WFA in the News

A meeting of the minds of the largest providers of wild med training, an effort spearheaded by Tod Schimelpfenig of the Wilderness Medicine Institute and David Johnson of Wilderness Medical Associates, produced a first draft of minimum requirements and scope of practice for wilderness first aid. Several attempts to produce such a document in the past failed despite the fact that, as Tod says, in his opinion, ". . . the content of the major providers is very consistent." Tod continued: "Conversations with David Johnson, MD, of WMA over the past year, and the actions of the BSA WFA curriculum project led us to sense we are at a tipping point and should move forward on these questions of standard content." Perhaps at last the time has come for a national standard. I have certainly witnessed a few near misses. If you're interested in taking a look at the document, send me a comment with the email address you wish it sent to. And you can read more at www.wildmed.com/blog/is-there-a-standard-in-wilderness-medicine-training/.

H1N1

It may be impossible to avoid contact with H1N1 (the piggy flu) or with at least some flu virus this year. But you can avoid allowing the virus to proliferate enough to cause disease. Keep in mind the pathways for the germs to enter your body are the nose and mouth, and keep in mind these six preventative outdoor and/or indoor steps:
1. Wash your hands often (and if you haven't gotten that message, you are from off-world).
2. Keep your hands off your face unless you are eating or bathing (and wash your hands before eating).
3. Gargle twice a day to rinse out germs that might have entered your mouth. Listerine works fine, but so does warm, salty water.
4. Blow your nose at least once a day. A quick swabbing with salt-water-soaked cotton would be even better.
5. Get enough vitamin C via fresh fruits and veggies and/or supplements.
6. Drink plenty of warm fluids, such as coffee and tea, every day. It's sort of like gargling in reverse. Flu germs in your mouth are flushed into your tummy where they cannot survive.

Bagged Arms Go Numb

A question that comes across my desk semi-often is this: why do my arms go numb from the elbow to the hand after a night in my sleeping bag? The numbness usually can be explained by the fact that people sleep differently in their bags. With less room, they curl their arms at the elbows and often at the wrists as well, especially if they snooze with their hands tucked under their chins. This position, if prolonged, will irritate the median and/or ulnar nerves, and the result is numbness. On the positive side, nothing serious is happening, and soon after the arms are straightened, the numbness goes harmlessly away. If folks had rather avoid the problem, they can try a bigger and/or more insulated bag. Bigger, of course, means more room and less need for elbow flexion. More insulated could mean sleeping warmer with less need to curl up to hold in body heat.

Charlie Houston

On September 27 Charles Houston, MD, slipped away peacefully in his Vermont home at the age of 96. As a pioneering mountaineer, he had few equals. First ascents of Foraker and Nanda Devi were his, and numerous other climbs in Alaska and the Himalayas. A fine writer, Houston's book, K2: The Savage Mountain, chronicling his second expedition to the world's second highest mountain, is a true classic in mountaineering literature. But Charlie Houston contributed most profoundly to the world through his unprecedented research into high altitude medicine. He is indeed credited with the first identification of high altitude pulmonary edema. Houston established and for ten years directed altitude medicine research on Mount Logan in Canada. Much of what we know today and depend upon when we acclimatize to high altitude or treat those who have not acclimatized can be traced to roots on Logan. A classic in wilderness medicine literature, Going Higher: Oxygen, Man, and Mountains, was written by Houston. I remember him best as a kind man who generously answered all my questions when I was young in the field of wild med. I will miss him.

Sprained Ankles

Sprained ankles remain one of the most common wilderness injuiries--and if you're surprised, you haven't been paying close attention. A recent study strongly suggests that severely sprained ankles recover more quickly when the ankle is completely immobilized in a rigid cast that keeps the ankle in the position of function--for a short time. The study does not specific exactly what a "short time" is, but you can read more about it at www.healthline.com/blogs/outdoor_health. In the meantime, we can rest assured that properly applied elastic wraps fall far short of immobilization. Elastic wraps, however, are far better than nothing. And if you've mastered, or at least partially mastered, the art of "immobilizing" a sprained ankle with athletic tape, we can extrapolate and say that a great ankle-taping job, a job often performed by athletic trainers and less often by Wilderness First Responders and WEMTs, will speed healing and promote usefulness far better than an elastic wrap. Sprained ankles are going to remain common for a long time, but we can add even more weight to the skill of taping a sprained ankle in the wilderness.

Two-Step Disinfection

The lapse in blogs, and please forgive me, arose from classes starting back at Central Wyoming College where I teach. I was asked today about two-step water disinfection processes. There are several, but of specific interest this afternoon was the combo of filtering and adding chemicals. Which should you do first? No hard science tells us. Here are some thoughts: If you use your filter first, you'll remove quite a few "things," including larger germs, leaving your chemical with less demand being put on it. Speaking much more practically, it's simple to filter some water, say, out of a lake, and then add a chemical. Not so easy, it is, to collect water, add a chemical, and then, after waiting the appropriate amount of time, use a filter. But throw this into the mix: if your filter has a charcoal (carbon) stage, using the filter second will remove the unused chemical--and its taste and smell.

How to Die

My newest book, How To Die In The Outdoors: 110 Grisly Ways to Croak, can be ordered pre-publication now at www.amazon.com. Here is an excerpt:

"One of America's greatest losses, bison (Bison bison) once flowed like a vast, hairy sea, numbering in the millions, from the Alleghenies to the Sierra Nevada, from southern Texas to the Great Slave Lake in Canada, wandering in search of grass and water. Resembling old world buffaloes, North American bison are a different species distinguished by massive, shaggy heads and shoulders and relatively small hindquarters. A mature bull may reach 6.5 feet in height and weigh in at more than a ton. Unmolested, they are a docile group, what remains of them, not given to harming humans.

Often viewed with pet-like affection by tourists to areas where they are protected, bison are sometimes pressed too closely by humans, arousing their sense of preservation, a survival instinct that has caused bison attacks in parks to outnumber bear attacks by more than four to one. Thundered into by the huge weight and muscle of a bison, you'll go somersaulting, coming to a stop battered, bruised, probably broken, and often dead. In addition, a horn or two will have gored you, in the butt if you’re running away, in the abdomen if you face the charge. Your day will really fall apart if you happen to disturb an old bull whose herd follows nervously after him. In such a case of trampling, depending on the size of the herd, what is left of you may be difficult to recognize and separate from the chips of dung that typically litter bison feeding grounds.

To Live: American bison rarely charge a human unless they approach to within 25 feet or less.

To Paste or Not

Leon Nelson, dentist and mega-avid backpacker, recently shared a few thoughts about toothbrushing, and I found them highly informative--and interesting. When thinking of your teeth, start by remembering that the source of all gum disease and tooth cavities is plague, a film of bacteria that forms on your chompers. Healthy teeth and gums require you to disorganize the plague at least once every 24 hours. To do this you do not need toothpaste--but you do need to brush, says, Leon, for at least four (4) minutes. And you do need to floss once a day. Brushing should be with a regular toothbrush, and you should clean the cheek side of your teeth for two (2) minutes and the tongue side for two (2) minutes. Flossing, continues Leon, should be up and down and not back and forth. But, hey, is it okay to use toothpaste? Sure, but leaving the paste at home you save weight, attract no bears with your minty white stuff, and the paste, according to Leon, does not make your teeth cleaner if you follow Leon's Dry Brushing Plan. He does further suggest, however, that a 30-second dry brushing now and then removes food sticking to your teeth, undoubtedly to some benefit--at least socially.

Stroke? Stick Out Your Tongue

A stumble and fall on the trail could have numerous causes including, more likely of course in older hikers, a stroke. Remember an individual can fall, rise up, seem fine (without a closer check), and collapse later. For years the first three letters of STRoke have served as a reminder of ways to check the patient for indications of stroke.
S: ask the patient to Smile.
T: ask the patient to Talk, to repeat a simple sentence such as "It's a sunny day today."
R: ask the patient to Raise both arms.
A fourth indicator of stroke should now be added to your checklist. Ask the patient to stick out his or her tongue. If the tongue goes to one side or the other, instead of straight out, if the tongue looks "crooked," you have another sign that a stroke has occurred. If any one of the four subtle indicators is present, the patient should be kept at rest and help should be summoned ASAP. The sooner the patient arrives at a hospital, the greater the chance of survival!

Paddling PFDs

Over the past week I paddled a string of lakes in northern Wisconsin with family and friends (and it was an excellent vacation). I was also reminded, while reading an article in a local paper, about the importance of wearing PFDs. Of all the drownings recorded so far this year, only two of the fatal events involved people in PFDs, and those drowning were in whitewater. PFDs save lives! But yours needs to fit properly and be appropriate for the activity. To get the best fit, buy from a reputable dealer and ask to be fitted. Fit-wise, it is especially important that your PFD is not too loose: you can slip out of it and/or find yourself floating with your head too low in the water. Activity-wise, the USCG approves five types--Types I-V (www.pfdma.org). Type IV is throwable and Type V is for "special use," and both types are seldom appropriate for paddling. With Types I-III, the lower the number the greater the flotation. Type I PFDs are recommended when you might be drifting a long time waiting for rescue, and they are heavier and less comfy than Types II and III. Type II will give you plenty of flotation in almost all paddling conditions, but they are not as comfortable as Type III. Most paddlers end up with Type III. But consider safety first, and choose wisely.

The Recovery Sock

"Compression" shows up commonly in medical conversations. It's uses have been well known for more years than even I have. Compression prevents, or at least significantly reduces, venous stasis (blood pooling in areas where you don't want blood to pool). It, in other words, promotes healthy circulation. The use of compression in athletics to encourage healthy blood flow and thereby reduce lactic acid buildup and, more than likely, increase performance to some degree is relatively new technology. Enter the Recovery Sock (http://recoverysock.com) and I wore a pair on my last adventure. They are padded in the high impact areas, and the compression they provide decreases gradually, and appropriately, from toe toward knee. It has literally been years since my feet have felt as good after a bout of use. Some of you know I have a fused ankle, and a puffy right foot and ankle are among the prices I pay for staying on the trail. I removed the socks each night to find a greatly reduced amount of swelling. Do they do what they claim to do? I can't say for sure about everything, but I can say that Recovery Socks will be on my feet in the foreseeable future. They are pricey at about $35 per pair, but the benefits as I see them are worth the dough.

Numb of Toe

"Numb toe," most often the big toe, and even more often the outside of the big toe, is a pretty common complaint I hear from hikers. The cause, again most often, is an improper boot fit. Or maybe those same boots are not laced snugly enough. Either way, on the downhill leg of trails, the part where toes are smushed against the toe end of the boot, this happens: the nerves of the toe are crushed and/or the circulation gets cut off too long--and the toe gets numb and stays numb. If it happens occasionally, it's not a big deal. But if it happens all the time, and especially if the toe does have enough recovery time before the next hike, you should try to find a boot that alleviates the problem and/or try lacing up more snugly. Go for boots that are wider in the toe box and/or boots that are a bit longer than the offending footwear. If that doesn't work, custom insoles may alter the pressure on your toes enough to keep numb toe away. And if that doesn't work, a visit to a foot specialist is recommended. Persistent toe numbness may lead to permanent damage.

Adios Iodine

The European Union has banned the sale of iodine as a water disinfectant as of 25 October 2009, a decision that will affect all 27 countries that are members of the EU. Will this decision lap over into the United States? Who knows? The potential for a global impact certainly exists. The use of iodine in field water treatment has been questioned by some authorities for years, primarily due to the lack of definitive info--is it safe? or is it not safe?--and so far I have not found any reasons clarifying why the EU made their decision. The Centers for Disease Control (CDC) still approves use of iodine but warns the use should be limited to no more than "a few weeks." Consumption of iodinated water remains contra-indicated for pregnant women, anyone with a history of thyroid disease, and anyone with a known allergic response to iodine. You can find a few more details at www.outdoorindustry.org.

Ticked Off

Recently a disease transmitted by a tick developed into encephalitits (an inflammation of the brain) and a human being died. The case was reported in the New England Journal of Medicine (http://content.nejm.org). It is not usual for an encephalitis to be the end result of a tickborne illness--the disease can, in fact, produce very few symptoms--but obviously death does sometimes occur. Ticks may also be carrying other diseases, such as babesiosis, Rocky Mountain spotted fever, and Lyme disease, that occasionally become a serious threat to life. The bottom line: it is that time of year to be wary of ticks. Most insect repellents, despite the knowledge that ticks are not insects, repel ticks. Wear light-colored clothing, allowing you to see free-ranging ticks and pick them off before they embed. After a walk outside, a careful inspection for ticks on your body is highly recommended. Remember ticks like to embed in well-hidden spots, and ticks in the nymph stage, when they are incredibly tiny, can pass germs--you will do well, therefore, to have a friend help you with the inspection. Remove all embedded ticks immediately with sharp-pointed tweezers, grasping the tick perpendicular to its long axis, and gently pulling it straight out. If an illness develops after removing an embedded tick, seek a physician's evaluation ASAP.

Don't Get Sunburned

And now for a moment (or two) of blatant self-promotion: my new book is out and available for purchase. The title is Don't Get Sunburned: 50 Ways to Save Your Skin. It's all about how ultraviolet light damages your skin, how ozone depletion increases the chance of damage, and about how to keep from getting damaged. In case you didn't know, there's a new UVA rating system for sunscreens (the old system only rated protection from UVB) and I cover the new system and things like the effects of UV light when altitude, wind, latitude, season, and skin wetness are added to the equation. There's info on skin types, baby skin, already-sunburned skin, and skin cancer. The price: $7.95--and the cover is as pink as burned epithelial tissue. You can see more at www.mountaineersbooks.org.

A Death in the Family

On 28 April John Evans, a complete mountaineer and rescue ranger on Denali, a wonderful gentleman, and a great friend died in a climbing accident in Wales. I had the immense privilege of working several patrols on Denali with John, the last in the spring of 2008. In past years, we had taught together, climbed together, and sipped quite a few fine drams of single malt together. He was the kind of man you could not help loving, and I will miss him tremendously. I chose to post the news here, knowing many of you never had the pleasure of meeting John Evans, but feeling the need to send out a few words in quiet celebration of his life. Thank you for listening.

The Sunglasses Myth

Tod Schimelpfenig over at NOLS has been investigating the notion that cheap sunglasses can keep your pupils dilated and cause sunburn of the retina. Experts questioned by Tod agree this is a myth. Simply stated, not enough radiation is going to reach the retina to cause a burn, even with intensely reflected light from snow, and even with really inexpensive sunglasses. But there's more at risk than your retina! If your cheap sunglasses have low UV protection you most likely will increase your risk of injury to the cornea--the risk of snowblindness. And, over time, the risk of cataracts, macular degeneration, and even eye cancer. Cheap sunglasses, however, can have high UV protection, which is, of course, what you want--and need. Bottom line: Your sunglasses need to provide protection as complete as possible from all ultraviolet light, and they need to wrap around to keep UV light from creeping in from the side. You don't have to pay a lot of money for protection, but you do have to pay a lot of attention to what you're purchasing.

Fight or Flight: Lion Attacks

Mountain lions, according to a recent article in Scientific American (www.ScientificAmerican.com), may be less likely to attack if you run away. This, of course, is contrary to popular expert opinion. The article reports a study done by Richard Coss, an expert on predator-prey relations, that involved 185 lion attacks between 1890 and 2000. Coss said 43% of people who stood still facing a lion were injured compared to 17% who were injured while fleeing. The study does admit, however, that those who fled had a slightly higher chance of being killed, although he reports that only 18 people actually ran. Half of those who ran escaped without injury. Coss did not study encounters with mountain lions or near-attacks from lions.

I'm confused. First, he does not define "attack" and "near-attack." Were the 185 people pounced on? Or did they just "feel" attacked? Second, he says the people stood still. That's not what you're supposed to do. You're supposed to shout and scream, show your teeth, stand tall, and, finally, counter-attack with sticks and stones (to less than claw range) if the lion charges.

Bottom line: Almost all experts remain convinced that cats chase things, and usually catch them. So, I won't run. And I won't just stand there. Besides, I'm really slow.

Big Bite Protection

Although snow threatens to fall on Lander today, there are places where the sun shines warmly and bears are starting to wake up. They wake up hungry. And even though humans remain way down on the list of choice items to break a bear's fast, numerous questions related to staying safe in bear country have flowed onto my screen in the past week. Here are several:

If food has spilled on a sleeping bag, could the smell attract a bear? Answer: Yep. Don't eat in or near your bag, wash it when food has spilled on it, and don't even sleep near the clothes you cooked and dined in.

Can you outrun a bear by running downhill? Answer: Nope. They are more clumsy and slower going downhill than up, but they are still a lot faster than a human, even a really scared human.

Does the odor of DEET attract bears? Answer: Nobody knows for sure. No bear has ever been seen showing interest in DEET products. DEET does not smell like food, so the chances of it drawing a bear to you are slim.

Will bear spray repel snakes? No snake repellent has ever been licensed as a product, but people report bear spray drives snakes, even venomous snakes, away. If you feel threatened, shoot for the snake's face. For more info: www.peacemakerpepperspray.com.

A Pain in the Tooth

My wife Kat had been complaining of pain in her mouth for about two weeks while I, the questionably considerate husband, kept repeating absurdities that all resembled "Hey, suck it up." Then, several mornings ago, she woke me to display a red right cheek obviously swollen from about an inch below her eye to the line of her jaw. She stated emphatically--and convincingly--that the pain was now intense. The dentist could see her the next day. She swallowed the strongest painkillers we had on hand, which helped a little, and applied cold packs to the cheek, which helped a bit more. She rinsed her mouth with warm, salty water. She kept complaining. Inspection revealed no discoloration of the gum near the pain site, even though I now suspected I would see it. The dentist diagnosed an abscessed tooth, prescribed an antibiotic, did a root canal to remove the diseased nerves and pulp, and filled the empty space. If this had occurred way back in the wilderness, there isn't really anything else you can do. However, the infection in an abscessed tooth can migrate and become, in the worst-case scenario, a threat to life. You need to recognize one, and evacuate the patient ASAP. (Early assessment could also, possibly, improve marital relations.)

No Gas Shortage

Reading recently that the average human passes gas about 14 times every day caused me some thought. Mostly I asked myself: how did they figure that out?--and I decided I like my current job just fine. The report stated that this gas normally does not smell bad. Ah, at least the researchers have that going for them. Wilderness flatulence is rarely a problem, other than socially, but it has greatly disturbed a few high altitude climbers. At higher elevations, gas expands more quickly, causing, sometimes, a great deal of pain, a problem dubbed High Altitude Flatus Expulsions (HAFE). If gas proves a problem, here are a few tips: eat smaller meals, take it easy on fats, and leave the bubbly drinks behind. (I have seen more than one party on Denali lugging a sled full of Coke and beer.) And when you're packing your food bag, cut down on foods containing beans, eggs, meat, and cauliflower, sources not only of gas but of smelly gas. You might also like to know that exercise helps keep your bowels moving smoothly and with less gas. Consider, finally, packing an anti-gas product such as Beano (www.beanogas.com). Save on gas!

UV Light Disinfection

A busy schedule, much of it keeping me away from computers the past month, has caused a marked decrease in my postings. Hello to all who have checked back in--and thank you for your patience.

With the increasing use of ultraviolet light devices to disinfect water an increasing number of questions about the devices have hit my screen during my absence. If you follow the manufacturer's directions, you're pretty much assured safe drinking water (see www.steripen.com). But what about the water on the outside of the bottle? It's not safe. Only the water inside the bottle is disinfected, and that does not include the water trapped in the threads of a standard water bottle. If you wipe the threads dry with a clean cloth, however, you will remove most--maybe all--of the pathogens trapped there. In other words, a thorough drying of the threads and it is highly unlikely you'll get a waterborne illness. On the other hand, the safest bet of all is to use a container other than your water bottle to scoop up the water you'll be disinfecting. A cup you'll be washing later will work fine.

Tooth Talk

Someone asked recently if it's really possible to replace a tooth that has been knocked out of a mouth--or is the idea just wishful thinking. Fact is you can probably get the tooth back in the empty socket if you don't dally. Hold the tooth by the crown (the white part) and gently rinse it clean. Do not scrub it clean. The tooth's owner should rinse his or her mouth clean with water, as if rinsing the mouth after a tooth brushing, spitting out, of course, the rinse water. Be sure to orient the tooth correctly, and press it gently but firmly into the socket. It should settle in with a soft and satisfying little "click." This does not necessarily mean the tooth will survive--but it does have the best chance in the socket. If you can't get the tooth back in the socket, save it, preferably in milk (yes, that story is true), but water will do. However, an hour or more away from a dentist and the tooth is unlikely to be successfully replaced.

HAPE Country News

High Altitude Pulmonary Edema (HAPE), a non-cardiogenic form of pulmonary edema, remains a threat to people who ascend quickly to elevations above 2500 m (8250 ft). In a recent report in Wilderness & Environmental Medicine, Vol 19, No 4, 2008, the journal of the Wilderness Medical Society (www.wms.org), Drs. Stream and Grissom briefly reviewed a study showing inhaled salmeterol reduces the risk of HAPE in HAPE-prone individuals by 50 percent. (You' ll have to chat with a doc about a 'script for salmeterol.) But, more importantly, it was reported that there is nothing new in the preferred treatment for the problem: patients who descend 500-1000 m (1650-3300 ft) and/or who are treated with supplemental oxygen at a rate high enough to keep their oxygen saturation at 90 percent or more, get better--given adequate time. Those patients on O2 should avoid strenuous activity as well.

An Abrasive Thought

New evidence suggests a long-held belief might not be as worthy of being held onto as we have thought. I just returned from a short trip to Dallas (actually Irving, TX) where a group met to discuss wilderness first aid (and I hope to report more on that later). One topic was abrasions, a wound typically causing the patient pain--sometimes more than a little--when it is scrubbed clean. According to Dr. William Forgey, an application of an antibiotic ointment applied liberally within 10-15 minutes of the injury and you do not need to scrub. The ointment penetrates the skin, promoting the resistance of infection while protecting the site--and patient's so treated may actually develop an infection less often than when scrubbed. Doc Forgey did recommend removing large particles contaminating the wound prior to applying the ointment. You can brush those particles out with sterile gauze. And he further noted that we need to be ready to scrub if the wound is older than the 15 minutes (or so) time limit.

Two People and One Bag

The temp dropped to zero again in Lander, and that might help explain the return of an annual winter question: are two people in one sleeping bag effective when one person is hypothermic? Despite the popularity of this proposal, snuggling is not a great warming method. The warm person adds very little heat, certainly not enough to reverse significant hypothermia quickly--and there are possible negative results. Two people seldom fit into one bag, and if you can't close the bag, heat retention is lost. If the heat donor wants out, much of the heat that has been retained is lost when the bag is opened. The warm person might be more useful making hot water bottles for the cold person, building a fire, or carrying out a message asking for help. It is not necessarily "wrong" to put two people in one bag, but neither is it the "standard of care," and there are usually better things to do.