Search for tag: "frostbite"

Announcer: Is it bad enough to go to the emergency room, or isn't it? You're listening to "ER or Not" on The Scope.

Interviewer: Time for another episode of "ER or Not." That's where we give you a scenario and you get to play along and decide whether or not you think that this is something worth going to the emergency room for. Dr. Troy Madsen's an emergency room physician from University of Utah Health Care. Today's "ER or Not": frostbite. Let's say the scenario is somebody's out shoveling their driveway, a particularly heavy snow, out for a long period of time using the snow blower or whatever, think they might have frostbite. ER or not?

Dr. Madsen: So frostbite would be a reason to go to the ER. And the reason I say that is because this is the sort of thing where if it's severe frostbite and it's not treated appropriately, it can really put you at risk of potentially losing a finger or a toe, sometimes even a little bit more than that, depending on how extensive this frostbite is.

So as you mentioned, you always hear about these cases in the news of people being trapped in the wilderness and getting frostbite there. And now and then, we'll see those sorts of things, but for the average person, the times frostbite happens are exactly like you mentioned. It's often early in the season, really cold weather, you get a big snowstorm, someone gets out there, maybe they're not dressed adequately for the cold. They're out there shoveling snow for an hour or whatever period of time to get that driveway cleared off, it's cold, their feet are getting cold.

Interviewer: Maybe even like a wind chill going on.

Dr. Madsen: Yeah, a little bit of wind chill, as well, and then they come inside. You know, their toes are numb out there. They figure, "Okay, I'm in the cold. Yeah, my toes are numb." They come inside, and then their toes are still numb and then just really, really, really start to hurt. And they look down at their toes, they look like they're not getting a lot of good blood perfusion. Maybe they're just like this kind of whitish color to them.

Those are all signs of frostbite, and that's really classically the kind of frostbite cases we see. It's not like we see this all the time, but when we see it, that's often what we see, the average person just out there or something, just thinking, "My hands are cold, my feet are cold," ends up being something much more serious.

Interviewer: Normally feet? Normally hands? Normally extremities?

Dr. Madsen: Most cases I've seen have been feet.

Interviewer: Okay.

Dr. Madsen: And certainly, you can see . . . but for whatever reason, it's been feet that I've seen most of the serious cases on. So, again, the reason to come, to make sure we get that area rewarmed, which we do by just continually circulating, putting that foot in lukewarm water, continually circulating water through there to get it rewarmed, get it back to a normal temperature. It's incredibly painful to go through that process. We'll treat it with pain medication as well, as you're going through it to get that blood perfusing back into those toes.

Oftentimes, we have to get our burn doctors to take a look at these areas if it's severely affected to get their input in terms of the care of the wounds there. But it can be a serious thing and a reason to go to the ER.

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Announcer: Medical news and research from the University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Host: Did you know that you could get hypothermia when it's 40 degrees outside? I'm with Dr. Troy Madsen, emergency room physician at the University of Utah Hospital. Let's talk about hypothermia. Is there a comparison to be drawn between heat exhaustion and heat stroke here?

Dr. Troy Madsen: Absolutely. Heat stroke is when the body temperature gets really high. Hypothermia is when it gets really low.

Host: Okay.

Dr. Troy Madsen: Neither of those is good. So think about it this way. Probably the easiest way to compare this is to your car. If your car's really hot, it doesn't run well. But then think about these cold mornings we're having now, going out there, trying to start your car up. You're just trying to get that engine going. It just starts to turn over a little bit, and once it gets going, it doesn't work well.

Host: Yeah. And then even you try to shift it into gear, the transmissions sloggy.

Dr. Troy Madsen: Exactly. It just does not work well. That's exactly what the body does. You know, your heart's kind of the engine of your body. If it's cold, it does not work well. You know, at high temperatures, same thing with your heart. Absolutely. There's definitely a comparison there.

Host: So 40 degrees, it could start happening. Is it normal at 40?

Dr. Troy Madsen: Not normal at 40. The big thing in the 40's is if you're in damp weather, if it's raining on you, you've got cold clothing, you can get hypothermia. So people who are outside maybe. You know, it's a little late in the year for people to be hunting, but maybe for outdoor activities, you may think, "Hey, its 40 degrees outside. I should be fine." But you could or your children could be experiencing hypothermia if you start to get cold or you just don't have the right clothing on.

Host: What temperature does it normally happen? When do you really need to start worrying about it?

Dr. Troy Madsen: This last winter, I saw several cases of it in the ER because we had some really cold days. But usually, once you get these temperatures down in the teens and the single digits at night, we see it a lot in people who are homeless, who are out on the streets, who don't have any place to go or may have not gotten into the place, into some of the resources that we have available. Or people who may be intoxicated, who may not be aware exactly what's going on, that their body temperature's dropping. That's where we really start to see some serious cases in the ER.

Host: So generally, it's not somebody that's doing some outdoor activities such as snow shoeing, skiing, that sort of thing?

Dr. Troy Madsen: Typically not. You know, I think most of us, we know when we're getting cold. It's not, like, you're walking out to your car in the morning and you get overcome suddenly by the cold. It's usually people who are in some other situation. They may be out skiing. They may be out in the back country where they just can't get to where it's warm soon enough. But for most of us, in our day-to-day activities, it's not a big issue.

Host: So frostbite's probably a little bit more predominant though? Because I can be out doing an activity and not have gloves on.

Dr. Troy Madsen: Right.

Host: I could be warm enough, but my extremities are not?

Dr. Troy Madsen: Exactly.

Host: Okay.

Dr. Troy Madsen: And that's one, too. You know, the big thing with skiing is usually these temperatures are in the single digits, and those can be some pretty cold days. When you're snow shoeing or hiking or whatever, when it kicks up, you've got part of your face exposed. You can get some frostbite on your face or on your nose. Certainly on your hands if you don't have the right equipment on. And when it gets cold like that, your body's going to pull blood from your hands, from your feet to your core to keep it warm. That's when you get some issues in your hands, some frostbite in your hands and fingers.

Host: So if my face gets frostbitten. What does that mean?

Dr. Troy Madsen: Basically, what it means is you got dead tissue there. You got tissue where there's just not enough blood supply there because the blood has been pulled away from it, and the temperatures have gotten so cold in that part of the body that the tissue actually dies. So, real cases of frostbite, that's dead tissue. Oftentimes, if it's severe enough, you know, we'll have cases of people who come in with frostbitten toes. I've seen cases, interestingly, of just people who are just out working, just out shoveling their snow. I've had a couple cases of that. They had some other medical problems that I think made things worse, but they've had amputations of some of their toes because of that, because the frostbite was so bad.

Host: So frostbite can cause things to have to be amputated?

Dr. Troy Madsen: It can. It can. You know, usually, it may cause some cosmetic issues. Certainly if it's on your face, that can be a problem. But in some cases, you actually have to have an amputation.

Host: What are the symptoms of either one of these that I need to watch out for? You know, because I've been really cold before.

Dr. Troy Madsen: Yeah.

Host: So cold that I think, "My toes are going to fall off."

Dr. Troy Madsen: Right.

Host: But was I really in danger?

Dr. Troy Madsen: I think the first one with hypothermia, you know, if you're shivering, that's a good sign. So you think the normal body temperature's 98.6. Once it starts to drop down around 97 or 96, you're going to start shivering. And that's just your body's way of trying to produce heat. You shiver. It produces heat. It tries to warm up the core. But the really concerning thing is if you stop shivering. That's when your body temperature gets less than 90 degrees, and that's where it becomes life threatening. Your heart just starts to do weird rhythms. It gets really slow. And certainly, if you're with someone and they just are not shivering and you're really cold, and they're just not shivering at all, and they are not really responding to you, those are signs of severe hypothermia.

Host: Is there anything that you could do for them at that point if you can't get them to help?

Dr. Troy Madsen: It's not everyone's ideal scenario or consideration, but if you have to, the best way to get someone warm is number one, make sure they're dry. Number two, if you've got a sleeping bag or something to insulate you, strip them down. Strip yourself down. Get your body heat next to them. That's the best way to warm them up.

Host: And that's about all you can do at that point?

Dr. Troy Madsen: That's about all you can do besides trying to get help. You know, obviously, if you can make a fire or whatever resources you have there, but that's going to be the quickest way to warm someone up.

Host: Any other thoughts?

Dr. Troy Madsen: Yeah. I think the number one thing is just preparation. Make sure you know where you're going. Know what the temperatures are. Make sure you're prepared for that, so that doesn't happen to you.

Host: And bundle up when you're shoveling your driveway.

Dr. Troy Madsen: Exactly. Stay bundled up.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, the University of Utah Health Sciences Radio.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: My name is Vivian Lee. I'm the senior vice president for health sciences at the University of Utah, and today we're going to talk about the cold. This can mean dangerous medical problems for people that are exposed to the cold for long periods of time and even short periods of time. Joining me today is Dr. Amalia Cochran, assistant professor of medicine at the University of Utah's department of surgery. She's also an attending surgeon in the university hospital's burn unit and a leading expert on frostbite. Welcome to the show.

Dr. Amalia Cochran: Thank you very much.

Interviewer: We had an experience that made me have to go online and look up frostbite and I realized there wasn't as much information as I would hope. My daughter came back. She was fine after a whole day of skiing, and then she got into the bathtub and she started screaming because she said her feet were really painful and then the tips of her toes were dark red, almost bluish. At that point in time you can imagine I just panicked and tried to look online. I thought, here you are, the expert, let me ask you, what was happening with her? How could I have prevented that?

Dr. Amalia Cochran: It honestly sounds to me like she probably had a case of frost nip. When you're out skiing you've got a prolonged exposure, as does anyone who's outdoors during this weather. The fact that prior to that exposure to the warm water bath she hadn't really had any significant complaints and you hadn't really noticed anything different . . .

Interviewer: No, and is that because you have numbness so you don't even realize what's happening?

Dr. Amalia Cochran: Precisely. There is numbness with frost nip and you see very few changes in the skin if someone has a case of frost nip.

Interviewer: Frost nip is different from frost bite?

Dr. Amalia Cochran: Frost nip is the extremely mild form of frost bite. The way that we tend to differentiate between them is that frost bite involves tissue changes where the skin will actually blister up versus frost nip where there is some of that damage to the skin and the soft tissue but not to the level where it blisters.

Interviewer: Is it blistering because the tissue is actually freezing? What's actually happening there in the skin?

Dr. Amalia Cochran: There are really two different things that occur in the skin with a frost bite or a frost nip injury. One of those is the direct cold injury from the temperature. That impacts the tissues. They do freeze. Little crystals form in them. The other phenomenon that occurs in association with that is ischemia where there is poor blood flow to the cold effected areas. Initially, when the outdoor temperature drops or when we're exposed to lower temperatures somewhere in the neighborhood of 50 degrees fahrenheit, there's a cold induced phase of dilation that occurs.

Interviewer: Blood vessels expand. All of a sudden this blood rushes back in, and then what happens?

Dr. Amalia Cochran: Right. But then after that they constrict. They narrow back down and so the blood flow diminishes.

Interviewer: One of the things about this that worries me is that because of the numbness the kids don't even seem to know that it's happening, so how do we know that that damage is occurring?

Dr. Amalia Cochran: Cold checks are what are recommended in the Alpine mountaineering literature. I think they apply to those of us that are recreational outdoor in the winter as well. The concept of cold checks is that you get yourself to a relatively sheltered location, and I phrase it that way since this is from the Alpine mountaineering literature because there would be a relative shelter if you're skiing, you can say, hey, let's take a hot chocolate break after an hour and a half, and go in and check fingers, check toes.

Interviewer: We do them every half hour sometimes.

Dr. Amalia Cochran: Some days that's really appropriate. You can check everyone's fingers, check everyone's toes. If you notice that the fingertips or the toes are looking particularly pale, if they start getting a little bit woody in terms of how they feel, if they're not as soft as they normally feel, any of those sort of characteristics, that would make you concerned that you may have the early phases of a cold injury occurring.

Interviewer: How can we prevent it?

Dr. Amalia Cochran: Preventing it is a little bit tough if you have a love for winter sports. One of the things is that if you are someone who knows that you have circulatory challenges finding ways to keep your fingers and toes warm.

Interviewer: So even when it's not that cold our fingers and toes get kind of cold. We're particularly sensitive to developing it.

Dr. Amalia Cochran: Absolutely. Be mindful. I tell people I have something known as Raynaud's phenomenon, which means that when I get cold my blood vessels in my fingers and my toes clamp down. So I not only very easily get cold fingers and toes but I'm at higher risk for cold injury. So when I ski I have heaters in my boots and my mittens.

Interviewer: Those hand warmer, toe warmer type things?

Dr. Amalia Cochran: They're actually battery packs.

Interviewer: Oh, I didn't know they made that.

Dr. Amalia Cochran: Yeah, they're a little spendy but they're worth it. I whine a lot less and I have to take fewer breaks.

Interviewer: But short of that, you recommend the hand warmers and toe warmers?

Dr. Amalia Cochran: They're definitely helpful.

Interviewer: Dr. Cochran, you're not only an expert in frostbite but you're also a leader in burn injuries. I noticed we recently had an avalanche victim who had frostbite and was cared for in our burn unit. Maybe you can explain to us this relationship. Why are the frostbite patients and the burn patients all cared for by the same people?

Dr. Amalia Cochran: That surprises people and I know our avalanche victim was a little confused when I showed up and introduced myself and said I was a burn surgeon. She gave me this puzzled look. I said, "Trust me. This is going to be okay." There are a couple of reasons that frost bite victims end up in the care of the burn unit, and one of those is because the mechanism of injury, the way that the body works to generate the frostbite injury or the cold injury is actually very similar to what ends up happening if people have a burn injury. The underlying pathophysiology, to use the big fancy word for it, of what causes the tissue damage is very similar. The other part of it is that with more major cases of frostbite when people have blisters or if they don't get treatment in a timely fashion they can even have gangrene where the tissues die, we are experts in managing soft tissue loss and getting areas of soft tissue loss closed or covered because of the fact that that's what we do with burns. So it ends up making our frostbite practice a very logical extension of what we're already doing.

Interviewer: One of the things I read online when I was reading about this was that you're not supposed to rub the tissues. Why not?

Dr. Amalia Cochran: That's an old wives tale. Historically, people were advised to remove their gloves and their boots and rub the area with snow even to help with cold injury if they thought they were getting cold injury. The problem with doing that is you extend the damage in the soft tissues with the friction. So it's actually not helpful to do that

Interviewer: So the tissue is already pretty fragile and if you're rubbing it you're just making the damage worse.

Dr. Amalia Cochran: Right. So the recommendation for rewarming now is a 40 degree centigrade, which is around 100 degree fahrenheit, warm water bath.

Interviewer: Is 100 degrees about a normal temperature bath?

Dr. Amalia Cochran: It would be a warm bath.

Interviewer: A warm bath.

Dr. Amalia Cochran: Yes.

Interviewer: I was always told that you need to keep your central body really, really warm and if you kept your trunk warm your extremities would sort of take care of themselves. But you're sort of saying, no, those hand warmers are important too.

Dr. Amalia Cochran: Yes, it's both. You need to keep your core warm because of the risk of hypothermia, but when you're looking at a risk for frostbite you need to look at keeping your extremity areas, your fingers, your toes, even your nose is an area that's at risk for lower blood flow when you get really cold.

Interviewer: So those face warmers too.

Dr. Amalia Cochran: Yes.

Interviewer: Well, Dr. Amalia Cochran, thank you so much for being my guest today.

Dr. Amalia Cochran: Thank you, Dr. Lee.

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