Any substance you inhale, ingest, absorb through your skin, or get injected into your body can cause a malfunction in normal biological processes. The substance is then called a poison. Most deaths from poisoning occur in homes to small children. In the wilderness fatal poisonings are rare. When they do happen, it is usually the result of ingesting a deadly fungus or cooking in an inadequately ventilated tent or snow cave that lets carbon monoxide build up. The two episodes that follow will clue you in to recognition, treatment, and prevention of the common backcountry poisonings.

Scene One: Your child wanders into camp chewing and holding half of a Little Brown Mushroom. Your reaction is predictable. Panic! Hours later, flushed and sweaty and crumpled after a run to the car while carrying the child, a 90-minute drive to the hospital, and a dash into the emergency room, you're trying to make a photo ID of the LBM from a mycology reference book while the medical staff stands in a corner with their heads together trying to figure out what to do. In the meantime the kid discovers the TV in the waiting room and sits as happy as a pig in truffles.

It's true that approximately "75 percent of mushroom exposures," says the Clinical Toxicology Forum (Vol 6, Num 4), "involve children less than six years of age." But out of 85,556 documented, questionable mushroom ingestions reported to the American Association of Poison Control Centers in a recent 11 year period, only 14 resulted in fatalities. Almost all the deaths were in adults who mistakenly gathered bad 'shrooms for dinner or in hopes of a hallucinogenic high.

The mushroom most likely to kill? The Amanita species (Death Cap, Death Angel, Destroying Angel) responsible for 90-95 percent of all human deaths and containing cyclopeptide amatoxins which can produce fatal liver and kidney failure in two to three days. Typically growing under deciduous trees in the United States, Amanitas show a yellowish to white cap four to 16 cm in diameter and a thick stalk five to 18 cm long with a large bulb at the base. The gills under the cap are usually easily visible and white to green in color. Onset of gastrointestinal distress (severe nausea, vomiting, abdominal cramps, diarrhea) with Amanita, and with all potentially death-causing mushrooms, usually falls in the six-to-12 hour range. "As a general rule," continues the Clinical Toxicology Forum, "if symptoms develop within approximately two hours of ingestion, it is unlikely that the mushroom is one of the potentially fatal hepatotoxic varieties." In other words, if stomach discomfort soon follows mushroom munching, the chance of serious mushroom poisoning is extremely slim.

Here's the main point so far: by the time signs and symptoms show up in serious mushroom poisonings, it's too late to do anything except hurry to a hospital where supportive care might save the life of the patient. That means if you think someone has eaten a bad 'shroom, or ingested anything poisonous, start treatment quickly. If you're in doubt, as with the child in Scene One, start treatment quickly. You don't want to wait for signs and symptoms! Each moment that passes lets more and more poison be absorbed into your patient's system. It would be nice to have a Wilderness Poison Control Center to call. They could provide immediate and exact information to guide you. In their absence, you are left with some management principles.

1) If the patient is still conscious, limiting the absorption of the poison from the gastrointestinal tract is the prime goal of field management. There are two practical methods of doing this in the wilderness: A) inducing vomiting and B) binding the toxin with activated charcoal.

If vomiting can be induced early, within one hour, it may be very beneficial, especially when a mushroom poisoning is suspected. Emetics are vomiting-inducers. A lightweight emetic for your first aid kit is a small bottle of syrup of ipecac. An adult (about 10 years old or older) gets two tablespoons with eight-to-16 ounces of water. Younger people get one tablespoon with the same amount of water. Do not sit facing them. The vomit tends to come suddenly and forcefully, and may repeat several times. If they haven't vomited in 20 minutes, repeat the dose.

Without ipecac, stimulation of the gag reflex may work to induce vomiting. Lean the patient forward, gently reach into their mouth with a finger, and tickle the back of their throat.

Do not induce vomiting if:
1. Patient is losing consciousness.
2. Patient has a seizure disorder or heart problems.
3. Patient has swallowed corrosive acids or bases which can increase damage as they come up.
4. Patient has swallowed petroleum products which can cause serious pneumonia if even a small amount is breathed into the lungs.

Note: It is unlikely you'll be carrying many chemicals in the backcountry. But in case of ingestion of corrosive chemicals or petroleum products, get the patient to drink a liter bottle of water or milk. Diluting the poison will reduce its effects. If someone takes an accidental swallow of white gas, the petroleum product you brought for the stove, do not induce vomiting. White gas ingestion can typically be managed with dilution and without any harm to the patient. But don't let them smoke for a couple of hours . . . or fart near an open flame!.

Activated charcoal is post-combustion carbon residue treated to increase absorbency. With most poisons, even if your care will be short-term, binding the toxins with charcoal is even a better treatment than inducing vomiting. Why?: By the time you realize you have a poisoned victim, much of the toxin has already passed out of the stomach, and there are no contraindications for the use of activated charcoal. Charcoal may also be administered post-vomiting. The usual dose is 50-100 grams for adults, and 20-50 grams for children. Although it is odorless and tasteless, swallowing the slurry of fine black powder may prove a chore. It can be added to flavored drinks (e.g., fruit drinks), but it should not be mixed with milk or milk products.

2) If the patient goes unconscious, evacuation to a medical facility is probably what is going to save a life. Keep the patient on her side during the evacuation to maintain her airway.

In general with any suspicion of an ingested poison, ask early about nausea and vomiting, abdominal cramps, diarrhea, loss of visual acuity, muscle cramps, or anything else unusual. It would be a healthy idea to become very wary of any change in the level of consciousness of the patient. LOC changes are indicative of serious poisonings. Vital signs are also important clues indicating the seriousness of the poisoning, so watch for signs of shock. The historical evidence you gather may be extremely helpful in assessing the problem. What has the patient put into her mouth in the last 24 hours? When did she do it? How much did she eat? If more than one person suffers, what have they consumed in common? If the patient is unconscious, what is lying around that could have poisoned her? And ask about underlying medical problems that could be simulating a poisoning. Give all this information to the doctor when you hand over the patient.

Scene Two: Unseasonable snow has kept you and your partner huddled in the tent for almost 24 hours. Hunger and thirst led to firing up the stove under the vestibule, but the wind tempted you into moving it inside. Several cups of tea and a freeze-dried dinner later, your mild headache has reached throbbing proportions, and you're thinking your culinary efforts might resurface on the tent floor. Your partner, complaining of head pain earlier, now seems irritable and increasingly confused.

Stoves burn inefficiently in an enclosed space with inadequate oxygen. Higher altitudes increase the chance of poor combustion. The result of incomplete combustion of any organic fuel (gasoline, kerosene, natural gas, charcoal, wood) is carbon monoxide (CO). Carbon monoxide is invisible, odorless, and tasteless, and once inhaled, it enters the blood of the victim where it is about 200 times more bondable to the hemoglobin of red blood cells. Hemoglobin normally carries oxygen out to the cells of the body. With CO attached, hemoglobin can't carry as much oxygen and can't release what is attached as efficiently. The brain and heart, the organs most in need of a constant flow of oxygen, begin to deteriorate. Tissue death can occur rapidly, and lead to the death of the organism (e.g., you or your tent partner). CO poisoning accounts for approximately one-half the poison deaths in the United States every year and creates one of the few serious poison threats on wilderness ventures.

As the amount of attached carbon monoxide increases in the body to approximately 20 percent of the maximum potential, the patient develops a terrible headache, nausea, vomiting, and a loss manual dexterity. At 30 percent, the level of consciousness descends into irritability, impaired judgment, and confusion. It will be increasingly difficult for him to get a full breath, and he will grow drowsy. At 40 to 60 percent, the patient lapses into a coma. Levels above 60 percent are usually fatal. Death typically results from heart failure. Death by CO is not a pleasant drift into slumber depicted in some movies.

In the field the treatment is simple: move to fresh air. If you have been exposed to low concentrations of CO, you'll probably recover completely in a few hours. The half-life of carbon monoxide attached to hemoglobin runs around 5.5 hours. If the concentrations have been high, you may die even removed from the source of the gas. Rapid evacuation to a high pressure chamber and high concentrations of supplemental oxygen are necessary. Unconscious victims of CO poisoning will need to have their airway maintained during the evacuation.

QUICK RESPONSE
1. If the patient ingested a poison, find out what, when, and how much.
2. If appropriate, induce vomiting ASAP, especially with mushroom poisoning.
3. For other ingested poisons, administer activated charcoal ASAP.
4. If the patient inhaled a poison, remove him from the source. Unless he recovers completely and soon, evacuate.
5. Evacuate anyone who does not show signs of improvement quickly.

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