Energy from a Bottle

2012, November/December Adirondac Adirondoc

On a super-hot day last summer, I was hiking in the Woodhull Lake area and came across two parties, several of whose members were carrying bottles of sports/energy drinks. I wasn’t sure if this was a trend I was missing, so I did a little research.

All of my favorite online gear distributors offered powdered versions of various energy drinks, some with glowing recommendations for their benefits in the backcountry. A usually reliable source of information, rei.com, touted them. My local purveyor of camping goods also carried them. A number of hiking blogs have also started to comment favorably on these products. I guess that I have been missing something!

So, should you add Gatorade®, Powerade®, or similar items to your shopping list along with mac ‘n’ cheese and coffee?

Don’t bother.

This question opens a door onto a rather unsavory story, which was recently uncovered in an investigation reported in one of the world’s foremost medical journals, The British Medical Journal (BMJ). The entire matter is a rather disgusting example of the way in which corporate money can provide a veneer of respectability to flimsy science, while enticing consumers to pay ridiculous prices for products they don’t need. While hikers are probably a niche market for them, sports and energy drinks cost U.S. consumers nearly $2 billion annually.

The advertised rationale for “energy drinks” is deceptively simple. Vigorous exercise causes us to burn energy and Jose electrolytes and water. These losses can cause diminished performance. Replacing the losses with a carefully researched formula of water, electrolytes (mainly sodium and potassium), and a ready source of energy (basically sugar) maintains performance and enhances health.

As is often the case with “simple” explanations, this one lacks scientific foundation, although the casual reader could be duped into thinking otherwise. There are plenty of “statements” by important-sounding organizations like the U.S. National Athletic Trainers’ Association, the American College of Sports Medicine, and even the Gatorade Sports Science Institute. There are even “research” articles in journals such as the Journal of Sports Science and Medicine and Science in Sports and Nutrition.

The problem that the investigators for the BMJ uncovered is that the sports beverage industry has been the major sponsor of virtually all of this work, and that many of the rather “low profile” medical journals in which the research has been published also have ties to the industry through their editorial boards.

In an effort to bring some objectivity to the analysis, the investigators had a team of experts in evidence-based medicine review the science behind hundreds of claims for these performance-enhancing products. Three of these-‘-that’s right, three were judged to be high-quality science with a low risk of bias.

Other than wasting money, is there a downside to all these drinks? One big one is the caloric content. Although marketed as “health” products, many sports drinks have calorie contents close to those of “unhealthy” soda.

A more worrisome risk is the increasingly recognized problem of “hyponatremia” -basically water intoxication with severe brain complications – from over-hydration during exercise. There are many well-documented deaths from over-hydration during exercise, especially in marathon running. A study in a “real” medical journal (The New England Journal of Medicine) showed that the risk is unrelated to the beverage consumed (water versus sports drinks). The “sports medicine” industry has promoted the entirely unsubstantiated mantra that dehydration is a dangerous complication of exercise and that athletes must be encouraged to drink even when they are not thirsty.

Readers who are aware of my minimalist tendencies will not be surprised by the quote I provide in dosing, from Tim Noakes, a distinguished (independent) sports scientist from South Africa: “… [dehydration] is a normal biological response to exercise. You lose water; you get thirsty; you drink End of story.”

~ Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide, a certifying inst111ctor 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. The BMJ investigative report is in their July 18, 2012, issue, and available online at www.bmj.com/highwire/filestream/594 7 55/field_highwire_article_pdf/O.pdf

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Topics: Diet & Nutrition

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BackPacker’s Pain

2013, January/February Adirondac Adirondoc

Believe it or not, back pain is the second most common reason for patients to consult with a primary care physician. The physical and financial burden of chronic lower back pain in the U.S. is substantial. Although the topic is extraordinarily complex and confusing, most experts agree that many individuals with chronic lower back pain can experience improvement with exercise, and that such pain may be more common among sedentary folks. Thus, there is no absolute prohibition against, and there may be benefit from, hiking, camping, or backpacking for individuals with chronic back pain.

Let’s consider two aspects of the relationship between back pain outdoor recreation: what to do if it develops unexpectedly on a hike or camping trip, and how someone with a history of back pain should approach backcountry hiking.

Sudden onset
I have talked with plenty of individuals who rather suddenly developed lower back pain during the course of a backpacking trek. Typically, this is something with which they awaken after a day or so on the trail-or, perhaps, it awakens them during the night. In the absence of a prior history of back problems, with no specific injury (e.g. a fall), and with no evidence of neurologic problem (e.g. weakness or tingling in the legs), such pain is most often nothing more than muscular soreness from new activity (“overuse”).

Although this pain may be quite disabling initially, the condition is likely to improve with time and some simple measures. As with any musculoskeletal pain, a non-steroidal anti-inflammatory (NSAID) medication such as ibuprofen will bring some relief. Be sure to take this with plenty of water. Some easy walking on a level surface may help as well.

Putting on and carrying a back pack may become a problem for someone with acute low back pain. Once a companion has helped you into your pack (and perhaps taken on some of its content), try making some adjustments to find the best positioning for minimizing back pain. Most packs allow field adjustment of the shoulder straps, sternum and strap, and hip belt. Such adjustments alter the mechanics of the pack, shifting the amount of weight placed on the hips, back, and shoulders. What to tighten, loosen, or leave alone is a trial and error process. In rare cases, if the pain has not improved sufficiently within a day, a “pack-free” walkout may be needed.

For the chronic sufferer
What is the best advice for someone who already has lower back pain? The days of enforced bed rest for back pain are thankfully behind us. There is now excellent evidence that exercise helps to maintain strength and flexibility, and may help back pain. Of course, any effect exercise may have on weight reduction is positive for back pain relief as well.

Obviously, the first step is to discuss your trekking plans with your health care provider, · if you are already seeing someone for back pain. this is especially the case if you have had recent surgery.

Realistically, however, it may be difficult for any examiner to judge the effect of hiking and camping on one’s back pain. The safest thing is probably to duplicate the planned trek in an environment from which an easy “escape” is possible. Most everyone lives near a park or recreational area with a hiking trail not too far from a street or highway. In my area (Syracuse), the Erie Canal towpath and Green Lakes State Park offer great opportunities for long hikes without getting too far from one’s car. One should be able to hike (with a pack) one’s planned wilderness distance in such an area before heading into the woods. Unfortunately, few duplicate the elevation changes of mountainous areas; walking downhill with a pack is often particularly problematic for someone with back pain.

The firm surface of level ground may be better for sleeping than some beds. Nonetheless, a trial in one’s backyard should insure that the combination of ground and sleeping pad is not going to be a problem.

Finally, remember that lifting is sometimes the trigger for a worsening of back pain. There are ample opportunities for this on treks: packs, tents, canoes, etc. Ask for help, and refer to one of the many online resources that provide lifting techniques. One useful site is FamilyDoctor.org.

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

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Topics: General First Aid

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Teeth and Treks

2013, March/April Adirondac Adirondoc

Dental care gets short shrift in the backcountry. I am not sure why this is. In well over a thousand nights in the wilderness, the only personal health problem I have encountered is a lost filling during a three-week Alaskan trek. Fortunately, it was not painful, but it could well have ruined the trip for me.

As with any wilderness health issue, prevention is the first step in ensuring that a dental emergency will not come up in the woods. Although it is rarely mentioned in wilderness medical writings, I believe that any trek of a week or more should be preceded by a visit to one’s dentist. A careful check for loose fillings or other potential dental catastrophes is probably more useful than one of those “complete physicals” that are often recommended. This is particularly important for those who, like me, grew up in the pre-fluoride era and have the mouthful of metal to show for it.

Another aspect of prevention deals with stocking the first aid kit. Backcountry kits should include some sort of dental “patch” such as Dentemp®. This can provide a temporary replacement for a lost filling and even a temporary adhesive to reset a loose crown. Unfortunately, the instructions on the package are not very complete. However, the company website has a very useful graphic for the non-dentist: paste after brushing. www.majesticdrug.com/v/vspfiles/assets/images/PDFs/Dentemp_OS_lnstructions.pdf (updated link: cdn.shopify.com/s/files/1/1003/0106/files/Dentemp_Instructions_655742f0-dfe9-4418-a43a-44b2b78c211b.pdf).

One of my other favorite first aid items, which rarely makes it into published lists of kit contents, is a bottle of contact lens saline solution. In addition to its advertised use, I find the squeeze bottle of a sterile saline solution useful in a variety of other ways. Flushing out a cavity prior to applying Dentemp ® is recommended; the contact lens solution in a squirt bottle is perfect for this purpose.

This is also a good time to consider personal dental hygiene on trips. A few days in the woods are not the time to cut back on regular care, and not only for the benefit of your tent mates. Flossing and brushing should continue on backcountry treks in the same way they do at home. The environmental impact of this is nil. A small plastic zip bag can hold those used lengths of floss. While spitting toothpaste on the ground has trivial environmental impact, it can be sort of gross. For that reason, I just swallow my tooth.

No doubt some readers will be horrified about fluoride ingestion. Rather than debating, I will simply recommend a non-fluoride paste for them. (For another useful bit of dental advice in the backcountry, see the letter to the editor in this issue from Dr. Fass.)

Finally, a word about injuries to teeth. Superficial chips or cracks to teeth are those which do not expose deeper layers of tooth and consequently are not painful. They can also be covered with Dentemp until a dentist can see them. Deeper cracks are referred to as dental fractures and require a dentist’s intervention if the tooth is to be saved. These are also portals of entry for infections of the dental pulp. Again, Dentemp can be used for first aid, but evacuation should be considered. “Avulsions” are injuries in which the entire tooth-root and all-is dislodged from the jaw. Such teeth actually can be saved if they are implanted into the socket immediately. Rinse the root and the socket with saline and gently insert the tooth into place. While one can also wrap the tooth in wet gauze and bring it to a dentist, the most successful reinsertions are done within less than an hour from injury, which generally means in the field.

~Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. More information is available at his website and blog: www.adirondoc.com.

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Topics: Head & Neck

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Hantavirus: Yet another worry in the Adirondacks?

2013, May/June Adirondac Adirondoc

Just when I think I have heard everything when it comes to health concerns in the Adirondacks, something new comes along. As many readers who follow local media in the Park have heard, the most recent is hantavirus infections.

First, the basics. Hantavirus is a particularly nasty bug, which causes a couple of distinct conditions in humans. Hantavirus pulmonary syndrome (HPS) is a severe illness in which fluid accumulates in the lungs, leading to complications from lack of oxygen. Hantavirus hemorrhagic fever with renal syndrome (HFRS) is a devastating condition in which shock, bleeding, and failure of many organs develop over a period of a few days. Neither condition has any specific therapy, other than life support, and as many as half of patients die. Although the condition has probably been with us for a long time, it is only recently being widely recognized, and is thus considered an “emerging infectious disease.”

The condition is not known to spread from human to human. Rather, it is spread by rodents, especially mice, who carry the virus without having any symptoms, and excrete it in their feces, urine, and saliva. Humans apparently become infected through inhalation of the virus in areas that have experienced heavy rodent infestation. This could certainly include camping structures such as lean-tos.

The most dramatic, and well-studied, hantavirus event traced to backcountry activity occurred last year in Yosemite National Park. Ten individuals acquired hantavirus infection over a brief period of time; three of these died. Nine of them had camped at a particular “tent cabin” village in the park. The outbreak was studied by the U.S. Centers for Disease Control and Prevention (CDC) and the California Department of Health. Warnings were issued, and the tent cabins in question were closed.

At roughly the same time as the Yosemite event, there was a confirmed case of hantavirus infection in New York State. The infected individual, who thankfully recovered, reported rodent exposure in a lean-to in the Adirondacks. The New York State Department of Health (DOH) confirmed that the individual reported that he was bitten by a rodent while camping in the lean-to. No other rodent exposures were identified in a thorough investigation by the DOH. Absent additional cases from the same location, or other supporting information, it is impossible to make a definitive statement about the way in which this infection was acquired.

Regardless of whether or not it came from an Adirondack lean-to, the message is clear. The history of infectious diseases over centuries reminds us that humans should avoid sharing sleeping and living space with rodents! Hantavirus is but one of scores of infectious diseases whose transmission involves mice and their kin. As iconic as the Adirondack lean-tos are, I assiduously avoid sleeping in them-and now have yet another reason to continue to avoid them. The detritus of decades of campers has made these structures home for many rodents, and a quick look inside most of them shows evidence of this inhabitation. For those who still enjoy the ambiance of lean-tos, the DOH has some helpful advice at www.health.ny.gov/press/releases/2012/2012-10-22_hantavirus

~ Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide, a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at www.adirondoc.com. Cynthia Morrow, MD, MPH, Onondaga County’s Commissioner of Health, provided helpful advice and comments on this manuscript.

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Topics: Insects & Spiders

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Lightning Strikes Again

2013, July/August Adirondac Adirondoc

Ask someone to name the top weather-related cause of death, and hurricane, tornado, or similar catastrophes are likely answers. While dramatic, these actually aren’t at the top of the list. The annual fatalities caused by lightning (about one hundred in the U.S., and it is likely that many lightning deaths are unrecognized or unreported) are exceeded only by those from flash floods. Since lightning generally affects only one person at a time, it rarely makes the national news typical of other weather-related fatalities. Just a few weeks ago, I stood on the spot where famous Irish climber Ian McKeever was killed by a direct hit on Mt. Kilimanjaro earlier this year; lightning is no respecter of outdoor experience or fame.

The key to lightning injuries is prevention; backcountry “first aid” options are limited. Because lightning injuries rarely make the news, many hikers and campers fail to take approaching storms as seriously as they should. And because lightning injuries occur so randomly, it is difficult to validate “evidence-based” advice. Consequently, most of my comments represent expert consensus from outdoor educators.

The “30-30” rule
If there is one “take home” message on lightning safety, it is the “30-30” rule: Begin taking lightning avoidance precautions when there is a 30-second-or-less interval between the lightning flash and the thunder clap; discontinue lightning avoidance 30 minutes after the last flash.

What does “lightning avoidance” entail? If above treeline, on an open ridge, or in an open field, movement into a safer area is imperative. The ideal backcountry locale is within a stand of similarly sized trees. Tents, with their metal poles, are not safe locations despite the desire to be dry. Stay away from potential lightning rods such as fishing gear, trekking poles, and external frame backpacks.

What if a safe location is not available? The most frightening weather related experience I have had occurred when I was leading a group of twelve students during a thunderstorm on a huge open tundra in Alaska’s Denali Park. In such a circumstance, the usual recommendation is for the group to disperse widely, minimizing the chance of more than one person being struck. Again, stay away from potential lightning rods. It is frequently recommended that one sit on a non-conducting surface such as a pack or ground pad. While reasonable, an evidence basis for this recommendation is lacking.

The physical damage caused by lightning entails direct effects and secondary injury. The impact of lightning generates explosive forces, which have been known to throw a person a considerable distance. Obviously, this can cause a nearly limitless catalog of injuries requiring a thorough assessment and appropriate first aid treatment.

The strike itself, while lasting but a fraction of a second, causes a variety of problems related to electricity traversing the body. These include burns, sudden paralysis (including that of the respiratory muscles), and cardiac arrest. While the latter may be survivable in the front country with immediate access to advanced life support, options in the wilderness are limited. While CPR should certainly be initiated, the outcome is not likely to be successful.

There is a lot of detailed, very useful additional information on the National Weather Service website, www.lightningsafety.noaa.gov.

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

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Topics: Environment

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Duck Itch: A Gift from the Water

2013, September/October Adirondac Adirondoc

If you’ve spent any time near populated Adirondack waters, you no doubt have seen signs warning against feeding the ducks. Perhaps these signs have given the reason: prevention of “duck itch” (sometimes also called “swimmer’s itch”). What is duck itch? How is it transmitted? Does tossing a few bread crumbs off the dock really cause it?

Duck itch is a skin reaction to the larva of a parasitic worm from the genus Schistosoma. While the skin reaction seen in the U.S. is rarely more than an annoyance, other schistosomes cause very serious disease in the developing world. Indeed, the burden of disease from schistosomiasis is second only to malaria as a cause of global human misery.

The worm’s life cycle takes it from freshwater snails to waterfowl. The larval form, called the cercariae, is released into water from the snail and makes its way into hosts such as ducks. Infected ducks then pass worm eggs in their feces, which ultimately infect additional snails, completing the cycle.

Duck itch is caused by cercariae settling on the skin after a swim. Although the organisms do not actually live in the human host, the body reacts to their presence on the skin, causing an itchy eruption. Since this eruption is a form of allergy to the cercariae, it can become worse with subsequent exposures.

The diagnosis of duck itch is “clinical,” a technical term meaning that the doctor takes a look at it and decides that’s what it is! There is no readily available laboratory study that can establish the diagnosis with certainty. Thus, there probably are a lot of itchy summer rashes called duck itch that are not. And vice versa. Treatment of duck itch is really just relief of symptoms. Topical creams such as 1% hydrocortisone help to relieve inflammation. Intense itching can be relieved by an oral antihistamine such as diphenhydramine (Benadryl®). If the rash lasts more than a couple of days, or if it begins to show signs of infection such as the presence of pus, a physician should be consulted. Folks who are susceptible to duck itch should dry vigorously with a coarse towel upon leaving the water; this can remove the cercariae before they have a chance to irritate the skin.

How big of a problem is duck itch in the Adirondacks? Actually, we have no idea. Since there is no diagnostic test, the disease is not reportable to the state Department of Health, as are infections such as hepatitis, meningitis, and others. Consequently, there are no reliable statistics on the problem. Interestingly, exposure to the much-publicized blue-green algae blooms can result in symptoms possibly indistinguishable from duck itch. Perhaps fertilizer runoff is a bigger problem than tossed bread crumbs!

The Department of Environmental Conservation (DEC) has some statistics on the problem, although they also suffer from lack of a definitive test. For nearly three decades, DEC has been gauging local opinion of water quality through a survey form completed by trained water samplers through the Citizen’s Statewide Lake Assessment Program (CSLAP). One of the items on the survey asks whether swimmer’s itch has been reported to samplers. Scott Kishbaugh, from the DEC, tells me that over the past three years there have been sixteen such reports. These have been distributed throughout the state, with few repeat reports.

Is feeding ducks a problem? It certainly is, for the same reasons we should avoid feeding any animals in the wild: it conditions them to a food for which they may not be suited and attracts them into an area that may not otherwise be hospitable. Since the form of the infecting worm responsible for the condition is coming from snails, however, this practice probably plays a minor role in spreading disease.

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

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Topics: Environment, Skin

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Wilderness CPR

2014, January/February Adirondac Adirondoc

First, let’s be very clear. CPR, or cardio-pulmonary resuscitation, in some settings can work wonders if begun in a timely manner by someone who knows what he or she is doing. Knowing how to perform CPR, in my opinion, is almost a requirement of citizenship, one of those things which we should expect of our fellows.

On the other hand, we should also know that many folks have a better opinion of the success of CPR than is realistic. Perhaps the media are to blame for this. A recent study claimed that CPR on a number of American TV “medical shows” was successful in 75 percent of cases. In actuality, CPR that is performed by medical personnel in the hospital leads to a patient surviving to discharge in good condition only about 10 percent of the time, depending upon age and diagnosis. When CPR is begun by a bystander outside the hospital, the results are even more dismal.

But what about CPR in the wilderness? Although CPR training is required as part of wilderness first aid courses, and for trip leaders such as licensed guides, I have never heard of a well-documented situation in which it was successful in a true backcountry setting. This is not for want of finding out: I regularly inquire about it whenever I am attending meetings of wilderness educators or physicians.

Why does CPR not always work? To understand that, we must appreciate what events cause the heart to stop in the first place. For anyone who dies of a severe injury or illness, stopping of the heart is the final event. CPR is unlikely to do anything for such a person unless one can also correct the responsible injury or illness. It is analogous to attempting to jump start a car with major transmission failure. An accident in a remote location resulting in injuries so severe that the heart stops simply cannot be reversed; CPR will be futile.

The second major cause for the need for CPR is a primary insult to the heart, such as could happen with a “heart attack,” a rather imprecise layperson’ s term for myocardial infarction.

In these situations, quickly establishing circulation with CPR is much more likely to be successful. In the front country, success in this setting is much improved if there is access to an automated external defibrillator (AED).

Death from “heart attack” certainly occurs on backcountry trails. If one comes across someone in such a situation, the individual with the most current training and experience should commence CPR immediately. Although the standard teaching is that bystander CPR continues until the rescuer is exhausted or a higher level of care is available, this suggestion may not be realistic in the backcountry. Definitive care may be days away. In such circumstances, beyond rescuer exhaustion or safety concerns, obvious signs of death such as rigor mortis are appropriate reasons to discontinue CPR. Fortunately, most “heart attacks” do not immediately result in cardiac arrest. There are a variety of first aid procedures for someone in whom a cardiac event is suspected; I will cover these in a subsequent column.

Finally, keep in mind that there are some wilderness settings in which CPR may have a better chance of success. An example of this is cold-water drowning. There are well documented instances of survival approaching an hour after such an event, so vigorous, continued CPR would certainly be appropriate. Hypothermia is another oft-cited example, although heart function in severe hypothermia is complicated and controversial.

The bottom line: backcountry users should do their civic duty and maintain certification in CPR. They just need to realize that they are more likely to use the skill in a diner on the way home than on the trek itself. CPR training today has been simplified (“compressions only”), and information on courses can be obtained through the American Red Cross (http://www.redcross.org/ take-a-class) or American Heart Association (http://www.heart.org/ HEARTO RG/ CPRAndECC/Finda Course/ Find-a-Course_ U CM_ 303220_SubHomePage.jsp ).

~Tom Welch, MD, is professor and chair of pediatrics 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. Drs. Craig Byrum and Jeremy Joslin, avid outdoorsmen and cardiologist and emergency medicine specialists respectively, reviewed this column and provided helpful advice.

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Topics: General First Aid

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Poison by Food

2014, March/ April Adirondac Adirondoc

On a very hot summer afternoon many years ago, I was approached by a fellow camper in the Dix Wilderness. He and some of his group had rather suddenly developed abdominal discomfort and vomiting, which was becoming quite disabling. Based on the history, I was pretty certain that they were suffering from enterotoxin-mediated food poisoning. I gave them some anti-nausea medication, recommended frequent sips of liquids, and got out of the way quickly. As best I know, they recovered uneventfully. (I can’t help but wonder if today someone would have called for urgent evacuation, perhaps by helicopter!)

Food poisoning, a relatively common front country ailment, is fortunately unusual in the backcountry. It can range from an uncomfortable nuisance to a cause of death. Since it is easily prevented, it is a good idea to review it.

There are three basic ways in which our food can cause illness (not including eating too much of it, the major problem). The first of these is by the presence of a natural chemical in the food which causes injury. The best example of this is poisoning by ingestion of some mushrooms, most often of the genus Amanita. These can be overwhelming poisonings, often resulting in liver failure and the need for liver transplantation. The best treatment of this, of course, is prevention. At one point in time, I used to instruct some of my guiding clients on the recognition and preparation of mushrooms in the field. As a rank amateur mycologist, however, I now consider this far too risky.

Serious poisonings can also result from a number of fish, of which ciguatera fish poisoning is the most familiar. Fortunately, these are conditions associated with fish in much warmer climes than that of the Adirondacks.

The second mechanism of food poisoning is that which caused the problem for the campers I introduced earlier. Bacteria (such as Staphylococcus) get into unrefrigerated foods (especially creams, egg products, and the like) and multiply. The bacteria produce a substance (“enterotoxin”) which when ingested produces nausea, vomiting, and cramps within a few hours. Note that it is not the bacteria themselves which are causing the problem, but the toxin they produce. Thus, onset of this illness occurs quickly after ingestion-the bacteria need not multiply in the host.

This is why you probably do not want to sample the cream puffs sitting out at the church picnic in July. Nor do you want to carry egg salad sandwiches in your pack for later consumption. Puddings, cream sauces, and similar delicacies are fine to prepare in the woods-just be sure to eat them completely after preparation. Leftovers are fine if kept in your refrigerator at home, but not in your BRFC in the summer!

The final category of food poisonings results from contamination with microbes which directly cause disease themselves. In these cases, the offending organisms need a period of time to grow and multiply in the intestine before they cause symptoms. Thus, there is an “incubation period” of a few days between ingestion of the food and the development of symptoms.

Many bacteria and viruses can cause this picture. In the U.S., a specific variety of bacteria called E. coli is responsible for particularly severe food poisoning. The condition can progress to kidney failure and death. Although outbreaks have been associated with a host of foods, undercooked ground beef is the most common culprit. There is no such thing as a safe hamburger that is pink in the middle. If you plan to heat up some burgers on a trip, be sure they are well done. Better still, try falafel patties!

The Centers for Disease Control (CDC) has a very helpful website with additional information regarding food-borne illnesses: www.cdc.gov/foodsafety/facts.html# mostcommon.

~Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide, a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog: www.adirondoc.com. Infectious disease expert Jana Shaw, MD, MPH provided helpful review of this column.

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Topics: Diet & Nutrition

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Barefoot Hiking

2014, May/June Adirondac Adirondoc

I’ll start with a mea culpa. I believe that I mentioned hiking without shoes in an article quite some time ago. My recollection is that I found the practice curious and possibly unsafe, and generally was not too positive. I’ve grown up. While there is still no evidence-based medical literature to guide us, and while I am in no position to endorse the practice, I have come to realize that the folks who practice this may be on to something.

My change of heart came during winter vacations over the past couple of years. Although my favorite “beach” remains Sand Lake in the Five Ponds Wilderness Area, I’ve been frequenting the ocean beaches of the Gulf. Not a fan of typical beach activity, like sunning, building sand castles, or reading trash novels, I started using beach time for running. After a couple of tepid tries, I became hooked. There is simply no better way to have a good run than barefoot on the beach.

First of all, the benefit of the softer impact of a bare foot on sand, compared to a running shoe on concrete, was very noticeable. The differing textures of beach, from soft and dry to smooth and firm, as well as ankle-deep water, provided for very different types of workouts. At first, the experience of running over broken shells was uncomfortable, but I gradually accommodated to this as well. Actually, the feel can be somewhat invigorating.

I have yet to translate this into barefoot running on roads, although many folks do so. Some very elite runners have competed successfully in bare feet: Abebe Bikila in the marathon and Zola Budd in the SK are perhaps the most famous examples. I have a surgical colleague (also a yoga instructor) who regularly trains barefooted, and has completed a couple of marathons in minimalist (“FiveFingers”) shoes. Fans of barefoot running swear that it is much easier on the joints; there is no evidence that injuries are increased by this practice. Although this style is not yet mainstream, barefoot runners rarely get much more than a passing glance these days. The running literature on the barefoot style is sparse and mixed, although few authorities are strongly opposed.

Still, it is quite a jump from jogging on sand to hiking into Panther Gorge. Conventional teaching has always stressed the importance of firm ankle support for safe backcountry travel. Can barefoot hiking possibly be safe or sane?

I increasingly believe that it can. For millennia, of course, our ancestors tromped over all sorts of terrain with little or nothing covering their feet. The evolutionary success of humans surely did not depend upon the development of shoes. There is excellent documentation of societies today in which shoes are not used. Of these, perhaps the most well-known are the Tarahumara of northwestern Mexico. These individuals live in rocky, mountainous country and run ungodly distances either barefooted or with thin homemade coverings over their soles. The human foot is designed to be flexible and adaptable, and probably can conform well to most types of terrain. The environmental impact of the bare foot on fragile Adirondack ground is surely better than that of heavy Vibram-soled boots.

For those not quite ready to shed foot covering completely, there are a host of “minimalist” hiking shoes available. Some “almost barefoot” hikers choose minimalist running footwear such as Vibram FiveFingers. Bottom line: barefoot travel is not for everyone, to be sure, but also not something inherently unsafe. I plan to give it a try on a carefully selected trail this summer, but will be sure to have some good socks and my Asolos in the daypack!

~Tom Welch, MD, is professor and chair of pediatrics 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: Foot

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Drowning: A neglected outdoor threat

2014, July/August Adirondac Adirondoc

One of my many pet peeves with much of the wilderness medicine crowd these days is their lack of attention to the actual risks in various outdoor pursuits. Auto accidents en route to the trailhead, for example, kill far more outdoor enthusiasts than do actual incidents in the backcountry. As I pointed out in an earlier column, skin cancer from sunburn claims thousands of summer sports participants. Yet, many wilderness first responder courses put their students through exercises like fashioning trekking poles into splints for femur fractures and debating the merits of wider availability of epinephrine auto-injectors, therapies for which the documented need in the backcountry is virtually nil.

Water safety is another example of our misplaced priorities in backcountry health and safety. Nearly four thousand Americans drown annually. Although annual backcountry data are not available, two major providers of outdoor adventure education, Outward Bound and the National Outdoor Leadership School, have lost participants to drowning. Indeed, the most recent analysis of Outward Bound fatalities (which are actually quite rare) cited drowning as the most common. Yet, while many organizations require some form of wilderness first aid training for their trek leaders, few have a requirement for water safety certification. (A notable exception is the New York State Department of Environmental Conservation, which has a water safety requirement for all of its guide license applicants.)

Drowning occurs in several clearly delineated situations, and the implications for prevention are consequently specific. Two large groups are children between ages one and four ( most often from wandering into pools) and adolescent and young adult males who are drunk Prevention strategies for these are largely self-evident, although difficult to achieve in the case of the latter.

Drowning in the context of outdoor sports is most commonly associated with boating. Nearly 90 percent of drownings among boaters occur in individuals not wearing a personal floatation device (PFD). This fact never ceases to astound me. Few folks leave their canoes or kayaks for a controlled entry into the water: they overturn, fall, lose consciousness for some other reason, or have other risks for being incapacitated upon entry. In such a circumstance, one’s swimming ability counts for naught, but a properly donned PFD will be life-saving. I’m a former competitive swimmer, but would not dream of setting out on even the calmest of Adirondack lakes without my PFD fully secured.

Another risk factor for water fatality in the backcountry is diving into waters whose depths or hidden obstacles are unknown. This means just about every natural swimming area one can imagine. Diving is for pools or marked natural waters, not for backcountry swims.

Although one associates danger from currents with ocean swimming, fast-flowing natural waters can be immensely powerful-far more so than they might appear. Readers may recall the tragic loss of four lives in a popular swimming spot on the Boquet River a decade ago. Since such incidents are usually isolated, they rarely get the kind of publicity that would make people more aware of this danger. As one who has spent countless hours in the (now off-limits) pool at the base of Hanging Spear Falls, I can never recommend taking friends (or, for guides, clients) into such an area.

Obviously, knowing how to swim reduces the risk of drowning. A recent article in the New York Times (http://well.blogs.nytimes.com/2014 / 04 / 28 /a-stroke-you-must-have/?_ php=true&_type=blogs&_r=0) highlighted the number of adults who are non-swimmers, while pointing out that it is never too late to learn.

Finally, a word about the treatment of near-drowning. This is the one situation in the backcountry in which CPR is possibly effective. Although the current teaching in layperson CPR courses is for “hands only,” drowning death is respiratory, and chest compressions should be accompanied by rescue breathing if the rescuer knows the technique. Drowning in very cold water can actually be “protective,” and recovery after up to an hour of CPR has been reported in such circumstances. Don’t give up.

Finally, if one is able to resuscitate someone after a near-drowning, he or she is not out of the woods. There are possible metabolic and infectious complications of having water in one’s lungs, so immediate transport for complete medical evaluation is indicated, even with apparent recovery.

~ Tom Welch, MD, is professor and chair of pediatrics 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

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