Wilderness Medicine Newsletter

Cholera and Diarrhea

wildernessmedicinenewsletter — Thu, 01 Jan 2009 15:28:42 +0000

CHOLERA and DIARRHEA

At this very moment there is an outbreak of cholera in Zimbabwe– not a worldwide pandemic, but a localized epidemic. This is not a trivial point of interest, but a major news event that will not only have a dramatic impact on the population of Zimbabwe but also on the entire world as the aftermath of this epidemic will require international aid. Cholera will most likely kill thousands of people in Zimbabwe, impact tens of thousands of lives, and will continue to be a constant threat around the world and a very real concern for the adventurous and international travelers.

What is cholera?
Cholera, an acute infectious diarrheal illness that can cause death in less than 24 hours due to the profuse diarrhea, is caused by the bacteria, Vibrio cholera. Spread by oral-fecal contamination of food or water supplies, it is highly contagious, as has been demonstrated by at least seven worldwide pandemics over the past several hundred years.

How does cholera cause illness?
When consumed, the cholera bacteria passes through the stomach, where, fortunately, most of the bacteria are killed by the gastric juices and acid. Once the surviving bacteria have made it into the small intestine, they invade the lining of the small intestine and begin to multiply. In the process the bacteria produce an enterotoxin, and it is this enterotoxin that is responsible for causing the profuse, watery diarrhea that results in large quantities of fluid and electrolyte loss.

How does cholera cause death?
Death is a result of hypovolemic shock brought on by the profound dehydration from the enterotoxin-induced diarrhea. The very watery, grayish diarrhea is referred to as a rice water diarrhea. The victim of cholera can easily have massive diarrhea at a rate of 3 – 4 liters per hour or even more, literally dehydrating and shriveling up right before your eyes. Cholera is a very dehumanizing, debilitating disease.

What are the signs and symptoms of cholera?
Diarrhea – copious amounts of watery, rice water diarrhea.
Dehydration leading to hypovolemic shock – rapid, weak pulse; hypotension; rapid, shallow breathing; pale, cool, clammy skin; anxiety; and a sense of impending doom
Headache
Exhaustion and prostration
Malaise
Possible nausea and vomiting

How is cholera treated?
Hydration, Hydration,Hydration
The initial goal, and that means IMMEDIATELY is to replace the lost fluids and electrolytes. Then continue to replace the fluids that are being lost as quickly as they are being lost. As long as these patients can drink, oral therapy works very well. However, you have to replace the electrolytes as well as the water that is being lost. Water alone will not improve their survivability.

Electrolytes are charged ions: sodium (Na+), chloride (Cl-), potassium (K+), and bicarbonate (HCO3-). Glucose is also required to supply the energy that is needed to live. These electrolytes with the addition of glucose maintain the basic and vital functions on a cellular level to sustain life as we know it.

How do you make an Oral Rehydration Solutions (ORS)?
1. ORS can by made by mixing a commercially available ORS powder with water.
2. Home remedy can by made by simple adding sugar and salt to water.
1 liter of water + 1 teaspoon of salt + 8 teaspoons of sugar
3. Rice water is also a very effective ORS. It is made by cooking rice as usual.
1 liter of water + ½ cup of the cooked rice + 4 teaspoons of sugar + 1 teaspoon of salt. Stir to create a drinkable liquid.
The calories from sugar are very important. If sugar is not available you substitute molasses, brown sugar, fruit juice (contains glucose and fructose), or green coconut water. In fact molasses and brown sugar are better as they contain additional compounds that are also helpful.

Antibiotic Therapy:
Cholera is also caused by the bacteria, Vibrio cholera, and fortunately it is susceptible to several different antibiotic therapies.

Antibiotics that can be used to treat cholera:

Oral rehydration is the cornerstone of therapy. Antibiotics will shorten the course of the diarrhea and speed recovery. Following is a list of several antibiotics and their dosages that will help to eliminate the Vibrio cholera in the small intestine. There are several options, all are equally efficacious.

Single dose antibiotics:
Doxycycline: single dose – 7mg/kg up to 300mg.
Tetracycline: single dose – 25mg/kg up to 1000mg.
Ciprofloxacin: single dose – 30mg/kg up to 1000mg.

Multiple dose antibiotics:
Trimethoprim/sulfamethoxazole: 5-10mg/day, divided bid x 3 days, up to 320mg of the
trimethoprim/day and 1600mg of the sulfamethoxazole/day.
Ampicillin: 50mg/kg/day, divided qid x 3 days up to 2000mg/day.
Erythromycin: 40mg/kg/day, divided tid x 3 days, up to 1000mg/day.

How can the spread of cholera be prevented?

Cholera is spread by oral-fecal contamination of the food and water supplies that are then consumed by others causing further spread of the illness.
Therefore, drink only water that has been properly treated with iodine, chlorine, filtration, boiling, or UVC light.
Avoid ice as freezing does not sterilize water.
Eat only properly prepared foods:
Vegetables that can be peeled or cooked.
Well cooked meats and fish.
Avoid raw or undercooked meats.
Beware of sanitation practices, hand washing, and dirty dishes.
In addition, health care providers must take Body Substance Isolation (BSI) precautions and practice extremely safe hygiene when working with cholera patients.
Quick summary of Cholera and its influence on recent history:
1816-1826: Cholera Pandemic:
The outbreak began in Bengal and then spread across India. Approximately 10,000 British troops and countless Indians died during this pandemic.
1829-1851: Cholera Pandemic:
This outbreak lasted 22 years and extended initially from Russia into Europe. In London, the disease claimed close to 7,000 victims, and in Paris alone another 20,000 perished with approximately 100,000 deaths in all of France.
The epidemic reached Quebec, Ontario, and New York in 1832 and the Pacific coast of North America by 1834. The number of deaths appears to not have been recorded. In 1848, a two-year outbreak occurred in England and Wales which claimed about 52,000 lives.
1849: A second major outbreak spread in Paris and London. In London it claimed 14,137 lives, twice as many as the 1832 outbreak.
1849: Cholera was responsible for 5,308 deaths in Liverpool, England, and 1,834 in Hull, England.
1849: Cholera spread into the Mississippi river system killing over 4,500 in St. Louis and over 3,000 in New Orleans, and thousands more in New York. Cholera also spread along the California and Oregon trails; hundreds died during the California Gold Rush.
1852-1860: Cholera Pandemic:
The pandemic mainly affected Russia, with over a million deaths.
In 1853-1854, another London’s epidemic claimed 10,738 lives.
1854: An outbreak of cholera in Chicago killed about 3,500 people.
1863-1875: Cholera Pandemic:
Occurring primarily in Europe and Africa, at least 30,000 of the 90,000 Mecca pilgrims died from cholera during their pilgrimage. Cholera also claimed 90,000 lives in Russia in 1866.
1866: A cholera outbreak took place in North America while at the same time in London where cholera killed 5,596. Also more than 21,000 people died in Amsterdam, The Netherlands.
1881-1896: Cholera Pandemic:
The 1883-1887 epidemic took 250,000 lives in Europe and at least 50,000 in America. Cholera claimed 267,890 lives in Russia, 120,000 in Spain, 90,000 lives in Japan, 60,000 in Persia, 58,000 in Egypt, and 8,600 in Germany.
1899-1923: Cholera Pandemic:
This pandemic killed more than 800,000 in India.
1961-1970s: Cholera pandemic:
Beginning in Indonesia, this pandemic reached Bangladesh in 1963, India in 1964, and the USSR in 1966. From North Africa it spread into Italy by 1973. In the late 1970s, there were small outbreaks in Japan and in the South Pacific.
January 1991 to September 1994:
An outbreak in South America, beginning in Peru where there were 1.04 million identified cases and almost 10,000 deaths.
November 2008 – Doctors Without Borders, (Medicines Sans Frontiers) reported an outbreak in a refugee camp in the Congo.
November – December 2008
Is has been estimated that more than 11,000 people in the African nation of Zimbabwe are infected, and there have been more than 600 deaths.
Please note that these statistics come from a variety of resources. If you are interested, one of the most complete sources of the history of cholera pandemics can be found on Wikipedia by looking up cholera.

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Improvised Pelvic Splint

wildernessmedicinenewsletter — Wed, 30 Jul 2008 13:00:05 +0000

In keeping with the other video demonstrations that we have posted on this site, below you will find a video of an improvised splint for a possible fractured pelvis….

Improvised Traction Video

wildernessmedicinenewsletter — Wed, 11 Jun 2008 14:08:56 +0000

Back in December of 2007 we wrote a series of posts on lower Extremity injuries. Here is a video demonstration of an improvised traction splint to go along with that post.

IX. Patient Assessment System – Checklist

wildernessmedicinenewsletter — Tue, 29 Apr 2008 20:31:52 +0000

Part 9 of 9: PATIENT ASSESSMENT CHECK LIST:

SCENE SURVEY:
Is the SCENE SAFE?
Is the PATIENT SAFE?

PRIMARY SURVEY:
Are they CONSCIOUS?
Do they have an OPEN AIRWAY?
How is their BREATHING?
Do they have a PULSE?
Are they BLEEDING?
Are there any serious injuries on the CHUNK CHECK?
Is their neck and spine STABLE?
Do they need to be MOVED?
Do we need to protect them from the ENVIRONMENT?
How is everyone else DOING?

SECONDARY SURVEY – VITAL SIGNS:
What is their RESPIRATORY RATE & EFFORT?
What is their HEART RATE & EFFORT?
What is their LEVEL OF CONSCIOUSNESS?
What is their SKIN COLOR, TEMPERATURE, & COLOR?

SECONDARY SURVEY – PATIENT EXAM:
HEAD  - scalp, face, eyes, nose, mouth.
NECK  - spine, trachea.
CHEST - clavicles, shoulders, ribs.
ABDOMEN - compress the abdomen.
PELVIS - compress the pelvis anterior/posterior and lateral.
LEGS  - circulation, sensation, and motion.
ARMS  - circulation, sensation, and motion.
BACK  - log roll and palpate the length of the spine.

SECONDARY SURVEY – AMPLE HISTORY:
ALLERGY - allergy to drugs, foods, insects, etc.
MEDS - prescription and non-prescription drugs.
PREVIOUS - significant past medical history, surgeries, etc.
LAST - last intake & last output.
“ EVENT - events leading up to this crisis.

SOAPnote:
Putting it all together and creating a treatment plan.

RESCUE PLAN:
“ Looking at all factors and creating a rescue or evacuation plan.

VIII. Patient Assessment System – Rescue Plan

wildernessmedicinenewsletter — Tue, 22 Apr 2008 20:28:58 +0000

Part 8 of 9: PAS – STOP – RESCUE SURVEY: Do we need help?

Are we staying or going?
What is our plan to get help?
Who is going to go to get help?
What do we do to protect the patient while waiting for help to arrive?
What do we do to protect ourselves while waiting for help to arrive?
Is the scene safe?

RESCUE PLAN: Do we need help?

Group’s condition:
How well is each individual in the group doing?
How well prepared is the group to stay put and bivouac?

Decisions:
Do we need to evacuate the patient or can we all go on?
If evacuation is needed, send for help.
While waiting for rescue – build a bivouac.

Sending for help:
Send two to get help if possible.
Send out a SOAPnote on the patient.
Send out a list of the rest in the group and how well prepared you are to bivouac.
Send out a map with your exact location and time marked on it.

While waiting for help to arrive:
Know where everyone is; pair people up to massage each other’s feet, etc.
Keep everyone busy.
Create shelter for everyone.
Get water or melt snow and make something warm to drink.
If food available, make a meal & eat.
Keep spirits up, be positive, reassure, make sure everyone has something to do.
Create light and warmth; build a fire.
Make yourselves big, easy to find.
Continuously monitor your patient.
Continuously monitor everyone else in the group.

VII. PAS – Secondary Survey – SOAPnote:

wildernessmedicinenewsletter — Tue, 15 Apr 2008 20:25:26 +0000

Part 7 of 9: PAS – SOAP note: What is our patient care plan?

The SOAP note is organized into the Subjective date, Objective date, the Assessment, and the Plan.

Subjective:
The subjective date is their age, sex, the mechanism of injury (MOI), and the chief complaint (C/C), i.e., what they are complaining of.

Objective:
The objective date consist of their vital signs, the patient exam, and the AMPLE history.

Vital signs:
Time the vitals signs are taken:
RR & Effort
HR & Effort(BP)
LOC
Skin: C/T/M

Patient exam: Describe locations of pain, tenderness & injuries.

AMPLE history:
Allergies:
Medications:
Past pertinent medical history:
Last intake & output:
Events leading up to accident:

A – Assessment: (problem list)
1.
2.

P – Plan: (plan for each problem on the problem list)
1.
2.
3. MONITOR - reSOAP your patient every 5 – 15 minutes.

VI. PAS – Secondary Survey – AMPLE History:

wildernessmedicinenewsletter — Tue, 08 Apr 2008 20:25:05 +0000

Part 6 0f 9: PAS – AMPLE History: What is their past medical history?

ACTION:
Talk with your patient or others to determine the following information:

A – Allergies:
Are they allergic to any medications, foods, insects, etc.?
If they are what happens and how is it treated?

M – Medications:
What medications are they taking, both prescription and over-the-counter?
If they are taking medications, how often and how much do they take and have they taken their meds today?

P – Previous Injury or Illness:
Is there any recent or past injury or illness that could contribute to the current problem?
Have they ever been hospitalized over night for any medical problems, is so what?

L – Last Input and Output:
When was the last time they had anything to eat or drink?
What did they eat and drink?
When was the last they voided or had a bowel movement?

E – Events leading up to the crisis:
What lead up to or occurred just prior to the critical event?

V. PAS – Secondary Survey – Patient Exam:

wildernessmedicinenewsletter — Tue, 01 Apr 2008 20:12:42 +0000

Part 5 of 6: PAS – PATIENT EXAM: What are their injuries?

PRINCIPLES OF THE PATIENT EXAM:
You are trying to discover all possible injuries by:
LOOK:
Inspect: Is there any bleeding, wounds, impaled objects, or deformities?
Compare: Are their body parts symmetrical?
LISTEN:
Complaints: Are they complaining of pain or tenderness, if so, isolate where it hurts?
FEEL:
Palpation: Is there tenderness in muscles, bones, or joints?
Circulation: Are there pulses in all four extremities?
Sensation: Is there normal sensation in all four extremities?
Motion: Is there normal range of motion is all four extremities?

ACTION:
Keeping the above principles in mind do a hands on head-to-toe exam:
HEAD: scalp, face, eyes, ears, nose, mouth.
NECK: cervical spine, trachea.
CHEST: clavicles, gently compress the rib cage.
ABDOMEN: compress the abdomen in all four quadrants.
PELVIS: compress the pelvis front to back and laterally.
ARMS: palpate the muscles and flex the joints.
LEGS: palpate the muscles and flex the joints.
BACK: palpate the length of the back.

IV. PAS – Secondary Survey – Vital Signs:

wildernessmedicinenewsletter — Tue, 25 Mar 2008 16:16:16 +0000

Part 4 of 9: Patient Assessment System – Vital Signs:

STOP – SECONDARY SURVEY: How hurt are they?
The Secondary Survey consist of:
How well are they? Vital Signs
What are their injuries? Patient Exam
What is their past medical history? AMPLE History
What is our patient care plan? SOAPnote

VITAL SIGNS: How well are they doing?

Respiratory Rate and Effort:
Respiratory rate and effort shows us how well the Respiratory System, the airway and lungs, is doing at oxygen exchange and in particular, in supplying the brain with O2.
LOOK – Do they look like they are having difficulty breathing?
LISTEN – Are they complaining of shortness of breath or difficulty breathing?
FEEL - Is the chest moving properly with breathing?

Heart Rate and Effort (blood pressure):
The heart rate and effort, blood pressure, tells us how well the Circulatory System, the heart and blood vessels, are doing.
LOOK – Do they look shocky?
LISTEN – What is there heart rate, beats per minute.
FEEL – Take a blood pressure by palpation (systolic), if you do not have a BP cuff.

Level of Consciousness:
Level of consciousness tells us how well the Central Nervous System, the brain and spinal cord, are doing.

Action:
Level of Consciousness (LOC) is determined using the AVPU scale:
Awake, Verbal, Painful, Unresponsive.

Conscious: “The lights are on, is anyone home?”
Awake, their eyes are open but, are they alert oriented times 3, person, place, and time?
Person, do they know who they are?
Place, do they know where they are?
Time, to they know the day, week, and year?

Unconscious: If their eyes are closed they are unconscious, but how responsive are they?
Verbal stimuli, “Hello, anyone in there?”
Speak to them, do they react to hearing their name?
Do they follow simple commands?
Painful stimuli, “That’s got to hurt.”
A knuckle rubbed on their sternum?
Is it an appropriate response to pain?
Unresponsive, “Speak to me; say something.”
No response to verbal or painful stimuli.

Skin color, temperature, and moisture:
Skin color varies by individual and race.
Look – What is their skin color, pale, ashen, cyanotic?
Listen – Are they complaining about feeling hot or cold?
Feel – Is their skin dry, moist, clammy, hot, or cold?

III. Patient Assessment System – Primary Survey

wildernessmedicinenewsletter — Tue, 18 Mar 2008 16:15:23 +0000

Part 3 of 9: Patient Assessment System – Primary Survey

STOP – PRIMARY SURVEY: Are they alive, and are they going to stay alive?

A: Approach and Assess – Are they conscious and can they speak?
A: Airway – Do they have an open airway?
B: Breathing – Are they breathing?
B: Breathing – How well are they breathing?
C: Circulation – Do they have a pulse?
C: Circulation – Are they bleeding?
D: Deformity – Are there any obvious deformities?
D: Disability – Is their neck or back at risk of injury?
E: Environment – Can they stay where they are?
E: Everyone Else – How is everyone else in the group doing?

A: Approach and Assess – status of the central nervous system
Are they conscious and can they speak?
Look – Are they awake; are their eyes open; what position are they lying in?
Listen – Speak to them. Do they speak back?
Feel – What is your general impression of the situation?

A: Airway – status of the respiratory system
Do they have an open airway?
Look – Is there anything in their airway?
Listen – Can you hear air moving in and out of the airway?
Feel - Can you feel air moving in and out of the airway?

B: Breathing – status of the respiratory system
Are they breathing?
Look - Is their chest wall moving as they breathe?
Listen – Can you hear any adventitious breath sounds indicating a partially occluded airway, such as wheezing, gurgling, or snoring?
Feel - Is the chest wall moving appropriately with respirations?

B: Breathing – status of the respiratory system
How well are they breathing?
Look – Is their chest wall moving as they breathe?
Listen – Can you hear any adventitious breath sounds indicating a partially occluded airway, such as wheezing, gurgling, or snoring?
Feel – Is the chest wall moving appropriately with respirations?

C: Circulation – status of the circulatory system
Do they have a pulse?
Look – Is there any bleeding?
Listen - Can you hear a heartbeat?
Feel - Can you feel a carotid pulse?

C: Circulation – status of the circulatory system
Are they bleeding?
Look – Is there any bleeding?
Listen – Can you hear a heartbeat?
Feel – Can you feel a carotid pulse?

D: Deformity
Do they have any obvious injuries or deformities?
Look – Do you see any obvious injuries or deformities?
Listen - Where are they complaining of pain?
Feel - Where does it hurt? As you touch them, where can you cause pain?

D: Disability
Is their neck or back at risk of injury?
Look - What was the mechanism of injury (MOI)? Can they move their extremities?
Listen - Are they complaining of any neck or back pain?
Feel - Do they have normal sensation in their extremities?

E: Environment
Can they stay where they are?
Look - Where are they lying?
Listen – Are they complaining about being hot, cold, or wet?
Feel – Is their skin warm, dry, cold, or wet?

E: Everyone Else
How is everyone else in the group doing?
Look – How does the rest of the group look?
Listen – Is anyone complaining of being cold, wet, hungry, or thirsty?
Feel – What is the emotional status of the group?