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The iPhone TickDoctor

Dr. Jeremy Joslin is a wilderness medicine aficionado and has without question posted the greatest number of intelligent and useful comments to posts at this blog. So, I’m pleased to learn that he has created a very useful iPhone application named TickDoctor.

TickDoctor provides a stunning visual atlas of the most common ticks encountered in North America. Although not yet comprehensive, most common ticks are represented. For each tick species, the user is able to identify males, females, and nymphs. In many instances, there are included images of the engorged female, which often looks very different from its non-fed state.

More than just a beautiful atlas, TickDoctor provides instructions for prevention of tick bites and how to remove them if bites should occur. If a bite has occurred, or if you’re just plain curious, Dr. Joslin has included medically relevant data on each species, describing which diseases have been associated with it.

While this application should never substitute for the advice of a physician, it will help guide you to the identification of the tick in question and provide a framework of reference for dealing with “what to do next.”

I’ve been informed by Jeremy that, “if you have a great photo of a tick and want it considered for the next application update, let me know. You can do this by posting a comment and I’ll follow up with you. We’re always interested in making the atlas better.”

This post, The iPhone TickDoctor, was originally published on by Paul Auerbach, M.D..

New Mosquito-Born Virus Could Come To US

In the June 11, 2009 issue of the New England Journal of Medicine appears an article by Mark Duffy and colleagues entitled “Zika Virus Outbreak on Yap Island, Federated States of Micronesia.” This outbreak occurred in 2007, and was described as a cluster of 108 persons with confirmed or suspected infection, characterized with main symptoms of skin rash, fever, conjunctivitis, and painful joints. Other less common symptoms were muscle aches, pain behind the eyes, tissue swelling and vomiting.

As reported by the authors, there were no hospitalizations, bleeding problems in victims, or deaths. The predominant mosquito culprit was Aedes hensilli. The disease was determined to be mild in this outbreak. Zika virus is in the family of flaviviruses, which include West Nile, dengue, and yellow fever viruses. It has been diagnosed in Asia and Africa, and is transmitted by infected mosquitoes. Before this particular outbreak, there had only been 14 cases of human Zika virus disease previously documented.

The diagnosis was made in this outbreak by sending serum samples from patients to the Centers for Disease Control and Prevention (CDC) Arbovirus Diagnostic and Reference Laboratory in Fort Collins, Colorado.

How did this virus turn up in Yap? The most likely introducer was an infected mosquito or human. So, given the abundance of mosquitoes and propensity of people to travel, we may soon see this disease in other regions around the globe.

image courtesy of

This post, New Mosquito-Born Virus Could Come To US, was originally published on by Paul Auerbach, M.D..

Blood Under The Nail – What To Do

The following is a message that I received from a reader:

“Professor Auerbach – I am an avid reader of your blog ‘Medicine for the Outdoors.’ Your two posts about foot blisters are really interesting. In my hiking experience there is another foot related issue, that is the subungual hematoma in the toenail. I think it could be an interesting subject in one of your blog posts. Thank you very much for the attention.”

Well, it just so happens that I have been a sufferer myself, so I’m happy to write a bit about this. Subungual hematoma refers to blood under a toenail or fingernail. In the fingers, this usually occurs from a blow or pinch, such as catching a finger in a door or striking it with a hammer. In the foot, it is commonly caused by repetitive blows in a confined space, such as hiking in a boot with a toe-box that is too small and/or too stiff. The photo above is my foot after a 10 mile hike over rocky terrain in hiking shoes that didn’t fit quite right. They were broken in, but they weren’t sufficiently flexible for that type of hike. A couple of hours in, I knew I was in trouble because of the pain, but there was no turning back. No surprise, when I took off my sock, I saw the blue color and knew that eventually that particular toenail was a goner.

What can be done about this condition? When it first happens, applying an ice pack might relieve the pain. Certainly, you should trade out the poorly fitted shoes for ones that provide greater room and comfort. If possible, curtail hiking activities for a day or two, and let the situation settle, or the blood collection might increase.

When a fingertip is smashed between two objects, there is frequently a rapid blue discoloration of the fingernail, which is caused by a collection of blood underneath the nail. Pain from the pressure may be quite severe. If the pain is intolerable, it is necessary to create a small hole in the nail directly over the collection of blood, to allow the blood to drain and thus relieve the pressure. This can be done during the first 24 to 48 hours following the injury by heating a paper clip or similar-diameter metal wire to red-hot temperature in a flame (taking care not to burn your fingers while holding the other end of the wire; use a needle-nose pliers, if available) and quickly pressing it through the nail. Another technique is to drill a small hole in the nail by twirling a scalpel blade, sharp knife, or needle. As soon as the nail is penetrated, blood will spurt out, and the pain will be considerably lessened. Before and after the procedure, the finger should be washed carefully. If the procedure was not performed under sterile conditions, administer an antibiotic (such as dicloxacillin, erythromycin or cephalexin) for 3 days.

In the case of my toe (above), the pain subsided with a day’s rest from hiking, so there was no benefit to be obtained by draining the blood. A new nail grew in underneath the one shown in the picture, with the entire process taking a full nine months from injury to nail replacement.

This post, Blood Under The Nail – What To Do, was originally published on by Paul Auerbach, M.D..

Book Review – Over the Edge: Death in Grand Canyon

Michael Gighlieri and Thomas Myers are coauthors of Over the Edge: Death In Grand Canyon, which is one heck of an interesting read. It is an encyclopedic rendition of all of the fatal accidents known (at the time of the writing) to have occurred in the Grand Canyon. The over-arching observation, made by the authors and almost certainly by the readers, is that the vast majority of these deaths were avoidable. Failure to recognize risk, or frank disregard for hazards, led to tragic loss of human lives. For every person who died, countless more suffered.

Early in the book and at intervals thereafter, the authors apologize for the graphic descriptions and for articulating the opinion that the fatalities were avoidable. They are apologizing for accurately observing that people can be uninformed, or informed and foolish. There is, of course, an element of risk inherent in many outdoor recreational activities, but the authors present an entirely different spin on risk – namely, unambiguously unnecessary risk. They are correct – too many people have paid the price, in the theme of this book, with loss of life and great emotional suffering (presumably) to family and friends.

There is a bit of adventure in the telling of tales, but this is not an adventure book. It is, rather, a series of accountings, some written in great detail and some more superficially. There is nothing boring about this book, but it is easily put down after a section is completed.

From the back cover: “Two veterans of decades of adventuring in Grand Canyon chronicle the first complete and comprehensive history of Grand Canyon misadventures. These episodes span the entire era of visitation from the time of the first river exploration by John Wesley Powell and his crew of 1869 to that of tourists falling off its rims today. These accounts of the nearly 600 people who have met untimely deaths in the Canyon set a new high water mark for offering the most astounding array of adventures, misadventures, and lifesaving lessons published between two covers. Over the Edge promises to be the most intense yet informative book on Grand Canyon ever written.”

The major and minor sections represent the categories of accidents: falls from the rims, falls within the canyon, heat illness (and dehydration), flash floods, river accidents (including crossings and drownings), air accidents, rockfall, envenomations, freak accidents, suicide, and murders.

The book is replete with lessons learned and safety advice – all of it useful for educators, adventurers, explorers, search and rescue personnel, and casual visitors. The book truly serves a purpose, which is to articulate history in such a way that the reader can learn from it, and hopefully, avoid the catastrophes that befell the unfortunate victims portrayed in these tales. Other interesting books co-authored by Dr. Myers are Fateful Journey – Injury and Death on Colorado River Trips in Grand Canyon and Grand Obsession – Harvey Butchart and the Exploration of Grand Canyon.

This post, Book Review – Over the Edge: Death in Grand Canyon, was originally published on by Paul Auerbach, M.D..

At Last: An Antidote For Scorpion Stings

In the May 14, 2009 issue of the New England Journal of Medicine, in an article entitled “Antivenom for Critically Ill Children with Neurotoxicity from Scorpion Stings,” Dr. Leslie Boyer and colleagues report the results of a study in which the efficacy of scorpion-specific F(ab)’2 antivenom was compared to placebo in the treatment of 15 children ages 6 months to 18 years who were admitted to a pediatric intensive care unit with clinically significant signs of scorpion envenomation (N Engl J Med 2009;360:2090-8). The primary clinical end point was the resolution of the clinical syndrome within 4 hours after administration of the study drug. Secondary end points included the total dose of concomitant midazolam (Versed) – a sedative – and quantitative plasma (bloodstream) venom levels, before and after treatment.

The results showed that the clinical syndrome resolved more rapidly among recipients of the antivenom than among recipients of placebo, with a resolution of symptoms in all 8 antivenom recipients versus one of 7 placebo recipients within 4 hours after treatment. More midazolam was given to the placebo recipients (by necessity to treat symptoms) than in the antivenom recipients. Plasma venom concentrations were undetectable in all 8 antivenom recipients, but in only one placebo recipient one hour after treatment, which indicates that the antivenom neutralized circulating antivenom.

The conclusions are very helpful for clinicians treating scorpion envenomation syndromes with neurotoxic manifestations in critically ill children. They are that intravenous administration of scorpion-specific F(ab)’2 antivenom resolved the clinical syndrome within 4 hours, reduced the need for concomitant sedation with midazolam, and reduced the levels of circulating unbound venom.

This is very important new information. It is estimated that in North America, predominately in Mexico, more than 250,000 people per year are stung by scorpions. The major culprits are of the genus Centruroides. The antivenom used in this study was scorpion-specific F(ab)’2 antivenom (Anascorp, Centruroides [scorpion] immune F(ab)2 intravenous [equine], Instituto Bioclon).

The authors note that there has never been an approved, marketed antivenom therapy for scorpion envenomation in the United States. The only previously available scorpion antivenom in the U.S. was a goat-derived whole IgG (immunoglobulin G) preparation that has not been produced since 1999. Based on the current study, it now appears that there is a relatively safe product for treatment of critically ill children. Its use for critically ill adults and for children and adults with non-critical scorpion envenomation syndromes remains to be studied with the degree of rigor necessary to suggest its regulatory approval for use in the U.S.

image courtesy of Phoenix

This post, At Last: An Antidote For Scorpion Stings, was originally published on by Paul Auerbach, M.D..

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