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Common medical emergencies

If your travels will take you to wilderness settings, remote rural areas, or developing countries — that is, out of easy reach of definitive medical care — then it's a very good idea to bring along a practical book or two on common medical problems and emergencies. Abdominal or pelvic pain, dislocated joint, gastrointestinal bleeding, headache, heart attack, stroke, toothache, urinary tract infections and wounds are discussed in this section.If your travels are mainly to urban areas in developed countries, you may not ever need to self-treat anything more complex than a hangnail or a headache. But if your travels will take you to wilderness settings, remote rural areas, or developing countries — that is, out of easy reach of definitive medical care — then it's a very good idea to bring along a practical book or two on common medical problems and emergencies. Here are several additional sources of well-researched, dependable travel health information.

And below is a brief review of a few of the issues that can arise — no matter how healthy you are — when you're traveling:Pain in the abdomen or pelvis may be a simple "tummy ache," but it can also be an indication of a significant underlying problem — especially if it's associated with prolonged pain, hypotension (low blood pressure), fever, rigidity of the abdominal wall, or bleeding within the gastrointestinal system. Among the diagnoses that should be considered are a ruptured bowel, diverticulitis (an inflammation within the intestine or colon), appendicitis, kidney stones, ulcers, or a bowel obstruction. Evacuation to a medical facility may be necessary to diagnose and treat the underlying condition.

If there will be a considerable delay in arranging for evacuation, it's important to pay close attention to the patient's hydration status; administering a course of antibiotics may be indicated as well. Dislocation of a large joint, such as a shoulder or hip or even the jaw, can be caused by trauma of various sorts but can also result from relatively minor forces. A dislocation can cause intense pain, as well as swelling, bruising, numbness, and instability of the affected joint. In cases of an apparent dislocation, it is always important to check for neurovascular compromise — to see whether the dislocated joint has pinched a nerve or blood vessel.

There are several effective methods for relocating joints, depending on which joint is affected; it is advisable for adventure enthusiasts in particular to become familiar with them. A successful relocation is usually possible in the field and typically results in pain relief and even improvement in neurovascular symptoms. Gastrointestinal (GI) bleeding is a relatively common but potentially life-threating condition; it has an overall mortality rate of up to 10 percent. GI bleeding is classified as upper GI bleeding or lower GI bleeding, depending on where the bleeding originates from. Upper GI bleeding typically comes from the esophagus, stomach or the upper part of the intestines. Lower GI bleeding typically originates from the distal small intestine, the colon or a brisk upper GI bleed.

The most common causes of upper GI bleeds include gastritis, peptic ulcers, esophageal tears due to vomiting, or blood vessel abnormalities (varices). Lower GI bleeds can be a result of hemorrhoids, diverticulosis, tumors, varices or a brisk upper GI bleed.

The most common symptoms of an upper GI bleed are chest or abdominal pain; vomiting blood; weakness; shortness of breath; nausea; dark, tarry stools; or red blood in the stools. Depending on the cause and the extent of the bleeding, an individual with an upper GI bleed may be in shock from the blood loss. The diagnosis of an upper GI bleed is usually made based on a combination of history, physical examination and laboratory evaluation, along with esophageal endoscopy (examination of your digestive tract by means of a camera inserted through your mouth and into your stomach via a flexible tube).

The most common symptoms of a lower GI bleed are dark red blood in the stools, bright red blood from the rectum, abdominal pain, rectal pain, a change in bowel patterns, nausea, weakness or malaise. Again, severe bleeding can lead to shock. The diagnosis of a lower GI bleed is usually made based on a combination of history, physical examination and laboratory evaluation, along with CT scans and rectal endoscopy. Individuals with severe bleeding may require both upper and lower endoscopy — or a procedure known as a tagged red blood cell scan — to fully evaluate the source of the bleeding.

The treatment of a GI bleed is determined mostly by the cause of the bleeding. Anyone with significant bleeding will need a full evaluation to determine the severity of bleeding, followed by treatment of any reversible causes. All significant bleeding requires administration of intravenous fluids and possibly of other blood products as well, depending on the severity of the bleed. Individuals who take anticoagulant drugs such as Coumadin or heparin (popularly known as "blood thinners") may require reversal of their anticoagulation status. Antinausea medications will likely be administered to anyone with severe nausea and active vomiting. And drugs known as proton pump inhibitors (PPIs) may be beneficial for individuals with upper GI bleeding; they can be administered to patients who are still actively bleeding. Admission to the hospital is likely for most individuals diagnosed with a GI bleed.

There is a high mortality rate in individuals who suffer heavy, ongoing GI bleeds. If you suffer significant upper or lower GI bleeding aboard a boat, far from shore, you will need to be evacuated from the boat for evaluation and treatment. Some treatments can be rendered immediately, however, on the boat or while you're en route to the hospital, including antinausea medications, PPIs, and intravenous fluid resuscitation. But minor bleeding, or bleeding that stops without any other symptoms occurring, can simply be monitored very closely by the crew. If your symptoms worsen or you develop dark, tarry stools; weakness; ongoing abdominal pain; severe nausea; or recurrent vomiting, you will need to be evacuated for further evaluation.

If you've been prescribed medication to lessen your body's production of stomach acid (such as PPIs or antihistamines) and you're undertaking a boating expedition, you should keep taking the medication during the voyage. And if you've been diagnosed with an H. pylori infection, which can lead to ulcers, the infection should be eradicated before your departure. It is also a good idea to avoid alcohol and tobacco as you might be at risk of a GI bleed. There is no definitive data regarding what type of diet is best for patients who are prone to GI bleeding. Many foods may cause dyspepsia (an upset stomach), but there is no convincing evidence that specific foods cause or perpetuate GI bleeding.A headache is likely to affect everyone at some time or another. Headaches may be relatively mild and transient — or crushing and long-lasting. They can be caused by stress, dehydration, migraine, a stroke or a brain tumor. The most common causes of headaches in travelers are stress, fatigue and dehydration. Other possibilities that should be considered are caffeine withdrawal, sinus abnormalities, and carbon dioxide retention (especially in divers); headache can be associated with decompression illness as well.

Red flags for a serious underlying cause include accompanying neurologic abnormalities and continuous vomiting. A stiff neck and a fever in concert with a headache can signal meningitis. Another critical problem, intracranial bleeding (bleeding in the brain), can be signaled by a severe, sudden-onset headache — often described as "the worst headache of my life." On the other hand, an intracranial mass, or brain tumor, may manifest itself with a headache that increases slowly over time, as well as with neurologic symptoms. (Learn more about conducting a field neurological examination.)A heart attack, also known as a myocardial infarction (MI), is an interruption in the flow of blood to your heart — usually caused by a clot lodging in your coronary arteries, which supply your heart itself with blood. The most common symptoms of a heart attack are chest pain or discomfort; discomfort radiating to the arms, back, neck, jaw, or other parts of the upper body; and shortness of breath. Other symptoms can include nausea, dizziness, and a cold sweat. (It is of note that the symptoms women experience may be different — often vaguer and/or milder.) An MI should be suspected in anyone who experiences such symptoms — especially those with risk factors such as hypertension (high blood pressure), hyperlipidemia (high cholesterol), obesity, diabetes, a personal history or family history of MI, or a history of smoking. Individuals with any of those risk factors are advised to receive a thorough cardiac evaluation prior to traveling, since access to good, timely care is difficult or impossible in some locations.

When an MI is suspected, especially in individuals short of breath, administering supplemental oxygen can be considered. Individuals with a suspected MI should also be given 324 milligrams of aspirin — assuming they aren't allergic to aspirin and have never been told they shouldn't take it. Cardiac patients who have been prescribed nitroglycerin to treat angina (chest pain brought on by a reduction in the flow of blood to the heart) can consider taking a dose of that drug. And patients who have been prescribed an anticoagulant (a drug that reduces the blood's tendency to clot) or a beta blocker (a class of drugs used to treat angina, high blood pressure and heart rhythm disturbances) should take such medications if they haven't already done so. Any such patients should be placed in a comfortable, supine position (flat on their back, face up) — with their head elevated if congestive heart failure is a concern. In the meantime, plans should be made to evacuate the patient to the nearest treatment facility. A stroke — an interruption in the flow of blood to your brain, usually caused by a clot lodging in your cerebrovascular system — typically manifests itself through a variety of neurologic abnormalities. Symptoms of a stroke can be as mild as subtle changes in mental capability or as marked as paralysis of one side of the body (a condition known as hemiplegia), blindness, or loss of consciousness. (Learn more about field neurological examinations.) Prompt evacuation to a medical facility, preferably one with expertise in treating strokes, is essential. The recommended therapy varies depending on the cause of the stroke. If the affected individual did any diving in the recent past, be sure to mention the possibility of decompression illness to all medical personnel. A toothache can be caused by dental trauma or an infection of the teeth or gums, as well as by an infection of the sinus cavities. Trauma can result from a direct blow to the mouth — as well as, in divers, from barotrauma due to a differential in pressure between the ambient environment and the gas-filled space in a tooth with a cavity. If a tooth is dislodged, it is often possible to reimplant it. (Learn how to save a knocked out tooth). If the cause of a toothache is an infection or abscess, antibiotic treatment may be required. If a toothache is accompanied by swelling and rapidly expanding pain, it should be considered an emergency, since it may result in obstruction of the airway in severe cases.The urinary tract is composed of the kidneys, the ureters, the urinary bladder and the urethra. Urinary tract infections, or UTIs, are quite common, with more than 3 million cases diagnosed each year in the U.S. alone. The urethra is much shorter in women than in men. It is for this reason that UTIs are much more common in women. UTIs are rare in children, however. It is usually a self-diagnosable disease, although lab tests and imaging are often required; definitive treatment involves prescription antibiotics.UTIs can be divided into upper UTIs and lower UTIs. The upper urinary tract consists of the kidneys and the ureters, while the lower urinary tract consists of the urinary bladder and the urethra. Upper UTIs usually affect the kidneys — a condition called pyelonephritis, an infection of the kidney itself and the "renal pelvis," which can cause fever, nausea, vomiting and other severe symptoms. Lower UTIs involve the bladder (a condition called cystitis) and/or the urethra (a condition called urethritis).Symptoms of both upper and lower UTIs usually include a variable degree of pain in the pelvic area, an increased urge to pee and sometimes some pain or a burning sensation during urination (a condition called dysuria); dark-colored urine or traces of blood may but may not be present as well. It is also common for individuals with UTIs to feel that their bladder is still full even after they've urinated. Upper UTIs may also cause lower-back pain, cramping, nausea, vomiting and fever.

Kidney percussion is a simple medical test that can assist in diagnosing a UTI in or around the kidney. With the patient in a sitting position, the examiner places a flat hand over the costovertebral area (the area in the lower back where the rib cage meets the spine), and performs gentle fist percussions over the flat hand. In the absence of an infection or an inflammatory process, this maneuver should not elicit any pain or discomfort; but because the kidney lies right below the flat hand, the gentle taps of the fist percussion will cause a sharp moderate pain if the kidney tissues are inflamed. This test is usually positive in people with an upper UTI and almost always positive in those with pyelonephritis.

If you suspect you may have a UTI, it is important that you stay well hydrated. If you're able to produce a good amount of urine, that results in a good flow of urine throughout the urinary tract. This can help wash out the bacteria causing the infection, which may not necessarily control the infection but may reduce its progress.

Definitive treatment involves taking antibiotics, usually orally. Travelers should always seek professional medical evaluation if they suspect they have a UTI. As long as you're near land, no matter how remote your location and regardless of cultural differences, UTIs are so common that a medical doctor anywhere, of any specialty, should be able to diagnose and treat a UTI. Do not delay seeking evaluation and treatment, for a neglected UTI can cause complications and require hospitalization.Bleeding can often be stopped by applying steady, direct pressure to a wound. Once bleeding has slowed or stopped, the wound should be cleaned of debris and irrigated generously — preferably with saline solution or some other sterile liquid — especially if it will be closed. There are a variety of methods for closing wounds, including so-called butterfly bandages (also known by the brand name Steri-Strips), topical adhesives, staples and sutures. Some experts recommend loose closure of a wound to allow for drainage in case an infection develops during the healing process. Depending on the circumstances, it is also worth considering a prophylactic (preventive) tetanus booster and antibiotics to forestall infection. Hand injuries are particularly serious, as long-term functional impairment can result from some wounds to the hand. Injuries near joints, tendons, and nerves are also of particular concern and may warrant consultation with a specialist as soon as possible.

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