As summer quickly approaches – swimmers beware!

Drowning is almost always a deceptively quiet event. The waving, splashing, and yelling that dramatic conditioning (television) prepares us to look for, is rarely seen in real life.

The new captain jumped from the cockpit, fully dressed, and sprinted through the water. A former lifeguard, he kept his eyes on his victim as he headed straight for the owners who were swimming between their anchored sportfisher and the beach. “I think he thinks you’re drowning,” the husband said to his wife. They had been splashing each other and she had screamed but now they were just standing, neck-deep on the sand bar. “We’re fine, what is he doing?” she asked, a little annoyed. “We’re fine!” the husband yelled, waving him off, but his captain kept swimming hard. ”Move!” he barked as he sprinted between the stunned owners. Directly behind them, not ten feet away, their nine-year-old daughter was drowning. Safely above the surface in the arms of the captain, she burst into tears, “Daddy!”

How did this captain know, from fifty feet away, what the father couldn’t recognize from just ten? Drowning is not the violent, splashing, call for help that most people expect. The captain was trained to recognize drowning by experts and years of experience. The father, on the other hand, had learned what drowning looks like by watching television. If you spend time on or near the water (hint: that’s all of us) then you should make sure that you and your crew knows what to look for whenever people enter the water. Until she cried a tearful, “Daddy,” she hadn’t made a sound. As a former Coast Guard rescue swimmer, I wasn’t surprised at all by this story. Drowning is almost always a deceptively quiet event. The waving, splashing, and yelling that dramatic conditioning (television) prepares us to look for, is rarely seen in real life.

The Instinctive Drowning Response – so named by Francesco A. Pia, Ph.D.,  is what people do to avoid actual or perceived suffocation in the water.  And it does not look like most people expect.  There is very little splashing, no waving, and no yelling or calls for help of any kind.  To get an idea of just how quiet and undramatic from the surface drowning can be, consider this:  It is the number two cause of accidental death in children, age 15 and under (just behind vehicle accidents) – of the approximately 750 children who will drown next year, about 375 of them will do so within 25 yards of a parent or other adult. In ten percent of those drownings, the adult will actually watch them do it, having no idea it is happening (source: CDC). Drowning does not look like drowning – Dr. Pia, in an article in the Coast Guard’s On Scene Magazine, described the instinctive drowning response like this:

Except in rare circumstances, drowning people are physiologically unable to call out for help. Th e respiratory system was designed for breathing. Speech is the secondary or overlaid function. Breathing must be fulfilled, before speech occurs.

Drowning people’s mouths alternately sink below and reappear above the surface of the water. The mouths of drowning people are not above the surface of the water long enough for them to exhale, inhale, and call out for help. When the drowning people’s mouths are above the surface, they exhale and inhale quickly as their mouths start to sink below the surface of the water.

Drowning people cannot wave for help. Nature instinctively forces them to extend their arms laterally and press down on the water’s surface. Pressing down on the surface of the water, permits drowning people to leverage their bodies so they can lift their mouths out of the water to breathe.

Throughout the Instinctive Drowning Response, drowning people cannot voluntarily control their arm movements. Physiologically, drowning people who are struggling on the surface of the water cannot stop drowning and perform voluntary movements such as waving for help, moving toward a rescuer, or reaching out for a piece of rescue equipment.

From beginning to end of the Instinctive Drowning Response people’s bodies remain upright in the water, with no evidence of a supporting kick. Unless rescued by a trained lifeguard, these drowning people can only struggle on the surface of the water from 20 to 60 seconds before submersion occurs. (Source: On Scene Magazine: Fall 2006)

This doesn’t mean that a person that is yelling for help and thrashing isn’t in real trouble – they are experience aquatic distress. Not always present before the instinctive drowning response, aquatic distress doesn’t last long – but unlike true drowning, these victims can still assist in there own rescue.  They can grab lifelines, throw rings, etc.

Look for these other signs of drowning when persons are n the water:

• Head low in the water, mouth at water level
• Head tilted back with mouth open
• Eyes glassy and empty, unable to focus
• Eyes closed
• Hair over forehead or eyes
• Not using legs – Vertical
• Hyperventilating or gasping
• Trying to swim in a particular direction but not making headway
• Trying to roll over on the back
• Ladder climb, rarely out of the water.

So if a crew member falls overboard and every looks O.K. – don’t be too sure. Sometimes the most common indication that someone is drowning is that they don’t look like they’re drowning.  They may just look like they are treading water and looking up at the deck. One  way to be sure?  Ask them: “Are you alright?” If they can answer at all – they probably are.  If they return  a blank stare – you may have less than 30 seconds to get to them. And parents: children playing in the water make noise. When they get quiet, you get to them and find out why.

One of the leading causes of amputation and disability in the United States, diabetes is an endocrine problem where the pancreas fails to produce adequate amounts of insulin, or perhaps doesn’t produce any insulin at all.

It’s a pretty common problem, so you may very well encounter someone with diabetes while you’re in the wilderness. In a healthy person, once ingesting food, the body breaks it down and insulin is used to transport nutrients (such as sugar) into the cells for use.

TYPES OF DIABETES
There are two types of diabetes: insulin dependent diabetics (Type I) that rely almost entirely upon supplementary insulin to “feed their cells” and survive, while non-insulin dependent diabetics (Type II) have a pancreas that creates enough insulin for survival, but needs to be helped with proper diet and oral diabetes medications (some decrease sugar, and some tell the pancreas to make more insulin).

Type II diabetes has been shown to be linked with obesity; and sadly, is being diagnosed in younger and younger patients. After some time, a person with non-insulin dependent diabetes may become insulin-dependent.

Any diabetic should be prepared for an outing with adequate supplies and testing capabilities. They should discuss with the group leader ahead of time what the evacuation parameters are in case of a diabetic emergency (for example: two readings over 250, or one reading below 60). The two manifestations of blood sugar levels causing a potentially life-threatening condition are hypoglycemia and hyperglycemia.

HYPOGLYCEMIA (95%)
Hypoglycemia accounts for nearly 95% of all diabetic emergencies, and occurs when the body’s blood sugar levels drop too low. Though diabetics are more at risk of this, non-diabetics may suffer episodes of hypoglycemia from time to time.

If someone suddenly exhibits signs such as cool/clammy skin, a shallow, rapid pulse, and a case of the “umbles” (grumbles, mumbles, stumbles, fumbles, tumbles, etc.), they may be experiencing a hypoglycemic event. This can be caused by skipping meals, illness, strenuous activity, or too much insulin. If our blood sugar drops too low, we are at risk for coma or even death. Treat this person by administering sugar!

HYPERGLYCEMIA (5%)
Accounting for only about 5% of all diabetic emergencies, hyperglycemia has a more gradual onset. Hyperglycemia takes place when blood sugar levels are too high. Depending upon a diabetic’s normal blood sugar level, they may begin exhibiting symptoms of hyperglycemia when their sugar is 200, or it may be 600 before they show symptoms.

These patients may appear to have flushed dry skin, be restless, may appear drunk, be tachycardic (have a very fast heartbeat), have rapid breathing, and have “fruity” breath. If hyperglycemia continues unmanaged, the patient may become comatose. The treatment for this is evacuation. You do not want to administer their insulin because even the slightest overdose can be fatal. They will die faster from hypoglycemia than from hyperglycemia. Remember that!

TREATING DIABETIC EMERGENCIES
Besides using the patient’s glucometer to measure their blood glucose levels, there is no definitive way of telling the difference between hypo- and hyperglycemia. Both diabetic emergencies present themselves as a patient who is ALoR, may be having trouble breathing, is most likely combative, and may appear to be teetering on the verge of shock.

SIGNS & SYMPTOMS: DIABETIC EMERGENCIES
+ Altered Level of Responsiveness
+ Cool, clammy skin
+ Weak & shallow heart beat
+ Classic signs of shock
+ Combative behavior
+ Sweet mouth odor

We know that over 95% of all diabetic emergencies are due to low blood sugar levels, and therefore the treatment for all diabetic emergencies is the same: administer sugar. Since most diabetic related emergencies are due to low blood sugar levels, this approach should warrant you seeing a noticeable increase in their overall appearance and level of responsiveness within minutes.

If you don’t see a dramatic increase in the patient’s mental status, suspect hyperglycemia and begin planning your evacuation route immediately. Simple sugars are the best type of sugar to administer, and can be found in cake icing, pop-rocks candy, and sugar paste.

For patients showing decreased mental status, place sugar in their mouth along the gums to avoid choking. You may need to administer a significant amount of sugar to have an effect.

If you decide to use cake icing, be sure to get white icing as white isn’t a color that is easily confused with other liquids, etc. Blue icing would turn your patient’s lips blue. Are they blue now because of the icing or because they are turning cyanotic?

Illustration © Ron Leishman

There are many myths related to outdoor medicine. These need to be “debunked,” so that people do not fall prey to outdated and useless techniques. Here are some of the most common myths (in italix):

1. Mechanical suction, electric shock, and immersion in ice water are effective first aid (“field”) therapies for snakebite. In truth, these are not only not helpful, they may be quite harmful. Antivenom therapy is the only therapy that has been proven effective, with the possible exception of pressure immobilization for certain elapid (e.g., coral) snake bites.

2. Urinating on a jellyfish sting is an effective method to reduce pain. This is of very limited value. Some persons will cite that it was helpful in their particular case, but at least as many persons will state that it did not diminish the pain. The most effective therapy is decontamination with a specific topical compound, such as vinegar or ammonia. The decontaminant chosen depends upon the species of stinging jellyfish.

3. Applying a cold pack to a jellyfish sting is the most effective method to reduce the pain. Current information indicates that application of warmth (e.g., immersion in non-scalding hot water) may be much more beneficial.

4. Rabies shots are injected into the abdomen and are horribly painful. Not true- post exposure rabies vaccination may include a painful component as rabies immune globulin is injected into the bite site, but the subsequent vaccine, which is administered as part of the post exposure treatment, is given as a series of very tolerable injections into the arm or thigh.

5. In any circumstance of frostbite, rapid rewarming is essential. Actually, this should only be done if the body part can be relatively guaranteed to remain thawed. Otherwise, re-freezing the tissue causes significantly more damage than does the initial episode of freezing.

6. The Heimlich maneuver should be used for any victim of submersion (near-drowning) to remove water from the lungs and improve the chance for survival. The Heimlich maneuver has never been proven to be of use in humans in this situation, and may in fact increase the risk for vomiting and harmful inhalation of gastric contents. There is no evidence that it removes water from the lungs. 

7. Drinking large amounts of liquids is harmful during exercise because it promotes stomach cramps. Quite the opposite – so long as the ingested amounts are prudent and don’t promote nausea from a full stomach, it is essential to replace fluids and electrolytes constantly during periods of high exertion, particularly in the heat, to avoid dehydration.

8. A person struck by lightning is “electrically charged” and may not be safely touched. This is not true. It is perfectly safe to touch such a person, and in fact the sooner that breathing can be supported, the more likely that the victim will survive with maximal neurological recovery.

9. In cold water, it is better to remain in the water where one feels warm that to pull oneself onto a rescue vessel or platform and be exposed to wind chill. Absolutely not true – one may lose heat 25 times as fast in the water as in air, so no matter how uncomfortable you feel, if it is possible to get out of the water, do so. 

10. Sharks and bears are attracted to menstrual blood, so it is important for women to avoid diving and hiking during menstruation. This is a false concept, and has never been proven to be true, either epidemiologically or scientifically.

The journal Annals of Emergency Medicine publishes abstracts each year of presentations delivered at the American College of Emergency Physicians Annual Scientific Assembly, which in 2009 was held on Boston. The reference is Annals of Emergency Medicine Volume 54, Number 3, September 2009. There were a few abstracts related to outdoor medicine. Two of these were related to copperhead (Agkistrodon contortrix) snakebites.

The first abstract, by BW Anderson et al, was entitled “Coagulopathy in Pediatric Copperhead Snakebites.” In this study, the investigators sought to determine the incidence of coagulopathy (bleeding disorder in which blood clotting is altered, generally manifested by increased propensity to bleed) in copperhead bites affecting children. This study was done by reviewing charts of children bitten by venomous snakes and treated at St. Louis Children’s Hospital over a 15 year period.

The review yielded a final data set with 78 venomous snakebites, of which 18 were positively identified as copperheads, 36 were presumptively identified as copperheads and 24 were unknown. In no case did clinically apparent bleeding complications develop. The conclusion reached by the authors is that “in snakebites known with certainty to be from copperheads, it is safe to forego coagulation testing, thereby saving significant money and patient discomfort.” This may well turn out to be true, but I would like to see this conclusion confirmed by similar retrospective reviews at other medical centers that treat similar numbers of copperhead bites.

The second abstract, by NS Bhakta et al, was entitled “Copperhead (Agkistrodon Contortrix) Snakebites in the United States: 2000-2007.” In this abstract, the authors noted that bites from copperhead snakes are the second most common snake envenomations reported in the U.S. They commented that the effects from these bites, which include coagulation abnormalities, are felt to be less severe than those of other pit viper snakes. They obtained their data by contacting all U.S. poison centers (National Poison Data System). In the 7,748 total copperhead bites reported, there were 1,754 (22.6%) children under the age of 18 years.

Only one death was noted, in a 51 year old male. Only 249 (3.2%) of victims had “major” effects. From this study, the devil is in the details. Unfortunately, there are few details other than the state in which the bites occurred (80% of bites occurred in 10 states: Texas, North Carolina, Missouri, Georgia, Virginia, Kentucky, Oklahoma, Tennessee, Louisiana and West Virginia), and a general index of symptom severity. There are no details about the presence or absence of coagulopathy.

What to make of all this? The general perception that copperhead bites are less severe than those of other pit vipers, namely rattlesnakes, is no doubt true. It is also likely true that coagulopathy (propensity to bleed) is not as much of a problem with copperhead bites. However, the wise clinician will remain vigilant. I recall caring for an elderly copperhead bite victim in Tennessee who developed a coagulopathy that responded favorably (e.g., reverted to a normal situation) to administration of antivenom.

So, I believe that it can happen; however, I am in agreement with the authors that it is far less likely to happen than it would following a rattlesnake bite, and may even justify changing our current recommendations for laboratory testing. Further analyses will hopefully settle this issue. The authors of both studies are to be commended for their work.

More information about snakebites and snake safety is available in the new book, The Comprehensive Guide to Wilderness First Aid, by Clifton Castleman (www.WFAbook.com).

Since the organization was started by two Penn State alumni who are both Eagle Scouts and are still involved in the realm of wilderness and outdoor education at Penn State, we felt it appropriate to issue a brief statement regarding the recent events at the University.

We have received many inquiries and correspondance from CWS alumni, and we thank you for your support – however we feel that it is the victims and their families who deserve your support more than us. We are but a minute part of a much larger Penn State family of alumnus, and although PSU will certainly have some hard to overcome challenges over the next few years, we are certain that one day, it will be restored to its former glory.

We too, are deeply saddened by the events that have taken place recently regarding a number of prominent PSU figures regarding allegations regarding child sexual abuse and subsequent perjury allegations against those higher-up. We do not have any power over what has happened at the University, and must learn to accept the actions of the Board of Trustees, as it holds the best interest of Penn State at heart.

As we hold the ideals of hope, compassion, integrity, and honesty close to our hearts, we pray that the children and their families are safe and will recover from this incident through closure and reassurance that something like this will never happen again.

Despite the recent events surrounding Penn State University, we recognize that Penn State is far more than simply “sports”. It’s an institution of learning, and has given the opportunity to succeed to literally hundreds of thousands of its alums. We will continue to support the University in its endeavors to strive as one of the cornerstone foundations of educational excellence, and we will always be thankful for all that we learned and accomplished while at our Alma Mater.

– — –

Clifton Castleman, Executive Director, Co-Founder
Philip W. Gardner II, Program & Curriculum Director, C0-Founder

What Do They Look Like?

Named for its habit of hiding in dark corners, the brown recluse spider (Loxosceles reclusa) is also known as the violin spider or fiddleback spider because of a violin-shaped marking. The brown recluse spider is about a half-inch long (including legs) and is a solid light brown color. The violin marking is configured with the base of the violin beginning at the eyes and the neck of the violin pointing toward the “waist.” The violin marking is difficult to see clearly.

Brown Recluse spider

Two other features can help identify the brown recluse: it has six eyes rather than the typical eight and the tail-end segment has no markings. If you see a brown spider with markings on the tail end, it cannot be a brown recluse spider. Any markings, patterns or spots on the tail end of a spider immediately eliminates the possibility that it is a brown recluse spider. It is, instead, one of dozens of brown spiders that live in houses and yards. They may bite, but they are not dangerous.

Where Do They Live?

Spider experts across the US agree that the true brown recluse spider is native to Kansas, Texas, Oklahoma and Mississippi. There are many related species found in virtually all other states however, and have been spotted everywhere from the colder states like Maine and Vermont, to the Mojave and Sonoran deserts, but not in Northern California, Oregon and Washington states.

In any case, the brown recluse is called a “recluse” because it hides and is not commonly found out in the open. The brown recluse will hide in dark, moist, quiet, out-of-the-way areas where it will not easily be disturbed.

What If I’m Bitten?

In most cases of bites from these spiders, there is pain or burning at the bite site in the first 10 minutes. The bite from this group is usually described as looking like a “target” or “bull’s-eye.” The center of the wound is usually a blister surrounded by a reddened area. A pale or blanched area may surround the discolored reddened area. The blister may rupture, leaving an open ulcer. In severe cases the ulcer can become deep and infected causing tissue breakdown or tissue death (necrosis).

Worsening pain, itching and a burning sensation develop. A patient may also have symptoms such as a red, itchy rash over the torso, arms and legs that is usually seen in the first 24-72 hours. Patients may have pain in the muscles and joints, fever, chills, swollen lymph nodes, headaches, and nausea and vomiting.

Due to the necrotic nature of the brown recluse spider’s venom, a bite usually causes some pain or burning in the first 10 minutes, accompanied by itching. The wound takes on a bull’s-eye appearance, with a center blister surrounded by an angry-looking red ring and then a blanched (white) ring.

The blister breaks open, leaving an ulcer that scabs over. The ulcer can enlarge and involve underlying skin and muscle tissue which may grow for days – even with IV medications. Pain may be severe. A generalized red, itchy rash usually appears in the first 24-48 hours. Other symptoms include fever, chills, nausea, vomiting, muscle aches and hemolytic anemia (a condition where the red blood cells are destroyed).

People bitten by an unseen spider sometimes blame the brown recluse spider because their bite resembles a brown recluse spider bite. However, there are a number of other spiders and insects, as well as other medical conditions, that are capable of producing tissue wounds of similar appearance, but these are usually of a lesser severity.

What Is The Treatment?

Treatment consists of washing the wound and applying an antibiotic ointment. The victim should seek medical attention if there are signs of an infection, an ulcer that does not heal, a bite accompanied by nausea, vomiting, fever or a rash. There is no special treatment or medication used to treat a brown recluse spider bite. If infection develops, antibiotics are used. If a wound becomes deep and infected, occasionally surgery is needed. Anytime there is a bite or a wound that is not healing and getting worse, see a physician for evaluation.

While most spider bites are not dangerous, there is a group of spiders that can produce bite wounds that look similar to a brown recluse spider bite. Unless the spider was actually seen, captured and brought to the physician, the brown recluse spider is not likely to be the culprit. Some of the spiders in this group that can cause a nasty bite include the running spider, jumping spider, wolf spider, sac spider, orbweaver spider and the brown spider, also known as the hobo spider.

Frequently, when people with spider bites call Poison Control (800-222-1222) they think there is some special treatment that is necessary for their bite. There is no specialized therapy other than treating the symptoms. Most importantly, keep the wound clean to prevent infection. If the wound does not heal or does develop an infection, see your physician. Do not wait days and weeks while the wound continues to get worse.

There are tales of people having limbs amputated after spider bites. These involve people who refused to see a physician even though they had massive wounds that did not heal and became grossly infected. A wound that may have been originally treated with simple oral antibiotics, but left untreated, may require surgical intervention in extreme cases.

What Else Causes Similar Symptoms?

Kissing bugs, fleas, bed bugs, flies, mites, wasps, ants and blister beetles have produced lesions similar to a brown recluse spider bite. Many skin disorders and medical conditions can produce lesions that can also mimic a brown recluse spider bite. Some of these include infected herpes outbreaks, bedsores, diabetic ulcers, poison ivy/oak and Lyme disease. Again, use common sense: If there is a wound that is not healing as expected or getting worse, see a physician.