Adirondoc – ADIRONDOC

Hooked

December 23, 2025 adirondoc

2025, Winter Adirondac Adirondoc

a fishing hook and a finger

As a long-time vegetarian, fishing is not one of my outdoor pursuits. Yet, I have had plenty of experience removing fishhooks from unfortunate anglers or their bystanders. As I suspect that many readers may encounter this problem themselves at some point, it seems like a good topic to review.

Many experii;mced anglers have encountered errant fishhooks enough themselves to have their favorite removal methods. I would never suggest altering a technique that one has found works well. What I will share is a techn•ique that is frequently described in the wilderness medicine literature, and one that I have used in the field successfully.

The operative term here is “in the field.” I have also removed plenty of hooks in my days working in emergency departments, and there is one big difference between these settings: availability of local anesthesia. Removing hooks is a painful procedure, regardless of method, so the ability to eliminate pain by an anesthetic takes away the major barrier to removal. Once the area around the entrance wound is adequately anesthetized, one can choose almost any method, and undertake it slowly and deliberately. For example, the oftdescribed method of advancing the barb upward through intact skin, cutting it off with pliers, and then backing out the remaining hook is easy and effective in anesthetized skin; attempting this in the field without anesthesia, regardless of recommendations in some first aid texts, is extremely painful and difficult.

The method I am describing, often called the “string/yank,” is suitable for most embedded hooks, except those on loose tissue (e.g., earlobes), or anywhere on the face, especially near or in the eye. I suggest that anyone unfortunate enough to have a hook in such a location be evacuated for definitive treatment in a medical facility. The same recommendation applies to hooks deeply embedded in the palm of the hand, as damage to important structures can occur as the hook is removed.

The advantage of the “string/yank” technique is that it is quick-enough so that the pain is intense but fleeting, if it is done correctly. To begin, tie a piece of strong cord (such as fishing line) around the midpoint of the bend of the hook. Secure the cord tightly around your hand or wrist, while keeping it in line with the shank of the hook. With your other hand (or, better, the hand of a helper), depress the eye of the hook such that the shank is parallel to the skin surface. When all is positioned, give a quick, strong yank on the cord. The hook should come out with ease. Keep in mind that the hook will fly out very quickly, so be sure to take precautions (such as eye protection) to ensure that someone else is not “hooked” as it comes out. The technique is shown in the illustration. There are also several online videos describing the method; this is my favorite: ADK.org/ string-yank.

Once the hook is removed, the wound should be treated as any puncture: clean it with soap and water, apply a topical antibiotic ointment, and observe for any sign of infection .. A recent study in the journal Wilderness and Environmental Medicine (2025, 32:166-170) demonstrated no benefit to administration of oral antibiotics after these injuries. We should also say a word about tetanus prevention. Fishhook embedment should be considered a potentially ”tetanus-prone” injury. The organism that causes tetanus can be found in mud, on lake bottoms, and on stream edges. Puncture wounds are more of a tetanus risk because it is challenging to irrigate their depths. This means that the immunization recommendations for tetanus-prone injuries should be followed. Although a tetanus booster within the past ten years is adequate for most wounds, individuals with tetanus-prone injuries should have a booster if their last one was more than five years previously.

a diagram showing how to remove a hook from a finger

~Tom Welch, MD, is a physician at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide, and a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog, adirondoc. com.

Download PDF

Topics: General First Aid, Hygiene, Infections, emergencies

Continue Reading →

Take a Shot

July 13, 2025 adirondoc

2025, Summer Adirondac Adirondoc

cartoon image of a woman with a shield and germs and bacteria approaching her Although I have covered the topic of immunizations for backpackers a few times in the past, it is an area of medicine with rapid developments and as such demands occasional updates. At a very basic level, immunizations are a method of teaching our immune system to recognize a potential disease-causing microbe and disable it before it can result in disease. Most disease-causing microbes enter our bodies either through the respiratory tract (e.g., influenza, coronavirus, measles) or gastrointestinal (band to mouth) tract (e.g., polio, hepatitis A, norovirus). Camping provides an ideal setup for such diseases to spread: sleeping closely together in tents, group food preparation and eating, limited options for hand washing, etc.

Most infectious diseases require a period of incubation in the body before disease actually develops; this period ranges from a few days to over a week. Thus, if one is exposed on a weekend campout, the patient will likely be back in the front country by the time symptoms develop. On extended treks, however, the potential for disease spread within a group is substantial, and symptoms could begin in remote areas.

We should begin with immunizations for the common respiratory illnesses: influenza, coronavirus, and respiratory syncytial virus (RSV). Although most of the public attention recently has been directed at coronavirus, all three of these are very common conditions, and while for most healthy adults the diseases they cause are bothersome but not serious, they are each capable of causing severe illness and death. Globally, these illnesses account for about 2.5 million deaths annually.

All three are mainly spread by the inhalation of infectious particles in the air from the cough secretions of other infected individuals. I can imagine no more effective way to accomplish this than by several folks sharing the small enclosed space of a tent for several hours!

The influenza and coronaviruses mutate (change) frequently, so vaccines are continually “tweaked” to target the most current strains. This results in the need for annual immunization for both of these. The RSV vaccine is new. A one-time dose is recommended for everyone over seventy-five years of age and anyone over sixty years of age with an underlying medical condition. There is no reason why all three cannot be administered simultaneously.

Another vaccine-preventable respiratory disease is caused by the bacteria Pneumococcus. Although this produces a severe disease, it is not “contagious” in the same sense as the other three, and not a particular concern to the camper. All adults over fifty should receive immunization for Pneumococcus (imprecisely called “pneumonia vaccine”).

Although gastrointestinal infections are by far the major cause of trek disruption (reports of widespread norovirus infection in back country travelers are exploding, as we have discussed previously in this column), very few of these are vaccine-preventable. One exception is hepatitis A, a serious liver disease which can be spread by contact through water and food. There is a very effective vaccine available for this disease; it is probably a reasonable choice for anyone, although there is no elevated risk for North American backpackers. Travelers to specific other regions, however, should definitely receive this.

I am frequently asked about two other conditions associated with outdoor pursuits. Rabies is an exceedingly rare but almost uniformly fatal disorder associated with exposure to some wild animals. Although certain occupational groups (zoo workers, veterinarians) receive routine rabies immunization, the vaccine is otherwise only given (always along with rabies immune globulin) on a case-by-case basis after animal exposure. Local health departments have clear protocols for deciding when to advise the vaccine, and should be consulted immediately after exposure.

Tetanus is actually the vaccine about which I receive the most questions. This disease results when wounds become contaminated with a specific bacterium. Everyone should have a tetanus vaccine booster every ten years. For most wounds, a tetanus vaccine within the past ten years should suffice. Physicians will recommend a booster for anyone with a particularly complex and dirty wound if the vaccine has not been given within the past five years. Such injuries are virtually unheard of in backpacking, and if they were to occur, they would be seen by a physician anyway. Today, tetanus vaccine is typically given combined with some other diseases (diphtheria, whooping cough), which while serious themselves are not specific concerns to the back country user.

For anyone today, the annual visit to one’s health-care provider should be an opportunity to review and update immunization status. As I have said before, this may be the most important part of the pre-trek physical examination. Finally, remember that these recommendations are only for North America. Increasingly, folks are extending their travels to more exotic locations. These present the risk of a host of diseases, many unheard of by most of us. Dengue, malaria, yellow fever, and typhoid, for example, are serious risks in certain locales and all may be prevented by vaccine or medication. This is a very specialized area of medicine, however, and a travel or wilderness medicine specialist should be contacted for current, specific recommendations. The CDC website (cdc.gov/vaccines/ hep/by-disease/index.html) has been a useful source of information for decades. Hopefully, this continues.

~Tom Welch, MD, is a physician at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog, adirondoc.com. Sarah Long, MD, an internationally known vaccine expert and past member of the CDC’s Advisory Committee on Immunization Practices ( and a proud Alaska native) reviewed this column and provided helpful suggestions.

Download PDF

Topics: COVID-19, General First Aid, Hygiene, Infections, Snake Bites, Vaccines, emergencies

Continue Reading →

Huffin’ and Puffin’

April 5, 2025 adirondoc

2025, Spring Adirondac Adirondoc

woman using an asthma inhaler Recently, a reader asked me for some information on exercise-induced asthma (EIA). Although I have covered asthma generally a couple of times, the reader was absolutely correct that EIA is a “special case” that can be very relevant to the hiker.

First, a little refresher on asthma itself. This is a condition in which the tubes that carry air into the depths of the lungs tighten and narrow, making it difficult to move air in and out. This limits the exchange of” old air” for “newer air” with a higher oxygen content. This, in turn, limits activity. When the lungs are examined during an episode of asthma, one finds that the entry of air is diminished and there is often an audible wheeze upon breathing out. We call this narrowing of the air tubes “bronchoconstriction.” Folks with asthma find that a variety of triggers can set off bronchoconstriction. Certain allergens in the air, such as pollens, are a common trigger, as are the viruses that cause respiratory infections. For individuals with EIA, the trigger is a change in the volume, temperature, or humidity of air moving into the lungs.

Although there is considerable variability among patients, typically the signs of EIA develop within a few minutes of beginning exercise. The condition peaks after about fifteen minutes, when shortness of breath, coughing, and weakness develop; sometimes, there is a worrisome tightness in the chest. Often, the symptoms improve after about an hour. If symptoms improve, there may be a period of a few hours when the bronchoconstriction is less bothersome, only to return later. It should be noted that most of the studies on EIA have been done with exercise that occurs in bursts, such as running; the pattern of symptoms in the hiker, especially walking over changing terrain, may be different.

Many people with established asthma find that exercise is one of their triggers. In these cases, the diagnosis is pretty straightforward. A bigger challenge is the individual who has no other signs of asthma, but who develops shortness of breath with exercise. A number of other heart, lung, or airway problems can cause symptoms resembling EIA, so a careful workup is needed. This often involves some sort of”provocation” on a treadmill or similar device.

The treatment for EIA in folks with known asthma begins with optimizing the overall control of their disease. There are a host of drug options for controlling asthma these days, with inhaled steroids typically as the cornerstone. With modern approaches to treatment, good control should be possible in almost everyone. For these folks, EIA symptoms generally respond to a short-acting beta agonist inhalation such as salbutamol (Albuterol®). If they find that the onset of symptoms with exercise is predictable, a preventive dose of inhaler fifteen minutes or so before exercise is often useful.

There is much less data available on the best treatment for EIA in folks who do not have underlying asthma. Most authorities recommend starting with inhaled beta agonists in these individuals as well.

EIA that does not respond to these measures can be a real challenge, but there are several options. I strongly recommend consultation with an experienced asthma specialist in such cases. These individuals may respond toother inhaled drugs such as ipratropium, or may need oral medications such as montelukast. I cannot stress highly enough that intractable EIA is treatable, but it generally requires expertise outside the wheelhouse of most general physicians.

One critical point about EIA in closing. Although the goal for most patients with asthma is to avoid triggers, no one with asthma should avoid exercise! There is much evidence that aerobic exercise is good for patients with asthma, as it is for almost everyone else. The goal of treating EIA is to ensure that exercise can be undertaken comfortably.

Tom Welch, MD, is a physician at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at adirondoc.com, his website and blog. Leonard Weiner, MD, SUNY Distinguished Professor of Infectious Diseases at Upstate Medical University, reviewed this column and provided helpful suggestions.

Download PDF

Topics: General First Aid, asthma, emergencies, exercise

Continue Reading →

Hot

November 22, 2024 adirondoc

2025, Winter Adirondac Adirondoc

On a warm summer’s day in 2021, a young family living near California’s Sierra Nevada Mountains parked their truck and began a day hike. They were never seen alive again.

When the family was reported missing by friends, a massive search began. Not long afterward, their bodies were discovered near a trail. The father, young daughter, and dog were peacefully seated; the mother was a bit further away, apparently attempting to scramble up a hillside. There was no evidence of foul play.

The tragic discovery set off a flurry of speculation. There were a number of old mines nearby; could there have been a sudden discharge of poisonous gas? Toxic algae had been noticed in some nearby water sources; could they have been poisoned? Carbon monoxide? Snakebite? Online commentaries entertained even more exotic explanations.

After extensive scene investigations and autopsies, including of the dog, officials announced the cause of death. High environmental temperatures, combined with exertion and limited water intake, had resulted in severe heat stroke.

Sadly, this tragic experience has not been unique recently. A healthy 30-year-old woman succumbed to heat while hiking in Utah’s Snow Canyon State Park this past July. A few days before, a father and daughter died from the same thing in Canyonlands National Park in Utah. The previous July, a 57-year-old woman died from heat stroke while hiking in Grand Canyon National Park.

None of these folks had serious underlying illnesses. None were practicing “extreme” sports in challenging environments. All were on day hikes in areas frequented by travelers.

Because there is no registry of such deaths, exact numbers are impossible to ascertain. There were at least seventy- seven heat-related deaths in national parks between 2007 and 2023. News reports of such deaths are frequent. One thing is quite clear: this is a relatively new phenomenon.

These catastrophes have caused me to redo my teaching on heat problems in my wilderness first aid classes. For years, I taught that ”heat exhaustion” was simply dehydration occurring in a hot environment. It could be treated by rest, cooling, and fluids. That is still correct. “Heat stroke,” the more serious heat illness, was mainly restricted to extremes of activity or environment, or to the elderly or chronically ill. It was not an issue for the typical user of the wilderness.

I was wrong. We need to revisit this topic.

Basically, human life involves the continuous, simultaneous operation of a number of chemical reactions. As for any chemical reaction, these work only in a narrow range of temperatures. In order to maintain temperature in this range, the body has mechanisms to dissipate heat. Evaporation of sweat from the skin produces cooling. Radiation of body heat to the outside occurs with increased blood flow. to the skin.

When the outside temperature is higher than that of the body, radiation is limited or absent. When environmental humidity is also high, evaporation ceases. Thus, even for healthy persons, remaining in an environment of high heat and humidity eventually causes the body to overheat. If the temperature is significantly above that of the body (say, 110 degrees or above), decompensation occurs rapidly. Once the core body temperature is consistently above 105 to 107 degrees, blood flow to vital organs slows and failure of most organs occurs. Once this is established, death is almost inevitable.

When a patient with heat stroke is encountered, they will have dry, red skin and feel warm to the touch. There will be impaired consciousness, and shock will likely be present. Once the airway is secured, the only possible field treatment is external cooling. Unfortunately, options for this in the wilderness are quite limited. Providing shade and, if possible, soaking the patient in water are about all that is possible. Emergency medical services teams in cities with a high frequency of heat illness actually utilize body bags filled with ice. Unless immediate evacuation to hospital care is available, the chance of survival is nil.

There are plenty of ways in which one can stay warm in extremely cold environments. The opposite, unfortunately, is not true. Until someone develops a backpackable air conditioner, there is simply no way in which humans can survive long-term exposure to high heat and humidity. Hydration is obviously important to maintain blood pressure and the ability to sweat, but ultimately the benefits of sweating are lost in humid environments.

The only “prevention” is avoidance. We are beginning to learn that even a hike of a few hours in high temperatures and humidity may be fatal. A reasonable guideline is to look for the predicted “heat index”; an index of 105 degrees or above should preclude outdoor recreation. (A “wet bulb” temperature of over 95 degrees is similarly dangerous, although this measurement is not as readily available.)

Finally, why is this happening now? The same reason we are seeing “new” infectious diseases in the continental United States. Climate change. Heat already claims more lives than any weather-related event. Unless we do something about it soon, we have only begun to see the painful consequences. (For further reading on this topic, I recommend Jeff Goodell’s new book, The Heat Will Kill You First. Despite the dramatic title, this deeply researched book is on my best environmental books of the decade list.)

Tom Welch, MD, is a physician at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide, and a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog, adirondoc.com.

Download PDF

Topics: General First Aid, Heat stroke

Continue Reading →

Wilderness as therapy

March 4, 2024 adirondoc

A small, but highly visible part of the outdoor education industry is the “wilderness therapy” world: a movement based upon the premise that since being in the outdoors is healthy for most of us, it should be healing for persons (mostly youth) with emotional challenges. Although superficially appealing, this premise has never been validated.

An unfortunate part of the wilderness therapy movement has been fatalities occurring with participants during programs. These are nothing new; a book by Maria Szalavitz drew attention to the problem nearly twenty years ago. They have continued. The most recent episode involved a 12 year old boy in North Carolina. This incident prompted an investigation by reporters for USA Today (North Carolina wilderness therapy death and the trauma for survivors (usatoday.com)). This report deserves close reading.

Regular users of the wilderness will be particularly struck by one portion of this report. It was claimed that the participants were “…living in filth.” A big part of this was because of their need to defecate in plastic bags, and use natural items (“…sticks and leaves…”) for toilet paper. While the uninitiated reader of USA Today may find this appalling, I doubt that many readers of this blog will be impressed or surprised. Avoiding toilet paper by using natural substitutes is pretty standard wilderness technique; most of us look upon this as an expectation for environmentally-responsible use of the outdoors and have no problem with it. Carrying out human waste, while not universal, is clearly the appropriate approach in certain high-traffic areas, or with specific environments (e.g. glaciers). I have undertaken numerous enjoyable expeditions with my waste in my backpack or pulled in my toboggan.

The report further decries the participants’ being taken with their 40-pound packs on a “grueling 3-mile hike.” While I suppose that it depends on the terrain, this would quality as an easy day on most of my trips! And I am far from adolescence.

So, what’s the problem here? Those of us who happily carry packs up mountains and clean ourselves with sticks and leaves (actually, small stones work better…) do so voluntarily because we find the entirety of the wilderness experience uplifting and positive, We understand the need to care for wild places. No one compels us to do these things. This is not the case for teens in most wilderness therapy programs. They are plucked from their lives (albeit largely chaotic) and thrown into something they did not ask for with people they don’t know. Enjoyment of the wilderness begins with the well-considered decision to immerse oneself in it. It cannot be forced.

Careful analyses of some of the incidents in these programs clearly shows some problems with staff training, equipment, and policies. These are inexcusable. More basically, the fundamental notion that forcing one into vigorous wilderness travel can be therapeutic is likely flawed. Let’s not, however, focus on hygiene and hiking effort!

Tom Welch, MD

Topics: General First Aid

Continue Reading →

The Most Dangerous Wild Creature

February 27, 2024 adirondoc

2024, Spring Adirondac

I often begin my wilderness first aid courses with a little quiz, to assess participants’ ability to recognize risk. A favorite question, rarely answered correctly, is, “What wild animal is responsible for the most human deaths?”

Bears? Not by a long shot. Sharks? Nope. Snakes? A much bigger problem, but still not correct. Give up? Mosquitoes.

Mosquitoes are vectors (carriers) of a number of viruses from the arbovirus family and at least one parasite. One of these organisms causes a disease, malaria, which kills over 600,000 people annually. Some mosquito-borne diseases occur regularly in New York State (“endemic”), and a number of others have been identified in New Yorkers who have traveled, including on “adventure” travel. For reasons I will outline, these problems are likely to get worse in the coming years.

Here is a brief summary of six serious diseases, all transmitted through mosquito bites, and all reported in New York in recent years.

West Nile virus (WNV) and eastern equine encephalitis (EEE): These two diseases are endemic in New York, transmitted by our own mosquitoes. Both diseases are characterized by fever, body aches, .and headache. While WNV is generally mild (even asymptomatic), EEE is fatal in as many as a third of patients. Both are transmitted between birds and humans, while EEE has a number of other mammalian hosts, including horses. When either of these infections progress, they are associated with severe headaches, delirium, seizures, and loss of consciousness.

WNV and EEE should be considered in any New York resident suffering an unexplained neurologic illness with fever and headache during mosquito season. No vaccine or specific treatment is available for either. Prevention and supportive care are all we can offer.

Chikungunya: Although this disease has been around for a long time, we’ve only recently started hearing about it. While death is quite rare, patients with chikungunya may have debilitating fever and joint pain. Until about ten years ago, the condition was only seen in the United States (including in New York) in travelers returning from endemic areas such as the Caribbean. Now, however, locally acquired cases are regularly reported in Texas and Florida.

Zika: This infection was in the news quite a bit a few years ago. While news reports have dropped, the disease has certainly not gone away. Although patients may have a mild (even undetectable) illness, the real danger is to unborn children. Mothers infected with the virus during pregnancy may give birth to children with severe birth defects. Other than avoidance, there is no vaccine or treatment for the infection or for the associated birth defects. There had been local, mosquito- borne transmission of zika in the United States, but this has not occurred recently. U.S. cases now are all acquired through travel. The Centers for Disease Control and Prevention has published helpful information for people who are pregnant contemplating travel (cdc.gov/pregnancy/zika/ protect-yourself.html).

Dengue: Dengue is another “tropical” disease now seen in the U.S. As with most arbovirus infections, fever a11d joint or muscle pain are the hallmarks of dengue. Some patients, however, progress to dengue hemorrhagic fever, with bleeding and dysfunction of many organs. More than 20,000 people die of dengue annually.

Malaria: Malaria causes more human death and misery on an annual basis than any infectious disease other than tuberculosis and HIV/ AIDS. The disease is caused by one of a few species of parasites (Plasmodium) which is transmitted between humans by mosquitoes. The organism infects red blood cells and, from there, can affect nearly every organ system. For every fatal case, many more people are disabled. Although there are medications that prevent and treat malaria, the organism has been displaying resistance to some of them.

While most malaria in the U.S. is also acquired during travel, transmission in Florida and Texas is increasingly being reported. Many regions with a significant malaria burden are also popular destinations for the adventure traveler; I recently had to take a malaria preventive medication during an expedition to Kilimanjaro. Anyone contemplating travel to such an area should consult with a travel or wilderness medicine specialist for the most up-to-date recommendations.

Mosquito-borne diseases are spreading into areas in which they have not been seen before. Why? Climate change. Although we tend to think of mosquitoes as a single group of creatures, there actually are thousands of species. Each of these has specific environmental conditions (heat and humidity) in which it thrives. In turn, each of the organisms causing mosquito-borne diseases has preferred species of mosquitoes in which they reside. As areas become warmer and wetter, new mosquito species carrying “new” diseases may come in.

Tom Welch, MD, is a physician at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog, adirondoc.com. Leonard Weiner, MD, SUNY Distinguished Professor of Infectious Diseases at Upstate Medical University, reviewed this column and provided helpful suggestions.

Download PDF

Topics: Bears, Disease, Environmental Injuries, General First Aid, Insects & Spiders, Snake Bites, Vaccines

Continue Reading →

Scary Movements Seizures in the Wilderness

November 20, 2023 adirondoc

2024, Winter Adirondac

Seizures, although rarely serious emergencies, are very frightening to those unaccustomed to them. A seizure developing in the backcountry setting would be even more terrifying.

Seizures (convulsions, “fits”) are triggered by chaotic electrical activity in the brain, which results in uncontrolled movements. Although they occur in many types, the most common result is a rhythmic contraction of muscles, giving the appearance of jerks or spasms. Persons experiencing seizures are usually unaware and unresponsive during the episode, often exhibiting abnormal facial and eye movements. In most cases, seizures are self-limited; patients typically experience a period of confusion following resolution of the seizure. “Seizure” refers to a single event. An individual who is susceptible to recurrent seizures is said to have a “seizure disorder” or “epilepsy.”

First aid for a person experiencing a seizure is straightforward; the old medical axiom “first, do no harm” is a particularly good principle here. The patient should be helped into a safe location and eased to the ground on their side (the “recovery position” as taught in CPR). Obviously, packs and other constricting material should be removed or loosened. Ancient teaching recommended stuffing items in the mouth to prevent biting or “swallowing” the tongue (whatever that means!). Such maneuvers should be avoided, as they clearly risk more damage than they prevent. Time seems to move slowly when someone is observing a seizure. Keeping an accurate record of the length of the seizure may be helpful to the physician ultimately caring for the patient.

Once the seizure has stopped and the patient has regained consciousness, the next step in backcountry first aid is assessing the cause and making definitive plans. The most important determination when a seizure is observed in the wilderness is whether it represented an entirely new phenomenon or if the individual already had a history of seizures. This one determination will drive the next steps.

Seizures in individuals with previously known and controlled seizure disorders on a wilderness trek will almost invariably be caused by disruption in their medication administration; changes in their sleep and meal times may also play a role. Modern therapy for epilepsy is quite effective, thanks to a broad array of medications. Control of seizures requires precise levels of these medications in the body. Because of this, unlike the case with some other prescription drugs for which precise timing is not always necessary, anti-seizure medications need to be taken at predictable times daily. Some of these medications also have requirements of timing in regard to meals. So, if an individual with a seizure disorder has a “breakthrough” seizure on a trek, carefully review the medication, meal, and sleep times and adjust if needed. I would also suggest adjusting the trek goals, and even consider terminating it early.

A new onset of seizures in a backcountry traveler is much more serious, and is likely a medical emergency. Some of the possible explanations include recent head trauma, an infection of the brain or nervous system, or a disturbance in the body’s fluids and electrolytes. None of these can be diagnosed or treated outside a hospital setting, so immediate evacuation is needed. Under most circumstances, unless the group is highly experienced and well equipped, this will entail mobilizing outside help.

Is it even safe for individuals with known seizure disorders to participate in wilderness activities? Professional societies have not weighed in on this question directly. The Epilepsy Foundation (epilepsy.com/lifestyle/ 1 summer-camp) has a lot of suggestions and information regarding children participating in summer camps but does not directly address trekking. The British Columbia Epilepsy Society, while not taking an official position on the subject, has published a terrific post by an individual with epilepsy who is an avid, serious backpacker (bcepilepsy.com/blog/ epilepsy-in-the -wild-tips-on-hiking-and-epilepsy). This post contains a host of valuable suggestions that certainly seem reasonable. Certainly, a multi-day expedition should not be the first trek for an individual with a known seizure disorder. Rather, a “training process” beginning with day hikes and progressing through brief overnights close to trailheads, accompanied by a capable partner, seems like a prudent way to prepare.

Tom Welch, MD, is a physician at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide, a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog, adirondoc.com. Luis Mejico, MD, chair of the department of neurology at Upstate Medical University in Syracuse, reviewed this column and provided very helpful suggestions.

Download PDF

Topics: General First Aid

Continue Reading →

New Approaches to a Very Old Problem

October 1, 2023 adirondoc

2023, Fall Adirondac

Timber rattlesnake in the Catskills. Cheryl Miller

One way to guess a person’s age is to ask what they were taught in their earliest first aid class about the treatment of snakebite. I hesitatingly show my own age by admitting that I learned to use my Scout knife to make two X-shaped cuts, about one-half-inch deep, in the skin over the bite wound. Then, to use my mouth to directly suck the wounds,” Thankfully, I never had to nse this technique. Indeed, I actually doubt that anyone did it as described. The muscles, tendons, and ligaments of the extremities (where most bites occur) are extremely tough. Making such incisions would be extremely difficult, not to mention almost unbearably painful. That is even before getting to the “suck the wound” part!

In no particular sequence, first aiders had also been taught to apply tourniquets, use a commercial suction device, apply cold compresses, splint, and wrap the areas tightly with an elastic wrap. Most of these approaches have also been abandoned or modified as we have learned more about these troublesome wounds.

In the U.S., snakebites are a rather minor problem, as wilderness injuries go, There are only about five reported fatalities in our country yearly; there have been none in New York in decades. Globally, however, snakebites are a very serious matter. Firm data are virtually impossible, since the regions most affected are also impacted by severe poverty and lack of access to medical resources. There are likely over a hundred thousand deaths worldwide from snakebite, a large number of them children.

This column will focus exclusively on venomous snakebites in the U.S. With one exception (coral snakes in western states), virtually all of these are caused by snakes of the pit viper subfamily (rattlesnakes, regularly found in the eastern Adirondacks and Catskills, cottonmouths, and copperheads). The first aid for other species of snakes is more complicated and beyond our scope.

The first step in snakebite first aid is avoiding another bite. Snakes rarely stick around after biting a human, but take a very careful look about the area to be sure that the animal, or its kin, are no longer a threat. It is often recommended to snap a photo of the animal for definitive identification; this is reasonable if it can be done safely. Also, it is crucial to recognize that there is absolutely nothing one can do in the field that will improve the final outcome of a venomous snakebite. Prompt evacuation for definitive care is paramount.

Unlike venom from the more dangerous species of Asia and Africa, pit viper venom is principally active locally, in the region of the bite. More generalized symptoms may occur, but these are uncommon and relatively easy to treat in an experienced center. The venom contains dozens of chemicals, which cause severe damage to tissues. Over a short period of time, wounds tend to swell, redden, and become very painful.

The bite wound itself should be treated as any puncture wound, with gentle soap and water cleansing followed by a sterile dressing. Any constricting items (rings, watches, etc.) should be removed. There is some evidence that splinting the involved extremity may help minimize absorption of the venom, but it is very important that this splint not be tight; compression of the bite may worsen tissue damage. Using a pen, mark the limits of any redness in order to assess progression of injury. Once these measures are undertaken, evacuation by the quickest safe means is essential.

Definitive care of snakebites, including determining which ones require antivenom, is a matter for specialized centers and experts. Fortunately, there are resources, including a national poison control center (800-222-1222), available for twenty-four hour consultation. For further information, the Wilderness Medical Society has published guidelines for pit viper envenomation; these are available at wemjournal.org/article/S1080-6032(15)002203.pdf. For world travelers, who may come into contact with far more dangerous snakes, the World Health Organization also has guidelines, available at who.int/publications/i/item/9789290225300.

Download PDF

Topics: General First Aid, Infections, Snake Bites

Continue Reading →

Norovirus

June 10, 2023 adirondoc

2023, Summer Adirondac

This issue’s column discusses a rather unpleasant ailment that has been in the news quite a bit lately. Norovirus is the most common cause of gastroenteritis (an inflammation of the gastrointestinal tract resulting in nausea, diarrhea, and vomiting) in the United States. The condition is named for Norwalk, Ohio, where the first outbreak was described. (Seems like a rather unfortunate thing for which to immortalize a town!) It was once called “winter vomiting disease” because of a (variable) seasonal pattern and the marked vomiting that characterizes it. The disorder is extremely contagious, with only a few particles of the virus capable of infecting an individual. Norovirus has a very short incubation period, often less than a day or two, so it can spread with incredible rapidity through a population. Although the condition is short-lived (mercifully only twelve to sixty hours), it can render patients miserable while it is active.

Like most gastrointestinal infections, the greatest danger of norovirus infection is dehydration. This accounts for most of the 200,000 annual worldwide deaths from the virus. Other causes of gastroenteritis such as cholera and rotovirus are more likely to cause death, but norovirus is far more common than either of these. The typically short duration of the illness is probably the reason that severe disease is uncommon.

As is the case with most gastrointestinal infections, the virus spreads when one ingests fecal particles from infected individuals. Yup. You read that right. How does this happen? Not surprisingly, sloppy hygiene is the typical culprit. Infected individuals may leave microscopic traces of fecal material on their hands after using the restroom, and then transfer these to surfaces or, if they are involved in food preparation, into food. Since only a few particles of virus are needed to cause infection, the disease spreads when others touch contaminated surfaces or consume contaminated food. Some viral particles are shed by patients for several days after symptoms have cleared, so even “well” persons can spread the disease.

Outbreaks of norovirus are most common in closed settings; these environments simply provide more opportunities for interaction between infected and healthy individuals. Thus, the infection has disrupted cruise ships, nursing homes, restaurants, schools, and similar spots. Contaminated water rarely plays a role in norovirus transmission; when it does, it is most likely consequent to plumbing issues which lead to cross-contamination of potable water with waste.

What are the implications of all his for the backpacker/camper? Actually, although folks seem to love to focus on giardiasis, a relatively uncommon cause of wilderness-related illness, there are scores of reports of norovirus outbreaks among outdoor recreationists. Most recently these have involved rafting groups on the Colorado River. And, in case you were wondering, drinking contaminated river water was not involved in these outbreaks, which impacted specific groups of rafters, not everyone using the river. Surface contamination of equipment and shared supplies were to blame, just as on cruise ships. Closer to home, data from New York’s state health department show that gastroenteritis including norovirus is the most common reportable illness among summer campers in the state.

Once the infection has hit, there is precious little to do beyond gearing up for an uncomfortable day or two. Maintaining fluid balance by drinking is obviously important, but the severe vomiting of norovirus may make that challenging. Take small sips, at least an hour or more after vomiting. Diarrheal medications such as loperamide (Imodium®) are not likely to be useful. There are reasonably effective anti-emetic (“vomit stopping”) medications such as ondansetron (Zofran®), but these are available only by prescription. Prevention is. the key, and is amazingly simple: keep your hands clean! Although alcohol-based sanitizers are convenient, they really don’t address the main problem: hands contaminated with microscopic bits of infected debris. For that, there is no substitute for a good lathering with plain soap and water. Such practice is most critical after defecation and prior to any food handling. The environmental impact of pure soap, used at a distance from any water source, is nil.

Download PDF

Topics: General First Aid, Infections, Water

Continue Reading →

Sun and Snow

February 1, 2023 adirondoc

2023, January/February Adirondac

In several recent columns, I have drawn attention to the problem of sun-induced skin injury-surprisingly, the major cause of death associated with outdoor recreation. It’s time for a reminder that sun protection is not just for the summer.

My introduction to the need for sun protection came while mountaineering in the Northern Cascades in late January one year. The combination of vast expanses of unshaded snow and ice, clear skies, absent pollution, and high altitude subjected us to intense UV exposure, both directly and reflected. Fortunately, we had been well schooled in sun protection and got through the expedition unscathed.

Although severe snow-enhanced sun injury is most common at higher altitudes, it can occur in any setting of clear skies and expansive snow fields. Thus, the Adirondack skier on a sunny day could be at risk.

How does the combination of altitude and snow create an enhanced risk of sun damage, even in winter? First, the atmosphere at altitude is less dense than that at sea level. This means that there is less opportunity for UV light to be absorbed and filtered before striking us. Similarly, alpine areas are generally less polluted, also allowing more UV radiation through. Of course, we also don’t have the luxury of taking a breather in the shade of trees while traversing a glacier.

The reflective nature of snow and ice also contributes to the problem. Dirt and vegetation absorb most of the sunlight striking them, while over 90 percent of light hitting clean snow is reflected. Thus, the winter climber is subjected to radiation both direct and reflected. The latter can hit spots about which we don’t typically worry in the summer: under the chin and in the nostrils, for example. Because of intense sunlight, coupled with dry cold air, the lips are also at great risk.

Fortunately, bitter temperatures force us to keep most of our skin well covered while traveling on snow and ice. What should we do for those areas that are exposed? As in the summer, sunscreens with SPF factors of thirty and above are the mainstay. Stopping to reapply sunscreen in cold, blowing snow is not pleasant, so I also recommend “barrier” types of sun protection; zinc oxide is a good example. These leave an impenetrable “paste” on exposed surfaces such as the nose and cheekbones. Don’t forget areas that can be hit by reflected snow, including under the chin and the interior of the nostrils.

Regular sunscreen or zinc oxide may not be practical or comfortable for the lips. Fortunately, there are lip balms with sunscreen; be sure to find one with an SPF of thirty or above. There are also specially formulated zinc oxide preparations suitable for mucous membranes such as the lips.

A final word about the importance of eye protection in snow and ice environments. The cornea is the “skin” of the eyes, and is particularly sensitive to UV radiation. Prolonged, unfiltered exposure can ultimately result in a horrible problem called “snow blindness,” an exquisitely painful condition which renders travel nearly impossible. Short of this problem, accumulated UV exposure can be a risk factor for early cataract development. Therefore, high-quality wrap-around sunglasses are an essential element for winter mountain travel. It even makes sense to have a spare along-at least one for the party. I have a pair of glacier glasses with side shields that transmit only about 10 percent of light hitting them; while these would be far too dark for July on Mt. Marcy, they are ideal for extreme winter mountaineering at altitude.

While hikers who confine themselves to the Northeast may not be as vulnerable as those at higher altitudes, they are still vulnerable. And the ADKer heading to the Rockies for some spring skiing may especially want to heed these warnings .

Download PDF

Topics: Environmental Injuries, General First Aid, Skin, Sunburn

Continue Reading →