Summertime in Montana: It's Not Just the Bears

Paul E. Shingledecker, MD, FACP, Hospitalist
Marcus Daly Memorial Hospital
1200 Westwood Drive
Hamilton, MT 59840

Many people think of bear attacks as the main danger of a Montana summer. However, the bigger health risk is from the small things that you don't see that such as insects, microbes, ultraviolet light, and heat. This is especially true for those with chronic health issues, such as congestive heart failure, angina, hypertension, COPD, asthma, diabetes, cirrhosis, and sleep apnea.

Insects including mosquitoes and ticks are a well-known hazard during the Montana summer. Lewis and Clark first recognized this as they wrote "the musquetors were extremely troublesome to us", often requiring them to change campsites. Besides being irritating, mosquitoes can transmit West Nile Virus and encephalitis while ticks can transmit diseases that include Rocky Mountain Spotted Fever, Colorado Tick Fever and Tickborne Relapsing Fever. The best ways to prevent these issues are avoidance and use of repellents. You should restrict outdoor activities during the prime mosquito times of dusk and dawn.

Bug bites are also prevented by applying insect repellents that contain at least 20% DEET and wearing clothing pretreated with permethrin. To reduce the itching and swelling after a mosquito bite, apply OTC hydrocortisone or antihistamine cream, use a cool compress, and take an oral antihistamine. If you are bitten by a tick, remove it with a fine-tipped tweezer, grasping the tick as close to the skin as possible and pulling upward with steady pressure while avoiding twisting or jerking. You should seek medical attention if, within several weeks after a tick bite, you develop fever, chills, muscle or joint aches, fatigue, headache, or a rash.

Bacteria and other microbes are unseen hazards often encountered during the summer. It is easy to get acute gastroenteritis (food poisoning) such as salmonella from food eaten at picnics and outdoor events. To prevent food poisoning, meals need to be served at the proper temperature. Cooked foods should be kept at an internal temperature of 140 degrees or greater. Cold foods such as potato salad should be kept at less than 40 degrees. Food left out at room temperature should be discarded after 2 hours. Because it may contain giardia and other microbes, surface and untreated well water can also be a source of gastroenteritis. Water should only be used from known safe sources or after it has been properly treated. If you do develop mild diarrhea after ingesting bad food or water, you can use OTC medications such as Immodium AD and drink electrolyte-containing beverages. You need to seek further medical attention if you experience diarrhea with fever, excessive vomiting, abdominal pain, or blood in stool.

Another unseen summer risk in Montana is exposure to increased ultraviolet (UV) light from the sun causing those painful sunburns. UV light can also produce burns of the eye cornea and can later lead to cataracts. The amount of UV light increases by 4% for every 1000 feet of elevation gained and is further increased by reflection from sand and water. That's why you're more likely to get a sunburn by laying on the beach at Lake Como or floating down the Bitterroot. Medications can further increase sensitivity to sunlight and include sulfonamides, phenothiazines, diuretics, doxycycline, and topical antibiotics. To reduce your risk of UV exposure, you should wear sunscreen SPF 30 or greater and sunglasses.

Sunscreen should be applied 20 minutes before exposure and reapplied every 2 hours. If also using bug spray, first apply sunscreen and let it dry. Mild sunburn can be treated with cool wet towels, ibuprofen or naproxen, acetaminophen, hydration, cool bath, and moisturizing cream. You shouldn't go back into the sun until the burn has healed. You should seek medical attention if the sunburn is severe with blistering second degree burns that involve more than 15% of the body or if you have a high fever greater than 101 degrees, dehydration and extreme pain that lasts more than 48 hours.

Summer also brings heat and increases the risk of dehydration, heat exhaustion and heat stroke. For those with chronic kidney disease, diabetes, hypertension, heart disease, or otherwise using diuretics ("water pills"), this can lead to acute kidney failure and electrolyte problems. It is essential to stay well hydrated. You should have at least 8 glasses of water (64 ounces) per day. A good rule of thumb that we used in Iraq is to drink fluid until your urine is nearly clear.

Altitude presents its own unique challenges for those travelling during a Montana summer. Acute mountain sickness (AMS) can occur as low as 5000 feet but becomes more common above 8000 feet.

Symptoms include headache, nausea, poor sleep, loss of appetite, and fatigue. Severe forms of altitude sickness include swelling of the brain or high altitude cerebral edema (HACE) with additional symptoms of drowsiness, confusion, and loss of coordination. Another form is high altitude pulmonary edema (HAPE) or fluid accumulating in the lungs with marked shortness of breath, cough, and weakness. These conditions are treated by immediate descent to a lower altitude and require further medical treatment. AMS can be prevented by not going from a low altitude to sleeping at higher than 9000 feet in 1 day. You should also minimize caffeine use, avoid alcohol above 8000 feet for the first 48 hours, and not smoke.

Higher altitude can be even more hazardous for those with chronic health problems especially conditions that require wearing oxygen. The amount of oxygen available to you decreases with altitude, by 25% from sea level at 8000 ft and 44% at 14,000 ft (such as Pikes Peak, Colorado). Travelling by air also lowers oxygen levels as airplane cabins are pressurized down to an equivalent maximum altitude of 8000 ft. The average person's oxygen saturation decreases by 4% after 3 hours of flight. If you have use supplemental oxygen or have a borderline oxygen level, you should consult your physician before travelling to higher altitude or on an airplane. Guests should be cautioned about this risk before travelling to Montana. Out of state visitors with chronic health problems are frequently hospitalized with shortness of breath and respiratory difficulties.

Travelling during the summer presents other health challenges. The risk of a blood clot (deep venous thrombosis and pulmonary embolus) increases with sitting on an airplane or in a car for an extended time. It is further increased if you have cancer, a family history of clots, use estrogen pills, had recent surgery, or a previous blood clot. You should take frequent breaks, walk every 1-2 hours, wear compression stockings, perform calf exercises, and ask your physician about using aspirin during trips.

Those with chronic health problems should take further precautions while travelling. You should never be separated from your medications and medical equipment. They should be kept in a personal item or carry-on luggage. I recommend packing extra medications to last the entire trip plus extra days in case of delays. You should always carry a list of your medications, allergies, medical history, and emergency contacts. If indicated, obtain a medical alert bracelet or necklace. Always take your essential medical equipment including diabetic supplies, epinephrine pens, inhalers, extra oxygen, and CPAP machine. As the advertisement says, "Don't leave home without it".

Following these tips can lead to a healthy and safe summertime in Montana.

Besides being a hospitalist at MDMH, Dr. Shingledecker is a former NPS Ranger and retired US Air Force flight surgeon/critical care physician.

The weekly health column is brought to you by Marcus Daly Memorial Hospital and the Ravalli Republic. For questions regarding this week's health column please contract, Paul Shingledecker, MD Hospitalist at Marcus Daly Memorial Hospital, 1200 Westwood Drive, Hamilton, MT 59840. Working together to build a healthier community!