Did You Know? Update Your Knowledge

Linda Ebner Erceg, RN, MS, PHN
November 2018

Staying abreast of health-related updates that impact camp practices is challenging but worth the effort, especially for readers who supervise staff providing care to campers and/or other staff. Here are some of those updates.

Wilderness First Aid (WFA and WFR)

A new version of Wilderness First Aid: Emergency Care in Remote Locations (Thygerson, Thygerson, & Thygerson, 2019) was published this past spring. The book, a commonly used text for introductory wilderness courses, reflects information from the Wilderness Medical Society (WMS), the professional practice community that establishes guidelines for those giving care in the wilderness setting. Readers are urged to stay abreast of these guidelines by following information at wms.org/research/ guidelines as well as knowing what aspects of their camp program fall under wilderness care protocols (see sidebar, "How is Wilderness Defined?").

Changes in the revised Wilderness First Aid that are helpful for experienced and previously credentialed camp professionals include (Thygerson et al., 2019):

  • Updated CPR and emergency cardiovascular care (ECC) guidelines
  • Decision tables that provide a concise summary of signs to note and treatment to initiate
  • Flowcharts that reinforce decision-making and appropriate procedures
  • Skill sheets with step-by-step explanations and visual summaries of important skills
  • New content on first aid and emergency care for dogs

In addition to the updated text, the Wilderness Risk Management Conference, held in Portland, Oregon, this past October, moved some practice updates more deeply into the skill set of providers. For example, RICE (as in rest, ice, compression, elevation) is no longer taught as a treatment acronym for musculoskeletal injuries because some aspects of that approach aren't supported by evidence. There's no evidence that compression aids healing, and elevation is of limited help. Recommended practice is to manage musculoskeletal injury using supports (e.g., splints, taping), short-term use of ice (cooling) as a nonpharmaceutical pain management tool, elevation especially when throbbing keeps one from sleep, and over-the-counter medications for pain. Judicious use of the injured area is encouraged as tolerated.

Wilderness practices are more strongly recognizing the impact of psychological stress on the client's perception of pain and developing strategies to minimize that. While pain from an incident triggers this stress, continued pain and/or a perception that a provider cares little has the potential to exacerbate things. Consequently, wilderness practices are incorporating simple intervention techniques such as using the client's name, meeting basic needs (e.g., hydration, warmth), allowing the client to put themselves in a position of comfort, and keeping the client informed and involved in their care. These, supported by efforts to prevent further harm, help decrease anxiety. Wilderness first-aid instructors are beginning to incorporate these stress-reducing skills in their scenarios and learner assessments.

Other modifications center on hydration and heat illnesses. The term "heat cramps" has been replaced by "exercise-induced muscle cramps" to minimize heat as a causative agent and place emphasis on cramping that happens during any exercise regardless of ambient temperature. Characteristics of people who tend to experience exercise-induced muscle cramps include lack of fitness and lack of acclimating to exercise in warm temperatures and profuse sweating with its associated sodium loss.

The popular emphasis of sayings such as "hydrate or die" and/or sipping from one's water bottle over and over may trigger hyponatremia, a water-overdose problem. Interestingly, the signs of hyponatremia can mimic dehydration: headache, nausea, feeling weak, and so forth. Some camp injury-illness data sets (personal communication, 2018) have shown a growing problem with over-hydration. Campers and staff are drinking too much and, in the process, diluting their bodies' electrolyte base. The adage "moderation in all things" plays well to the hydration message, especially if accompanied by noting the color of one's urine and eating salty snacks during hot, muggy weather. Note, however, that eating these snacks won't correct significant hyponatremia.

NOLS' website, specifically nols.edu/en/about/risk-services/ wilderness-risk-management-conference/ wrmc-resources/, contains information from presentations done at the Wilderness Risk Management Conference. One can scan titles and readily access a variety of PDFs on a range of topics with particular emphasis on risk reduction.

School Preparedness Plans Have Implications for Camp

In early August, the CDC's Morbidity and Mortality Weekly Report (Kruger, Brener, Leeb, Wolkin, Avchen, & Dziuban, 2018) carried an article that discussed development of school-based preparedness plans over time. The report has implications for camp practices specifically regarding the vulnerability of youth to respond with negative mental, emotional, social health (MESH) behaviors and feelings when insecure and/or concerned about inadequate preparedness planning. Granted, the study was based on school experiences, but it doesn't take much to generalize to the camp setting, another youth-centered environment.

In examining preparedness changes over time, the study found no statistical changes to incorporating post-incident mental health services in school plans. Might that same statistic be reflected by camp plans? In the recent past, camp professionals have read, talked about, and listened to content that discusses MESH topics. Yet how many camp plans have incorporated MESH needs — from preparedness to response and recovery phases — in their incident action plans?

Four topic areas from school plans also have impact for camp planning:

  • Family reunification procedures
  • Responding to infectious (communicable) disease outbreaks
  • Provision for people with special needs (both youth and adults)
  • Providing MESH services post-incident for youth and adults

In planning to address these areas, camp professionals are reminded that the community surrounding camp will be vying for the same resources needed by camp and, depending on the incident, may also be coping with compromised resources such as a power outage taking out technology-based communication plans. Review your camp's Incident Response Plan with these topics in mind, and coordinate with the local community's response team so your camp remains connected to that bigger plan.

See Something, Say Something — For MESH Too!

Camp professionals have long recognized that many camp staff are pre-professionals. Their college student status often means they come to camp with caring hearts but limited skills, including skills associated with addressing the MESH needs of campers. Yet they are the ones who routinely see the day-to-day behaviors of campers in cabins and activities — but do they really notice those behaviors, especially when a camper demonstrates behavior that is atypical for that child? Perhaps the child's eye contact has diminished over time, or the camper's "nervous behavior" occurs more often. Might the camper be pulling away from activity with others, choosing more alone time when they used to enjoy cooperative play?

Noting these MESH-related behavior changes and bringing that observation to the attention of the appropriate camp professional is a skill that's both teachable and observable. Yet many camps do not include this in their staff performance process. That needs to change. Just as we note and act when we see a camper who is injured or ill, so, too, should we respond when a camper demonstrates behaviors that telegraph their MESH status, particularly those behaviors associated with negative outcomes. We do so when things are going well, when campers are upbeat and happy. Why not also catch the behaviors that indicate feelings of tension, anxiety, and lonesomeness? Coaching cabin and activity staff to notice and then verify their observation might include directing the observing staff member to ask something like, "Your fingers are really moving and you haven't looked at me in a while; how are you feeling?"

It's time to add this skill to your staff processes.

Trends in Youth Risk Behaviors

Recognizing that health disparities exist among youth based on factors such as sex, race/ethnicity, and parental income, the Youth Risk Behavior Surveillance — United States, 2017 (Kann, Harris, Shanklin, Flint, Lowry, Whittle, Thornton, Lim, Bradford, Yamakawa, Leon, Brener, & Ethier, 2018) used population-based data from various sources to gather information about 121 health-related youth behaviors for 2017. For camp professionals interested in the background that arrives with campers and many staff, and things that counselors might hear discussed in cabins and staff supervisors overhear in the staff lounge, the information contained in the report has impact. For example:

  • A growing concern for all demographics lies with texting while driving, a behavior reported by 62.8 percent of youth who drove a car during the 30 days prior to completing the survey. Does your camp have a no texting policy for drivers of camp vehicles? Assuming so, how do you monitor compliance? It's an interesting question, especially because having a text-enabled phone during those town runs makes it easy to ask someone to get items not on their shopping list. But might texting behaviors also emerge when a person is supervising your ropes course, monitoring the Buddy Board, on an overnight camping trip, and so forth? While driving a vehicle is commonly emphasized by the popular press, texting — or other uses of mobile phone devices — has the potential to be equally problematic during other camp activities.
  • During the 12 months prior to the survey, 14 percent of adolescents reported misuse of prescription pain medication. This adds emphasis to medication being in the controlled possession of the person responsible for administering it (Standard HW.19; American Camp Association, 2012). In addition, 29.8 percent of surveyed youth reported current alcohol use, and 19.8 percent reported current marijuana use. These risk behaviors have implications for staff training around noting behavior indicative of substance misuse and acting on that observation. It also means health center staff should be alerted to consider substance misuse when client signs/symptoms don't jive with what the client reports as a problem.
  • The "urge to merge" is robustly present among youth, as evidenced by the 39.5 percent who reported being sexually active and 9.7 percent who reported sexual intercourse with four or more persons. Of the sexually active teens, 53.8 percent reported condom use by themselves or their partner. While the supervision of campers is often relieving — but not a guarantee — for camp leaders, supervision of staff poses a different challenge.
  • During the 30 days prior to the survey, 13.2 percent of youth had used an electronic vapor product on at least one day, and 8.8 percent had smoked cigarettes. Our camp noses often catch the smell of cigarette smoke on a person, but what about noticing use of vaping products — or withdrawal behaviors when a person gets to camp and can't use their device as they've been doing?

Physical inactivity is a growing concern. Forty-three percent of youth use a computer for three or more hours a day for something other than schoolwork, and 15.4 percent reported not being physically active for at least 60 minutes during the seven days prior to the survey. This suggests that youth come to camp less physically prepared for the day-to-day efforts of camp activity let alone a strenuous activity. Might your camp program need to emphasize gradually building tolerance for physical activity among both campers and staff? The study's reported 15.6 percent of overweight youth adds importance to this.

Camp professionals working with specific subgroups of youth are encouraged to obtain more discrete information by reading the study, something that's readily available at cdc.gov/mmwr/volumes/67/ss/ss6708a1.htm.

These and other items help inform our work as camp professionals, especially as we strive to target specific outcomes for our campers and staff. Use the content that impacts your camp program, but also share this and other information with your camp colleagues. Improving the health status of our youth needs everyone's support.

How Is "Wilderness" Defined?

The Wilderness Medical Society defines wilderness as "a remote geographic location more than one hour from definitive medical care" (Thygerson, Thygerson, & Thygerson, 2019, pg. 1).

The geographic location of some camps is such that the camp readily meets the criteria of this definition, but other camps may have aspects of the program — such as tripping and/or the location of other activities — which means one moves in and out of wilderness protocols depending on the location of a given incident.
Camp professionals: Know the emergency response time from your program components so you can effectively direct your staff as to when they’re under wilderness protocols.


Teach about Hydration

Google "color of urine when dehydrated" and you’ll find several images. Select one from a reputable source that’s a good "fit" for your campers and staff population. Put the printed image where people will see it, perhaps on stall doors in bathrooms as well as in your health center.

Couple this strategy with a caution about being too hydrated. A tint of yellow in one’s pee is a good thing!

References 

  • American Camp Association. (2012). Accreditation process guide. Monterey, CA: Healthy Learning.
  • Kann, L, McManus, T., Harris, W.A., Shanklin, S.L., Flint, K.H., Queen, B., Lowry, R., Chyen, D., Whittle, L., Thornton, J., Lim, C., Brandford, D., Yamakawa, Y., Leon, M., Brener, N., & Ethier, K.A. (2018). Youth risk behavior surveillance: United States, 2017. Morbidity and Mortality Weekly Report (MMWR), 67(8), 1–250.
  • Kruger, J., Brener, N., Leeb, R., Wolkin, A., Avchen, R.N., & Dziuban, E. (2018). School district crisis preparedness, response and recovery plans — United States 2006, 2012 and 2016. Morbidity and Mortality Weekly Report, 67 (30), 809–814.
  • Thygerson, A.L., Thygerson, S.M., & Thygerson, J.S. (2019). Wilderness First Aid: Emergency care in remote locations. Burlington, MA: Jones & Bartlett Learning.
  • Wilderness Medical Society. (2017). Practice guidelines. WMS. Retrieved from wms.org/research/guidelines

Linda Ebner Erceg, RN, MS, PHN, is the program coordinator for Bemidji State University's Certicate in Camp Nursing (MN). Her experience includes over 30 years as a year-round camp nurse for Concordia Language Villages and deep experience in working with camp professionals to address camp health needs. She currently chairs ACA's Healthy Camps committee where her time at camp as well as her former role as executive director for the Association of Camp Nursing now contribute to her educational and research activities.