Common Wilderness Diseases

Introduction to Wilderness Medicine

Wilderness medicine incorporates many different methods and practices of medicine. It borrows from emergency medicine, sports medicine, military medicine, and environmental medicine (Backer, 1995) It incorporates a unique spectrum of topics and special perspectives that facilitate it as a distinct field of study. Wilderness medicine can be seen as patient care in a remote environment. This means that anyone who is more than one hour from getting care from a hospital or ambulance crew is under the protocols of wilderness medicine. Wilderness activities such as hiking, back packing, rock-climbing, skiing, snowboarding, all forms of kayaking, and wilderness therapy are often held in places that facilitate the rules of wilderness medicine.

Geographical boundaries and the absence of people may define what a wilderness is (Backer, 1995.) However, wilderness medicine often envelopes more than just physically being in a remote setting. Natural disasters may create a wilderness in the midst of a city by destroying transportation, communication, and health care facilities. Evidence of this has been obvious in the past twelve months with the hurricanes in Louisiana, with the earthquakes in Pakistan and more seriously, with the tsunami last December in Southeast Asia. Each of those situations called for the observation of wilderness medicine regardless of where the event occurred.

Wilderness medicine protocols are slightly different from the protocols practiced in an urban setting. Medical professionals who are trained and authorized to practice wilderness medicine have a greater scope of practice that they can use for wilderness patients. These advanced practices include more medications, the ability to dress and close wounds, the ability to put dislocated bones back into place, and finally the ability to diagnose death without a coroner (Backer, 1995.)

Aside from its focus on medical problems and practice in remote environments, several things make wilderness medicine a unique discipline. It is an inclusive field that incorporates not only primary care providers, but also every other medical specialty—from dermatologists to trauma surgeons to infectious disease specialists. Its also incorporates rescue personnel and wilderness guides who usually provide the first line of medical care and have the best opportunity to educate the public in wilderness safety. Wilderness medicine is also unique in its dependence on clinical judgment. Even the most basic diagnostic equipment, such as a blood pressure cuff, is not likely to be available in the wilderness. Finally, wilderness medicine is unique in its reliance on improvisation (Forgey, 1979.) One must utilize whatever supplies or materials are available; it is impossible to have optimal equipment to manage all situations. Non-medical equipment must often be used for splints, airway control, or other medical purposes. Any medical equipment and medications carried should have multiple uses to be efficient.

The wilderness psychotherapist must be aware of the protocols of wilderness medicine. They must also address the stressors and rigors put on their clients. People who have little or no exposure to nature will have psychological stresses that they may have never had to address before.

The psychology of wilderness medicine

A difficult task of the wilderness psychotherapist is to prepare someone mentally for a stressful and threatening wilderness experience. Given the inherent isolation of wilderness and the risk of becoming lost or being stranded by severe weather, medical problems are often inseparable from problems of being in the wilderness (Forgey, 1979.) The ability to manage unexpected adversity may be an innate individual characteristic or one that can be developed by repeated experiences in situations where the client feels uncomfortable. The psychology of wilderness medicine is fascinating, because there are many accounts of individuals who are similar in all measurable ways who face the same challenge, yet one person can thrive while another on chokes under pressure (Warrell & Anderson, 2003). Perhaps it is analogous to sports psychology; those willing to push themselves through pain may fit a profile, yet in groups with identical measurable physical characteristics and training, one will be the winner.

It is not surprising that the average person will have some psychological reactions during a wilderness medical crisis. Some of the psychological hurdles that the wilderness therapist must addressed are some of the major internal reactions might be experienced during this stressful time. Fear and anxiety are emotional responses to dangerous circumstances that may have the potential to cause death, injury, or illness (Warrell & Anderson, 2003.) Fear in a wilderness setting during a medical emergency must be acknowledged and addressed by the responding medical professional. They must immediately realize that they may have one medically injured patient, but many potential emotional problems coming from the people present.

The wilderness medical professional can address their fears with the medical training that they have as well as maintain their professional demeanor as they take charge of a medical situation. Experience helps with understanding the psychological pressures that can come to the one who has to make difficult medical decisions. With the psychotherapist practicing in the wilderness, they may have one medical patient, but still need to control and assist the other members of their client group who are now under the additional stress of seeing one of their members in a medical crisis.

Anger and frustration can be present when a person is continually thwarted in their attempts at a goal. During a wilderness medical emergency, the responding medical professional is the highest trained person available. This puts immense stress on them to deal with the situation at hand. If their training is inadequate, then it is plausible that anger and frustration will surface as they attempt to address their medical knowledge to the situation. They have no one to refer to or to discuss the options of their patient.

Depression is closely linked with anger and frustration (Tagney, et al, 1996). The frustrated person becomes angrier as they fail to reach their goal of helping the injured client. A destructive cycle between anger and frustration continues until the person becomes worn down-physically, emotionally, and mentally. When people reach this point, they start to give up, and focus shifts from “What can I do” to “There is nothing I can do.” Depression is an expression of this hopeless, helpless feeling.

The wilderness therapist must be aware of all of these feelings and emotions within themselves before they surface and escalate a wilderness medical situation. Knowledge of self, awareness of emotions, and the ability to step back and take a personal moment can assist the wilderness responder.

Common wilderness diseases

During a wilderness therapy session, the therapist needs to be concerned not only with the clinical therapy of each client, but the health, safety and physical well being as well. Generally, during a wilderness therapy expedition, the therapist will have assistance from a wilderness guide who will focus on the physical aspects of safety and health of the clients. Even so, the therapist still must be concerned about these subjects when working with clients in a wilderness setting. Within a wilderness therapy expedition, the physical capabilities and limits of each client is carefully observed and maintained, but injuries can still occur.

Illness and injury rates during wilderness activities are low (Gentile et al, 1992.) This has profound implications for studies in wilderness medicine. Many studies of wilderness diseases are resource intensive with poor data due to a commitment for a concurrent prospective study design. Such studies can take years to complete and a generation of new knowledge in wilderness medicine can cause the research to be obsolete (Brandt, 1993.)

Infectious disease is a rapidly evolving field; new viral agents are continually being identified, and the geographic ranges of known viruses continue to evolve (Berger et al, 2003.) As recent experiences with West Nile virus, severe acute respiratory syndrome (SARS), and Avian flu dramatically illustrate, people in any setting may be called on to consider infectious entities from any part of the globe due to shifts in geographic disease distribution, travel-related imported infections, or even potentially intentional releases of exotic viruses. The recent crisis of avian flu shows the importance of knowledge of infectious diseases for the clinical psychologist working in a wilderness setting.

Few diseases frequent a wilderness excursion. However, these ailments have common occurrences in the North American wilderness. They are Cryptosporidium, E. Coli, Rocky Mountain Spotted Fever, Giardia, Lyme’s Disease, and finally Tularemia. This list is by no means comprehensive. The wilderness psychotherapist should research what diseases and vectors are prevalent in the area where they are practicing.

Cryptosporidiosis

Cryptosporidiosis is a disease caused by microscopic parasites of the genus Cryptosporidium. Once a person is infected, the parasite lives in the intestine and passes in the stool. The parasite is protected by an outer shell that allows it to survive outside the body for long periods and makes it very resistant to chlorine- based disinfectants. During the past two decades, crypto has become recognized as one of the most common causes of waterborne disease within humans in the United States. The parasite may be found in drinking water and recreational water in every region of the United States and throughout the world (Guerrant, 1997.)

Cryptosporidium is passed from person to person by fecal-oral pathways. In a wilderness environment, it is imperative that everyone washed his or her hands before ingesting anything. This is often difficult with adolescent youth.

Cryptosporidium causes symptoms that could manifest as watery diarrhea, abdominal cramps, vomiting, and fever. In immune competent persons, symptoms last an average of six to ten days but can last up to several weeks. In persons with severely weakened immune systems, cryptosporidiosis can become chronic and can be fatal (Guerrant, 1997.)

Some people with Cryptosporidium will have no symptoms at all. While the small intestine is the site most commonly affected, Cryptosporidium infections could possibly affect other areas of the digestive or the respiratory tract. Treatment for Cryptosporidium is Nitazoxanide. The wilderness therapist should consult a physician before using this as is has ill effects on people in poor health (Morgan-Ryan, 2002.)

E. Coli

Escherichia coli is an emerging cause of food borne illness. An estimated seventy three thousand cases of infection and sixty-one deaths occur in the United States each year (Fischer et al, 2001.) Infection often leads to bloody diarrhea, and occasionally to kidney failure. Most illness has been associated with eating undercooked, contaminated ground beef. Person-to-person contact in families and childcare centers is also an important mode of transmission. Infection can also occur after drinking raw milk and after swimming in or drinking sewage-contaminated water.

Most persons recover without antibiotics or other specific treatment in two weeks. There is no evidence that antibiotics improve the course of disease, and it is thought that treatment with some antibiotics may precipitate kidney complications. Antidiarrheal agents, such as loperamide (Imodium), should also be avoided (Fischer et al, 2001.)

Like Cryptosporidium, E. Coli can stay in a client’s system without symptoms for extended periods. Prevention is the same as Cryptosporidium. The wilderness psychologist should maintain a rigid regiment of hand washing and person hygiene within their client community.

Giardia

Giardia is a diarrhea causing illness. It is a one-celled, microscopic parasite. Once an animal or person has been infected with Giardia, the parasite lives in the intestine and is passed in the stool. Because the parasite is protected by an outer shell, it can survive outside the body and in the environment for long periods.

During the past two decades, Giardia infection has become recognized as one of the most common causes of waterborne disease in humans in the United States (Berger et al, 2003). Giardia is found worldwide and within every region of the United States.

The Giardia parasite lives in the intestine of infected humans or animals. Millions of germs can be released in a bowel movement from an infected human or animal. Giardia is found in soil, food, water, or surfaces that have been contaminated with the feces from infected humans or animals. Spread of this infectious disease is caused by fecal-oral pathways, unsanitary food preparation, or ingestion of untreated water.

The symptoms for Giardia are diarrhea, flatulence, greasy stools that tend to float, stomach cramps, and upset stomach or nausea. Treatment for Giardia is taking an antibiotic series. The symptoms will go away from two to six weeks after initial diagnosis.

Rocky Mountain spotted fever

Rocky Mountain spotted fever is the most severe and most frequently reported tick-borne illness in the United States (Archibald & Sexton, 1995.) The disease is caused by a species of bacteria that is spread to humans by ticks. Initial signs and symptoms of the disease include sudden onset of fever, headache, and muscle pain, followed by development of rash. The disease can be difficult to diagnose in the early stages, and without prompt and appropriate treatment, it can be fatal.

The characteristic rash can be spotted after the fifth or sixth day after the client displays the symptoms of Rocky Mountain spotted fever. The rash does not always show up. It often occurs in the palms and soles of the feet, but this is more of a late description of the disease.

Prompt removal of embedded ticks is the most effective way to reduce the possibility of contracting the disease. It may take extended attachment time before organisms are transmitted from the tick to the host. In persons exposed to tick-infested habitats, prompt careful inspection and removal of crawling or attached ticks is an important method of preventing disease.

Treatment is antibiotics that should be started immediately when there is even a suspicion of contracting the disease (Archibald & Sexton, 1995.)

Lyme Disease

Lyme disease is caused by bacteria that is transmitted to humans by the bite of infected ticks (Hayes & Piesman, 2003.) Typical symptoms include fever, headache, fatigue, and a skin rash. If left untreated, infection can spread to joints, the heart, and the nervous system. Lyme disease is diagnosed based on symptoms, physical findings, and the possibility of exposure to infected ticks; laboratory testing is helpful in the later stages of disease. Most cases of Lyme disease can be treated successfully with a few weeks of antibiotics.

During 2002, over twenty three thousand new cases of Lyme’s Disease were reported to Center for Disease Control, more than in any previous year (Hayes & Piesman, 2003.) Factors potentially contributing to the increase in reported cases include growing populations of deer that support the hard tick vector, increased residential development of wooded areas, and tick dispersal to new areas, improved disease recognition in areas where Lyme’s Disease is endemic, and enhanced reporting (Hayes & Piesman, 2003.)

Detection and removal are the two best methods for reducing all diseases caused by ticks. Tick checks should be conducted morning and night, especially before sleep. Ticks carrying Lyme’s Disease characteristically need more than twenty-four hours embedding within their host in order to pass on the disease (Hayes & Piesman, 2003.)

Tularemia

Tularemia is another disease passed on by ticks. It can also be passed by other infected insects such as deer flies or misquitoes (Schmid et al, 1983.) People can also become infected by handling infected sick or dead animals, by eating or drinking contaminated food or water, or by inhaling airborne bacteria.

Tularemia is a widespread disease in animals. About two hundred human cases of tularemia are reported each year in the United States. Most cases occur in the south-central and western states. Nearly all cases occur in rural areas, and are caused by the bites of ticks and biting flies or from handling infected rodents, rabbits, or hares. Cases also resulted from inhaling airborne bacteria and from laboratory accidents (Schmid et al, 1983.)

The signs and symptoms people develop depend on how they are exposed to tularemia. Possible symptoms include skin ulcers, swollen and painful lymph glands, inflamed eyes, sore throat, mouth sores, diarrhea or pneumonia. If the bacteria are inhaled, symptoms can include abrupt onset of fever, chills, headache, muscle aches, joint pain, dry cough, and progressive weakness. Tularemia can be fatal if the person is not treated with appropriate antibiotics. Francisella tularensis can remain alive for weeks in water and soil.

From 1990 to 2000, over one thousand new cases of tularemia were reported to CDC from forty-four states, averaging over one hundred new cases per year.

Rabies

Rabies is a preventable viral disease of mammals most often transmitted through the bite of a rabid animal (Berger et al, 2003.) The vast majority of rabies cases reported each year occur in wild animals like raccoons, skunks, bats, and foxes. Domestic animals account for less than ten percent of the reported rabies cases, with cats, cattle, and dogs most often reported rabid.

  Rabies virus infects the central nervous system, causing a person’s brain to swell possibly causing death. Early symptoms of rabies in humans are nonspecific, consisting of fever, headache, and general malaise. As the disease progresses, neurological symptoms appear and may include insomnia, anxiety, confusion, slight or partial paralysis, excitation, hallucinations, agitation, increased salivation, difficulty swallowing, and fear of water. Death usually occurs within days of the onset of symptoms (Berger et al, 2003.)

         One of the most effective methods to decrease the chances for infection involves thorough washing of the wound with soap and water. Medical treatment should be administered immediately. Treatment consists of a regimen of one dose of immune globulin and five doses of rabies vaccine over a month long period.