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Alternative HealthWhat's In Your Kit?By Tim Platts-MillsThe ideal expedition medical kit would weigh nothing yet contain everything found in a well-stocked Emergency Department. But Emergency Departments are heavy, and finding a balance between the Ray Jardine (the "light is right" backpacking guru) approach and the Carolinas MED-1 truck is not simple. Although no "best" medical kit exists, once trip length and participants reach a critical mass, some key items need to come along. This article describes 40 of the most useful medicines and supplies to bring into the backcountry and presents principles that apply to both small and large expedition medical care. A recommended reading list is provided for those wanting to learn more. Preparation, Organization, and Communication Although not part of the kit, these represent the surest and lightest way to stay healthy. Study the area you're traveling to, learn about the problems others have encountered, and anticipate the injuries and illnesses you will have to treat. If trekking in the tropics, review the CDC recommendations for vaccinations and malaria prophylaxis. Identify team members' medical problems and substance dependencies and be prepared to address them. Encourage team members to ready themselves physically. Wilderness medical problems often stem from failures in leadership and communication; a fancy medical kit is not a substitute for either. Teams should have clearly defined objectives and agreed upon alternative plans if hazardous weather or illness occurs. Although you may travel sans cell phone, they're now a standard safety device for U.S. backcountry travel. Outside the U.S., satellite phones may be appropriate. Waterproof paper and pencil weigh little and can be critical when trying to find a lost team member or recruit help for a search and rescue party. Foot Care and Skin Care Unless you are sea kayaking or orbiting Mars, you will be on your feet, and eventually they will hurt. Ask team members to tell you immediately if they have any foot discomfort. I drain blisters with a small incision, cover them with cyanoacrylate tissue adhesive (Dermabond), cover the dried adhesive with mole skin, cover the mole skin with duct tape, and put Vaseline over the duct tape to decrease friction between the foot and the footwear. There are lots of other ways to do this, but you need a plan. A petroleum-based antibiotic ointment serves as a lubricant and is useful for the treatment of superficial skin infections. Essential in most environments Ð sunscreen, lip protection, and sunglasses. At altitude, at sea, and on snow an extra pair of sunglasses for every two team members is recommended. Respiratory Problems Epinephrine is an essential medication because of its role in anaphylaxis treatment. The recommended dose for adults is 0.3 mg (0.3 ml of 1:1000) intramuscularly. The EpiPen can deliver this dose, but it's bulky, painful when injected, and only provides a single dose. An alternative — bring a 1 mL vial of 1:1000 epinephrine (3 doses). Pack albuterol inhalers to treat asthma and bronchospasm associated with cold, altitude, or respiratory illness. Intramuscular epinephrine may be used for the treatment of severe asthma. Asthmatics should continue their routine medications and carry a burst dose of oral prednisone, typically 60 mg for 5 days. A 7-day course of levofloxacin (Levaquin) 500 mg is appropriate treatment for those with fever and respiratory complaints consistent with pneumonia. Oxymetazoline nasal spray (Afrin) and a non-sedating antihistamine with pseudoephedrine such as Claritin-D treat congestion. Oxymetazoline applied to a small piece of cotton wool or tissue paper also serves as anterior packing for nose bleeds. Throat lozenges quiet coughs and are particularly appreciated at high-altitude and in cold environments. Altitude Illnesses Altitude illness treatment depends on three drugs. Acetazolamide (Diamox) 250 mg orally twice a day both prevents and treats acute mountain sickness. Dexamethasone (Decadron) 8 mg intramuscularly followed by 4 mg injections every 6 hours treats high altitude cerebral edema. Oral prednisone is an acceptable dexamethasone substitute, but an injectable steroid is preferable due to altered mental status and vomiting in many with cerebral edema. Nifedipine (Procardia) 10-20 mg orally every 6 hours is the drug of choice for high altitude pulmonary edema. Supplemental oxygen should also be given if available. Wounds The key to wound care in the backcountry is cleansing and hemostasis. Use clear flowing water to wash wounds initially; the bacterial concentrations are likely to be lower than on the skin. Thereafter, a plastic water bottle with a hole or a 20 ml syringe with an 18-gauge needle can be used for high-pressure irrigation. Wound closure prevents further contamination and controls bleeding, but is usually not essential and is inappropriate for puncture or dirty wounds. An Ace wrap works well as a compression bandage and keeps the wound clean. Tissue adhesive closes small cuts. A skin stapler or suture kit may be appropriate. Reasonable choices for suture are 3-0 and 4-0 vicryl and 4-0 and 5-0 nylon. Several 0-silk sutures are useful for the repair of backpack straps and tents. A sharp-tipped knife aids in splinter removal. Treat infected wounds or those with crushed tissue, gross contamination, or exposed tendon or bone with cephalexin (Keflex) 500 mg every 6 hours. Fashion splints out of insulation pads and duct tape. Abdominal Complaints There are a few bad belly problems common enough to consider that cannot be definitively addressed in the backcountry. Abdominal pain and fever, not obviously due to gastroenteritis, requires antibiotics and evacuation. Levofloxacin 500 mg once a day and metronidazole (Flagyl) 500 mg four times a day are appropriate. Pregnant trekkers with abdominal pain also require evacuation; bring a urine pregnancy test. Both urinary infections and traveler's diarrhea can be treated with levofloxacin. For symptomatic treatment of gastrointestinal complaints bring prochlorperazine (Compazine) 25 mg suppositories, antacid pills, doacusate sodium (Colace), bismuth subsalicylate (Pepto-Bismol), loperamide (Imodium), and hydrocortisone hemorrhoid cream (Anusol HC). Analgesia and Central Nervous System Treatments Traveling solo, you might forgo pain medications, but if you're responsible for an expedition you need to have options. Ibuprofen (Motrin) 600 mg tabs and oxycodone and acetaminophen (Percocet) 5/325 mg tabs will cover most situations. Use intramuscular morphine for those with major injuries. Remember, large narcotic doses cause respiratory depression. Injectable lorazepam (Ativan) treats seizures, agitation, and alcohol withdrawal, and works synergistically with oxycodone and morphine to control pain. Caffeine 200 mg tabs are useful for caffeine withdrawal headaches and during long drives or prolonged rescues, but are unnecessary if you have coffee. Miscellaneous Fluconazole (Diflucan) 150 mg orally treats vaginal candidiasis and athlete's foot. Insect repellent containing DEET repels flies and mosquitoes. A mixture such as Cavit is useful for filling cavities. Ciprofloxacin ophthalmic drops (Ciloxan) treats bacterial infections of the eye and corneal ulcers associated with contact lens use. When traveling with older individuals, carry aspirin 325 mg tabs to treat chest pain. Nitroglycerine and furosemide (Lasix) tabs should be brought for patients with congestive heart failure and are important in the treatment of severe high-altitude pulmonary edema. Intravenous start kits, intravenous fluids, tube thoracostomy equipment, and advanced airway equipment may be appropriate for large groups with a base camp. Recommended Reading 1. Wilkerson JA. Medicine for Mountaineering and Other Wilderness Activities, 5th ed. Seattle WA: The Mountaineers Books; 2001. 2. Zell SC, Goodman PH. Wilderness preparation, equipment, and medical supplies. In: Auerbach PS, ed. Wilderness Medicine, 4th ed. Philadelphia, PA: Elsevier Inc; 2001:1662-1685. 3. Lentz M et al. Mountaineering First Aid, 4th ed. Seattle WA: The Mountaineers Books; 1996. 4. Vonhof J. Fixing Your Feet, 2nd ed. Manteca, CA: Footwork Publications; 2001. 5. Forgey WW. Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care. Old Saybrook, CT: The Globe Pequot Press; 1995. Tim Platts-Mills is a senior resident in Emergency Medicine in Fresno, California. He thanks Dr. Michael Burg for assistance in preparing this article and Dr. Matt Lewin for insights into providing medical care in remote settings. Reprinted with permission, Wilderness Medicine Magazine, Volume 24, Number 2 Spring 2007
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