Independence Day

Happy July 4! As we celebrate Independence Day, we should be grateful for our freedoms, families, friends, and wonderful country. We are especially indebted to all who serve and have served America, be it military, education, environment, health care, or any other public service. Few of us would be able to enjoy much of our lives in the U.S. without the continual selfless devotion of others. When you watch the fireworks (from a safe distance) this year, think hard about what you might do in the coming year to make our nation healthier, safer, stronger, cleaner, and more wise.

The 4th of July holiday is usually a wonderful time to be outdoors. In the hope that you will all have a wonderful weekend and enjoy the scenery, here are a few tips for injury prevention that will help you have fun safely, and not need to visit me or any other emergency physician:

1. Be extremely careful with fireworks. Firecrackers, bottle rockets, sparklers, and the like are always the cause of unfortunate accidents on the 4th of July. Do not leave children unattended with fireworks - that would be a recipe for disaster. Wear eye protection around fireworks. Eye injuries from extremely hot-burning and explosive fireworks are common, particularly in children, and they can be devastating, including loss of vision. Obey the law. Whether or not it is legal to use fireworks in your location, do not make the mistake of igniting a wildland fire.

2. Supervise all young children when they are swimming, even in the backyard or hotel swimming pool. Never take it for granted that someone else will safeguard your child, particularly if a swimming pool is crowded. For teenagers and older, remember that alcohol and water sports do not mix. Finally, ignore the misguided folklore that informs people never to swim after eating. The truth is that swimming is exertion, and swimmers need fuel. A small amount of carbohydrate and a beverage are important to maintain energy, and are advised before strenuous or prolonged aquatic exercise.

3. Stay well hydrated, particularly in the heat. If you are hiking, climbing, running a road race, cycling, or doing anything else that causes you to sweat, breathe rapidly (particularly at altitude), or be outdoors in hot weather, take extra care to drink plenty of fluids. There are many recommendations floating around regarding how much of ingested fluid should be plain water, or supplemented (usually with electrolytes and carbohydrate) water, but the bottom line is that you should keep up with what you perspire, respire, excrete, and sweat.

4. Wear your bicycle, motorcycle, climbing, whitewater or other helmet. There are more people on the roads (so more collisions), people are on holiday, alcohol is consumed, and the river rocks and rockfall from cliffs are unforgiving. Many a head is bonked (hard) on the 4th of July. To put it simply, the people who wear helmets often live unimpaired, while those who are not wearing helmets suffer brain injuries and die or become disabled. If you should be wearing a helmet, forgo the freedom to suffer and be smart.

5. Leave no trace. Whether you are camping, boating, or hiking, pack out your garbage and dispose of it properly. Know how to build a proper latrine at a safe distance from your campsite or natural water sources, pick up paper, cans, and other refuse, and try to leave the wilderness the way you found it. Besides the obvious benefit to the environment and scenery, you are practicing good public health, by not contaminating the soil and groundwater, and thereby doing your part to control the spread of infectious diseases. Because everyone will not be as thoughtful as you, take care to wash your hands carefully, and consider using a disinfectant gel or lotion, before you eat or handle food.

fireworks image courtesy of www.selmanc.info
sparkler image courtesty of www.ric.edu
drowning image courtesy of www.firstaidinaction.net
fly on flower image courtesy of www.freewallpaperdesktopwallpaper.com
campsite trash image courtesy of www.diglloyd.com

Preview the 25th Anniversary & Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 25-30, 2008.

Tags: drowning, fireworks, helmet, wilderness medicine, outdoor medicine, healthline

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Thank You to The Covert Rationing Blog for Grand Rounds

Thank you to Richard N. Fogoros, MD of The Covert Rationing Blog for including my post about smoke from wildfires in this week's edition of Grand Rounds. Grand Rounds is a weekly compilation of posts related to health care compiled by a host, who makes a great effort to compile an interesting collection for readers.

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Tomatoes and Salmonella

Let's just say that people who like to be outdoors are often the same people who like to eat tomatoes. Tomatoes are a staple food at cookouts, on backpacking trips when fresh food is carried, for lunch and dinner on the river, etc. Nothing tastes better than a homegrown beef tomato sprinkled lightly with a bit of salt and pepper, and perhaps a touch of balsamic vinegar.

Over the past few weeks, we were informed that now we all needed to be extra careful, because we were supposedly in the midst of a multi-state (U.S.) outbreak of infections caused by Salmonella serotype Saintpaul, attributed to consumption of raw tomatoes, and in particular, red plum, red Roma, or round red tomatoes.

Thirty-two states and the District of Columbia were said to have reported infections to the Centers for Disease Control, via the identification of Salmonella strains from ill persons routed for identification through the State health departments. The reports were presumedly linked to tomatoes - consumed at home or in restaurants. There was no definitive link to tomatoes consumed "in the wild" - and none to my knowledge on an expedition. Now it appears that these Salmonella infections may not have originated with tomatoes after all, but from some unknown carrier(s) of the bacteria. We are not yet even sure if the contaminated food was produce, but that is a possibility. If it was not tomatoes, perhaps it was something served with tomatoes, or a food product made with tomatoes, such as salsa. If it was salsa, then it could have been any of the other ingredients, such as green onions, cilantro, or jalapeño peppers.

If there are contaminated tomatoes, or any other vegetable, meat, or other food product(s) in circulation, sooner or later, someone will get become sick after eating the product during a picnic or an outdoor trip. In retrospect, and for the purpose of avoiding future illness, it is very important to note that we do not have information about how the culprit tomatoes were supposedly handled prior to consumption - were they washed, and if so, in what manner? I don't imagine that we will ever learn these details, particularly if the very origins of the reported illnesses are in doubt.

So, that leads us back to a general discussion of infection with Salmonella, which is a very real cause of diarrheal illness. There are multiple species of Salmonella, including Salmonella typhi, which causes typhoid fever. The bacteria normally reside in the intestinal tracts of humans and other animals, including birds. The most well known causes of Salmonella food poisoning are contaminated beef, poultry, milk, and eggs. Salmonella food poisoning (infection), usually caused by S. typhimurium or S. enteritidis, typically causes diarrhea (loose and watery stools, usually without blood), fever, and abdominal cramping 12 to 72 hours after incubation of the infection. Untreated with an antibiotic, the illness usually lasts from 4 to 7 days. The infection may spread and cause the victim to become seriously ill, or rarely, to die. On occasion, persons with Salmonella infection develop a post-infection syndrome of painful joints, irritated eyes, and pain on urination.

For gastroenteritis, antibiotic therapy is usually not indicated, because it does not shorten the duration of the disease. Furthermore, antimotility drugs, such as loperamide (Imodium), are not recommended, because they may prolong contact time of the bacteria in the bowel, and prolong or worsen the illness. However, antibiotics are often recommended for Salmonella gastroenteritis in infants younger than 3 months, infants younger than 12 months with temperatures higher than 102.2°F (39°C), and persons with certain blood disorders, HIV infection or other cause of immunosuppression (e.g., diabetes or chronic steroid therapy), cancer, or chronic gastrointestinal illness. The recommended antibiotics for such individuals include ampicillin, amoxicillin, trimethoprim-sulfamethoxazole, cefotaxime, ciprofloxacin, and ceftriaxone, among others.

So far, in this current Salmonella outbreak, there have been no directly-attributable deaths reported, but at least 53 persons have been hospitalized. Overall, the number of afflicted persons is likely greater than that reported, because many people who develop diarrhea don't seek medical care and/or obtain a stool culture.

The Food and Drug Administration (FDA) has been advising consumers in the U.S. to be cautious, and to choose for consumption cherry tomatoes, grape tomatoes, tomatoes sold with the vine attached, homegrown tomatoes (more reason to "go organic"), and to avoid red plum, red Roma, and round red tomatoes unless they come from reliable sources. Of course, much as one needs to avoid contaminated ice in beverages, one should be aware that if tomatoes are the culprits, then raw tomatoes used to prepare sauces, salsa, cold soups, and other food products can carry Salmonella. Ditto for lettuce or any raw fruit or vegetable. The truth is that right now, we don't know precisely what to avoid.

Here are additional precautionary measures that place emphasis on food handling and preparation:

1. Within 2 hours of use, refrigerate or discard cut, peeled, or cooked fruits and vegeatables.
2. Do not purchase bruised or damaged fruits or vegetables.
3. Wash all vegetables and fruits thoroughly under running water. If you are camping, use properly disinfected water. Soaking vegetables and fruits with a skin or "peel" in an iodinated disinfecting solution, then rinsing with disinfected water to remove the residual iodine (and improve the taste) is a common practice in some third world restaurants.
4. Keep raw produce for consumption separate from raw meats and seafood.
5. Wash all cutting boards and surfaces, dishes, utensils, and counter tops with soap and hot water in between handling different types of food products.
6. One might consider peeling tomatoes, but there is not yet evidence that this makes a difference in diminishing the number of infections, which may not be caused by the tomatoes anyway.

The U.S. Department of Agriculture has an excellent Fact Sheet entitled "Salmonella Questions and Answers."

In summary, the recent reports of Salmonella infection, while perhaps attributable to tomatoes, may well have been created by an alternative source(s). The rules for safe food handling and avoidance of food-borne infection apply to all foods, not just tomatoes.

image of "Tennessee tomatoes go camping" courtesy of blackstarjewelry's photostream

Preview the 25th Anniversary & Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 25-30, 2008.

Tags: tomato, Salmonella, disinfection, wilderness medicine, outdoor medicine, healthline

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Smoke from Wildfires

AIRNOW is a cross-agency U.S. government website devoted to air quality and its impact upon human health. The fire season has begun with a vengeance in California, with approximately 1100 fires burning today. Because of the tremendous number of wildfires burning in California, an unprecedented portion of the state is suffering hazy, smoke-laden air. Utilizing information from AIRNOW and other sources, including the American Lung Association and Environmental Protection Agency, here is a brief overview of important considerations related to what will undoubtedly be a very active fire season.

First and foremost, smoke from fires can affect your health. A person does not acclimate to smoke in any way, and repeated exposures can diminish lung function. So, avoidance is very important.

The discussion of intense exposure to heat and smoke when in the immediate proximity of a raging forest fire is a separate topic, because there are considerations of becoming burned, asphyxiated from lack of oxygen, affected by carbon monoxide, and injured by other severe, acute causations. The focus of what follows is exposure to smoke exposure of a degree to create a hazy horizon, where you can see, smell, and taste the smoke, and must make a decision to what extent, if any, you should modify your behavior and activities.

Healthy persons are usually not at a major risk from such smoke. But of course, it's always a good idea to avoid breathing smoke if you can help it. Smoke is not good for you.

Smoke is a mixture of gases and fine particles produced when wood and other organic matter burn. It reflects the fuel, so can contain products of combustion from rubber, plastics, and any other material consumed in the blaze. Firefighters have the greatest exposures to smoke, and they are often affected. It has been estimated that nearly 40 to 50% of medical encounters by wildland firefighters are for respiratory problems. Whether or not this statistic can be perfectly extrapolated to a non-firefighter population passively exposed to wildfire-generated smoke is not known, but it is highly likely that respiratory ailments and diminished lung function would be a logical result of exposure to smoke.

What's in the smoke. Some of the combustion products of concern include these classes of materials: particulate matter (organic and inorganic), carbon monoxide, ozone, organic acids, polynuclear aromatic hydrocarbons, volatile and semi-volatile organic compounds, and free radicals. These are present or absent in varying degrees depending on the fuel burned, temperature of the fire, suppression method(s) used, and other factors. Therefore, the toxicity of the smoke may vary, but for the purposes of this discussion, all smoke from wildland fires should be considered comparable.

Because particulate matter dominates in proportion within wildland fire smoke, the greatest health threat from smoke comes from the fine particles, which are often microscopic. The particles easily get into the eyes and respiratory system, where they can cause health problems such as burning eyes (conjunctivitis), irritated throat, runny nose (sometimes associated with an allergic response), and illnesses such as bronchitis (cough). Fine particles also can worsen chronic heart and lung diseases. Because death rates from these conditions have been noted to rise in a smoky environment, the smoke has been linked to premature deaths in people with these conditions, in a fashion analogous to increased mortality during heat waves.

Persons who are more susceptible to ill effects at lower smoke levels are those heart disease (congestive heart failure, symptomatic angina, cardiomyopathy), lung disease (asthma, reactive airway disease, chronic obstructive pulmonary disease [COPD]), and any medical condition in which oxygen delivery and heart and lung function are essential for health and wellness.

Older adults appear to be at increased risk of being affected by smoke, as do children with high activity levels. Firefighters, athletes, soldiers, and others who exercise in smoky conditions often report feeling poorly, sometimes up to the point of incapacitation.

It is not difficult to know if smoke is affecting you, if you develop symptoms. It is less easy to know if you are being affected if the impact is subtle. Obvious symptoms are irritated and reddened eyes; painful throat; fatigue; decreased exercise tolerance; palpitations; chest pain; shortness of breath or inability to draw a deep breath; coughing; wheezing; sinus irriation; headache; or worsening of pre-existing conditions that manifest any of these symptoms.

Prevention is key. One must know how to limit exposure to smoke:

Pay attention to local air quality reports, and to the Environmental Protection Agency's Air Quality Index (AQI)(more about this below). Stay alert for any news coverage or health warnings related to smoke. You can check out news on current status of wildfires by going to the website http://www.nifc.gov/

Use visibility guides, if they're available. Not every community has a monitor that measures particle levels in the air. In the western United States, some areas without air quality monitors have developed guidelines to help people estimate the AQI based on how far they can see.

Common sense is the cornerstone of everything we do in wilderness medicine. If it's smoky outside, do not plan to exert yourself. Do not run the race and consider keeping your children indoors. If you develop smoke-related symptoms, curtail any contributing activities and seek an environment away from the smoke. Ordinary dust masks are designed to filter out large particles, so do not count on them to diminish exposure to small particulate matter found in smoke.

The air indoors is also important during times of high smoke levels outdoors. So, you should keep indoor air as clean as possible. Unless it is extremely hot outside and you need to open windows and doors for air circulation, you should keep them closed. If you have an air conditioner, allow it to run, with the fresh air intake closed and the filter clean. Certain air cleaners might decrease particulate matter indoors, but be certain that the device does not emit ozone. Do not vacuum or smoke tobacco products, and do not burn anything that will emit smoke. If it becomes too hot inside a building or enclosure, find a cooler shelter, so that you are not overcome by the heat. When driving a car in smoky areas, keep the windows and vents closed.

AIR QUALITY INDEX (AQI) FOR PARTICLES

The AQI (see the color chart above) is an index for reporting daily air quality that indicates how clean or polluted is the air, and what associated health effects might be of concern. The EPA calculates the AQI for five major air pollutants regulated by the Clean Air Act: ground-level ozone, particle pollution (also known as particulate matter), carbon monoxide, sulfur dioxide, and nitrogen dioxide. Ground-level ozone and airborne particles are the two pollutants that pose the greatest threat to human health in the U.S. In the setting of smoke from a wildland fire, it is the particulate matter that is of greatest concern.

The AQI is reported as a numerical rating that runs from 0 to 500. The higher the AQI value, the greater the level of air pollution and the greater the health concern. For example, an AQI value of 50 represents good air quality with little potential to affect public health, while an AQI value over 300 represents hazardous air quality. When AQI values are above 100, air quality is considered to be unhealthy, at first for sensitive (to the harmful components) groups of people, then for everyone as AQI values get higher.

The AQI categories are:

0 to 50 Green Good
51 to 100 Yellow Moderate
101 to 150 Orange Unhealthy for Sensitive Groups
151 to 200 Red Unhealthy
201 to 300 Purple Very Unhealthy
301 to 500 Maroon Hazardous

Each category corresponds to a different level of health concern. The six levels of health concern are:

"Good" - The AQI value is between 0 and 50. Air quality is considered satisfactory, and air pollution poses little or no risk.

"Moderate" - The AQI value is between 51 and 100. Air quality is acceptable; however, for some pollutants there may be a moderate health concern for a small number of people.

"Unhealthy for Sensitive Groups" - The AQI value is between 101 and 150. Members of sensitive groups may experience health effects. The general public is not likely to be affected when the AQI is in this range.

"Unhealthy" - The AQI value is between 151 and 200. Everyone may begin to experience health effects. Members of sensitive groups may experience more serious health effects.

"Very Unhealthy" - The AQI value is between 201 and 300. This triggers a health alert, because everyone may experience more serious health effects.

"Hazardous" - The AQI value is over 300. This triggers health warnings of an emergency nature. The entire population is more likely to be affected.

People living in close proximity to the fire-stricken areas should remain indoors and avoid inhalation of smoke, ashes, and particulate matter in the area. Ordinary dust masks, designed to filter out large particles, will not help as they still allow the more dangerous smaller particles to pass through. HEPA filter masks can remove nearly all airborne particles 0.3 micrometers (microns) in diameter, but they are more expensive and may be difficult to use for people with lung disease, because it can be hard to draw air through them.

If outdoor trips in smoky areas are necessary, breathing through a damp cloth may help filter out some of the particles that are floating in the air, but this is a temporizing measure only and should not be counted upon to significantly diminish smoke exposure for more than a few minutes.

Preview the 25th Anniversary & Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 25-30, 2008.

Tags: smoke, wildfire, air quality index, wilderness medicine, outdoor medicine, healthline

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The DAN Guide to Dive Medical Frequently Asked Questions (FAQ)

The DAN Guide to Dive Medical Frequently Asked Questions (FAQs) is a book to which I and other dive medicine authorities have contributed. This compilation of questions and answers by the Divers Alert Network (DAN) is available through DAN or from Best Publishing Company.

Here is the table of contents:

SECTION 1 - GENERAL
• Mask squeeze
• The scuba blues: DAN examines the possibilities behind flu-like symptoms following a dive
• Hand and foot edema after a dive
• To mix or not to mix: Is there a conflict with pseudoephedrine and enriched air diving?
• A tangled question: Is there a connection between aluminum scuba tanks and Alzheimer’s
• Post-dive symptoms
• Identifying the problem: DAN offers assistance in helping the non-diving companion to determine when or if the partner needs to call DAN
• Basic instincts: DAN explores a hypothetical underwater emergency using a medical perspective
• The training perspective: Dealing with the injured or panicked diver at depth

SECTION 2 – CARDIOVASCULAR
• Cardiovascular fitness and diving
• Pacemakers and diving
• Vasovagal and carotid sinus syncopes

SECTION 3 – DECOMPRESSION SICKNESS
• Return to diving: DAN takes a look at getting back in the water after experiencing decompression illness
• Diving after flying
• The industry examines flying after diving
• Low living, high diving: DAN discusses living at a subsea level and diving above sea level

SECTION 4 – DENTAL
• Dental work and diving
• Realignment: DAN talks about diving with dental braces
• Root canal
• Toothy wisdom: DAN sinks its teeth into dental issues & diving

SECTION 5 – EAR, NOSE AND THROAT
• Before the pressure gets too great, equalize
• The trauma of barotrauma
• Unplugged: DAN examines the use of earplugs

SECTION 6 – FITNESS TO DIVE
• Exercise training and scuba diving
• Fitness issues for divers with musculoskeletal problems
• Healthy, but overweight

SECTION 7 – GASTROINTESTINAL
• Gastrointestinal issues

SECTION 8 – HEMATOLOGY (BLOOD)
• Risk of diving with hemophilia

SECTION 9 – MARINE LIFE
• I’ve been stung: What should I do?
• Taking the sting out of jellyfish envenomations
• No fish tale: If you eat fish, it’s good to know about ciguatera – before you get sick

SECTION 10 – MUSCULOSKELETAL
• Diving & the body systems
• Lupus
• Diving after bone fractures

SECTION 11 – NERVOUS SYSTEM
• CNS considerations in scuba diving

SECTION 12 – OPHTHALMOLOGY (EYES)
• High pressure ophthalmology
• Eye surgery for divers
• The eyes have it: Mask defoggers

SECTION 13 – PSYCHOLOGICAL
• Psychological issues in diving – Part I: Depression, manic depression, and drugs
• Psychological issues in diving – Part II: How anxieties and phobias can affect diving
• Psychological issues in diving – Part III: Schizophrenia, marijuana and alcohol use

SECTION 14 – RESPIRATORY (BREATHING)
• Pulmonary considerations in diving
• Breathing easy
• Tight squeeze: Discomfort in a diver’s lungs and windpipe can come from a number of irritating sources

SECTION 15 – WOMEN’S ISSUES
• DAN explores fitness and diving issues for women

SECTION 16 – DECOMPRESSION ILLNESS AND SYMPTOM RECOGNITION

INDEX

The book carries a 2003 copyright, so there are a number of topics, including mine - entitled “I’ve Been Stung: What Should I Do?” – that would benefit from updates. Divers will be the beneficiaries of many new drugs and medical devices, so it is important that information about these as they relate to diving be kept current. As we learn more about the long-term effects of surgeries and medical conditions, opinions may be modified. However, despite the advances in medicine in general and in dive medicine in particular that have occurred since 2003 and that will continue to occur, there is a wealth of information in the book, so it should be useful to anyone who is a scuba diver or who intends to take up diving.

Preview the 25th Anniversary & Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 25-30, 2008.

Tags: DAN, Divers Alert Network, wilderness medicine, outdoor medicine, healthline

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