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Go to “My Library” } Enhanced images with annotations, labels, and hot spots for zooming on specific details * } Live streaming video and animations * } Self-assessment tools such as questions embedded within the text and multiple-format quizzes * * some features vary by title Use of the current edition of the electronic version of this book (eBook) is subject to the terms of the nontransferable, limited license granted on ExpertConsult.com. Access to the eBook is limited to the first individual who redeems the PIN, located on the inside cover of this book, at ExpertConsult.com and may not be transferred to another party by resale, lending, or other means. For technical assistance: Email: “Most frst aid books describe a condition and sometimes advise simple frst aid measures, but ultimately end up with the admonition to ‘seek medical attention.’ Tis is safe advice when a clinic or hospital or ambulance is right around the corner. But what about when you’re on the adventure of a lifetime—in the wilds of Mongolia or the mountains of Tibet or several days out to sea? ‘Seek medical advice’ helps not a bit. In these situations, there is no better resource (including having a direct line to your hospital ER) than Medicine for the Outdoors. Dr. Paul Auerbach is to wilderness medicine what Bill Gates is to computers; he is the source, and so this book is a treasure trove of information not only for untrained laypeople but for most physicians. Tere is no more understand- able or complete collection of information on what to do for anything that might befall an adventure traveler—from high altitude cerebral edema to soapfsh dermatitis to cougar attack to how to stitch a laceration. Even better, Medicine for the Outdoors provides essential guidance in advance of an adventure to help with planning and prevention—from immunizations to equipment and clothing to dietary precautions. Te handy appendices include a drug reference, conversion tables, and def- nitions of common medical terms. Contemplating an adventure? Te old adage ‘Seek medical attention’ has been replaced with ‘Get Medicine for the Outdoors.’ ” Luanne Freer, MD, FACEP, FAWM, Past President, Wilderness Medical Society; Medical Director, Yellowstone National Park; Founder/Director, Everest ER, Nepal “Tis book has the information you need to prevent, recognize and treat medical emergencies in any environment. Primarily a medical guide for outdoor, wilderness and remote areas, it is also an excellent reference for home and disaster situations. Most importantly, it is written by one of the foremost experts in this feld, so you can trust this information.” Howard Backer, MD, MPH, FACEP, Director, California Emergency Medical Services Authority “Te sixth edition of Medicine for the Outdoors is more impressive and indispensable than ever. Te uncomplicated clear writing and illustrations are delightfully easy to understand, and the book is remarkably thorough and superbly detailed. I highly recommend it to anyone who is serious about working and playing in the outdoors.” Donald C. Cooper, PhD, MBA, Editor, Fundamentals of Search and Rescue; Chair, National Fire Protection Association Technical Search and Rescue Committee “When a crisis occurs in the backcountry, punching in 911 may not even get you a dial tone—you’re on your own. Tis book is your wilderness 911. Take the time to read it and know the principles of care provided within it. Medicine for the Outdoors just might save your life.” Frank Hubbell, DO, Founder of Stonehearth Open Learning Opportunities (SOLO); President, New Hampshire Osteopathic Association; Member, New Hampshire Medical Control Board; Director, Conway Walk-In Clinic “Students with a broad range of experience take wilderness medicine courses. It’s not easy to fnd a comprehensive text that accommodates all their needs. Medicine for the Outdoors engages the non-professional while keeping the most seasoned provider informed in the latest techniques for backcountry medical practice. Dr. Auerbach has written another book that is a gold standard for anyone with an interest in health and safety outdoors.” William Fred Baty, WEMT-P, Retired Fire Chief, City of Knoxville Fire Department; Lead Wilderness Medicine Instructor, Te Wilderness Medicine Program, Roane State Community College, Knoxville, Tennessee “Tis manual contains a wealth of succinct, up-to-date, and practical advice. It is an indispensable medical guide for wilderness enthusiasts and health professionals.” Kent R. Olson, MD, Clinical Professor, UCB-UCSF Joint Medical Program; Clinical Professor of Medicine & Pharmacy, UCSF; Medical Director, San Francisco Poison Control System “You always hope for the best and plan for the worst. Being well prepared for the unexpected in the wilderness is greatly enhanced by our ‘survival bible,’ namely, Medicine for the Outdoors. Our guides, trip leaders, and clients never adventure without this well-written and easy-to-understand book, and we invariably beneft from it. Te common sense approach and complete coverage have helped us mitigate situations and avoid greater emergencies. In all reaches of the globe, with Medi- cine for the Outdoors, we’re much closer to defnitive care.” Laurence Alvarez-Roos, Co-founder, Bio Bio Expeditions World Wide “Auerbach’s Medicine for the Outdoors continues to serve as an ideal portable reference. Whether you are in the front country, exploring tropical reefs, or trekking at high altitude, Medicine for the Outdoors rapidly guides to solutions for the most important medical problems. I strongly recom- mend this reference as a primary source for laypersons as well as a supplement for individuals with advanced wilderness medicine training.” Brad L. Bennett, PhD, NREMT-P, FAWM, Captain, US Navy (Retired); Adjunct Faculty, Military and Emergency Medicine Department, Uniformed Services University of the Health Sciences; President, Wilderness Medical Society “Traveling in the wilderness or abroad can be punctuated by unexpected illness or injury. If you plan to travel where medical care is not readily available, Medicine for the Outdoors is the resource you want to have with you. Dr. Auerbach, one of the foremost experts on wilderness medicine, covers topics from basic frst aid to major medical illnesses, trauma, medications, and medical kits. Medicine for the Outdoors provides knowledge that can help you survive until further assistance is available.” Albert R. Wheeler III, MD, Emergency Medicine of Jackson Hole; Medical Director, Grand Teton National Park EMS; Medical Director, Teton County Search and Rescue “From frst aid for minor wounds to treating altitude sickness, from poisonous mushrooms to haz- ardous aquatic life, Medicine for the Outdoors covers all the information an adventurer might need for emergency care in the wilderness. My previous editions are well-read and dog-eared. Auerbach’s book is a must-read on any explorer’s list.” Bill Clendenen, CEO, Health & Safety Institute “Marine research takes me to remote corners of the globe, ofen distant from immediate rescue and medical care. Medicine for the Outdoors is packed as an essential item along with oxygen and frst aid kit should my diving team need emergency feld care. It is by far the most comprehensive, well-written and useful reference available—a must-have for remote feld work.” Dr. Michael A. Lang, Senior Vice President, OxyHeal Health Group; Adjunct Faculty, UC San Diego– Emergency Medicine “Curiosity entices us to places on this planet where there are neither 911 nor emergency rooms. Whether we hike in a forest, climb along the frozen edge of a mountain top, trek deep within a rainforest, or dive in the rich waters of a coral reef, the most valuable asset to that trip is emergency preparedness. In my travels around the globe, I have seen frst-hand the life-saving value of proper frst aid. Paul Auerbach’s encyclopedic knowledge, vision, advice and instructions ofer priceless preparation for that moment we hope never comes. Paul’s sixth edition of Medicine for the Out- doors is an essential read before any expedition, and should be the frst item to go into the gear bag.” David Doubilet, Contributing Photographer, National Geographic Magazine MEDICINE FOR THE OUTDOORS THE ESSENTIAL GUIDE TO FIRST AID AND MEDICAL EMERGENCIES th 6 EDITION PAUL S. AUERBACH, MD, MS, FACEP, FAWM Redlich Family Professor of Surgery Division of Emergency Medicine Department of Surgery Stanford University School of Medicine Stanford, California 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 MEDICINE FOR THE OUTDOORS, SIXTH EDITION ISBN: 978-0-323-32168-6 Copyright © 2016 by Elsevier, Inc. All rights reserved. Copyright © 2009 by Mosby, Inc., an afliate of Elsevier Inc. Cover photos by Mathias Schar, MD. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. Tis book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this feld are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identifed, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Copyright © 2003 by Paul S. Auerbach Library of Congress Cataloging-in-Publication Data Auerbach, Paul S. Medicine for the outdoors : the essential guide to frst aid and medical emergencies / Paul S. Auerbach, MD, MS, FACEP, FAWM, Redlich Family Professor of Surgery, Division of Emergency Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, California.—Sixth edition. pages cm Includes index. ISBN 978-0-323-32168-6 (pbk. : alk. paper) 1. Outdoor medical emergencies. 2. First aid in illness and injury. I. Title. RC88.9.O95A94 2016 616.02’52—dc23 2014047120 Executive Content Strategist: Kate Dimock Content Development Manager: Lucia Gunzel Content Development Specialist: Gabriela Benner Publishing Services Manager: Catherine Jackson Project Manager: Rhoda (Bontrager) Howell Design Direction: Amy Buxton Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 PREFACE Te outdoor environment is miraculous, but it is ever-changing and can become hostile in a moment. Good fortune favors the well prepared, and there are no more important considerations for a successful outdoor experience than safety and frst aid. Severe weather, rugged terrain, wild animals, and equipment failure all conspire to create or complicate medical hardships that must be diagnosed swifly and remedied with certainty. Te therapies can be integral to survival. Medical education is thus as compelling as any other category of learning. Tis revised sixth edition of Medicine for the Outdoors has been thoroughly updated and rewritten based on advances in medical knowledge, suggestions from readers, and reviews of the previous edition. I am indebted to my family, professional colleagues, and friends, who always support me in my medical activities and writing endeavors. Brian, Lauren, and Danny share the outdoor spirit and have each put this book to good use. As always, Medicine for the Outdoors is dedicated to all the wonderful people who have given generously of their time to the Wilderness Medical Society and other reputable organizations, and thereby advanced the specialty of wilderness medicine. With as much efort as we seek to maintain our personal well-being, let each of us seek to maintain the wilderness. It is my fervent hope that we can approach preservation of planet Earth with the same passion that we devote to our vital medical missions; for without the wilderness, there can be no wilderness medicine. Paul S. Auerbach, MD Spring, 2015 v This page intentionally left blank INTRODUCTION Te purpose of this book is to provide you with brief explanations of a wide variety of medical problems and to ofer practical solutions. Medicine for the Outdoors is arranged to make infor- mation easy to retrieve. Part One outlines basic principles of health care that should be applied to all outdoor travel. Parts Two and Tree describe medical situations, beginning with life threats and covering, in turn, major and minor medical problems you might encounter. Part Four discusses disorders related to various wilderness settings from both medical and safety perspec- tives. Part Five covers additional practical information, such as evacuation guidelines and techniques, water disinfection, useful knots and hitches, drug injection techniques, and recom- mendations for immunization. Appendix One lists medications and doses, with an emphasis on medications mentioned elsewhere in the book. Conversion tables for common measurements are found in Appendix Two. Appendix Tree outlines guidelines for prevention of hepatitis, acquired immunodefciency syndrome (AIDS), and other diseases transmitted by human body fuids. Appendix Four describes and illustrates commonly used applications of the SAM Splint. Appendix Five ofers advice about personal safety in an age of global confict, kidnapping, and terrorism. Appendix Six is a brief description of emergency canine medicine. Te glossary defnes medical and technical terms. Te index will guide you swifly to any topic. To keep the book to a manageable size, I assume that you have a basic understanding of how your body works. Tus, explanations are brief and to the point. Tis is neither a survival manual nor an outdoor sports medicine encyclopedia. Rather, the book is meant to be carried on a journey as a ready reference for a layperson who needs to medically rescue or aid an ill or injured victim. I have included information that is necessary to make simple, accurate diagnoses and to act on them. Tis book does not transform a layperson into a physician, but we all recognize that there are times when medical help is miles or even days away. No intervention is completely without risk; however, some familiarity with diseases and injuries can minimize that risk. Although some of the techniques and drugs described could worsen a situation if misapplied or incorrectly administered, the treatments presented are current and well accepted. Still, the recommendations should not be considered substitutes for prompt evaluation by a trained medical professional. If at any time a diagnosis is uncertain, or a victim appears to be more than minimally ill, all eforts should be directed at seeking a professional medical opinion. Te basic therapies recommended do not include all those that could be rendered by a physi- cian with advanced equipment and a large armamentarium of drugs. I have not described every infectious or tropical disease that could possibly be contracted during a journey abroad. However, the diagnosis and management of illnesses such as schistosomiasis, malaria, Lyme disease, ana- plasmosis, Ebola virus disease, yellow fever, dengue fever, West Nile viral disease, and Rocky Mountain spotted fever are relevant to many people who travel domestically and overseas in wilderness areas, and have therefore been included. Because we live in an age of biohazards, information has been added to include a few of these entities, such as anthrax. In addition to “Western medicine,” there exists “complementary and alternative” (from the Western perspective) medicine, sometimes referred to as “naturopathic” medicine. While many of the recommendations of naturopathic doctors are appropriate and efective, I personally do not have the expertise upon which to make such recommendations. However, in a wilderness setting, and certainly when being treated by healers in non-Western countries, you may wish to be the benefciary of such remedies. If so, you will need to perform your own validation of remedies, such as Melaleuca alternifolia (tea tree) oil as a topic antiseptic or anti-itch preparation. vii viii Introduction To use this or any medical reference to best advantage, review the pertinent sections before your expedition. Practice the manual skills, such as the application of splints and slings, until you are confdent. I have also provided information that is as important as medical knowledge. Tis includes such topics as how to avoid being struck by lightning, drowning prevention, and what to do if you fall through the ice or are caught in a food zone or near a forest fre. I hope that you are enlightened, and that good luck prevails.