Saturday, January 23, 2010

Hypothermia: Jack Frost's idea of a Sick Joke, the Beastard

The start of 2010 brings with it streamers, noisemakers, happy people singing, and a busload of freaking-cold weather.

We look outside and see that pretty white stuff glistening in what could barely be deemed sunshine, and we think, 'wow, it would be so much fun just to roll around in that making angel figures because I want to freeze my butt off.'

See that's what the snow wants you to think. It's sending out subliminal messages: "Play in me, I'm soft and fluffy. You'll love it. Don't mind the frozen extremities; they'll grow back." It's evil, I tell you. Pure evil!

So, knowing this, you do what any sane person would do: You take the sled out with the kids and get completely iced over. At the same time, Jack Frost is waiting out there, stalking your noses like a polar bear does a herd of seals.

In a perfect world, we'd have built in heating pads. Okay in a perfect world, we'd all have killer bodies and own mansions. But we're not in a perfect world: we're in a world of chapped lips, runny noses, and frostbite. Yes, as you can see, I am a-cup-is-half-full-kind-of-girl. The chapped lips thing is making me bitter. ;)

I'm going to plug a very good book at this point, and the sad thing is that the authors aren't paying me a lick of doe for it. I know, I know, you're feeling great sympathy for my plight. Thank you, I appreciate every tear on my behalf. :)

In all seriousness, Hypothermia, Frostbite, and Other Cold Injuries: Prevention, Survival, Rescue, and Treatment by Gordon G. Giesbrecht, Ph.D. and James A. Wilkerson, M.D. (www.mountaineersbooks.org) is a very good book for this time of year, especially if you have children.

My brother has seven kids, which includes two sets of twins. Can you ever imagine wrangling two 2 years and two infant babies at the same time? He and his wife have got their hands full. One afternoon their eight year old girl came home crying of her feet being so cold they were numb. So as any knowing parent would, my brother said, "Well, if your toes fall off, you'll remember that I told you to come straight home and not to play out in the snow."

Let's talk about numb toes and red noses, or in other words, hypothermia: The cold's and water's evil love-child.

Just in case you were wondering: "Hypo" means under and "thermia" is Greek for heat or temperature. (I feel like that father on My Big Fat Greek Wedding; "Show me a word, any word and I will show you the Greek root of the word.")

Hypothermia occurs when the body's core temperature drops below 35 degrees Celsius or 95 degrees Fahrenheit. That's not a lot of leeway considering the normal human body temperature is around 37 degrees C (98.5 degrees F).

You see our bodies are stubborn: they hate change. Any change and they decide to shut down. It's like some sort of mutiny. "You wanna drop my temp a couple of degrees, huh? Well, I'll show you!" It's like a living Union.

Truth be told, in acclimated populations, the human physiology has incredible mechanisms that tolerate severe cold. For instance, the aboriginals of Australia can easily sleep on frozen ground without shivering. (See Giesbrecht and Wikerson's book) The women of Tiera del Fuego can breast feed during a blizzard without discomfort. Inuit men can easily work with their bare hands in sub-freezing temperatures for extended periods of time. Well, good for them. Let's give them a medal. As for the rest of us, we have a hard time adjusting to falling temperatures. Hence, we develop hypothermia

The worst part about it is that we are bull-headed enough that during the first stage of hypothermia that we deny the fact that we even are cold. Then we get irritable if anyone dares suggest that we bundle up or put on gloves. Yes, it's true. One good dose of hypothermia and we become like the Exorcist. Our heads start spinning, and we smack-talk to anyone trying to help us.

For instance, just the drop of 1 degree C in core temperature causes impaired judgment and slows our reaction time by half. If our temperature falls below 35 degrees C, then we lose the ability to make rational decisions. We become, well... like mean drunks. I can just see the TV ads now: "Friends don't let friends drive under the influence of hypothermia." Or the support groups: "My name is Joe and I am a hypothermic."

Temperature drops below 32 degrees and our only innate heating system of shivering stops. At that point, we are two steps away from laying down and becoming a human icicle.

Here's a question for all the parents out there: Who tends to get hypothermia worse, you or your kidlets? Unfortunately, the kidlets do. Actually, babies, children, and elderly are most at risk. But for the purposes of this post, we'll focus on children, since the elderly are more likely to stay indoors during this time of year. They don't seem to find the joy in freezing their butts off. Go figure.

Anyone remember the little brother on "A Christmas story" being bundled up to look like the Michelin man? Now that mother was smart, she knew about this kid-care fact. Forget about her child's social life, she prevented his hypothermia.

Okay, so maybe she went overboard. I mean really look at him, the boy looks like he can barely waddle. That's a sure ticket to getting your kid beat up. And then you'll have to deal with taking care of broken bones and bloody noses... but that is a totally different blog.

Now, we don't have to go to that much of an extreme. But we can take into consideration that the manifestations of hypothermia in children don't present in the same manner as in adults. Due to this fact, hypo- and hyperthermia are very common ailments in children.

All on their own, children are interesting little rug rats. Just like my brother's little girl, kids get so engrossed in playing that they tend to forget they even have bodies. Whereas an adult would say, "Heck with this, I'm cold. I'm going inside." A child would say, "What those are fingers turning into ice chunks? Who cares, just one more turn on the sled."

In addition to that, children lose heat more quickly than adults do, mostly through their head. And you wondered if they stored anything up there at all.

You know, I was studying the causes of hypothermia in children and one of the most common causes was alcohol ingestion.

Now, I just want to know: Who goes about giving alcohol to kids? "Hey, Billy, I know you are five, but I think it's high time that you start drinking if you want to fit into with the rest of Mickey's club house." What the heck?!

Granted, the ingestion of alcohol could be due to taking OTC cold medicines like Nyquil, but who in their right mind would send a kid with a head cold out and doped up on medicine into the snow?

(Just FYI, alcohol causes vasodilation of blood vessels, preventing the body's natural defense against hypothermia of shunting blood away from the extremities and skin.)

Anyway, I'll step off my soap box and get back to this post.

Other common reasons why children are more susceptible to getting hypothermia than adults:

*Children have smaller body masses, relative to their surface areas, leading to increased heat loss.

*Children have limited glycogen stores to support increased heat production in response to cold.

*Very young infants don't have the ability to increase body heat through shivering.

Also, once children develop hypothermia, they are less likely to turn into mean drunks like adults do, despite having more severe hypothermia.

The following is a list of things which you can do to prevent hypothermia when outdoors:

-Use a weatherproof outer layer. In sub-freezing temperatures, use a breathable nylon fabrics with an insulating layer of fiberfill like Lamilite.

-Avoid Cotton. Wool base layers are essential, and most importantly avoid wearing cotton under clothes.

-Don't over layer. When playing or working, people sweat. I know, I know: it's hard to believe, but the little sweat fairies wave their magic wands over your pits and boom! Beautiful, glistening, saline comes oozing out of your pores.

Now, what happens is that people get hot under too many layers while playing or working, so they sweat. Then, they unzip the layers and the sweat evaporates, cooling them down. They zip their layers back up. Yet, they still are damp underneath and thereby their core temperature drops even more, and pretty soon, they are hypothermics.

-Instead, layer when not active. When you are working or playing, wear only enough layers so that you're a little cold. When you sit down to rest, add on more layers. When you get back up to play, remove the extra layers.

-Items to Bring. Hat (extremely important). Gloves. Bandanna or hankerchief. Extra socks.

-Stay Dry. Don't get wet inside your clothes or outside your clothes.

-Eat high energy snacks. Snickers bars do come in handy. ;). Actually, eating things like granola and apples can help a lot.

Next time, the clinical manifestations of hypothermia will be discussed and how to treat it.



Here are the links of the day:

http://www.osteopathic.org/index.cfm?PageID=you_frostbite This link is for information on how to fight frostbite.

http://www.emergency.cdc.gov/disasters/winter/staysafe/hypothermia.asp

http://www.nia.nih.gov/HealthInformation/Publications/hypothermia.htm

http://www.outdoors.org/recreation/hiking/hiking-hypothermia.cfm

Thursday, January 21, 2010

Incoming: Eminent Delivery, Part 1

::::::WARNING: Due to the graphic nature of some of the images and videos of, there is some medical and anatomical details that may be not appropriate for children.:::::::::::

Then again, if you're a medical crazy person like me than you wouldn't mind your children learning this kind of stuff. (Image taken from www.babybumpdiaries.com)

Alright, here we go. Get out your full body armor, because we're about to take on blood bath.

Actually, the process of birth can be a quite beautiful thing. This is where women come as close to what it feels like bring life into this world. It's the great blessing from the Lord that allows us a chance to take part in creation. I say epidurals are great blessings too, but that's just me.

The first thing you must remember is to: STAY CALM and DON'T PANIC!

You may think it's funny, but I've seen grown men faint at the thought of their wives going into labor. You wouldn't beleive how many unconscious fathers that I have had to scrape up off the hospital floor.

The next thing to do is to get a birthing area set up. The area has to be level and flat, with lots of light and warmth. Believe it or not, but the baby, just after being born, is bare-butt-naked and wet. It's kind of like being a nudist in Florida and immediately being transported to the arctic circle for the little tikes.

Don on barrier gloves (preferably sterile), goggles, and gown.

Next take the chuk from your birthing kit, and place it under the mother's pelvis with the cotton-side up. remember cotton-side up.

When the mother looks at you like you're insane and yells, "What the heck are you doing?!" (Note: women in labor are less likely to censor their words.)

You can calmly say, "Don't worry, mam; I know what I'm doing: I read a blog."

Now as for the positioning of the mother, I have provided a video clip of a vaginal birth for you to have an idea of how things should be during the delivery.

Graphic Childbirth video



The following steps are to be considered during heavy labor:

1. Breathing. Yes you should breathe, but actually it is important to breathe. Have the mother take deep breaths, concentrating on her breathing when she is inbetween contractions.

2. Crowning. The baby's head appearing at the vaginal opening is known as crowning. At this point during contractions, instruct the mother to push, while two assistants push her bent knees back at her chest. (Having assistants push the mother's knees back towards her, opens up the mother's pelvis making delivery easier.) The mother should NOT push in between contractions.

Instruct the mother to take a deep breath and hold it for at least ten seconds while she pushes. The idea of pushing is similar to that of bearing down to go to the bathroom... I know the guys can relate to this one. They have their newspaper and spend hours bearing down.

Warning: because the mother is pushing, most times the baby is not all that is 'delivered', so don't be surprised if a bowel movement precedes the baby's delivery. Just place another chuk or towel over the feces and continue with the birth.

3. Assist the head. Place your hand against the area below the vaginal opening and gently apply pressure during each contraction.

I had an OB preceptor that liked to used his knuckle here and dig in hard, because he could get his knuckle under the baby's chin through the perineal tissue. But since emergent deliveries are natural (non-epidural) deliveries, I highly suggest that you gently place your palm there... that is, if you want to live.

4. Appearance of entire head. As the baby's head is being delivered, gently support it with your hands. The baby's head, in most deliveries will appear chin down, then as the body turns to reconstitute, so that the shoulders can deliver, the baby's head will then turn to the side.

As soon as the head is out, tell the mother to stop pushing. Because at this point, you need to clean out the baby's nose and mouth.

5. Cleaning out the mouth and nose. The bulb syringe in your kit is essential for this step. Suction out the baby's mouth then nose. Use a clean towel if no syringe is available. (Images and videos taken from: Bookside press)

video

6. Nuchal Cord. If the umbilical cord is wrapped around the baby's neck, DO NOT attempt to cut the cord. Instead, place a finger under the cord to slip it off over the head.

If the cord will not slip over the baby's head, keep a couple fingers bracing it from tightening further around the baby's neck during delivery.

Normally, OBs cut and clamp the cord, but it takes experience to be able to effectively perform it. So I would highly suggest avoiding cutting the cord at this point in the delivery.

7. Head is delivered. The rest of the body should deliver with ease. Some baby's are with such ease that they literally slip out, others have broader shoulders and take some work.

The upper shoulder should present first, help it along by guiding the baby's head downward while the mother pushes. Once the top shoulder has delivered, then help guide the baby's head up when the mother pushes. (And I seriously mean guide, not pull on.) Then the bottom shoulder will deliver and then all baby's pop out at this point. So be prepared to catch.

8. Baby is out. Wrap the baby in a clean, dry and preferably warm towel or blanket. The baby should cry. Then place the baby on the mother's stomach.

If the baby doesn't cry or isn't breathing, keep the baby at the level of the mother's vagina. Place the baby's head lower than its feet. Stimulate the baby by rubbing its back. If still not breathing, give two quick gentle puffs of air into the infant's nose and mouth.

(Further resuscitation measures, should be left for a different discussion.)

Once baby is crying and breathing, place baby on mother's stomach. Skin to skin is the best.

DO NOT pull on the umbilical cord.

9. Cutting the cord. There should be two plastic, sterile clamps in your OB kit, or two kelly clamps. If you don't have either available then tie a clean shoelace or thick string, firmly around the umbilical cord, no closer than 4 inches from the baby's navel. (DO NOT use thread: it will cut through the cord.)

Tie another shoelace or thick string a few inches away from the first tie towards the mother's side of the umbilical cord. Make sure that both ties are secure, then using a sterile pair of scissors or scalpel cut the cord in between the ties.
video

10. Placenta. The placenta normally delivers itself. Usually a gentle kneading on the mother's belly helps the process, but I am going to leave the details of delivering the placenta to the following video. As for after the placenta is delivered, place it in an airtight container to take to the hospital with the mother.

video

11. Clean up. Gently (and I mean GENTLY!!!) wipe the blood off the mother with gentle soap and water. (Baby shampoo is a very good form of soap for wounds.) Fill a thick, feminine napkin pad with a little ice and place over the vagina.

12. Get to the Hospital. If you cannot get to medical help at all, then keep both mom and baby dry and warm. Keep the mom hydrated and watch the both of them closely for signs of shock.

13. Now you can Relax. Well, either that or pass out, because you just delivered a baby.



Since there is so much material concerning emergency births, I was unable to cover it all. Please refer to the following sources for more information on emergent deliveries:

ParasolEMT.com

Babypartner

Planbaby.com

Healthopedia.com

AHealthyme.com



Tuesday, January 5, 2010

Delivering Babies: So Grizzled

Delivering babies can be a grizzled job. How grizzled?

Let's just say that the field of Obstetrics (OB) is kind of a Wes Craven meets the Care Bears situation: Blood, guts, gore, and cute little baby butts.

So there's a very good reason why obstetricians prepare like nuclear fallout specialists to deliver a baby. They have to fend against an all-out military airstrike with the baby as the Drill Sergeant: "Alright you bodily substances, you better hit 'em with everything you've got! Darned, if they make me come out into the world! So bring on the rain!" Then hence starts the artillery.

During one of the last deliveries that I performed, the umbilical cord sought its revenge and sprayed my face like Old Faithful. It was not pretty; kind of like the aftermath of the movie Carrie. I think I heard the dad scream.

For instance, cesarean section yields enough blood to make a general surgeon cry, "oh mommy!", but then the OB doc pulls out a tiny baby buttocks out of the gaping abdominal wound and everyone in the room goes, "Ahhhhhh! Isn't that cute!"

Now, you are probably wondering, why I would bother to talk about baby butts in a disaster and wilderness medicine blog. But that's just the point, just like in the world of OB, anything can happen. And you just might find yourself needing to deliver a baby.

First, in this post I am going to discuss the things that you should have on hand in order to perform an emergent delivery. (Emergent delivery: if you are in a situation where in you can't contact 911 or are unable to get the laboring mother to a hospital in time.)

In the next post, I will describe how to perform an emergent delivery. This is not to replace the work of medical professionals, instead it is designed to help you handle an imminent situation where appropriate medical help can not be obtained. (Image obtained from www.lifemedicalsupplier.com.)

As for gear, many companies offer pre-made OB kits which you can purchase online, which I personally prefer, because I'm too lazy to make my own. Or you can purchase the products separately and build your own. Lazy way is better.


The following is a list of items that should be contained in any Ob kit:

*One pair or more of sterile exam gloves. These are the gloves that are generally worn by OB docs in order to perform sterile cervix exams. I suggest having more than one pair.

*One disposable plastic apron or surgical gown. I'd personally go with the surgical gown, more coverage. You know, from a disaster perspective, I would stock up on disposable surgical gowns, but that's just me and I am biased towards having more medical supplies.

*One 17" x 24" under pad. In the medical arena, we call these "chux pads". These are plastic on one side and cotton plush on the other. The closest thing out in grocery stores to them are puppy pads, but I wouldn't suggest using a puppy pad for delivering a baby.

*Disposable Absorbent Towels. I would stock up on these. They are good for any medical emergency dealing with body fluids.

*Biohazard bag. Again, good for any medical emergency where instruments can become contaminated with fluids.

*Plastic Drape sheet. Okay, I have to admit that lots of blood equals need for lots of plastic coverage, whether it be in the wilderness or in your home.

*One heavy duty feminine pad and Ice. I personally like the ones that you can either fill with ice or can open enough to shove ice in them. The ice helps alleviate the pain that occurs post-partum in the perineum. The pad itself absorbs the post-partum blood.

*At least Four Sterile 4 x 4" guaze sponges. Really, if you don't have these in your emergency medical kit already than you have a very poor quality kit.

*One Sterile Scalpel. Preferably a #10. (Image taken from www.canfsupply.com)

*One Sterile 2 oz bulb syringe. I think this should be in any emergency kit notwithstanding whether the kit is designed for baby delivery or not.

*Alcohol Prep pads. Okay, these are a must regardless.

*At least two Sterile Umbilical Cord Clamps. Or you can use Kelly Hemostats. (To sterilize the hemostats: Place hemostats in water that has been brought to rolling boil for at least 15 minutes. Note: water sterilization kills most bacteria and inactive viruses, but doesn't kill prions which are the cause of Bovine Spongiform Ecephalopathy [also known as Mad cow disease] or Creutzfeldt-Jakob disease. But most likely, you won't encounter Prions on clean medical equipment.) The sterile clamps are the cream colored plastic pieces seen in the picture.

If you are unable to obtain these things, or they are not on hand when an emergency birth takes place. Get out your boiling water, toss a sharp blade in and some shoelaces. Boil for 15 minutes.

In a later post, I will describe the different types of sterilization techniques.

Next time, we'll discuss how to perform an emergent delivery when birth is imminent and medical help is unavailable.

If you have any questions or comments, please feel free to email me at disaster_medicine@yahoo.com.

Until next post,

Christine