The End of the Line

It's painfully obivious that I have not been blogging for a long time. Life, frankly, has become far too busy, and I'm not going to pretend that it will change any time soon. If, however, anyone wants to chat, please give me a call on my cell: 307-349-8371. I hope I'll be at "the end of the line."

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).