A Discussion About Wilderness Medicine – Hawaii Public Radio January 6, 2014

Here’s a link to a discussion I had with Dr. Kathy Kozak about Wilderness Medicine on Hawaii Public Radio on 1/6/14.

 

Listen Here:

 

Happy New Year,

Scott Rennie, DO

 

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Legal Concerns in the Wilderness

shutterstock_133594121Sadly, due to our litigious world, our well-meaning care giver has concerns of legal liability even in the wilderness.   I enjoy going out into the wilderness and on some occasions I’ve come across an accident victim or other medical emergency in the back country.  It is my instinct to provide medical care for someone who needs it, and according to the World Medical Association’s International Code of Medical Ethics, “…a physician shall give emergency care as a humanitarian duty…”

I will attempt to summarize information about legal concerns in the wilderness as given by a recent class in Advanced Wilderness Life Support and the information comes from their student book.  I am not an attorney and the information presented here is for informational purposes only.  I do not gain anything from presenting this information, but I think it’s important for all of us to understand legal concerns when providing medical care in the wilderness.   If you have a specific situation or concerns, I recommend that you speak to an attorney to get your questions answered.

Again just to clarify, I am not the originator of this material.  The information here comes from a recent class in Advanced Wilderness Life Support and from their instruction manual.  You can contact the company who teaches these classes (Wilderness Medical Society) at the address shown here:  http://www.wms.org  I highly recommend taking their AWLS (Advanced Wilderness Life Support) class.

Good Samaritan Laws:  The purpose is to provide liability protection to those with the ability to help in an emergency to remove the deterrent of litigation as long as the caregiver is not grossly negligent.  There are differences in each State in how the law is interpreted.  Actual fines may be imposed in some states, in Quebec and in Europe if there is a failure to render aid.  That obligation might be satisfied by immediately reporting the situation to the proper authorities who can provide help and aid to the victim.

For a medical provider to be protected under the Good Samaritan Doctrine, the following five guidelines must be met:

1)   The person rendering emergency care must not have caused the emergency, either in whole or in part.

2)   The person rendering emergency care must act in “good faith.”

3)   The emergency care must be provided gratuitously, without any compensation.

4)   The provider must not commit gross negligence when rendering emergency care.  It would be difficult to list all possible acts or omissions that might constitute gross negligence.  Once initiating emergency aid in the back country and then either terminating treatment or transferring care to an inadequately trained person before the patient is stabilized to a medical facility can be considered abandonment and that can be seen as gross negligence.

5)   The person rendering emergency care must not have preexisting duty to care for the patient.  A guide for example, would have a preexisting duty to render emergency care to a customer if the customer had contracted with the guide to be taken on a hike and the guide had agreed to provide care to the customer in case of injury when hiking.

If any one of the give conditions above is not satisfied, then the Good Samaritan law, with all it’s protection, will not apply.

It would seem that the most frequent violation that would cause the Good Samaritan Law to be nullified arises from the presence of a preexisting duty on the part of the care giver to provide aid to the patient because of contract law.

Contract Law:  It would behoove a medical provider on an expedition, to avoid being involved in a contract that in any way gives the belief or guarantees that safety and health are ensured during the trip.  A contract is an agreement or promise between two or more parties for performing or not performing certain specified acts in exchange for adequate consideration.  Contracts can be either “express” or “implied-in-fact.”  An express contract usually states explicitly in words, either written or oral leaving little or no doubt as to the existence and terms.  An implied contract is created by conduct or circumstances that “imply-in-fact” a contract exists.

A brochure from a summer camp, expedition company or an adventure guide might sometimes expressly state that they have a trained person available to provide medical care to customers in emergencies arising during the adventure activity.  This could also be implied during an oral presentation or in a brochure.  Good Samaritan law will not be of protection from liability if a court finds that the complaining customer took part in the expedition in part because the company contractually agreed to provide medical aid during an emergency.

Tort Law:  Torts are legally defined as civil (non-criminal) wrongs that might result in harm or injury and, thereby, constitute the basis for a claim (or law suit) by the harmed or injured party against the person who allegedly committed the tort.

Three categories of torts:

1)   An intentional tort (where one person intentionally harms or injures another).

2)   A strict liability tort (making and selling an obviously defective product).

3)   A negligent tort (a careless an unintentional act, such as an automobile accident, which harms or injures another person or another person’s property.)

Most often law suits claim that the tort of “negligence” occurred.  In order to prove that a person who provided emergency medical care in the back country committed the tort of negligence, the person who was harmed must prove the four elements of a negligence claim:

Four elements of a Negligence Claim:

1)   Duty to Provide Care at the Standard of Care:  If the provider gave care that met the prevailing standard in the medical profession, the healthcare provider will likely not have been seen as negligent.  The question of what the prevailing standards are can sometimes be in question.  That standard is often not yet well established in law.  When in doubt, courts will rely upon the traditional legal definition of the standard, which is the “behavior of a reasonably prudent person in the same or similar circumstances.”  Some factors the court may look to in determining the applicable standard of care are:

  1. The defendant’s education
  2. The defendant’s training
  3. Government or organization medical protocols that apply to the particular situation
  4. Industry practice
  5. Private business protocols that might apply

Generally, if there is a duty to provide care that meets a certain standard, an informed consent is obtained from the patient before the treatment is given.  In an emergency however, a health care provider might rely on “implied consent” where most would reasonably assume that the patient would have agreed to the care offered under the emergency circumstances if they were able to do so.

2)   Failure to Perform the Duty:  It is very important to remain well informed of the prevailing medical standards and protocols and be well trained in wilderness medicine to ensure that any care provided meets the applicable standards.  The plaintiff must prove that the care provider did not perform the duty of providing aid consistent with the specified standard of care.  Usually the plaintiff asserts that the provider failed to act at all (an omission) when the provider had a pre-existing duty to provide care.  The plaintiff may also assert that the provider provided care that did not meet the prevailing medical standard or did not perform as would a reasonable person with the provider’s background, education and training.  If the provider prematurely terminates care or transfers care to a less qualified provider before the patient has been stabilized, this can be considered abandonment and constitute negligence.

3)   Loss of injury:  The plaintiff must prove that they sustained a loss or injury which can include damage to property, medical expenses, fright, emotional trauma, personal injury, pain and suffering, and loss of life.

4)   Causation:  The plaintiff must prove that the loss or injury was caused or contributed to by the provider’s failure to perform the duty of providing aid meeting the specified standard of care.

Defense in a tort law claim:  Experience teaches that a record including dates, times, patient history, a description of the scene, and a complete and accurate record can help defeat a plaintiff’s claims.  The care provider can defeat the plaintiff’s claim if the plaintiff failed to carry the burden of proof on one or more of these four elements of the negligence claim.

Jurisdiction:  Laws can widely vary from country to country and even state to state.  Knowing ahead of time, what the jurisdiction is will allow for maximum protection from litigation and optimal conduct.

Malpractice Insurance:  It makes good sense to check with malpractice carriers before undertaking a trip to find out if they will be covered when rendering support during expeditions in various jurisdictions.

References:  Advanced Wilderness Life Support Student Handbook

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider or your attorney.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Lightning Injuries and Prevention

shutterstock_15532345I’ve met a few people who have been struck by lightning and lived to tell about it, and I thought I’d pass along some information about lightning injuries and how to prevent them.  Much of this information comes a recent class in Advanced Wilderness Life Support (AWLS)

Interesting facts about lighting:

•  Lightning strikes are the second leading environmental cause of death (behind flash floods) in the United States, with an average of 50-300 deaths per year.

•  There are 3-5x as many people who are struck by lightning and survive than die.

•  Nationally, there are 20 million cloud-to-ground flashes detected annually.  In some summer afternoons, more than 50,000 flashes per hour are detected.

•  The most common months of injury are June, July and August, although lightning strikes may occur during any time of year (even in snowstorms).

•  The most common time of day for deaths due to lightning strikes is in the afternoon between 3pm and 6pm local time and this is because of the sun heating the ground which causes vertical cumulus clouds to form that may be tall enough to produce lightning.

•  Florida is the worst state for lightning deaths with nearly 2x as many deaths than the next state.

•  The most dangerous times for a severe lightning strike are before the storm appears and after it has passed.

•  Lightning may travel nearly horizontally as far as 10 miles in front of a thunderstorm and seem to occur out of a “clear blue sky,” or at least when it is sunny.

•  Lightning does commonly strike twice in the same place.

•  A lightning bolt is a unidirectional massive current impulse carrying up to 30 million volts.

•  A lighting bolt is about 6-10cm in diameter, but the ionized sheath is much broader (up to 20cm).  The temperature of the sheath is usually around 8,000 degrees centigrade.

•  There is no need to be concerned about getting shocked or injured by rescuing a person who has been struck by lightning because lighting does not leave a residual charge on a victim.

•  Contrary to popular myth and what is seen in cartoons, deep burns are unusual after lightning injury.  At the most, some minor second-degree burns may occur from superheated metal objects.

Mechanisms of injury:  People can be injured by lightning in several ways:

1)   Direct strike:  a person is hit directly by a bolt of lightning and this happens most commonly with people who are caught in the open and unable to find cover.  This is the deadliest type of strike.

2)   Side splash:  lightning directly strikes another object such as a tree or building, but the current flow, which seeks the path of least resistance, jumps from its original pathway onto the victim.  This is the most common cause of lighting injury. Side splashes may also splash indoors from metal objects such as plumbing or telephones and may even occur from person to person when several people are standing close together.

3)   Contact exposure:  occurs when a person is holding onto or touching an object that is either directly hit or splashed by lightning.  The current passes through the object onto the victim.

4)   Ground current or step voltage:  lightning strikes the ground or a nearby object and the current spreads through the ground.  If a person has one foot closer to the strike than the other foot, an electrical potential difference between the two feet may occur and the current may pass up one leg and down the other leg.  This is a common mechanism for several people being injured at the same time.

5)    Blunt trauma:  injury due to the impact of the concussive force of the strike itself or from being thrown due to the extreme nature of the muscular contraction from the electrical charge.

How lightning affects the body:  injuries occur from a “short circuiting” of several of the body’s electrical systems as well as the more direct trauma and indirect trauma due to the muscular contraction and being thrown.  The most common cause of death in a lighting strike victim is cardiopulmonary arrest.

Treatment:  I think it’s important for everyone to be trained in CPR.  In lightning victims, we usually perform reverse triage and initiate CPR on those patients who are pulseless and apneic (not breathing) before caring for those who have spontaneous signs of life.  This is because those with no spontaneous breathing or heartbeat may recover and will require assisted breathing until their respiratory drive returns.  Assisted breathing for these patients may prevent a secondary cardiac arrest due to low oxygen intake.  If a victim does not regain a pulse within 20-30 minutes we usually then discontinue the resuscitation.  The patient will need evacuation to the nearest medical facility even if the individual does not have any overt evidence of damage.  There is a high likelihood of some sort of injury that is not served best by staying in the outdoors.  Splinting fracture and spinal precautions is necessary.

Avoiding lightning injuries:

1)   30-30 Rule:  The first “30” is when the time between seeing the lightning and hearing the thunder is 30 seconds or less, then people are in danger and should be seeking appropriate cover.  The second “30”:  outdoor activities should not be resumed until 30 minutes after the last lightning is seen or last thunder is heard.

2)   Seek shelter in a substantial building or in an all metal vehicle:  small shelters such as golf, bus and rain shelters may increase a person’s risk of being struck due to side splash as the lightning flows over the building.  All metal vehicles are safe because the metal will diffuse the current around the occupants to the ground.  A convertible is not a safe alternative.  It is a myth that rubber tires provide insulation.

3)   If you are caught in a storm outside without a safe building or vehicle:  Stay away from metal objects and those items that are taller than you.

4)   Avoid areas near power lines, pipelines, ski lifts, and other large steel objects.

5)   Do not stand near or under tall isolated trees, hilltops, or at a lookout or other exposed area.

6)   In a forest, seek a low area under a growth of saplings or small trees.  Seeking a clearing free of trees makes a person the tallest object in the clearing.

7)   If you are completely in the open, stay far away from single trees to avoid lightning splashes and ground current.

8)   If you are on the water, seek the shore and avoid being the tallest object near a large body of water.

9)   If indoors, avoid open doors, windows, fireplaces and metal objects such as sinks and plugged in electrical appliances.  Do not talk on the telephone, as the telephone lines are not usually grounded like electrical wires.

References:  Advanced Wilderness Life Support Handbook

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Wilderness Dentistry

shutterstock_101677420I recently returned from a wilderness medicine conference in Whistler, British Columbia.  Eric Johnson, MD gave a great talk on dentistry in the wilderness so I give him credit for much of the information presented here.

On wilderness backpacking adventures there are many possible dental problems.  Many patients have dental crowns or veneers that get broken.  Dental cavities or broken teeth can often be spotted before leaving for a three week journey, so it’s important to get a dental pre-trip exam to look for problems before departure.

Some of the most commonly encountered dental problems in the wilderness are:

1)  Cracked or dislodged fillings

2)  Inflammation of the gums around the tooth (the piece of popcorn stuck between the tooth and gum)

3)  A cracked tooth or crown

4)  A chipped tooth

5)  Trauma causing a completely knocked out tooth (exodontia)

6)  Dental abscess

Treatment:  Treatment of dental problems should always be attempted by someone trained in dental surgery, however in an emergency situation in the wilderness a dentist may not be available.  Adequate lighting is essential when treating dental problems in the backcountry.  I like to carry a headlamp so that my hands are free to work with the patient.

Cavit is a temporary filling material that is self curing that you can bring with you and is very helpful to treat problems such as dental crown or filling that has broken or come off.  It comes in small tubes or containers and is similar in consistency to silly puddy but hardens and can be very helpful to reduce dental pain from exposed pulp/nerve.

If a tooth needs to come out, it can be removed in the back country but it should only be attempted by someone with experience in this procedure.

Exodontia:  The extraction of a tooth.  If the tooth is not extracted in its entirety or there is a root that does not come out they can get infected.  Extracting a tooth is not as simple as simply pulling it, there are many possible complications of tooth extraction such as:

1)  Accidentally removing the wrong tooth  – it’s easy to do because pain from one tooth can feel like it’s coming from somewhere else in the mouth

2)  Breaking a tooth while pulling it – can cause severe abscess

3)  Excessive bleeding

4)  Dry socket – extreme pain after the extraction

Extrusion:  Dental trauma causing the tooth to get knocked out completely.

If a tooth gets knocked out, it’s important to protect the tooth and try to get it re-implanted as soon as possible.  If re-implantation is done within 20 minutes there is usually a very good chance that there will be a good outcome.  If it’s longer than 1 hour, there is less chance that the tooth will live.  Some tips on what to do if a tooth gets knocked out:

1)  Keep the tooth moist with saliva (keep it in your mouth)

2)  If there is not a dentist in the back country with you, a medical provider may be able to anchor the tooth into the socket using a figure of eight stitch (suture).  I have also heard that dental floss can be used to tie one tooth to another.

3)  Do not chew

Dental Blocks:  Sometimes it can be very helpful to provide local anesthesia using a dental block to help alleviate pain.  On the upper teeth, injecting on either side of the tooth (around the tooth) with lidocaine may provide adequate analgesia rather than having to do full dental block.  Anesthesia for teeth on the lower jaw (mandible) is more difficult and may require a block.

20% Benzocaine gel can decrease the discomfort at the injection site and is a good item to have in your dental kit.  It can also be used on tongue or lip ulcers or canker sores.

Equipment:  1” 27 gauge needle, 3ml syringe, 2% lidocaine with epi (or similar agent)

Back Country Dental Kit:  Here are some items that you might consider taking with you into the back country if you are the medical officer on an expedition with a group of hikers:

1)  Number 150 or 151 universal extraction forceps

2)  Straight elevator

3)  Mouth mirror

4)  Orabase with benzocaine

5)  Orthodontic wax

6)  Dental floss

7)  Dental syringe

8)  27 gauge needles with anesthetic

9)  Cavit or IRM for temporarily filling/sealing a tooth

10)  #11 blade scalpel

11)  20% benzocaine gel

If you’re in the Seattle area and are looking for an excellent dentist, I highly recommend Robert Odegard, DDS.  He has been my dentist for more than 20 years and has excellent skills and his staff are great.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Tick Bites – Will I Get Lyme disease?

shutterstock_17720305shutterstock_148613042Last night a patient came into the Urgent Care with a tick on his belly.  He recently returned from a trip to New York State and he was concerned about the possibility of developing Lyme disease.  When I looked at the tick, I noticed that it was small and almost translucent.  It was attached to his skin but its head was still clearly visible and had not burrowed below the surface of the skin on his abdomen.

Tick bites are common this time of year.  They occur on humans as well as animals such as dogs.  Many different types of ticks in the United States, only some of which are capable of transmitting infections.  The risk of developing an infection such as Lyme disease after being bitten depends upon the geographic location, season of the year, type of tick and how long the tick was attached to the skin.

The risk of acquiring an infection from a tick is actually quite low.  In the case of my patient, the tick hadn’t even taken a blood meal – ie. it was not engorged with blood.  His risk of developing Lyme disease from that tick was absolutely 0%.  Ticks transmit infection only after they have attached and become engorged with blood.  Deer ticks that transmit Lyme disease must feed for more than 36 hours before transmission of the organism called Borrelia burgdorferi.

If you come in to see me after you’re bitten by a deer tick (the type that carries Lyme disease), I would generally advise one of two approaches:

1)   Observe the area and treat with antibiotics only if signs of infection develop

2)   Treat with antibiotics immediately as a preventative measure

The individual patient’s history, the type of tick and how long it was attached and the patient’s wishes will help determine which approach to take.

How to Remove a Tick:  Some patients come in to see me after they’ve already tried removing a tick and have been unsuccessful or partially successful.  I commonly see patients who come in after they’ve removed only part of the tick and the head and are concerned because the tick head is still buried below the skin.  Here is the technique that I use to remove a tick:

1)   Do not attempt to use a match, cigarette, nail polish, Vaseline, liquid soap or kerosene because it may just irritate the tick and cause it to inject the harmful organism into the wound

2)   Use fine tipped tweezers to grasp the tick as close to the skin as possible

3)   Pull back gently but firmly using even, steady pressure without jerking or twisting the tick

4)   After removing the tick, wash the skin and hands with warm soapy water

5)   If any part of the tick is still in the skin, they generally come out on their own.  I don’t recommend attempting to remove little pieces of the tick at home as this can cause skin trauma and scarring.

6)   Go see your medical provider if you are concerned about not being able to remove the tick.

Treatment:  The Infectious Diseases Society of America recommends treatment with antibiotics preventatively only in people who meet ALL the criteria below:

1)   The attached tick was identified as an adult or nymph deer tick

2)   The tick was attached for more than 36 hours based on how engorged the tick appears and the amount of time since outdoor exposure

3)   Antibiotic treatment can begin within 72 hours of tick removal

4)   The area where the tick bite occurred was in an area where the organism B. burgdorferi infection rate is greater than 20% – generally in parts of New England, parts of the mid-Atlantic states and parts of Minnesota and Wisconsin.

5)   The patient can take doxycycline – i.e. the patient is not pregnant or breastfeeding a young child or allergic to this antibiotic.

If all the criteria above are met, the treatment is a single dose of doxycycline 200mg for adults and 4mg/kg up to a maximum of 200mg for children older than 8 years of age.

Symptoms of Lyme disease:  What the area where the tick bite occurred and observe for expanding redness.  The rash that is associated with Lyme disease is called erythema migrams (EM).  This rash is a salmon color usually and typically expands over a few days or weeks and can reach up to 8 inches in diameter.  The center of the rash tends to become skin colored (clear) as the rash grows in size.  This gives the rash a sort of “bull’s eye” appearance.  The rash generally doesn’t cause any symptoms.

Other associated symptoms of Lyme disease could include:

1)  A few days to a month after the bite:  fatigue, malaise, lethargy, mild headache, mild neck stiffness, aches, joint pain and enlarged lymph nodes.

2)  Weeks to months after the bite:  Inflammation of the heart, heart rhythm problems, meningitis, encephalitis, severe joint pain, multiple areas of rash, eye pain/vision problems, liver disease, kidney disease.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

All about Bloody Noses – Epistaxis

shutterstock_80516140A patient came into the urgent care today with a bloody nose after being hit with a baseball in the nose while playing catch.  The bleeding was so intense that blood was actually coming up through the tear ducts of his eyes.  His nose had been bleeding for about an hour prior to me seeing him and by that he came to the exam room the bleeding had almost stopped.

Nosebleeds can be dramatic and frightening but usually they stop on their own without need for intervention by a doctor.  I do however have some recommendations about what to do if you get a bloody nose (also called epistaxis) that will not stop.

1)   If your nose has been bleeding for awhile and is not stopping, blow all that goo that’s in the affected nostril out. This might cause the bleeding to increase temporarily and that’s ok.

2)   Get into a comfortable position and relax.  Don’t lay on your back, just sit up straight.

3)   If you have some Afrin (Oxymetazoline)

spray into the affected nostril.  It’s a nasal decongestant and causes the blood vessels to shrink down and this slows the bleeding down

4)   Grip the soft part of your nose  – both notrils (do not grip the bony part of the nose as that will not stop the bleeding).  Hold pressure over the nose for 15 minutes.  This is easier said than done.  You need to have a watch with you and actually keep holding pressure without letting go for the entire 15 minutes.  I’ve asked patients to hold pressure for this period of time and watched them let the pressure off after 2 minutes, thinking that they’d held for long enough, so make sure you have a watch and time this procedure.  If you take the pressure off too early, the bleeding will restart

5)   If, after performing all the above treatments your nose is still bleeding then you need to come in for evaluation.

There are two main types of nosebleeds.  The most common type is the anterior nosebleed that starts towards the front of the nose and causes blood to flow out through one of the nostrils.  The other type originates in the back of the nose near the throat.  Posterior nosebleeds are much less common and can be serious because stopping the bleeding can be more difficult.

When to seek medical care:

1)   The bleeding makes it difficult to breathe

2)   You become disoriented or light-headed

3)   The bleeding doesn’t stopped after you’ve tried the steps above

4)   You’ve recently had nasal surgery

5)   You’re having other symptoms such as chest pain

6)   You’ve had facial trauma and may have broken your nose

7)   You’re bleeding won’t stop and you’re taking a blood thinner such as Coumadin or Plavix

Prevention:  Some people seem to have issues with frequent nosebleeds.  Part of the reason is that sometimes the mucus membrane inside the nose become dry.  When that occurs the skin can rip or tear more easily and cause bleeding.  Also if the inside of the nose becomes itchy, often a patient might scratch the nose in the middle of the night and not realize it, causing trauma to the skin, bleeding and scab formation. The first line of prevention involves keeping fingers out of the nose.  I also recommend using a small amount of petrolium jelly (Vasoline) applied to the skin inside the nose to moisturize the skin and prevent bleeding for those people with recurrent nosebleeds.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

It’s Cloudy in Seattle, so why Worry about Sunburn?

shutterstock_5810650Recently I’ve been noticing patients are coming in with sunburns even though the weather has been cloudy.  They are often unaware that the sun is causing damage to their skin at the time, and come in later with severe sunburns.  Even on cloudy days, it is important to protect your skin because UV radiation can pass through the clouds and cause sunburns.  In addition, UV rays can be reflected off surfaces like sand, snow, cement and water.

Prevention:  Here are several ways to help prevent sunburn:

1)   Avoid sun exposure:  If you plan to be out in the sun during the day, keep in mind that the suns rays are strongest between 10:00am and 4:00pm in the continental U.S. and avoiding exposure during these hours decrease your risk of burning.  Wearing a topical sunscreen as well as clothing that blocks the suns rays are helpful in reducing your chance of sunburns.

2)   Find Shade:  Areas that don’t have direct sunlight reduce your chances of sunburn.  These areas include under trees, an umbrella or structures such as porches, or tents.  A topical sunscreen is still recommended while sitting in the shade because your skin is still exposed to some UV radiation.

3)   UV Index:  One way to predict your risk of sunburn on a given day is a numerical value called the UV index.  It is a number between 0 and 11+, in which 0 indicates a lower risk of sun exposure and 10 indicates high risk with 11+ an extreme risk.  You can find the UV Index online.

4)   Sunscreen:  There are many sunscreen products on the market, and most of them work by protecting the skin via absorbing the radiation or reflecting it.  SPF or Sun Protection Factor is a numerical indicator that gives us some idea of how much protection the sunscreen offers against UVB (Ultraviolet B) burns.  It’s important to look for a sunscreen that protects against both UVA (Ultraviolet A) and UVB rays – sometimes they label these products broad-spectrum.  Here are some additional tips.

A)  I often get asked what SPF rating is best.  My first response is usually “the maximum you can get,” because I realize that even low levels of ultraviolet radiation increase your risk for sun damaged skin, skin cancers and a poor cosmetic outcome with increasing age.  The American Academy of Dermatology recommends an SPF of 30 or greater on sun exposed skin with protection of UVA and UVB and recommends a higher SPF in your are fair-skinned or will be out in the sun for longer periods of time or anticipate intense exposure (such as on a beach or skiing trip).

B)  Use enough:  I find that most people don’t use enough sunscreen, and they don’t put it on soon enough.  Your really need about 2 tablespoons of lotion to cover an adults arms, legs, neck and face.  If you want to cover your back and chest, you will need more than that.  You should also apply it at least 15-30 minutes before going out in the sun for it to become active.

C)  Reapply:  Even if the sunscreen bottle says that it’s sweat-proof, or water-proof, I recommend reapplying every 2-3 hours or after drying off with a towel or swimming.  There is some evidence that suggests that after being out in the sunlight for 20 minutes, you should reapply the sunscreen even if you’re not in the water or haven’t been sweating profusely.

D)  Protect your lips:  Make sure your remember to protect your lips with lip balm that has an SPF of 30 or higher and reapply frequently.

E)  Buy new sunscreen each year:  Chemical sunscreens become less effective with time.  Leaving them in the sun or where it is hot, such as in the car may speed this degradation process.  Expired sunscreen is likely less effective and reduces the SPF rating.

Definition:  Sunburns occur when the skin is burned by UV radiation.  Often sunburns are not severe, but it’s the exposure over years that increase your risk of skin cancer, wrinkles and other cosmetic concerns.  In todays society, we often think about the immediate gratification which might include a suntan, however often the harmful consequences come years later often after we are no longer spending as much time in the sun.  I show my younger patients who have sunburned skin several photos of older patients who’ve spent years in the sun or had sunburns over years.  Hopefully that helps them understand the consequences that come with repeated exposure so they can make more informed decisions about protecting their skin from harmful radiation.

Symptoms:  Sunburns are often not immediately apparent because the redness and pain develop 3-5 hours after being out in the sunshine.  Redness of the skin that is hot and painful to touch is common.  There may also be blistering and swelling over the affected areas.  The redness is usually at it’s worst by 12-24 hours after sun exposure and this fades over 72 hours.

Causes:  Melanin is a pigment in the skin that causes your skin to appear dark or light colored.  Your skin can temporarily increase the amount of melanin to help protect from burns (suntan).  The amount of ultraviolet radiation that is needed to burn your skin depends on several factors:

1)   Melanin:  The amount of melanin in your skin affects how quickly you can get burned.  People with light colored skin and light hair generally have a higher risk of sunburn compared with patients with dark colored skin.  Some individuals with a low amount of melanin can burn in less than 15 minutes.

2)   Location:  There is increased UV radiation due to more direct sunlight near the equator so individuals who are in these locations are at more risk of sunburn (Hawaii for example).

3)   Medications:  Certain medications can increase the risk of sunburn including ibuprofen, some blood pressure medications such as hydrochlorothiazide (HCTZ), and some antibiotics such as tetracycline.

Complications:  Premature skin aging, permanent discoloration of the skin, wrinkles, skin cancers such as malignant melanoma, basal cell and squamous cell carcinomas, cataracts (the lens of the eye becomes cloudy).

Treatment:

1)   Stay out of the sun until the redness and pain go away.  Repeated sun damage after a recent burn is even more harmful.

2)   After noticing a sunburn, I often recommend immediately taking ibuprofen or Aleve to help with the pain

3)   Cool compresses, and aloe-based lotions and sprays

4)   Sprays with a local anesthetic that numbs the skin such as Solarcaine may help decrease the pain but they do not decrease the long-term risks of skin cancer and sun damaged skin.

If you have had repeated sunburns, a history of skin cancer, or strong family history of skin cancers, I recommend that you see a dermatologist at least every year for a head to toe skin examination.

To find a Dermatologist in your area, the American Academy of Dermatology’s Website has a very useful locator:  http://www.aad.org/find-a-derm

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com