Opening Remarks - Doctors Hospital at Renaissance

Opening Remarks
Kip Owen, MD
Agenda
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Border Safety Luis Solis
Security Briefing James Kniestedt
Disorientation and Getting Lost David Hinojosa
Poaching and Conservation Oscar Jaimez
Spider Bites Dr. David Lee
Bacon Bites Dr. Henry Stroope
Lacerations and Hand Trauma Dr. Sergio Rodriguez
Hearing Preservation Dr. Turner Wright
Wilderness Medicine Dr. Eron Manusov
Foot Trauma and Blisters Dr. Robert Brace
Near Drowning Dr. Noel Oliveira
Diarrhea Dr. Alberto Peña
Water Purification Dr. Robert Alleyn
Gunshot Wounds Dr. Jesus Valdes
Bones and Groans Dr. Kip Owen
Closing Remarks Israel Rocha
Border Safety
Luis Solis
Customs and Border Protection
Organizational Chart
5
5
Department of Homeland Security
Customs and Border Protection
Rio Grande Valley Sector
6
34 Counties
34,085 Square miles
316 River Miles
317 Coastal Miles
9 Stations
3 Checkpoints
2 Air Branches (MCA/HOU)
3 Marine Branches (PI, CCT, GAL)
7
RGV Sector – Special Operations
K9
BORTAC
Riverine Patrol
BORSTAR
Horse Patrol
Rescue Beacons
8
8
Sector Apprehensions
300000
250000
200000
150000
100000
50000
0
255,546
154,453
Total Apprehensions
97,762
59,766
59,243
FY 10
FY 11
FY 12
FY 13
FY 14 *
250000
192,359
200000
150000
100000
50000
Mexicans
96,829
40,732
19,034
47,823 49,939
38,353
57,624
63,187
OTMs
20,890
0
FY 10
FY 11
FY 12
FY 13
FY 14 *
9
MS-13 Gang
10
Talking Points
• Border Patrol works very closely with federal, state
and local partners.
• We appreciate the efforts of concerned citizens and
non-governmental organizations as they act as our
eyes and ears.
• However, we do not endorse or support any private
group or organization taking matters into their own
hands.
• Securing the borders can be dangerous, and
requires highly-trained law enforcement personnel.
11
Talking Points
• Please wear bright colored clothing and hats so
agents can easily identify you.
• Drug smugglers and militia usually wear military
camouflage – steer clear of them.
• Don’t attempt to detain immigrants for any reason.
If you do encounter, contact Border Patrol and
report direction of travel.
• Be prepared for unpredictable weather and
medical issues that could arise.
12
Questions?
13
Security Briefing
James Kniestedt
14
Disoriented / Getting Lost
David Hinojosa
15
Being Positionally Challenged
o Tracking an animal
o Ingress/Egress
Determining Direction
o Position of Son
o Wind direction
o Land Marks
o Tendencies to travel left or right
Situational Awareness
o Maps (Google Earth)
o Time of Day (Sunrise/Sunset)
o Monitor Weather conditions
o Tell someone your plans
Essential Equipment
o Compass
o GPS (Rhino)
o Phone
o Flashlight
o Water
o First Aid
Poaching and Conservation
Oscar Jaimez
Texas Game Wardens
Texas Game Warden
• Hidalgo County Game Warden
Will Plumas
Ira Zuniga
Harry Rakzosky
Oscar Jaimez
21 Years of service
15 Years of service
4 Years of service
11 years of service
Poaching
• Poaching has traditionally been defined as the
illegal hunting, killing or capturing of wild
animals, the term poaching has also been
used for the illegal harvest of wild plant
species.
Operation Game Thief
• Operation Game Thief is Texas' Wildlife Crime-Stoppers
Program, offering rewards of up to $1,000 for information
leading to the arrest and conviction for a wildlife crime.
Begun in 1981 as a result of laws passed by the 67th
Legislature to help curtail poaching, the program, a
function of the Law Enforcement division of The Texas Parks
and Wildlife Department, is highly successful, having been
responsible for the payment of over $195,000 in rewards.
Privately funded, the program is dependent on financial
support from the public through the purchase of OGT
merchandise and memberships, donations, sponsorships,
and gifts.
Fishing
Fishing
Hunting
Border Operations
Texas Game Warden
Ira Zuniga
(956) 371-7556
Oscar Jaimez (956) 270-3878
Operation Game Thief 1 800 792 GAME
Snake Bites
Rick Martinez, MD
TYPES OF POISONOUS SNAKES IN THIS AREA
Rattlers
 Water Moccasins
 Copperheads
 Coral snakes

RECOGNIZE THE SNAKE
Markings
 Pits
 Bite marks
 Wound characteristics

DO’S

Seek medical attention as soon as possible dial 911 or call local Emergency Medical Services

Get to Hospital as soon as you can

Try to remember the color and shape of the snake, which can help with treatment of the snake
bite don’t try to catch the snake

Keep still and calm. This can slow down the spread of venom.

Inform those who accompany you

Apply first aid if you cannot get to the hospital right away.

Wash the bite with soap and water.

Cover the bite with a clean, dry dressing.

Lay or sit down with the bite below the level of the heart
DON’T’S
Do NOT do any of the following:

Do not pick up the snake or try to trap it.

Do not wait for symptoms to appear if bitten, seek immediate medical attention.

Do not apply a tourniquet.

Do not slash the wound with a knife.

Do not suck out the venom.

Do not apply ice or immerse the wound in water.

Do not drink alcohol as a painkiller.

Do not drink caffeinated beverages.

Do not shock yourself
WESTERN DIAMONDBACK RATTLER
NO IT ISN’T!
BULL SNAKE
WESTERN DIAMONDBACK RATTLER
NO IT ISN’T!

DIAMOND BACKED WATER SNAKE
WESTERN DIAMONDBACK RATTLE SNAKE
WESTERN DIAMONDBACK RATTLESNAKE
READY POSITION
COPPERHEADS
COTTONMOUTH
WATER MOCCASIN RANGE
TEXAS CORAL SNAKE - “RED ON YELLOW”
CORAL SNAKE DISTRIBUTION
Spider Bites
David Lee, MD
64
General Information
 20,000 species of spiders in North /South America
 60 capable of biting humans
 4 dangerous to humans
 2 cause possible death and disability


Brown Recluse
Black Widow
 Both Spiders have venom more toxic than a rattlesnake.
Black Widow is fourteen to fifteen times more potent.
 Death is rare with both spiders


Usually in young person (less than 7 years of age)
Elderly
 Both located in North America

Midwestern and Southern States
Brown Recluse
 Size
 6-10 mm in diameter
 Light to Medium Brown
 Distinct Marking of a Violin on its head and upper back
Brown Recluse Habitat
 Usually found in the south and middle of the United States.
Not present in Florida or California.
Brown Recluse
 Initial Bite
 Thought the bite when compressed, tends to run and hide.
 Not a painful bite, frequently hours before any discomfort noted. Have
very small fangs and difficult to bite through clothing.
 Wound slowly enlarges with discoloration
o Red, turning to blue or black
o Skin necrosis (38%)
o Occasional Illness Symptoms
Brown Recluse
 Initial Treatment
 Ice on wound (rotate every 10-15 minutes)
 Elevate wound above level of heart
 Avoid activity
 Acetaminophen (Tylenol ) ok to use
Brown Recluse
 Secondary Treatment
 Tetanus Immunization
 Pain Control
 Antibiotics (probable later)
 Antihistamines (Benadryl)
 Controversial
 Use of Corticosteroids
 Dapsone (avlosulfon)
 Close follow up with MD
Brown Recluse Bite
DO NOT
 Apply Heat
 Use Steroid Cream (corticosteroids)
 Do Not attempt to remove venom
 No tourniquet on extremities
Black Widow
 Size
 Body 25-30mm
 Shape
 Has the “classic” Red Hour Glass shape on abdomen
 Spider
 Eight Eyes
 Lives 2 -3 years
Black Widow Habitat
 Mostly Central and Southern USA
 Primary a night hunter
 Prefers dark corners / crevices
 Garages, outhouses, under house.
Black Widow
 Bite
 Small single or duel pin prick, not painful for thirty (30) minutes to and
hour.
 Venom is neurotoxic
 Primarily muscle system effect
 Several muscle spasms and pain, extremities to abdominal muscles and
shoulders.
 Pain followed by weakness and tremors.
Black Widow
 Treatment
 Pain Control is primary concern
 Frequently IV meds
 Muscle relaxants
 Anti venom (very cautious use)
 Relieves pain in 30 minutes
Thank you!
David A. Lee, MD
Plastic Surgery
2505 Cornerstone Blvd.
Edinburg, Texas 78539
956-627-2878
Bacon Bites:
Wounds From Feral Hogs
Henry Stroope, MD
80
Henry F. Stroope M.D.
University of Arkansas
University of Arkansas for Medical Sciences
Feral Hog Attacks
•
Uncommon
•
Usually by a wounded or cornered animal
•
Can be unprovoked
•
May become more frequent as hog population
increases and hunting hogs becomes more
popular
Feral Hogs in Texas
Wounds
•
Created by slashing and gashing from the
lower jaw tusks
•
The upper tusks serve as permanent
whetstones against which the lower tusks grind
and produce sharp edges
Wounds
•
Usually the lower legs are involved but, any
body part may be wounded
•
Bleeding usually moderate but, severe
hemorrhage can occur
•
May lead to fatality from toxemia and blood
loss
Treatment
•
Pressure for bleeding / +/- tourniquet
•
Tetanus prophylaxis
•
Surgical debridement and repair
•
Antibiotics
Wooooo Pig Sooie
“RAZORBACKS”
Lacerations and Hand
Trauma
Sergio Rodriguez, MD
92
COMMON HAND INJURIES
IN THE BRUSH AND ON THE
WATER
Sergio Rodriguez, M.D.
McAllen Hand Center
51 21 S McColl Rd. - Edinburg, TX 78539
EPIDEMIOLOGY
Hand injuries are common in outdoor enthusiasts.
Some of these injuries are easy to diagnose, and
others are more difficult, usually because the signs
and symptoms are subtle or because the examiner is
inexperienced. In the field, when there are
environmental stresses, poor lighting, noise, and
perhaps even danger, it is even more difficult to
make the diagnosis.
DIFFICULT TO DIAGNOSE INJURIES
 A recent article in the European Journal of Emergency
Medicine points out “Four hand injuries not to miss: (18:186191 , 2011)….ulnar collateral ligament of the thumb injury,
Bennett’s fracture at the base of the thumb, the volar plate
avulsion fracture that occurs to the middle phalangeal bone of
a finger, and avulsion of the flexor digitorum profundus
tendon.
 Remember that these are all injuries that will eventually be
referred to a hand specialist, so the point is to suspect these
injuries so that they do not remain undiagnosed and undertreated.
ULNAR COLLATERAL LIGAMENT OF THE THUMB
INJURY…A .K.A . GAMEKEEPER’S THUMB (CHRONIC)
OR SKIER’S THUMB (ACUTE)
 This condition is commonly observed among athletes such
as volleyball players and Scottish fowl hunters.
 It can occur among ordinary people who sustain a fall onto
an outstretched hand.
NOT SURE WHY SCOTTISH FOWL HUNTERS
SUFFER THIS INJURY MORE COMMONLY
IMPORTANCE OF THE U.C.L. OF THE THUMB
METACARPOPHALANGEAL JOINT
 The ulnar collateral ligament is an important
stabilizer of the thumb. Thumb instability resulting
from disruption of the UCL profoundly impairs the
overall function of the involved hand. Because of
this, it is critical that these injuries receive
appropriate attention and treatment .
IMPORTANCE OF THE U.C.L. OF THE THUMB
METACARPOPHALANGEAL JOINT
IMPORTANCE OF THE U.C.L. OF THE THUMB
METACARPOPHALANGEAL JOINT
BENNETT’S FRACTURE AT THE BASE OF THE
THUMB METACARPAL BONE
 This type of injury can occur when a person punches a hard
object or falls onto the thumb. This can also occur if you fall
while holding onto handle bars or a firearm.
VOLAR PLATE AVULSION FRACTURE OF THE
MIDDLE PHALANGEAL BONE OF A FINGER
AVULSION OF THE FLEXOR DIGITORUM
PROFUNDUS TENDON….AKA “JERSEY FINGER”
A Jersey finger is an injury to a FDP tendon at its point of
attachment to the distal phalanx. The tendon ruptures at or near
its insertion into the bone.
HOW TO TREAT SPECIFIC INJURIES
FISH HOOKS!!!!
FISH HOOKS IN WANTED PLACES
FISH HOOKS IN WANTED PLACES
FISH HOOKS IN FINGER
HOW TO REMOVE A FISH HOOK FROM THE
FINGER
COMPLICATED FISH HOOKS IN THE FINGERS
HAND LACERATIONS
Simple
“Complicated”
TREATMENT OF SIMPLE WOUNDS
STOP THE BLEEDING !
 Apply direct pressure to the wound.
 Elevate it above the level of the heart.
 Sit the victim down, lie them down if they are feeling
lightheaded.
This works to stop the bleeding in the vast majority of cases
NEXT STEP IN TREATING SIMPLE WOUNDS
 The sooner the wound is cleaned and washed out
(irrigated) and foreign body decontamination is
removed, the less likely the wound is to become
secondarily infected.
 To accomplish this, do the following:
Soapy water is antibacterial even though it doesn't contain
agents that kill bacteria. It's useful in cleaning a grossly
contaminated wound or soaking a puncture wound. If you have
nothing than the cleanest water available.
 Dress the wound.
TREATMENT OF MORE SEVERE WOUNDS
STOP THE BLEEDING
More serious cuts may require using pressure points. A pressure
point consists of applying hands to an area where an arter y goes
over a bony prominence. If this cannot be done then a tourniquet is
an option. The whole idea of a tourniquet is to keep blood from
getting to the wound that isn't closing or clotting. This too must be
done quickly and can involve placing a belt or a rope over a pad
that is between the heart and the wound. It can be tightened using
a stick to stop the bleeding.
Get professional medical help as quickly as possible
CRUSH INJURIES TO FINGERTIPS
Simple
Complicated
SUBUNGEAL HEMATOMA
Treatment: consists of Trephination
FINGERTIP AMPUTATIONS
FINGERTIP AMPUTATIONS
Classification
EXAMPLES OF FINGERTIP AMPUTATIONS
MANAGEMENT OF THE AMPUTATED PART/S
MANAGEMENT OF THE AMPUTATED PART
Step 1: Briefly rinse amputated part
with water (to remove any dirt)
Step 2: Place amputated part in
plastic bag (to protect and keep
clean)
Step 3: Place plastic bag containing
the part in a container of ice water
(to keep cool and preserve tissue)
Note: Take patient and
amputated part to emergency
department immediately!
TREATMENT OF AMPUTATIONS
Revision of Amputation
REVISION AMPUTATIONS
FINGERTIP COVERAGES
Advancement flaps
OTHER FORMS OF COVERAGE
TREATMENT OF AMPUTATIONS
Replantation of digit
SPECIFIC INFECTIONS
Paronychia
Felon
PARONYCHIA
Attempt warm soaks
with antibacterial soap
and antibiotics….
if it does not resolve then
drainage.
FELON
Attempt warm soaks with
antibacterial soap and
antibiotics….
if it does not resolve then
drainage.
SPECIFIC INFECTIONS
Pyogenic flexor tenosynovitis
SPECIFIC INFECTIONS
Mycobacterium Marinum
MYCOBACTERIUM MARINUM
TREATMENT
A prolonged course of antibiotic therapy is curative
in most superficial cases but adjunctive surgical
intervention is sometimes indicated in extensive
and deep infections.
M. Marinum is heat sensitive and very hot
compresses applied directly to the infected area
have been effective in eradicating the bacterium.
QUESTIONS???
ARGENTINA
Hearing Preservation
Turner Wright, MD
134
Introduction
Education:
Undergraduate -Texas A&M
Medical School - University of Texas Southwestern Dallas
General Surgery - University of Texas Health Science Center
Houston
Residency Otolaryngology and Head and Neck Surgery – Duke
University Medical Center
FACS
Valley ENT, McAllen –since 2001
Hearing Protection
Rifles, shotguns and pistols
Wind noise while boating
Ear muffs
Gun Noise
Gun Noise
Wind Noise
Noise Limits
Foreign Body in Ear/Nose
EAR
Bugs – drown with any liquid such as baby oil, water, beer
NOT COLD
Beans or seeds – do NOT flush with liquids
Other objects – see your doctor later
Never use Q-tips
Foreign Body in Ear/Nose
NOSE
If you cannot see it leave it alone
Afrin
Nosebleeds
Pinch nostrils, not the bridge of the nose
Lean slightly forward
AFRIN, AFRIN, AFRIN
Be very careful packing the nose
Allergic Reactions
Simple stings – ice, Benadryl, Claritin
Any swelling of the lips or throat – get to the nearest ER ASAP
Thanks
I do make ranch calls.
956-998-NOSE (6673)
DR. TURNER WRIGHT
"Make the Wright Choice"
Www.wrightsinuschoice.com
Wilderness Medicine:
Heat, Scratches, and Cuts
Eron Grant Manusov, MD
148
OBJECTIVES AND GOALS
Objectives: Each learner
will be able to:
Goals:
• Recognize and treat heat injury:
rash, exhaustion and stroke
• To prevent heat injuries
• Recommend fluids and electrolyte
replacement for the heat.
• To understand fluid and salt
rehydration
• Prevent skin injury
• Treat local infections
• Recommend contents of a medbag
• To manage heat injuries
• To prevent skin injury
• To prevent infection
• To treat local wounds and
infection
HEAT INJURY
HEAT STRESS INJURY
• Takes 10 days to acclimate to heat
• Sweat production
• Humid and Wet Bulb Reading
• Reflection, strenuous work, wind
• 8 hour shift 6-8 liters of sweat with
6-16 gm of salt (10-15 gm salt per
day average American diet)
• Over-hydration and low sodium
FLUID
• .1% or 1 tsp/gallon to prevent
water or salt depletion.
• 400-600 ccs of water before
• 90-190 ccs every 10-15 minutes
• DO NOT GO LONGER THAN 30
MINUTES during active period
• < 6gms per 100 cc of water
• Watch sugar!
HEAT RASH PRICKLY RASH
Cool
Fluids
Rest
Dry skin
Loosen clothes
HEAT CRAMPS/HEAT EXHAUSTION
• Salt depletion can cause cramps,
abdominal cramps
• Treat for shock
• Compensatory shock
• Lie down elevate feet
• Dizziness, headache, light headed
• Sweating
• Loosen clothes
• Remove from sunlight, elevate feet
• Temperature may be elevated
• Spray with body temperature
water
• Treat 10-15 gm of salt
• Massage limbs
• Ice in groin and arm pits
HEAT STROKE
Symptoms
•
•
•
•
•
•
•
•
•
Mental status change—heat stroke
Mortality 10-20 %
Hyperpyrexia
Seizures
Focal deficits
Coma
Hallucinations
Don’t give antipyretics
Don’t give alcohol sponge bath
Risk Factors
• Alcohol
• Laxative use
• Medications
• Cocaine, pseudoephedrine,
thyroid
• Antihistamines/anticholinergics
• Ephedrine/caffeine
SCRATCHES AND
SKIN INJURY
Prevention
Keep clean
Avoid infection
Treat
PREVENTION
Gloves
Long sleeves
Boots: acclimated
Balaclava
TREATMENT
• Iodine tablets: 5-15 /liter
• Salt water
• Bee honey
• Sugar
• Sphagnum Moss
TREATMENT CONTINUED
• Avoid Alcohol
• Cleanse gently with mild soap or
Hibiclens
• Consider tetanus
• Antibiotic Salve (Neosporin) (Triple
antibiotic)
• Remove Splinter
• Spyroflex Wound dressing
• Air Dry
• KEEP CLEAN
MEDICAL SUPPLY
• Antibiotic Ointment
• Spyroflex 2 x 2 dressing 2/person
• Hibiclens 4 oz bottle
• Spenco 2nd Skin Burn Dressing
• Tetrahydrozoline Ophthalmic .05%
• Nu-Gauze
• Hydrocortizone cream 2%
• Coverlet bandage strips 1 x 3
• Clotrimazole cream 2%
• Water proof tape
• Cavit dental filling paste
• Sam splint 36 in
• Gloves 2 pair
• Elastic bandage 2,3,6 inches
• Irrigation syringe
• Surgical kit
• Skin glue (super glue)
ADVANCED MEDICAL
•
•
•
•
•
•
•
•
•
•
•
Topical Steroid (topicort)
Clortimazole 2% Cream
Diflucan
Diphenhydramine (Benedryl)
Loperamide 2mg (diarrhea)
Bisacodyl 5 mg (constipation)
Ibuprofen 200 mg
Percogesic= Tylenol/benedryl
Cimetidine 200mgs
Norco 10mg/325 pain and cough
Antibiotics
• Levequin
• Doxycycline
• Rocephin
Foot Trauma and Blisters
Robert Brace, DPM
162
Overview
Definition
Causes
Complications
Treatment
Prevention
Definition
1.
Superficial fluid filled lesion commonly found on the
extremities- hands and feet.
Causes:









Friction-“Hot Spot” Poor fitting shoes, socks, wet feet.
Insect Bites- Brown Recluse Spider, Blister Beatle.
Poison Ivy, Oak
Drug Reaction
Puncture Wounds, Thorns, Nails
Infections, Diabetes, ect.
Bunions, hammer toes, callous formation
Excessive sun exposure
Burns, fire
Complications
 Infections- Necrotizing Fasciitis “Flesh eating
bacteria”, from Bay Fishing Water, Stagnant Water
Tanks, Ponds.
Cellulites, Red Streaks
Loss of limb
Fever
Treatment
A.
Remove Irritation Source
Shoes, Socks, Decrease Pressure
B.
Pop or no Pop



Pop if infected
Increased Pressure
Pus filled
Leave intact if common blister, due to ill fitting shoes or
increased activity.
D. De Root
E. Dressing, Pad, Covers or Cease Activity
F. Change shoe gear, sandals, ect.
C.
First Aid
A. Stop source of cause
B. Clean and Protect Area
C. Medication
Betadine, Neosporin, Antibiotics, Keflex
D. Watch for: Streaking, Bleeding, Swelling, Fever
increased warmth.
Prevention






Old shoes already broken in well fitted.
Pads- Mole Skin, Band Aids, Sponge pad
Soft Cushion Socks
Keep Feet Dry- Powder, J & J ect.
Ethol medications
Your limitations



Health, diabetes, obesity
Physical shape- out of shape
PVD, Swelling feet
 Medications





HBP
Diabetes
Blood Clots, Blood Thinners, Neuropathy
Decreased sensation to pain
Allergies
Near Drowning
Noel Oliveira, MD
170
DEFINITION
 "Near drowning" means a person almost died from not
being able to breathe (suffocating) while under water.
 Preventing drowning accidents is one of the number
one reasons dive teams are established. Drowning is
the second leading cause of accidental death,
averaging approximately 8000 deaths per year in the
United States alone.
CONSIDERATIONS
 Thousands of people drown in the United States each year. Most drownings
occur within a short distance of safety. Immediate action and first aid can
prevent death.
 A person who is drowning usually cannot shout for help. Be alert for signs of
drowning.
 Children can drown in only a few inches of water.
 It may be possible to revive a drowning person even after a long period under
water, especially if the person is young and was in very cold water.
 Suspect an accident if you see someone in the water fully clothed. Watch for
uneven swimming motions, which is a sign that the swimmer is getting tired.
Often the body sinks, and only the head shows above the water.
 A near drowning is a multi system disorder with the lungs
as the primary target organ and hypoxemia the major
adverse effect. The victim will present with manifestation
of hypoxemia, acidosis, hypoperfusion, respiratory distress,
and CNS anoxia. Complications of near drowning are
respiratory arrest, disseminated intravascular coagulation,
coma, postimmersion respiratory syndrome, neurologic
sequella, and multi system failure. Prevention, through
education and improved safety measures, should be the
goal of every rescue team. Help promote water safety and
knowledge of CPR and resuscitation techniques.
CAUSES
 Attempted suicide
 Blows to the head or seizures while in the water
 Drinking alcohol while boating or swimming
 Falling through thin ice
 Inability to swim or panicking while swimming
 Leaving small children unattended around bathtubs and pools
 Running out of air while SCUBA Diving
Victims of Near Drowning episodes are
usually children. The time under water and
the temperature of the water determine the
degree of damage suffered by the individual.
The cooler the water the better, since cold
water can slow down the body’s metabolism
allowing for the brain to use less O2.
Lack of oxygen when complicated by cardiac
arrest worsens the damage of near drowning
because of the inflammatory response
following loss of cellular nutrients and
oxygen.
FIRST AID
When someone is drowning:
 Do NOT place yourself in danger.
 Do NOT get into the water or go out onto ice unless you are absolutely sure it is
safe.
 Extend a long pole or branch to the person or use a throw rope attached to a
buoyant object, such as a life ring or life jacket. Toss it to the person, then pull
him or her to shore.
 If you are trained in rescuing people, do so immediately only if you are
absolutely sure it will not cause you harm.
 Keep in mind that people who have fallen through ice may not be able to grasp
objects within their reach or hold on while being pulled to safety.
 Near Drowning while SCUBA Diving has different implications (The Bends and
Pneumothorax)
SCUBA DIVING
Barotrauma is associated with SCUBA diving with the
worst cases being air embolism or CNS Bends. Any
SCUBA diver who is a near drowning victim and
exhibiting CNS depression should be assumed to have
one of these.
The near drowning is not his major problem but
secondary to it. Hyperbaric recompression therapy must
be started as soon as possible.
 The CXR may be normal, especially in
children, if laryngospasm (diving reflex)
occurs. Otherwise, a "batwing" pattern of
pulmonary edema is seen. The situation
may be complicated by ARDS.
CONCLUSIONS
 Near drowning accidents are estimated at 500 to 600
times more common than drownings
 Initiation management is the most crucial
determinant of survival of the victim.
Surviving Diarrhea in the
Brush
Alberto Peña, MD, FACS, FASCRS
182
Surviving Diarrhea in
the Brush
Alberto A. Peña, MD FACS, FASCRS
ColoRectal Specialist of South Texas
Edinburg, TX
Disclaimers and Disclosures
• I have no disclosures
• The following slides may be of a
graphic nature and not appropriate for
young children or the faint of heart and
for the most part are kind of yucky.
What is diarrhea?
Osmotic
• water drawn into bowel
• bowel prep
Secretory
• body releases water into
bowel
• infections
Exudative
• blood, pus
• Infections
• IBD
What causes Diarrhea?
o Infections
• Viral
• Bacterial
o Medications
o Foods
• Allergies
• Irritants
o Cancer
o Diseases
• Hyperthyroid
• Diabetes
• IBD
o Laxative Abuse
o Alcohol Abuse
o Stress
Wilderness Acquired Diarrhea
Unique
• No where to deposit
• Difficult to clean and maintain sanitation
• Ingesting water or food can make it worse
• Water or food contamination
Diarrhea in Wilderness
Most often waterborne
•
•
•
•
•
•
•
Giardia lambila
Cryptosporidium
Esherichia coli
Campylobacter jejuni
Salmonella
Shigella
Norwalk virus
Danger!!
o Dehydration
• Loss of up to 25 L in 24 hours
o Electrolyte disturbances
• Sodium
• Potassium
Survival
Prevention
o Disinfect all drinking water
• boiling
• filtration
• halogenation
o Proper food handling
• do not eat left overs
• durable foods
Survival
Prevention:
Camp hygiene
o wash your hands
o keep sick people out of kitchen
o wash and dry cooking gear after each use
o don’t share personal items
o human waste disposal
• 100 yards from nearest water
Survival
Treatment
o Replace lost water
•
clear liquids
 avoid juices
o Replace electrolytes
•
Oral Rehydration Salts
•
1 L water +1 teaspoon salt +8 teaspoons
sugar
o Pepto-bismol, Imodium, Lomotil
Survival
o
o
o
Anti-diarrhea medication
• Do not take if blood or pus in stool
Antibiotics
Avoid high fiber
• Berries
• Plants
Effects of Diarrhea
Effects of Diarrhea
Effects of Diarrhea
Effects of Diarrhea
Questions?
Alberto A. Peña, MD FACS, FASCRS
ColoRectal Specialist of South Texas
Edinburg, TX
Water Purification
Robert E. Alleyn, MD, FACS
199
Gunshot Wounds
Jesus Valdes, MD
216
Penetrating Trauma
The Hole Story
Treatment Goals
• Safety!!
• ANY penetrating trauma should be
treated with the utmost urgency.
• A small hole on the outside might be
hiding a large hole inside.
• A large hole outside can mask
massive internal damage.
Treatment Goals
• ABCs, as always.
• Rapid scene times… grab ‘em and get
moving to the hospital.
• Airway support to include intubation
(more often needed for thorax injuries.)
• Ventilatory support as needed.
• IV enroute, fluids as protocol/Med
Control requests.
Treatment Goals
• Hemorrhage control if possible.
• Occlusive dressings for sucking chest
wounds.
• Needle Thoracostomy as needed for
tension pneumothorax.
• Bilateral needle decompression ONLY
in an intubated patient.
Treatment Goals
• Early notification of the hospital.
• Constant reassessment…A GSW to
the chest can cause the patient’s
condition to change RAPIDLY. Be
vigilant.
• Again, rapid transport is the single best
method for treating a gunshot victim.
• Nothing else will be as helpful as a
physician and hospital trauma care.
Treatment Pitfalls
• Wasting time looking for the bullet or shell
casing.
• Thinking that a small hole is not a major issue.
• Wasting time trying to classify wounds as
entrance or exit.
• Closest facility vs. Closest appropriate facility.
• Delaying transport for ANY reason, other than
EMS crew safety.
Bullet Characteristics
• Caliber of the bullet (.22, .45, .357,
9mm, etc.)
• Blunt vs. Hollow vs. Pointed end
• Casing (unjacketed/full metal jacket)
• Density of material
Tissue Response
• Cavities – temporary and permanent
– Temporary is larger than the size of the
bullet, and is caused by compression of
air around the projectile.
– Permanent is the destroyed tissue from
the bullet itself.
Cavities
• The size of the cavity is not simply a
factor of the bullet size. Other factors
are important, but often unknown
– Deflection
– Yaw of bullet at impact
– Speed of bullet at impact
– Angle of impact
– Range from gun to target
Cavity Formation
Tissue
Temporary
Cavity
Diagram of bullet passing through tissue showing sonic
shock wave and the formation of a temporary cavity by
outward stretch of the permanent cavity.
38 Special Lead Bullet wound
.38 Special
Velocity = 880 fps
.45 Automatic Pistol Wound
.45 Cal Automatic pistol
- full metal jacket
- velocity = 870 fps
.357 Magnum Pistol Wound
Remington .357
Magnum
Velocity = 1400 fps
.22 Long Rifle Wound
.224 Cal Hollow Point Wound
NATO 7.62 Wound
M-80 7.62 mm NATO cartridge:
-Full Metal Jacket
-Non-fragmenting, Non-expanding
-Velocity = 2800 fps
7.62 mm Soft Point Wound
Winchester .308 Caliber Hunting Rifle (civilian)
-civilian equivalent of military M-16
-Soft Point bullet
-Fragmenting bullet
-Velocity = 2,900 fps
AK-74 Rifle Wound
M-16 Rifle Wound
M-16 .22 Cal Military Rifle
-Full Metal Jacket
-Fragmenting rifle bullet
-Velocity = 3035 fps
Buckshot wound pattern
12 gauge shotgun
- 27 pellet #4 buck shot
- Velocity = 1350 fps
QUESTIONS
Bones and Groans
Kip Owen, MD
261
OBJECTIVES
Life threatening injuries
Dislocations
Fracture care
LIFE THREATENING
INJURIES
Head Injuries
Spine Injuries
Pelvic Fractures
Total Assessment

Airway

Level of consciousness

Spine control

Localizing symptoms
LIMB INJURIES ARE DRAMATIC
Altered sensorium
EXPERT TRANSPORT ASAP

Assume spine injury

Stabilize

Midline pain

Extremity symptoms
HEAD INJURIES
HEAD INJURIES
EXPERT TRANSPORT ASAP
 Midline
pain
 Extremity
symptoms
SPINE INJURIES
PELVIC
FRACTURE
EXSANGUINATE

EXPERT TRANSPORT ASAP
STABILIZE THE PELVIS
THE USUAL SUSPECT
DISLOCATIONS
FINGER
ELBOW
SHOULDER
PATELLA
FINGER
FINGER
ELBOW
SHOULDER
SHOULDER DISLOCATION
SHOULDER DISLOCATION
REDUCTION
REDUCTION
PATELLA DISLOCATION
PATELLA DISLOCATION
REDUCTION
ASSESSMENT


WOUNDS?
STERILE(clean) moist dressing
after irrigation

COMPRESSION to control
bleeding
FRACTURE CARE
FRACTURE CARE
NEURO EXAM
Motion
Sensation
DETERMINE A METHOD OF
IMMOBILIZATION

ALIGNMENT
IMMOBILIZE a joint above and

a joint below


DO NOT over constrict
ASSIST & stabilize during

transfers

FRACTURE CARE
SLOW DOWN
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Closing Remarks
Israel Rocha, Jr.
DHR Chief Executive Officer
301