Sustainment Medical for the Field: Preventable Field Injuries, by Teddy Bear (DO)

Having recently completed the Jaeger course from Mike Von Steuben, I wanted to briefly discuss some common health issues that can arise during an extended period in the field. These topics include, but are not limited to, issues that arose during the tactical scenario. We will be discussing Dehydration, Poison Ivy, Ankle sprain, Sleep cycle, and Tick bites.

Dehydration

Loss of  water through the skin is by far the most common route. During exertion in a hot, dry climate these losses can be as extreme as 1 to 2 liters per hour. This is a natural part of our cooling system, but we must replace that loss to maintain normal function.

Victims of dehydration can present with multiple signs and symptoms. The earliest warning sign is if you have gone for several hours adequately hydrating without needing to urinate.  Symptoms are pretty much what you would expect; thirst, “brain fog,” easy fatigue, muscle cramps, and dizziness when you stand up. More severe fluid loss can lead to abdominal pain, chest pain, or lethargy and confusion.

A variety of electrolyte and acid-base disorders may also occur in hypovolemic patients, depending upon the composition of the fluid that is lost. The more serious symptoms and associated abnormalities include the following:

• Muscle weakness due to high or low potassium
• Lots of urination and drinking due to severely low potassium
• Rapid breathing due to acidosis
• Neuromuscular irritability and confusion due to metabolic alkalosis
• Lethargy, confusion, seizures, and coma due to low or high sodium

Physical signs of dehydration in fighting age individuals is a loss of skin turgor. If the skin on the thigh, calf, or forearm is pinched in normal subjects (A), it will immediately flatten back out when released (B).  With dehydration, the skin flattens more slowly after release (C). In older patients (>55 years old), this test is used over the sternum (breastbone). Also, keep in mind that normal  turgor does not rule out dehydration, particularly in mildly dehydrated young individuals with more elastic skin, and in obese patients where adipose underlying the skin prevents tenting.

https://nursekey.com/wp-content/uploads/2016/11/B9780323086783000174_f017-011ac-9780323086783.jpg

Dry mucous membranes such as inside eye lids  or under the tongue are associated with advanced  dehydration, as is dry armpits. While you may or may not have a blood pressure cuff  on hand to evaluate for decreasing systolic pressures, you should  be able to tell if radial pulses are becoming less easy to find or “thready.” Heart rate will also be rising to compensate for falling BP.  These are signs that rehydrating your teammate needs to be a very high priority.  Be familiar with your team members normal vital signs and physical exam, such as radial pulse, so you know when they are outside their normal. Do this work ahead of time.

 As a side note, signs like diarrhea, vomiting, and severe skin burns, are also causes of dehydration that lie outside our focus on simply losing fluids due to exertion.

Adding sugar to hydration fluid so that 30-60 grams are consumed per hour reduces fatigue. Also, sodium should be included in fluids consumed during exercise lasting longer than 2 h or by individuals during any event that stimulates heavy sodium loss (more than 3-4 g of sodium).

• Sterns R. 2022. Etiology, clinical manifestations, and diagnosis of volume depletion in adults. In UpToDate. Accessed 2023 May 23

Solutions (no pun intended)

“It is recommended that individuals drink about 500 ml (about 17 ounces) of fluid about 2 h before exercise. During exercise, athletes should start drinking early and at regular intervals to consume the maximal amount that can be tolerated. It is recommended that ingested fluids be cooler than ambient temperature and flavored to enhance palatability. Addition of proper amounts of carbohydrates and/or electrolytes to a fluid replacement solution is recommended for exercise events of duration greater than 1 h since it does not significantly impair water delivery to the body and may enhance performance.

During exercise lasting less than 1 h, there is little evidence of physiological or physical performance differences between consuming a carbohydrate-electrolyte drink and plain water. During intense exercise lasting longer than 1 h, it is recommended that carbohydrates be ingested at a rate of 30-60 grams per hour to delay fatigue. This rate of carbohydrate intake can be achieved without compromising fluid delivery by drinking 600-1200 mL per hour of solutions containing 4%-8% carbohydrates (1 gram per 100 mL). The carbohydrates can be sugars or starch.

Inclusion of sodium (0.5-0.7 grams per liter of water) is recommended since it may be advantageous in enhancing palatability, promoting fluid retention, and possibly preventing hyponatremia in certain individuals who drink excessive quantities of fluid. There is little physiological basis for the presence of sodium in oral rehydration solution for enhancing intestinal water absorption as long as sodium is sufficiently available from the previous meal.”

[emphasis added]

• Convertino, V.A. American College of Sports Medicine position stand. Exercise and fluid replacement Med Sci Sports Exerc. 1996 Jan;28(1):i-vii. In PubMed 2023 May 28.

For example, here are the nutrition facts for DripDrop’s packets, intended for 16 oz. Most Nalgene-type bottles are 1L ~ 1 Qt = 32 oz, so double it for a quart/liter canteen. Sugars per liter 28g. Sodium 1.34g

https://www.dripdrop.com/products/dripdrop/bold-variety-pack-16-80

The nutrition facts below are from Liquid I.V. (it’s redundant, but I didn’t choose it), and are for an 8 oz  volume. Multiply by 4 for a quart canteen. Sugars 44g. Sodium 2g.

https://www.liquid-iv.com/products/seaberry-hydration-multiplier?variant=40599377739812

This is for Gatorade Thirst Quencher in a 12 oz volume, so multiply by 2.67. Sugars 56g. Sodium 0.4g

https://www.gatorade.com/fuel/hydration/gatorade-thirst-quencher/6-gallon-canister-powder/lemon-lime

As it happens, I listed these different products in order regarding sugar content. Gatorade is the heaviest on sugar compared to sodium. I have experience with Liquid I.V., and find it adequate. Others don’t care for the taste. DripDrop is recommended by Jack Lawson in his two-volume Civil Defense Manual (https://civildefensemanual.com/). I can say that I saw DripDrop had a booth at the Special Operations Medical Association Scientific Assembly (SOMSA), so someone who knows a thing or two is giving them business.

For further reading on this topic, I recommend Dr James Li’s “The Special Forces handbook of medical secrets.”  Among other topics, he talks about oral rehydration and the preferred balance of sodium, potassium and sugar in treating dehydration. Also consider “Improvised Medicine” by Dr Kenneth Iserson for a more technical discussion of the subject, as well a wealth of other information.

https://www.amazon.com/Special-Forces-handbook-medical-secrets/dp/1521465010/

https://www.amazon.com/Improvised-Medicine-Providing-Extreme-Environments/dp/0071847626/

Poison Ivy

While a fortunate 10-15% of people are immune to the irritant oils of this plant, everyone else has some degree of sensitivity to it. The hypersensitivity reaction is caused by oil leaking from a damaged plant. The oil evaporates from the skin within 4 hours, but evaporates much more slowly from other surfaces such as garments, allowing re-exposure. This includes ash in smoke of burning leaves. Recurrence of the rash is not due to leakage from the original blisters, as that liquid does not have irritant content. Rather, recurrence of the rash is due to re-inoculation from an affected surface such as clothing.

https://tse2.mm.bing.net/th?id=OIP.8dFG71qOJcKO2WTKIvG8vgHaFC&pid=Api

Prevention

Washing off oil with soap and water within 10 minutes of exposure may prevent the rash. Scrub for several minutes. Solvents like Tecnu, Zanfel, acetone, rubbing alcohol work as well, but soap and water work well, cheaply. Do not dab on solvents, as this can spread the oil. Only use     such solvents when there is no risk of further exposure, as the solvents also remove the protective oils on the skin.

Clean your exposed clothing, shoes, and equipment. Uroshiol can otherwise remain for years. Launder washables, and use solvents for non-washables.

While there is variable efficacy, consider a blocking agent such as Ivy X Pre-Contact, applied to skin prior to exposure.

            https://www.forestry-suppliers.com/p/25366/40331/ivyx-pre-contact-solution

Treatment focuses on symptom management.

1. Mild steroids like hydrocortisone 1% cream should be your first OTC choice in severe reactions if prescription steroids are not available. Most effective before the little blisters (vesicles) form. During the course, the skin became so swollen that it began to split and seep serous fluid. Cortizone 10 from the nearby Dollar General brought marked improvement within an hour.
2. Cool compresses for 15-20 minutes per hour
3. Colloidal Oatmeal Bath (Aveeno bath)
4. Calamine lotion applied several times per day
5. Burow’s Solution (aluminum acetate) astringent
   1. Preparation: dissolve one packet in one pint of water
   2. Soak 6 to 8 layers of gauze in solution
   3. Wring out gently, and apply to area for 15 to 20 minutes
   4. Change every 2 to 3 hours
6. Antihistamines like benadryl (diphenhydramine) offer minimal help with sleep, but do not address the underlying cause. Topical antihistamines may cause the opposite of the desired effect by sensitizing the skin.
7. Antibiotics may be considered if there are signs of secondary infection due to compromise of skin integrity. Topical antibiotic cream is a good place to start, moving to oral antibiotics if the infection becomes severe. These antibiotics would be aimed at normal gram positive skin flora. For the Staph and Strep species common on the skin, Cephalexin, Clindamycin, and Doxycycline are your top three choices, with >90% absorption in the gut.
   1. On a completely unrelated note, Clindamycin for fish has been demonstrated to be indistinguishable from some of the forms intended for human use. https://fishmoxfishflex.com/collections/clindamycin-fish-cin-fish-antibiotic/products/fish-cin-clindamycin-150-mg-capsules-30-count
   2. The same applies to Cephalexin. https://fishmoxfishflex.com/collections/cephalexin-keflex-fish-antibiotics
   3. And oddly enough, to Doxycycline. https://fishmoxfishflex.com/collections/fish-antibiotic-fish-doxy-doxycycline/products/fish-doxy-equivalent-fish-biotic-doxycycline-100-mg-30-count

Clinical course is mild in 90% of people. Small, itchy, blisters form over 1-2 days, and resolve     over 10 to 14 days. For the remaining 10%, a debilitating rash begins over the first 4 to 8 hours.

Ankle Sprain

https://www.drvikramsharma.co.in/images/sport-injury/Ankle-Sprain.jpg

While we were fortunate to not have anyone roll an ankle during the Jaeger course, it is a very common type of injury and is worth discussing. Most sprains are inversion, rather than eversion.

Management of sprains is pretty conservative.

https://www.farrerpark.com/patients-and-visitors/patient-family-education/ankle-sprain-management.html

https://healthjade.net/how-to-treat-a-sprained-ankle/

Ottawa Ankle Rules in Acute Ankle Sprain

1. Ankle XRay not needed if both are true:
   1. Able to ambulate for 4 steps
   2. No pain over distal posterior 6 cm (2.4 inches) of tibia, fibula
2. Foot Xray not needed for mid-foot pain if both true:
   1. Able to ambulate for 4 steps
   2. No pain at fifth metatarsal base and navicular bone
3. Efficacy
   1. Test Sensitivity for Malleolar fracture: 95%
   2. Requires alert adult or child age 5 or older
   3. Injury within prior 10 days

This is a useful technique to determine if a foot injury is more likely to be a simple sprain rather than involve a broken bone. While the guideline mentions obtaining an X-ray, we are simply using this as a guide for how concerned we should be for a broken bone.

Sleep Cycle

One of the issues we ran into during the Jaeger course, given the need to maintain security, was getting everyone enough sleep. By the time we were down to a five-man element, maintaining a two man watch greatly decreased sleep cycle length. Assuming a guard shift of one hour, you would prefer to do this schedule with no fewer than five people with one person awake at a time. If you have more people, you can consider increasing the watch, or simply shorten the amount of time everyone is awake. In the long-term, you will need to make sure your people are getting proper sleep.

From “Army Training Publication (ATP) 3-21.8: Infantry Platoon and Squad”

6-57. The platoon leader must develop and enforce the unit sleep plan that provides Soldiers with a minimum of 4 hours of uninterrupted sleep in a 24-hour period. If sleep is interrupted, then 5 hours should be given. During continuous operations when uninterrupted sleep is not possible, blocks of sleep which add up to 6 hours in a 24-hour period are adequate for most people. Remember, 4 hours each 24-hour period is far from ideal. Do not go with only 4 hours sleep each 24 hours for more than two weeks before paying back sleep debt. Recovery time should be approximately 8 to 10 hours sleep each 24 hours over a 5- to 7-day period.

Tick bites, Doxy, Deet, and Permethrin

Anyone who has spent time outdoors most places in the US is quite familiar with these eight-legged blood suckers. The risk for disease varies by region and tick species, the most common examples being Lyme disease and Rocky Mountain Spotted Fever. Both of these conditions can be treated with the antibiotic Doxycycline 100mg. The appropriate dosages and treatment plan can be found for free at such websites as fpnotebook.com  As mentioned above, doxycycline sold for fish in 100mg strength can be found at fishmoxfishflex.com under the name FishDoxy.

 Note:

Antibiotic treatment affects 15% of patients with a reaction that manifests as increased temperature, myalgias (muscle aches) and arthralgias (joint aches) in first 24 hours of treatment.

https://fpnotebook.com/ID/Vector/LymDs.htm

One quick distinction between treatment for Lyme versus RMSF is that the preventative dose for Lyme is 200mg  administered within 72 hours of the tick bite (remove the tick). This has an 87% prevention rate. Rate of infection is 1%  under 24 hours and rises to 20% at 72 hours, so frequent checks are important.

Prevention is even more important, and this where permethrin and deet help out. As part of my preparation for the Jaeger course, I heavily soaked my pants and over shirt in permethrin, as well as my boots, poncho, and pack. I did not treat any underlayers with permethrin, as per the instructions. I sprayed deet-based bug spray on my socks on the first day, and failed to  refresh it during the next five days. However, at the end of that time, I found a total of one loosely attached tick halfway up my shin. I attribute this entirely to the permethrin.

This concludes a brief discussion on a few of the issues that can arise when trying to accomplish tasks in a contested and/or austere environment. I hope that this helps you to train safer, so that you are more likely to get out there and train more.

Disclaimer

Teddy Bear holds a Doctor of Osteopathy (D.O.) degree, and is a general medical practitioner. As a hobby, Teddy collects various state’s medical licenses. Having entered medical school specifically with a coming collapse in mind, Teddy appreciates the opportunity to educate, viewing it as a form of caching. However, the information contained in this article does not constitute medical advise, and does not create a patient-physician relationship between the reader and author.

Financial disclaimer: All provided links are for educational purposes or representational examples only.

At the time of this writing, there are no financial associations with any product mentioned or linked.

All products are examples only without personal knowledge of how they perform, except where noted.

Teddy Bear trains to protect the innocent from monsters when the lights go out.