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.