Emergency Medicine

It’s almost summer, and the outdoors beckons. So to be on the safe side, I consulted a few of Stanford Hospital & Clinics’ wilderness medicine experts on avoiding and treating bites and stings from a few of the potentially hazardous critters one could encounter in the Bay Area while hiking, barbecuing or taking a dip in the ocean. I also referred to the definitive tome on the subject, the more than 2,300-page Wilderness Medicine, by Stanford physician Paul Auerbach, MD.

What may have surprised me most is how a safety razor can be used in treating a jellyfish sting. As I write in my article published today:

Rinse the wound with seawater. … Remove any attached tentacles with forceps or a gloved hand. Apply a soak-compress of vinegar or isopropyl rubbing alcohol to the wound for about 30 minutes or until the pain subsides. Then apply a lather of shaving cream and shave the affected area with a safety razor to remove any remaining nematocysts.

Meanwhile, my colleague Sara Wykes has investigated another peril of the active summer lifestyle: blisters. She spoke with Stanford’s Grant Lipman, MD, one of the foremost authorities on the subject. Her article, published today, talks about avoiding and treating those uncomfortable sores, which Lipman notes affect a surprising number of people:

An estimated 10 million Americans go out hiking each year, and at least one in seven will develop the classic blister caused by friction between foot, sock and shoe. The numbers also show that the less experienced hikers are more likely to develop a blister.

Have a question about wilderness medicine or health precautions to take before enjoying the outdoors? Submit it to Auerbach this week via Twitter using the hashtag #AskSUMed. Or type it in the comments section on Scope.

Previously: Ask Stanford Med: Chief of Emergency Medicine taking questions on wilderness medicine and Stanford’s Paul Auerbach writes on treating emergencies mid-adventure

Photo by Joel Levis, MD

This summer families, nature lovers and thrill seekers will head outdoors. While many may spend hours planning camping trips, researching hiking gear or picking out the perfect sleeping bag, few are likely consider the potential health hazards that can arise on even an ordinary trip.

To help you prepare for those potential mid-adventure emergencies, we’ve enlisted Stanford Professor Paul Auerbach, MD, to respond to your questions about safety outdoors.

An expert on wilderness medicine, Auerbach is editor of the medical textbook Wilderness Medicine and author of Medicine for the Outdoors and Field Guide to Wilderness Medicine. He was a member of the Stanford medical team that provided assistance to survivors of the 2010 earthquake in Haiti, a volunteer physician at the Hospitalito Atitlan in Santiago, Guatemala, and instructor and examiner for the Nepal Ambulance Service in Kathmandu, Nepal. A founder and past president of the Wilderness Medical Society, he was named a Hero of Emergency Medicine in 2008 by the American College of Emergency Physicians.

Questions can be submitted to Auerbach by either sending a tweet that includes the hashtag #AskSUMed or posting your question in the comments section below. We’ll collect questions until Wed., June 13 at 5 pm.

When submitting questions, please abide by the following ground rules:

• Stay on topic
• Be respectful to the person answering your questions
• Be respectful to one another in submitting questions
• Do not monopolize the conversation or post the same question repeatedly
• Kindly ignore disrespectful or off topic comments
• Know that Twitter handles and/or names may be used in the responses

Auerbach will respond to a selection of the questions submitted, but not all of them, in a future entry on Scope.

Finally – and you may have already guessed this – an answer to any question submitted as part of this feature is meant to offer medical information, not medical advice. These answers are not a basis for any action or inaction, and they’re also not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and give you the appropriate care.

Previously: Stanford’s Paul Auerbach writes on treating emergencies mid-adventure, The importance of being a health-conscious traveler, Most valuable tools for physicians working in Haiti and Reports from Stanford medical team in Haiti
Photo by skyseeker

This evening, Pulitzer prize-winning journalist Sheri Fink, MD, PhD, will deliver a keynote speech at the annual Medicine and the Muse Symposium on arts, humanities and medicine.

Fink earned her doctoral and medical degrees at Stanford and won 2010 Pulitzer Prize in Investigative Reporting for her story about patients injected with lethal doses of drugs in the aftermath of Hurricane Katrina at New Orleans’ Memorial Medical Center. She recently discussed her experience reporting the story in a recent 1:2:1 podcast.

Her keynote tonight is titled “Reporting in an emergency: The complex trauma narrative in the age of the tweet.” We’ll be live tweeting Fink’s talk, which begins at 5:30 p.m. You can follow the tweets on the @SUMedicine feed or using the hashtag #medmuse.

Previously: Pulitzer Prize-winner Sheri Fink: the final hours at New Orleans Memorial

South Dakota’s Rosebud Hospital provides care to patients both on Rosebud Reservation and in surrounding areas. My recent visit to the emergency medicine department there gave me a glimpse of the successes and challenges faced by the Indian Health Service (IHS). Although IHS overcomes many hurdles to providing care, limited funding also presents it with significant challenges – and the many social determinants of health also contribute to health disparities on the reservation.

For example, because of scant resources, the hospital does not offer rapid strep testing and, as a result, strep throat was not definitively diagnosed in one patient when I was there. A physician treated a patient with a history of high blood pressure, depression, and diabetes – major health challenges on the reservation. Another resident of Rosebud noted that she was twenty-one years old and a mother of three before she received sex education.

Although I saw no alcohol-related accidents during my time there, a physician discussed the many visits resulting from accidents associated with alcohol consumption. He also discussed how alcohol use leads to motor vehicle accidents and is associated with sexual violence on the reservation.

Later in the week, two medical students observed how doctors efficiently cared for patients who were in a methamphetamine lab accident on the reservation. According to Ira Salom, MD, the chief medical officer of the IHS serving the Rosebud Sioux Tribe, methamphetamine use has also become a major problem on the reservation.

Several doctors also noted that IHS offers financial support to medical students interested in working with the service after graduation.

Amaya Cotton-Caballero is a senior at Stanford majoring in human biology. She recently visited the Rosebud Reservation in South Dakota as part of her Rural and American Indian Health Disparities class. The goal there was to learn about socioeconomic determinants of health through visits with various Indian Health Centers, community members, and tribal educational institutions. Cotto-Caballero is interested in public health and medicine.

Previously: Lessons from a reservation: South Dakota trip sheds light on a life in rural medicine

Reading about Wilderness Medicine, the new book from Stanford emergency medicine physician Paul Auerbach, MD, I wondered whether the author ever got ideas for fun outdoor adventures from the patients he sees.

A post today on Health Blog focuses on the new book and selects some of the tips Auerbach includes in the nearly 2,300-page text he penned with other contributing experts. The advice is wide-ranging and specific to each activity and climate – staying above water if your boat capsizes, staying out of the air after deep-water diving, to summarize two.

Although medical professionals are the intended first readers, and the book (also available in i-format) is rich with photos of torn limbs and festering infections, civilian appreciation runs high. Health Blog reports:

[Auerbach's] favorite compliment was from a reader who told him “artistically it is as close to a coffee-table book as exists in medicine,” and its interesting information spoke of adventure.

Previously: The importance of being a health-conscious traveler
Photo by CK | PHOTOGRAPHER

Attention hikers, skiers, campers, mountain climbers and anyone aspiring to visit Denver or Tibet: A study published today in the Annals of Emergency Medicine finds that ibuprofen may help to prevent acute mountain sickness, also known as altitude illness or hypobaropathy.

The condition often occurs when people first find themselves at altitudes of roughly 8,000 feet or higher. Symptoms feel like a “really nasty hangover,” Grant Lipman, MD, told me. The Stanford Hospital & Clinics emergency medicine physician led the double-blind, placebo-controlled study of 86 men and women, who ascended 12,570 feet into an area of the White Mountains northeast of Bishop, Calif.

In my press release about the study, I discuss some of the findings:

Of the 44 participants who received ibuprofen, 19 (43 percent) suffered symptoms of altitude sickness, whereas 29 of the 42 participants (69 percent) receiving placebo had symptoms, according to the study. In other words, ibuprofen reduced the incidence of the illness by 26 percent.

Photo by bobwitlox

For treating prolonged seizures outside a hospital setting, a quick intramuscular shot of anti-convulsant medication with an auto-injector, a kind of spring-loaded syringe, is as effective — if not more effective — than starting an intravenous line to administer the medicine directly to the bloodstream.

That’s according to findings from a first-of-its-kind study by researchers at Stanford and 16 other universities and hospitals nationwide. Their work appears in the New England Journal of Medicine.

The finding is important because giving a shot into the muscle of someone who is convulsing is generally safer and less time-consuming than starting an IV, said James Quinn, MD, a professor of emergency medicine here and a study investigator.

The intravenous route has always been considered the gold standard for treating status epilepticus in the field. But, as Quinn pointed out, “If patients are having a grand mal seizure, it can be tough to find a vein and get the medicine started, and it may increase the chance of a needle-stick injury either to the patient or medic.”

The aim of this study was to gather and compare data on the safety and efficacy of the shot, which administers midazolam, a sedative, versus the IV drip, which administers lorazepam, a similar sedative. As described in a National Institutes of Health release:

The study found that 73 percent of patients in the group receiving midazolam were seizure-free upon arrival at the hospital, compared to 63 percent of patients who received IV treatment with lorazepam.  Patients treated with midazolam were also less likely to require hospitalization than those receiving IV lorazepam.

…

[The study] involved more than 79 hospitals, 33 emergency medical services agencies, more than 4,000 paramedics and 893 patients ranging in age from several months old to 103.

An interesting, behind-the-scenes aspect aspect of the research: Because they were the first responders, roughly 250 firefighter-paramedics in Santa Clara and San Mateo Counties had to be trained on how to conduct the clinical trial. “It required tremendous coordination,” Quinn told me. “For most of the firefighters, it was the first time they had done research. They did a great job, and I am proud of the job they and our research team did in this unique endeavor.”

Photo by gregfriese

This morning StorytellERdoc shares a disheartening but fascinating account of a difficult patient in his emergency department:

“May I help you?” the nurse asked the mother.

“Yeah,” the mother answered, “my baby here got a fever two hours ago and I want her looked at. And as long as you all are looking at her, I want my son and me both looked at, too, since we’ll probably get what she got.” The nurse looked at the baby, sitting on the counter, cooing and slobbering over a lollipop given to her by her mother. The nurse felt the baby’s forehead, feeling its coolness, and reassured the mother that they would attend to her and her children as soon as possible. “We’ll get your histories and take your vital signs as soon as we take care of these people before you.”

The rest of the story is totally compelling, but it ends on a rather sad note that typifies the challenges facing EDs across the country.

A recent report from the Centers for Disease Control and Prevention found that emergency department visits are on the rise in the United States, resulting in overcrowding at some hospitals. Concerned about the infectious risks caused by emergency department crowding, and wanting to better understand the role of workers in spreading pathogens among patients, a group of researchers at Brigham and Women’s Hospital in Boston launched the largest study to date to evaluate hand hygiene of ED workers.

In the study (subscription required), researchers collected and analyzed data on more than 5,800 patient encounters in an urban, academic emergency department between January 2009 and April 2010. Study results, which appears in the November issue of Infection Control and Hospital Epidemiology, showed that appropriate hand washing practices were used 90 percent of the time. But it also identified some areas in which improvement is needed. According to a release from the Society for Healthcare Epidemiology of America:

… researchers observed providers wearing gloves during patient care instead of washing their hands, an inappropriate substitution for infection control purposes.

The study also found that workers who transport patients between hospital departments and rooms were less likely to wash their hands compared to other healthcare workers. This may be because these workers receive less training in hand hygiene procedures than other workers.

Study authors say they hope the findings spur additional research on hand washing compliance in emergency departments, which are visited by nearly 124 million Americans visit annually.

Previously: Good advice from Washyourhandsington, Hey, health workers: Washing your hands is good for your patients, Clean hands save lives and Everything you ever wanted to know about hand hygiene
Photo by James Emery

Grant Lipman, MD, recently provided medical aid to 10 people living like cavemen in near-Paleolithic conditions – an area of the Rockies three hours by car and all-terrain vehicle from Steamboat Springs, Colo.

Lipman was serving as medical director for the production of “I, Caveman,” a kind of reality TV show that is airing at 8 p.m. Sunday, Oct. 2, as part of the Discovery Channel’s Curiosity series.

“We wanted to ask, ‘Were people better off as cavemen?’ How would our lives work without all the material stuff we depend on today?” Alan Eyres, an executive producer at the Discovery Channel, told me in a phone interview about the show.

I describe Lipman’s role in the production in my press release:

As an expert in wilderness medicine, he was particularly well suited for the job of treating members of a 10-person clan – six men and four women – who hunted with stone weapons and wore animal skins last summer in a remote patch of wilderness in the Southern Rocky Mountains.

And Lipman got plenty of opportunities to use his particular skills:

In one case, the most skilled hunter in the group badly cut his hand – his throwing hand, for that matter – while fashioning an obsidian spear tip. The cut got infected, and Lipman had to intervene with some antibiotics. Others suffered from mild hypothermia, altitude sickness and, in one case, acute bronchitis, which he closely monitored. “It could have led to high altitude pulmonary edema” – a life threatening condition in which fluid builds up in the lungs, he said. In another case, a cavewoman partially dislocated a rib, which he had to realign.

“Even though my patients were cavemen, they got the highest standard of modern medical care,” he said.

Lipman also treated production crew members, some of whom suffered from mild hypothermia, altitude sickness, twisted ankles and leech wounds.

Photo by Lord Jim