“Shin Splints”

2022, March/April Adirondac

One of the ironies of modern medicine is that it sometimes seems that little attention is devoted to the things that bother folks the most. “Shin splints” are a terrific example of this. I put the term in quotes since there isn’t complete agreement among experts on what to call the condition. The currently preferred terminology among orthopedists and sports medicine specialists is “medial tibial stress syndrome” (MTSS). I’ll stick to “shin splints.”

Most of us have a pretty good idea what shin splints are, often from personal- experience. The condition causes pain along the inner border of the tibia, the most prominent bone in the front of the lower leg. It typically develops after strenuous exercise, most often running but also hiking. Hiking which produces a lot of impact (such as walking down a steep trail) can be a particular culprit. It typically comes on during exercise, and remits somewhat after rest. With time, however, it may continue even after active exercise has stopped.

Several muscles involved in walking attach to the inner surface of the tibia, and it is believed that constant pulling of these muscles on the surface of the bone is the cause of the pain. There is really no laboratory or x–ray test which is positive with shin splints.

The diagnosis is primarily made by the history. Unlike the sudden pain of something like a sprained ankle, shin splints develop gradually during exercise. The discomfort generally extends from the middle of the bone upward and downward. There is typically no single spot at which tenderness is located; rather, pain extends quite a bit along the entire bone. There is rarely any swelling or bruising over the painful area, but it may be somewhat painful to palpation. Again, however, the pain usually extends over a few inches of the inside of the bone.

Beyond rest, there is really no definitive treatment for shin splints. The old standby medication, NSAIDS such as Advil or Aleve, may provide some relief. Although unquestionably uncomfortable, shin splints rarely are disabling. Most hikers can continue their trip, albeit at a perhaps slower and gentler pace. For most casual hikers, shin splints are little more than an inconvenience. For some competitive runners, however, the condition may result in the loss of an entire season.

For those predisposed to shin splints, prevention may involve modulating the choice of terrain and hike length. Although some advocate the use of a cushioning insole (orthotic), there is no strong evidence basis for this recommendation. It can’t hurt, however.

Finally, a few things can beconfused with shin splints. Lower leg fractures are associated with a definite injury, and typically have exquisite point tenderness. A special type of fracture, “stress fracture” is an exception. These are tiny hairline cracks in the bone which result from continuous “micro trauma.” Stress fractures are more likely to persist after exercise stops, and may be more painful upon palpation. From a practical standpoint in the field, there is no real difference in management from shin splints.

Far more dangerous is compartment syndrome. This refers to swelling of or bleeding into muscles that are contained by firm tissue (“fascia”). Although it typically follows injury, compartment syndrome has occasionally been reported after unaccustomed exertion. Unfortunately, one of the common locations is in the muscle groups of the lower leg, similar to the area involved in shin splints. The pain is far more severe than that of shin splints, and does not remit upon stopping exercise. The affected area is quite tender, and may be swollen. There is typically weakness of the involved muscles, and pain if they are stretched. The pressure within the muscles can result in permanent injury. Urgent evacuation for definitive care is the only field treatment.

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.


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Topics: Environmental Injuries, General First Aid, Orthopedics

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Life in Balance

2022, January/February Adirondac

Wilderness medicine” is about a lot more than splinting complex fractures on steep slopes in a snowstorm. Much of the specialty should deal with prevention of injuries and encouragement of fitness. Fitness and wilderness trekking are closely interrelated; outdoor adventure pursuits are a terrific way to maintain one’s fitness, and physically fit adventurers are less likely to require wilderness medical treatment.

When we think of fitness for hiking, strength and endurance are probably the first things we consider. For this column, though, I want to remind readers about balance.

Two of the most common injuries in hikers, ankle sprains and forearm (Colles) fractures, are typically triggered by a momentary loss of balance, resulting in a slip or fall. Although this can happen to anyone, some individuals are plagued by balance difficulties. While a host of factors contribute to balance disorders, most can be treated or prevented.

Underlying joint problems, such as knee osteoarthritis, are a common antecedent to balance difficulties. Pain or limited movement of a joint may make one compensate with awkward movements, leading to an unstable position and loss of balance. This is one of the reasons I highly recommend trekking poles for folks with such problems (see “AdironDoc,” March-April 2021).

Blood pressure problems or the use of certain medications may cause temporary decreases in brain blood flow, especially with a sudden change in position such as getting up from a rest. This can result in momentary lightheadedness and a stumble.

Balance requires a sensation of position, something we inelegantly refer to as “proprioception.” Many factors, including aging, can contribute to diminished proprioception.

Balance also requires the function of a complicated apparatus in our inner ear, the “vestibular system.” This is the system that makes one dizzy after amusement park rides or queasy on a boat. Head injuries, illnesses, and (again, unfortunately) aging can impact vestibular function.

A visit to one’s primary care provider is the way to begin addressing issues affecting balance. Many balance problems can be uncovered by a careful medical history and exam. Depending upon the issues, treatments ranging from physical therapy to medication may be prescribed. For example, there are now physical therapists who specialize in customized exercise programs for individuals ,-vith balance problems caused by inner ear abnormalities (“vestibular rehabilitation”).

For folks without overt balance problems who are interested in maintaining or improving their balance, there are a number of terrific options. One particularly worth mentioning is tai chi. This ancient Chinese practice, which frankly looks a bit odd the first time one observes it, is a gentle form of exercise that has measurable positive effects on balance, as well as a host of other benefits. A nice description of these was provided in a Harvard Health blog (health.harvard.edu/ staying-healthy /the-health-benefitsof- tai-chi). Although there are videos that can teach tai chi at home, I suggest starting with a group class. These are frequently available through community centers, senior programs, and gyms.

For some reason, many folks are attracted to the drama of wilderness medicine. How exciting to diagnose a Colles fracture just below timberline on a high peak, shortly before sunset! How thrilling to package the patient to prevent hypothermia and splint the fracture while observing for shock and ensuring hydration! How exhilarating to orchestrate an early-morning helicopter evacuation! Contrast this to the abject dullness of recommending a tai chi class, which could have prevented all the drama. The best medicine is often the least exciting.

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, Readiness

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Too Hot to Handle?

2021, November/December Adirondac

I WRITE THIS COLUMN as we end one of the warmest summers in memory. All indications are that this sorry trend is going to continue. As the climate warms, heat injuries become increasingly important, and not only for hikers and paddlers. Any season of the year is now a good time to discuss such injuries as we plan for travel in warmer climes or for next summer’s weather.

As with any health issue, we need to begin by understanding some science. The countless metabolic functions that make human life possible all require a fairly narrow range of temperature to operate optimally. For this reason, evolution has equipped our bodies v.rith many mechanisms for cooling (for example, sweating) and warming (shivering). Cold illnesses (hypothermia) occur when the warming mechanisms are overstressed, while heat illnesses (heat exhaustion and heat stroke) result from failure of the cooling mechanisms.

As we exercise in a hot environment, we begin to sweat. Since evaporation results in cooling, the evaporation of sweat from our skin has a cooling effect, especially if low humidity or a breeze facilitate evaporation. Blood flow to the skin increases, further facilitating the removal of heat from the body. If the ambient temperature and humidity are high, these mechanisms are compromised and less efficient.

Heat exhaustion develops when the body’s attempts at compensation for heat stress begin to fail, often precipitated by dehydration related to sweating and loss of fluid in breath. The symptoms of heat exhaustion range from mild fatigue and lightheadedness to severe headache, weakness, and fainting. The patient with heat exhaustion will typically feel cold and clammy because of intact sweating; body temperature is normal or only slightly elevated. He or she is likely to be very thirsty.

Field treatment of heat exhaustion is relatively simple, and based on the underlying physiology. Exertion needs to stop, which means sitting in a shady spot and taking off the pack. The need is for both salt and water. Oral rehydration solutions (mixtures of water with optimal mineral and glucose content) are available, but not typically carried on wilderness treks. My suggestion is water alternated with salty snacks such as peanuts. Using water alone for heat illness risks the development of low body sodium (hyponatremia), a potentially fatal affliction I discussed in my November-December 2020 column. More severe cases may require hospitalization for intravenous fluid replacement.

Heat exhaustion occurs on a spectrum, and most cases are relatively minor. I suspect that many readers of this column have “survived” mild heat exhaustion with no treatment other than rest and drinking.

Heat stroke is an entirely different matter. In patients with heat stroke, there has been a complete breakdown of the body’s cooling mechanisms. This results in severe elevations in temperature, with consequent failure of many body systems. Victims of heat stroke are hot and dry (because sweating is no longer operative), with extremely elevated body temperatures. They are likely to be delirious or unconscious, and the condition may progress into cardiorespiratory, liver, and kidney failure.

True heat stroke in the wilderness is most unlikely, and meaningful survival would be impossible. Treatment in even the most high-tech setting is complex; in austere environments, external cooling with copious amounts of water, immersion if feasible, and attention to the “ABCs” of resuscitation are about all that can be done pending evacuation.

Although progression from heat exhaustion to heat stroke may occur, it is unusual; most heat stroke occurs in very specific contexts. Endurance athletes, military recruits, and similar folks undertaking strenuous exercise (which generates body heat) in hot weather (which compromises dissipation of heat) are at great risk. Elderly or disabled individuals living in very hot environments and unable to maintain hydration and other selfcare activities are a second risk group. Sadly, we can expect more of the latter as climate change progresses.

Further information on heat illness is available in the clinical practice guidelines of the Wilderness Medicine Society at wemjournal.org/article/ S1080-6032(18)30199-6/fulltext.

~ 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, Water

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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.

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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Another Reason to Hate Ticks

2021, July/August Adirondac

READERS COULD BE forgiven for wondering “What more could he possibly have to say about ticks?” Indeed, the wilderness medicine literature is replete with articles on the subject. For most tick-borne diseases, the paradigm is the same: Tick bites mammal and acquires an organism. Tick then bites human and passes on organism. Organism causes disease in human. The disease can be treated, but preventing tick bites is the best strategy. For everything from Lyme disease to Colorado tick fever, these four sentences pretty much summarize the situation.

Now, for something completely different: alpha gal syndrome (AGS).

Although AGS as a complication of tick bites has been reported in a number of esoteric medical journals over the past few years, it has remained a medical curiosity. A recent case report in the widely circulated New England Journal of Medicine (N Engl J Med 2021;384:462-7) may give the condition greater visibility.

Unlike most tick-related disorders, which are infections, AGS is an allergic reaction to a molecule, alpha gal for short, which is present in all mammals except primates (like us). This includes animals in our diet such as cows and pigs. Ticks may ingest tiny quantities of alpha gal when feasting on deer, then may transfer some of the material to their next human host. Some humans, upon being exposed to alpha gal from a tick bite, develop antibodies to it in large enough quantities to produce an allergic reaction upon consumption of red meat. Interestingly, the reaction seems to be specific to the meat; patients with AGS after consumption of beef generally can tolerate milk.

We have no idea why only a subset of folks suffering tick bites develop these antibodies and AGS. Although in theory any tick can transmit alpha gal, thus far the problem seems limited mostly to the lone star tick, a species seen in New York.

The symptoms of AGS are quite variable. Some patients develop an itchy rash, urticaria (“hives”), following meat ingestion. Unlike other food allergies, this may be delayed in onset. Patients have described awakening from sleep with hives after a red meat dinner, for example. Other reactions may be more specific to the intestinal tract, with abdominal pain or diarrhea, similar to other forms of food intolerance.

Although unusual, more dramatic symptoms can occur with this disorder. The rare patient can experience swelling of the lips (angioedema), difficulty breathing, and even the severe generalized allergic reaction called anaphylaxis. Without immediate treatment, such individuals can die.

Like the rest of the tick-related disorders, AGS is prevented by the whole suite of tick avoidance measures to which users of the outdoors are becoming accustomed. Once it has developed, prevention involves avoidance of meat. Although as a vegetarian for decades I would not find this difficult, my carnivorous friends tell me it can be a burden! Mild reactions to alpha gal respond to over-the-counter antihistamine medications such as Benadryl®. More severe reactions may require the administration of steroids. Like anaphylaxis from any allergen, life-threatening reactions require the immediate administration of epinephrine, such as from an EpiPen®.

Since the symptoms of AGS are somewhat vague, and since they may not allows follow meat ingestion immediately, the condition is often difficult to diagnose. Many patients report years passed before a definite diagnosis was made. Users of the outdoors who have had tick exposures (the frequency of the condition increases with the number of tick bites) and who experience unexplained allergic symptoms such as hives should mention their tick exposures to their primary physician or allergist. There are both blood tests and skin tests which can be used to confirm the diagnosis of AGS.

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.

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Topics: General First Aid

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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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