Common Summertime Medical Ailments, by Dr. J.

I’m a board-certified family physician currently working as an urgent care provider in the southeastern United States. I really enjoy the work and split my time between a larger urban urgent care center and a small rural ‘fast-care’ facility about an hour outside the city. I grew up rurally and having always enjoyed country living and the self-sufficiency that comes with it, this also led to my interests in preparedness and survivalism. One of the most important aspects of preparedness is being comfortable in dealing with the variety of medical issues that will inevitably arise, ranging from inconveniences to emergencies. In this article, I plan to discuss some of the most common medical complaints I come across during the summer months in urgent care, as well as their background and first-line treatments. I also plan on writing a similar article in a few months covering fall/winter common complaints and treatment strategies.

While is it prudent to be prepared and supplied for significant or life-threatening injuries, you’re much more likely to encounter these more commonplace injuries and annoyances in day-to-day life, perhaps even moreso in a survival situation. Proper and prompt treatment of these conditions can shorten their duration and prevent them from progressing to more dangerous and debilitating conditions. So while I’d encourage you to hang onto your CAT tourniquets and Israeli pressure dressings (and learn how to use them!), keep some room in your med kit for more commonplace medications and supplies. You’ll likely need them more often than you think. For convenience and ease of acquisition, I’ll try to keep treatment strategies mostly to medications and supplies you can get without a prescription. Let’s get started!

Disclaimer:

The opinions and information in this article are for entertainment and general education purposes in a hypothetical survival situation. This article does not constitute medical advice and should not replace diagnosis and standard medical care performed by a qualified medical professional. A doctor-patient relationship does not exist and is not implied between the author and readers of this article.

Ankle Injuries:

These are a common occurrence during the summer months as everyone is out and about running, hiking, etc. They can also be expected in a survival situation, as people will likely be much more mobile and physically active. So how do you know if that rolled ankle is broken or not? The Ottawa Ankle Rules provide a good reference point to know whether you should x-ray (or be concerned for a fracture):

• Bony tenderness over lateral or medial malleolus (the bony mounds on the inside and outside of your ankle)
• Inability to bear any amount of weight and walk at least 4 steps at the time of injury or at the time of evaluation.

So if you have no bony tenderness in the ankle and are able to bear some weight and hobble around a bit, the ankle is most likely sprained as opposed to broken. The Ottawa Foot Rules add another caveat:

• Bony tenderness at base of 5^th metatarsal (the most lateral bone in the foot, extending down from the pinky toe)
• Bony tenderness at the navicular (follow the big toe straight back towards the ankle)

Joint instability, deformity (your foot is twisted 90 degrees to one side), bony tenderness, and/or inability to ambulate all indicate a 3^rd degree sprain (most severe) or a fracture, and require prompt medical attention. If none of the Ottawa rules apply to your injury, you may just have a sprain.

Treatment:

• Compression: I prefer Ace bandages because they’re versatile. Compression with an ace wrap provides support and helps with swelling. Try to wrap from above the injury on down, then back up again. Wrap tightly, but don’t cut off circulation!
• Ice/heat: I usually recommend icing the injury during the first 48 hours and using heat or warm water soaks thereafter.
• NSAIDs, or Non-Steroidal Anti-Inflammatory Drugs: Ibuprofen (Advil, Motrin) and Naproxen (Aleve) help decrease pain and inflammation. Ibuprofen can be dosed 600-800mg about every 6 hours. Naproxen can be dosed 220-550mg every 12 hours. Don’t use NSAIDs with other NSAIDs, and don’t use if you have kidney disease or stomach ulcers.
• Acetaminophen (Tylenol): can be used in conjunction with an NSAID, as they are processed by your body differently. Use 650-1000mg no more often than every 6 hours. Do not use if you have liver disease, and do not drink alcohol while taking Acetaminophen.
• Rest: For a sprained ankle, you do not need to keep all of your weight off of the leg. I usually advise progressive weight-bearing, walking as you are able while avoiding long walks, hikes, heavy exercise, etc.

Broken Toes:

With summertime comes bare feet and flip-flops, and with exposed toes comes toe injuries. Whether due to dropping something on an exposed foot or ‘stubbing’ your toe, injured toes must be properly protected. I will not go into detail on treating subungual hematomas, ingrown toenails, nailbed suturing, or toenail removal as these all involve minor surgery that should be performed by a medical professional, if possible.

Treatment:

• Suspected toe fractures do not always need x-ray imaging. If no angulation or open fracture, bruised or broken toes can be managed conservatively with ice and NSAIDs as discussed above.
• A shoe with semi-rigid sole that prevents flexing should be used to protect the toe and decrease toe movement. Consider footwear like workboots or thick-soled walking shoes.
• Buddy taping may be used if it adds comfort or reduces pain, but it is not always necessary.
  • Buddy taping is using an adjacent toe as a ‘splint’ and taping the injured toe to it, using several thin strips of tape wrapping the toes together. A thin piece of gauze may be used in between the toes as a cushion.
• Do not buddy tape a deformed toe injury, if angulated the patient will need a digital nerve block of the toe and reduction by a medical provider.
• Open toe fractures (bone protruding through skin) should not be buddy taped, they will likely need reduction, possible washout and closure, and antibiotics. These should be evaluated by a medical professional.

Bee Stings:

Warmer weather brings people outside and into contact with bees, wasps, and hornets. These stings are painful and can cause local inflammatory and hypersensitivity reactions to the venom, or in rarer cases can cause systemic reactions and anaphylaxis.

Treatment:

• For minor stings, an ice pack will help with pain relief and swelling, as will an NSAID or acetaminophen.
• Usually several hours after the initial sting, we develop a local hypersensitivity reaction to the bee’s venom that involves increased swelling, redness, itching, and/or pain. This is not an infection and does not require antibiotics.
  • Treat with an antihistamine like Diphenhydramine (Benadryl), 25 to 50mg orally, for some relief from itching and swelling.
  • Topical steroid cream like hydrocortisone or triamcinolone may also provide relief.
  • For more severe local reactions, oral steroids like prednisone may be used if you have access to them.
• Severe allergic reactions (anaphylaxis) include systemic symptoms, i.e. symptoms that spread over your whole body instead of just the localized area where you were stung.
  • These reactions often require immediate treatment in an urgent/emergent setting.
  • Signs/symptoms include generalized hives, decreased blood pressure, wheezing, tongue/back of mouth swelling, chest tightness, weakness/confusion. These symptoms most often appear during the first hour after the sting.
  • Treat with oral Benadryl, oral steroids if you have them, an H2 blocker like ranitidine (Zantac) or famotidine (Pepcid). The patient will likely also need intramuscular injections of epinephrine, steroids, and antihistamines in a hospital setting.

Tick Bites:

Another common summer occurrence, but not every tick carries Lyme disease or Rocky Mountain Spotted Fever (RMSF).

• For tick removal, grasp the tick with narrow forceps near where the tick is attached to the skin. Pull straight up with gentle traction. Try not to squeeze the tick’s body or twist.
• If the tick’s head is still attached, clean the area with alcohol or betadine and gently scrape the head or mouth parts away with a scalpel or knife.
  • Of note, burning or using bleach or other substances to remove a tick doesn’t work well and may increase chance of infection. Stick to tweezers and blade.
• When to use prophylaxis for Lyme or RMSF?
  • If the tick is not a deer tick (Lyme transmission) or dog tick (RMSF in eastern US) or wood tick (RMSF in Western US) prophylaxis with doxycycline is NOT needed.
  • If the tick was attached less than 36 hours and is not engorged, prophylaxis is NOT needed.
  • If the tick is a deer/dog/wood tick and appears to be engorged with blood, no matter how long it was attached, use a one-time, oral, 200mg dose of Doxycycline as prophylaxis.
  • If the tick is confirmed to be a deer tick and was attached longer than 36 hours, the one-time, 200mg oral dose of Doxycycline may be used as prophylaxis.
• When to treat for Lyme or RMSF?
  • To make it simple, any signs of fever, muscle aches, joint aches, headache should warrant treatment with Doxycycline, typically 100mg twice per day (morning and evening) for 14-21 days.
  • Any sign of erythema migrans, which is the typical “bulls-eye” red rash associated with Lyme disease, warrants treatment with Doxycycline as above.
    • Erythema Migrans has a red outer ring, paler area in the middle, and redness surrounding the bite. This gives it the typical “bulls-eye” or “target” appearance.

Rhus Dermatitis

Rhus dermatitis is the itchy, weepy rash that comes from contact with the oils of poison ivy, poison oak, or poison sumac. This is a common reason for an urgent care visit in the summertime.

Treatment:

• Do not use bleach or other caustic substances to try to treat the rash. The rash is your body’s reaction to the plant oils, not an infection that can be killed by bleach.
• After known exposure to poison ivy, oak, or sumac, try to shower or rinse off with cool to lukewarm water. A hot shower can open your pores more, and allow the oils to soak further into your skin. Change your clothes. Over the Counter poison ivy washes, such as “Zanfel”, also work well and can bind the oils and prevent spread.
• If the rash appears in just one area of your body, treatment with topical steroid cream will help treat the rash and associated itching. The stronger the steroid cream, the better.
  • Steroid creams should not be used extensively on the face, as they can cause some skin thinning and blanching.
• With a widespread reaction, involvement of face, hands, or genitals, or history of severe reaction, systemic steroids will be needed. Oral prednisone at 60-80mg per day for at least 1 week or intramuscular steroids should be used; as you may not have access to these medications, seek treatment with a medical provider.
• Baking soda/cornstarch bath (1 cup each in half full bathtub) or oatmeal baths (1 cup in half full tub) may provide relief from itching. Diphenhydramine and other antihistamines can also provide itching relief.
• Keep open, irritated rash areas clean. These put the patient at greater risk for secondary infection!

As always, prevention is key. Learn to recognize these plants and dress appropriately when working near them.

Corneal Abrasions

Another common complaint during the summer, these most often occur after foreign body hits the eye or the eye is scraped by a finger, tree branch, etc.

Formal diagnosis of these injuries may be difficult, as proper equipment is needed to see the actual abrasion. However, suspect abrasion with symptoms of light sensitivity, excessive tear production, pain, and blurred vision in the affected eye with a history of being poked in the eye or feeling pain after insertion/removal of contact lenses.

Treatment:

• Use numbing drops if available, then remove any noted foreign bodies and flush the eye repeatedly with saline solution or drops.
  • Lift up and evert the eyelids to look for any retained foreign bodies.
• Antibiotic drops or ointments are recommended, however there are studies that suggest just using normal saline drops and keeping the eye clean and protected will result in similar healing. This may be the only option in a prepping/survival situation where there isn’t much access to antibiotic drops or ointments.
  • Erythromycin ointment or drops are usually used for people who do not wear contacts.
  • Contact wearers usually require a ciprofloxacin ointment/drop.
• Keep eye clean, use normal saline drops as needed, and use oral medication for pain control. This is important as corneal abrasions can be quite painful.
  • Alternating an NSAID and Tylenol about every 3-4 hours can help control pain for less severe corneal abrasions. Larger abrasions may need prescription pain meds for 1-2 days.
• If patient is a contact wearer, use glasses until eye is fully healed. Do not put contacts back into the injured eye.

Most corneal abrasions improve and fully heal within a few days, minor abrasions within about 24 hours. If the eye continues to worsen instead of improve, develops worsening redness, thick drainage, or worsening pain/vision, follow-up with a medical professional is necessary.

Heat-Induced Illnesses

Summertime sun, heat, and humidity exposure can be more dangerous than we realize. Long exposures to heat and sun can quickly spiral out of control, sometimes resulting in death. The spectrum of heat illness spans from the milder heat edema, heat cramps, heat syncope up to more serious heat exhaustion, and finally heat stroke (which is a medical emergency).

Treatment:

• For all levels of heat illness, remove patient from the hot environment and get them to a cooler, indoor area if possible.
• For heat edema, patients may notice mild swelling to extremities. The problem is benign but the swelling can sometimes last for a few weeks. Keep extremities elevated when able.
• With heat cramps, a combination of muscle stretching, muscle massage, and rehydration with an electrolyte solution should resolve the issues. Stress the importance of hydration during outdoor activities.
• Similar interventions should be made for heat syncope (fainting) or pre-syncope. Patient should be taken to cool environment and rehydrated, either orally or intravenously. If resources and medical facility are available, patient should have a workup to evaluate for other causes of syncope (heart conditions, stroke, head injuries, etc).
• Heat exhaustion can entail dehydration, weakness, mild confusion, muscle cramps, and/or fatigue after prolonged exposure to heat.
  • Temperature may be normal or patient may be hyperthermic (with body temperature up to 104 degrees Fahrenheit).
  • Tachycardia (elevated heart rate) and profuse sweating usually present.
  • Patient’s mental status is normal.
  • Treat heat exhaustion, especially in hyperthermic patient, with evaporative cooling (spraying or sponging patient with lukewarm water and fanning them to enhance evaporation) or cold water bath if tolerated. Oral or IV rehydration with water and/or electrolyte solution is also necessary.
  • Patient should be evaluated in a medical facility, as their labs may show altered levels of electrolytes and need to be corrected.
• Heat exhaustion, if not caught and treated in time, may progress to heat stroke. This is a medical emergency and should be treated in an emergency room or similar setting. Patients will have altered mental status and usually have hot, dry skin as they can no longer sweat to regulate their temperature. They are usually hyperthermic with temperatures above 104 degrees.
  • Treat similarly to heat exhaustion with evaporative cooling, cool water baths, ice packs near armpits, groin, or neck (as major blood vessels run close to the skin here). IV fluid rehydration is necessary.
  • Do not force the patient to drink if they are unconscious or have altered mental status, as this could lead to aspiration.
  • Again, this is a medical emergency that can lead to arrhythmias, severe lab abnormalities, shock, and death. All efforts should be made to get patient to an appropriate medical facility.

For heat-related illnesses, it is important to recognize the earliest signs and symptoms and prevent the patient from progressing to more severe stages. Treating a friend or family member with heat cramps or heat presyncope is much easier and safer than treating heat exhaustion or heat stroke.

Conclusion

As I’ve mentioned a few times throughout the article, preventing these injuries and ailments is much easier than treating them. ‘An ounce of prevention is worth a pound of cure’! Wear appropriate clothing for the activity you’ll be undertaking, stay hydrated, and wear protective gear when necessary. Take breaks when working in hot weather; check yourself for ticks after walking/working in wooded or high-grass areas. Carry an EpiPen if you have a history of anaphylaxis; keep an extra pair of glasses readily available. Keep extra Acetaminophen, NSAIDs, ACE bandages, antihistamines, eye drops, and steroid cream on-hand. If you can get them, oral steroids and oral antibiotics are useful in certain cases. And as always, review and practice your skills so you can use them when the time arrives.