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Interviewer: So during the summer months, temperatures are rising, people are getting out more, and you might be getting a little concerned about heat exposure and how it might be impacting your health.

We're here with emergency room physician, Dr. Troy Madsen. And Dr. Madsen, when it comes to heat exposure, what do people need to be concerned about?

Dr. Madsen: Well, the biggest thing with heat exposure is just your body overheating. That's where you really start to see issues not just with feeling uncomfortable, but potentially having even a life-threatening situation. Some people . . . you know, you may be familiar with just being out in the heat, you've been hiking or on your bike, or you know, whatever you might be doing, and you're probably familiar with that feeling of just feeling thirsty and tired and maybe a little bit nauseous and maybe a little bit of a headache. Well, at that point, you may be experiencing what we call heat exhaustion. But the big risk becomes when you move beyond that, and your body temperature continues to rise. And then you can experience what's called heatstroke. And that becomes a much more serious thing.

In those situations, your body temperature is often very high. You can have damage to the organs in your body, meaning damage to the kidneys, even potentially the heart, the brain. And in some of those situations, when you hear about these stories of people in places where there is just extreme heat and people are dying of the heat, it is often because of heat stroke that that's happening.

Interviewer: Yeah, we hear about these deadly heat waves and things on the news. And it's, you know, what does that even mean? We're talking like organ damage. Like the heat is getting so high that . . . are you talking brain? Are you talking heart? Who is at risk, and what is it actually doing to the body?

Dr. Madsen: It's exactly that. The body is getting so hot that it is leading to damage and breakdown of the tissues in the brain, the heart, the kidneys. Sometimes part of that is dehydration that's contributing to that as well where that's affecting your kidney function. But in terms of risk, there are a few groups who are really at risk of this. Number one is people who are experiencing homelessness, who may be out in the heat, aren't in a cool place. Other people who are out doing outdoor activities. And maybe you find yourself in a situation where you're out, you're exposed, you know, there's no way to really cool down, maybe you didn't bring enough water along on your hike or your bike ride.

But then there are also certain groups that are really at risk. And these are the very young and the very old. So young babies, infants, and then older people have a tougher time regulating their body temperature. So you might be out, and let's say you take your baby, you know, in a stroller, you're out on a walk, or you go to the zoo or something and you're feeling okay, or maybe you're feeling just a little bit of a headache or a little bit hot. Your baby could be experiencing very severe symptoms in that situation. So if you live with the very young or the very old, just be aware that if you're not feeling great, they're probably experiencing a whole lot more of the heat and much worse effects than you are.

Interviewer: So it sounds like heat exposure affects basically anyone and everyone if you don't, you know, take the right steps. What are some of the ways that a person can, say, prevent heat exhaustion and then later heat stroke?

Dr. Madsen: Well, the biggest thing, you know, is to try and be in a situation where you can cool down. If you're out on a hike or you're out somewhere in the outdoors, try to go in shaded areas, ideally areas that have a water source, something where you can cool down if you need to. Carry plenty of water, you want to make sure you have lots of water with you. The general rule of thumb is 16 ounces of water per hour. I tell people start with at least eight ounces if you're just doing moderate activities. Sixteen ounces can be a lot to carry if you're out on several hours, but try and do that if you can, or at least know where you can get some water.

The big thing I would suggest too is if you have elderly parents, relatives, friends, neighbors, check in on them. One of the sad things that sometimes happens is older people, especially right now, may not have checked their air conditioner, may not know if it's working, or it may work and then it stops working. And sometimes a very sad thing we see is people in this situation then are either embarrassed to reach out for help or don't know who to call for help. And the house temperature gets very hot, and they experience severe symptoms with heatstroke or even death. So check on those people. If you have babies as well, just be aware that they can experience these heat symptoms much more than you may be experiencing at that same time.

Interviewer: So heatstroke, something to keep in mind, something that could be very, very dangerous. ER-worthy if it gets bad enough?

Dr. Madsen: Absolutely, yep. If it's bad enough, if you have a family member or yourself who's just confused, not feeling well, absolutely, get to the ER. Try to get cooled down quickly. Call 911 if you need immediate help.

Interviewer: Coming up next we're going to talk about a common hiking hazard and how to make sure it doesn't happen to you. That's next on The Scope.

I want you to think about it. When you go hiking, what problems do you normally run into? Maybe sore feet, tired legs, blisters. Pretty common problems, but today Dr. Emily Harold, a sports medicine specialist at University of Utah Orthopedic Clinic, is here to tell us about one of the more common hiking problems that isn't something that a lot of people really think about, and that's dehydration. And when I heard about this I'm like, "Really? Dehydration? Don't we all drink enough water? It seems like everybody's got a bottle of water."

Dr. Harold: Well, I think we all drink some water. I think that we don't all drink enough water. I mean, I think that we are blessed to live in a great state that has an amazing climate, and it's a very low humidity climate. And because it's a low humidity climate, when you're outside and it's hot outside and the sun's beating down, a lot of times your sweat dries quicker and you don't really realize how much you're sweating. And it can almost be pleasant when it's 80 degrees outside in this environment versus 80 degrees in Houston, Texas, in which case everybody knows they're sweating.

And so a lot of times people are sweating more than they realize and they're losing more water than they realize and they don't replenish enough, and that can lead to headaches, and tiredness, and in extreme forms can even lead to things like heat exhaustion, heatstroke, which can cause a lot of damage over time.

Interviewer: So if I was just going out for like an hour or two hike, do I really need to take water? Is that enough time to start getting symptoms of dehydration?

Dr. Harold: It's enough time. We would recommend at least a quart an hour. So if you're going to go out for a two-hour hike, one, we recommend probably drinking a liter before you go. And then while you're out, at least a quart an hour while you're out. More if you are running, trail running, doing activities that are more than just walking.

Interviewer: You've covered more endurance-based events like marathons and whatnot, and you say that it can really be common in those events. Explain that a little bit.

Dr. Harold: It's a common problem. A lot of times in marathons, people are out on the course for four, five, six hours. On a hot day, they don't drink enough fluid when they're out running and a lot of times when they come in after they cross the finish line, they can have some dangerously high body temperatures, 103, 104, 105. And so we really kind of institute a rapid cooling part and we try to give IV fluids for hydration, but it's very important that you drink enough water, especially when the temperature gets up above 70.

Interviewer: And when that sun's out, is it even worse?

Dr. Harold: Yeah, because the sun dries the sweat off a little quicker, and so you don't get the same cooling effect as you get when it's a little cloudier.

Interviewer: So drinking water, very easily preventable of dehydration. What about extra salt in those situations?

Dr. Harold: It is recommended that if you're out for more than an hour that you do ingest some salt.

Interviewer: Really? And above and beyond what I would normally get in my diet?

Dr. Harold: I think that's why trail mix became so popular. Because people realized if they went walking for a long time, that salt that comes from peanuts and that kind of thing can actually help to retain some of that water that you're drinking, and that helps to replenish their water stores a little easier.

Interviewer: Gotcha. And then also we're talking about kids. If you go out hiking for a couple hours with kids, that has a different effect on a kid than it might an adult.

Dr. Harold: Exactly, and if you're like my kids, you like to run ahead and you're constantly exploring. So you're not drinking water and no matter how much you tell them to drink water, by they time they're to start drinking when they're thirsty, they've already gotten a little bit dehydrated. So it gets really important just to watch your kids' water bottles. I usually recommend bringing a water bottle for each kid and having them drink from it, so you can monitor how much they're consuming.

And if you get somewhere and you realize they haven't really drunk very much water at all, then you can push their fluids a little bit just to keep them from getting dehydrated.

Interviewer: How often does heat exhaustion and heatstroke really lead to things? I mean is that not too common, more common than I might think?

Dr. Harold: I think both. I think we'll see a lot of hyperthermia or high temperatures sometimes in the emergency room. Usually if you catch them early and you cool people quickly, it doesn't lead to bad outcomes. Now if you have someone who is in Canyonlands or Moab and gets lost and wanders, that's something that can lead to heatstroke and it can lead to some, exactly, brain injury.

Interviewer: Just kind of wrap up, then, for myself or for my kids, what would I look for for symptoms to indicate they need to be drinking more water? Or is it just monitor water drinking?

Dr. Harold: I think it's easy enough to monitor water drinking. A lot of the symptoms are kind of difficult. Things like fatigue, they get that when they hike anyway. Headache is a common one. So if your child or you notice that you are starting to get a headache when you're walking, a lot of times that's because you're dehydrated. So that's the earliest one.

Interviewer: So in that instance drink water, get out of the sun for a little bit, rest for how long?

Dr. Harold: Exactly. Find a shady spot.

Interviewer: How long would you want to rest for?

Dr. Harold: Some people find a shady spot, drink some water, you want to rest for probably a good 10, 15 minutes until you start to feel better.

Interviewer: Yeah, and that will start to go away. And then you're fine to go back out again?

Dr. Harold: Absolutely.

Interviewer: I mean, this seems just like one of those topics that I don't think a lot of people think about and a lot of people don't think is really all that serious in their life.

Dr. Harold: Yeah, I think that's my final thought. It's something that I know I could do better at and most of us can do a better job of hydrating, but it is something that can lead to problems and it does make for a much more comfortable walk if you're properly hydrated.

updated: June 16, 2021
originally published: August 24, 2016

Interviewer: You come back from a hike and you find that you have a tick on you. Is that something that you need to go see a doctor for? We'll talk about that next on The Scope.

Announcer: This is "From the Frontlines with Emergency Room Physician Dr. Troy Madsen" on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health Care. If you ever get a tick on you, is that something you need to go see a doctor about? Or is it something you can just kind of take care of on your own? Should I be a "do it myself" kind of guy with a tick or come see you?

Dr. Madsen: It's not an uncommon question. It's more of these questions where I may have a family member ask me this sort of thing, like, "I went out hiking. There's this tick."

Interviewer: Do you go to the ER for a tick?

Dr. Madsen: I wouldn't. Generally, not. It's probably something you could see your doctor for. But there are certain things you're looking for. When we think about ticks, we think about infections. We're fortunate in Utah that the more serious infections you think about with ticks aren't really such a big issue, like Lyme disease and Rocky Mountain spotted fever, which is funny. It's called Rocky Mountain spotted fever, but it's not so much in the Rocky Mountains. I think it was discovered in Denver and that's how it got its name. But it's more in the Southeast that that's an issue.

But regardless, if someone comes and they say, "Hey, I had this tick on me," I'm asking them, "How long was it on you?" They may not know exactly, but they may say, "Okay. I was camping. I've been home for two days." If that's the case, I'll say, okay, it's probably been on there at least 48 hours. Typically in those cases, we give antibiotics to prevent any kind of infection from the tick. Kind of the rule of thumb is if the tick's been there for 24 to 36 hours, we'll start antibiotics just to prevent an infection.

Now, if you've had a tick and it's been on you and you look at that spot where the tick was located and you start to see redness around there, like a circular sort of rash, maybe some puss in that wound that have kind of built up, then I'm more concerned, number one, about an infection from the tick, like a head being embedded in the wound. Or, number two, an infection that a tick has transmitted to you, like Lyme disease. Again, reasons to see a doctor.

But I think the bottom line is if you see a tick on yourself, let's say you're out camping, you pulled the tick off, you get rid of the tick, you don't need to feel like you need to rush right into the ER. Unless you're seeing some of these other things.

Interviewer: So is that the way to get rid of it? Just pull it out gently with tweezers? My dad used to go to the gas cans. I lived out on a ranch and he'd put gas in a a baby food jar and turn it upside down on the tick until it backed out. Or I've heard maybe nail polish. You put nail polish on them and they have to back out.

Dr. Madsen: Yeah, I've heard these things too. Some people have said to put petroleum jelly on it because the tick breathes through its body. I'm not a tick expert. There are probably tick experts out there that are cringing as I say this.

Interviewer: So we don't know if they breathe through their body or not, is what we're saying.

Dr. Madsen: I've heard people say that and then the tick will back out. I think one of the challenges with those is sometimes, it just makes the tick sit there and just makes it kind of moist. And then it becomes harder to pull it out. The thing I've learned is just to grab some tweezers, grasp down by the tick's head.

Interviewer: As close to the head as you can get, close to the skin, probably.

Dr. Madsen: Yep. And then just pull directly back.

Interviewer: Pull straight out.

Dr. Madsen: Pull straight out and then drop the tick in some water, like a toilet or something like that so it's not climbing on someone else or climbing on your pet. Just so you're drowning the tick and getting rid of it.

Interviewer: And if you end up doing that, breaking the head off, then you need to go see a doctor? No?

Dr. Madsen: Possibly.

Interviewer: The body could handle that? Is that what you're . . .

Dr. Madsen: If you did break the head off and you came in, I would probably put you on an antibiotic for a few days and tell you to watch for signs of infection. But the reality is the head's probably not going to be that deep where it's going to cause any major issues. And it's probably just going to work its way out within a few days anyway.

Interviewer: So watch it for those other symptoms you talked about.

Dr. Madsen: Watch for those other symptoms, primarily. You're right. If you came in, I would probably say, "You've got the tick head still in there. Let's just put you on something for a few days just to prevent any infection from that."

Interviewer: But an urgent care could handle that?

Dr. Madsen: Exactly.

Interviewer: All right. Or a doctor the next day.

Dr. Madsen: Exactly, yeah. Not an emergent thing to get into an ER.

Announcer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Interview: You're out in the back country and something happens. Do you call Search and Rescue? How do you know? We'll examine that next on The Scope.

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

Interview: So you're out maybe hiking in the back country or camping, or maybe it's just a day hike, and something happens to you or somebody your with. Is it bad enough that you should call Search and Rescue? How do you even know? Are there times where you should absolutely call Search and Rescue?
Dr. A. J. Wheeler is from St. John's Medical Center in Jackson, and he's also the medical director and a member of the Teton County Search and Rescue in Wyoming. He's going to try to help us figure that out.
I'm out. How do I know if I should call Search and Rescue, because that's kind of a big deal to me? I don't think I'd want to do it unless somebody was bleeding and about ready to die. But are there other times that you might want to do that?

Dr. Wheeler: I think that there is definitely hesitancy on the part of people that are recreating in the back country to call Search and Rescue. From the Search and Rescue standpoint we see a lot of incidents where we are notified late in the game and wish that people had called us earlier so that we could have helped them in a more timely fashion.

Interview: That's interesting because I would think that there would be some instances where I'd call and you guys would show up and you'd say, "Well, why did you call us? This isn't a big enough deal." So how do I know when I should call you? What are those instances?

Dr. Wheeler: From a medical standpoint, I think that anybody who has an altered mental status, who has fallen, is injured and can't think straight deserves a call to Search and Rescue. Definitely, it could be a sign of a significant head injury. It may just be "a concussion" and improve on its own, but it's hard to tell in the back country, especially for non-medical people, and if a person does have a serious head injury then having some medical resources heading that way could certainly speed their recovery and evacuation.

Interview: And time is of the essence when it comes to any head injury, from what I understand.

Dr. Wheeler: Yes, in many cases.

Interview: What are some other cases where you should call Search and Rescue right away?

Dr. Wheeler: We see a lot of orthopedic injuries in people that are recreating in the back country. Anybody who is clearly non-ambulatory after their injury, if their ankle is sticking out the wrong direction, they're clearly not going to get up and walk on that leg. They're going to need some major assistance to get that person out of the back country. We would want a call as soon as possible from that party to start planning and getting people in the field to help with that evacuation.

Interview: So even if you thought you could carry that person or put them on the back of another four-wheeler, you should still call Search and Rescue if there's a bone sticking out?

Dr. Wheeler: Well, certainly, if there's a bone sticking out, that would be what we call is an open fracture and definitely is a bit more time-sensitive. More common is a closed fracture where the bone doesn't come through the skin. But even those instances, if people are looking at carrying out an individual, from a Search and Rescue standpoint we use a wheeled litter and four to six attendants on that litter, and we think with that we can move about one mile per hour.

Interview: Oh, wow.

Dr. Wheeler: And so without those resources, you can just imagine a party trying to carry somebody in the back country on their own is probably going to move quite a bit slower than that, which is another thing that we like people to think about when they are injured or considering whether to call Search and Rescue. If they're injured earlier in the day and they start to try that self-evacuation and it's taking them a long, long time, often what we see is people wait until dark is upon them and they call for Search and Rescue, and that's now limited our resources because we can't fly helicopters safely in the mountains at night. Helicopter evacuation would be out of the realm of possibilities, and we'll be looking at sending in a ground team which may take 4 to 6 more hours to help evacuate that person.
Some of the other things that definitely deserve a call are anybody who has major bleeding, bleeding that cannot be stopped with a simple bandage in the field, and anybody who's having any significant breathing problems. Those are always reasons to call for help, whether or not you're in the back country or in an urban location.

Interview: Has there ever been a time somebody has called Search and Rescue and you kind of thought they shouldn't have? I guess what I'm looking for here is a common theme that probably you don't need to call Search and Rescue.

Dr. Wheeler: I think people tend to think that, but I have found almost every time that we have been activated on our Search and Rescue team, people really needed our help. It wasn't always a major evacuation. They did need help and we were happy to provide it. I think that people really should try to get over any hesitancy in calling Search and Rescue when they feel they need it, as long as they are using common sense. We want to be there to help them.

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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.

Scot: Avalanche danger super high across the entire state of Utah. Unfortunately a couple people have already died because of avalanches. We're with Dr. Troy Madsen, Emergency Medicine at Utah Hospital. Have you ever seen avalanche victims come into the ER?

Dr. Madsen: I have. I have seen avalanche victims come into the ER. Sometimes these are patients who have been transported. In some cases-I haven't cared for them personally-but I've heard of cases where they have just been basically had no heartbeat but they continue to work on them to try and get them back, and brought them to the ER, transporting them from the mountains. I've seen patients who have come in who have had multiple injuries those types of things. So kind of the full range of avalanche victims have come into the emergency department.

Scot: So I would have thought if somebody had died because of an avalanche they'd just say well, "They're dead," but they bring them to the ER.

Dr. Madsen: They will, and the reason they'll work on them, and continue to try and treat them for longer than, say, a victim of a motor vehicle accident is because if you're in an avalanche you're often under the snow for a prolonged period of time. If they don't have a pulse on that person that person is also hypothermic, their body is very cold, and being very cold can preserve the brain function, and sometimes help us get that person back, where if the average person had had a heart attack and was down for 30 minutes, the likelihood of getting that person back, and having any kind of a good outcome is very low.
So avalanche victims it's a little bit different in that sense where they may have been very cold and that can kind of preserve things so they may continue to work on those patients longer than we would otherwise.

Scot: Really? So there's a better chance you could resuscitate them?

Dr. Madsen: Yeah, potentially. Yeah.

Scot: And have a good recovery?

Dr. Madsen: Yeah. It's kind of like drowning in cold water, we think of it the same way. Being in that just really cold temperature, that's kind of like preserving meat in a freezer in a sense.

Scot: Sure. I guess that makes sense, but I never realized that was actually fact. That's interesting.

Dr. Madsen: It really does work, and you know it's interesting too if we do CPR on a patient and we get them back, we cool their body down at that point to try and preserve them and kind of preserve their brain function, and we've shown it helps them to have a better outcome.

Scot: Interesting. All right. So let's talk about avalanche danger in general. What are some of the things people should be aware of?

Dr. Madsen: Yeah. I think the number one thing to be aware of right now is the avalanche danger is extremely high, and I'll preface this by saying I'm not an avalanche exper.t I'm an ER doctor who's cared for the consequences of avalanches, and I would kind of casually like to go in the outdoors, and in the back country. But keep in mind the danger is extremely high, and we're not talking about people going up you know high in the back country, on back country skis. We're talking about people snowshoeing next to the road. This person who died, American Fort Canyon, from what I can tell was pretty close to the road in what may seem a very tame area.

Scot: Wow. Because my wife and I joke about that, we snow shoe and we're like, "Oh, the avalanche, that's not going to affect us."

Dr. Madsen: And that was my thought too. You know you think, "I'm in my neighborhood. I'm just in the foothills," or, "I'm just up in the mountains, I'm not high up at 10,000 feet." This was not at 10,000 feet. Avalanches can happen on any slope, but classically they say 30 degrees or more. And it's always tough for us to tell what's exactly is 30 degrees. But we're talking about a decent slope there but not a real steep slope. So you could be anywhere in the backcountry, hiking, snow shoeing, just getting out, certainly snowmobiling, these sorts of things.
It is just an incredibly high risk right now, and if there's any advice I would give it would be to always go to the Utah Avalanche website, UtahAvalanche.org. They're going to have all of the ratings for the risk, and right now it's approaching extreme. It's very high right now, and if that's the case it's just best to avoid the backcountry because of the risk there.

Scot: All right. Let's talk about somebody does go out into the backcountry. An avalanche happens, I'm not buried but somebody that I'm with is. What do I do at that point?

Dr. Madsen: Well, first of all, at that point it's you're in a tough situation. I think that's the bottom line. The teaching I've had, and learned . . . and there's a great book if you ever go in the backcountry. You should read it. It's called Surviving an Avalanche Training is the title of it, I think. But it talks about how the best thing to avoid is certainly being in an avalanche in the first place. Because when you're in an avalanche, 25% of the time you're going to get killed just by the trauma, just by rocks, boulders, that sort of thing.
So then there's a 75% chance you're going to be buried under the snow. If you're under the snow you're not going to be able to dig yourself out. It's like being encased in concrete. You can't move; you're stuck there. So if you're with someone where that happens, hopefully, first of all, you're wearing a beacon, and beacons are something you can get. They're a little expensive; you're looking at like a $150.00, but it's something where basically it's going to allow another person with a beacon to detect where you are.

Ideally, before you're in the backcountry you've used these things, you know how they work, but you're going to use your beacon to try to find where this person is. Again, trying to find a person that doesn't have a beacon on is extremely difficult. We're not talking about a small pile of snow this person's under. We're talking often times about a slope that's a 100, 200 feet wide, that has slid for 400 feet, and is covering someone somewhere underneath it.

Scot: Is it bad enough to go to the emergency room? Or isn't it? Find out now. This is ER or Not, on The Scope.
All right, it's time for another edition of ER or not with Dr. Troy Madsen, Emergency Physician at the University of Utah Hospital. It's the game that you get to play ER doctor and decide whether or not it's bad enough to go to the ER or not. Are you ready?

Dr. Troy Madsen: I'm ready.

Scot: All right, I was out hiking and I stepped on a rusty nail. ER or not?

Dr. Troy Madsen: Great question. So, the question I would have for you is, "When was the last time you had a tetanus booster?"

Scot: Okay, how long ago should I have had it?

Dr. Troy Madsen: That's the question that always comes up. So the rusty nail itself is probably not going to be an issue. We always think about infection, and if it goes through the sole of your shoe there have been some things out there that have said, well it probably needs to be on antibiotics, just because the sole of your shoe can have some bacteria in it that you might not get exposed to otherwise. So a lot of times we'll err on the side of caution, maybe put you on some antibiotics to prevent infection, but the big thing I think about is, "Do you need a tetanus booster?"
So the limit is ten years, and we always err on the side of caution in the ER just because people's memory may be a little fuzzy. We try and keep that at about five years. If they cannot clearly state, "I've had a tetanus booster within the last five years", then we're going to give that and that would be a reason to go to an ER. It's also one of those things you might be able to go to an urgent care for, but wherever you can get into.

Scot: How serious is it if I have not had a tetanus shot? What could happen?

Dr. Troy Madsen: Tetanus is very serious and tetanus is something that's contained in spores in the dirt, just kind of sits in there. It's when it gets in your skin and into your bloodstream it really causes problems. The big issue with tetanus is if you get tetanus there's not a lot we can do for it. It's very serious, very fatal. That's why we always make sure your tetanus booster is up-to-date to make sure you're not going to get that.
We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Science Radio.