On The Trail - Guide to outdoor activities!

The Thru-Hiker’s Medical Guide

By: Stewart Anderson, MD PCT Cabron

(This article has been copied form http://www.whiteblaze.net/)

About me: I grew up in Texas and went to med school there in Galveston. After which, I walked the PCT from So Cal to Canada in 2003 between my internship and residency in Emergency Medicine in Boston, MA.

Introduction:
I began thinking about writing this guide about 4 years ago while plodding my way up the PCT. Then, in 2006, I passed out a survey on the AT and PCT to see what were the most common injuries and illnesses, and from that and my own experience came this guide. I also leaned heavily on a few excellent and thorough texts and websites that I recommend if you’re interested in learning more (they are listed at the end). In the interest of keeping the guide light and useful, I purposely did not dwell on disaster injuries, like “I fell off a cliff and broke my_____”. If this happens make the crooked things straight and get help.

Most of the treatments recommended can be found at your local pharmacy. I think it is a good idea to carry a few specific prescription medications that you can get from your doctor and call him/her from town for instructions and recommendations. There are a myriad of herbal/homeopathic remedies out there that may or may not work. I don’t have any training with herbs, but I’m not opposed to them, just mind your source
There are a couple of pages that cover recommendations for first aid kits, medications to carry, etc. Please feel free to rip them out after you read them or save them for that cold, wet day when you need something to burn. I will apologize in advance for any typos or confusing statements. This was an all-volunteer effort so be patient.
Underlying all the recommendations in this book is an understanding that almost every illness and injury can be avoided through good judgment. Use it. If there is anything missing from the book that you think needs to be, send me a note.
A note of thanks to the staff at Boston Medical Center, the Binghams of Stehekin, Gary Beale of Glenclif, NH, Matt Heid for his editing, and to Blair for acting interested.

This is dedicated to the wandering, good souls who call themselves thru-hikers. May your trail stay high and the evening light be long.

Waiver: The following are recommendations. Seek professional medical advice if you are ill or concerned. This was a volunteer project and I cannot accept any liability although I do sincerely hope that you have a safe trip.

Disclaimer: I have no financial or professional relationship with any of the companies that make the medications or treatments described.

How to use this book: It is meant to be carried and referred to as the situations arise, or it can be referred to on the internet. If you are going to carry it, print 4 pages to a page, cut long ways and fold. Staple these together and put in a ziploc bag.

CONTENTS:

I. Foot Care
a. Blisters
b. Subungal Hematomas|
c. Athlete’s Foot
II. Bones and Moans
a. The Acutely Painful Joint
b. Fractures
c. Chronic knee pain
d. Achilles tendonitis
e. Shin Splints
f. Numbness/Tingling/Burning Sensation
III. Hiker Belly
a. Diarrhea
b. Water Treatment v. Washing your Hands
IV. Skin
a. Blistering Sunburns
b. Poison Ivy/Poison Oak
c. Jock Itch/Yeast Infections|
d. Chaffing
e. Boils/Abscesses/Skin Infections
f. Spider Bites
g. Tick-Borne Diseases (ie. Lyme)
h. Snake Bites, just for the hell of it.
V. Urine/Kidneys/Menstrual stuff
a. Urinary Tract Infections
b. Changes in Menstruation
VI. Before you Go
a. First Aid Kits
b. Non-prescription Medications
c. Prescription Medications
FOOT CARE:
The importance of your feet can’t be overemphasized. In order to keep you feet healthy and happy here are a few basic tips: Wash feet daily. Trim toenails often. Have at least 2 pair of socks and rotate them regularly. Have a dedicated pair of sleeping socks so your feet have something dry, clean and warm to hang out in at night. Hikers with Diabetes should pay special attention to sores and infections on their feet. Would care for diabetics should probably be done under the guidance of a medical professional.

Blisters: Blisters are the result of friction. So prevention and treatment should be directed against anything causing friction inside your shoe. Most of you understand basic blister care and have your own unique methods as far as moleskin, taping or other dressings go. The addition of a dab of Neosporin over the blister will help prevent further blister formation by reducing the friction and will be much more comfortable. The Neosporin also works well for those blisters between the toes (and for preventing them).
Once a fluid filled blister has already formed they can be quite uncomfortable. Rupturing fluid filled blisters does carry a small risk of infection because it is sterile until it is ruptured. So if you decide to open the blister (or if it has already ruptured on its own) then do so with a clean knife or needle that has been sterilized with a flame. Make a hole along the bottom part of the blister then cut off the dead skin. Wash with soapy water and cover it with Neosporin and a bandage to prevent further blister formation. Be vigilant for signs of infection such as redness, warmth, severe pain and pus. Blisters that are small, not bothersome and not infected are better left alone to heal on their own.

Blood Blister Under Toenail (Subungal Hematoma):
Symptoms: Painful, purple collection of blood under the toenail, often caused by poorly fitting footwear or a heavy object squashing your toe.
Treatment: Heat up the end of a needle or safety pin (a paper clip also works) until it is red hot, then gently drill through the nail (directly over the fluid collection) until fluid starts coming out. Stop. You don’t need to go any deeper. This should not hurt at all. Put a bandaid with Neosporin over the hole. It may continue to drain on its own.

Athlete’s Foot:
This is a contagious, fungal infection. Symptoms include dry skin, scaling, itching, burning, and blisters (usually between the toes). When the blisters crack they expose raw skin, which causes burning and discomfort. The fungus thrives in the moist, warm environment inside your shoes and can infect other moist, warm areas like your groin or armpits. Its spread is usually caused by scratching, though it can be transmitted on clothing or sleeping bags.
Treatment begins with good foot care. Wash your feet with soapy water every evening, particularly between the toes. Dry well. Take your shoes and socks off during breaks and in camp to air out your feet. Pull the soles out of your shoes and put the shoes, soles, and socks in the sun to dry whenever possible. Wear dry socks to sleep. Don sandals when possible, cleaning them occasionally with rubbing alcohol or peroxide.
A variety of over-the-counter powders are available for athlete’s foot. There does not appear to be any one brand that is better than another. They need to be used for at least 2 weeks to kill the fungus. They will not work if you aren’t taking care of your feet. Tea Tree Oil may help reduce the burning caused by open sores.
There are three reasons to consult a doctor about athlete’s foot. 1) If a severe infection does not respond to the above measures after two weeks. 2) If your feet become swollen and red, or red streaking develops on your legs. 3) If you have diabetes. Severe reactions may require antibiotics due to a secondary bacterial infection.

Note: Chemical irritations from dyes, fabrics, detergents, etc in your socks or shoes can look similar to athlete’s foot. This may be the cause if symptoms commence immediately after starting new socks or shoes.

The Acutely Painful Joint
Sprains and strains occur when the ligaments and tendons in joints are overly stretched, torn, or damaged. A fracture could occur if significant amounts of force are involved. Indications of fracture include exquisite tenderness at one particular spot over the bone, and/or an inability to bear weight on the affected joint for at least 4 steps. If this is the case immobilize the joint and seek medical care for further evaluation. In the absence of a fracture, focus on stabilizing and supporting the joint, RICE (see below), and controlling the pain until symptoms improve. Healing time will vary depending on the degree of injury, how much you allow it to heal, and how much strengthening and stretching are done. For mild injuries, plan on resting for at least a couple of days. Remember that a sprain or strain will not heal if you continue hiking on it.
Prevention: 1) Good shoes (light, and comfortable). 2) Daily stretching of hams, quads, calves and back.
Management:
-RICE: Rest, Ice (20 minutes every hour), Compression, and Elevation (above your heart while lying flat). Start immediately after the injury and continue for the next 3-5 days. This will help reduce the swelling, inflammation, and pain in the early stages of the injury.
-Stabilizing or Immobilizing the Joint: If the situation requires that you continue walking on the injured joint, snugly wrap the joint with ACE bandages or whatever you have available in a figure 8 fashion around the joint. Use hiking poles or a walking stick to minimize the load on the joint. It’s OK to put as much weight on the joint as you can tolerate. If you are unable to bear weight and/or have severe pain, make a rigid splint. You will have to be creative with your available resources but the basic idea is to create firm structural supports on both sides of the joint that will completely immobilize it. Make sure the splint is well padded and does not inhibit blood flow. Sleeping pads work well for knees (think burrito). Ice axes, hiking poles, and tree limbs can work for ankles. A rigid splint will significantly reduce pain during evacuation, as will medications like Motrin or Tylenol.
Braces may be available at the local pharmacy when you get to town. If RICE and a simple brace are inadequate, you should get checked out in the ER. While you’re there you should get a plastic splint (Air-Cast). These are great splints that can be worn with a shoe on and should be worn at night as well. Stretching and rehabilitation exercises should begin within 3-5 days of the injury and should continue daily for several weeks. Look on the internet or talk with your doctor for specific exercises. I liked these sites:http://www.mckinley.uiuc.edu/Handout…klesprain.html
Knees: http://www.med.umich.edu/1libr/sma/sma_medollig_rex.htm
Basic rehab for ankles: 1) flexing the foot up and down. 2) moving the foot in circles. 3) painting the alphabet with your toe. These can be done several times a day.
Returning to activity: When you can walk down the stairs without pain or hop on the foot 4 times without pain, you are good to go.

Fractures/Dislocations:
This chapter was initially quite lengthy, bit I almost all of it out because fractures and dislocations are pretty uncommon and if you suspect such an injury you should seek medical attention. Your goals for management of such fractures in the field essentially are to straighten out the bones (when possible), splint for stability, pain control (Ice, elevation, motrin), and seeking medical attention Identifying fractures without an x-ray can be challenging, however, the ability to bear weight on the affected extremity, and move the joints back and forth with only mild to moderate pain makes a fracture unlikely. But if you are concerned or you have too much pain, seek medical attention. Fractures are generally not life threatening unless the skin is open around the fracture (which can lead to infection) or when self-supported evacuation is dangerous or impossible. If the skin is open, pour 2-3 liters of purified water through the wound and wrap it in something clean, and seek medical attention.

Numbness, Tingling and Burning (i.e. Paresthesias)
Paresthesias can feel like “pins and needles”, burning, or can be a decreased sensation like there is a layer of tape over the skin. They can occur in arms, hands, thighs, or feet. They are caused by compression or repeated direct injury to the nerves. They are disturbing but generally temporary and resolve on their own within a few weeks of correcting what is causing it. Motrin should help if it is painful.
Arms/Hands (Ulnar paresthesias): These are usually characterized by numbness or tingling in the ring and little finger. They are usually due to compression of the nerves in your armpit by your shoulder straps. So change the positioning of the straps and increase the padding.
Outside of thighs (meralgia parestheitica): Due to nerve compression by hip belt. Change position of hip belt, quit wearing it or increase the padding.
Heel/Sole of foot (Tarsal Tunnel Syndrome): Due to your shoes or boots pushing into rear aspect of your inside ankle bone and compressing a nerve that passes through there. Change the type of footwear or cut them back.
Toes (digitalgia paresthetica): Due to repeated compression of nerves on bottom of foot from walking. Stiffer shoes and less foot padding are more likely to cause this. Try running shoes or new padded insoles.

Chronic Joint/Leg/Foot Pain:
This section covers several different types of over-use injuries. The causes of these injuries can generally be boiled down to inadequate stretching and strengthening, and poor footwear. Spend some time researching footwear and choose something that will work for your foot.
www.drpribut.com/sports is a website that I used a lot for this section. It was written by a podiatrist and runner’s doc that has some excellent articles about footwear and more detailed information about injuries, stretching, etc.

Chronic Knee Pain: Runner’s knee is condition characterized by pain at or near the medial (inside) or bottom of the knee-cap. It is usually worse walking downhill or sitting with knees bent and is caused by the knee cap not tracking smoothly over the joint due an imbalance in the strengthening of the medial (inner) and lateral (outer) thigh muscles, or excessive pronation (walking on the inside of the foot) while walking. If the soles your shoes are wearing much more on the inner aspect compared to the outside, you may bee pronating excessively and could benefit from a shoe with better arch and heel stability. Also you can strengthen the inner thigh muscle by doing leg straightening exercises: lay flat with something under your knee so that the knee is at a 30 degree angle. Raise the foot until the knee is straight. Do 5 sets of ten or as many as tolerated daily. Motrin 600 mg up to 3 times a day as needed should work well for pain. And finally, consider orthotics.

Achilles Tendonitis: The Achilles tendon attaches the calve muscles to the heel. The calve is a very powerful muscle group, but the Achilles tendon has a poor blood supply so injuries are slow to heal. Tendonitis is an inflammation of the tendon caused by footwear and/or tight calve muscles. Footwear in the soles are too stiff or that have excessive heel cushion (particularly air cells) can put more stress on the tendon, causing repeated minor injury. Calve tightness can be improved with regular, gentle stretching. A ¼ inch heel lift may provide some relief. RICE (see acute joint injuries) and decreasing mileage will help as well. If the pain is limiting walking, or got suddenly worse, then rest for a few days and consider seeking medical advice.

Shin Splints:
These are thought to be due to inflammation of the lining of one of the bones (tibia) in the lower leg. Typically described as pain and tenderness in the anterior (frontal) or medial (inside) aspect of the lower leg. The pain and tenderness usually extends vertically 3-12 cm above the inner ankle bone. It may be in both legs. Patients usually can hop on the affected leg and do not have an isolated spot of tenderness in the leg. Inability to hop on the leg, pain at single point or that is horizontally oriented may suggest a stress fracture, which should be evaluated by a medical professional.
Shin splints are an over-use injury, caused or at least made worse by inadequate footwear. Excessive pronation (rolling your arch in) is usually the culprit.
Management: Motrin, rest, ice (20 min/h), stretching and strengthening. Decrease your miles or rest until the pain resolves. Consider changing your footwear.

DIARRHEA:
Prevention: WASH YOUR HANDS!!!! after every time any form of bodily fluid (feces, urine, or other) leaves your body and before you eat. Washing your hands and cleaning cooking pots and utensils with warm, soapy water is MORE likely to prevent diarrhea than water purification. This has actually been studied. That being said, PURIFY YOUR WATER consistently. Erratic water purification has similar rates of diarrheal illness as never purifying.
There are essentially 3 types of diarrhea: 1) Secretory: watery diarrhea caused by lots of different bugs but usually resolves within 3-5 days.
Treatment is replacing fluid losses, Peptobismol and Immodium. 2) Inflammatory: bloody diarrhea usually caused by specific types of bacteria. It may be associated with fevers. Treatment usually involves the above + antibiotics. If you have blood in your diarrhea, you should go see a doctor as soon as possible. 3) Chronic diarrhea: We usually blame this on Giardia. This includes persistent and recurrent diarrhea (keeps coming back). If there is no blood in it, and you don’t feel significantly dehydrated, then take tinidazole or flagyl (antibiotics) as directed by your doctor. Symptoms should improve within 24 hours.
Management: Increase fluid intake (water and//or soups). You need salt in your body to absorb the water so either eat salty foods or mix up some Oral Rehydration Cocktails: Alternate Glass 1: 8oz (250 ml) fruit juice (apple orange or lemon), ½ tsp of honey, and 1 pinch of salt. Glass 2: 8 oz of water (purified) and ¼ tsp baking soda.
Medications: Most diarrheal illness will resolve on its own in 2-3 days without medications. For nonbloody diarrhea Peptobismol is safe, cheap, readily available and may help reduce output and abdominal cramping. Immodium is not an antibiotic and I generally don’t recommend it (especially with bloody diarrhea) but will it slow down your output, which is important especially in the setting of the explosive diarrhea variety. Take 2mg after first episode of diarrhea and 1 mg after subsequent episodes for a maximum of 8mg in 24 hours.
Giardia: Symptoms can vary from large volumes of foul smelling, soft stool to explosive diarrhea, nausea, vomiting, malaise and a characteristic “rotten egg” smell to bowel movements and gas. Chronic (>2 weeks) or recurrent diarrhea can develop. Treatment: Flagyl 750 mg once a day for 5 days, or Tinidazole 2 gm once. I would go with the tinidazole since you only have to take it once. Don’t drink alcohol while taking these medications, as they will make you feel hungover.

Skin and Soft tissue:
Scrapes and Cuts:
The Basic principles are 1) get it clean, and 2) keep it clean. Lacerations (cuts) are closed with sutures primarily to reduce scar formation, and this can be delayed for 24-36 hours without untoward effects as long as you keep it clean (see below). Abrasions can simply be cleaned and covered.
Management: Hold pressure with dressing and elevate to stop the bleeding. Clean with soapy water and pour 1-2 liters of purified water through the wound. Cover the wound with antibiotic cream (e.g. bacitracin) and wet gauze. Repeat every 12 hours until you can be seen by a medical professional if you need sutures, otherwise it will heal on its own eventually. Preventing an infection by keeping the wound clean is absolutely more important than getting to the clinic a little faster. Also, trying to “Rambo” it with a fishing hook and 5 lbs line is not going to help.
Concerning features: signs of infection, and lacerations into joints or involving tendons. If you have any of these go the clinic. Most wounds do not need antibiotics (except maybe punctures).
Puncture Wounds: Whether due an animal, nail or hiking partner’s teeth, they should be cleaned the same as lacerations AND probably be seen by a medical professional due to the higher likelihood of infection.

POISON IVY, POISON OAK AND POISON SUMAC:
Eastern Poison Ivy: climbing vine with three serrated-edged pointed leaves which grow in clusters of 3.
Western Poison Ivy: similar leaves but it is a low-growing shrub.
Poison Oak: 3 leaves. Grows in sandy soil as a low shrub in the East, and a large standing shrub or climbing vine in the West.
Poison Sumac: a shrub or bush with 2 rows of 7-13 leaflets.
Characteristics: red, itchy rash, with fluid-filled vesicles. If you’ve had it before, symptoms usually develop 4-96 hours after exposure, otherwise symptoms could be delayed for a day or two.
Management: Wash all exposed skin clothing gear with copious COLD (keep the pores closed) soapy water (not alcohol based soap) immediately.
This inactivates the toxin (called urushiol) and prevents further spread to yourself and others. Be sure to clean under fingernails well.
Once the skin has been thoroughly cleaned, you are no longer contagious. The fluid in the blisters is sterile and toxin-free.
A new product, Zanfel cream, is by many accounts the most effective therapy available (the company reports that itching will go away within 30 seconds). It can be bought without a prescription at the pharmacy, although it is quite expensive at $40. For severe reactions, or debilitating reactions not responding to the above regimens, go to the clinic. For mild reactions, just clean the wound, and take benadryl (25 mg every 12 hours as needed) for the itch. Calamine lotion, cortisone 1% cream, or aveeno oatmeal baths may help with the symptoms.

Prevention: Long pants, long-sleeve shirts, and identification/avoidance of noxious plants. Creams to prevent exposure (e.g. Ivy Block) are safe and will prevent reactions most of the time, but they must be re-applied every 4 hours.
http://www.pennhealth.com:80/health_info/allergy/images/19330.jpg

Jock Itch/Yeast Infections:
MEN: It is essentially athlete’s foot in your groin. It usually does not involve the scrotum or penis. Clean the affected areas with soapy water. Avoid tight fitting underwear. The antifungal powders could be helpful. Be sure to use them as directed and for at least 2 weeks. Wear clean, dry boxers to sleep in. This is contagious so avoid sharing shorts or sexual activity until resolved.
WOMEN: Generally don’t get Jock Itch. If you have burning in the vaginal area then it is likely one of two things: a yeast infection or vaginitis (a bacterial infection). Neither is life threatening. Yeast infections are usually associated with a white, cottage cheese-ish discharge. Vaginitis is usually associated with a brown or grey fish smelling discharge.
Vaginitis can be transmitted sexually or it can just be a bacterial overgrowth (it is not caused by gonorrhea or Chlamydia). Treatment is Flagyl 2 gm one time. Consult a doctor before treating.
Yeast Infections can occur after taking any antibiotics, and from bodily stress or hormonal changes. Prevention: If you are taking antibiotics you should also eat yogurt with live cultures, and/or take lactobacillus (nonprescription pills with bacteria in them). Keep genital area clean and dry. Avoid perfumes, feminine hygiene sprays and douches. Treatment: Prescription: Diflucan 150 mg (tablet) once. Nonprescription: Monostat vaginal suppositories (use as directed). Please make sure you are not pregnant before taking any of these medications.
Reasons to see a doctor: 1) You need a prescription. 2) You develop severe abdominal pain, bleeding from your vagina, or fevers. 3) Infection not responding to the above measures. 4) If you are pregnant.

Sunburns: For simple sunburns, keep your skin covered and clean. Apply cool soaks and aloe vera for comfort.
Blistering Sunburns: Cool the affected area with cold packs and cool, clean water. Remove loose skin and debris. Drain and cut back blisters larger than a quarter or if they look like they are going to burst. Apply antibiotic cream (e.g. Bacitracin) and a clean dressing. Sunburns generally do not need to be seen by a medical professional unless they are getting worse or infected (worsening redness, pain or pussiness) .

Burns: Burns can be very serious as they have a tendency to get infected. All burns other that dime-size superficial burns should be evaluated by a physician.

Boils/Abscesses:
Boils (abscesses) are walled off infections under the skin, like acne but bigger. They are painful and feel like tight water balloons. They generally occur in armpits, buttock creases, and other hairy places, but can occur anywhere.
If it looks red and angry, go to the doctor. If it doesn’t try putting rags soaked in hot water and Epsom salts on the abscess, which may induce it to open on its own. Once it is draining, the pain will go away, and the abscess may resolve. They do commonly recur and you should continue the warm compresses for a couple of days until you are sure it has resolved. If that doesn’t work, go to the ER and have someone open it. Don’t try cutting into it unless you have been trained to do so.
Treatment is drainage. Antibiotics ae generally neither necessary or helpful, unless there is a surrounding skin infection.

Bees, Wasps:
If the person starts having difficulty breathing, swallowing, hoarse voice, hives covering their body, or other signs of anaphylaxis, USE THE EPI-PEN. Do not delay. Then evacuate.
Otherwise, just remove the stinger, apply ice, and clean the wound.
Snake Bites: Pit vipers (rattlesnakes, water moccasins, etc) and coral snakes are the only poisonous snakes in North America. Pit vipers have triangular heads, and cat-like pupils. Coral snakes have to chew on you to envenomate, so don’t let them.
The Sawyer Extractor might work if used within 2-3 minutes. Remove jewelry as swelling will likely occur. Do not try to capture the snake (a simple description will do). Begin evacuating to the closest road immediately.
DO NOT: immobilize the limb (will just slow you down), shock the would with a car battery, put ice on it (may worsen tissue necrosis), the “cut and suck” thing (doesn’t work), apply a torniquet (not effective at limiting spread of toxin, and will guarantee loss of the limb).
Anyone who has been bit by a snake that they are not absolutely sure was not a pit viper or coral snake, should seek medical attention.

Spider Bites: The only spiders in North America that are dangerous to humans are: Black Widow, Brown Recluse and Hobo Spiders. The symptoms are not specific but generally occur within 36 hours and could include: local tissue destruction, muscle cramps, fevers/chills, nausea and vomiting. If you know that you were bitten by one of these spiders or you develop these symptoms then go to the clinic or at least stay close by. Keep the wound clean and covered.

Ticks: Lyme Disease (classically a Northeast disease that has quickly worked its way South and across the Mississippi, although I am not aware of any reports along the PCT) and other tick-borne illnesses such as Rocky Mountain Spotted Fever, and Ehrlichiosis are a concern along the trails.
Prevention: Permetherin-soaked clothes, and DEET are very effective at keeping the ticks off. If you can’t handle that, then be vigilant with “tick checks”. Removing ticks within 48 hours has been reported to prevent infection. If the head is stuck then pick it out with a needle. Do not burn the tick, cover it in gasoline, twist it or smother it in alcohol. Just pull straight back. Then clean the wound with soapy, warm water.
Signs of Lyme Disease: fever, headache, unexplainable joint pain, and/or classic rash that is red, round and clear in the middle, resembling a “target sign”.
If you develop these symptoms go to a clinic, even if symptoms resolve. Lyme can be difficult to distinguish from the flu. Depending on the situation, they may do blood tests or just go ahead and treat you.
Treatment: for mild/moderate infection is doxycycline 100 mg twice a day for 6 weeks. Infections can become severe, or chronic if not treated correctly. Please do so under the supervision of a doctor.

Eyes:
Bugs, dirt, etc in your eye: typically the eye is red, watery and it feels like someone is dragging a rake across your eye every time it moves.
Management: Remove contacts (and do NOT replace for several days until redness has completely resolved) Pour copious amounts of purified water directly into the eye until the raking sensation is gone. If you can see the object (flip the lid up) then an assistant could try gently removing it with a moistened Q-tip. Pain should be resolved by the next morning. If you develop worsening pain, worsening vision or other problems go to the ER promptly.

Snowblindness:
Solar radiation particularly on snowfields can lead to a sun burn on the cornea (skin) of your eye if you don’t wear sunglasses. The pain does not generally develop until later in the afternoon or evening, however, it is particularly intense and will result in severe discomfort for at least the next 1-2 days.
Treatment is symptomatic and is primarily pain control (usually requires narcotics). Eye drops to paralyze the eyes may be prescribed and will provide some relief. Artificial tears or contact solution can be bought at the store and will provide some relief as well. Medical evaluation is helpful to ensure there is not debris in the eye and no ulcers have formed. Contacts should be removed and not replaced until symptoms are gone.

Urinary Tract Infections:
They are characterized by burning with urination or increased frequency of urination. Generally they are uncommon in men. However, the presence of symptoms warrants medical evaluation. For women, since UTI’s are so common, they may elect to carry antibiotics to take should symptoms develop. It is important to do this under the guidance of a medical professional. Ensure that you are not pregnant with a home pregnancy test prior to taking antibiotics, as some of them are not safe in pregnancy.
The development of fevers, vomiting or pain in your back could signify that the infection has spread to the kidneys. Kidney infections can be serious, so go to the ER if flank pain or fevers develop.
Treatment: Bactrim DS 80/160 twice a day (3 days for bladder/urethral infections, 10 days for kidney infections). Pyridium (aka Azo) 100 mg twice a day for 3 days will help with the pain of urination but is not an antibiotic.
Drink plenty of fluids, particularly cranberry juice which may help fight the infection.

Menstruation:
Changes in womens’ menstrual cycles are very common among long-distance hikers (about 50%) and are likely due to decreased body fat and other nutritional factors. The long-term affects of this are unclear, however, cycles generally normalize when an adequate diet resumes. That being said, a “home pregnancy test” should be performed whenever there is a change in menstruation.

BEFORE YOU GO…
The vast majority of hikers are going to have a relatively uneventful trip from a medical standpoint, but there are a few things you can do prior to leaving that could make a big difference. 1) obtain at least some sort of catastrophe medical insurance. It’s cheap and could be useful. 2) go visit with your doctor (or PA/NP or college health clinic). Having a few prescription medications available and someone to call when you get sick will help you get well sooner and save you a significant amount of money by possibly preventing a long and expensive trip to the local ER. They will likely be really excited about your trip and enjoy being the “expedition doc” even if it’s via telephone or email, so don’t be shy. 3) Put together a first aid kit yourself that way you know what is in there and why. 4) consider taking a Wilderness first Responder or First Aid course.
First Aide Kit:
There are a myriad of ready-made first aid kits available in the market for backpacking, however, I feel that we can go lighter and smaller without missing much. Your first aid kit should allow you to deal with minor injuries and have a few other select medications and tools to treat or temporize other issues until you can make it to town, AND it should fit in a small Ziploc bag. The following list is what I take with me. It does change depending on what is wrong with me. Your kit should reflect any previous medical problems you’ve had and current issues. Extra supplies can be shipped along in your “bounce box” or bought in the local store. Just because you may need a splint or bandages on your way through Washington, doesn’t mean you have to carry them through the desert. Buy things as you need them. Adapt.
My Basic Kit:
1) Band-aides (enough to last a week, not the whole box)
2) Bandages (2 4×4’s should be fine)
3) Antibiotic ointment (Neosporin or bacitracin)
4) Safety Pins (for securing, popping, drilling)
5) Mole Foam/Second Skin or other Blister stuff
Note: having scissors on your pocket knife will make it immensely easier to cut up the blister stuff.
6) Uncle Ben’s tweezers
7) Sunscreen
8) Small bar of soap (fragment of Bronner’s in bar form)
9) DEET (for when you can’t take it any longer)
10) Lip balm
11) Emergency Fire Starting Kit
Non-Prescription Medications:
12) Gold Bond Medicated Powder (for chaffing)
13) Motrin or Tylenol for pain
14) Peptobismol chewable tabs (8 should get you to town)
15) Zanfel (poison ivy dope)
16) Oral Reydration Packets (2-3)
Prescription medications:
-Antibiotics:
-Flagyl OR Tinidazole for chronic diarrhea (Giardia)
-(Tinidazole is only one time dosing, so I prefer it)
-Bactrim 80/160 can be used for skin infections, pneumonias, and urinary infections
-Pain Medications
-19) Ketorolac (an NSAID, not a narcotic, similar to motrin but stronger. Avoid motrin (ibuprofen), Aleve (naprosyn) while taking it)

**If you’ve ever had an anaphylactic reaction, or if you just want to be prepared, carry an Epi-Pen. It is one of the few “weird” drugs I carry because you can actually save someone’s life with it [think: bee sting, puffy face, can’t breathe (talk with your doctor, and read the instructions before you go)]. You’ll need a prescription.

Visit your doctor prior to leaving. I think a reasonable plan is to get prescriptions and fill them while you are home. Carry these medications in your first aid kit and then you can call your doctor when you get ill and they can make recommendations about what to take and how often. Do not take them without the supervision of a medical professional. If the actual prescription paper is from out-of-state or is out-dated, it may not be honored by the local pharmacist, so try to “fill” the prescriptions prior to leaving home. Most other bandages, splints and such can be improvised from things already in your pack. Be creative. And get to town when you have a significant injury.
Wilderness Medicine Resources:
1) Fred Darvill, Jr. MD Mountaineering Medicine and Backcountry Medical Guide
2) William Forgey, MD Wilderness Medical Society: Guidelines for Wilderness Emergency Care
3) Advanced Wilderness Life Support (Syllabus) this is an excellent course accredited through the Wilderness Medical Society. Edited by David Della-Giustina, MD and Richard Ingebretson, MD
4) Paul Auerbach, MD Wilderness Emergency Medicine