the outdoors? The educational goals are to be better informed, become inspired, and take action. In the countless debates that will ensue, physicians and their patients should be positioned to wisely explain the medical ramifications of environmental issues. It is time to eliminate complacency and acknowledge the common “planetary patient” for whom we all share responsibility. Through education and personal resolve, each of us should strive to be active advocates for the environment.

image courtesy of www.ephonline.org

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

Tags: climate change, environment, global warming, ozone,wilderness medicine, outdoor medicine, healthline

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Storm Case

I recently attended Beneath the Sea, which is a fabulous multi-day event for the dive industry. I was there to receive an award for "Diver of the Year" in the science category. Walking the exhibition hall, I was pleased to see the emphasis on marine conservation, such as the work being done by Oceana, which campaigns to protect and restore the world's oceans.

Commercial exhibitors had many innovative products and services on display. One that caught my eye was a collection of cases carrying the name "Storm Case." I have used Pelican cases for years, but will likely switch to the Storm Cases for the following reasons:

1. For their features and ability to withstand impact, they are extremely light in weight.
2. The latches are very easy to open, yet hold securely.
3. Some of the cases carry excellent convenience features, such as in-line wheels.
4. The design is very thoughtful, including comfortable handles, telescoping handles, stacking ribs, molded-in hasps, flat-surfaced hinges with "feet" to allow upright stability, and a functional pressure-release valve.

The features highlighted by Hardigg are:

Tough, Rugged and Lightweight
Airtight, Watertight, Impervious to Mother Nature
Dent-resistant, Shatter-resistant, Virtually Unbreakable
Guaranteed for Life
Safe and Secure
Waterproof - Tongue and groove locking lid seals tight
Impact Resistant
New HPX™ High Performance Resin Shell - Superior to ABS
Customizable - Multilayer cubed foam insert, custom foam, and movable dividers available
Superior Panel Mount - Riveted aluminum panel mounting rails
Custom Logo Applications
Vortex™ Valve - Automatic pressure regulation for changing environments
Press & Pull Latch - Simple one-button release with superior hold-down capability
Interlocking Base-to-Lid Construction - Prevents shifting and reinforces closed-case protection
Strong, Rounded Corners
Durable Soft-feel Handle - Lifetime strength with a soft grip
Colors - Black, Gray, Yellow, Olive Drab, Orange, Coyote Tan
Full Lifetime Warranty

The internal part of the cases can feature multi-layer cubed foam and/or dividers to allow configuration for organization of carried items. Lid stays and lid organizers are available. The cases are available in a wide selection of colors and sizes.

When traveling in a rugged environment, where moisture, cold, heat, and impact are often present, first aid supplies, precious camera equipment, and other items that must be shielded from the elements should be carried in impact- and waterproof containers. You would be wise to consider the Storm Case series.

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

Tags: Storm Case, wilderness medicine, outdoor medicine, healthline

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Independence Day

Happy July 4! As we celebrate Independence Day, we should be grateful for our freedoms, families, friends, and wonderful country. We are especially indebted to all who serve and have served America, be it military, education, environment, health care, or any other public service. Few of us would be able to enjoy much of our lives in the U.S. without the continual selfless devotion of others. When you watch the fireworks (from a safe distance) this year, think hard about what you might do in the coming year to make our nation healthier, safer, stronger, cleaner, and more wise.

The 4th of July holiday is usually a wonderful time to be outdoors. In the hope that you will all have a wonderful weekend and enjoy the scenery, here are a few tips for injury prevention that will help you have fun safely, and not need to visit me or any other emergency physician:

1. Be extremely careful with fireworks. Firecrackers, bottle rockets, sparklers, and the like are always the cause of unfortunate accidents on the 4th of July. Do not leave children unattended with fireworks - that would be a recipe for disaster. Wear eye protection around fireworks. Eye injuries from extremely hot-burning and explosive fireworks are common, particularly in children, and they can be devastating, including loss of vision. Obey the law. Whether or not it is legal to use fireworks in your location, do not make the mistake of igniting a wildland fire.

2. Supervise all young children when they are swimming, even in the backyard or hotel swimming pool. Never take it for granted that someone else will safeguard your child, particularly if a swimming pool is crowded. For teenagers and older, remember that alcohol and water sports do not mix. Finally, ignore the misguided folklore that informs people never to swim after eating. The truth is that swimming is exertion, and swimmers need fuel. A small amount of carbohydrate and a beverage are important to maintain energy, and are advised before strenuous or prolonged aquatic exercise.

3. Stay well hydrated, particularly in the heat. If you are hiking, climbing, running a road race, cycling, or doing anything else that causes you to sweat, breathe rapidly (particularly at altitude), or be outdoors in hot weather, take extra care to drink plenty of fluids. There are many recommendations floating around regarding how much of ingested fluid should be plain water, or supplemented (usually with electrolytes and carbohydrate) water, but the bottom line is that you should keep up with what you perspire, respire, excrete, and sweat.

4. Wear your bicycle, motorcycle, climbing, whitewater or other helmet. There are more people on the roads (so more collisions), people are on holiday, alcohol is consumed, and the river rocks and rockfall from cliffs are unforgiving. Many a head is bonked (hard) on the 4th of July. To put it simply, the people who wear helmets often live unimpaired, while those who are not wearing helmets suffer brain injuries and die or become disabled. If you should be wearing a helmet, forgo the freedom to suffer and be smart.

5. Leave no trace. Whether you are camping, boating, or hiking, pack out your garbage and dispose of it properly. Know how to build a proper latrine at a safe distance from your campsite or natural water sources, pick up paper, cans, and other refuse, and try to leave the wilderness the way you found it. Besides the obvious benefit to the environment and scenery, you are practicing good public health, by not contaminating the soil and groundwater, and thereby doing your part to control the spread of infectious diseases. Because everyone will not be as thoughtful as you, take care to wash your hands carefully, and consider using a disinfectant gel or lotion, before you eat or handle food.

sparkler image courtesy of www.ric.edu
drowning image courtesy of www.firstaidinaction.net
fly on flower image courtesy of www.freewallpaperdesktopwallpaper.com
campsite trash image courtesy of www.diglloyd.com

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

Tags: drowning, fireworks, helmet, wilderness medicine, outdoor medicine, healthline

Labels: drowning, fireworks, hydration, July 4, safety

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Thank You to The Covert Rationing Blog for Grand Rounds

Thank you to Richard N. Fogoros, MD of The Covert Rationing Blog for including my post about smoke from wildfires 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.

Labels: Grand Rounds, The Covert Rationing Blog

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Tomatoes and Salmonella

Let's just say that people who like to be outdoors are often the same people who like to eat tomatoes. Tomatoes are a staple food at cookouts, on backpacking trips when fresh food is carried, for lunch and dinner on the river, etc. Nothing tastes better than a homegrown beef tomato sprinkled lightly with a bit of salt and pepper, and perhaps a touch of balsamic vinegar.

Over the past few weeks, we were informed that now we all needed to be extra careful, because we were supposedly in the midst of a multi-state (U.S.) outbreak of infections caused by Salmonella serotype Saintpaul, attributed to consumption of raw tomatoes, and in particular, red plum, red Roma, or round red tomatoes.

Thirty-two states and the District of Columbia were said to have reported infections to the Centers for Disease Control, via the identification of Salmonella strains from ill persons routed for identification through the State health departments. The reports were presumedly linked to tomatoes - consumed at home or in restaurants. There was no definitive link to tomatoes consumed "in the wild" - and none to my knowledge on an expedition. Now it appears that these Salmonella infections may not have originated with tomatoes after all, but from some unknown carrier(s) of the bacteria. We are not yet even sure if the contaminated food was produce, but that is a possibility. If it was not tomatoes, perhaps it was something served with tomatoes, or a food product made with tomatoes, such as salsa. If it was salsa, then it could have been any of the other ingredients, such as green onions, cilantro, or jalapeño peppers.

If there are contaminated tomatoes, or any other vegetable, meat, or other food product(s) in circulation, sooner or later, someone will get become sick after eating the product during a picnic or an outdoor trip. In retrospect, and for the purpose of avoiding future illness, it is very important to note that we do not have information about how the culprit tomatoes were supposedly handled prior to consumption - were they washed, and if so, in what manner? I don't imagine that we will ever learn these details, particularly if the very origins of the reported illnesses are in doubt.

So, that leads us back to a general discussion of infection with Salmonella, which is a very real cause of diarrheal illness. There are multiple species of Salmonella, including Salmonella typhi, which causes typhoid fever. The bacteria normally reside in the intestinal tracts of humans and other animals, including birds. The most well known causes of Salmonella food poisoning are contaminated beef, poultry, milk, and eggs. Salmonella food poisoning (infection), usually caused by S. typhimurium or S. enteritidis, typically causes diarrhea (loose and watery stools, usually without blood), fever, and abdominal cramping 12 to 72 hours after incubation of the infection. Untreated with an antibiotic, the illness usually lasts from 4 to 7 days. The infection may spread and cause the victim to become seriously ill, or rarely, to die. On occasion, persons with Salmonella infection develop a post-infection syndrome of painful joints, irritated eyes, and pain on urination.

For gastroenteritis, antibiotic therapy is usually not indicated, because it does not shorten the duration of the disease. Furthermore, antimotility drugs, such as loperamide (Imodium), are not recommended, because they may prolong contact time of the bacteria in the bowel, and prolong or worsen the illness. However, antibiotics are often recommended for Salmonella gastroenteritis in infants younger than 3 months, infants younger than 12 months with temperatures higher than 102.2°F (39°C), and persons with certain blood disorders, HIV infection or other cause of immunosuppression (e.g., diabetes or chronic steroid therapy), cancer, or chronic gastrointestinal illness. The recommended antibiotics for such individuals include ampicillin, amoxicillin, trimethoprim-sulfamethoxazole, cefotaxime, ciprofloxacin, and ceftriaxone, among others.

So far, in this current Salmonella outbreak, there have been no directly-attributable deaths reported, but at least 53 persons have been hospitalized. Overall, the number of afflicted persons is likely greater than that reported, because many people who develop diarrhea don't seek medical care and/or obtain a stool culture.

The Food and Drug Administration (FDA) has been advising consumers in the U.S. to be cautious, and to choose for consumption cherry tomatoes, grape tomatoes, tomatoes sold with the vine attached, homegrown tomatoes (more reason to "go organic"), and to avoid red plum, red Roma, and round red tomatoes unless they come from reliable sources. Of course, much as one needs to avoid contaminated ice in beverages, one should be aware that if tomatoes are the culprits, then raw tomatoes used to prepare sauces, salsa, cold soups, and other food products can carry Salmonella. Ditto for lettuce or any raw fruit or vegetable. The truth is that right now, we don't know precisely what to avoid.

Here are additional precautionary measures that place emphasis on food handling and preparation:

1. Within 2 hours of use, refrigerate or discard cut, peeled, or cooked fruits and vegeatables.
2. Do not purchase bruised or damaged fruits or vegetables.
3. Wash all vegetables and fruits thoroughly under running water. If you are camping, use properly disinfected water. Soaking vegetables and fruits with a skin or "peel" in an iodinated disinfecting solution, then rinsing with disinfected water to remove the residual iodine (and improve the taste) is a common practice in some third world restaurants.
4. Keep raw produce for consumption separate from raw meats and seafood.
5. Wash all cutting boards and surfaces, dishes, utensils, and counter tops with soap and hot water in between handling different types of food products.
6. One might consider peeling tomatoes, but there is not yet evidence that this makes a difference in diminishing the number of infections, which may not be caused by the tomatoes anyway.

The U.S. Department of Agriculture has an excellent Fact Sheet entitled "Salmonella Questions and Answers."

In summary, the recent reports of Salmonella infection, while perhaps attributable to tomatoes, may well have been created by an alternative source(s). The rules for safe food handling and avoidance of food-borne infection apply to all foods, not just tomatoes.

image of "Tennessee tomatoes go camping" courtesy of blackstarjewelry's photostream

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

Tags: tomato, Salmonella, disinfection, wilderness medicine, outdoor medicine, healthline

Labels: disinfection, Salmonella, tomato

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