RICE Revisited

Thanks to Dr. Gabe Mirkin, who gave us the acronym RICE, we have used rest, ice, compression, and elevation for musculoskeletal injuries for years. Then, for a while, we taught IRICE, adding ibuprofen to the acronym. Time hiked on, and we dropped ibuprofen, after learning the negative effects on healing from high doses of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. Now we have a small but suggestive study that could lead to dropping the second I.

The fact: we don't know when inflammation is a healthy response of the body and when it's not. We often try to suppress it, in brain injury being one example, in some heart attack patients being another.

This recent study was done on mice by well-respected researchers. The short version is this: 1) Ice slows the entry of macrophages into injured muscle. 2) Macrophages release IGF-1 which promotes healing. 3) Markedly lowered levels of IGF-1 are associated with delayed healing.

RICE will continue to be the standard of care, but watch the evolving literature on this question. Ice may be another do-do bird of medicine, like ibuprofen in high doses, a mask for pain that gets you back into action sooner, but which is mistakenly interpreted as healing.

Going Up

Thanks to a tip from my friend Tod Schimelpfenig at WMI of NOLS (www.nols.edu), I checked out an article--available free if you type "High Altitude Medicine and Biology" into Google--entitled “Incidence and predictors of acute mountain sickness among trekkers on Mount Kilimanjaro.”

Kilimanjaro, the highest point on the African continent at a smidge over 19,300 feet, is notorious for altitude illness due to the rapid altitude gain it requires. Schedules and park fees apparently drive people to make the ascent from just about sea level in 5-6 days. While the study has some significant limitations, it showed a high rate of Acute Moutain Sickness (45%) and no protective effects from a mid-climb rest day or from acetazolamide. The study suggests, but does not prove, that you can go so high so fast that an occasional rest day or acetazolamide does not help.

The study also reports that a large number of climbers continue to ascend even though they have the signs and symptoms of AMS. You will also see, should you choose to read it, a reportedly and amazingly high rate of High Altitude Cerebral Edema (18%).

David Shlims, MD, long a doc for the Himalayan Rescue Association, gave the staff of WMI three, simple, golden rules for altitude at the WMI Staff Meeting in 2007:

1) If you feel unwell, it is altitude sickness until proven otherwise.
2) Never ascend if you have symptoms of altitude sickness.
3) If you are getting worse, then descend immediately.

Wise words indeed.

Eyeball Injuries

Just a few days ago, my younger daughter, aged 7, and I sat in the office of the local eye doctor. She, the doctor, announced my child's distress was due to a scratched eyeball. And thus this blog. Scratches to the eye that do not involve any loss of sight--which the local doc made sure of--are best treated with an ophthalmic ointment and no patch. They usually heal faster, in a couple of days, without a patch, and foregoing the patch allows the owner of the eye to keep walking in the woods--if that's where you are--without being blind in one eye. I probably would not rinse the eye unless I had sterile eye wash. The abrasion will hurt, and tears will pretty much wash out the wound. A small, inexpensive tube of eye ointment is available OTC and a great idea for a first aid kit. Out there, tell the eye owner to keep sunglasses on as much as possible. If pain is really severe, however, after an injury to the eye, I would seek medical attention for the patient. I would, however, not necessarily place a patch over the eye. If I saw blood leaking from an open wound in the eye and/or if there is a loss of ability to focus that eye, I would seek medical attention also. Remember, however, the patient will be usually be light-sensitive, and that is not a loss of ability of focus. With a bleeding wound to the eye, I would patch the eye. If a hike out is then required, please assign someone to walk, at all times, with the patient.

Trekking Poles Revisited

Few are those who haven't at least heard of the advantages of trekking poles. The short version is this: You are better balanced, and that means easier walking with less energy required and fewer injuries. You may be taking a few pounds off your hips and shoulders. But are you maximizing the use of your poles? First, I suggest avoiding the straight grip. An ergonomic grip on your poles will be more comfortable, and your hands will be less tired. Some hikers with arthritic hands, as you might anticipate, report less pain with ergonomic grips. Second, be sure your poles have wide, comfortable wrist straps, and use them correctly, and use them all the time. In case you aren't sure: Put your hands up from the bottom of the wrist loops, up through the loops of the straps, and then settle the straps comfortably around your wrists. Snug them up--but not too up. Tight straps cut off blood and comfort, and too loose the straps do not work nearly as well as snug-fitting straps. The straps will take a lot of additional stress off your hands. Finally, you might possibly get an even easier "ride" with poles that have shock absorbers. But, yep, all the extras bump up the retail price quite a chunk. For more info: www.rei.com/expertadvice.

Being a Lightning Rod

Lately in these parts, a lot of discussion has been about what makes you more attractive to lightning, more likely to be injured or killed. Recent data indicates that human fatalities each year occur approximately half the time from the effects of the ground current (the human is not hit directly) while only about two to four percent occur when the human is the target. With ground current as the most likely culprit, you definitely want to limit your contact with the ground during a storm. The old "lightning position," huddled up on a non-conductive pad with your feet close together (although it has never been proven safer), is suggestive of being safer. If you are walking toward a safer spot with trekking poles, do not let them touch the ground during a storm. They may conduct ground current up into your body. Carry them in your hand and away from the ground or in your backpack. The old and basic principles of lightning safety still apply: look for the safest spot as soon as you start hearing thunder, stay out of the open, avoid being near large bodies of water, do not hang out beneath or even near tall isolated objects, and stay out of wet caves or overhangs. Look for low rolling hills or trees of approximately uniform height.

The Gaper

No, not someone who gapes, often with a dumb look on his or her face, but a wound, typically a laceration, that gapes open after being cleaned (with pressure irrigation). In the wild med biz, there has been a sort-of guideline stating a wound that gapes open more than one-half inch is best treated by being pulled closed and held in place with wound closure strips or improvised strips (say, from tape). There has been the birth of a new guideline: If the wound gapes open after cleaning, consider closing it with . . . well, you know the rest. If the wound has been well cleaned, there are several healthy reasons, way out there, to close it. It's more comforting to most patients, it usually heals better with less scarring, and it may reduce the chance of infection (since you have "closed the open door" that invites germs in).

Snakes Again and Again

With the season of the serpent well upon us, a couple of interesting (I thought) snake questions recently appeared on my screen. The first reader wondered if it was true that a pit viper will bite itself in order to kill itself if it knows it's dying anyway. People who know snakes much better than I do say "no," and, in fact, state that poisonous snakes are immune to their own specific venom. So, there you go. The second reader asked if putting kerosene on pit viper bites would help. Well, that theory goes back a long way, at least more than a century in U. S. where rural dwellers soaked snakebitten extremities in kerosene and didn't die. But so few people die from poisonous snakebite in the U.S. anyway, almost always less than 10 deaths a year from thousands of bites in recent decades, the I-tried-it-and-it-worked theory is useless. And, again, the experts are pretty sure, based on science, that a kerosene-soaked snakebite, although it wouldn't hurt, wouldn't help.

Evolutionary Diarrhea

Three or more loose or watery expulsions from your bowels in a day and most docs would declare you a sufferer of diarrhea. But today's question is not whether or not you have it but whether or not you should try to stop the rush of fluids from your GI tract. “Diarrhea is a natural cleansing and should not be stopped,” say a growing number of people. That might be true--more importantly, it might not. Some diarrheal illnesses may be simply though uncomfortably removing bad things from your body, and some may be a symptom of serious sickness, perhaps even a threat to your longevity. And sadly, out there in the wild places, we don't know for sure which is which. Therefore we take steps based on what we do know--and that means we do not treat all cases of diarrhea. We know that if the patient is threatened with dehydration from prolonged diarrhea, we need to try to stop the diarrhea. And we know if travel is necessary but hindered by diarrhea, we need to try to stop the diarrhea. Otherwise it's a matter of inconvenience, and let the natural cleansing continue. The whole idea, by the way, that many of our responses to health challenges are the result of evolutionary adaptations is a very interesting one. For more ideas such as diarrhea-as-cleanser can be found by typing "evolutionary medicine" into your search engine.

New Treatment for Rabies?

The 15 year old female in Wisconsin who recovered after being diagnosed in an advanced stage of rabies after a bat bite marked a milestone in medicine. According to the Centers for Disease Control and Prevention (CDC) this has never happened before. A few people have recovered after showing the early signs of rabies and after being given the rabies vaccine--but no recoveries from advanced rabies have ever been reported. Doctors induced a coma and administered a mixture of antiviral medications, the names of which I do not know. Could this be a new treatment worth using on the next patient with rabies? Who knows? Certainly the treatment will be tried again, and, if it works, the medical world will be closer to learning the answer.

With warming temps and larger numbers of bite-able humans going to the wild places, a few reminders about rabies, it seems to me, are in order:

- Regard all animal bites as a potential rabies exposure.
- Clean the wound thoroughly with soap and disinfected water.
- Evacuate all animal bites immediately for the initiation of the rabies vaccine.
- Avoid close contact with animals, especially if they demonstrate erratic or unusual behavior.
- A prophylactic rabies vaccine is available for people who work or travel in high risk areas.

Blisters Revisited

More and more here in Wyoming, the weather favors hitting the trails, and that makes it seem as if a few reminders on blister prevention (and a bit of fairly new data) could be in order. But first a pre-reminder reminder: blisters are formed where shear forces are at work, separating outer layers of skin from inner layers--and they probably form easiest on damp, hot skin. Logic would suggest, therefore, that anything to keep your feet dry and cool will help prevent blister formation. But that isn't true. Some things work, some don't. Reducing the shear forces on blister-prone sites, such as of course the heels of your feet, is preventitive and possible with moleskin and other products made especially to do the job, such as Blist-O-Ban. Lightweight liner socks that wick away foot moisture are also preventitive when worn beneath heavier socks. Tape can work, but blisters can form beneath tape, so beware. On the other foot, lubricating agents (such as petroleum jelly, mineral oil, glycerin) work for a brief period of time, about a hour, but then increase the risk of a blister by softening the skin. Drying powders seem like a good idea since they absorb moisture, but they typically clump and can form an abrasive surface--and are not recommended for most people. Antiperspirants work to prevent sweating, and some hikers love them on their feet, but whether they actually work or not to prevent blisters remains uncertain. And, finally, you are still wise to buy your hiking footwear late in the afternoon, when your feet are puffiest, and make sure your boots fit.

When Ca-Ca Fails to Occur

A nephew of mine, a young one, wound up hospitalized recently due to a lack of doo-doo. Okay, not really a lack but a failure for it to appear. He was seriously constipated. Extended periods of time with no bowel movements, and the nasty stuff we want on the ground can become even nastier inside of a GI tract. And fatal cases of constipation are not that unusual--although they are usually related to drug use and more common in the elderly. It is not out of the question, however (and it has happened), that you could face an evacuation decision (stay or go) when your assessment is constipation. The patient typically reports several days of inadequate hydration. You may have to curiously dig for more info than the standard SAMPLE history will supply, going back over a week of history. High fat diets (say cheese) and low dietary fiber may also contribute to constipation. Combine those factors in someone who is hesitant to squat in the wild outdoors, and you have a formula for serious constipation. You can try increasing hydration for the patient, adding fiber, stimulating the bowels with caffeine or alternating cold fluids with hot fluids. But if vague abdominal pain in the lower quadrants increases, perhaps becoming less vague, and especially if a fever develops, you have someone on your hands who needs to be in other hands--those of a hospital-based physician. My nephew, by the way, seems to be on his way to wellness, thank you.

Putting Salt in a Wound

Well, actually, no, I am not advocating putting salt in a wound. But there was a time when many of us, including me, thought a hot salt water soak for a dirty and/or infected wound and salt water gargles for a sore throat or a dental infection were beneficial, or at least more beneficial than plain water. Perhaps, we said, bacteria were dehydrated by salt, and died. And we kind of figured that salt water would draw germs from an infected wound because body fluid, being less salty, would flow out into salty water as nature sought a balance. Then one day someone asked for evidence--and there was none, not even from the docs who had recommended salt water for medical use in the wilderness. Now we know the salt not only fails to help, it dehydrates the healthy tissue along the edges of wounds, possible slowing the healing process and certainly not helping. So, save the salt for improving the taste of food and remove it from your list of first aid uses.

Apologies

When you have a "real" job, which I think I do, it's simply amazing how quickly the days pass between postings. Once upon a time--and for more than 20 years--I worked in the field of wilderness medicine--and that was all I did to earn a living (and my mom still asks if that was a real job). Now I have to be on campus and at least near my office every morning by 8:30-ish. Otherwise the administration of Central Wyoming College becomes . . . well, suspicious. It is, to say the least, astounding that it's been almost a month since I posted.

In that month, however, I received the third edition of Wilderness First Responder, one of only two books I've written that has (1) not only persisted but also (2) received an award for being well written (that award coming from the American Medical Writers Association). It has once again been adopted for another year by NOLS (National Outdoor Leadership School) as their text for WFR courses, despite the fact that the picture on the front cover shows a young man pulling an elastic wrap onto an extremity instead of rolling it on, something that disturbs me a bit. Anyway, you can find the book by clicking on Buck's Books back on my home page or going directly to www.amazon.com. And if you check here regulary, I apologize for being away.

Does Your Dog Bite?

You might be surprised--or maybe not--to learn that dogs bit to death an average of 19 human beings in the United States every year between 1979 and 2005 inclusive of '79 and '05. You might be further surprised to learn that dogs inflict wounds on humans more than 4 million, yep million, times per year. Although the fatality rate is low, a lot of bites cause permanent scars (physical and emotional), serious infections, and, generally speaking, a bad time for the patient. Almost all of the biting dogs are domestic (not wild) and they are pets (not aimless wanderers in search of a handout), and many of the bitten are owners of the biters. I have a sweet little dog, a Corgi, and he wouldn't bite a flea--okay, maybe a flea--but in some situations could he become a biter? Here are some points to ponder:
__Do not smile at a strange dog. A show of your teeth could be considered aggression.
__A dog holding its head high usually is curious. A dog with its head held low usually means potential danger.
__Never run away. It signals the dog to chase you.
__Speak firmly: "No," or "Go away."
__Do not face a threatening dog and make eye contact. Stand sideways to the dog and watch it peripherally--it's less challenging to the dog.
__Do not extend your hand for a threatening dog to sniff. Despite lots of opposing opinion, it gives the dog something easy to bite.
__Remain still and at least appear calm. Most dogs have short attention spans and will soon lose interest in you.
__If the dog bites, attempt to stay still. Struggling tempts the dog become more vicious. Most dogs, even after delivering a bite, will eventually lose interest and leave the area.

Ibu to the Rescue

A recent study reported in the Annals of Emergency Medicine 2009:54 revealed that children aged 4-18 years who had suffered fractured arms and who were treated with ibuprofen experienced less side-effects (not surprising) and less pain (very surprising) than children--same ages, same injuries--who were treated with acetaminophen and codeine. Who wudda thunk it? The dose of ibuprofen, by the way, was 10 millgrams per kilogram (2.2 pounds) of body weight. It's a bold extrapolation, yes, to say anyone in pain treated with ibu (over-the-counter) will suffer less than if treated with acetaminophen and codeine (prescription)--but it certainly seems worth a try. And out there in the wilds ibuprofen is often our only choice. I will certainly use it with even more confidence than in the past. You can read more about the study and Paul Auerbach's thoughts on it at www.healthline.com/blogs/outdoor_health.

Neck and Neck

An argument heard at least now and then at gatherings of those who at least think themselves savvy in the ways of wilderness medicine concerns the effectiveness of improvising a cervical collar with a SAM Splint (http://sammedical.com). Whether you are pro or con, take a look at Wilderness and Environmental Medicine (Volume 20, Number 2, 2009). You'll be able to read a report on a study done by McGrath and Murphy comparing a Philadelphia cervical collar (used on ambulances) with a collar improvised with a SAM Splint. The results, briefly stated, suggest the SAM Splint, used according to the directions that come with the device, are, once again at least, as effective as the Philadelphia collar. The study, in case you're interested, tested motion of the neck in extension and side to side. Personally, I have been teaching use of the SAM Splint as an improvised cervical collar for just about 25 years. I will continue to do so--but with renewed confidence.

Back At It

No blog since November 10? In case someone was wondering if I had died, the answer is no, but I felt, now and then, sort of like I was. My lumbar spine, slowing giving out over the past decade or so, gave up completely. The first signal was pain in the posterior region of my acetabulum, the back of my right hip. Gradually the pain moved down the outside of my thigh, under my knee, and down my shin to the top of my right foot. "Classic presentation," said the spine surgeon in Billings, Montana. I said the pain, classic or not, was keeping me pretty much off my feet. So he operated, removing bits of my lower two vertebrae and a smidge of my sacrum to make room for the nerves to emerge freely. I am quite happy to report I feel like a new man--or at least a man with a new lower spine.