Excerpt from A Comprehensive Guide to Wilderness & Travel Medicine, 3rd Edition, by Dr. Eric A. Weiss.

If a person who has diabetes becomes confused, weak, or unconscious for no apparent reason, he may be suffering from insulin shock (low blood sugar) or diabetic ketoacidosis (high blood sugar).

INSULIN SHOCK (LOW BLOOD SUGAR)

If a person with diabetes takes too much insulin or fails to eat enough food to match his insulin level or his level of exercise, a rapid drop in blood sugar can occur. Symptoms may come on very rapidly and include an altered level of consciousness, ranging from slurred speech, bizarre behaviour, and loss of coordination, to seizures and unconsciousness.

Treatment
If still conscious, the victim should be given something containing sugar to drink or eat as rapidly as possible. This can be fruit juice, candy, or a non-diet soft drink. If the victim is unconscious, place sugar granules, cake icing, or Glutose® paste from your first aid kit under his tongue, where it will be rapidly absorbed.

  DIABETIC KETOACIDOSIS (HIGH BLOOD SUGAR)

Diabetic ketoacidosis (formerly called diabetic coma) comes on gradually and is the result of insufficient insulin. This eventually leads to a very high sugar level in the victim’s blood. Early symptoms include frequent urination and thirst. Later, the victim will become dehydrated, confused, or comatose, and will develop nausea, vomiting, abdominal pain, and a rapid breathing rate with a fruity odor to his breath.

Treatment
The victim needs immediate evacuation to a medical facility. If vomiting is not present and the victim is awake and alert, have him drink small, frequent sips of water. If you are unsure whether the victim is suffering from insulin shock (low blood sugar) or ketoacidosis (high blood sugar), it is always safer to assume it is low blood sugar and administer sugar.

Excerpt from A Comprehensive Guide to Wilderness and Travel Medicine, by Eric A. Weiss, M.D.

Lightning kills more people every year in the United States than all other natural disasters combined. Carrying or wearing metal objects, such as an ice axe, umbrella, backpack frame, or even a hairpin, increases the chances of being hit.

To calculate the approximate distance in miles from a flash of lightning, count in seconds from the time you see the flash to when you hear the thunder, then divide by five.

Prevention

• When a thunderstorm threatens, seek shelter in a building or inside a vehicle (not a convertible).
• Occupants of tents should stay as far away from the poles and wet cloths as possible.
• Do not stand underneath a tall tree in an open area or on a hill top.
• Get out and away from open water.
• Get away from tractors and other metal farm equipment.
• Get off bicycles and golf carts.
• Stay away from wire fences, clotheslines, metal pipes, and other metallic paths which could carry lightning to you from some distance.
• Avoid standing in small, isolated sheds or other small structures in open areas.
• In a forest, seek shelter in a low area under a thick growth of saplings or small trees. In an open area, go to a low place such as a ravine or valley.
• If you are totally in the open, stay far away from single trees to avoid lightning splashes. Drop to your knees and bend forward, putting your hands on your knees. If available, place insulating material (e.g. sleeping pad, life jacket, rope) between you and the ground. Do not lie flat on the ground.

LIGHTNING CAN CAUSE INJURY BY FOUR MECHANISMS:

1.DIRECT HIT
Lightning directly strikes a person in the open. It usually does not enter the body, but instead is conducted over the skin surface (“flashover”), producing a variety of injuries. The greatest damage may occur to skin beneath metal objects worn by the victim, such as jewelry, belt buckles, or zippers, which tend to disrupt the flashover and allow current to penetrate. Current may also penetrate the body through the eyes, ears, and mouth, causing deeper injuries to those parts. The victim is exposed to a tremendous elec-tromagnetic field, which can disrupt the workings of the brain, lungs and heart and lead to a cardiac and respiratory arrest. Finally, the instant vaporization of any moisture on the victim’s skin can blast apart his clothing and shoes.

2. SPLASH
A more common scenario is for the victim to be struck by lightning “splash,” which occurs when a bolt first hits an object, such as a tree or another person, and then “jumps” to the victim who may have found shelter nearby. Splashes may also occur from person to person who are standing close together.

3. STEP VOLTAGE
Lightning hits the ground or a nearby object and the current spreads like a wave in a pond to the victims. Step voltage is often to blame when several people are hurt by a single lightning bolt.

4. BLUNT TRAUMA
The explosive force of the pressure waves created by lightning can cause blunt trauma, such as spleen or liver injuries and ruptured ear drums.

TYPES OF INJURIES

1. HEART AND LUNG
Lightning can cause a cardiac arrest and paralyze the lungs. The heart will often restart on its own, but because the lungs are still not working, the heart will stop again from lack of oxygen.

2. NEUROLOGIC INJURIES
The victim may be knocked unconscious and suffer temporary paralysis, especially in the legs. Seizures, confusion, blindness, deafness, and inability to remember what happened may result.

3. TRAUMATIC INJURIES
Bruises, fractures, dislocations, spinal injury, chest and abdominal injuries from the shock wave may occur. Ruptured eardrums can result in hearing loss.

4. BURNS
Superficial first or second-degree burns are more common than severe burns after a lightning strike and form distinctive fern patterns on the skin.

TREATMENT

Lightning strike victims are not “charged” and thus pose no hazard to rescuers.

1. The immediate treatment of lightning strike victims differs from other situations in which you have multiple trauma victims. Rather than adhere to the standard rescue dogma of ignoring the victims who appear dead and giving priority to those who are still alive, after a lightning strike, treat those victims first who appear dead, because they may ultimately recover if quickly given mouth-to-mouth rescue breathing and CPR. If you’re successful in obtaining a pulse with CPR, continue rescue breathing until the victim begins to breathe on his own or you are no longer able to continue the resuscitation.
2. Stabilize and splint any fractures.
3. Initiate and maintain spinal precautions if indicated.

Q. What’s the best way to treat rattle snake bites in the wild?

Thanks –Lorenzo.

A. Lorenzo, please check out the “Venomous Snake Bites” chapter (excerpted below) from Dr. Weiss’ A Comprehensive Guide to Wilderness & Travel Medicine, 3rd.

Treatment

The definitive treatment for snake venom poisoning is the administration of antivenin. The most important aspect of therapy is to get the victim to a medical facility as quickly as possible.

Signs and Symptoms of Envenomation

• One or more fang marks (rattlesnake bites may leave one, two, or even three fang marks).

• Local, burning pain immediately after the bite.

• Swelling at the site of the bite, usually beginning within five to 20 minutes and spreading slowly over a period of six to 12 hours. The faster the swelling progresses up the arm or leg, the worse the degree of envenomation.

• Bruising (black and blue discoloration) and blister formation at the bite site.

• Numbness and tingling of the lips and face, usually 10 to 60 minutes after the bite.

• Twitching of the muscles around the eyes and mouth.

• Rubbery or metallic taste in the mouth.

• After six to 12 hours, bleeding from the gums and nose may develop and denote a serious envenomation.

• Weakness, sweating, nausea, vomiting and faintness may occur.

First Aid

1. Rinse the area around the bite site with water to remove any venom that might remain on the skin.
2. Clean the wound and cover with a sterile dressing.
3. Remove any rings or jewelry.
4. Immobilize the injured part as you would for a fracture, but splint it just below the level of the heart.
5. Transport the victim to the nearest hospital as soon as possible. If you pass by a telephone, stop and notify the hospital that you are bringing in a snakebite victim so they can begin to locate and procure antivenin.
6. It is not necessary to kill the snake and transport it with the victim for identification. If the snake is killed, it should not be directly handled, but should be transported in a closed container. Decapitated snake heads can still produce envenomation
7. Extractor pumps designed to provide suction over a snakebite wound are sold in many camping stores and endorsed by some as a first aid treatment for snakebites. Based on recent scientific evidence, these devices are no longer recommended. A study published in the Annals of Emergency Medicine in 2004 showed that these devices remove an insignificant amount of venom, and may also be harmful to the victim. The best first aid for snakebite is a cell phone (call the hospital that you are going to so that they can procure antivenin) and a car or helicopter to get the victim there as quickly as possible.

Other First-Aid Treatments That May Be Beneficial

Immediately wrapping the entire bitten extremity with a broad elastic bandage (the “Australian Compression and Immobilization Technique”) has proven effective in the treatment of elapid and sea snake envenomations only. It is only recommended when the victim appears to have suffered a severe envenomation and is several hours from medical care.

The wrap is started over the bite site and continued upward toward the torso in an even fashion about as tight as one would wrap a sprained ankle (Fig. 60). Monitor the color, pulse and temperature of the hand or foot to make sure that there is adequate circulation. If circulation appears compromised, loosen the wrap. Otherwise the bandage should not be released until after the victim has been brought to a medical facility. The limb should then be immobilized with a well-padded splint.

Things Not To Do

1. Do not make any incisions in the skin or apply suction with your mouth.
2. Do not apply ice or a tourniquet.
3. Do not shock the victim with a stun gun or electrical current.

By Chris Van Tilburg, M.D.

The Wilderness Medical Society (WMS) recently published recommendations that guides carry epinephrine in outdoor education settings, according to a consensus statement in Wilderness and Environmental Medicine. The reason: allergic shock, called anaphylaxis, can be deadly in minutes. But, the practice of letting lay, non-medical guides use prescription medicine on clients is fraught with difficulties, and some potentially deadly effects.

A Word About Anaphylaxis

Anaphylaxis is a severe allergic reaction that occurs when a person eats an unfamiliar food, takes new medicine or gets stung by a bee. The body reacts with instant inflammation to shut out what it sees as a foreign toxin. No one can predict which people will react to which toxins—making this doubly deadly, especially in the backcountry. The throat swells shut and the lungs spasm; both can lead to death by hypoxia, or a lack of oxygen in the body’s tissues. Epinephrine is a powerful medicine that stops the swelling and restores breathing. It’s used in conjunction with over-the-counter antihistamines, like Benadryl, which block the hormone causing allergic reactions.

Doctors routinely prescribe epinephrine to kids in the form of easy-to-use auto-injectors like EpiPen or TwinJect and teach their parents on proper administration. But prescribing the same medicine to guides is problematic.

First, it’s illegal in most states for a guide to carry a prescription medicine and use it on a third party. A few states provide exceptions. North Carolina lets docs train lay people in epinephrine use. New York allows training for summer camp counselors.

Second, epinephrine is powerful medicine not to be used lightly. Anaphylaxis can be misdiagnosed, epinephrine can cause life-threatening heart arrhythmias, and the rescuer can accidentally inject their thumb if the auto injector is inadvertently used upside down, which can cause potentially limb-threatening decreased blood flow in the rescuer. That means two patients, instead of one.

Nonetheless, in the WMS’ view the risk is worth it, as epinephrine can save lives, especially in remote settings. Each year, anaphylaxis causes 1500 deaths in the U.S., but we really don’t know how big the problem is in the wilderness. The National Outdoor Leadership School database cites two cases of anaphylaxis in 2.5 million participant days, spanning 20 years. A separate study published in 1996 reported 8 cases in a 16-month span in Sequoia and Kings Canyon National Park, suggesting it’s more common.

For now, the WMS advocates lobbying state medical boards and state lawmakers to allow the drug to be carried by guides for use on clients. But even that can be problematic legally, because a guide trained in one state may be leading a trip in another. Perhaps the best option is to push to change laws at the federal level, as was the case with Canada’s Sabrina’s Law, which mandated anaphylaxis training in Canada’s school system. That 2006 law requires that teachers and school staff learn how to recognize symptoms of anaphylaxis and how to properly inject epinephrine.

Q. What do you think? Should there be a federal law allowing guides to carry and administer epinephrine?

Christopher Van Tilburg, MD, is the editor of Wilderness Medicine and the author of eight books on safety in the outdoors. His most recent book, Mountain Rescue Doctor: Wilderness Medicine in the Extremes of Nature, is now available in paperback.

Excerpt from A Comprehensive Guide to Wilderness and Travel Medicine, by Dr. Eric A. Weiss.

Fractures of the neck and spine can damage the spinal cord and lead to permanent paralysis. Any accident that places excessive force or pressure on the head, neck, or back, such as a fall, head injury, or diving accident, can also result in a fracture of the spine.

The decision to initiate and to maintain spine immobilization in the wilderness has significant ramifications. An otherwise walking victim would require a potentially expensive and arduous rescue. The added delay could worsen other injuries and predispose the victim and the rest of the party to hypothermia or other environmental hazards. Although in general it is always better to err on the side of being overprotective, everyone with a bump or cut on their head does not need to have their spine immobilized.

TREATMENT

If a spine injury is suspected, the rescuer should immobilize the head, neck, and trunk to prevent any movement. If the victim is lying in a dangerous location and must be moved quickly, the victim’s head and neck should be held firmly by one rescuer’s hands, while as many people as available place their arms under the victim from either side. The rescuer at the head says, “Ready, go,” and with everyone lifting simultaneously, the victim is lifted as a unit and moved to a safer location. After the victim is moved, one rescuer should continue to hold the head firmly with two hands until the spine is completely immobilized.

If the neck lies at an angle to the body, it should be straightened with gentle in-line traction. A second rescuer should then place a cervical collar around the neck to provide some stability. Cervical collars alone do not provide adequate immobilization. After a collar is placed around the neck, plastic bags, stuff sacks or socks filled with sand or dirt, or rolled up towels and clothing should be placed on either side of the head and neck and secured to the head with tape or straps to prevent any side-to-side movement. The rest of the body should then be secured to a flat board to prevent any movement.

WHEN TO WORRY

Suspect a spinal injury, and initiate and maintain spine immobilization, after trauma when:

• The victim is unconscious.
• The victim feels pain in the back of the neck, in the middle of the back, or experiences discomfort when those areas are touched.
• There is numbness, tingling or diminished sensation in any part of an arm or leg.
• There is weakness or inability to move the arms, legs, hands, or feet.
• A victim has an altered level of consciousness or is under the influence of drugs or alcohol.
• A victim has another very painful injury that may distract him from noticing the pain in his neck, such as a femur or pelvic fracture, dislocated shoulder, or broken rib.

‘WEISS ADVICE’
Improvised cervical collars

A cervical collar can be improvised by using a Sam® splint, sleeping pad, newspaper, backpack hip belt, fanny pack, sleeping pad, life jacket, or clothing.

SAM® Splint Cervical Collar
Create a bend in the SAM® Splint approximately six inches from the end of the splint. This bend will form the front support which holds the chin. Place the front support underneath the chin and wrap the remainder of the splint around the neck. Create side supports by squeezing the slack in the splint together to form flares under each ear. Finally, squeeze the back of the splint in a similar manner to create a back support and secure the whole thing with tape.

Sleeping Pad Collar
Fold the pad long-ways into thirds and center it over the back of the victim’s neck. Wrap the pad around the neck, under the chin, and secure it in place with tape. If the pad is not long enough, extensions can be taped or tied on. Blankets, beach towels, or even a rolled plastic tarp can be used in a similar fashion.

Padded Hip Belt
A padded hip belt taken from a large internal or external frame backpack can sometimes be modified, after removal, to function as a cervical collar. If the belt is too long, overlap the ends and secure them with duct tape.

Clothing
Any bulky item of clothing can be used. Wrap a wide ace-type bandage around the entire item first, to compress the material and to make it more rigid and supportive before placing on the neck. If the victim must be rolled or turned to place insulation or a spine board under him, or if he is vomiting, log-roll him with the head and body held as a unit. In the event of a suspected spine injury, it is generally better to send for professional rescue assistance rather than attempt to transport the victim yourself.