Wilderness & Environmental Medicine

In the Forefront

Scott E. McIntosh, Tracy Cushing, Linda E. Keyes — 2012-03-01

This issue of Wilderness & Environmental Medicine represents the exciting and vast scope of our field. High altitude, wilderness toxicology, long distance events, hypothermia diagnosis, avalanche dangers, among many other topics are here. The papers are as interesting as the environment in which we practice.

Lessons From Dr Strangelove

Jay Lemery — 2012-03-01

In the early 1980s, a group of visionary physicians founded a medical organization predicated on the advancement of a singular health issue. This society was not one dedicated to patient care in the wilderness, but rather to promote understanding of the health risks of nuclear proliferation. They called themselves the International Physicians for the Prevention of Nuclear War (IPPNW), and their clinical assessment was a sober rebuke to Cold War strategists: “Nuclear war would be the final epidemic; there would be no cure and no meaningful medical response.”

A Time Has Come for Wilderness Emergency Medical Service: A New Direction

Brad L. Bennett — 2012-03-01

In this issue of Wilderness & Environmental Medicine, an article by Warden et al provides a timely overview of various specialized operational emergency medical service (EMS) programs that serve in either tactical, hazardous, or austere environments as part of the entry level medical care in the US health care system. These specialized EMS programs function in unique environments and provide, in most cases, point of injury medical care beyond what can be provided by traditional EMS agencies. These programs include classic programs in rural and wilderness settings, for example, ski patrol, water rescue, and wilderness search and rescue (SAR). More contemporary operational EMS programs that have evolved significantly in the past 10 to 20 years are tactical emergency medical services, military tactical combat casualty care (TCCC), urban search and rescue, and aviation medical support. As with all traditional EMS programs within the United States, these unique operational EMS programs should be held to the same rigorous or continuous quality improvement programs that are designed to ensure standardization of medical care. Unfortunately, not all operational EMS fall within any medical jurisdiction at the city, county, state, or national level. The point of the article by Warden et al is that the role for a medical director is lacking for wilderness and operational EMS programs; and that these programs, where lacking, should have a formal role in emergency response and be formally integrated into the local and state EMS system so that training and certification standards are met and all patients receive safe, quality health care, whether it be in remote and austere settings or as it is now within our cities and communities in the United States.

Nifedipine for the Treatment of High Altitude Pulmonary Edema

Rajesh Deshwal, Mohd Iqbal, Sidhant Basnet — 2012-03-01

Objective: The purpose of this study was to assess the risk factors, patient profile, clinical features, and oral nifedipine as a treatment option for a series of 110 patients with high altitude pulmonary edema (HAPE) in a military hospital in India. Methods: This was a prospective cross-sectional study in a military hospital. In all, 110 patients with HAPE admitted and treated over a period of 3 years are reported. The following measurements were noted: dyspnea, cough, chest pain, cyanosis, pulse rate, blood pressure, respiratory rate, crepitations, radiographic abnormalities, electrocardiogram, peripheral pulse oximetry (Spo2) at admission, Spo2 normalization time, total leukocyte count, and length of hospital stay. Results: The risk factors identified for development of HAPE in our patients were improper acclimatization/faster rates of ascent, higher defined height (10 500 feet [3200 m]) for first stage acclimatization due to logistic reasons (usually 9000 feet [2743 m]), cold exposure, severe exercise, and respiratory infection. All patients were treated with reduction of altitude, supplemental oxygen therapy with nasal prongs, and bed rest. Oral nifedipine or placebo was administered to alternating patients. None of the patients deteriorated during their hospital stay, and all recovered fully to be discharged an average of 4.01 days (range 2–6 days) after admission. Patients were monitored for time taken for normalization of oxygen saturation, duration of hospital stay, time needed for resolution of lung crepitations, and radiographic infiltrates. Nifedipine administration was not found to be better than placebo for any of these variables (P > .05). Conclusions: Improper acclimatization remains the foremost risk factor for HAPE. In addition to descent and supplemental oxygen, nifedipine appears to provide no additional benefit in the resolution of HAPE.

Background Rates of Acute Mountain Sickness-Like Symptoms at Low Altitude in Adolescents Using Lake Louise Score

Jon Dallimore, Jo-ai Foley, Peter Valentine — 2012-03-01

Objective: To record the incidence of symptoms consistent with a diagnosis of acute mountain sickness (AMS), using the Lake Louise questionnaire, in adolescents hiking at low altitude. Methods: The study was carried out on a cohort of 123 adolescents during a 3-day trip on Dartmoor, UK, at an altitude of less than 500 m. The incidence of symptoms experienced was measured using the Lake Louise questionnaire, which was completed twice daily by each participant. An episode consistent with AMS, but in the low altitude setting, was defined as a score of 3 or more on the Lake Louise questionnaire in the presence of a headache. Results: There were 59 boys and 64 girls in the study with an average age of 16.7 years. The response rate was 100%. A total of 59 episodes of scores consistent with AMS was recorded during the 3-day period. Forty-two of these episodes were reported by girls (71%). AMS scores between 3 and 8 were recorded, and the daily incidence rates of scores consistent with AMS but at low altitude were between 7.3% and 11.3%. Conclusions: This study shows that adolescents at low altitude reported a background incidence of symptoms that at high altitude would lead to a diagnosis of AMS.

Peripheral Arterial Desaturation Is Further Exacerbated by Exercise in Adolescents With Acute Mountain Sickness

Sarah A. Major, Ryan J.K. Hogan, Elizabeth Yeates, Chris H.E. Imray — 2012-03-01

Objective: Rapid ascent to altitude can result in the development of high altitude illnesses such as acute mountain sickness (AMS). This study aimed to investigate AMS symptoms in adolescents and study basic cardiopulmonary measurements at altitude. Methods: Thirty-eight adolescents aged 16 to 19 years flew to 3500 m from 215 m and continued over a 23-day period to ascend to a maximum altitude of 5200 m. Each member of the expedition completed a Lake Louise Self-Assessment Questionnaire (LLSAQ) on a daily basis, and AMS was defined as a score of ≥3, with an associated headache. Physiology measurements included a step test, and both before and after exercise pulse oximetry, blood pressure, and pulse rate. Results: Oxygen saturation inversely correlated with altitude (P = .001). Mean pulse rate increased from 70 beats/min (±6.5) at 215 m to 83 beats/min (±2.2) at 3500 m (P = .01), and a rise in blood pressure with ascent was highlighted (P = .004). The majority of subjects (84%) had an LLSAQ of 3 or more on at least 1 occasion, and they tended to record higher pulse rates (P = .005) and lower oxygen saturations (P = .001). Exercise-induced drops in oxygen saturation and raised pulse rates were more prolonged in subjects with severe AMS compared with subjects not having AMS (P = .046 and P = .005, respectively). Conclusions: The LLSAQ scoring system appeared to be a simple and effective technique to aid the diagnosis of adolescents who have AMS, and it may help improve the safety of large groups traveling to altitude. The AMS subjects tended to have low oxygen saturations and high pulse rates, highlighting potential areas for further research.

Recombinant Angiotensin-Converting Enzyme 2 Suppresses Pulmonary Vasoconstriction in Acute Hypoxia

2012-03-01

Objective: Alveolar hypoxia as a result of high altitude leads to increased pulmonary arterial pressure. The renin-angiotensin system is involved in the regulation of pulmonary arterial pressure through angiotensin-converting enzyme 2 (ACE2). It remains unknown whether ACE2 administration alters pulmonary vascular pressure in hypoxia. Methods: We investigated 12 anesthetized pigs instrumented with arterial, central venous, and Swan-Ganz catheters exposed to normobaric hypoxia (fraction of inspired oxygen = 0.125) for 180 minutes. After taking baseline measurements in normoxia and hypoxia, ACE2 400 μg·kg−1 was administered to 6 animals, and another 6 served as control. Ventilatory variables, arterial blood gases, ventilation/perfusion () relationships, and plasma angiotensin II concentrations were assessed before and at 30, 90, and 150 minutes in hypoxia after ACE2 or placebo administration. Hemodynamic variables and cardiac output were observed every 30 minutes. Results: We observed lower pulmonary arterial pressure (maximum: 30 vs 39 mm Hg, P < .01) and lower pulmonary vascular resistance (maximum: 4.1 vs 7.5 Wood units, P <.01) in animals treated with ACE2. There was a trend (P =.09) toward lower angiotensin II plasma concentrations among ACE2-treated animals. Cardiac variables and systemic arterial pressure in hypoxia remained unaffected by ACE2. Ventilation/perfusion relationships and Pao2 did not differ between groups. Conclusions: In acute pulmonary hypertension, administration of ACE2 blunts the rise in pulmonary arterial pressure that occurs in response to hypoxia. Recombinant ACE2 may be a treatment option for high altitude pulmonary edema and hypoxia-associated pulmonary hypertension.

Physiological Bone Responses in the Fingers After More Than 10 Years of High-Level Sport Climbing: Analysis of Cortical Parameters

2012-03-01

Objective: Sports activity can induce bone modeling processes with apposition of new bone and changes in bone morphology. Sport climbing places extreme forces and stress on the hands, especially on the bones of the fingers. This study examines sports-induced physiological adaptations of the finger bones of climbers. Methods: In this cohort study, the radiographs of 31 high-level (Union Internationale des Associations d'Alpinisme [UIAA] metric scale range 8.33 to 11.33), experienced (median 20 years climbing time) adult climbers were compared with those of a control group of 67 patients. Cortical dimensions and variables were measured and analyzed in a total of 330 fingers. An association analysis of climbing-related variables was also performed. Results: The climber's bones showed a 25% higher cortical proportion than those of the control group. On average, the outer cortical width of the climbers' bones was 6% larger and the medullary canal was 20% narrower than in the control group (P < .05). The differences between groups were more pronounced in the sagittal plane and more pronounced distally in the fingers. No associations were found between age, climbing experience, climbing level, and the cortical hypertrophy. Conclusions: Differences in bone morphology can be observed in the finger bones of adult climbers when compared with controls. Because the differences are more pronounced at the palmar and dorsal cortices, the analysis of the sagittal plane should always be included in future investigations. To evaluate climbing-related factors influencing these adaptive morphologic differences, further studies with larger, more specific study cohorts are needed.

Medical Direction of Wilderness and Other Operational Emergency Medical Services Programs

Craig R. Warden, Michael G. Millin, Seth C. Hawkins, Richard N. Bradley — 2012-03-01

Within a healthcare system, operational emergency medical services (EMS) programs provide prehospital emergency care to patients in austere and resource-limited settings. Some of these programs are additionally considered to be wilderness EMS programs, a specialized type of operational EMS program, as they primarily function in a wilderness setting (eg, wilderness search and rescue, ski patrols, water rescue, beach patrols, and cave rescue). Other operational EMS programs include urban search and rescue, air medical support, and tactical law enforcement response. The medical director will help to ensure that the care provided follows protocols that are in accordance with local and state prehospital standards, while accounting for the unique demands and needs of the environment. The operational EMS medical director should be as qualified as possible for the specific team that is being supervised. The medical director should train and operate with the team frequently to be effective. Adequate provision for compensation, liability, and equipment needs to be addressed for an optimal relationship between the medical director and the team.

Novel Use of a Hemostatic Dressing in the Management of a Bleeding Leech Bite: A Case Report and Review of the Literature

Preston J. Fedor — 2012-03-01

Persistent bleeding from leech bites is a common occurrence, although little evidence is available to guide management. Detailed here is the case of a 30-year-old American man who presented with two leech bites after a trek through the jungle in Nepal, one of which continued to briskly ooze blood despite standard wound care. The wound was ultimately treated with QuikClot gauze, which allowed for rapid hemostasis without rebleeding. This case report describes the first use of a hemostatic dressing for this purpose, and reviews what is known about hemostatic agents and about leeches in order to discuss how they make us bleed and what to do when a leech bite occurs.

Wolf Spider Envenomation

2012-03-01

Although wolf spider venom has been implicated in necrotic arachnidism without acceptably documented verification, limited, prospectively collected data demonstrate a lack of cutaneous necrosis. The infrequent nature of exposure and inherent difficulty in confirming wolf spider bites in humans makes it challenging to study such envenomations. We present the case of a 20 year-old man with confirmed exposure to the wolf spider who developed cutaneous erythema with ulceration following the bite. There was no evidence of skin necrosis. He was treated with aggressive wound care and systemic antibiotics for wound infection, with subsequent resolution of symptoms. This case adds to the limited knowledge regarding wolf spider envenomations and describes the clinical effects and management of wolf spider envenomation.

Managing Anaphylaxis in a Jungle Environment

Suzy Stokes, Sean Hudson — 2012-03-01

Anaphylaxis is a medical emergency requiring prompt action to prevent death from cardio-respiratory collapse. It can be a biphasic, unpredictable, and challenging reaction to deal with even in a hospital environment. The wilderness environments afforded by expeditions, remote health posts, and military exercises pose additional challenges often involving casualty evacuation. This article identifies and addresses some of these points using a case report from the Costa Rican jungle.

Increasing Creatine Kinase Concentrations at the 161-km Western States Endurance Run

2012-03-01

Objective: Very high blood creatine kinase (CK) concentrations have been observed among recent finishers of the 161-km Western States Endurance Run (WSER), and it has been suggested that there is a link between rhabdomyolysis and hyponatremia. Therefore, the purpose of this study was to compare CK concentrations of finishers in the 2010 WSER with past values, and to determine whether there was an association between blood CK and sodium concentrations. Methods: Consenting 2010 WSER finishers provided blood samples at the finish for determination of blood CK and sodium concentrations. Finish time, age, and gender were obtained from official race results, and running experience was determined from our database as number of prior 161-km ultramarathon finishes. Results: From 216 (66%) of the 328 finishers, median and mean CK concentrations were found to be 20 850 IU/L and 32 956 IU/L, respectively (range 1500–264 300 IU/L), and 13 (6%) had values greater than 100 000 IU/L. These values were statistically higher (P < .0001) than those reported from the 1995 WSER. The CK concentration was not significantly associated with finish time, age, gender, or running experience. Blood sodium concentrations were obtained from a subgroup of 159 runners, and the relationship between blood CK and sodium concentrations did not reach statistical significance (P = .06, r = −0.12). Conclusions: Creatine kinase concentrations of 2010 WSER finishers are higher than values previously reported. More research should focus on explaining this observation and on whether there is a possible link between higher CK concentrations and hyponatremia.

Improvised Traction Splints: A Wilderness Medicine Tool or Hindrance?

Lori Weichenthal, Susanne Spano, Brian Horan, Jacob Miss — 2012-03-01

Objectives: To investigate whether a traction splint made from improvised materials is as efficacious as commercially available devices in terms of traction provided and perceived comfort and stability. Methods: This was a prospective randomized crossover study utilizing 10 healthy, uninjured volunteers. The subjects were randomized to be placed in 4 different traction devices, in differing order, each for 30 minutes. Three of the traction splints are commercially available: The HARE, Sager, and Faretech CT-EMS. The fourth traction device was an improvised splint made as described in Medicine for the Backcountry: A Practical Guide to Wilderness First Aid. At the end of 30 minutes the pounds of force created by each device was measured. The volunteers were also asked at that time to subjectively report the comfort and stability of the splint separately on a scale from 1 to 10. Results: All traction splints performed similarly with regard to the primary outcome measure of mean pounds of traction created at the end of 30 minutes of application with results ranging from 10.4 to 13.3 pounds. There was little difference reported by participants in regard to stability or comfort between the 4 traction devices. Conclusions: In this small pilot study, an improvised traction splint was not inferior to commercially available devices. Further research in needed in this area.

Animal-Related Motorcycle Collisions in North Dakota

2012-01-20

Objective: To study the epidemiology and mortality of animal-motorcycle collisions. Methods: A retrospective study of all motorcycle collisions recorded in the North Dakota Department of Transportation Crash Reporting System from January 2007 to December 2009 was conducted. Mortality was designated as the main outcome measure. Results: Seven hundred sixty-six collisions involving 798 motorcycles were included in this study; 48 of these collisions were with animals (6.3% of all motorcycle collisions). Deer were the most common animal involved (81%). Most animal-motorcycle collisions took place during nighttime with clear weather and on straight rural roads. Drivers were older in animal collisions compared with nonanimal collisions (median of 44 vs 30 years old, respectively, P < .0001). Most drivers were males, whereas most passengers were females. Helmets were worn by only 32% of drivers and 12% of passengers. There were 4 (8%; 95% CI, 3%–20%) fatal animal collisions; 9% of the collisions with large animals were fatal compared with 3% of nonanimal collisions (P = .0411). Conclusions: Animal-motorcycle collisions are a small subgroup of all motorcycle collisions, but with a high mortality rate. Efforts should be made to increase helmet usage, mitigate these collisions, and increase awareness of this problem among motorcycle riders.

Homemade Thermometry Instruments in the Field

Mathieu Pasquier, Valentin Rousson, Grégoire Zen Ruffinen, Olivier Hugli — 2012-03-01

Objective: Esophageal temperature is the gold standard for in-the-field temperature monitoring in hypothermic victims with cardiac arrest. For practical reasons, some mountain rescue teams use homemade esophageal thermometers to measure esophageal temperature; these consist of nonmedical inside/outside temperature monitoring instruments that have been modified to allow for esophageal insertion. We planned a study to determine the accuracy of such thermometers. Methods: Two of the same model of digital cabled indoor/outdoor thermometer were modified and tested in comparison with a reference thermometer. The thermometers were tested in a water bath at different temperatures between 10°C and 35.2°C. Three hundred measurements were taken with each thermometer. Results: Our experimental study showed that both homemade thermometers provided a good correlation and a clinically acceptable agreement in comparison with the reference thermometer. Measurements were within 0.5°C in comparison with the reference thermometer 97.5% of the time. Conclusions: The homemade thermometers performed well in vitro, in comparison with a reference thermometer. However, because these devices in their original form are not designed for clinical use, their use should be restricted to situations when the use of a conventional esophageal thermometer is impossible.

A Rash

Natacha Chough — 2012-03-01

A 31-year-old, otherwise healthy woman presented to a clinic in California with a rash on her arm (). Ten days earlier she had traveled by car from Michigan. Erythema migrans (Lyme disease).

Snow Blindness and Other Eye Problems During the Heroic Age of Antarctic Exploration

Henry R. Guly — 2012-03-01

During the heroic age of Antarctic exploration, snow blindness was a common problem, but not all the descriptions of it fit the modern view of the disease, and some of the explorers complained of long-term problems. This article describes the snow blindness and other eye problems that occurred during this era. It also describes how snow blindness was prevented and treated.

Wilderness Medicine Within Global Health

Steve Donelan — 2012-03-01

Those of us who started teaching first aid and emergency care decades ago have seen the curricula for the courses taught to lay people shrink as the emergency medical services (EMS) system in this country expanded. For example, the American Red Cross Standard First Aid & Personal Safety textbook, second edition (1979) is 269 pages long, and includes detailed instructions for many bandages and splints, as well as emergency lifts and carries and water rescue techniques. Standard First Aid courses typically lasted up to 24 classroom hours, much of that time spent practicing the skills. By comparison, American Red Cross and American Heart Association Basic First Aid courses today are about 4 hours long, and most of that time is spent watching the video.

Wilderness Medicine Within Global Health: A Strategy for Less Risk and More Reward

Jay Lemery, Dana Sacco, Amita Kulkarni, Liz Francis — 2012-03-01

In the last several years, healthcare workers and trainees have demonstrated an unprecedented interest in global health and the medical challenges facing developing countries and regions in crisis. Perhaps nowhere is this interest so apparent than in our medical schools and universities, where educators have moved quickly to create programs that meet this enthusiasm. It is now common for medical schools to build relationships with partners overseas and to create formal programs in global health education. The Association of American Medical Colleges (AAMC) documented that 45 US medical schools have some sort of global health component in their curricula, with 29.9% of graduating US medical students stating they have had a “global health experience.” However, these programs vary widely, making it unclear whether schools are meeting a baseline standard of global health knowledge in the types of academic and hands-on opportunities offered to students.(p11)

The American Journal of Emergency Medicine

2012-03-01

This study aimed to evaluate the efficacy of mobile phone networks for remote medical consultations. This experimental study compared the use of mobile phone radiology consultation to hospital workstation radiology consultation for spinal injury patients in the Czech Republic.

Western Journal of Emergency Medicine

2012-03-01

This article summaries the current contingency operations and resources for a mass casualty incident (MCI) in Antarctica. The authors cited surveyed literature and past incidents to describe the current state of medical preparedness. They also noted the increased number of personnel in Antarctica owing to tourism and research, noting a presence of more than 30 nations, 80 research stations, and 10 000 tourists during the summer months. These numbers dwindle to 1000 people in the winter.

Morbidity and Mortality Weekly Report

2012-03-01

This report provided valuable information about the incidence and characteristics of heat illness related to sports and recreation. The Centers for Disease Control (CDC) analyzed data from the National Electronic Injury Surveillance System (NEISS) from 2001 to 2009 and found that approximately 5946 people were treated in a US Emergency Department (ED) each year for heat illness. The NEISS monitors consumer product-related injuries treated in 100 US hospital EDs. Cases were excluded that were not precipitated by natural or environmental causes.

Archives of Surgery

2012-03-01

This retrospective observational study assessed the effect of tranexamic acid (TXA) in combat injury on total blood product use, thromboembolic complications, and mortality. Tranexamic acid is a lysine analog that inhibits fibrinolysis and was shown to reduce mortality after civilian trauma in the CRASH-2 trial (Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage). The MATTERs study reviewed 896 admissions due to combat injuries in Afghanistan that required at least 1 unit of packed red blood cells and was further subdivided into a massive transfusion cohort requiring 10 or more units of packed red blood cells within 24 hours. A total of 293 patients (32.7%) received TXA within 1 hour of injury. Outcome measures were mortality, postoperative coagulopathy, and thromboembolic complications.

Journal of Applied Physiology

2012-03-01

The authors of this article investigated the link between vasogenic edema associated with acute mountain sickness (AMS). One contributing factor to the development of vasogenic edema may be the disruption of the blood-brain barrier. Numerous mediators of inflammation and angiogenesis known to cause disruption of the blood-brain barrier can be modulated by hypoxia. This experimental study seeks to identify whether circulating biomarkers known to influence blood-brain barrier function are also related to AMS.

Mountain Clothing and Thermoregulation: A Look Back

George W. Rodway — 2012-03-01

At the time humans began exploring the upper reaches of the world's highest mountain ranges in the early 20th century, knowledge about survival in extreme climates was undergoing rapid development. Early polar exploration provided a bedrock of understanding that mountaineers were able to build on. Whereas Norwegians such as Fridtjof Nansen and Roald Amundsen seemed to have perfected the art of travel in the Arctic and Antarctic by the late 19th/early 20th century, British polar explorers such as Dr John Rae and Francis McClintock respected the lessons of cold weather native living and travel before 1850. Some early Himalayan mountaineers, such as Martin Conway, also went to the Arctic. It thus seems reasonable to suggest that some early synergy existed between polar exploration and mountaineering regarding clothing and equipment.

Pulse Oximetry After 6-Minute Walk Test and Summit Success on Kilimanjaro

Rob Daniels — 2011-12-02

Kilimanjaro, at 5896 m, is famous both as 1 of the 7 summits and as an accessible trekking peak that can be climbed with minimal experience or technical skill. It is a popular destination for charity fundraisers from the United Kingdom; each year approximately 30,000 trekkers attempt the climb, with success rates of 61% to 75%, and symptoms of altitude illness developing in as many as 77% of trekkers.

Utilizing Avalanche Safety Equipment to Prevent Snow Immersion Asphyxiation Revisited

Christopher Van Tilburg — 2012-03-01

The final week of 2010 was bittersweet for snowriders. Massive storms pummeled the western mountains in North America with big fat flakes. Skiers and snowboarders flocked to the deep powder snow on holiday break. Unfortunately, in a 2-week span between December 2010 and January 2011, 6 died of snow immersion asphyxiation (SIA), also called nonavalanche-related snow immersion death, in deep snow and tree wells. Fortunately, a seventh skier was able to extricate himself from a tree well, but just barely.

Surgical Tick Removal

Stylianos Roupakias, Paraskevi Mitsakou, Angelos Al Nimer — 2011-12-05

Tick-borne diseases are increasing in prevalence. Ticks are best removed as soon as possible, because the risk of disease transmission increases significantly after 24 hours of attachment. Furthermore, signs and symptoms of tick paralysis improve within hours of tick removal, and complete recovery occurs within 24 hours. Removing ticks may not be easy and it is very difficult to remove nymphs without damaging them. It is important to completely remove the tick, including the mouth part and the cement the tick has secreted to secure its attachment. A small tick remnant in the skin is difficult to detect and localize, and attempts to remove these parts may result in significant skin trauma or a secondary skin infection. Improper tick removal may lead to infection or granuloma formation, which must always be surgically resected during a second procedure. An effective tick removal method must reduce the possibility of fluid regurgitation and transmission into the host during the procedure. Although there is conflicting evidence whether the removal technique influences infection rates, killing the tick in situ may increase the risk of regurgitation and transmission of infectious agents. Theoretically, touching the tick during the removal attempt may also irritate the tick and cause it to force more liquid into the wound. To prevent tick-borne disease, therefore, it is important to urgently remove the tick, to use the correct removal procedure, and to remove the whole tick, intact and alive, without any remnants. It is preferable that a medical practitioner remove the tick as an office procedure and not in an outdoor condition, especially in areas where ticks are endemic.

Chortens Before Ama Dablam

Luanne Freer — 2012-01-19

Burchell's Zebra

Peter Kummerfeldt — 2012-01-19