Achilles Ankle

2020, September/October Adirondac

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

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

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

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

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

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

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

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

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

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

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Topics: Environmental Injuries, General First Aid, Orthopedics

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Social Distancing, and backcountry ethics

2020, July/August Adirondac

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

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

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

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

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

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

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

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

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

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

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Topics: COVID-19, Hygiene

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

2020, May/June Adirondac

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

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

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

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

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

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

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

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

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

Tom Welch, MD, is a physician at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog, www.adirondoc.com. Hospital infection control specialist Jana Shaw, MD, MPH, reviewed this column and supplied helpful suggestions.

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Topics: Disease, General First Aid, Hygiene, Skin

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Where Does It Hurt?

2020, March/April Adirondac

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

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

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

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

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

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

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

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

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

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

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

Tom Welch, MD, is a physician at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog, www.adirondoc.com. Luke Probst, PharmD, director of pharmacy services at Upstate Medical University, reviewed this column and provided helpful suggestions.

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Topics: General First Aid

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The “Other” Problems with Ticks: Part 2

2020, Janurary/February Adirondac

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

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

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

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

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

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

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

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

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

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

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

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Topics: General First Aid, Insects & Spiders

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Psychological First Aid

2019, September/October Adirondac

AS I HAVE WRITTEN MANY TIMES, in decades of leading expeditions into the wilderness ranging from days to months, I have had precious few circumstances calling for more medical knowledge than one would acquire in a basic first aid course. One of the most dramatic incidents I recall was actually a mental health emergency.

While leading a youth group going through a high pass in Montana’s Bob Marshall Wilderness, I was called to look at a 17-year-old who was having severe respiratory distress. The boy had a history of asthma, and had been using his prescription inhaler multiple times because of difficulty breathing. On exam, he was clearly distressed, sweating profusely, breathing rapidly, with a rapid heart rate, and quite anxious. He did not, however, have the characteristic breathing pattern of asthma (prolonged exhalation and wheezing). He was actually experiencing a panic attack, worsened by the medication in his inhaler.

Once it was clear what was happening, it was quite simple to help him. I had him sit down, take off his pack, sip some water, practice regular “mindful” breathing, and relax. I reassured him that he was not having an asthma attack, talked about his concerns, connected to him by holding his hand while talking to him, and in about half an hour he was ready to continue. He did well for the rest of the trip.

I have thought about this incident many times in the years that have followed, and have described it while teaching and lecturing about wilderness medicine. Nothing I did for this kid required any sophisticated first aid technique, yet without intervention the situation could have gone downhill rapidly. Most concerning to me is that very few wilderness first aid courses include meaningful content on psychological first aid.

My experience is hardly novel. Maia Szalavitz’s book, Help at Any Cost (an indictment of the “troubled teen industry”), has some terrifying anecdotes about teens on wilderness expeditions experiencing life-threatening (even fatal) incidents because the expedition leaders did not know how to recognize or address psychological disorders. Many of these leaders were fully trained and certified “wilderness first responders,” or had even more advanced training.

Admirably, some wilderness first aid courses have begun to include material on “psychological first aid.” Unfortunately, much of this content is intended to address the psychological complications of severe injuries, such as PTSD. Indeed, the content and techniques are drawn from the mass casualty literature. While this is important information in some contexts, its applicability to most backcountry travelers is nil. It is further evidence of the disconnect between much “wilderness medicine” and the actual medical needs of wilderness expeditions.

The basics of mental health first aid center around “de-escalation”: Rest, reassurance, demonstrating calm control, regular breathing. Not surprisingly, there are now vendors of structured training in mental health first aid, such as www.mentalhealthfirstaid.org.

While there have been very few good studies of the utility of these interventions, this is the unfortunate common denominator for much first aid anyway. Based upon their curriculum, however, the methods seem sound and the content appropriate for leaders of backcountry treks. I know that some New York State youth camps have begun to include similar training for their counselors. As my experience that summer afternoon in the Rockies demonstrated, a mental health emergency in the backcountry is every bit as real and dangerous as an asthma attack.

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, www.adirondoc.com.

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Topics: General First Aid, Mental Health

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The “Other” Problems with Ticks: Part 1

2019, November/December Adirondac

Deer Tick black-leggedALONG WITH NEIGHBORING PENNSYLVANIA, New York State is the epicenter of tick-borne illnesses in the U.S. Outdoor publications, including this one, have been in the forefront of educating readers on the problem. For most folks, “tick-borne illness” means Lyme disease. Certainly, that condition has been the most widely discussed in the media. While clearly the most common of the conditions carried by these pests, it is neither the only, the most serious, nor the most life-threatening one.

In this and the next column, I will review the basics of several other tickborne diseases which have been reported in New York. It is probably important for users of the backcountry to have at least a passing familiarity with these conditions. Many of them have rather nonspecific symptoms, some of which might not even prompt an immediate call to one’s physician.

Connecting features of these conditions to one’s recent tick exposure will permit early evaluation and treatment before the disease can progress. The importance of this hit home to an active outdoorsman/physician colleague of mine a few months ago, when he needed to remind his own physician to consider anaplasmosis when he became ill after tick exposure.

Anaplasmosis, a disease affecting many organ systems, is caused by a bacterium called Anaplasma phagocytophila. Several species of ticks may be carriers of this bacterium; at least one of them may carry both this and Borrelia burgdorferi, the organism responsible for Lyme disease. The white-tailed deer and the white-footed mouse are the animal reservoirs of anaplasmosis. In 2017, the most recent year for which we have data, there were 1196 cases of anaplasmosis in New York.

The symptoms of anaplasmosis are varied and somewhat nonspecific. The disease most often follows tick exposure by one to two weeks. Fever is one of the most common initial features; this sometimes may be severe enough to be associated with soaking sweats and chills. Generalized ill-feeling, along with muscle aches and vomiting, frequently develop. Unlike Lyme disease, for which rash is often a hallmark, rash is uncommon in anaplasmosis. If the disease is not recognized and treated, symptoms may progress to a very serious condition, requiring hospitalization and carrying a mortality which may be as high as 5 to 10 percent.

Standard blood tests in anaplasmosis are usually abnormal, but not diagnostic. The white blood cell count is often very low, as is the number of platelets in the blood. Particularly astute laboratory technicians may see the organisms in the patient’s blood cells. Liver tests may also be abnormal.

Confirmatory laboratory testing for anaplasmosis is possible, but is done in specialized labs and is not rapidly available; waiting for these results may delay treatment. Thus, most experts begin treatment with doxycycline if the clinical picture is suggestive of anaplasmosis. Patients will generally do very well unless diagnosis is delayed or there is an underlying condition impairing the immune system.

Ehrlichiosis is caused by a bacterium closely related to the one that causes anaplasmosis, Ehrlichia chaffeensis. Although many tick species have been implicated, the lone star tick accounts for the bulk of E. chaffeensis infections. White-tailed deer are the usual animal reservoir. In 2017, there were 170 reported cases of ehrlichiosis in New York.

The symptoms of ehrlichiosis overlap those of anaplasmosis, to the extent that they are nearly indistinguishable. The only exception is that rash, nearly unheard of in anaplasmosis, occurs in about one-third of patients with ehrlichiosis. Similarly, standard laboratory tests show low white blood cells and platelets, along with abnormal liver testing. In contrast to anaplasmosis, it is very unusual to find the organism in blood cells.

Again like anaplasmosis, definitive testing for ehrlichiosis is available, but not timely. Thus, initiating therapy (also with doxycycline) upon suspicion of the disease is vital. Reported fatality rates for ehrlichiosis are as high as 5 percent, mostly in cases of delayed diagnosis or underlying illness.

[See “Conservation and Advocacy Report,” May-June Adirondac for more on tick-borne diseases.]

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. SUNY infectious disease expert Leonard Weiner, MD, reviewed this column and provided helpful suggestions. This discussion will be continued in the next issue.

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Topics: General First Aid, Insects & Spiders

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Painful Pee

2019, July/August Adirondac

URINARY TRACT INFECTION (UTI) is one of the most common complaints bringing folks to their primary care providers. Since the urinary tract encompasses everything from the kidn s, where urine is made, to the urethra, the final tube through which it leaves the body, a UTI can involve a host of structures. UTIs can range from simple infections in the bladder, which may be more of a nuisance than a real threat to health, to pyelonephritis, an infection of the tissue of the kidney that can be life-threatening. UTIs rarely may spread to the bloodstream, a condition called urosepsis and which carries a very high mortality rate.

The symptoms of UTI generally depend upon what part of the urinary tract is infected. The vast majority of infections involve the bladder, and are associated with painful urination, the sudden urge to urinate, and increased frequency of urination. Systemic symptoms such as fever are not common with bladder infections.

Infections in the kidney tissue itself tend to have more dramatic symptoms. These are the infections that typically have fever and general ill-health. There may be significant back or flank pain with pyelonephritis, as well as gastrointestinal symptoms such as nausea and vomiting.
While UTI may occur spontaneously in an otherwise normal urinary tract, it is also a frequent complication of underlying problems such as obstruction of the urinary tract (as in older men with prostate problems) or with kidney stones.

Treatment of suspected UTI begins with a laboratory examination of a urine sample, which should dictate the appropriate type of antibiotic required, if any.
There is little in the way of first aid available in the event of a suspected UTI in the backcountry. Because of the risk of fulminant (quick and severe) urosepsis, anyone suspected of a kidney infection (fever, back or flank pain, with or without urinary symptoms) should be evacuated for definitive evaluation and care immediately. While bladder infections are not life-threatening, the symptoms can be so disabling that continuation of a trek could be untenable. Maintaining a good fluid intake and emptying the bladder as often as possible may help to minimize symptoms until definitive care can be reached.

Prevention of UTI in the backcountry begins with preparation. Some folks are predisposed to recurrent UTI, sometimes because of underlying problems such as stones or kidney cysts but otherwise for no apparent reason. These individuals may wish to consult with their personal health care providers regarding the potential benefit of carrying a supply of appropriate antibiotic to be used in the event that symptoms were to develop. This is a somewhat controversial approach, but it is certainly worth a discussion prior to embarking on a trek into the wilderness. (This is one of the few situations in which I recommend campers carry antibiotics with them.) Homeopathic remedies such as cranberry juice are either not evidence-based or, when studied, have proven unhelpful.

A couple of situations can predispose to UTI, and could occur on a trek. When urine sits for prolonged periods in the bladder, it may become more susceptible to infection. Thus, both maintaining a good urine output by taking adequate fluid and regularly emptying the bladder during the day and before nighttime are advisable. Constipation may interfere with complete bladder emptying, so avoiding this is also important. Finally, to the extent feasible in the backcountry, women should try to maintain good perineal hygiene.

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. For more information, www.adirondoc.com.

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Topics: Hygiene, Infections, Water

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Camping with Joe

2019, May/June Adirondac

GLOBALLY, caffeine is the most widely consumed psychoactive drug. In vehicles ranging from coffee and tea to energy drinks and soda, its use is ubiquitous; one report cites 90 percent of adults in the world consuming caffeine daily. Although the ranges are wide, the highest concentration of caffeine in beverages is in coffee, followed by tea and soft drinks. Energy drinks have an even wider range of content, sometimes exceeding that of coffee. Although the data are “soft,” it is generally believed that a daily intake of about 400 mg caffeine is safe. The amount represents about three to four cups of brewed coffee.

The short-term medical effects of caffeine are well known and fairly incontrovertible. It improves alertness and concentration, and increases heart rate. Although it is frequently considered a diuretic (a substance increasing urine production), this effect is actually quite modest; much of the increase in urine output is simply a function of the liquid in which it is consumed. Many studies have confirmed improvement in various measures of exercise capacity following consumption of caffeine.

The long-term (“chronic”) effects of caffeine are much more difficult to identify. Indeed, hardly a week goes by in which the media do not report some study showing that caffeine either increases or decreases the risk of conditions ranging from cancer or dementia to heart or Parkinson disease. The problem with all of these studies is the fact that caffeine consumption is so widespread it is difficult to find a true comparison group of individuals who do not use the drug. Some obvious candidates, for example members of the Church of Jesus Christ of Latter-Day Saints, are not appropriate for comparison because of their other admirable health habits, such as avoidance of alcohol and tobacco. Some studies have tried to use “dose response” techniques in an effort to show if increasing caffeine consumption is associated with increasing (or decreasing) risk of specific outcomes. While usually a valid technique, the problem with such studies is their reliance on self-report. How reliable is one’s report of his or her average daily caffeine intake over a few decades?

In comparison to the risk of lung cancer with tobacco or cirrhosis with alcohol, none of the purported associations between long-term caffeine use and health are particularly convincing or worrisome. While there may be many reasons to modify one’s caffeine intake, concern about health consequences should not be the major one. While data on chronic health effects is conflicting, it is well known that sudden discontinuation of caffeine intake can produce withdrawal. These symptoms generally begin about twenty-four hours after the last dose, and may last for a week. Headache, muscle aches and pain, and fatigue are the most common manifestations of withdrawal.

What are the implications of caffeine consumption for camping? None of the health effects, such as the mild diuretic property, interfere with outdoor activity. While the benefits for alertness and performance may be helpful, they probably are not important enough for those naive to caffeine to start using it. The most important implication is probably avoiding with drawal. This means having a reasonable idea of one’s daily consumption, and trying to maintain it during the trek. I have found this to be a problem in one particular group-those non-coffee drinkers who consume a lot of caffeine-containing soda. I have had teenagers whom I led on treks experience significant caffeine withdrawal symptoms when their daily sodas were not replaced by other beverages. Unless these folks are willing to take up coffee drinking, I suggest a gradual weaning from caffeine for a couple of weeks prior to a trek.

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: Diet & Nutrition

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Bloom in the Waters

2019, March/April Adirondac

LATELY I HAVE BEEN SPLITTING my time between the Adirondacks and the Gulf Coast of Florida. While these areas are about as dissimilar as one can imagine, they share a serious problem: Deterioration of water quality from periodic “blooms” of organisms. A lot is written about the ecology of this phenomenon, so I will only touch upon it here. My emphasis will be on the health implications and “first aid.”

HABs might have the appearance of pea soup or spilled green paint.
HABs might have the appearance of pea soup or spilled green paint. Courtesy DEC.

The biology here is complex, but can be distilled. Both fresh and salt water are normally colonized by a host of organisms, which are rarely harmful and which actually are important constituents of the aquatic food chain. Among these are a number of species of primitive plants classified as algae. Under most conditions, the populations of these organisms are kept in check by environmental factors such as temperature and the availability of nutrients, as well as through consumption by higher organisms. Thus, they are not usually a concern.

Factors such as changes in water temperature and the presence of nutrients (like fertilizer runoff) can upset this delicate balance. The result is the occasional rapid, unchecked growth of algae. Depending upon the actual species, these “blooms” may produce discoloration of the water. Thus, the Gulf Coast has suffered from “red tide” while some Adirondack lakes have been struck by greenish discoloration, generally referred to as “harmful algae blooms” (HABs).

The negative health effects of these blooms are not usually from the algae itself, but rather from a number of substances produced by the organism, called “toxins.” The toxins do their damage when people drink contaminated water or eat fish that have been consuming the algae, or when they inhale or experience skin contact with them.

Worldwide, there are very severe complications of toxin ingestion. In particular, contaminated shellfish can cause a variety of devastating neurologic illnesses such as ciguatera poisoning. While important, these illnesses have not been associated with Adirondack freshwater HABs.

It is unlikely that humans would consume Adirondack waters contaminated with HABs. When this has occurred, the result has been a gastrointestinal illness characterized by abdominal pain, diarrhea, and vomiting. Individuals exhibiting such a reaction should receive medical attention, although supportive care is about all that can be provided. (Note that consumption of contaminated water by dogs or other pets can cause life-threatening reactions, and animals should receive emergency veterinary care immediately.)

No method of personal water treatment will remove toxins. Skin and eye contact with toxins is more common, because the toxins can get into the air, bypassing one’s direct exposure to water. Thorough removal of a toxin from skin with soap and water is the first step in first aid. Irritated eyes can be flushed with plain water. Antihistamines such as Benadryl® can be taken to ease symptoms.

Inhalation of toxin can produce respiratory symptoms, ranging from cough and runny nose to severe respiratory distress. The latter is much more common in individuals with chronic lung problems such as asthma; there may be an allergic component to them. Such reactions should prompt medical attention. Obviously, individuals with severe chronic lung disease should avoid even proximity to waters with HABs.

The New York State Department of Environmental Conservation (DEC) has taken a leadership role in educating the public about HABs. One of their very helpful resources is at www.dec.ny.gov/chemical/77118.html. The U.S. Centers for Disease Control and Prevention also have resources devoted to the health implications of HABs. One such source of information is at www.cdc.gov/habs/general.html.

Hopefully without introducing a political subtext to this discussion, I would simply remind readers that both of the factors I cited as contributing to these blooms (temperature change and nutrient excess) have clear human causes.

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: Environment, General First Aid, Water

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