2010 Medical Wilderness Adventure Race (MedWAR)

The race series for the 2010 MedWAR events have been announced! MedWAR is a unique opportunity for you to learn about and test your wilderness survival and medical skills through a combination of wilderness medicine and adventure racing. These races usually sell out 3-4 weeks in advance.

Check out the following resources on MedWAR:

• Upcoming schedule of their races
• Mission and objectives of MedWAR
• MedWAR slideshow

A woman slipped and fell on the ice three feet in front of me. While she was lying on the ground in great pain she reported that she was recovering from a hip replacement. I had my hip replaced a couple of months ago and thus knew she was at risk for a femur fracture. She said it felt like her femur broke. I immediately rushed into action using my WFR skills by having someone dial 911 (we were in front of a drug store, one building over from the Cleveland Clinic where I had just had an MRI on my hip). I also immediately used my WFR skills by protecting the woman from would-be rescuers. The ambulance arrived in under 3 minutes, and she was transported the one block to the ER at the Cleveland Clinic. Turns out she did have a femoral neck fracture. So, thanks for the wonderful training, and know that if we had been more than 2 hours from a hospital I would have done more than call 911. Phil and Robyn’s lesson that many times the best thing you can do is “protect the patient from other rescuers” was very pertinent in this case b/c two would be rescuers first reaction was to try to have her stand up and “walk it off”. Not a good idea with a femur fracture…. Also, their constant reminders of the difference between street reaction (e.g., call 911) and field reaction immediately came to mind.

I do not believe that you should have a particular concern regarding work at altitude because of the recent concussion per se.

Also frequently referred to as a traumatic brain injury (TBI), a concussion is commonly diagnosed clinically when a person experiences any loss of consciousness, confusion, or amnesia following a blow to the head.  Increased intracranial pressure (increased ICP) or brain swelling is the anticipated problem or what we worry about afterward.  The swelling results from bleeding or the accumulation of edema (fluid) in brain tissue.  The early symptoms of increased ICP include persistent vomiting, worsening headache and deterioration of one’s mental state.  It does not sound like you had these symptoms or have this problem now.

Do you have any other symptoms now?  Frequently, following a blow to the head, even without ever experiencing a concussion, people can develop a post concussive syndrome (PCS).  The symptoms of PCS include headache, insomnia, feeling more tired than usual, blurry vision, light sensitivity, difficulty concentrating, feeling off balance, and emotional liability.  These are not signs of increased ICP; they can last for weeks.  If you have any of these, they could get worse at altitude and thereby potentially make you more accident prone.

People who go to altitude, especially over 3000 m (9800 ft), are at risk to develop altitude-related increased ICP called high altitude cerebral edema (HACE).  This is related to the lower oxygen levels and in part, to the resulting reflex increase in brain perfusion or blood flow.  Theoretically, I suppose, if you were continuing to have a slow blood leak from your injury, it could increase in size more quickly as a result of going to 3100 m.  But without ICP symptoms now, this seems very unlikely…unless you sustain another TBI.

I do not know whether a TBI with or without PCS makes one more susceptible to HACE. I doubt it but I could find no substantive references one way or the other.

Bottom Line

If you are feeling fine, go for it and have a great time.  Remember, the best way to minimize altitude symptoms is to ascent gradually, especially over 2500 m (8200 ft).  In addition, increase your physically activity as you acclimate to the new environment.   Some good rules include:

1.  If you can, before sleeping above 3000 m, spend a night above 1500 m (5000 ft).

2.  Above 3000 m, don’t sleep higher than 300 – 500 m (1000 to 1650 ft) above your previous night’s sleeping altitude.

3.  With each 1000 m (3300 ft) in altitude gain, add a rest day and/or sleep at the same altitude for 2 consecutive nights.

If you want more information on altitude, check out The International Society of Mountain Medicine.  They have a nice summary.

After spending some time and given the resources I have at hand, I cannot give you a satisfactorily accurate answer.

Hydrocortisone is available in a pill form and is used particularly by people whose adrenal glands are absent or not functioning properly.  In this form it is rapidly absorbed in the gut.  4 mg of hydrocortisone equals 1 mg of prednisone.

Hydrocortisone is sold for topical use (on the skin) either as 0.5 or 1% creams or ointments.  1 gm of 1% topical hydrocortisone is equal to 10 mg of hydrocortisone.  That would give you nearly 300 mg in a 1 ounce/30 gm tube or, theoretically, the equivalent of 75 mg of prednisone.  What I don’t know and what I was unable to find out easily is what happens to hydrocortisone topicals on ingestion.   The cream is water soluble so, at least theoretically, it is more easily absorbed in the gut than the ointment. In addition, I could not find any pharmacokinetic (movement of a drug through the body) data about rates of absorption from the gut or subsequent blood levels and I have no idea what happens with either when exposed to digestive enzymes.  Aside from nausea and vomiting or diarrhea, the poison control literature suggests that a mouthful is not likely to be toxic.

So yes, theoretically, it could help but any potential effect would be unpredictable.  By the way, a tube cost about 5$US; thirty 20 mg tablets of prednisone tablets are less than 10$US.  I think you know what I would choose.

As you may have seen, ‘The Man’ has been traveling around the globe- climbing trees, swimming rivers, hiking trails, helping those medically needy, and even spreading some holiday cheer!

It took us, in the WMA office, a long time of pawing through these amazing photographs to finally decide one which ones to select for the three $100 cash prizes, but we have come to our decision. Thank you to the many contestants who submitted photos and shared your stories!

Winners of the $100 Cash Prizes

Click on the photos above to see their full entry.

Honorable Mention

Thank you to Josh Martin and Paul Cunningham at Northern Cairn who submitted the very first entry and came with the idea of holding this great contest. What a wonderful way for instructors, students, and others to interact and compete for some cash!

Stay tuned to see what contest we will be holding this year!

This past December the Annals of Emergency Medicine published an article by Herbert and Hayes (2009; Volume 54 #6: p 831) in which they argue that a protective layer of denim over the skin may help to decrease the severity of an envenomation from a defensive strike by a southern Pacific rattlesnake. (I leave you to view the details and decide for yourselves.)   In their study, after provoking a test snake, they presented it a latex glove filled with warm water, one time bare and another time covered with a denim glove.  After a bite, they measured the venom in the water within the latex glove and, when used, on the denim glove.  The order of the trials were randomized and occurred 2 weeks apart.  They found that the amounts of venom measured were consistently and significantly greater from the larger (greater than 66 cm in length) versus the smaller (less than 55cm) snakes.

In the discussion section, they point out the volume differences as well as information from other sources that argue against the smaller is more dangerous theory.  Included are the facts that larger snakes are more likely to strike and that their strikes are more accurate.  Large snakes have longer fangs with larger hollow spaces allowing for deeper penetration and more venom flow.   They cite references (that I did not check) that claim that larger snakes cause more serious envenomations.  Herbert and Hayes state:

Thus, the more effective antipredator deterrent of bites from larger snakes may explain why they resort to biting more readily than smaller snakes.

And maybe Homo sapiens don’t learn to stand back.

Bottom Line

Although the results from this study do not definitively answer the question about size it does lend some scientific basis for debunking an unfounded belief.  Practically, of course, it does not really matter.  The anticipated problem of a venomous snake bite is an envenomation.  There is no good way to predict beforehand who will be envenomated, and if so, how bad it will be.  We treat what we see.  By the way, some skin covering, like denim, seems better than none.

Click to enlarge.

Somewhere deep in the woods near Camp Dandelion, future WFR’s bring in the New Year on snowshoes.

Robin Nesbeda, WMA lead instructor, sent in these submissions of ‘The Man’ surfing through the holidays on a family vacation.  Click on the pictures to enlarge.

Today is the last day to submit your photos for consideration. 3 $100 cash prizes are at stake. If you would like to submit your last minute entry, please email webmaster@wildmed.com with your picture and a caption.

Congratulations to the students that received their WFR certification on December 16, 2009!

Even though some people are reluctant to carry epinephrine (delivered via autoinjectors like Epipens or a syringe) into the field, it continues to be the treatment of choice for anaphylaxis, a life threatening allergic reactions involving multiple body systems.  Specialty groups in Australia, Canada, the UK and US, have published position statements emphasizing this point.  Even relatively conservative organizations, including the American Red Cross and the American Heart Association, have advocated for training lay providers in its administration.  And yet, fear abounds, but not for medical reasons.  The fear is based on presumed legal issues.  The reason and questionable logic for this position is a topic for another blog.

Antihistamines like diphenhydramine (e.g., Benadryl) are often an effective treatment for simple urticaria (aka hives, welts, whelps).  Although urticaria frequently accompany anaphylaxis, they are absent in nearly a quarter of the cases.  While an antihistamine may suppress the urticaria that can accompany anaphylaxis, they will not reverse the life-threatening upper airway, pulmonary or vascular manifestations.  To suggest otherwise is incorrect and potentially dangerous.  Plus, there are many non-allergic causes of urticaria.

Transmucosal (through mucus membranes in the nose and mouth) administration represents a major step forward for some medications.  This route is potentially a great alternative to pills and awful tasting syrups for kids.  Medications administered this way are also better tolerated by people with nausea and vomiting and could be absorbed more quickly.  I have no experience with the strips and could not easily find information on their pharmicokinetics.  One web link from ABC news suggested that they would also be helpful when a reaction occurs in the mouth.  I think that advice is of questionable value.  An allergic reaction in the mouth with swelling can result in difficulty swallowing.  That sounds like anaphylaxis to me.

Transcutaneous (through the skin) is another potentially useful method for medication administration.  It has been particularly valuable for medications that need to be released slowly over time, obviating pill schedules or the need for needles and expensive pumps.  Current formulations of diphenhydramine cream are meant for topical (surface only) and not transcutaneous use.  They are poorly absorbed through the skin and therefore do not have predictable or significant absorption.

Cost seems to be the biggest downside of the strips, about 1$US as opposed to less than 0.1$US for an equivalently dosed capsule of generic diphehydramine.

Bottom Line

If your friend’s reaction to tree nuts is predictably simple urticaria, isolated to the trunk or limbs, an antihistamine in any form (other than a cream) should be equally effective.  Why pay more for the strips if they are no better?  But remember, allergy related urticaria can progress to signs and symptoms suggestive of airway, lung or vascular involvement at any time.  If they do, think anaphylaxis; think epinephrine.

I still believe that properly trained people should have epinephrine available when they are traveling outside of easy access to EMS.  It becomes essential if you are traveling with anyone known to have allergies to substances that could be encountered on the trip.