How Sweet It Is: Tips for hiking safely with diabetes

2021, September/October Adirondac

DIABETES MELLITUS is one of the most common chronic health conditions, and a major contributor to premature death. In addition to the effects of the disease itself, diabetes increases the risk and severity of a number of other conditions, including cardiovascular disease, stroke, and chronic kidney disease. Globally, about half a billion people may be affected by diabetes.

"ANOTHER DAY AT THE OFFICE"
zack clothier: The view from my campsite along the Nun-Da-Ga-O Ridge as the afterglow from sunset slowly fades into the night.

The basic defect in diabetes is in the body’s ability to utilize glucose as a source of energy. This results in a rise in blood glucose (“sugar”) levels. The defect is caused by a decrease in either the ability of the pancreas to produce insulin (the hormone central for the use of glucose as a fuel) or the body’s ability to utilize insulin. The former is “type 1” diabetes; the latter is “type 2.” Type 1 diabetes requires the use of injectable insulin, and most often develops in children and adolescents; type 2 (far more common) typically develops in adults and is usually managed with diet and medication other than insulin. While the prevalence of both types of diabetes is increasing, this is especially the case for type 2 disease. Rising obesity levels are a major cause of this.

Exercise is very important in the management of diabetes, because it both improves glucose metabolism and may help with weight control. Exercise is also important in averting some of the complications of diabetes, such as cardiovascular disease. Outdoor adventure travel, thus, can be very beneficial for folks with diabetes, although it is very important to discuss this in detail with one’s diabetes specialist.

A few issues that are important to any hiker or camper are particularly important for people with diabetes. Suboptimal control of the disease may make one more susceptible to poor healing, especially of foot wounds. Blister prevention and early treatment are important in every hiker, but particularly so in those with diabetes. Careful meal-planning is critical in managing diabetes, and the increased caloric needs of backpacking need to be factored into this. The treatment of diabetes renders many patients susceptible to episodes of hypoglycemia (low blood sugar). Hypoglycemia can be dangerous if not treated immediately, and the treatment commonly is the administration of some form of oral sugar (although some non-sugar drug alternatives are now available). While the principles of bear avoidance require the removal of such items from one’s tent, I would make an exception for patients with diabetes. One simply cannot be exiting the tent and rooting around in the bear-resistant food container in the middle of the night to secure emergency hypoglycemia treatment!

For decades, I taught wilderness medicine students that wilderness expeditions, even overnight camping, were not feasible for folks with type 1 diabetes. The logistics of storing insulin, regular blood testing, and responding to dramatic changes in diet and energy expenditure were simply too complex for much beyond a’ brief overnight trip. Happily, recent developments have proven me very wrong. Individuals with type 1 diabetes regularly compete at high levels in such strenuous activities as triathlons and ultramarathons. A few people with type 1 diabetes have even successfully summitted Mt. Everest. Extended trips in austere environments are no longer out of the question.

Much of this change has resulted from major technologic achievements, including programmable insulin pumps, continuous glucose monitors, and easily transportable cold storage units. That being said, the logistics involved in such treks are daunting, not least because the energy requirements of backpacking may increase daily calorie needs by a factor of three or more, necessitating major changes in insulin dosing. Such treks require careful planning with a diabetes specialist who is familiar with the demands of adventure travel. Such an individual may be difficult to find, although major diabetes centers can probably help locate an appropriate specialist. It will also be important to have a companion along who is familiar enough with diabetes to be of assistance in emergencies .

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. Roberto Izquierdo, MD, a senior adult and child diabetes specialist at Upstate Medical University and the Joslin Diabetes Center in Syracuse, reviewed this column and provided very helpful suggestions.

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Topics: Diet & Nutrition, Disease

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Drowning Essential Tool or Silly Affectation

2021, May/June Adirondac

ALTHOUGH MOST Adirondack lakes are frozen as I write this column, they will be approaching swimmable by the time you read it. Thus, this is a good time to discuss an oft-neglected cause of wilderness fatalities.

Although there is no central registry of data, most experts cite three thousand to four thousand as the number of fatal drownings in the U.S. annually. Most are infants and toddlers, or adolescent and young adult males. For the first group, the culprit is often unsecured home swimming pools. For the second, the unfortunate combination of alcohol and youth bravado is a leading contributor. If there is an effective preventive strategy for this, I would love to hear about it!

Although fatalities in the wilderness are overall quite uncommon, drowning is one of the leading causes. A study of deaths at the U.S. Outward Bound schools showed drowning as the leading cause; overall, death in these programs was extremely rare. The National Park Service states that drowning has been the leading cause of unintentional death in national parks every year since 2007. The Adirondacks have not escaped this; reports of backcountry water tragedies occur regularly.

Despite these facts, most wilderness medicine or wilderness first aid courses and wilderness medicine books pay little attention to drowning. When they do, they often veer into esoterica such as the physiologic differences between fresh and salt water drowning – a topic of importance to the critical care physician but of little consequence to the High Peaks camper!

The treatment of drowning is well covered in CPR courses; as I mentioned in an earlier column, drowning is one of the few scenarios in which wilderness CPR is likely to be useful. The best “treatment” for drowning is prevention. Indeed, the vast majority of drowning deaths are preventable.

Unfortunately, there are not a lot of published resources for folks interested in learning about safe wilderness swimming. The curricula of most lifeguarding and water safety courses do not pay much attention to the topic. One resource is the Outdoor Swimming Society (yes, there is such a thing!), whose website (outdoorswimmingsociety.com) has a wealth of information. I will highlight what I consider to be the most important considerations, but urge readers to consult the organization’s site.

Selection of a safe spot is the first priority for a wilderness swim. Ideally, one wants clear, still water with a gentle slope and no underwater debris. (Think Sand Lake in the Five Ponds Wilderness.) Moving water is more problematic. Rapidly moving streams may produce vortexes and currents that may not be apparent, but which could be deadly. Since many New York streams have hydropower dams, the character of a seemingly still spot can change quickly.

Regardless of how the site appears, I always recommend footwear for wilderness swimming. One simply cannot risk a punctured foot while miles away from a trailhead.

Regardless of group size, any wilderness swim must use a “buddy system.” Each swimmer must agree to be in visual contact with his or her “buddy” at all times. Larger groups should designate one member to remain on shore as lookout and lifeguard for everyone else. When I guide canoe trips, I often have this role filled by someone in a canoe in the swimming area.

If one is leading a group from an organized camp, the New York State Health Department has very detailed regulations for wilderness swimming. Groups operating summer camps, such as the Boy Scouts of America, also have specific policies and practices for the activity.

Finally, remember that these comments pertain to “voluntary” swimming. Most drownings in the backcountry are due to inadvertent water entry. Although I was a competitive swimmer and still am very comfortable in the water, I would never venture onto my stand-up paddle board (SUP), kayak, or canoe without wearing a personal flotation device (PFD). Swimming in wild water at the end of a long day of hiking is a special treat. Just keep it safe!

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

 

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Topics: Environmental Injuries, General First Aid, Water

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Trekking Poles Essential Tool or Silly Affectation

2021, March/April Adirondac

I HAVE BEEN ACCUSED, often rightfully, of a lot of things. “Set in his ways” is not one of these. Over the years, I have made 180-degree turns on a lot oflong-held beliefs. Here is a big one. Trekking poles were rarely seen when I began Adirondack hiking. When they first appeared, perhaps in the 1980s or thereabouts, I recall looking disdainfully at them. I even recall jesting (inappropriately, in retrospect) with a summit steward over her lecturing visitors on Leave No Trace while decorating the summit with countless scratches from her carbide-tipped poles. (I still am bothered by that phenomenon, however.)

I first experienced trekking poles while climbing Aconcagua in the Andes many years ago. I have been sold on them ever since. In fact, I now use them on every hike, likely prompting some passersby to sneer at me the way I did at others decades ago!

Setting aside aesthetics and impact (while not trivializing their importance), are there health benefits of trekking poles?

There are some very good data upon which to base an opinion. A recent issue of a professional journal (Wild Environ Med 2020:31:482- 488) features a review of studies on the topic by authors from the School of Health and Human Performance at Northern Michigan University. There are countless other published studies, but this one is a good starting point.

The first observation ( confirmed in many studies) seems paradoxical. In most situations, the use of trekking poles increases cardiovascular work. This is likely because of increased demands on the upper extremities. The paradox is that the user’s perception of work is that it is decreased. Thus, one may get a better cardiovascular workout without realizing it. This is the principle behind exercise equipment such as the NordicTrack® and ellipticals, which incorporate upper extremity activity with lower body exercise. (Trekking poles may have originated in Finland, where “Nordic walking” with poles is a popular aerobic exercise.)

Most people use poles for musculoskeletal benefits. Here, again, there are a lot of studies, although this cannot be assessed as objectively as cardiovascular function. Many studies point to a reduction in lower back pain and in muscle soreness in users of trekking poles. Although these benefits seem reasonable, the data are obviously quite subjective.

trekkingThe benefit to joints has been better studied. Many studies point to improvement in pain and function among users with lower extremity joint (mostly knee) difficulties. There are multiple explanations for this. Poles absorb some of the load during hiking, and especially with carrying a pack this reduces stress on knees. Many studies have also shown that one’s stride length is increased using poles. This means that over the course of a day, a hiker using poles is taking fewer steps, decreasing further the stress on leg joints. There is also evidence that balance is improved when using trekking poles, possibly lessening the risk of falls.

Certain populations of hikers may have particular benefit from poles. There are, for example, studies suggesting particular benefits to those with obesity, balance disorders such as Parkinson’s disease, those with low back pain, and older folks.

Trekking poles might even be considered part of one’s first aid supplies. As I discussed in an earlier column on ankle sprains (September-October 2020), poles can make the difference between an assisted evacuation and a walk-out.

As with any gear, there are techniques for the safe and efficient use of trekking poles, which are outside the scope of this column. Proper use of wrist straps, adjustment of length for terrain, and appropriate use of the locking mechanism are critical in using poles effectively. I was fortunate to learn from a talented instructor (a Sherpa, actually), but there are countless websites and videos that can help.

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

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Topics: Accessories, Readiness

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Immunization Update

2021, January/February Adirondac

WITH ALL THE ATTENTION focused on the COVID-19 vaccine, folks may forget the host of very effective vaccines available already against other illnesses. This is unfortunate, in that vaccines (along with clean drinking water and fluoridation) are the most effective public health measures we currently have. I will focus on the backcountry traveler, but hit upon other important vaccines.

These comments address only North American travel; trekkers headed to other global regions should consult with a travel medicine expert.

The number one immunization question I get from individuals about to embark on a long trek is, “Do I need a tetanus shot?” The quick answer is, When was your last one?”

Tetanus is, fortunately, an extremely rare disease in the U>S> today (I have seen one case in a career spanning four decades). However, it is also an absolutely horrible, generally fatal, affliction. It is cause by a microorganism generally found in soil, usually when a would is deeply contaminated. The nature of wilderness trekking is such that tetanus-prone injuries are most unusual.

The tetanus vaccine is extremely effective. After the initial series of shots, a tetanus “booster” is recommended for adults every ten years, although some experts advise another booster after a tetanus-prone injury if five years have elapsed.

Today, tetanus immunization for adults should be combined with diphtheria and pertussis (TDaP0. While diphtheria is about as rare as tetanus, pertussis (“whooping cough”) is quite common. In small infants, it cause severe respiratory illness, resulting in several fatalities in the U.S. every year. In adults, it generally causes an upper respiratory infection with a severe, prolonged cough. One of the reasons for adults to maintain pertussis immunization is to avoid transmission to infants. Indeed, the importance of adult TDaP booster may be more for protection from pertussis than tetanus.

In terms of importance for wilderness traveler, I consider annual influenza (“flu”) immunization number one. Influenza is a nasty virus, with the clever ability t change its properties often enough that a vaccine which is effective this year is likely useless next year. This is why we need to repat our influenza vaccination annually. How effective the vaccine is in any particular year depends upon how successfully scientists predict the specific strains that will be circulating. (Epidemiology trivia: Before he became “distracted” by COVID-19, Dr. Anthony Fauci was deeply involved in the development of the “holy grail” of immunization: an influenza vaccine that would be effective against all strains of the virus.)

The next vaccine is one that may surprise readers. Hepatitis A (Hep A) is a virus that causes a form of liver inflammation that spreads quite easily within groups. Like most intestinal infections, it is spread by the hand-to-mouth route, or occasionally in water. Most Hep A infections in the U.S. today occur in small clusters. There have been several reports of such clusters among campers, although this has generally been in developed campsites rather than the wilderness. Hepatitis A vaccine is highly effective. It can be combined with a vaccine for hepatitis B, a more severe form of liver inflammation spread by contact with blood or other body fluids. Hepatitis B vaccine has been part of the routine childhood immunization series for many years.

Two other vaccines are strongly recommended for adults, although not specifically for wilderness travel. The pneumococcus vaccine (sometimes imprecisely referred to as “pneumonia” vaccine) protects against a variety of severe bacterial infections that are frequent causes of death in adults. And the shingles vaccine protects against a very painful condition associated with reactivation of childhood chickenpox.

Where should we get our shots? Ideally, we should all have a “medical home” with a primary care provider who can oversee all of our preventive care. From a practical standpoint, however, many pharmacies have better supplies of vaccines, much better hours, and access to up-to-date vaccine recommendations.

Tom Welch, M.D., is a physician at Upstate Medical University in Syracuse, and a member of the Wilderness Medical Society. He is a licensed professional guide and a Wilderness Education Association instructor, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available on his website and blog, www.adirondoc.com. Jana Shaw, M.D., M.S., a national authority in immunization practice at the State University of New York (SUNY), reviewed this column and provided helpful suggestions.

 

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Topics: Disease, Readiness, Vaccines

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With a Grain of Salt

2020, November/December Adirondac

BEFORE DIGGING INTO THIS MONTH’S COLUMN, I am afraid we will need to have a brief refresher on high school chemistry. “Salt” has a very specific meaning in chemistry: a compound formed by the reaction of an acid and a base. There are countless specific types of “salts.” In medicine, when one refers to salt it generally is assumed to be sodium chloride (which is also the major ingredient in cooking/table salt). The human body is about 60 percent water, and virtually all of that water is actually a sodium chloride solution. When one refers to “salt” in the diet, sodium chloride is generally being referenced. The quantity of “salt” in the diet is usually expressed as the amount of sodium (for example, “a two-gram sodium diet”).

Whew. Sorry.

Sodium is a constituent of virtually every food. Unlike most dietary constituents (such as protein, vitamins, or iron), sodium is not often used for bodily functions. Instead, virtually all of the sodium ingested in the diet is excreted in the urine. As one increases sodium intake, daily urinary excretion of sodium increases proportionately. Thus, although one will see a “daily value” of sodium on food labels, this is misleading. There is no actual requirement for a minimum sodium intake for most humans, in the way there is for calories or essential nutrients.

The quantity of sodium in the diet varies among cultures. Americans consume an average of about 3.4 grams of sodium daily, quite high by international standards. (One and a half teaspoons of table salt contains about 3.4 grams of sodium.) Most dietary sodium is actually contained within the food, rather than being added at the table. In general, the more processed a foodstuff is, the higher its sodium content.

High intakes of dietary sodium are unhealthy. Because dietary sodium is excreted in the urine, there is an association between high sodium diets and kidney stones. More problematic is the impact of sodium intake on blood pressure. Although the relationship is a bit complicated, it is generally agreed that high sodium intake contributes to hypertension, and reduction of dietary sodium intake is one of the first recommendations of physicians treating a patient with high blood pressure.

The body keeps the concentration of sodium in the blood tightly controlled within a very narrow range. Very serious complications occur in people with high (“hypernatremia”) or low (“hyponatremia”) blood sodium concentrations. Changes in the concentration of sodium in the blood usually occur because of changes in body water. Thus, too much water dilutes the sodium content and causes hyponatremia; too little water concentrates sodium, resulting in hypernatremia.

While hypernatremia is sometimes seen with severe dehydration, hyponatremia is the more common disturbance of sodium. Life-threatening hyponatremia has occurred in some endurance athletes, such as marathoners. This is thought to be caused by a combination of stress and overconsumption of water. There was recently a very disturbing report in a medical journal of an otherwise healthy backpacker in the Grand Canyon who developed fatal hyponatremia on a trek. She had been noted to be consuming large amounts of water before becoming ill.

Because extended treks in warm weather may result in increased sodium losses in sweat, folks often wonder if supplemental sodium is required for hikers. In general, the answer is a resounding no. Most commercial backpacking foods and snacks are quite high in sodium content, and should provide sufficient intake. Most trail snacks are also quite generous in sodium content. Sports drinks as a supplement for sodium and other minerals are a waste of money and also result in excess sugar intake. Folks taking a type of hypertension medication (diuretics, sometimes inaccurately called “water pills”) should consider discussing their proposed trek diet with their physician.

Over millennia of evolution, mammals have developed sophisticated mechanisms to monitor body sodium concentration and adjust salt and water intake to maintain normal values. Squirrels manage to regulate their salt and water intake without relying on recommendations! As for many things, the best advice for salt and water intake on a trek is to listen to your own body.

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

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Topics: Diet & Nutrition, Hyponatremia, Sport Drinks, Water

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Achilles Ankle

2020, September/October Adirondac

IN DECADES OF RUNNING, hiking, and climbing, I have had only one ankle sprain. I was running on a dark road at night (pretty dumb!), when my right foot stepped into a rut on the shoulder and I lost my footing. Within a minute, the ankle was painful, swollen, and unable to bear ,weight. Fortunately, I was a short distance from home. I treated it with BRICE (“RICE”-see below-plus a beer), located some crutches, and became the butt of jokes at work for the weeks it took to heal. I have not had any subsequent problems.

If this same injury had occurred in the backcountry, the outcome would have been very different. I probably would not have been able to get to a trailhead, unless I stayed put for several days until the pain and swelling improved. I likely would have needed assisted evacuation. I might have even wound up in this magazine’s “Accident Report”!

My experience illustrates why I teach ankle sprains as the defining injury of “wilderness medicine.” This single injury is responsible for about three-quarters of wilderness medical evacuations-vastly more than any other problem. Yet, the basic medical management of the problem is known by any 11-year-old Scout with a First Aid Merit Badge. As with most “wilderness medicine,” ankle sprains are a very straightforward issue that become a problem only because of remoteness. The competencies for handling them are not medical; they involve general wilderness skills, judgement, navigation, and so on.

The mechanics of ankle sprains are relatively simple. The two boney “bumps” on our ankles are the malleoli: lateral malleolus on the outside and medial malleolus on the inside. Strong ligaments extend from each malleolus downward to the other bones of the foot. These structures keep the ankle stable. A twisting motion can strain or even tear one of these ligaments, creating a sprain. Since snch twisting almost always occurs with the foot turning inward, lateral (outside) ankle sprains are the most common. The ankle is swollen, often bruised from damage to blood vessels, and unstable. Tenderness is virtually always below the malleoli, distinguishing the ankle sprain from other injuries such as lower leg fractures.

In the front country, treatment is straightforward RICE: Rest (stay off the ankle); Ice (as much as one can tolerate); Compression (an elastic wrap, not to “stabilize” the joint but to lessen swelling); Elevation. These require modification in the backcountry, mostly because of the lack of ice. Commercial cold packs are of little value on treks. Elastic wraps, however, are essential in trekking first aid kits.

The big question with wilderness ankle sprains is getting out. There is no simple formula; decisions need to be based on severity, terrain, available help, weather, and the overall health of the patient. An easy walk out with· trekking poles might work for a mild sprain in a healthy person, with a flat trail in nice weather. With sufficient help, the two-person assisted walk (one helper on each side) is very efficient in this setting. Keep in mind that there is quite a difference between doing this in a church basement during a first aid class and attempting it on a rugged trail; it is a physically difficult technique for all involved. Particularly challenging terrains and a very painful ankle may necessitate a more dramatic evacuation, even including a litter. Helicopter evacuations for ankle sprains in very challenging environments are not unheard of.

There are few evidence-based recommendations for preventing ankle sprains. Certain obvious hiking maneuvers (e.g., rock-hopping for a stream crossing) should be avoided, but my experience as a trek leader has been that most ankle sprains occur in fairly “conventional” walking. For many years, I taught my wilderness education students that conventional high-top hiking boots had superior ankle protection and were therefore safer. As I discussed in an earlier essay on barefoot hiking, that teaching was probably incorrect. I have now ditched my high-top mountaineering boots except for the most challenging environments,  and use lightweight low-profile boots for most hiking.

Minimizing pack weight can help prevent the instability which often predisposes to ankle injuries. There is some evidence that strengthening the muscles of the lower leg may help prevent foot inversion injuries. This is also important during the period of rehabilitation after sprains. A good physical therapist can help with this, and a number of exercises can be found at http://www.verywellhealth.com/ankle-exercises-a-complete-guide-2696480. Individuals who are prone to ankle sprains may wish to discuss the technique of ankle taping with a therapist.

Most of us take to the woods to enjoy remoteness. Unfortunately, such remoteness can also turn a rather straightforward injury into a major nightmare.

Tom Welch, MD, is a physician at Upstate Medical University in Syracuse, and a member of the Wilderness Medical Society. He is a licensed professional guide and Wilderness Education Association instructor, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available on his website and blog, www.adirondoc.com. His friend and colleague Dr. Joe Stem, a highly experienced mountaineering guide in Utah and Wyoming, reviewed this column; his suggestions were invaluable.

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Topics: Environmental Injuries, General First Aid, Orthopedics

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Social Distancing, and backcountry ethics

2020, July/August Adirondac

THE QUIRKS OF the Adirondac publication schedule are such that my last column, on handwashing, was written before we became overwhelmed by COVID-19. The advice seems even more relevant now. This issue’s comments, although published in the heat of the epidemic, were also in the planning stage for months before.

Although “social distancing” has been in epidemiologists’ lexicon for decades, it is a new concept for most folks. Current events make this an opportune moment to review the potential role of our outdoor pursuits on the spread of illness.

Spending a few days living in the backcountry with a few other folks is a great way to spread infection within the group. Infectious organisms are most often spread between people either by the hand-to-mouth route or by infectious respiratory secretions. I have dwelt on the importance of hand-to-mouth spread, and its prevention by handwashing, many times over the years.

Many organisms, mostly viruses, are spread through respiratory secretions. These are the germs that cause everything from minor colds through infectious mononucleosis (“mono”), up to influenza and, of course, COVID-19. When one of these organisms infects, it invades the cells lining the respiratory system (such as the mucous membranes of the nose), reproduces itself, and then “sheds” away from the surface. As soon as one coughs, sneezes, or otherwise expels these viruses, they become airborne in tiny droplets. If another person is within range, they can produce infection by contacting that person’s respiratory tract. It is important to recognize that the nose is not the only route by which these organisms can gain entrancethe mucous membranes around the eye are also susceptible. I was reminded of this a few years ago when I contracted a nasty parainfluenza infection from a young patient who coughed in my face. My mask didn’t make up for the fact that I did not have eye covering!

If handwashing is the intervention to prevent hand-to-mouth spread, what about respiratory spread of infections? That is where “social distancing” comes in. Although the data supporting this are a bit “soft,” it is generally accepted that few infectious organisms of any type can accomplish airborne travel of over six feet. Thus, maintaining an appropriate distance from one’s neighbors significantly reduces the chances of coming into contact with an infectious organism.

In backcountry travel, this brings up the issue of tenting. The tight quarters and poor ventilation of most modern backpacking tents virtually ensure transmission of respiratory organisms between tent mates.

The mathematics of spread of infection (the “modeling” we hear so much about) mean that the chances of infection are much higher in a large group than a small one. Although these data are also soft, ten is a commonly cited number for a group size above which infection is much more likely.

So … small groups, stay apart, wash your hands, consider one-person tents. Pretty simple. The thoughtful reader at this point may realize that personal safety from the standpoint of infectious disease may intersect with environmental safety from the leave-no-trace (LNT) perspective. Small group size and good personal hygiene, of course, are central to both. Social distancing is a bit tougher. Leave-no-trace principles dictate concentrating use within a group.

Scattering four folks in four personal tents rather than sharing one is not ideal. Spreading a group around during a rest stop off trail is more appropriate from an infection control standpoint, but constitutes a greater environmental impact. What is the answer? Like many ethical questions, it is not really clear. Decisions need to be made considering the best available evidence for the precise circumstances. For decades, we have been taught to integrate LNT principles into all of our backcountry decision making. Now, we may also need to factor personal and group health into these decisions.

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 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: www.adirondoc.com.

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Topics: COVID-19, Hygiene

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Soap, Water, and Sanitizing Gel? How to keep your hands clean

2020, May/June Adirondac

REGULAR READERS OF THIS COLUMN and my other writings know that I view maintaining good hand sanitation as the key to most illness prevention in the backcountry – as well as everywhere else. (Note that public health authorities began teaching early on that it would do more to prevent coronavirus spread than masks.) What may not be clear, however, is the best way to keep one’s hands clean: soap and water, or those rapidly proliferating hand sanitizer gels everyone seems to be carrying? As with a lot of things, the answer is unclear, and basically comes down context.soaps, clorox wipes, sanitizing gel

First of all, it is important to understand how each technique works. Soap and water are not intended to “kill” bacteria or other organisms; “antibacterial” soap is more of a marketing technique than product description. Soaps are chemical compounds (actually salts of fatty acids) that render a number of particles soluble in water. Through applying soap, particles on one’s hands are more easily dislodged and washed away with a stream of water. Thus, the act of “soaping up” is only one part of the process; vigorous rinsing with water is equally important.

Sanitizing gels work completely differently. These chemicals (mostly alcohols) do not remove particles from the skin and therefore will not “clean” soil from hands. Rather, they destroy organisms on the skin by a direct chemical action. How effective they are against specific organisms (viruses,bacteria, protozoa) is a matter of some scientific dispute and is affected by factors such as the quantity of organisms on the skin, and the time during which the gel is in contact.

In the health-care setting, hand washing is the “gold standard.” Before taking out your appendix, your surgeon does not rub Purell on her hands. She practices a carefully prescribed and timed handwashing process known as a “scrub.” Handwashing before and after direct patient contact is also the preferred infection control procedure as caretakers enter and leave patients’ rooms.

The problem in the health-care setting is that as strict hand sanitization was increasingly enforced, the time it required and the toll it was taking on the skin of staff who were needing to do it scores of times a day became a challenge. This led to the alternative of sanitizing gels and lotions being available outside exam rooms for the staff who were continuously coming and going. Most infection-control specialists accepted that this practice was not as good as handwashing, but was far better than nothing.

What about the backcountry? Hand washing is still the best practice, especially after defecation. In the absence of running water, technique is important. My practice has been to bring a full liter of water along for my morning ritual. I use a small amount to develop a lather with a dollop of soap. I then use the old trick of (silently) singing “Happy Birthday” as a timer while I develop that lather and rub it into my hands. The final step is using the rest of that liter for a thorough rinse. I do all of this over the cathole in order to “concentrate use.” I will freely admit that I have taken shortcuts with this procedure in some circumstances. An extended glacier trek comes to mind.

As in the health-care setting, the use of hand sanitizers in the backcountry is certainly better than nothing. It is obviously much more practical. Having the entire group use sanitizer prior to preparing and eating meals is a simple and probably effective intervention.

The choice of soap is personal and probably not evidence-based. I use a castile soap (“Dr. Bronner’s”) both at home and in the woods. Products without fragrance or preservatives are more environmentally sensitive. The environmental impact of tiny amounts of pure soap (assuming group dispersion and appropriate distance from water sources) is trivial.

If anyone along on your next trek questions the need for all of this, remind them of the findings in a recent research study by some colleagues and me. In a study of randomly encountered campers in various Adirondack locations (including a popular High Peaks trail), nearly one third had contamination of their hands by the types of bacteria found in human feces (American Journal of Infection Control 2012;40:893-895). Bon appetit!

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, www.adirondoc.com. Hospital infection control specialist Jana Shaw, MD, MPH, reviewed this column and supplied helpful suggestions.

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Topics: Disease, General First Aid, Hygiene, Skin

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Where Does It Hurt?

2020, March/April Adirondac

PAIN, OR RATHER THE TREATMENT OF IT, has been in the news a lot lately. In a cascade of poor decisions, American medicine (and the pharmaceutical industry) came to the consensus that all pain was bad and merited aggressive treatment. The disastrous consequence has been an opioid epidemic claiming tens of thousands of lives annually.

In retrospect, the entire premise upon which this catastrophe was based seems flawed. It is as if the profession of psychiatry were to declare that all sadness required treatment.

Pain is a frequent accompaniment of wilderness travel. When and how should we treat it?

Early in my guiding career, I included a veritable pain control armamentarium in my field first aid kit, including syringes and injectable morphine. It did not take long for me to drop these. I realized I never really needed them, and it was increasingly difficult, even as a licensed physician, to acquire them legally. In today’s environment, I would be loath to carry such items loose in a backpack! I substituted oral opioids for a few years, finally abandoning them as well.

Today, the only pain control medications I carry in the woods are the ones most readers have in their home medicine chests. What I also have, however, is a more mature understanding of how they work and when they should be used.

The bulk of over-the-counter pain relievers fall into two groups: acetaminophen and NSAIDs (non-steroidal anti-inflammatory drugs). These medications have distinct mechanisms of action, which is why it is sometimes useful to use one from each category. Most stores include many choices within these categories, under a variety of brand names. I will use the generic names, since there is no importa} 1t difference between these branded medications and their generic equivalents.

Acetaminophen appears to have its major site of action in the brain. No matter where the problem originates, what we “feel” as pain depends upon the way in which our brain interprets the signals sent to it. Thus, acetaminophen appears to work by blunting our perception of pain. For otherwise healthy adults, the maximum dose of this medication is 1000 mg (two 500 mg tablets) every six hours. This should not be continued for more than a few days without a physician’s advice. Serious side effects and reactions to acetaminophen are unusual. Since its major toxicity is to the liver, it should be avoided by folks with known liver disease or who are heavy alcohol users.

The effect of NSAIDs on pain comes from a different mechanism: Inhibition of the synthesis of substances (prostaglandins) made at sites of inflammation which produce myriad effects, including pain. This is why these drugs are particularly effective in certain forms of arthritis.

Although generally very safe, NSAIDs have an array of side effects that are a bit more problematic than those associated with acetaminophen. Foremost among these are irritation of the stomach and intestine, sometimes resulting in bleeding.

There are a variety of formulations of these drugs, differing in dosage and timing; naproxen sodium, for example, is taken twice daily, while ibuprofen is usually taken every six hours.

Because of this variability, it is best to consult with your pharmacist for precise dose advice. For most purposes, there is no meaningful difference between the types of NSAIDs available over the counter. Because acetaminophen and NSAIDs have distinct mechanisms of action, it is sometimes recommended that they both be used for a more potent pain-relieving effect. In any case, remember to address the cause of pain, as well as possible non-drug treatments, whenever possible. The headache of dehydration, for example, is best treated by drinking fluids; indeed, dehydration increases the risk of side effects with NSAIDs. The soreness of thigh and calf muscles that sometimes comes from a long day’s hike can benefit from massage and, perhaps, salty fluids .

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, www.adirondoc.com. Luke Probst, PharmD, director of pharmacy services at Upstate Medical University, reviewed this column and provided helpful suggestions.

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Topics: General First Aid

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The “Other” Problems with Ticks: Part 2

2020, Janurary/February Adirondac

IN THE LAST ISSUE, we began to review the host of other disorders associated with tick exposure besides Lyme disease, starting with anaplasmosis and ehrlichlosis. This time, we will focus on a few more of these rarer, yet far more severe, “non-Lyme” complications of tick bites.

Babesiosis, although spread between mammals by ticks, differs from the diseases we have already discussed because it is caused by a protozoan rather than a bacteria. Worldwide, a number of species of protozoa cause babesiosis; most are in the genus Babesiosis. After the bite of an infected tick, about one to four weeks are needed for the parasite to multiply and infect; many of these infections are so minor the patient is unaware of them.

In mild disease, fever, fatigue, and other non-specific symptoms are predominant; unlike in other tick-borne diseases, rash is rarely present. Severe disease, which may carry a mortality rate of 20 percent, causes multiple organ failure, with anemia, respiratory failure, and liver, heart, and kidney disease. Laboratory confirmation of diagnosis is complicated, and generally requires consultation with specialists. Similar to malaria, identification of the parasite in red blood cells by microscope examination is definitive. Mild babesiosis may not require treatment. More severe cases are generally treated with combinations of antibiotics and drugs used in the treatment of malaria. In 2017, there were 697 cases of babesiosis reported in New York State.

Rocky Mountain Spotted Fever is one of many diseases caused by an unusual group of bacteria called Rickettsia, others of which cause such exotic conditions as typhus. Since the specific bacteria causing RMSF is typically spread by ticks, it is included here.

After a period of up to two weeks, the causal bacteria establishes itself in the patient. The organism is particularly fond of the cells lining blood vessels. This causes damage and leaking from small blood vessels, one of the results of which is the spotty rash which gives RMSF its name. As with many tickborne diseases, fever, non-specific headache, and generalized achiness appear at the start of infection. Things can rapidly go downhill, especially if diagnosis is delayed, with brain inflammation, kidney and heart failure, liver damage, and respiratory distress.

Laboratory testing to confirm diagnosis is difficult, and generally only definitive after infection resolves. Since one of the risk factors for death is late recognition and treatment, it requires an astute clinician to diagnose RMSF and start treatment early.

As for many tick-borne diseases, antibiotics such as doxycycline are the mainstay of treatment. Thirty-six cases of RMSF were reported in New York State in 2017; many of these were probably acquired elsewhere.

Powassan virus disease is one of a large group of viruses that cause encephalitis- inflammation and swelling of the brain. Most spread by mosquitoes, but PVD is included in the tickborne disorders. Symptoms of encephalitis include fever, severe headache, and alteration in state of consciousness. The disease is difficult to diagnose, and there are no comprehensive data for New York as yet. There was at least one fatality from tick-borne PVD in New York State last summer, and it claimed the life of former North Carolina Senator Kay Hagan in late October. As with most diseases caused by viruses, there is no specific treatment.

New tick-borne diseases are being discovered and reported regularly; “Borrelia miyamotoi” and Bourbon virus disease are among these. Columns such as this one run the risk of being outdated nearly as soon as they are written.

If all of this information scares you, you are not alone. A number of individuals with whom I have spoken have told me they are limiting their backcountry travels because of concern about ticks. For those folks, let me end with some reassuring news. Last summer, I attended a lecture by a major tick researcher. This individual has spent the better part of the past few decades tracking down ticks in their habitats-literally crawling around in tick-infested areas for days at a time. He has never acquired a tick-borne illness. What is his secret? Nothing, really. He just follows all of the regular advice on tick avoidance, which is widely available in publications such as this one.

Tom Welch, MD, is a physician at Upstate Medical University in Syracuse, and a member of the Wilderness Medical Society. He is a licensed professional guide and Wilderness Education Association instructor, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available on his website and blog, www.adirondoc.com. SUNY infectious disease expert Leonard Weiner, MD, reviewed this column and provided helpful suggestions.

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Topics: General First Aid, Insects & Spiders

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