PAINFUL TESTICLE
If a male complains of a painful testicle, examine both testicles. Look for discoloration or swelling. If a testicle has been injured by a blow, provide support with an improvised jockstrap and apply ice packs. If a testicle suddenly becomes painful, particularly in an adolescent, and appears swollen and/or discolored, usually without a penile discharge, it may be twisted, or torsed. Since this usually happens if the testicle rotates inward (toward the midline) (Figure 175), gently see if you can rotate it outward within the scrotum. If this causes a dramatic relief of pain, you may have saved the testicle. If the maneuver increases the pain and appears to shorten the “hang” of the testicle, you may be worsening the torsion and might attempt rotating the testicle in the opposite direction.
Figure 175 Rotation of the right testicle in a torsion; an inflamed epididymis of the left testicle.
If you believe an unresolved torsion is present, this is an emergency and the victim should be rushed to a physician. If a torsion is not resolved within the first 4 to 6 hours, the testicle may be lost. The pain is usually followed by swelling in the scrotum and groin region. Sometimes the affected testicle is seen to be slightly higher than the uninvolved testicle. The pain may be of a severity to cause the victim to become nauseated or vomit, and to feel faint.
If a testicle is swollen and the victim complains of pain or burning on urination, he may suffer from an infection or inflammation of the epididymis, which is part of the sperm-collection pathway (Figure 175). Other symptoms include lower abdominal, flank, or groin pain. If the case is severe, the victim may suffer fever, chills, nausea, and muscle aches. This should be treated with doxycycline (100 mg twice a day), tetracycline (500 mg four times a day), levofloxacin (250 mg daily), norfloxacin (400 mg twice a day), or trimethoprim-sulfamethoxazole (one double-strength tablet twice a day) for 10 days.
One way to help distinguish epididymitis from testicular torsion is to gently elevate the scrotum—in general, with epididymitis, the pain is diminished, whereas with torsion it is commonly increased.
PENILE DISCHARGE
If a male complains of a discharge from his penis, particularly if it follows sexual intercourse by a few days and is yellow or greenish in color, you must suspect gonorrhea. In this case, it is safest to treat the victim for both gonorrhea and a chlamydial infection. If more than 24 hours will pass before a doctor can be reached, start the victim on tetracycline 500 mg four times a day or doxycycline 100 mg two times a day for 10 days (to treat Chlamydia). Azithromycin 1 g in a single dose is also effective against chlamydial infection. To treat the gonorrhea, administer cefixime 400 mg orally as a single dose. Alternative single-dose therapies for gonorrhea are cefpodoxime 200 mg, cefuroxime 1000 mg, ciprofloxacin 500 mg, ofloxacin 400 mg, azithromycin 2 g, and norfloxacin 800 mg. To treat gonorrhea and chlamydial infection at the same time (the two germs often “travel” together), you can use the one-dose azithromycin therapy. Syphilis may also have been transmitted, so the victim should be tested on return to civilization, even if the victim was treated with a 2 g dose of azithromycin, since there is occasionally resistance of the causative spirochete (Treponema pallidum) to azithromycin.
If there has been no sexual intercourse and a penile discharge develops, particularly if it is white or clear, treat with doxycyline or azithromycin.
In this day and age, no person should engage in casual unprotected sexual intercourse. A man should wear a latex (not lambskin) condom that has been stored in a cool, dry place. The package should show no evidence of leakage. The spermicide nonoxynol-9 (condom lubricant or vaginal foam) offers additional protection against viruses.
PSYCHIATRIC EMERGENCIES
The wilderness experience can be quite stressful, and a member of the party may behave in an unusual fashion. This may be directly related to the events at hand or reflect an underlying psychiatric disorder. It is imperative that someone recognize warning signs early and evacuate anyone who cannot retain mental stability, to avoid placing the impaired individual and his traveling companions at risk for injury.
ANXIETY
Anxiety is the most common psychiatric symptom, and may range from appropriate and adaptive minor doubts about success to a full-blown panic reaction. Minor anxiety is expressed as general discomfort about a situation. The excessive worrier may become timid and withdrawn, and may lose his enthusiasm for participation. His anxiety may be clothed in criticism of plans or refusal to cooperate. It is important that every member of the expedition voice fears and objections at the outset, so as not to be caught in a panic when crossing treacherous terrain or performing rescues.
The treatment is reassurance and support. Frequently, practice sessions that build up to a completed effort will relieve anxiety and improve the performance of the group. In no case should anyone be made to feel ashamed of his fears. Rather, the leader should seek to help the victim conquer them.
Approach what problems you can directly. Most people do much better if fear is identified and managed than if it is never confronted.
In certain circumstances, where anxiety must be conquered to allow extrication, rescue, or even survival, judicious use of an antianxiety drug, such as lorazepam (Ativan) 0.2 to 2 mg, alprazolam (Xanax) 0.5 mg, or diazepam (Valium) 2 to 5 mg may be useful.
PANIC
Panic is anxiety in the extreme. Signs and symptoms may include heart palpitations, sensation of pounding heart, rapid heart rate, sweating, trembling or shaking, shortness of breath or a sensation of “smothering,” choking sensation, chest discomfort, nausea, dizziness, fainting, a sensation of loss of reality, and fear of dying. The victim loses all judgment and becomes consumed with efforts at escape and self-preservation. Panic renders the victim unable to make reasonable decisions and immediately places him and all around him at risk for injury. The rescuer must assume a strong authoritative posture with the panic victim, assuring him in no uncertain terms that the situation is under control and the panic behavior is detrimental. Depending on the situation, this can be done with verbal explanations, convincing arguments, or demonstrations of safety. As for anxiety, antianxiety drugs such as diazepam, lorazepam, or alprazolam may be helpful. If the victim places other individuals at immediate risk for injury, he should be subdued, with force if necessary.
Persons who use cocaine, smoke marijuana or phencyclidine (PCP, angel dust), or ingest LSD are prone to panic reactions under conditions of stress. The management of these reactions is little different from that previously outlined; the exception is the risk of violent behavior from anyone under the influence of cocaine or PCP. If a person appears to be under the influence of psychotropic drugs, do your best to keep him from hurting anyone, but be careful not to become injured yourself in the process.
HYPERVENTILATION
One manifestation of anxiety that verges on panic is the hyperventilation syndrome, in which the victim, overcome by his fears, begins to breathe at an inappropriately rapid rate—40 to 100 times per minute. This causes the level of carbon dioxide in his blood to fall precipitously and to render the blood alkaline (from its normal neutral state). The symptoms are dizziness; fainting spells; numbness and tingling in the hands, feet, and around the mouth; muscle spasm in the hands and wrists; and, occasionally, seizures. If you are certain that the victim is hyperventilating because of anxiety (that is, there is no reason to suspect a collapsed lung, pneumonia, or other medical problem), place a paper bag or similar device over his mouth and nose for about 5 minutes. The victim breathes in and out of this bag (encourage “slowly and deeply”), and rebreathes his own expired carbon dioxide, allowing normalization of the level in the bloodstream and correction of the symptoms. At the same time, reassure the victim that he will be all right. Always pay close attention, as less oxygen is available to the victim while rebreathing from the bag, so do not use this technique for anyone with heart or lung disease. After the episode, make an attempt to identify the cause of the anxiety.
DEPRESSION
Depression occurs in the outdoor setting in response to situations that are perceived as hopeless. Some victims who are injured, lose their way, or are weakened by starvation and exposure may lose the will to continue. They become listless, fatigued out of proportion to their physical condition, uninterested, inattentive, without appetite, sleepy, and tearful. Clearly, the rescuer must encourage all party members to maintain their survival instincts, to continue to help others and to help themselves. In a cold environment, it is important to remember that hypothermia (see page 305) is a significant cause of apathy and should be corrected, if possible. An individual with chronic depression may go on a vacation trip with the enthusiastic expectation that his psychiatric disease will be alleviated or that his most recent depression has lifted. The sudden realization that such expectations are not fulfilled may put that person at risk for severe mood depression. Do not be afraid to inquire about a past history of psychiatric illness.
REACTION TO AN INJURY OR ILLNESS
People’s reactions to stress differ; they may become irrational, angry, apathetic, confused, or withdrawn following an accident or harsh environmental exposure. The most common reaction, given the presence of a strong leader, is to become dependent. It is crucial for the rescuer to bolster the victim’s self-confidence and self-esteem at every opportunity, for it may take extraordinary physical and mental effort to survive a catastrophe in the wilderness.
Try to individualize your approach to each person. To best understand the changing needs of victims and families, try to maintain regular dialogue intended solely for the purpose of psychological support. Stay with the victim as much as possible. Use frequent touch and reassurances to relay your sense of concern and offer comfort. As best as possible, involve the victim in his treatment and rescue, so that his thoughts are attuned to survival rather than to fear or grief.
When you are under stress, do your best to be supportive to others with less emotional control. Anger is rarely successful and commonly worsens an already difficult situation.
Equally important, the rescuer must constantly be alert for true medical problems that masquerade as psychological disorders. The uninterested victim may be hypothermic, the belligerent climber hyperthermic, the intoxicated hiker hypoglycemic, or the irritable child stricken with acute mountain sickness.
POSTTRAUMATIC STRESS DISORDER (PTSD)
This is a condition where the victim who has been exposed to an extreme stress or event to which he has responded with fear and helplessness reacts in a manner that includes reexperiencing the event, avoiding reminders of the event, and showing a condition of hyperarousal. Reexperiencing the event can include nightmares or flashbacks; symptoms of avoidance include eliminating any locations, persons, or situations that serve as reminders or showing loss of memory for the event; and hyperarousal means difficulty sleeping, being irritable or short-tempered, having difficulty concentrating, or being exceptionally fearful. Furthermore, a person suffering from PTSD may be having difficulty with activities of daily living, be apathetic, and become fatalistic.
This condition is different from the less complicated responses of fear, grief, anxiety, panic, and even depression. In a wilderness setting, it is more likely to follow a natural disaster with many casualties than one in which there were a small number of victims. Personal pain and violence contribute to the propensity for PTSD, as perhaps do extreme environmental exposures.
Treatment includes habituation that allows confrontation with and understanding of fears, creating an environment of education and support, and stress reduction. In some situations, antidepressant medications are useful, but antianxiety medications may not be very helpful.