Wilderness as therapy

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

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The Most Dangerous Wild Creature

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.

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

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Scary Movements Seizures in the Wilderness

2023, 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.

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Topics: General First Aid

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New Approaches to a Very Old Problem

2023, Fall Adirondac

Timber rattlesnake in the Catskills. Cheryl Miller
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.

~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.

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Topics: General First Aid, Infections, Snake Bites

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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.

~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.

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Topics: General First Aid, Infections, Water

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Sun and Snow

2023, January/February Adirondac

Welch skiing AdirondacksIn 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 .

~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.

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

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Hiking on Drugs

2022, November/December Adirondac

No, not those drugs …
Hypertension (high blood pressure), a major cause of cardiovascular death affects over 100 million Americans, 80 percent of whom are on medication for the problem. As I have discussed in other columns, aerobic exercise such as wilderness travel has a major positive impact on hypertension. This observation is tempered by the fact that several of the common medications used for hypertension may affect the hiker negatively. Although this is not a reason to avoid wilderness pursuits, being aware of the effects of several types of antihypertensives can help one prepare to enjoy a trek without nasty complications.

There are literally hundreds of individual antihypertensive drugs. I will focus on four categories that include the vast bulk of prescription medicines for hypertension and have specific concerns for backcountry use. I will avoid using names of the individual drugs since there are so many of them. Readers should check with their pharmacist or provider (or, of course, Google) to learn into which categories their own prescriptions fall.

The group of drugs that may be the most problematic are the beta blockers. These drugs lower blood pressure by interfering with the strength and rate with which the heart beats. They are highly effective medications, and particularly beneficial for those with prior heart attacks.

Most individuals experience fatigue and lowered exercise capacity when beginning beta blockers, although these effects may lessen with time. For some, however, beta blockers make strenuous exercise such as climbing a peak nearly impossible. Hiking requires an increase in the rate and strength of the heart’s contractions; this increase may be severely limited by beta blockers. Regardless of one’s prior experience, it would be unwise to plan a major hiking trip after starting a beta blocker without having a good idea of one’s current exercise capacity This would best be assessed by a series of hikes of gradually increasing length and difficulty.

There are a number of specific beta blockers, which vary in their impact on exercise capacity. This would be an important discussion with one’s provider before beginning the drug.

Diuretics are a group of drugs that increase urine output, lowering blood pressure by reducing blood volume. After being on a diuretic for a while most patients reach a new equilibrium of fluid balance and are generally comfortable.

Trekking, however, can upset this equilibrium by increasing the need for fluids. Thus, there may be a greater risk of dehydration for hikers taking diuretics. This may show itself with fatigue, light-headedness, and excessive thirst. Hikers experiencing such symptoms while taking diuretic, should increase their intake of fluids such as water, as well as salty snacks. As with many such things, there is no real “rule” for doing this, besides carefully heeding the signals of one’s own body.

Angiotensin converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs) are two different categories of antihypertensive that have similar mechanisms of action. These drugs inhibit a hormone that typically constricts blood vessels, thus lowering blood pressure. This effect may interfere with the body’s usual ability to raise blood pressure upon standing or becoming slightly dehydrated. Patients may therefore experience dizziness or lightheadedness when getting to a standing position or upon arising in the morning. While annoying, this is seldom dangerous. It is wise to be careful moving to stand, such as after stopping on the trail for a rest. One should also avoid dehydration while on these drugs.

Calcium channel blockers relax the tension in blood vessels, lowering blood pressure. Like ACE inhibitors and ARBs, these drugs may render one lightheaded upon standing, especially if slightly dehydrated.

~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.

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Topics: Diet & Nutrition, Drugs, General First Aid

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2022, September/October Adirondac

When a trivial injury results in some minor bleeding, our body activates a system for stopping the bleeding. Our coagulation system is truly a wonder. As blood flows through arteries, veins, and organs, it (usually) is unimpeded. Yet, as soon as a blood vessel is damaged or opened, a powerful cascade is set in place, the ultimate result of which is a clot that stops the bleeding. As the injured tissue is repaired, another cascade is activated in order to dissolve the clot. The entire process of clot formation-thrombosis- and clot dissolution-thrombolysis- requires the interplay of scores of individual proteins and cells, working in concert. As with any complex system, however, the thrombosis/thrombolysis mechanisms occasionally go awry.

One of the more common disruptions of the coagulation system is the formation of a blood clot in a large blood vessel in the absence of injury or bleeding. This condition is referred to as a deep vein thrombosis (DVT), and can have effects ranging from annoying to life-threatening.

The first sign of a DVT is usually swelling in the part of the body downward from the clot, often painless. A DVT in the large vessels of the leg, for example, may first show as painless swelling of the foot.

Once a DVT gets started, it often tends to grow in size and involve more of the vessel On occasion, part of the clot can break loose and begin to travel elsewhere in the body. At this point, the clot becomes an embolism and dire consequences can ensue. Most concerningly, the clot can become lodged in the lungs as a pulmonary embolism, resulting in severe pain, shortness of breath, and even sudden death.

Several factors can predispose one to the development of a DVT. Occasionally, an inherited defect in one of the components of the coagulation system may lead to a proneness to spontaneous clot formation. More commonly, prolonged positioning without movement is the culprit in DVT formation; this is why long airline flights in cramped seats are a notorious trigger for leg DVTs. Dehydration can also become a factor in DVT formation, by making blood cells more concentrated and “thick” Certain medications, such as oral contraceptives, may also predispose to the formation of spontaneous clots.

Backpackers’ concerns
What about the backpacker? The nature of hiking makes leg DVTs an unlikely event, although travel to the !railhead itself can be a risk Getting out of one’s vehicle for a quick drink of water and a stretch is a wise preventive. There are, however, several reports of DVTs in the blood vessel of the upper arm, the subclavian vein, in backpackers.

The mechanics of most backpack shoulder straps result in continuous pressure on the subclavian vein. If one combines this with dehydration, limited arm movement, or other DVT risk factors, such as medication use, clots could develop in one or both arms.

Preventing DVTs during backcountry travel (including on the way to the trailhead) involves some simple steps. Ensuring adequate hydration is a major one-indeed, it seems important in preventing a host of wilderness medical disruptions. One should pay close attention to backpack fit, and adjust the shoulder or chest straps if one feels heavy pressure on the area just below the collarbone. The backpack should come off at rest stops, and vigorous range-of-motion exercises of the shoulder should be done to ensure circulation. If one has a personal family history of DVTs, or is taking a medication that could increase the DVT risk, consultation with one’s provider before a trek would be wise.

First aid options for backcountry DVTs are limited. If one were to notice increasing swelling of the arms, beyond the fairly typical slight finger swelling most of us experience, a DVT should be suspected. Offloading the pack to one’s companions, ensuring hydration, and planning trek termination for definitive care are the only practical options. Although there is no evidence basis for the recommendation, taking a “baby aspirin” (81 mg) may be useful in attenuating progression of the clot, and has no real downside. In the event of symptoms of pulmonary embolism (cough, chest pain, shortness of breath, coughing blood), urgent evacuation is mandatory.

The CDC has a very helpful summary of DVT prevention available on its website, cdc.gov /ncbddd/ dvt/ facts.html.

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, adirondoc.com.

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Topics: General First Aid, Head & Neck

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Wilderness Evacuations

2022, July/August Adirondac

Trigger warning: Some readers may find this content gross.
Lots has been written, very importantly, on the safe and proper handling of human waste in the backcountry. That won’t be the subject here. We will discuss the mechanics of passing said human waste, or more to the point, difficulty in passing-constipation.

Constipation is defined as infrequent bowel movements (typically less than three per week). More important, it is associated with stools that are sometimes hard to pass, often with the sensation that the bowels did not empty completely. Severe constipation may be accompanied by abdominal pain and can lead to additional problems such as worsening hemorrhoids. According to a study from over a decade ago, constipation in the U.S. accounted for nearly six million physician visits and about $235 million in direct costs in a year. These figures have likely grown significantly since the study was published.

Why would this be a topic for a column on backcountry health and safety? There are a few reasons. First, the person with constipation at home can at least sit in relative comfort in a warm, dry room, reading a magazine such as this one. Squatting over a cathole in the rain or in black fly season, however, is a whole other experience. More serious constipation can result in abdominal pain that can be severe enough to be confused with appendicitis; there are documented wilderness evacuations from this problem. Finally, three major contributors to constipation (diet, hydration, and exercise) may be significantly affected by backpacking. This may result in a significant change in bowel habits for someone who ventures into the backcountry for a few days.

The substance in our diet that most helps to maintain the bulk and softness of our stools is fiber. Fiber content is listed in the nutrition information panel on most foods. Although the data are not firm, thirty grams per day represents a good fiber intake for most adults; this is not likely achieved by most Americans. Good sources of fiber include whole grains, oatmeal, dried fruits, nuts, and brown rice.

For many people, the backpacking diet may differ considerably from that at home. Some folks, for example, like to subsist with the relative simplicity of boxed “mac and cheese,” instant white rice, hard white rolls, and similar meals on the trail. While this may simplify meal preparation, it is a recipe for constipation-especially on a trek of more than a couple of days. As readers may ]mow from my other writings, I am a big proponent of healthier eating on the trail, like that described in resources such as NOLS Cookery. I have had students in my wilderness courses whose usual diets were low in fiber think that something was wrong after a few days of healthy trail eating upon finding that they were having one or two soft stools daily.

Hydration is the second factor impacting constipation. When one is dehydrated, the body absorbs as much water as possible from the gut, making stools drier and harder. Yet another reason to stay well hydrated in the backcountry! Remember, there is no “one size fits all” rule for liquid intake; one should drink as much as necessary to keep urine from being dark yellow.

Exercise is the final important factor in preventing constipation. Sedentary folks are at much greater risk, so maintaining bowel health is another good reason to hit the trail.

The backpacker with normal bowel habits at home who consumes a healthy trail diet and plenty of water should have no difficulty with constipation on the trail. Folks prone to constipation, or those with less fiber-rich diets, may want to bring along some medication for constipation. There are many types of these; the most common are stool softeners (such as Colace) and stimulants (such as Dulcolax). Stool softeners are less likely to result in a “quick need” to have a bowel movement, and are therefore a better choice on a trek.

The American Gastroenterological Association has a very helpful online resource with additional information about constipation, including warning signs of more serious problems. It can be accessed at patient.gastro.org/ constipation.

Tom Welch, M.D., 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, adirondoc.com. Bill Balistreri, M.D., an internationally known expert in constipation and other gastroenterological disorders, reviewed this column and provided helpful advice.

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Topics: Diet & Nutrition

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High Time

2022, May/June Adirondac

After twenty-three years of writing this column, some overlap of subject matter is probably inevitable. I am going to discuss a topic I reviewed on these pages over two decades ago. Although there is very little new science about the subject, it will be a good reminder for the older reader and a good introduction for a new generation of trekkers.

Every now and then, I encounter a hiker huffing and puffing en route to an Adirondack summit and making a comment along the lines of ”.Air is pretty thin up here, eh?” While that’s technically correct, the implication that the hiker’s exhaustion is a function of altitude is not. This does not imply, however1 that altitude is never a problem for the trekker-it most assuredly can be!

Every bodily function requires oxygen. Oxygen is delivered continuously to the muscles, brain, and other organs by red blood cells. These cells pick up oxygen as they flow through the lungs and deliver it through the network of blood vessels. After offloading oxygen to tissues, the cells return to the lungs for a resupply.

The amount of oxygen that a red blood cell can take up from the lungs is a function of two things: the percent of oxygen in the air, and the air pressure. As one ascends, the percentage of oxygen in air is constant, but the air pressure decreases; this is why commercial aircraft, flying at very high altitude, are pressurized.

Although air pressure decreases incrementally for every foot of elevation gain, the consequence for red blood cell oxygen delivery in healthy persons is inconsequential below about 8,000 feet. This is why folks climbing Mt. Marcy ( or any peak east of the Mississippi) can’t blame altitude for their fatigue. A ski vacation in the Rockies, or an alpine or Himalayan trek, is a very different story.

The medical effects of high altitude are all direct consequences of tissue oxygen deficiency. The earliest effect most folks notice is a lower threshold for exhaustion-becoming unusually fatigued by what seems like minimal effort. The body compensates for impaired oxygen delivery by increasing the respiratory rate and the heart rate (pulse). This is why one feels (and appears) much more “winded” by a jaunt in the Rockies than one of similar length and elevation change in the Adirondacks. There is no real “treatment” for this problem beyond factoring it into your trip planning.

Acute mountain sickness (AMS) is the next step in altitude illness. It is marked by headache, occasionally very severe, accompanied by some systemic complaint such as nausea, extreme fatigue, or lightheadedness. Many New Yorkers who make quick trips for Colorado ski vacations experience AMS, which they may attribute to hangover! (Actually, alcohol can worsen AMS.)

More severe altitude complications generally start at or above 11,000 feet. High-altitude cerebral edema (HACE) refers to brain swelling, which results in deterioration in mental function, delirium, and coma. Accumulation of fluid in the lungs, with cough, bloody sputum, and severe respiratory distress are the findings of high-altitude pulmonary edema (HAPE). Both of these conditions are life-threatening.

The most important preventive measure for altitude illness is allowing time for acclimatization. Once above about 11,000 feet, one should never sleep at a gain of more than 1,500 feet in a day. Extended climbs above this altitude should include a full rest day out of every three or four. Attention to hydration is important; one becomes dehydrated more easily at high altitude, and AMS, HACE, and HAPE are all worsened by dehydration.

Simple high-altitude headache typically responds to NSAIDS and fluids. There are additional prescription medications (acetazolamide and dexamethasone) useful for AMS and other complications. The only definitive therapy for severe altitude illness is descent; even seemingly severe symptoms seem to melt away upon a descent of a few thousand feet. Major expeditions may carry supplemental oxygen, or even portable hyperbaric devices, but neither are substitutes for rapid descent.

I always recommend consultation with a wilderness or travel medicine specialist prior to undertaking an extended, sojourn at very high altitude. Often, these physicians will provide prescriptions for possible use in the event of symptoms; they can also counsel folks with chronic conditions that could be worsened by high-altitude travel, or would make such treks unwise.

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.


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Topics: Altitude, General First Aid

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