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.
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.
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.
Stabilize and splint any fractures.
Initiate and maintain spinal precautions if indicated.
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?
When the earthquake of 12 January 2010 ended, much of Port-au-Prince lay in ruins and the lives of a quarter million human inhabitants had suddenly and violently ended. Then the hurricane hit, and then the deadly cholera epidemic. Haiti, poorest nation of the Western Hemisphere, has yet to recover. In an area just a little smaller than Maryland, an estimated 9.7 million people struggle for basic health and without hope for much more than that.
Supported generously by Adventure® Medical Kits and by Medical Student Missions, fellow AMK blog contributor Chris Van Tilburg, MD, and I will be traveling in May to near Verrettes, about 50 miles north of Port-au-Prince, to help at the Albert Schweitzer Hospital, the sole source of medical care for the 300,000-plus people of this central, mountainous region. I will also be teaching a Wilderness Advanced First Aid course, donated by the Wilderness Medicine Institute of NOLS. While the challenges for basic daily survival Haiti faces are many, below are the most serious health issues its people are dealing with and for which our team will need to be prepared for during our stay:
Food and Water A “high risk” label has been attached to Haiti by the U. S. Department of State, partly due to the crime rate, partly to the disease rate. With poor sanitation and rampant germs, food and water often contain pathogens capable of leaving Haitians and visitors with hepatitis, typhoid, and bacterial or protozoal diseases characterized by profuse diarrhea. My vaccinations against the viruses hep A and B are up-to-date, but I did take the oral drug that prevents the bacteria that cause typhoid fever from taking control. This anti-typhoid med should keep working for several years. And more on prevention: Food will be well-cooked and served hot, and fruit will be peeled shortly before consumption. Salads and dairy products will be avoided. Water—for drinking and toothbrushing—will be disinfected prior to use, most often via filtration.
Cholera Once the bacterium Vibrio cholerae infects the intestines of a person, it is passed in fecal matter. The germ ends up in water, most commonly, but it can also contaminate food if the food server has less than ideal hygienic practices. The Artibonite River Valley, where we’ll be working, is indeed the “epicenter” of the current cholera epidemic. In case of cholera, we’re packing the antibiotics doxycycline and azithromycin—which almost always work. Steps toward prevention will be the same as for any food and/or waterborne illness.
Vectors of Disease Mosquitoes promise to be not only bothersome in Haiti but carriers of illnesses including, most problematically, dengue fever and malaria. The virus causing dengue makes you miserable, then you get well. The parasite causing malaria, however, can have devastating results. I just started a course of chloroquine, an anti-malaria drug I’ll ingest once a week for two weeks prior to Haiti, during our visit, and for four weeks after we return. For repelling insects, I’m packing Natrapel® 8 hour for application to skin, and I’ll be treating my clothing, before leaving home, with permethrin. My bunk bed reportedly offers the protection of mosquito netting, but it was suggested I also treat a thin sheet from home with permethrin—and I’m going to do that, too.
We will probably stay healthy. Without efficient means to disinfect water, without antibiotics, without vaccinations, without even mosquito netting, the people of Haiti have a far smaller chance of doing so. Anyone can support the efforts of Medical Student Missions, by joining and/or donating. Visit www.medicalstudentmissions.org.
And thank you.
Buck Tilton has authored 36 books on outdoor safety, including Wilderness First Responder, which won an award for excellence in medical writing from the American Medical Writers Association. For the last 20 years, Buck has contributed hundreds of articles on wilderness safety to Backpacker. In addition to his writing and journalism, Tilton also co-founded the Wilderness Medicine Institute (now WMI of NOLS), which remains the largest school of wilderness medicine in the world.
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).
Prevention
of the Western Hemisphere, has yet to recover. In an area just a little smaller than Maryland, an estimated 9.7 million people struggle for basic health and without hope for much more than that.
