Wilderness Medicine Wilderness Medicine in the Neotropics:in the Neotropics:Challenges and special considerationsChallenges and special considerations

Luis A Camargo and Shana Lee TarterLuis A Camargo and Shana Lee TarterInstituto de Medicina para Areas Silvestres (OpEPA) / Wilderness Medicine Institute of NOLSInstituto de Medicina para Areas Silvestres (OpEPA) / Wilderness Medicine Institute of NOLS

WRMC 2005WRMC 2005

IntroductionIntroduction Cultural DifferencesCultural Differences Medical and Evacuation ServicesMedical and Evacuation Services Tropical DiseasesTropical Diseases Tropical WoundsTropical Wounds Tropical CreaturesTropical Creatures Client and Organizational Client and Organizational

PreparednessPreparedness Q & AQ & A

The NeotropicsThe Neotropics

What is the meaning of What is the meaning of Tropics?Tropics?

Remote WildernessRemote Wilderness Hot, Humid Hot, Humid

environment to environment to permanent snow permanent snow capscaps

Megadiversity:Megadiversity:biological & culturalbiological & cultural

0 - 6,000 meters 0 - 6,000 meters altitudesaltitudes

No prominent No prominent seasonsseasons

Developing CountriesDeveloping Countries Poor economiesPoor economies

GNI USD$746-GNI USD$746-2,975 2,975 (per capita, in (per capita, in USA GNI is USD$34,100, USA GNI is USD$34,100, World Bank)World Bank)

Limited resourcesLimited resources Limited Limited

infrastructureinfrastructure Limited access to Limited access to

education, healtheducation, health Survival dynamicsSurvival dynamics

Cultural DifferencesCultural Differences

Local idiosyncrasyLocal idiosyncrasy Beliefs and Beliefs and

perceptionsperceptions(world view)(world view) ““Shit happens”Shit happens” ““No problem”No problem” ““Its not my problem”Its not my problem” ““GringosGringos!”!”

BureaucracyBureaucracy

Medical and Evacuation Medical and Evacuation ServicesServices

Don’t make Don’t make assumptions about assumptions about

what will be what will be available, do your available, do your

homework, in homework, in person if possible!person if possible!

Medical ServicesMedical Services

Concentrated to citiesConcentrated to cities Limited AvailabilityLimited Availability

Emergency transportEmergency transport Rescue teamsRescue teams Emergency centersEmergency centers

Limited local staff Limited local staff trainingtraining

Need for Need for strengthened strengthened Instructor/guide Instructor/guide teamsteams

Assess ServicesAssess Services

LanguageLanguage PersonnelPersonnel SpecialistsSpecialists Scope of CareScope of Care Equipment ResourcesEquipment Resources Transportation OptionsTransportation Options General ImpressionGeneral Impression HistoryHistory

Consider EvaluatingConsider Evaluating

HospitalsHospitals ClinicsClinics Ground Ambulance ServicesGround Ambulance Services Air Ambulance ServicesAir Ambulance Services Helicopter ServicesHelicopter Services SAR TeamsSAR Teams

Emergency Service Emergency Service InventoryInventory

Hospital Profile Hospital Profile ScreeningScreening

Build RelationshipsBuild Relationships

Share who you are, what you doShare who you are, what you do Obtain names and contact Obtain names and contact

informationinformation Create realistic expectationsCreate realistic expectations Understand communication channelsUnderstand communication channels

Enhance Self SufficiencyEnhance Self Sufficiency

Consider having emergency Consider having emergency transportationtransportation

Use an in-country evacuation Use an in-country evacuation coordinatorcoordinator

Have translators availableHave translators available Have a supplemental medical kitHave a supplemental medical kit Realistically prepare clients for Realistically prepare clients for

delays and limitationsdelays and limitations

Tropical DiseasesTropical Diseases

Malaria (2002, Future Risk)

Global warming and climate change are recognized as mayor factors in changing distribution of infectious disease and vectors.

Tropical diseases are becoming an increasing threat to non tropical areas.

Cutaneous LeishmaniasisOnchocersiasis

DistributionDistribution

Soil HemintiasisLymphatic Filariasis

TransmissionTransmission

Broad CategoriesBroad Categories

Mosquito Borne Mosquito Borne Diseases Diseases

Flies Flies Parasitic Parasitic

Diseases Diseases Water / HygieneWater / Hygiene

MosquitoesMosquitoes

MalariaMalaria Lymphatic Lymphatic

FiliarsisFiliarsis DengueDengue Yellow FeverYellow FeverMalaria: 2 billion people (40% of the world's population) are

exposed. 10,000-30,000 travelers are affected annually

NOLS had 12 cases of malaria between 1986 and 2001 at our East Africa Base

FliesFlies

Furuncular MyiasisFuruncular Myiasis LeishmaniasisLeishmaniasis Onchocerciasis or Onchocerciasis or

River Blindness (Parasitic)River Blindness (Parasitic)

ParasitesParasites

America Trypanosomiasis (Chagas America Trypanosomiasis (Chagas Disease)Disease) Vector Vector Kissing Bug Kissing Bug

SchistosomiasisSchistosomiasis Vector Vector Fresh Water Snail Fresh Water Snail

Soil-transmitted Helminthiases Soil-transmitted Helminthiases (STH)(STH) Roundworms, Hookworms, WhipwormsRoundworms, Hookworms, WhipwormsIt is estimated that one quarter of the world's population is infected with parasitic worms.

Tropical Disease Evacuation Tropical Disease Evacuation CriteriaCriteria

High fever >102F (>40C) especially High fever >102F (>40C) especially with profuse sweating, head and muscle with profuse sweating, head and muscle achesaches

Uncontrolled diarrhea >24-72 hours or Uncontrolled diarrhea >24-72 hours or bloody diarrheabloody diarrhea

S/s serious abdominal illness/injuryS/s serious abdominal illness/injury Moderately-severely infected woundsModerately-severely infected wounds Abnormal skin lesions, necrotizing or Abnormal skin lesions, necrotizing or

ulcerating woundsulcerating wounds Any animal biteAny animal bite

Tropical Disease Tropical Disease PreventionPrevention

Insect protectionInsect protection Proper food choicesProper food choices Disinfect waterDisinfect water Maintain good hygiene practicesMaintain good hygiene practices Avoid walking barefootAvoid walking barefoot In high risk areas, avoid wading, In high risk areas, avoid wading,

swimming or bathing in fresh waterswimming or bathing in fresh water

Water TreatmentWater Treatment

Boil and coolBoil and cool Filter and HalogenateFilter and Halogenate HalogenateHalogenate

Pick trusted water sources.Pick trusted water sources.

Treat your water or treat Treat your water or treat your stomach!your stomach!

Wounds IssuesWounds Issues

High prevalence in outdoor activitiesHigh prevalence in outdoor activities Create pathways for pathogens to Create pathways for pathogens to

enter the bodyenter the body Tropical wounds often slow to healTropical wounds often slow to heal Infection is a significant issueInfection is a significant issue

Wound Management Wound Management

Control BleedingControl Bleeding Prevent Infection Prevent Infection Promote Healing Promote Healing

Principles do not change!Principles do not change!

Wound Complications Wound Complications

Mild-Severe InfectionsMild-Severe Infections Necrotizing Wounds/Tropical UlcersNecrotizing Wounds/Tropical Ulcers MyiasisMyiasis RabiesRabies Fungal Infections Fungal Infections

40,000-70,000 people die each year of rabies, 10 million

receive post-exposure treatment, 90% of exposure is through contact with infected

dogs (WHO)

Tropical Ulcer

Aggressive BiodiversityAggressive Biodiversity

Vipers, Reptiles and AmphibiansVipers, Reptiles and Amphibians InsectsInsects SpidersSpiders Water CreaturesWater Creatures

Snakes!Snakes!

VipersVipers

VipersVipers

ElapidsElapids

ElapidsElapids

Psyche!Psyche!

AntivenomsAntivenoms

Probiol, COLOMBIA

Wyeth, USA

Instituto Clodomiro Picado, COSTA RICA

Avoid Avoid using using

Suction Suction Devices Devices

on snake on snake bites!bites!

SpidersSpiders

AmphibiansAmphibians(Poison Dart Frogs)(Poison Dart Frogs)

InsectsInsects

Water CrittersWater Critters

Tropical Creatures Tropical Creatures Prevention StrategiesPrevention Strategies

Know what’s out thereKnow what’s out there Don’t put hands and feet where you can’t see Don’t put hands and feet where you can’t see

themthem Resist temptation to sample local ediblesResist temptation to sample local edibles Don’t hike at nightDon’t hike at night Don’t walk barefootDon’t walk barefoot Shake out clothes, sleeping bags, footwearShake out clothes, sleeping bags, footwear Keep tents zippedKeep tents zipped Do not eat plants or fruits you are not certain Do not eat plants or fruits you are not certain

aboutabout

Tropical Creatures Tropical Creatures Evacuation CriteriaEvacuation Criteria

Any snake biteAny snake bite Any animal biteAny animal bite Any wound of unknown origin not Any wound of unknown origin not

responding to treatmentresponding to treatment Any severe allergic reactionAny severe allergic reaction Any toxic reactions to plant or fruit Any toxic reactions to plant or fruit

consumptionconsumption

Training and Client Training and Client Organizational Organizational PreparednessPreparedness

Ensure that your program information Ensure that your program information effectively prepares the client for effectively prepares the client for

where they are going and what they where they are going and what they will be doing.will be doing.

VaccinationVaccination

Consult the WHO and CDC for Consult the WHO and CDC for recommendations and requirementsrecommendations and requirements

Common include: Common include: Hepatitis Hepatitis Yellow feverYellow fever TetanusTetanus Routine ImmunizationsRoutine Immunizations

Malaria ProphylaxisMalaria Prophylaxis

Staff Medical TrainingStaff Medical Training

WFA, WFR, WEMTWFA, WFR, WEMT Urban EMS skills-oxygen, airway, Urban EMS skills-oxygen, airway,

spinespine Tropical Medicine ModuleTropical Medicine Module Patient care experiencePatient care experience Language skillsLanguage skills Understand roles and Understand roles and

responsibilities responsibilities

Supplemental First Aid Supplemental First Aid KitsKits

Standard and supplemental kit advisedStandard and supplemental kit advised Extra gloves, multiple sizesExtra gloves, multiple sizes Other Personal Protective Equipment-masks, glasses, gownsOther Personal Protective Equipment-masks, glasses, gowns IV needles, IM needles, SQ needlesIV needles, IM needles, SQ needles Suture materials (needles, sutures, instruments)Suture materials (needles, sutures, instruments) Pain Medications (narcotics require special permits to cross Pain Medications (narcotics require special permits to cross

international borders)international borders) Local AnalgesicLocal Analgesic Anti-venoms (fragile, cost, availability, volume, allergic Anti-venoms (fragile, cost, availability, volume, allergic

response)response) Decadron (Dexamethazone)Decadron (Dexamethazone) Epi 1:1000Epi 1:1000 Surgery grade antibacterial soapSurgery grade antibacterial soap ORSORS For any medication: copy of prescription with generic name For any medication: copy of prescription with generic name

also, original container, indications, contraindications, dose, also, original container, indications, contraindications, dose, side-effects.side-effects.

Explore IntelligentlyExplore Intelligently

The tropics The tropics areare wilderness wilderness Mega diversity provides Mega diversity provides

Opportunities and RisksOpportunities and Risks Know your destination and what Know your destination and what

inhabits itinhabits it Being prepared and respectful Being prepared and respectful will will

reduce the risksreduce the risks

Questions?

Thank you!Luis A Camargo – luis@opepa.org

Shana Tarter – shana_tarter@nols.edu