Forget Me Not

Forget Me Not is an engaging and very well written memoir by Jennifer Lowe-Anker, the widow of the famous climber Alex Lowe and now the wife of Alex's dear friend and climbing partner, Conrad Anker. While it has been praised as a story of three people, it is really more about Jennifer and her relationship with Alex. After all, in relative terms, the story of her relationship with Conrad is yet to unfold, and in the aftermath of what she and Conrad have been through, some semblance of privacy is appropriate.

One is struck immediately by the openness of the writing - exposure really - on matters that must be as painful as they are sometimes joyous to recall. There is wonderfully detailed exposition of the nature of the great climber, Alex Lowe, but that is not what holds the reader. Rather, it is the recognition of the complexity of all relationships, and how much depth can be attained if one is willing to examine the details of life. Many of us would have such riveting stories to tell, if we could take the time and had the literary skills of Jennifer Lowe-Anker.

The foreword by Jon Krakauer is representative of his best work. It summarizes the amazing climbing capability of Alex Lowe, and accurately sets Lowe apart in skills and emotional suitability for climbing from most other climbers of his generation and eras past. As are most gifted explorers and adventurers, Alex was confident with an "edge," loving to instruct, but eager to attain new goals. He blossomed outside of the comfort zone of others, and was the climbers' climber. The trait of many of the "great ones" is to sleep very little, arise early, and lament that there are just not enough hours in the day. But, as Krakauer points out, no one is indestructible. When your profession or avocation has you often hanging from a rope or trying to outrun an avalanche, anything less that constant and complete perfection can be catastrophic. For the extreme being, it's not a question of if, it's a question of when.

Jenni Lowe-Anker is a masterful storyteller. In recounting her relationship with Alex Lowe, she is able to intertwine a sense for her family's "prairie values" with her youthful exuberance and willingness to take a chance on a relationship, with the sometimes rocky course of being in love with a partner who does not hesitate to ask for his fair share of tolerance and personal sacrifice. The pursuit of excellence is a laudable trait, but can be burdensome when it does not match up perfectly with other important things in life, such as family and down time. As Jenni Lowe tells it, living with and loving Alex Lowe was spontaneous at first, then became an acquired taste. There is never a truly major moment of doubt portrayed in this book, but perhaps Jenni is still holding something back. I of course respect her either way, because no matter how great a sense of foreboding may have come into play before the tragic death of her adventurous husband, that is not relevant for the future life she must lead. There is much work to be done raising her children and continuing to forge a relationship with her current partner, and doing the amazing and creative things she has always been meant to do.

For those who do not know the story, Alex Lowe was killed in a snow avalanche that spared the life of his good friend Conrad Anker. Jennifer and Conrad, among others, were grief stricken, to which Conrad added an element of survivor's remorse. In consoling Jennifer and her children, he was also consoling himself. He and Jennifer relatively rapidly escalated their relationship, fell in love, and married.

There is a great deal of intensity and self-analysis, and for any reader who has lived life to any significant degree, much with which to identify. Who among us has not had their behaviors molded to some degree by their relationships with their parents, and who among us has not fallen into and out of love? As we get older, we lose precious relatives and friends, less often to natural disasters than to cancer and automobile accidents, but the pain and lack of fairness are the same. How long are we to grieve, and when are we allowed to fall in love again? Lowe-Anker wrestles with the humanity of the living, and graciously bestows forgiveness and equanimity upon the obstacles that she has overcome to continue her life. For, as she notes, life goes on.

Forget Me Not, by Jennifer Lowe-Anker. The Mountaineers Books

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Side Effect of Transdermal Scopolamine for Motion Sickness

Transdermal scopolamine 1.5 mg is provided in a patch with the trade name Transderm Scōp, distributed by the pharmaceutical company Novartis. It is commonly used to treat motion sickness (such as seasickness), and is very effective. On our recent great white shark diving adventure, many of the participants wore patches at the outset of the journey, because we made our initial crossing to Guadalupe Island in the tail of some higher-than-usual (for this time of year) seas.

Here is some information on motion sickness:

Motion sickness (seasickness, or “mal de mer”) is a common annoying, and sometimes disabling, problem for boaters and divers. Motion sickness is a complex phenomenon that involves the cerebellum (the part of the brain that controls, among other things, balance), vestibular system (labyrinth of the inner ear that plays a major role in the control of equilibrium), the nerve connections between the eyes and the inner ear, and the gastrointestinal tract. It is made worse by alcohol ingestion, emotional upset, noxious odors (e.g., boat exhaust fumes), and inner ear injury or infection. Most persons adapt to real motion after a few days, but may require treatment until they are adjusted to the environment.

Signs and symptoms of motion sickness include a sensation of dizziness or spinning, a sensation of falling, pale skin color, sweating, nausea, headache, drowsiness, weakness, yawning, and increased salivation. Vomiting may provide temporary relief, but prolonged salvation doesn’t occur until the inner ear labyrinth acclimatizes to motion or you are able to intervene with an anti-motion-sickness device or medication. Persons who suffer from prolonged vomiting become dehydrated and exhausted.

To manage motion sickness:

1. Keep your eyes fixed on a steady point in the distance. If on board a ship, stay on deck. Splash your face with cold water. If the seas are rough, be careful to not slip or fall overboard. If you can have someone next to you who is not suffering, that is better than leaning over the rail by yourself to vomit when you are dizzy.

2.Use the ReliefBand device. It is advertised to relieve nausea and vomiting with gentle, noninvasive electrical stimulation on the underside of the wrist. It can be used before or after symptoms begin; carries no restrictions on food, beverages, or the use of medications; and has no drug-like side effects. The device looks like a wristwatch. The Adventurer model contains a battery-powered electrical stimulator that is easily adjustable for five different stimulation levels. The device is positioned over the P6 acupuncture site (the Neiguan, or Nei Kuan, point on the pericardial meridian). This is located 2 fingerbreadths toward the heart from the wrist joint between the two prominent finger flexor tendons. When the device is turned on, a pulse is generated every 4 seconds, and the user feels the episodic tingling sensation. It is theorized that the electrical signal transmitted via the median nerve in the wrist interrupts the nausea and vomiting messages that are transmitted between the brain and the stomach. The only side effect noted so far with the device is rare irritation where the electrodes make contact with the skin. This is easily managed by moving the device to the other wrist.

3. Some persons report that wearing a “sea band” is helpful. This is a knitted, elastic stretch band with a button(s) that applies pressure to an acupuncture point(s). This would not be expected to be nearly as effective as the ReliefBand device, but might help out in a pinch.

4. Ingest meclizine (Antivert, Bonine) 25 mg , cyclizine (Marezine) 50 mg , or dimenhydrinate (Dramamine) 50 mg orally every 4 to 6 hours, or cinnarizine (Sturgeron) 15 mg every 8 hours as necessary to prevent and control motion sickness. These are adult doses. To be most effective, the first dose of medication should precede the environmental change by 1 hour. Medication given after the onset of seasickness will often be ineffective. Obviously, if you are vomiting so severely that you cannot keep any medication down, you may need to use a suppository, such as prochlorperazine (Compazine) 25 mg or promethazine (Phenergen) 25 mg, noting that these drugs won’t cure the motion sickness–they might control vomiting, but have the side effect of drowsiness.

5. Place a transdermal scopolamine patch (Transderm-Scōp 1.5 mg) on the skin behind the ear. This patch releases the drug slowly through the skin and can be very effective against motion sickness for up to 3 days. Side effects include drowsiness, blurred vision (sometimes with a dilated pupil in the eye on the side of the patch), decreased sweating, difficulty with urination (particularly in elder males with enlarged prostate glands), dry mouth, and a propensity to be susceptible to heat illness during times of heat exposure. Persons with glaucoma should not use the patch. On a rare occasion, a person who uses a patch can become delirious or even psychotic as a side effect. Normal behavior returns within a few hours after the patch is removed.

The patch should be positioned at least 3 hours before rough seas are encountered. If you touch the medicated (sticky) side of the patch with a finger and then let that finger come in contact with your eye, your pupil will almost certainly dilate and stay that way for up to 8 hours. So, as the distributor strongly recommends, be sure to wash your hands thoroughly with soap and water immediately after handling the patch, so that any drug that might get on your hands will not come in contact with your eyes. Also, local absorption of the drug through the skin can dilate the pupil of the eye on the same side of the patch, causing difficulty with focusing of vision. The picture here shows someone with a dilated pupil associated with a patch.

6. Reduce head movement. Do not consume alcoholic beverages, because these make you more prone to vertigo. If you are on a large boat that is rocking bow to stern, seek the middle (equilibrium) of the vessel, so that motion is minimized. Look out from the boat and find a broad view of the horizon. Don’t do close-focused visual tasks like reading, writing, and navigation. If you are becoming motion sick and can’t control your symptoms, you might find some relief by lying faceup in a well-secured and ventilated bunk. Close your eyes and try to sleep.

7. Some people recommend “keeping something in your stomach” during a bout of motion sickness. You can put something in there, but if you are truly sick, it won’t stay there for long. Try to maintain your fluid intake with sips of something like an electrolyte-containing sports beverage (e.g., Gatorade or Gatorade G2). If you are known to suffer from motion sickness, take particular care to be well hydrated before your journey, because you will at a minimum have decreased appetite and fluid intake, and in the worst case, lose a fair bit of fluid by vomiting. While some persons recommend a light diet with predominately carbohydrates, there is no evidence that any particular food or diet is beneficial. Ginger (Zingiber officinale) is sometimes recommended to curb nausea. It is taken as 1,000 mg (two 500 mg capsules) every 6 hours, supplemented by gingersnap cookies, ginger ale, and candied ginger.

Headache, ringing in the ears, weakness in an arm or leg, difficulty with speech, difficulty swallowing, decreased vision, or palpitations are not features of motion sickness and should raise suspicion for another cause of dizziness. If any of these occur, particularly if the seas are not particularly rough and no one else is suffering, the victim should seek medical attention. Similarly, if the symptoms occur after a dive, one must consider the possibility of central nervous system decompression sickness (bends) or arterial gas embolism.

Finally, don’t try to cure serious motion sickness by putting on your dive gear and heading underwater. Mild nausea attributable to seasickness may disappear when you get under the surface (and the objectionable motion ceases), but if you are ready to vomit, you shouldn’t put yourself and your companions in a situation where you throw up underwater. It is not easy to vomit underwater and coordinate breathing through your regulator, and getting sick when you are in the water can lead to panic and a serious diving accident. Don’t dive until you are feeling well.

Tags: motion sickness, scoplamine, Transderm Scōp, wilderness medicine, outdoor medicine, healthline

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Surviving A Wilderness Emergency

This is the ninth post based upon educational sessions and syllabus material presented at the Wilderness Medical Society Annual Meeting & 25th Anniversary held in Snowmass, Colorado from July 25-30. It’s based upon an excellent presentation given by Peter Kummerfeldt, who is President and Chief Instructor for OutdoorSafe, Inc. of Colorado Springs, Colorado. In his presentation, Peter wisely made the point that the information provided was designed for educational use only and would not be a substitute for specific training or experience. When going into the outdoors it is the reader's responsibility to have the proper knowledge, experience and equipment to travel safely.

INTRODUCTION

Each year, many people find themselves trapped by inclement weather, caught out after dark, are injured, become ill, or are lost and end up having to spend a night or two away from their intended destination, and sometimes outdoors. Spending an unplanned night out does not have to become a “survival situation.” Rather, if you plan for the event, spending a night out is more of an inconvenience than an ordeal. If you accept the possibility that you might be the individual involved the next step is to plan for it. Mentally preparing is as important, if not more important, than the physical steps you need to take. The more mentally prepared you are, the less the likelihood that you will panic. Panic will be your greatest enemy and must be controlled. Coping with an emergency has been said to be 80% mental, 10% equipment and 10% survival skills -- use your head and you can survive.

STAYING FOUND

More people end up in survival situations because they become lost than for any other reason. Being lost is serious but it does not have to be dangerous if you react properly. An acronym to help you remember what to do when you lose your way is "STOP":

Sit down - don’t panic. Sit for at least 30 minutes to allow the emotion to drain away. Talk positively to yourself - out loud! Have a drink of water or eat a candy bar. Remember, your brain is your best piece of survival equipment.

Think about your situation. How bad is it, really? Are there injuries to which you need to attend? Are you losing body heat? What needs to be done first? How much time do you have before it gets dark or the storm rolls in?

Observe the area. What resources are available to help you survive? What natural hazards exist?

Plan what to do next - but be flexible. Remember that you have no control over the weather or the onset of darkness but you do have control over your actions!

When you become lost the first thing you must do is admit to yourself that you don’t know where you are - you’re lost! Or more accurately, you don’t know how to get back to your starting point. While you are sitting, go over in your mind what you did since leaving your car or camp earlier in the day and compare your recollections with the information provided by your map. What landmarks did you see along the way? Can you see these landmarks on your map? Have you been going uphill or down? How many rivers did you cross? How many ridges did you climb? Did you leave enough tracks to follow back to where you started? It helps to draw a map in the dirt. By a process of deduction and using common sense you may be able to unscramble your thoughts and reorient yourself. Often you’ll find that you’re not as lost as you first thought you were!

Unless you can positively locate yourself, the best advice to follow is to stay put and not travel. Do not run around looking for something familiar. Not only will this further confuse you - it will exhaust and dehydrate you and increase the likelihood of suffering an injury. It will also make the searcher's job much more difficult, because you may move into an area that has already been searched! Wait for the rescuers to find you. They are trained and equipped to rescue the lost and injured. Sit tight, protect yourself, signal and let them find you. Remember that most rescues in the United States are accomplished within 72 hours - especially if you have told someone where you were going! Your job is to survive until they arrive!

All outdoor users should carry and know how to use a map and compass before they go off into the backcountry. The first step in staying found is locating your position, and marking that position on your map, before you leave your vehicle or camp. Then identify the boundaries that surround the area in which you will be traveling. These boundaries could be prominent roads, railways, power lines or large rivers. Preferably you should identify boundaries on all four sides of the area in which you will be traveling. Having located yourself on the map and knowing the boundaries, you can then leave camp with the knowledge that, if you get lost, all you have to do is determine which boundary is closest and walk a straight line to it. Then relocate yourself and return to your vehicle or camp. Sometimes this can be a very long walk out!

Many people experience great difficulty walking a straight line and have wandered in circles until exhausted. The simplest way to walk a straight line is to use a compass, preferably an “orienteering compass.” Having determined the direction to the nearest boundary, point the “direction of travel arrow” towards your destination then turn the dial of the compass until “N” coincides with the north end of the compass needle. Follow the direction indicated by the direction-of-travel arrow always keeping the north end of the compass needle and the orienteering arrow aligned. Look up, sight on a landmark, and walk to it. Repeat these steps until you reach the boundary and can relocate yourself. In some areas only one significant boundary may be present. In this situation, determine, before you leave camp, the direction you will have to travel to get to the boundary in the event you become disoriented. Often the road or trail leading to your camp will serve as a primary boundary. If you walk in a westerly direction away from your camp you will have to directly opposite that, or easterly, to return to the road or trail that your camp is located on.

A compass needle is radically affected by any metal object that is nearby -- do not let firearms, knives, large metal belt buckles or other compasses near your compass when taking a reading or following a compass heading. The cardinal directions, north, east, south and west can be determined without a compass using the following procedures. Using a watch with hands, point the hour hand directly at the sun. The point half way between the hour hand and 12 o’clock will point generally “south.” North will directly opposite. At night, a line drawn through the two “pointer stars” in the bowl of the Big Dipper and extended approximately four times the distance between the two stars, intersects the Polaris, the North Star, which is never more than one degree from True North. Lay a stick on the ground aimed north so that you can determine the cardinal directions (north, east, south and west) the following morning.

To be continued…

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Thank You to Highlight Health for Grand Rounds

Thank you to Highlight Health for including my post with a Frostbite Update in this week's Grand Rounds. Grand Rounds is a weekly compilation of health care posts from around the web compiled by a host, who goes to great lengths to make the collection informative and entertaining.

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Frostbite Update

This is the eighth post based upon educational sessions and syllabus material presented at the Wilderness Medical Society Annual Meeting & 25th Anniversary held in Snowmass, Colorado from July 25-30. For this post about frostbite, we are grateful to be offered the wisdom of Luanne Freer, MD, FACEP, FAWM, who founded and directs the Everest Base Camp Medical Clinic, which operates each spring climbing season in Nepal.

From a historical perspective, frostbite has been known since ancient times, with indications of frostbite being present in a 5000-year-old pre-Columbian mummy discovered in the Chilean mountains. Napoleon’s surgeon general, Baron Dominique Larrey, described mechanisms of frostbite in 1812, during his army’s retreat from Moscow. He noted the harmful effects of the freeze-thaw-freeze cycle when soldiers warmed frozen hand and feet over the campfire at night, only to have them refreeze when they were removed from the warmth of the fire.

Frostbite has traditionally been considered a military problem, but it is now also a civilian one, as climbers, adventurers, explorers and others have put themselves into cold environments where they are susceptible to exposure and extremely cold external temperatures. It afflicts predominately males aged 30 to 49 years, attributable more to their activities than to their physiology. Dr. Freer reports that 10 to 15 cases per year require treatment on Everest, which represents 3% of persons who reach the summit.

The anatomy and physiology related to frostbite relate mostly to the organs that become frozen, namely, the hands, feet, nose, and ears. These all contain microsopic junctions between tiny arteries and veins, known as AV anastomoses. Within these junctions, adjustments in diameter and blood flow rates can cause flow to vary, say in the hands from 3 milliliters per minute to 180 milliliters per minute, an amazing 60-fold difference. In a cold environment, the body will sacrifice peripheral blood flow to maintain core temperature. Thus, determined by the temperature, state of hydration, degree of exposure, nervous control, and other factors, the blood flow through exposed skin can drop precipitously, setting the stage for a freezing injury.

Frostbite is tissue freezing and death, created by cellular damage, microscopic blood vessel insufficiency, formation of ice crystals inside and outside of cells, and permanent alteration of cell function, akin in devastation to a very severe burn wound. When frostbite occurs, it may be graded as 1st through 4th degree, depending on the depth, or more simply, as superficial (skin and subcutaneous tissues) or deep (muscle, bones, joints, tendons), which is a simpler classification to remember.

Predisposing factors to frostbite include blood vessel insufficiency, tight boots, trauma, being in a cramped position for a prolonged period, vascular disorders (such as Raynaud’s disease), high altitude, prolonged exposure to cold, wet skin, poor cold-induced vascular dilatation (CIVD can be protective), systemic dehydration, the period immediately after meals when blood is shunted to the gastrointestinal system, tobacco use, alcohol use, previous cold injury, and old age.

Frostbitten tissue is rewarmed in water (gently agitated or stirred, if possible) at around 40 to 42°C (under 44°C) if there is no danger of refreezing the tissue after it is thawed. This usually takes about 15 to 30 minutes. The thaw is completed when the tissue is red or reddish purple, and pliable (soft).Thawed tissue is intensely painful. Rarely, the previously frozen tissue may appear relatively normal; it is usually intensely red, mottled blue, yellowish-white, or “waxy.” Some degree of pain may persist for weeks or months, even after the tissue appears completely dead. The frostbitten limb may be numb or feel clumsy. Approximately 3 hours after the tissue is rewarmed, it begins to swell from edema (tissue fluid). This swelling may last for 5 or more days. Within 10 to 15 days, dead tissue blacken, and begins to turn hard and wither.

If possible, the victim of frostbite should move out of the wind and seek shelter. He or she should be given warm fluids to drink. Boots can be removed, but remember that it may be difficult to put them back on if swelling occurs. Wet gloves and socks should be replaced with dry garments. Ibuprofen 400 mg may be given by mouth. If the feet were frostbitten and sensation returns after rewarming, the victim may walk. If sensation does not return, then bring the victim to the nearest warm shelter, and do not allow walking if at all possible, because the lack of sensation may allow undetected injury, or in the worst case, another episode of freezing, which would be catastrophic to the tissues.

Blisters containing clear or milky-colored fluid is rich in substances that cause inflammation and should be drained, which bloody blisters are felt to be more protective than injurious, and are left intact. Aloe vera gel or lotion should be applied to all frostbitten tissue, blistered or unblistered, as it is felt to have a real anti-inflammatory effect. Continue administering ibuprofen in a dose of 12 milligrams per kilogram (2.2 pounds) of body weight per day.

Upon return to civilization, the victim of frostbite should be referred to a frostbite specialist, who will understand the different options (such as special scans) to determine the extent of the injury, as well as routine and experimental treatments, such as pharmacotherapy, neurostimulation, hyperbaric oxygen therapy, the desirability and timing of surgery, rehabilitation, and so forth.

Prevention of frostbite is essential, and even more important in tissue that has been previously frostbitten, because it is more susceptible to further injury. Methods available to prevent frostbite include, among others, heated insoles for footgear and heated gloves, wearing protective clothing in layers that are loose and heat-insulating, adequate nutrition and hydration, staying dry, wearing mittens instead of gloves, avoiding constrictive clothing and tight boots, and perhaps taking prophylactic aspirin or ibuprofen.

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Victorinox One Hand Sentinel

Regardless of the environmental setting, everyone's survival and first aid kits must contain sharp cutting implements. A sturdy knife that is easy to deploy is essential for cutting fabric, rope, vines, and game, sharpening a wooden point, and even sometimes slicing or trimming human tissue. There are many choices, ranging from single-blade knives to multi-purpose tools in which a knife blade(s) is a component.

I was recently sent a Swiss-made Victorinox One-Hand Sentinel Knife for evaluation. This is a knife only, and carries a single blade for one-handed opening. It is a basic, economical model with the workmanship and quality we have come to expect from Victorinox. Retailing as low as $23 U.S., depending where you purchase it, the knife has a serrated edge on a blade length of 3.25 inches. Closed, the unit is 4.4 inches in length and 1.4 inches in width, and weighs 2.6 ounces. I received a black unit, with the Swiss Army logo. The blade is very sharp. It can indeed be opened with one hand, using reasonable grip and finger strength. Two hands are required to close the unit safely. Near the integrated steel ring loop for attachment to a lanyard or carabiner are a small tweezers and toothpick.

The knife is sturdy and fits the bill for a decent, small rescue knife.

Preview the 17th Annual WMS Winter Meeting, "Wilderness & Mountain Medicine," which will be held at The Canyons in Park City, Utah, February 20-25, 2009.

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Cholera in Zimbabwe

Despite the pronouncements of Robert Mugabe, the President of Zimbabwe, it is apparent that there is a very significant outbreak of cholera in that country, and that it is not under control.

Cholera is a disease caused by an infectious agent that spreads in the general water supply when there is the presence of frequent contamination, such as occurs with the entry of sewage into a nation's water supply. General lack of sanitation is, of course, a contributing factor. Persons who travel to countries where there is little or no control of human wastes are clearly at increased risk in a time of cholera.

To make matters worse, panic has set in. Many Zimbabweans are fleeing their country, bringing cholera to their neighbors in Botswana, Zambia and Mozambique. In Zimbabwe, the death toll from this recent surge in cholera is probably over 1,000 individuals, given that there is almost certainly under-reporting. Soon, more than 20,000 persons will have suffered the disease, and the numbers could certainly go higher.

What has been done? The Zimbabwe health ministry's answer to the cholera outbreak was to shut off the public water supply in Harare, since it did not have the foreign currency to buy chemicals to ensure that the water supply was clean. Aid groups such as World Vision and Oxfam, and UN agencies such as UNICEF have taken up some of the slack by distributing food and water purification tablets, but these are stop-gap measures at best.This is a very sad state of affairs, particularly in light of the lack of food and sometimes shelter for the people of this impoverished nation.

So, anyone traveling to this region is advised to be extremely careful with hygiene, food preparation, sanitation, and choice of drinking water.

The Centers for Disease Control (CDC) distributes timely information about cholera, which includes the following:

Most persons infected with the bacteria that cause cholera suffer mild diarrhea or no symptoms. Less than 10% of persons infected with the El Tor biotype of Vibrio cholerae O1 have illness requiring treatment at a health center if they are adequately hydrated. However, if full blown cholera strikes in geographies where medical personnel are not acquainted with modern treatment methods, many people might die.

Cholera causes profound diarrhea and fluid loss. It has been characterized as a violent gastroenteric illness. Cholera patients should be evaluated and treated quickly. With proper treatment, mostly consisting of rehydration, even severely ill persons can be saved. Prompt restoration of lost fluid and salts is the primary goal of treatment. Delay to therapy can be fatal.

The symptoms of moderate to severe cholera are the hallmark profuse, watery diarrhea (sometimes referred to as "rice water stool") leading to dehydration, nausea and vomiting, muscle (particularly the legs) cramps, restlessness, irritability, signs of severe dehydration (such as dry mouth and tongue, thirst, "tenting" of loose skin, and altered mental status up to unconsciousness. A doctor or medic who examines a person with cholera will find a severely ill victim who is severely dehydrated, confused, in and out of consciousness, and unstable with low blood pressure, a thready pulse, and at risk of death.

Intravenous or oral rehydration are essential for recovery.

An antibiotic given orally will reduce the volume and duration of diarrhea. No other drugs for treatment of diarrhea (such as antimotility agents) or vomiting should be given.

Recommended antibiotics are:

The duration of cholera caused by Vibrio cholerae may be shortened by treating with azithromycin (1 g single dose), ciprofloxacin (1 g single dose; increasing resistance is being noted to this drug) or doxycycline (300 mg single dose) for adults, or trimethoprim-sulfamethoxazole for children (5 mg per kg, or 2.2 lb, of body weight, based on the trimethoprim component, for 3 days). Furazolidone is the antibiotic of choice for pregnant women. Furazolidone is administered in an adult dose of 100 mg 4 times a day for 3 days. The pediatric dose is 1.25 mg per kg of body weight 4 times a day for 3 days. Erythromycin may be used when other antibiotics are not available, or the organism is resistant to them. Resistant strains of the cholera organism are very common; for instance, in Bangladesh, cholera is resistant to tetracycline, erythromycin, and trimethoprim-sulfamethoxazole.

photo courtesy www.itn.co.uk

Tags: cholera, infectious diarrhea, Zimbabwe, wilderness medicine, outdoor medicine, healthline

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Thank You to A Chronic Dose for Grand Rounds

Thank you to A Chronic Dose for including my post about outdoor medicine and the environment in this week's Grand Rounds. Grand Rounds is a weekly compilation of health care posts from around the web compiled by a host, who goes to great lengths to make the collection informative and entertaining. This week, the readers are treated to posts submitted as the best of 2008. I highly recommend that you pay a visit.

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Outdoor Medicine and the Environment Redux

Earlier this year, I published a series of three posts based upon a commentary I wrote, entitled "Physicians and the Environment," that was published in the Journal of the American Medical Association. The commentary was an invited piece, and reflected some of my thoughts about current environmental issues and the role of the medical profession in achieving the education necessary to be able to intelligently respond to these issues. Recently, the AMA issued a statement supporting many of the concepts I presented in my commentary. Since that announcement, I’ve received numerous requests from readers of this blog to combine the posts into a single offering, which I offer here.

This post uses parts of my original commentary in JAMA to put this issue into context for the layperson, and so I am including the references where appropriate from the original commentary.

There is every reason for persons involved and interested in wilderness and outdoor medicine to be advocates for preservation of the environment. The entire concept of "wilderness medicine" is predicated upon the existence and improvement of wilderness areas, which are among the most pressured and rapidly receding parts of planet Earth.

In many circumstances in the past, the medical profession has responded to adverse situations of global reach, such as epidemic diseases, genocide, the threat of nuclear war and natural disasters. As the world’s scientists, governments, and businesses now confront the state of the environment, all manner of health care professionals also must be prepared to respond, because in the final analysis, health matters are integral to the predicament, predictions and discussion. Beyond being just a reliable resource, given the magnitude and complexity of issues as they relate to human health, the medical profession should accept the challenge of becoming a leader in the discussions and debates.

Despite our preoccupation with armed conflicts and the economy, the environment is perhaps today’s most pressing global issue, as it contributes not only to direct effects, but to other situations of concern, such as economic decline and civil disobedience. Environmental conditions contribute to the presence or intensity of many medical conditions, such as temperature-related morbidity and mortality, health effects of extreme weather events (e.g., storms, floods, tornadoes, hurricanes, and precipitation extremes) and their sequelae (e.g., oceanic algae blooms), ecological change (e.g., the potency of certain harmful plants, such as poison oak), starvation, allergies, pollution-related health effects, water- and food-borne diseases, and vector- and rodent-borne diseases.1,2

As we learn more, it becomes apparent that the full eventual effects of global climate change and other environmental issues are not necessarily easily defined or well predicted. There are multiple views surrounding every issue. Some of the most important issues that need to be continuously examined from every angle include global warming, depletion of stratospheric ozone and increases in ground-level ozone, destruction of forests, polar melting, deficiencies in water production and sanitation, and human population growth and dynamics.

There are and will be significant differences of opinions about what follows here. My comments are properly interpreted as being "pro-environment" or "green," leaning toward the perspective that advocates that there are significant environmental problems and that many of these can be attributed to the activities of humans. However, I most certainly acknowledge the rights and responsibilities of others to hold different viewpoints and opinions, and the value of their being skeptical about science and conclusions. The most important thing is that we do not become acrimonious or disengaged, because it will take all of our skills of observation, analysis, and collaboration to reach consensus on these matters in a timely fashion and in a way that promotes improvement, not conflict. The acts of remediation are expensive and potentially diverting (from other problems), so no significant change should be taken lightly.

Global Warming. Atmospheric accumulation of gases (predominately carbon dioxide, methane, nitrous oxide, and halocarbons) traps heat by the greenhouse effect.3 The Intergovernmental Panel on Climate Change predicted that average global temperature will continue to increase, and a major concern is the rate of warming.4 Compared with the century 1906-2005 required to raise the earth’s average atmospheric temperature by 0.56 degrees Centigrade, some suggest that only a decade may be needed to raise it another 0.28 degrees C.5 This rate of change has been created by burning fossil fuels in power plants and for transportation, a decline in carbon intensity reductions, and natural sinks removing a smaller proportion of emissions from the air.6 Each year, more than 1.2 cubic miles of oil, 3.5 billion metric tons of coal, and 100 trillion cubic feet of natural gas are burned worldwide, releasing 30 billion tons of carbon dioxide into the atmosphere.7 Without efforts to stabilize or decrease consumption of fossil fuels, the 14.9 billion metric tons of carbon emissions released by the United States, the European Union, China, and India in 2005 are projected to increase to 25.6 billion metric tons in 2030.8 Even if one disputes the precise numbers, we seem to be on an unsustainable spree of consumption. Is global warming due to rising carbon dioxide levels, and are these rising levels attributable to the activities of humans, or are these environmental "facts" part of a series of coincidences? We need to know the answer. How many barrels of oil, tons of coal, and cubic feet of natural gas can be extracted from the earth before we run out? At our current rates of consumption, when will this occur? We need to know the answers.

Depletion of Stratospheric Ozone. Chlorofluorocarbons and other ozone-depleting substances released into the atmosphere are major contributors to the destruction of ozone in the stratosphere. Depletion of the ozone layer exposes the earth’s inhabitants to increased amounts of harmful ultraviolet-B radiation. This contributes to skin cancer, cataract formation, suppression of the immune system, and damage to certain crops.9 This is counter-posed by accumulation of ozone at ground level, which contributes to lung disease and other health risks.

Destruction of Forests. Fires set to clear forests for agriculture and grazing release carbon dioxide, which is a contributing factor to global warming. According to the World Bank, approximately 22 million acres of rain forests are destroyed by intentional fires each year, accounting for approximately 20% of worldwide carbon dioxide emissions.10 Wildfires, often coinciding with droughts, generate additional atmospheric carbon dioxide.11 In preindustrial times, the atmospheric abundance of carbon dioxide was relatively constant at 280 ppm; in the 1950s, the level was 300 ppm; in 2006, it had attained 381 ppm; and in 2008 it is increasing.12 At what rate are these forests being re-planted? Can men and women continue to remove habitat, plants, animals, and minerals from planet Earth at current rates and be assured that this does not pose a catastrophic future for our populations of life forms? We need to know the answers.

Polar Melting. Consistent with the increase of global temperature, there is a loss of snow cover in the Northern Hemisphere, the amount of Arctic and Antarctic sea ice is diminishing, and glaciers are melting.13 Predictions suggest that in the next few centuries, sea levels could rise by as much as 17.8 cm to 6 m, and the Gulf Stream may be diminished or even eliminated.14 In low-lying coastal areas where populations cannot be protected by natural or artificial barriers, large numbers of climate refugees may be forced to migrate to other locations, thereby increasing population crowding. Global climate change also is predicted to contribute to flooding and fire risk; increase the intensity of cyclones (hurricanes) and heat waves; accelerate beach erosion and desertification; hasten species extinction; and diminish water and food (livestock, fish, and plants) availability.15 I have heard many arguments about animals, such as polar bears, that putatively face extinction because of hunting, habitat and climate change, loss of food supply, etc. Are important animal populations declining? Can or should we intervene in the decline of any species? What does history tell us about the effects of rising and falling sea level? We need to know the answers to these questions.

Deficiencies in Water Production and Sanitation. Sachs16 contends that global climate change will tighten the availability of water, and force migration of hundreds of millions of individuals over the course of a few decades. According to the United Nations, more than 5 billion persons on Earth may live under severe water stress by the year 2025.17 Currently, 1.1 billion persons lack adequate water worldwide, 2.6 billion lack adequate sanitation, and 1.8 million children die each year because of one or both of these deficiencies.18 The outdoors can be beautiful, marvelous, and a tonic for the body and spirit, but it can also be a cruel, terrifying environment of forced survival. What is the true status of our water supplies, nation by nation, region by region? We need to know.

Human Population Growth and Dynamics. The human population is increasing exponentially, which has an unprecedented global effect on ecology and biodiversity. This effect takes place through overharvesting, introduction of nonnative species, pollution, and habitat fragmentation and destruction.19 As large, developing countries face increasing energy demands, they will undoubtedly burn increasing amounts of fossil fuels. The environmental conditions and climate changes that have been touted as major influences on health may potentially involve millions of individuals being injured or killed by floods, tsunamis, and cyclones; tens of millions afflicted by poorly controlled diseases that might emerge as a consequence of unchecked vectors (such as mosquitoes); hundreds of millions malnourished due to desertification, loss of crops, and insufficient potable drinking water; and ultimately, poor health and the loss of prosperity as individuals are crowded into a reduced landmass that may be too small to reasonably support their survival.20,21 The worldwide growth of the human population dramatically increases the possibility of loss of life-sustaining resource bases during large geological and weather events in a manner that limits human survival. Simply put, the more pins standing behind the lead pin when the bowling ball strikes, the more that are vulnerable to being struck down and swept away. We need to be very thoughtful about this, because hunger and economic deprivation inevitably lead to conflict and even war. So, basic human needs may trump our desire to divert crops, such as corn, to alternative fuels. We are already witnessing these effects.

While there are a wide variety of opinions about the timeline for such events, the arguments supporting environmental trends are substantiated by reasonable scientific observations.2,22 Proponents of accelerating global climate change suggest that given the rapidity of changes and their unforeseen consequences, successful adaptation would appear unlikely and unattainable. The most viable solution is to halt the inexorable assault on the environment as quickly and effectively as possible. Arguments that do not support these trends are espoused by dispassionate and intelligent individuals, who also care very much about their planet, but do not necessarily agree with the scientific conclusions indicating human-generated planetary degradation and climate change. Which faction is correct? Issue by issue, point by point, we need to know. What might be at stake are the futures of species and resources that cannot be easily regenerated, if they can be regenerated at all. On the other hand, if there are better approaches than those currently favored by environmentalists, then let them be identified and implemented.

It is increasingly the case that environmental remediation recommendations are topics of great debate, for many reasons. Some reputable authorities do not agree with the proposed causation or acuity of environmental problems. Others astutely observe that some of the solutions proposed, such as diversion of crops for alternative fuels, may contribute to hunger and economic consequences that are more disruptive than expensive fuel, or even the consumption of fossil fuels.

Because the nature and magnitude of environmental changes have only recently come to be recognized, it is difficult to predict the attribution of inevitable to natural cycles, or whether the forces of nature are becoming unbalanced. Some suggest that while human activities have an effect on climate, there is not proof that this affects global temperature. For instance, there may be years during which global temperature declines. Others acknowledge the inevitability of global climate change, but recommend adaptation or geoengineering solutions.23 Opponents of those who predict irreversible global climate change and warming argue that until the precise nature and rate of these phenomena can be established, governments and industries should be tentative and cautious about making expensive policy decisions.24 Still, others point out that by focusing attention on global warming, there is a risk of not properly addressing more important environmental and health issues.

I am increasingly convinced that persons who argue against the magnitude and timing of global climate change are not doing so out of personal interests. They truly believe that our current surge in environmentalism is an over-reaction to a situation that may not be as dangerous as has been proposed. Wherein lies the burden of proof? Is it upon the conservationists, or those who demand data to support initiation of policies and practices with wide-reaching economic consequences? I think it is a shared responsibility. Beyond the data, we must certainly act with common sense.

Certain issues seem to me to be beyond calculated inaction. Developing alternative sources to substitute for fossil fuel consumption is widely supported. How can preservation of fossil fuels be bad, unless in the preservation, man unleashes some greater hardship upon the planet or its inhabitants? We are probably not yet at the stage where we should accept starvation in Africa as a consequence of our attempts to promote ethanol production for automobile fuel, but if we do not find a solution to pumping oil into our tanks, will be be creating even greater misery downstream? Despite the fact that there is almost universal assent and agreement on many issues, politics, economics, and special interests delay progress.

I cannot speak for everyone, but I have an opinion about the response needed from the medical profession. If one believes that there are situations upon which we should soon act, significant behavioral changes will be needed to begin to reverse apparent deleterious trends. Achieving global environmental change requires public and private efforts, led by a massive educational effort that should include all institutions of higher learning, including schools of medicine. By virtue of their knowledge and experience, physicians are rightfully concerned about individual and population health. However, the germs and disease processes with which we have become familiar may not pose as great a threat as what might result from such environmental eventualities as the melting of the polar caps.

It is my feeling that the time has come to broaden what the medical profession (and in particular, those with an interest in wilderness medicine) must learn, expanding awareness by educating physicians about the best environmental science. Given the hypothetical and known links of global climate change to human health, and the increasing concern that this change is accelerating, it is our duty to become informed.

Accordingly, in response to the environmental imperatives, an educational action plan is appropriate for the medical profession. Nelson25 noted about environmental studies, “ . . . the subject matter is all-encompassing. It includes . . . the air, water, minerals, soil, forests, oceans, lakes and rivers, as well as all living things in the seas and on land, the relationship and influence of each on the others, plus economics, politics, religion, culture, and philosophy. And, although we will never know or understand more than a small fraction of the endless intricacies of nature’s works, we can comprehend and learn the general principles that should guide our conduct as a society, if we are to preserve a livable habitat. The proposition is, quite simply, that we must conduct our activities in such a way as to protect the integrity of our ecosystems and their resources. . . ”

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 National Museum of Australia Canberra

REFERENCES
1. Patz JA, McGeehin MA, Bernard SM, et al. The potential health impacts of climate variability and change for the United States: executive summary of the report of the health sector of the US national assessment. Environ Health Perspect. 2000;108(4):367-376.
2. Confalonieri U, Menne B, Akhtar KL, et al. Human health. In: Parry ML, Canziani OF, Palutikof JP, van der Linden PJ, Hanson CE, eds. Climate Change 2007: Impacts, Adaptation, and Vulnerability: Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge, England: Cambridge University Press; 2007:391-431.
3. Collins W, Colman R, Haywood J, Manning MR, Mote P. The physical science behind climate change. Sci Am. 2007;297(2):64-73.
4. Parry ML, Canziani OF, Palutikof JP, van der Linden PJ, Hanson CE, eds. Climate Change 2007: Impacts, Adaptation and Vulnerability: Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel of Climate Change. Cambridge, England: Cambridge University Press; 2007.
5. Solomon SD, Qin M, Manning Z, et al. Climate Change 2007: The Physical Science Basis: Contribution of Working Group I to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge, England: Cambridge University Press; 2007.
6. Canadell JG, Le Que´ re´ C, Raupach MR, et al. Contributions to accelerating atmospheric CO2 growth from economic activity, carbon intensity, and efficiency of natural sinks. Proc Natl Acad Sci U S A. 2007;104(47):18866-18870.
7. Project Genie. Web site. http://www.projectgenie.org.uk. Accessed December 1, 2007.
8. International Energy Agency. Web site. http://www.iea.org. Accessed November 29, 2007.
9. Longstreth J, de Gruijl FR, Kripke ML, et al. Health risks. In: Environmental Effects of Ozone Depletion: 1998 Assessment. Nairobi, Kenya: United Nations Environment Programme; 1998.
10. World Bank Group. Pilot program to conserve the Brazilian rain forest. http: //www.worldbank.org/rfpp/overview/overview_what.htm. Accessed December 9, 2007.
11. Wiedinmyer C, Neff JC. Estimates of CO2 from fires in the United States: implications for carbon management. Carbon Balance Manage. 2007;2:10.
12. National Oceanic and Atmospheric Administration, Earth System Research Laboratory, Global Monitoring Division. Trends in atmospheric carbon dioxide. http: //www.esrl.noaa.gov/gmd/ccgg/trends/. Accessed January 15, 2008.
13. Nicklen P. Vanishing sea ice. Natl Geogr Mag. 2007;211(6):32-55.
14. BBC Weather Centre. Climate change. http://www.bbc.co.uk/climate/impact /gulf_stream.shtml. Accessed December 10, 2007.
15. Trenberth KE. Warmer oceans, stronger hurricanes. Sci Am. 2007;297(5):45-51.
16. Sachs JD. Climate change refugees. http://www.sciam.com/article.cfm? chanID=sa006&articleID=E82F5561-E7F2-99DF-36D3CB7EB5DA209C&ref=rss. Accessed January 12, 2008.
17. United Nations Water for Life. Fact sheet on water and sanitation. http://www .un.org/waterforlifedecade/factsheet.html. Accessed December 8, 2007.
18. World Water Council. Water crisis. http://www.worldwatercouncil.org/index.php?id=25. Accessed January 20, 2008.
19. Biodiversity & Human Health Web site. The effect of human population on biodiversity. http://www.ecology.org/biod/habitat/human_pop1.html. Accessed December 9, 2007.
20. Kerr RA. Global warming is changing the world. Science. 2007;316(5822):188-190.
21. Campbell-Lendrum D, Corvalan C, Neira M. Global climate change: implications for international public health policy. Bull World Health Organ. 2007;85(3):235-237.
22. Meehl GA, Washington WM, Collins WD, et al. How much more global warming and sea level rise? Science. 2005;307(5716):1769-1771.
23. Foreign Policy Web site. Why climate change can’t be stopped. http://www.foreignpolicy.com/story/cms.php?story_id=3980. Accessed December 9, 2007.
24. Botkin DB. Global warming delusions. Wall Street Journal. October 17, 2007;A19.
25. Nelson G. A clean environment and a prosperous economy: can we have both? J Wilderness Med. 1991;2(1):1-6.

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Search and Rescue and EMS in Utah's National Parks

The current issue of the journal Wilderness & Environmental Medicine, published by the Wilderness Medical Society, has a number of very interesting articles of significance to the layperson outdoor medicine enthusiast.

"Search and Rescue Trends and the Emergency Medical Service Workload in Utah's National Parks," by Travis W. Heggie and Tacey M. Heggie (WEM volume 19, pages 164-171, 2008), sought to identify the emergency medical service (EMS) workload and trends associated with search and rescue (SAR) operations in Utah's National Park Service (NPS) units. The information was gathered from annuals EMS and SAR reports for the years 2001 to 2005.

There were 4,762 EMS incidents, including 79 fatalities. There were 2290 SAR operations, including 67 fatalities. It is interesting to note that SAR operations most commonly occurred on weekends, involved male visitors in 59% of episodes, visitors aged 20 to 29 years in 23% of episodes (followed by visitors aged 40 to 49 years in 21% of episodes), and frequently were related to day hiking, motorized boathing, and canyoneering activities. Therefore, the environments included lake, desert, and canyon settings. The total cost of SAR operations recorded was $1,363,920.

In addition to identifying the specific parks needing EMS and SAR support, this study points out that there is a predictability to the nature of incidents, as well the expense of providing support. Interestingly, it was not possible to determine if the availability of mobile (cellular) phones, which were used to initiate 21% of SAR operations, made it easier to seek help and thereby somehow increased the number of operations. In more detailed analysis, the authors concluded that judgment errors, inadequate preparation and experience, physical conditioning, falls, and darkness were common factors contributing to the need for SAR. If for no reason other than this observation, the study is important support for education programs and resource allocation planning for EMS, SAR, and medical support in wilderness recreation areas.

photo courtesy of galleryone.com

Preview the 17th Annual WMS Winter Meeting, "Wilderness & Mountain Medicine," which will be held at The Canyons in Park City, Utah, February 20-25, 2009.

Tags: emergency medical service, search and rescue, Utah National Parks, wilderness medicine, outdoor medicine, healthline

Labels: emergency medical service, EMS, National Parks, SAR, search and rescue, Utah

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Stop Shark Finning

In a previous post, I described how impressed I am with a beautiful magazine, ASIAN GEOgraphic. Now I am even more impressed. ASIAN GEOgraphic and its sister journal, Scuba Diver AustralAsia, have jointed forces with ClubScuba, Malaysia Underwater.com and Underwater Studios to begin an online campaign against shark finning. ASIAN Geographic has also launched on online pledge against the consumption of shark fin soup. To join this pledge or find out more about the online campaign, visit www.asiangeo.com.

As I reported in the textbook Wilderness Medicine, the world’s shark populations are in danger from overfishing. Each year, more than 100 million elasmobranchs (sharks, skates, and rays), including 1.6 million metric tons, or approximately 3.5 billion lb of shark, or 10 million elasmobranchs for each human shark-related fatality, are killed in fisheries. Half of this total represents incidental by-catch (sharks caught in fishing nets or on longlines intended for swordfish or tuna). The National Marine Fisheries Service estimates that 20 million metric tons of marine wildlife are killed and thrown back into the sea as by-catch. This activity may double the estimated shark mortality figures.

Commercial fishing mortality of sharks in U.S. waters averages 20,000 metric tons (44,092,000 lb) per year. Great declines in shark populations along the east coast of the U.S. have occurred over the past two decades, a trend that is worldwide. Some commercially targeted species have declined by as much as 80%. The most dramatic declines were seen in dusky sharks. Innumerable animals are ground into fertilizer. More than 90% of captured sharks are discarded.

The fishery interest in sharks centers on the fins. These are of great value in the Orient, where they are made into shark fin soup, a traditional dish that signifies high economic status and is reputed to be an aphrodisiac. Interest in fins has also spawned the heinous practice of finning, in which a shark is captured, its fins are sliced off, and then it is returned to the water. Shark-fin soup is sold for upward of $150 U.S. per bowl. The prepared fins themselves may sell for more than $800 per pound. It has been estimated that 350 tons of shark fins may be consumed each year. The International Commission for the Conservation of Atlantic Tunas created a ban on shark finning in November 2004, to join the United States, which banned shark finning in the Atlantic Ocean in 1993 and in the Pacific Ocean in 2002, in such a prohibition.

To further imperil shark populations, shark flesh is a major food source in both developed (commonly the fish in European “fish and chips”) and undeveloped (artisinal fisheries) countries. Mako shark flesh is similar to that of swordfish and often serves as a more than adequate culinary substitute. To date, sharks are not farmed, so any sharks captured for any purposed are extracted from wild populations and there is no attempt made to replace them.

Websites where you can find out more about shark finning, shark activities and shark preservation include STOP SHARK FINNING, SHARKWATER, SharkFriends.com, Humane Society International, and the Shark Trust.

photo courtesy of www.stopsharkfinning.net

Preview the 17th Annual WMS Winter Meeting, "Wilderness & Mountain Medicine," which will be held at The Canyons in Park City, Utah, February 20-25, 2009.

Tags: shark fin, shark, shark fin soup, wilderness medicine, outdoor medicine, healthline

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Thank You to SHARPBRAINS for Grand Rounds

Thank you to SHARPBRAINS for including my post about muscle soreness as a side effect of statin drugs in this week's Grand Rounds 5:12 - Healthcare Reform Q&A. Grand Rounds is a weekly compilation of health care posts from around the web compiled by a host, who goes to great lengths to make the collection informative and entertaining. This week is no exception - great job!

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Muscle Soreness and Statin Drugs

Outdoor adventurers often exercise vigorously. So, it's pretty common to have post-exercise muscle soreness. For weekend warriors, who aren't conditioned to hike, trek, bike, climb, ski, or dive, it can mean extreme stiffness and sore arms and legs on Monday morning.

These days, increasing numbers of persons are taking "statin" (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor) drugs to control the level of certain lipids in their blood, and reduce the risk for cardiovascular disease (e.g., heart attacks and strokes). Perhaps the most common side effect (in up to 5% of persons) of these drugs is myalgia, which is pain or soreness in muscles, usually noted in the arms and legs. Certain statins, such as fluvastatin, are less commonly associated with this problem.

Because myalgia as a side effect of taking statins may be accompanied by muscle inflammation or tissue damage, it is important to make the diagnosis, and therefore, to be able to differentiate between muscle soreness from exertion (not related to drug effect) and muscle soreness from medication side effect. If one has recently (within two weeks) started taking a statin drug and is stricken with muscle soreness, it cannot automatically be attributed to exercise or exertion. One way to differentiate is to wait a couple of days while avoiding muscle exertion, and see if the soreness disappears. If you return to a normal pain-free state during this time period, the soreness is likely due to your exertion. However, if the soreness persists, you may have more going on - namely, a side effect from your statin medication. In that case, you need to contact your physician, who may decide that you need a physical examination and/or a blood test(s).

In a recent paper entitled "Toward "pain-free" statin prescribing: clinical algorithm for diagnosis and management of myalgia," the author, Dr. Terry Jacobson, described how medical professionals should, among other activities, monitor creatine kinase (a "breakdown product" created by muscle inflammation or injury) in the bloodstream as a measure of muscle toxicity and approach to statin prescribing. For persons interested in reading the original article, the reference is Mayo Clinic Proceedings 2008 June; 83(6):687-700.

Many health care professionals recommend that persons who take statins also take coenzyme Q10 supplements, on the rationale that myalgia may be in part related to inhibition by statins of endogenous synthesis of this coenzyme, which is felt to be important for energy production in muscle tissue. Its reputed clinical beneficial effect is mostly reduction in muscle soreness. The scientific evidence is sketchy, but there is anecdotal support for its use. For instance, in some circumstances, it is felt to allow a person to continue to take a statin drug, when he or she might otherwise be unable to do so because of the side effect of myalgia. Clearly more studies need to be done. To my knowledge, coenzyme Q10 has never been shown to diminish muscle soreness due to exercise or physical strain. However, this might also be amenable to study.

Preview the 17th Annual WMS Winter Meeting, "Wilderness & Mountain Medicine," which will be held at The Canyons in Park City, Utah, February 20-25, 2009.

Tags: coenzyme Q10, statin, myalgia, wilderness medicine, outdoor medicine, healthline

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NuMask

In the critical moment when you need to administer rescue breathing, there is not a second to spare. In every first aid kit, there needs to be a clearly marked, easily available rescue breathing kit, consisting of at least an intraoral "mask" to allow rescue breathing. The best of these allow air to flow in one direction only - into the victim - in order to prevent the victim's secretions (saliva, vomit, etc.) to travel back into the rescuer's mouth.

I was recently introduced to a new product that looks like it will have great utility "in the field," and certainly in the outdoor setting. NuMask is a novel intraoral mask composed of a cylinder through which breathing occurs and a flanged mouthpiece that slides easily into the victim's mouth between the gums and the cheeks, where it can be held in place by a single rescuer. The latex-free device comes in a configuration with a one-way valve for breaths administered from a rescuer's mouth, as well as a configuration that is two-way to allow placement of a bag-valve apparatus for medical rescuers such as EMTs or paramedics. Depending on the packaging, it may be paired with an alcohol swab and protective gloves (NuMask CPR Kit), or with an oral airway (adult or pediatric size for both the mask and oral [oropharyngeal] airway). The oral airway is used to maintain an open airway by controlling the tongue in an unconscious person who does not have a "gag reflex," which would otherwise cause him or her to vomit.

The NuMask was selected as a "hot product" in 2007 at the EMS Today conference, and I certainly agree. For medical professionals, it is available in a bag valve resuscitator kit, as part of a CPAP (continuous positive airway pressure)/BiPAP kit, and as a component of a nebulizer kit.

For the layperson, a barrier breathing assist device is essential. NuMask is an easily understood and useful device that should be welcome in any first aid kit if there is a chance that someone will need to assist with rescue breathing.

Preview the 17th Annual WMS Winter Meeting, "Wilderness & Mountain Medicine," which will be held at The Canyons in Park City, Utah, February 20-25, 2009.

Tags: NuMask, intraoral mask, rescue breathing, wilderness medicine, outdoor medicine, healthline

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Thank You to Mexico Medical Student for Grand Rounds

Thank you to Mexico Medical Student for including my post about a unique and important water filtration unit in this past 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 present them in an informative and entertaining manner.

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