| Whitewater Nepal - Medical Matters |
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Medical Advice Medical Advice and Chapters from the guidebook ‘White Water Nepal’ (ISBN 0-9519413-3-X) by Dr Andy Watt This information is copyright but is reproduced here as a service to river runners to Nepal. It may be reproduced with the condition that it is not edited or changed, sold for profit, and that full credit is given to ‘White Water Nepal’ and the author. It is written for the kayaker or rafter planning a trip to Nepal and the advice may not be relevant (and could even be dangerous) if used outside this specialised context. Before you go. Everyone thinks of immunisations, but some simpler measures are important too. A physical examination is not necessary, but if you have had the following problems you should discuss them with your doctor before you go. Jaundice Peptic Ulcer Pregnancy On regular medication Diabetes Asthma Back Trouble Previous Shoulder Dislocation Tenosynovitis Piles (Injection treatment possible?) Ear Trouble Cystitis or Thrush (medicine to take with you?) Epilepsy (there are special dangers in a water trip, -generally these aren't advised). Have any allergies (especially penicillin, sulpha and other drugs) Do try and get fit before going - you will enjoy your holiday more, and be less susceptible to minor injuries such as sprains. No special exercises are necessary, much better to do things that you enjoy. If you are a kayaker, then time playing in a boat is the most important thing. If you are going on a paddle rafting trip then you would be wise to concentrate on exercise for the upper body and arms - ideally canoeing, or swimming (good for the pessimists). Many people practice a daily routine of stretching exercises - these will keep you supple and less prone to strains and have the advantage that they can be done anywhere whilst travelling. Consider the consequences of a dental problem developing in a wilderness area. We have seen people's holiday ruined by tooth ache. We strongly advise a visit to your dentist for a check-up. Do this at least two months before departure in case any work needs to be done. Immunisations There are no official vaccinations requirements for entry into Nepal; however it is worth recording your vaccinations on an international vaccination certificate, if for nothing else than to remind you for when you return a couple of years later and start thinking about vaccinations again. The list below is fairly exhaustive and a bit frightening; however most people will already have had most of these vaccinations and will probably only need jabs for Hepatitis, Typhoid and Meningitis. Start thinking about these about two months before departure. This list can be supplemented by more up to date advice from a specialist source: your family doctor perhaps, a travel medical centre, or a hospital specialising in infectious diseases. Hepatitis A - strongly recommended. Hepatitis A is transmitted differently, and is usually less serious than, Hepatitis B (see later) The organism is common in Nepal and is spread by contaminated food and water. It is present in river water - which is why it is of especial interest to rafters and kayakers. The incubation period is commonly 3-4 weeks and common symptoms are an itch, lethargy, fever, diarrhoea, and jaundice. The virus attacks and can damage the liver (N.B. if you enjoy beer and wine!). A bad attack can put you into hospital and leave you very unwell for several months. After one injection, the Hepatitis A vaccination covers you for 6-12 months; after the booster, it then covers you for 5-10 years. Previously, gammaglobulin was used, and is still available but lasts for a much shorter period. Typhoid - recommended One injection, lasts 3 years then booster required. Oral vaccine available, as 3 doses, protection lasts for 1-3 years Meningitis - recommended The risk is low in short term travellers, but the disease is serious and the vac-cination (one injection) is safe. Tetanus - strongly recommended You should have current cover for this. If you have not had a booster in the last ten years, then get one now before you stab yourself with a garden fork! Polio - recommended Again, you should have a booster if you have not had one in the last ten years. Measles, Mumps, Rubella (German Measles). Immunisation is recommended if you have not been previously infected or vaccinated. General Note The above are the standard immunisations which can be recommended to all travellers in that the advantages of immunisation clearly outweigh any side effects. For the less common, or lower risk diseases below, then it is less easy to make a clear assessment of the risks, which may vary with each individual traveller. We suggest that the following immunisations are not so necessary for short-term travellers, unless they are particularly concerned. We suggest that they should be considered by long-term travellers, those going to remote regions, and those coming in close contact with local people. If considering these immun-isations, you can get up to date advice from travel clinics at either your health centre or hospital or from specialised commercial services. They will have more up to date, and specialised information to complement the advice of your local G.P. Tuberculosis If concerned, you should ask your Doctor for a Mantoux test, then, depending on the result, discuss a BCG vaccination. Hepatitis B This is spread by infected person's blood coming in contact with your own through cuts, re-used needles, blood transfusion, swallowing, sex, inhalation, etc. For most travellers this is probably very low risk, but it is a severe and occasionally fatal illness. Immunisation requires three injections and is safe but expensive. Rabies If you avoid dogs then the risk of infection is low. If however you do get bitten then very expensive modern treatment with anti Rabies Serum plus immunisation is essential, safe, but expensive; 3 doses over 1 month last for 2-3 years and readily available provided you can return soon to Kath-mandu - see Appendix A. If you are planning a remote river trip where you will be away from Kathmandu for an extended period then you may consider that the immunisation is worthwhile. Modern (‘Diploid cell’) vaccine is safe but expensive: three doses are needed over 6 months and it lasts three years. The expense can be reduced by intradermal injection of one tenth of the dose. Diptheria Unless you are working with children, there is little risk of infection. You were probably vaccinated as a child and are still immune. If you are concerned about this disease you should discuss a test or low dose booster with your Doctor. Cholera The World Health Organisation no longer recommend Cholera Vaccination for travellers because the vaccine is only partly effective and has significant reactions. Japanese B Encephalitis This a mosquito-borne disease so is not found above 1000 metres. Cases have been reported in the Terai, but not usually affecting tourists. It is, though, a very nasty disease and the vaccine is safe and effective; so if you plan to spend time (espec-ially in rural areas) in the Terai or North India, you should consider this vaccin-ation. Malaria Precautions Malaria is transmitted by mosquitoes; these like hot damp conditions, so malaria is fairly prevalent in the Terai (The lowland plain adjoining the Indian Border), especially in the monsoon and post- monsoon period, despite campaigns to control it. Mosquitoes are fewer in the dry season and become fewer the higher you go and are not usually found above 1000 metres: so the Kathmandu valley is quite safe. The illness is characterised by fevers and chills which can be easily mis-diagnosed. Modern treatment is normally effective - the disease is only fatal if it is not diagnosed and the parasite invades the brain (cerebal malaria). Simple preventative measures at evening and night-time to prevent mosquito bites are quite effective - long sleeved clothes, mesh on doors and windows, bed nets impregnated with insect repellent, mosquito coils and insect repellent. Only a few mosquitoes carry the parasite and these rarely bite in the daytime. Anti-malaria medicines are not 100% effective but are reasonably safe in long-term use. These need to be some time before arriving in the risk area (normally 2 weeks), taken regularly throughout your stay and for 4-6 weeks after leaving it. Note that there are usually very few mosquitoes or other biting insects on riverside beaches but you may be exposed when passing through the Terai at the end of your river journey. The one night journey from the end of the Sun Kosi to Kathmandu illustrates the risk/benefit decision that people have to make in regard to health problems nowadays - do you take 6 weeks of medicine (relatively expensive and tasting fairly horrible) for a one night possible exposure to a few biting insects? Covering up in the evening is probably the best compromise. If you are spending much time in the Terai or in India, then we would definitely advise you to take a course of anti-malaria drugs. Chloroquine is the most commonly prescribed drug but there are patches of resistance to this; thus European doctors usually prescribe an additional drug, Paludrine to cover these. Mefloquine is sometimes prescribed but has side effects. Doxycycline is occasionally prescribed but should be avoided by river runners because it frequently predisposes to Sun burn. Staying Healthy Introduction Most first-timers to Nepal are concerned about exotic diseases; indeed mention Nepal to most people and the subject of disease is one of the first things that they ask. Happily, the reality is that you are unlikely to experience anything worse than perhaps a mild case of diarrhoea. A few simple rules are outlined here - follow these and you should be able to avoid common diseases - and perhaps even that one episode of diarrhoea. More detailed advice on medical problems is given in Appendix A. Common Diseases By far the most important group of diseases are the ‘faeco-oral’ ones that enter your body through your mouth. These are excreted in someone else's stool and by various paths they come to your fingertips - this is the key point where your protection comes in. The diseases concerned are the diarrhoeas, hepatitis A, Typhoid, Polio and some worms. The reason that these bugs get to within arms reach is that, unlike home, toilet waste is not flushed away or treated, and is in contact with the drinking water supply. Any open water in the third world must be considered as infected so this is of particular relevance to kayakers and rafters Note that the beaches we camp on may look clean but hide disease. Food is involved because it is usual for local people to defecate in the fields where crops are growing. In addition, most vegetables are washed in untreated open water. However, the plus side of people shitting in the fields is that raw sewage does not normally flow straight into the rivers as it does in many countries, so most rivers in Nepal are surprisingly unpolluted. HELP! Does this mean that we dehydrate or starve? - No, a few germs will be dealt with by your bodies' natural defences; it's a lot of germs that can harm you. You can eat well, drink lots and stay healthy if you follow a few simple rules: Health Guidelines 1. Wash your hands before each meal - so simple, so easily forgotten! In the course of the day you will have picked up a few bugs, and hand washing (preferably with soap) will remove these. 2. Consider all water to be infected and not safe for drinking unless you sterilise it or have seen it boiled. Bottled or canned drinks are generally safe as is tea from Chai stalls where both milk and water are boiled. Check the seals on bottled water as some places refill the empty bottle with local water. Ice and ice cream can be made from infected water so are best avoided. 3. Vegetables and fruit should be either cooked or peeled (Hint: carry a small pen knife in your pocket on bus journeys). Salad type vegetables can be washed and soaked in an iodine solution - but avoid green leafy vegetables such as lettuce or spinach that have a large surface area to collect germs and are difficult to wash. It's probably best to think of all green salads and ice cream as dangerous treats - best avoid until you get home. 4. Eat freshly-cooked, hot, simple food - whether cooked in a smart restaurant, on a road side stall, or on your camping stove. Avoid reheated food. 5. Be wary of meat unless fresh and well cooked. Also be wary of dairy products with the exception of plain Yoghurt which is normally safe and good for you. Try to avoid any food with flies on it. 6. Try to eat off clean utensils. On the river trip these can be washed with boiling or sterilised water. On a bus trip, consider carrying a small pack of wipes or tissues for cleaning spoons, cup rims and hands. 7. Wear shoes - especially near villages or on popular beaches. Hook worm and scabies are caught by barefoot people. 8. Clean all open cuts, however small, with iodine at the end of each day. 9. Drink plenty so that your urine is always clear or a pale yellow. These simple rules should help you avoid most problems; it has been shown however, that even obsessive hygiene cannot prevent the occasional bout of diarrhoea in your group. If you are on a commercial raft trip your guide will be able to advise treatment and medications if needed. `If, as is more likely, you have diarrhoea in Kathmandu - from all those lovely cream cakes? - then there is a detailed treatise on the subject in Appendix A. Dehydration Probably the most common and yet least recognised health problem on raft trips is dehydration - people get dizzy, light-headed, suffer headaches and feel vaguely unwell: being surrounded by water all the time, dehydration is the last thing people think of! Physical exertion, dry air, sunshine and warm breezes mean that you need to drink lots more than you might imagine - 3 litres in a day would not be unreasonable. Oral Contraceptives If you are taking ‘the Pill’ (Combined oral contraceptive pill) then note that there may be problems of reduced absorption if you have to take antibiotics or have a gut infection. Probably the simplest way to manage is to keep taking the pill, the only proviso being that you miss out the fourth (placebo or sugar pill) week and go on to the next packet directly. In addition, start your alternative method of contraception and continue this for a week after the illness or antibiotic has finished. By then, you will effectively have started a new course of the pill and will be back to the same level of protection. If vomiting occurs within four hours of taking your pill, then take a second pill. If further vomiting, start using the alternative method of contraception (usually condoms) and continue the pill as above. It is a sensible precaution to carry an alternative method and a spare supply of the pill in a different bag. Water Sterilisation Dead easy - two drops of iodine tincture in a litre and wait ten minutes! This is generally acknowledged by authorities as the best method. Well-proven, convenient, cheap, and almost no side effects. It kills almost all known germs - even Amoeba and Giardia. Iodine has been taken continuously by some overseas workers for several months, however there is currently some research into the long term use of iodine and it's safety. Iodine comes in several forms *: the most common is tincture of iodine in alcohol. This is easily purchased in Kathmandu. It is available from your pharmacist back home - but not too readily because it's not in high demand and it is a cheap product with little profit. Your Pharmacist will probably try to sell you some much more expensive sterilisation tablets. Never mind, buy your iodine in Kathmandu and mollify your friendly home pharmacist by buying two plastic dropper bottles off him - he may not have empty ones, but eye or nose drop bottles are normally cheap enough just to empty - these are difficult to get in Kathmandu. (Buy two or three because you're bound either to lose them, or give them to friends). Two drops will sterilise one litre of water in ten minutes, double the dose if the water is cloudy and double the time required if the water is cold. If you don't like the faint taste of iodine then the flavor can be easily disguised with fruit drink powders (Cremola and Tang fans take note) but AFTER the water has been sterilised. Flavoured water like this is a good idea because it encourages you to drink plenty - important in a hot climate. If the water is very cloudy then it is a good idea to let it stand in a container so that the particles settle out before you transfer to your water bottle for purification. If necessary, cloudy water can be filtered through a clean cloth. It is possible to reduce the dose of iodine but you have to leave the water for a correspondingly longer time to sterilise. Forget the sales hype for filters and other purifiers - they are expensive, bulky, less effective and more to the point can be dangerous if the filter develops infection or hidden cracks. They may perhaps be useful on large raft trips. Water can also be sterilised by boiling, but this may be wasteful of precious fuel. It used to be thought that water needed to boil for 10-20 minutes to be safe, but recent research has shown that bringing to the boil, even at moderate altitude, is sufficient. If you are pregnant, have an over-active thyroid gland, or are allergic to iodine then chlorine based tablets e.g. Puritabs, can be used instead of iodine. These are considerably more expensive and probably do not protect against giardia and amoebas. * Other forms of iodine are :Lugol's Aqueous Iodine - use 8 drops a litre. Iodine crystals - keep in a small bottle of water and use the saturated solution at 15 mls per litre (careful you don't pour out the crystals). Iodine tablets - expensive and effective, but only have a limited shelf life - use one tablet per litre. |
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Medical problems Appendix A by Doctor Andy Watt Duty of Care In this guidebook, I discuss diagnosis, treatment techniques and drugs that are above what the average First Aider would normally be expected to use. I do this because I (and most other wilderness doctors) believe that, in the wilderness, the use of these advanced skills can reduce pain and distress, can prevent illnesses becoming worse, and (rarely) can prevent death. However, there are complications that can arise from problems like wrong diagnosis or side-effects of drugs. In a short guidebook, there is limited information that I can give. More information can be got from books like those mentioned below. What is here, is provided in good faith as being what I believe is the best balance of information. There is a responsibility, on me, in providing this - and this is part of what is called the 'duty of care'. River Runners, too, have a 'duty of care' i.e. a responsibility to each other, to the trip in general (e.g. taking reasonable steps to avoid accidents, keeping safety gear in condition) and for the medical aspects of the trip - note that this doesn't all fall on the trip First Aider. The duty of care includes: · Reasonable planning before departure · Implementing medical skills in accordance with the training and advice you have received (note that a higher level of training is not required - but that what you do know is applied properly). · Any person you treat is aware of your level of knowledge. · That they consent to treatment. Reasonable planning includes · Insurance · Anticipating common problems · Doing some research into what the medical kit should contain · Having backup in Nepal (e.g. notifying embassy, having a plan for dealing with evacuation, knowing where the nearest hospitals are, or having a local agent who can handle emergencies,).. Introduction As we said in the earlier section on staying healthy, you are unlikely to suffer anything worse than a stomach upset - however, if you do have more serious problems, these may well be many miles from any road, hospital or telephone.. Here, we don’t attempt to cover all serious injuries - (your First Aider should have some knowledge of these) but rather those problems that we feel are particularly relevant to river running in Nepal. An important skill for First Aiders to have is the ability to take a history and examine a patient (various texts offer different methods) or better is to attend a specialised wilderness medicine course. In our experience the common problems likely to be encountered are accidents (particularly around the fire), diarrhoea, and complications of colds. Diarrhoea, Dysentery and Food Poisoning Definitions: · Diarrhoea: Loose bowels due to simple gut infection not requiring treatment beyond fluid replacement. · Dysentery: A more severe infection with an ill patient, temperature, and blood and slime in the stool. · Food poisoning: Acute, often severe, episode of vomiting and diarrhoea start-ing and finishing within a day or two. Diarrhoea is a fear of many first timers, but this fear is usually exaggerated and the diarrhoea is just a minor inconvenience needing only fluid replacement. Again, we emphasise the importance of good hygiene being your best protection. Types · Viral - This is the commonest and usually self-limiting - the body restores order after one to several days - just as well, because antibiotics are no use against viruses. Treatment is simple fluid replacement - see later. · Bacterial - Often self-limiting as well. The severe, sudden onset diarrhoea’s and those that occur within 3 weeks of arrival in Nepal are usually bacterial. · Amoeba/Giardia - Much less common than the above and usually cause more chronic diarrhoea with a slower onset and lasting for days or weeks. · Food poisoning - This is caused by bacterial toxins, not the bacteria them selves; they are thus usually short, self-limiting illnesses. Within 2-6 hours of consumption of food there is sudden onset of vomiting, abdominal pain and diarrhoea leaving an exhausted, unwell patient. Recovery is often rapid: full recovery often takes place within two days. Fluid should be taken if possible, and anti-vomiting medication may be useful but antibiotics are of no benefit. ( Note that the first day of Bacterial dysentery is often similar so any antibiotics could be delayed for at least a day). Treatment Oral Rehydration Therapy (ORT) is your most important remedy. The discovery and promotion of ORT has saved millions of third world children from death. Even in the most severe form of diarrhoea, Cholera, it is the fluid replacement that saves the lives - not any drugs. A much simplified sum show why this can be important. 10% dehydration will make you very unwell. 50% - 60% of your body weight is water. Therefore, in a 65 kg person, a fluid loss of 3.5 litres brings them close to the edge. The aim of fluid replacement is the ability to produce a dilute (pale yellow) urine. Any clean fluid will do in the early stages, but after a while, salt and glucose replacement become important (N.B. Rafters rum punch is not recom-mended). If you have Jeevan Jel, Diorylate, or similar rehydration powders then use these (they taste a lot nicer - which makes it easier to persuade the patient do drink the quantity of fluid that is needed). A makeshift solution can be made from 2 level teaspoons of sugar and a small pinch of salt in a glass of clean water. Potassium can be gained from bananas or fruit juice. Severe Diarrhoea This requires treatment which should be aimed at the appropriate bug. However, no matter which bug causes diarrhoea; your stool looks the same to you, me, or even an experienced Doctor without his microscope. Therefore, some rules of thumb are required for those wilderness consultations halfway down the Sun Kosi: Simple diarrhoea with none of the symptoms below only needs simple fluid replacement. Carefully review your hygiene practices to try to identify any lapses. Both sufferer and the group should reinforce their hygiene to prevent further spread. Consider antibiotics if: 1. After 3-5 days the diarrhoea persists and the patient is tired and unwell. (If you are a self-sufficient group facing some hard paddling, with only limited time and supplies, then you may decide to take antibiotics before 3-5 days.) 2. If the diarrhoea had a sudden onset, with blood, slime, very frequent stools, and a temperature, then it is probably bacterial dysentery (but see the note above about food poisoning) and should be treated with Norfloxacin or Ciprofloxacin - bugs in Nepal are becoming increasingly resistant to the old favorite of Bactrim /Septrin. 3. If the diarrhoea has had a gradual onset there are two possibilities: · Eggy burps, excess farts, abdominal distension, intermittent diarrhoea, with no temperature; this is probably Giardia. · The above plus abdominal cramps, weight loss, and blood in the later stages; probably Amoeba. Follow up by a medical clinic is recommended - further antibiotics may be needed. Despite popular folklore it is uncommon. Treatment in both cases is Tinadazole or Flagyl. N.B. no alcohol. Anti-diarrhoea agents: Lomotil/Imodium and Kaolin/Morphine. These work by paralysing the bowel and therefore reduce the body's ability to flush out the infection. It is obviously better to flush out the infection and replace the fluid loss with ORT but these drugs are useful as temporary expedients to stop your bowels up whilst on extended bus or plane journeys, or if you get severe gut cramps. Why not take antibiotics preventatively or before the 3-5 days is up? · All viral, and some bacterial diarrhoea’s are self-limiting. · All antibiotics have side effects. · Antibiotics change the natural bugs in your gut, killing off good bacteria as well as harmful ones. · Bugs get resistant to frequently used drugs. The CIWEC clinic in Kathmandu has demonstrated that 85% of diarrhoea that starts within 3 weeks of arrival to Nepal is bacterial i.e. susceptible to antibiotics. However, many of us are not keen to take drugs too soon in an illness. One rule you could use is - take antibiotics if the diarrhoea is becoming a problem to the patient. Note that many Americans take Pepto Bismol to attempt to prevent and treat diarrhoea. Should I eat anything? Obviously keep taking fluids. You won't starve the bugs by not eating (as they have a 25ft tube of rich juices to thrive on) but you will provide further material for your gut to have diarrhoea with. The best rule is to follow your appetite - or lack of it! You should obviously avoid alcohol and spicy foods and in some long-term diarrhoea’s it is better to avoid dairy products. Simple Cuts River water is fairly dirty, so at the end of the days paddling, or for an extended lunch break, wash the cut and apply iodine (e.g. Betadine). If possible allow the cut to dry out and only apply a dressing to protect the cut when you are doing something dirty, or perhaps going on the water again. This daily routine of washing, iodine, and fresh dressings is important (especially for cuts in the legs) if you are to avoid infection - we all get minor cuts, and experienced groups almost make a group therapy of this! So called waterproof dressings are not, we find duct tape sticks well, although it’s not very stretchy. Hand Blisters These are fairly common on multi-day trips. If susceptible rubbing points become sore, try duct tape. Blisters usually de-roof with further paddling and treatment is then as for a simple cut: see above. Larger Wounds Check the patient is fully immunised against Tetanus. Cleaning the wound is vital - remove dirt and dead tissue, use antiseptic solution, or if none available, lots of iodine water. Remember to apply direct pressure, not a tourniquet, if there is excessive bleeding. Currently, First Aiders are taught to leave a wound open and apply Betadine iodine, a dressing and elevate. However on the river, providing a waterproof dressing that will keep the wound dry and clean, can be difficult if not impossible. There is a strong case for closing the wound if it is clean, not too deep, and not too contaminated. These cautions apply particularly to the legs. Closure is best done with steri-strips or butterfly sutures - remember to first shave either side of the wound. Tincture of benzoin ("Friars's Balsam) applied to the skin makes the steri strips stick better. The wound will be sealed and waterproof within 24 hours, but it must be kept dry and clean during this time - perhaps plan a rest day? Nowadays, some accident and emergency department use a medical form of supaglue to close wounds. (we have heard of people using regular supaglue, but don't know if this is safe or not.) - they use it to 'spotweld' cuts, rather than to glue along the length; and keep the lips of the cut peaking up (not diving into the wound). As the wound closure is more permanent than steristrip, the cautions above about cleanliness etc. are even more important, as any developing infection cannot get out. The danger of a closed wound is that any infection can be hidden but if the wound has been properly cleansed then the risk is low. Signs of infection include a reddening of the skin surrounding the wound and increased tenderness. Clear or blood stained fluid coming from the wound is normal, but cloudy fluid or pus indicates infection. If this happens, open the wound, wash, apply Betadine iodine again and a dressing; repeat this daily until the infection has been resolved. Antibiotics (Sporidex, Augmentin, or Erythromycin) are not needed unless the infection spreads beyond the stage mentioned, or if the patient has a temperature. Burns Wood fires are used a lot on river trips and burn injuries are fairly common. Even with removal of the heat source, the flesh will still be very hot and damage continues - thus the burn should immediately be immersed in any cold water for a reasonable period of time. The key thing here is fast decisive action to prevent serious flesh injury - we've seen rafters taking a running jump straight into the river! If the burn has not broken the skin, then simple washing and a dry dressing will be adequate. Blisters should not usually be pricked. With more serious burns, give pain killers, wash with an antiseptic solution and dry with sterile gauze. Apply Silver Sulphadiazine or Flamazine with a non-adhesive dressing on top, bandage and elevate. As bandages for the hands are obviously a problem, simply put cream on, then put the hand in a plastic bag and tie at the wrist. The problem with burns is not the initial injury, but infection of the damaged tissue: Silver Sulphadiazine is probably the best protection against this although Betadine iodine cream can be used. Try to keep the dressing dry and check for infection by changing the dressing and washing the wound in antiseptic solution every few days. If infection starts then do daily dressings and consider antibiotics. Any burn involving more than 10% of the body area is serious. Pain killers and fluid replacement in small frequent amounts are important and evacuation should be considered. Animal Bites The best prevention is to avoid dogs and monkeys altogether (don't allow dogs on your campsite). If bitten, then clean the wound immediately with anything, but preferably soap and water, followed by antiseptic solution and treat as a cut. Check if the patient has been immunised against tetanus. Rabies does exist in Nepal but your chances of getting it are very low. The immunisation is expensive and usually only travellers to remote areas feel that it is worthwhile. However, the disease is invariably fatal if not treated, so if you have bitten by a mammal (including a bat or monkey), you must assume the worst and get treatment. Rabies is an unusual disease in that you can be immunised after exposure, but before symptoms appear. Your most practical course is to return to Kathmandu within a couple of days for this treatment - sooner if bitten on the face. It is expensive (approx. $1000?) but normally covered by Medical Insurance. Note that even if before your trip, you were immunised against Rabies, you will still need one or two further injections if bitten by a rabid animal (but not the expensive immunoglobulin). Theoretically you could have the dog kept under observation for seven days and if it hasn't died by then it hasn’t got rabies. If it does die you should still have time to start a post exposure course. But how do you keep a rabid dog in a kayak? Snakebite in tourists is extremely rare. Tenosynovitis ("Tendonitis") Definition: Inflammation of the synovium (part of the sheath surrounding some muscle tendons) usually at the wrist. This is fairly common amongst kayakers doing continuous days of paddling. Diagnosis: Moderate to severe pain on slight wrist movement, sometimes with creaking felt over the wrist. One point is very tender to touch - usually on the thumb side of the back of the wrist. This area may be swollen. Point tenderness distinguishes tenosynovitis from other vague wrist pains incurred after sprains. Treatment: This is an ‘over-use’ injury and the only cure is complete rest in a splint and sling, sometimes for weeks - time to go trekking? If you have to continue paddling then we recommend that you splint (from forearm to knuckles) and elevate the arm in a sling when you are not actually paddling. Use a supportive wrist bandage whilst on the water and consider using a paddle with a different control (feather). It is worth taking an anti-inflammatory drug. Piles (Haemorrhoids) These are common in rafters, kayakers and mountaineers; no-one knows why. Symptoms are pain in your anus, bright red bleeding on defecation, or a lump sticking out. Treatment is purely symptomatic - careful washing and application of a local anaesthetic cream. Paradoxically, both diarrhoea and constipation can make them worse. Colds and Ear problems Colds and sore throats are fairly common on multi-day trips. Treatment is symptomatic (i.e. no antibiotics) but do remember to keep up your fluid intake. If the infection moves down to your chest, a dirty spit, sometimes green, can result. A chest infection worse than this should probably be treated with antibiotics, especially if the patient has a temperature. Kayakers sometimes complain of ‘water in the ear’ - often when they have a cold and have been rolling. The sensation is in fact not caused by water in the external ear but is due to a blockage of the very narrow tube that joins the inner ear to the throat and this can cause a painful inbalance of pressure. This may be eased by exhaling against a closed mouth and pinched nose, or swallowing - however don't do this if you've got a really snotty nose as this may spread infection. Inhaling steam helps and decongestants such as actifed or ephedrine nose drops may also help. A counsel of perfection is to wait until any colds have cleared before you spend a lot of time rolling around in holes. External ear infections should be mopped out 4 times a day with cotton wool and ear drops applied. Try an earplug made with cotton wool smeared with vaseline when on the water. If you suffer from exostoses (bony lumps in the ear) then you should get advice from your GP or ENT specialist about what precautions to take (these may include custom fitting earplugs). Major allergic reaction These are rare but can be fatal. Symptoms are collapse, throat swelling, and severe wheeze, especially after certain foods (including nut allergy) or insect bites. Treatment is 0.5 ml adrenaline injection into the muscle, and, if the patient can swallow, antihistamine and steroid/cortisone tablets. Dentistry Broken or lost fillings can be replaced by temporary fillings such as gutta percha (heat until soft and insert a plug in the cavity) or "Cavit". Remember to dry out the cavity thoroughly first with cotton wool. Oil of cloves may deaden any pain. Abscesses can be very painful and treatment with antibiotics should be consid-ered (Sporidex, Augmentin, or Erythromycin). Anti-inflammatory drugs are good dental pain killers. Any treatment is just a temporary measure until you can see a dentist - your Embassy in Kathmandu will be able to recommend one. Sunburn Be very aware of this on the first two days on the river. Treat symptoms with bland ointment or calomine lotion. An anti-inflammatory drug can be used for more serious cases. Skin Rashes Rashes are difficult to diagnose and are usually treated symptomatically with a bland cream. If persistent, try Hydrocortisone creams so long as you are sure that it is not a fungal infection (in which case try Canteen cream first). Anti-histamine pills or cream are useful for severe itch and for persistent insect bites. Headaches and dehydration Probably the most common and yet least recognised health problem on river trips is dehydration - people get dizzy, light-headed, suffer headaches and feel vaguely unwell: being surrounded by water all the time, dehydration is the last thing people think of! Physical exertion, dry air, sunshine and warm breezes mean that you need to drink lots more than you might imagine - up to 3-4 litres per day. A good basic rule is that your urine should always be white or a pale yellow - if its deep yellow or orange then you're almost certainly dehydrated. Infestations You are unlikely to acquire fleas on a river trip unless you are staying at local lodges. If these critters have befriended you then the best remedy is an extended lunch time to air your bedding and clothing in the heat of the midday sun. Flea powders are a good fall back. Scabies can be picked up by walking barefoot near local villages although it is more common in the hands. These small mites burrow in the web space between the fingers and toes. There will be a severe itch and close inspection will reveal ‘burrow holes’. Treatment is by applying lotion or cream (e.g. Scabex) over the whole body from neck down for 24 hours. Hair or pubic lice are picked up from staying in local lodges/houses or from very close contact with infected people. You would be very unlucky to become infected, but if you do, try Malathion (or Scabex may be coming back into use). Worms have a long incubation period, and won't pop out until you get home! Fever Management As you may be several days away from medical advice, you may be faced with the problem of a high fever, which may worsen if you don't treat it. Ensure adequate fluids are taken and give Paracetamol for the fever. By questions and examination you may be able to identify the source of the infection, e.g.: 1. Throat or Chest infection: see ‘Colds’. 2. Cystitis: see above. 3. Bacterial dysentery: see text. 4. Meningitis: severe headache with temperature, neck stiffness, severe eye pain with bright lights, and rash which doesn’t whiten when pressed. Treat with a high dose of Amoxycillin, or Erythromycin and evacuate. 5. Hepatitis A: (if not immunised). Itch, appetite loss and nausea with tender upper right abdomen. Diagnosis confirmed after 5 days when the patient turns yellow. Keep drinking fluids and use Aspirin (NOT Paracetamol). The other possibilities are: 6. Viral: usually with a flu-like feeling - sore eyes, headache and muscle aches. No specific treatment required; just fluids, paracetamol or aspirin. 7. Malaria: high fevers, chills, and headaches. Although the patient may have mild diarrhoea, there is no other source of infection identifiable. If patient has been in a risk area and hasn't been taking anti-malarial medicines, consider treatment with Chloroquine (not always effective), Mefloquine or Fansidar. This will need a review by a Doctor in Kathmandu. 8. Dengue - for those who have travelled in South East Asia in the last 10 days. As per viral, but muscle pains can be severe (" breakbone fever"), and can get easy bruising, or a rash. Female medical problems Gut infections and antibiotics interfere with the oral contraceptive pill - see the ‘Medical advice’ section. Cystitis is indicated by a "burning" pain whilst passing urine, frequent small trips to the toilet and cloudy or smelly urine. If mild just increase fluid intake. If it persists after one day then start antibiotics (Augmentin, Norfloxacin, or erythromtcin) Thrush can be precipitated by antibiotics given for other reasons. Symptoms include itchy white discharge and a red rash. Treat with Canesten and remember to treat any partners as well, to prevent reinfection. Mental aspects One of the characteristics of expedition life that we all experience is emotional swings - but this is rarely dicussed or admitted to. These highs and lows are an important factor in the good memories but also in the bad arguments that can arise between people in the wilderness. There are more and more people with little experience of wilderness travel embarking on tough, multi-day trips and they are especially vulnerable to emotional stresses. Factors that can help prevent this are good preparation before you go (including a group meeting and preferably outdoor activity); good leadership; and clear aims of the expedition - this last is often forgotten, but it is vital for people to say what their expectations are before they set off. We have seen people take big emotional dives on return from trips and especially on leaving the simple rural culture and returning to the affluent but complaining West. Leaving the group suddenly can also leave a feeling of anti-climax - and so post-trip group meetings can help people de-brief, and to realise that any big arguments from the trip weren't as important as they seemed. Fractures We cannot cover all fractures in this appendix. Basically the best pain relief is to splint the joint, immobilising joints above and below the fracture - give pain killers before you do this. Pad any parts of the limb that touch the splint and any bony parts, e.g. wrist, and elevate. If there is broken skin, then treat as for a cut but do not attempt to close any wound. If bone is visible then start treatment with anti-biotics (Augmentin, Sporidex). Check finger/toe circulation after putting on the splint and loosen strapping if white or painful. Sprains Ankle and knee sprains are common. Remember ‘RICE’ - Rest, Ice (or cold water) pad - half hour cycles of on then off; Compression and Elevation. Rest for 2 days, then start mobilising within the limits of any pain. Shoulder Dislocation Shoulder dislocations are relatively common amongst river runners and especially amongst intermediate kayakers who are often unfamiliar with the power of big water rivers. Prevention is better than cure: as a kayaker or paddle rafter you should never let your hands go above the level of your shoulders - forget those well-posed photos of boy racers desperately reaching over the top of a wave. In the wilderness situation, it is reasonable for you to try and reduce a dis-located shoulder - the technique is simple, you are unlikely to cause more damage than has already been caused, the healing process can start sooner, there is likely to be less damage to the shoulder in the long term, and the patient will be more com-fortable during the evacuation. We know of many instances where shoulders have been reduced on the river bank by people with little medical training - the technique is usually successful, but of course it should always be the patient's decision whether reduction is attempted. Action must be swift - relocation can easily be done in the first few minutes, but becomes progressively more difficult as muscle spasm sets in. In a very muscular person you have only a couple of hours, in a thinner person, maybe 4-6 hours. If you suspect a dislocated shoulder then: 1. Give your strongest painkiller and also, if you have it, 5 mg of valium to suck - absorbed faster than by swallowing (valium is a muscle as well as a brain relaxant). 2. Gently remove buoyancy aid and paddle jacket and carefully examine the arm and shoulder: Check if the patient can move his fingers, hand and wrist. Also check and record the pulse at the wrist. Diagnosis is usually obvious. The patient realises his shoulder is out, the elbow will lie away from his trunk and he will be quite unable to move his arm. The change in contour of his shoulder will be obvious. The head of the upper arm bone (humerus) lies outside and in almost all kayaking dislocations, in front of the cup of the joint where it can usually be felt. Complications are unusual but should be checked for: · Fracture of the upper humerus is rare in kayaking dislocations and indicated by severe pain, excessive swelling, and grating of the arm with movement. The elbow may touch the trunk. Strap up and evacuate. · Common, but not serious, is numbness in a small area of the outer upper arm. This indicates bruising of a small nerve close to the shoulder joint and should be just noted (subsequent physiotherapy will be delayed). · Very uncommon is paralysis of the fingers with definite numbness. This may indicate major nerve damage. This will recover slowly in the weeks after reduction, but it should be the patient's decision when reduction should be done; now or later. Gentle reduction now is probably still the best course, as it is likely that the most damage will already have been done and as early reduction will allow the nerves to heal sooner. Reduction The head of the arm bone ('humerus') is jammed outside the joint by muscle spasm - so the muscle has to be gently stretched first, to give the bone space to move back into the joint. Therefore, the principle of good reduction is: - - a v e r y s l o w c o n t i n u o u s p u l l - - to tease out the muscle spasm. When the humerus head comes to the edge of the joint, it will "clunk" into place. If you pull too hard or too sharply, muscle spasm will worsen and keep the humerus head more firmly outside the joint. There are several techniques and we particularly recommend two: · Lie the victim face down on a flat boulder, rock ledge, etc. with a table-like edge, so that his arm hangs freely down. Attach a weight to his wrist with a bandage, scarf, or similar - a helmet or bucket is ideal. Start with a weight of around 2 kg (3kg for a large patient) and very slowly increase this to double; if the patient has pain then decrease the weight. Leave the patient alone so that gravity does the work as the patient's muscles relax. The patient should feel a "clunk" which will indicate relocation. · The older technique has the patient on his back and you sit with legs extended, facing his head, holding his wrist between your thighs. If his right shoulder is dislocated, place the arch of your right foot (not the toes) in his armpit. Keeping you arms straight (less tiring), very, very slowly lean back. (Don't press too hard with your foot as it is resting close to nerves in the armpit). Up to 5 minutes later, a clunk will indicate relocation. After treatment, whether relocated or not, check and record the wrist pulse again and strap the arm to the front of the chest with the hand level with the other shoulder. On reaching civilisation, you should consult a doctor. We strongly recommend that you consult a good physiotherapist as soon as possible, to minimise long-term damage; you are best returning home for this. Hospitals Medical facilities in Nepal have improved significantly in the last few years and there are now several private clinics in the larger towns and cities whose standards are quite good. In Kathmandu, the Ciwec Clinic and the New Nepal International Clinic are both well-established and highly recommended. Both are staffed by western Doctors, charge western prices, and have 24 hour cover. Hospitals that have been recommended, with expatriate doctors on their staff are: Kathmandu; Patan Hospital. Pokhara; Gandaki Hospital. Tansen Hospital - convenient for the middle Kali Gandaki. Amp Pipal Hospital - half a days walk between Gorkha and the Marsyandi With the exception of the Gandaki Hospital in Pokhara, it is probably better to avoid the other government hospitals, where shortage of money means that they may lack even the most basic drugs. Suggested further reading ‘Dawood, R 'Travellers Health : How to stay healthy abroad" Oxford University Press is a good guide for travellers, although less on expedition problems. Dr Dave Shlim's chapter in Lonely Planet's book ‘Trekking in Nepal’. ‘Medicine for Mountaineering’, by J.Wilkerson; published by the Mountaineers, Seattle. Wilderness medicine is as much a product of experience as any known facts: you may have different experience, and your comments will be welcomed by Dr Andy Watt, c/o the publishers. Special thanks to: Dr Gill Irvine; Dr D Shlim and M Springer of the CIWEC clinic, Kathmandu |
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Suggested Medical Kit Appendix B By Dr Andy Watt (From the guidebook ‘White Water Nepal’) Introduction Please read ‘Duty of Care’ in Appendix A plus introduction to Appendix C. Make sure people know where the first aid kit is carried. Also think about a small back up medical kit in case you lose the main one. Most of the items and drugs listed here are usually available without prescription in Kathmandu. It’s a good idea to bring out waterproof containers and re-sealable plastic bags for the kit, also plastic dropper bottles for tincture of iodine. As the common problems are minor trauma, then the usual painkillers are sufficient. Rarely will you require anything stronger - but it is sensible to carry a strong painkiller should a serious situation develop. However, the strongest pills also have more side effects, including depression of breathing and confusion. Therefore, I recommend codeine or brufen in addition to paracetamol - effects can be additive. Tramadol is also being used nowadays but is stronger than codeine, therefore you should check it out for yourself, perhaps with advice from your own doctor. An alternative approach is to use a 'strong’ anti-inflammatory like voltarol for conditions like bad bruises or painful sprains. |
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Notes on Medical Drugs Appendix C By Dr Andy Watt (From the guidebook ‘White Water Nepal’) Introduction The use of prescription drugs in untrained hands can be risky - both with side-effects (S/E) (which can at worst include severe allergic reactions) and if given in the wrong situations (e.g. wrong diagnosis). If you do decide to take these drugs, then be aware of these caveats, and make sure you fully inform the patient and get their consent. The only injectable drug here is adrenaline (another is voltarol). For most people, those drugs in the 'Basic' list of the Medical Kit will be sufficient. We certainly don't expect you to buy all the drugs mentioned - we've listed a lot in order to give you greater flexibility in deciding in what to take in your own kit . You should take some time in deciding what to take, and not leave it to the last minute, (which is unfortunately my experience of most paddlers!) The best known name of the drug is in CAPITALS, the first name is the generic or ‘proper’ name, the second is the brand name, = means a second brand name, / means an alternative medicine. ACTIFED (Pseudoephedrine 60mg/ and Triprolidine) A decongestant and antihistamine that reduces that "bunged up" feeling in colds, sinus and ear infections. It does not alter the underlying illness. S/E are nervousness and possibly sedation. Dose: one tablet every 8 hours. Adrenaline injection = Epinephrine 1:1000 For collapse, throat swelling and wheeze due to major drug and allergic reaction. S/E fast pulse, nervousness. Dose 0.5 ml of 1:1000, into muscle (e.g. outer thigh) ( remember, after getting the needle into the muscle, to pull back on the plunger before injecting). Keep solution cool as it degrades in heat. Ampicillin / Amoxycillin Penicillin antibiotic drugs for chest, ear, throat and urinary tract infections. S/E are diarrhoea and occasionally a rash. Check the patient is not allergic to penicillin. Dose 250-500 mg, every 8 hours, for 5 days. ANTACID / Gelusil / many other names For indigestion and gastritis. Dose 1-2 tablets or teaspoons up to every 3 hours. Anti-diarrhoeals: Loperamide = IMODIUM / Diphenoxylate = LOMOTIL See note in Appendix A. Recommended only as a temporary expedient when on bus or plane rides, or for severe gut cramps. Dose: 2 tablets or capsules initially, then one with each bowel movement, up to a maximum of 8 tablets in 24 hours. IBUPROFEN is good but Voltarol is stronger. Not for stomach ulcers or asthmatics. ANTIHISTAMINES: Chlorpheniramine = PIRITON / Diphenhydramine = BENADRYL Drugs for skin rashes and severe itching. Also used for travel motion sickness. S/E are sedation. Piriton dose: 4 mg up to 6 hourly. Benadryl 50 mg up to 6 hourly. (Anti-histamine creams can be useful for itching rashes). Anti-vomiting: Prochlorperazine = STEMETIL / Promethazine = PHENERGAN /Avomine. ASPIRIN For mild pain relief, fever treatment, and anti inflamatory. This flexibility however must be balanced against the gastritis it can cause and occasional worsening wheeze in asthmatics. Not for those with ulcers, severe indigestion, or kidney disease. Other S/E (rarely) allergic reaction. Doseage 300-600 mg up to 6 hourly after food. Can be combined with Codeine or Paracetamol for moderate pain. AUGMENTIN As for Amoxycillin, but can also be used for skin infections. Doseage 1 tablet 8 hourly. Expensive in Kathmandu. Bonjela Local anaesthetic for the mouth. Cephalexin: SPORIDEX = Keflex Antibiotic for skin wound and other infections. A relative of penicillin therefore not for those sensitive to penicillin. S/E are a rash and unusually, a severe allergic reaction. Dose: 250-500 mg every 6 hours for 5 days. CHLOROQUINE: Nivaquine = Avlocor = Resochin See ‘Malaria precautions’ section. An anti-malarial medicine. S/E mild stomach upset, itch. Anti-malarial dose is two tablets weekly. Treatment dose (not always effective); initially 6-7 tablets depending on patient's weight, then 3 tablets 6 hours later. CIPROFLOXACIN = Ciproxcin Antibiotic for dysentery. Dose 250-500 mg twice daily for 3-5 days. S/E tendon damage, co-ordination problems. Clotrimazole = CANESTEN cream Cream for both skin fungal infections and the treatment of Thrush. S/E are local irritation. Skin dose; one application per day for 1-2 weeks. Thrush dose; 2 applications per day for 3 days (an applicator is useful and remember to treat the male partner). If not available, try Miconazole (DAKTARIN) for skin or iodine pessaries for thrush. Codeine A multi-purpose drug for mild to moderate pain relief, diarrhoea and cough. S/E are indigestion, sedation and constipation. Dose: pain 30-60 mg up to 4 hourly; 15-30 mg up to 4 hourly for cough and diarrhoea. Can be combined with Aspirin or Paracetamol for moderate pain. Diazepam = VALIUM Anti-anxiety agent, sleeping pill and muscle relaxant. Useful in shoulder dislocation. S/E are sleepiness. Dose: 5 mg up to 3 times daily. Dose may be higher if little response. Diclofenac = VOLTAROL Strong anti-inflammatory. S/E indigestion, occasional allergic reaction in asthmatic - not for patients with severe indigestion, ulcers or kidney disease. Dose 25-50 mg tablets, 2-3 times a day; or 75 mg injection once a day Ear drops: Neosporin or Otosporin For external ear infections. S/E occasional local sensitivity. Dose every 6 hours after mopping out the ear. (Also see note after eye drops) Erythromycin An alternative antibiotic for people sensitive to penicillin; for chest, ear, skin, throat and urinary infections - but not as good as the first line antibiotics. S/E are a rash and nausea, and upset stomach. Dose: 250-500 mg, every 6 hours for 5 days. FANSIDAR (Pyrimethamine 25mg, Sulphadoxine 500mg) For treatment of malaria (not for use as a prophylaxis). S/E rashes and (rarely) blood problems. Not for sulpha-allergic people. Dose 2-3 tablets depending on patient's size. Eye ointment: Sodium sulphacetamide = LOCULA /Chlortetracycline /Chloram-phenicol. For eye infections with discharge, or after injury. (DO NOT BUY eye drops containing STEROIDS or cortisone ingredients as these can worsen viral eye infections). S/E are occasional local allergy, Locula is not for those allergic to sulpha drugs. Dose: 6 hourly, or 3 hourly if severe. (Neosporin 0.5% ointment can be used for both eyes and ears.) Hydrocortisone cream 1% For persistent rashes, insect bites and severe itch. Not for fungal infections. Do not use on the face unless there is a severe condition. Do not use for more than two weeks without medical advice. Ibuprofen = BRUFEN Anti-inflamatory drug and good substitute for aspirin. Not for people with kidney disease or stomach ulcers. S/E are indigestion and occasional worsening wheeze in asthmatics. Dose: 400-800 mg every 8 hours. MEFLOQUINE = Lariam Anti-malarial. See "Malaria precautions" section. Expensive. S/E vomiting, faints and (rarely) behaviour changes. Anti-malaria dose; 250mg weekly and 2 weeks after leaving affected area (U.K. doctors advise a maximum of 6 weeks). Treatment dose 1 gram then 500mg 6 hours later. Metronidazole = FLAGYL For suspected Giardia or Amoebic dysentry. S/E with high doses are an "unwell feeling" and a metallic taste. Do not take alcohol. Dose for Giardia 400mgs 3 times a day for 3 days. Dose for Amoeba 800mgs 3 times a day for 5 days (follow up with Diloxanide from medical clinic). Miconazole = DAKTARIN cream For suspected skin fungal infections. S/E are occasional local allergy. Dosage as for Clotrimazole. NORFLOXACIN For suspected bacterial dysentry. S/E are nausea, abdominal cramps and diarrhoea. Dose: 400 mg twice daily for 3-5 days. PARACETAMOL = Acetaminophen = Tylenol For mild pain relief and fever. A good sustitute for aspirin. Dose: 0.5 -1.0 grams up to 4 hourly up to a maximum of 4 grams every 24 hours - DO NOT EXCEDE THIS DOSE. Pile ointment: Ultaproct / Anusol. Side efects are (occasionally) local reaction with a rash and itching. Dose: as indicated. Povidone Iodine = BETADINE cream or solution. For treating cuts etc. Not for people sensitive to iodine. Cream can be used as a burns dressing. Solution can be used in emergency for water sterilisation, 8 drops per litre. Prochlorperazine = STEMETIL Anti-vomiting. S/E (unusually) spasms of hand, eye, or head. Dose 25 mg suppository once, or 10mg tablet 5-8 hourly. Proguamil = PALUDRINE Anti-malarial, see ‘Malaria precautions’ section. S/E mild stomach upset, occasionally mouth ulcers. Dose 200mg daily. SILVER SULPHADIAZINE = Flamazine. For burns, see text. Not for sulpha-allergic people. Tinidazole = TINIBA = Fasigyn For suspected Giardia or amoebic dysentry. Not available in the U.S.A. DO NOT TAKE ALCOHOL. S/E are a metallic taste and nausea, severe hangover with alcohol. Dose for Giardia 2 gms once; for Amoeba 2 gms daily for 3 days (follow up with Diloxanide). Copyright ‘White Water Nepal’ |