Commentary on rabies case report

Last week I read an interesting case report with commentary in one of my favorite wilderness medicine publications, Morbidity Mortality Weekly Review*.   Although the case may be a bit arcane for many, I believe that there are some practical points for consideration for both novice and experienced practitioners.

The report describes a case of rabies in a 16 year old male, recently arrived in the US from Mexico.  At his first visit to an emergency department (ED) he had a low grade fever (38.1°C), tachycardia (pulse of 140/minute), sore throat, agitation, and some abdominal tenderness.  Prior to discharge he was given intravenous (IV) fluids, presumably for dehydration suggested by his tachycardia, blood work, and refusal to eat or drink.  He returned “several hours later” afebrile (37.3°), still tachycardic (160), agitated and uncooperative.  He was spitting frequently and refusing to drink so more IV fluids were administered.  A psychiatric evaluation was considered but it is unclear if one actually occurred.  Depression was one of his discharge diagnoses.  He continued to deteriorate and subsequently collapsed the next day at his aunt’s home and died in spite of resuscitative efforts.

Although in retrospect rabies jumps out as a possible diagnosis, I imagine that this was a difficult situation.  Unless we travel outside the protection of our sheltered lives few Western practitioners will ever see rabies.  It is not high on the differential list for a sore throat for most of us.  This case was further complicated by the fact that the staff needed a translator to communicate with this person.   Here are some points worth considering:

  1. High fever bad, low fever okay – This is a commonly held notion.  People do irrational things like dunk screaming kids into cool or tepid baths, give inadequate doses of antipyretics (e.g., acetaminophen/paracetamol, ibuprofen), and alternate those medications.  We keep kids in the ED until their temperatures decrease, fret when they do not and breathe a collective sigh of relief when they do.  But it is not the height of the fever that matters as much as the associated symptoms and clinical setting in which one appears.  In this case, his heart rate increased and his mental state worsened as his temperature normalized.  He was sicker with the lower temperature.   
  2. Behavior change equals a psychiatric problem – What practitioner hasn’t fallen into this trap?  This case is the definition of delirium.  It is why our psychiatric colleagues always ask for medical clearance.  The kinds of problems posed by a case like this would be compounded for any person with little clinical experience, working in a remote environment.  It is one of the reasons that people running outdoor focused youth-at-risk programs, for example, benefit from practical medical training that focuses on how to delineate the difference between a serious and non-serious problem; a  medical versus a psychiatric one.  Abnormal brain function is a serious problem.
  3. Put a size 12 foot into a size 10 shoe – Pre-hospital training has been too heavily focused on a limited number of specific conditions.  The more training the longer the list.   (Of course, these are never called diagnoses.)  If it doesn’t fit, the practitioner either the blows the problem off as nothing or tries to make it fit one on the list anyway, even if it does not make sense.  This is a side issue; I am not suggesting that it happened in this case. 

In wilderness medicine, clarity trumps precision.  It is much more important to be clear about the urgency of a situation than it is to have a precise diagnosis.  Oftentimes we just don’t have the diagnostic tools or therapeutic interventions.  The thing that jumps out here is the persistent tachycardia and abnormal, worsening mental state with seemingly bizarre behavior.   Fever or not, this kid was not right in a serious way. 

Please don’t misinterpret my intent here.  I am neither bashing the practitioners involved nor suggesting this would have been easy for me.  These are the stories that leave many of us sleepless and humble.  I plan to comment on this further next week. 

*Ellis E, et al. Imported human rabies – California, 2008.  Morbidity Mortality weekly Review 2009;58:713

Where’s the Man?: Ilulissat, Greenland

wherestheman greenland

My wife snapped this picture a couple of days ago at the edge of the Ilulissat Ice Fiord in Ilulissat, Greenland.  My wife, daughter and I have been here competing in the Greenland National Kayak Games.  It has been an unforgettable experience.
– Marcel (WFR Graduate)

Don’t forget! At the end of the year, we will select the 3 best submissions. The winners will receive $100 cash prize.  Send in a picture of yourself wearing your WMA course t-shirt to in order to be eligible for the prizes.

Wilderness First Responder to the Rescue

A Wilderness Medical Associates graduate of a Wilderness First Responder (WFR) course utilizes his training and helps a climber by performing a shoulder reduction at 10,000 feet!

mountain climbing“I thought that I would share with you an event from this past weekend in which I was able to use my WFR training.  While Deanna and I were climbing a 5.7 route on Cathedral Peak in Tuolumne Meadows, a climber above us suddenly screamed out in pain.  He felt said pain while trying to make a mantle move onto a ledge.  He immediately asked me for help; knowing the scene was safe, I climbed up to him, got him to a safe place on the ledge and helped him sit down.  I told him that I’m a [Wilderness First Responder] and asked if he wanted me to take a look at what might be going on with his shoulder.  During my bilateral eval, I determined that his shoulder was likely dislocated.  Since it was an indirect injury of the joint, I told him that I could reduce it, and explained to him the process and pain relief benefit.  He asked me to do it, so I helped him to a lying down position (thankfully it was a big ledge) and started the reduction process. It only took two minutes or so to reduce the injury, and as expected, he felt immediate relief from the pain. I told him that I wanted to sling and swathe the arm, and then haul him the remainder of the way to the top.  (Thankfully I was only looking at 40 feet or so, which with a 5:1 mechanical advantage pulley system isn’t all that terrible.)  He didn’t want to be rescued any more than necessary, so he said he was going to try to climb the remainder by himself.  I told him that my offer stood if he changed his mind.  He was able to make it the remainder of the climb (a 5.6 crack).

I’ve thought a lot about this situation since then only to realize how things would have been very different had Deanna and I not taken the WFR course.  Not only did that course give us the specific tools to deal with such emergencies, but I have never felt more competent to provide medical care in wilderness context or otherwise. (And I didn’t even suffer any ASR, sympathetic or otherwise! {smile})  That said, I want to thank you once again for the great training.  I’m sure you’ve heard more than enough such stories, but I thought that you might like to hear another.  I hope this finds you well.”

This story was also featured in the August 2009 issue of Journal of Mountaineering on page 18.

Wilderness First Responder Training Prepares for the Real Thing

Stock 2007Scott, who attended a Wilderness First Responder (WFR) course submitted this experience with us. Thanks for the great story!

Shortly after my WFR course with Wilderness Medical Associates, I got a call on my radio at our summer camp that a golf cart had just flipped going backwards down a hill.  The scene was exactly like the ones we covered in our course.  There were people running around with ASR, two people lying on the ground with (minor) head injuries (they were both fine, stitches but nothing else).

The scenarios in the course were amazingly accurate, and very helpful.  It took a second to realize who needed the most help, but once all of the knowledge kicked in I handled the situation as well as I could have. Although we are just on the edge of wilderness (a summer camp 15 miles from a hospital, but rather remote) the training was perfect.

Instructor Training Class of 2009- Saranac, NY

Nine new instructors graduated from the Wilderness Medical Associates instructor training program held in the beautiful Adirondack Mountains June 19-21st.  They bring to the company significant patient care experience, impressive back country resumes, and varied teaching experience.  We are delighted to welcome them to the WMA family and applaud their energy, fun-loving spirit, and commitment to provide the highest quality wilderness medical training.

The group includes: adirondack IT 2009

  • Ben Dowdy, WEMT-P, Kentucky
  • April Grisetti, PA-C, WEMT, New Mexico
  • Greg Hern, WEMT-P, Massachusetts
  • Bill Miller, WEMT-P, Maine
  • Cory Morse, WEMT-P, Maine
  • Brian Patten, WEMT-B, Michigan
  • Tony Shope, WEMT-P, Nevada
  • Alan Sleight, WEMT-B, Maine
  • Rekeisha Watson, WEMT-B, Michigan

Where’s the Man?: Damariscotta River in Maine

wheres the man scoutMichelle Murphy, an instructor for WMA, sent in this great photo of her daughter, Scout, experiencing her first paddling adventure on the Damariscotta River in Maine. Alongside Scout is WMA instructor Gabe Gunning.

Don’t forget! At the end of the year, we will select the 3 best submissions. The winners will receive $100 cash prize.  Send in a picture of yourself wearing your WMA course t-shirt to in order to be eligible for the prizes.

The National Conference on Wilderness Medicine

mountain-destination-walsAbout the National Conference on Wilderness Medicine:

Mountain Destinations will be hosting the 23rd annual National Conference on Wilderness Medicine between July 29, 2009 and August 2, 2009 in Big Sky, MT. The objective of this conference is to teach both practical and theoretical skills to medical/outdoor professionals and enthusiasts. After completing this course, participants will have the knowledge to describe, assess, and  treat medical problems and emergencies that are frequently encountered in wilderness settings.

Wilderness Medical Associates’ Curriculum Director, Jeffrey Isaac PA-C, will be conducting a wilderness workshop at the conference on Technology in Wilderness Medicine and Rescue on July 31.

Wilderness Advanced Life Support (WALS)

There will be a Wilderness Advanced Life Support (WALS) course offered as an optional class between July 28, 2009 and July 31, 2009.  The Wilderness ALS course will be conducted by WMA instructors Jeff Isaac, Will Smith, and Fay Johnson.

Useful Resources on the National Conference on Wilderness Medicine:

Click Here Register Online for the National Conference on Wilderness Medicine.

Huyck Preserve: A Natural Treasure

About Huyck Preserve

Huyck Preserve is a non-profit organization on 2000 acres  just southwest of Albany, NY.  Along with miles of trails to hike and enjoy, there is an abundance of wildlife and natural treasures, making Huyck Preserve a wonderful place to take a wilderness medical course.

huyck-logo“Our mission is to protect the natural beauty of the Rensselaerville Falls, the watershed of Lake Myosotis and surrounding lands, to conduct long-term research on natural systems as part of a global effort to understand and preserve the Earth’s biodiversity, and to increase appreciation of this effort through innovative, field-based educational programs for students, teachers and the community.”

Huyck Preserve’s dedication to preservation, education, and research is beyond admirable. For information on how you can do your part in keeping the Preserve unspoiled, visit Huyck Preserve’s membership page.

Upcoming Wilderness Courses at Huyck Preserve

huyck-2We are excited Huyck Preserve has chosen Wilderness Medical Associates for their first Wilderness First Responder (WFR) and their Recertification courses. Their first course, the full WFR, will be held between July 29, 2009 and August 5, 2009. Following the WFR class, Huyck Preserve will be offering an Open Recertification course between August 7, 2009 and August 2009. During the Open Recertification course, those holding a valid WMA certification may recertify a Wilderness Advanced First Aid (WAFA), Wilderness First Responder (WFR), or a Wilderness EMT (WEMT) certification. If you are a prospective student that was last certified through another organization, you may only recertify a WFR.

Wilderness First Responder Training Saves a Life

Ann Dunphy, a lead instructor for Wilderness Medical Associates, submitted this story to us regarding a student from a recent Wilderness First Responder Training:

I just needed to share a beautiful WFR story.  In the morning of day 4, my student Mike came in and told me we saved his mother’s life. He started with “Ann you always say, saving a life one drill at time.”

Mike is in his mid 50’s and called his folks the night before as his mom was scheduled for minor heart surgery.  His dad told him, “your mother fell and hit her head, she’s got a pretty good goose egg.”

Having just learned about TBI/ Increasing ICP, Mike told his dad what to watch for.  Sure enough,  within two hours, she developed a severe headache and vomiting.  His dad would have just let her go to sleep without monitoring her.  She was air lifted out, had neurosurgery, and is doing fine so far.

You just never know when you can impact a student.  As tired as I may get while teaching, this is why I teach for Wilderness Medical Associates.

Ann Maureen Dunphy
WMA Lead Instructor