Sawbones: Frostbite

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Hello everybody and welcome to Sawbones, a marital tour of Misguided Medicine.

I'm your co-host, Justin McElroy.

Yeah, I'm Sidney McElroy.

I'm feeling a little shaken up right now, Sid.

Why are you shaken up?

Well, we just did the ads and one of the ads, I'm not going to specify which one because I don't want anybody to

have their feelings here, but one of the ads I think was the best ad read I've ever done in my whole life.

It was a really good one.

It was like natural.

It was warm.

I felt really connected to the brand.

Right.

And it is like, I feel like sitting here, I'll never top it.

You know what I mean?

And I feel like that's important for people like me to have these aspirational goals out there.

We need something to climb.

We need a goal.

We need a mountain.

You know, we need a pole.

We need something to strive for that pushes us to the very limits of human endurance.

For me, for a long time, it was doing the best ad read possible.

And I know in my bones, and you saw it, and you can deny it if you want to to save my ego, but you know, I peeked during that ad read.

It really, I mean, you did.

No, it's true.

I do.

But what's next, but what's next for me on the horizon, Sidney?

I don't know how I'll continue to strive for excellence and push myself to the very limits of human endurance.

You could climb a mountain.

Have you thought about that?

I have.

I've tried.

Attentive viewers of the McElroy family website will see some of that prowess.

Was that a mountain?

I don't, I can't say anything else.

It's a secret.

But listen, I don't, we live in the mountain state.

Yeah.

So I feel like you should know what mountains are.

But we don't have mountains in the mountain state.

There's no mountains here.

No technical mountains.

But we are nestled within the Appalachian Mountains.

You can nestle, but there ain't any in this.

We're the only state.

that exists entirely in Appalachia.

And entirely outside of any mountains, because there aren't any in this state.

There's none.

Did you all hear them at the Super Bowl singing Country Roads?

Yeah.

That song's about us.

That song's about us.

I bet you didn't know it was about West Virginia, except for when they say West Virginia.

Yeah, well, it probably confused him because it was written about Virginia.

It just didn't fit the meter as well.

No.

And sorry, Virginia, we're cooler.

Sorry.

Sorry.

Sorry.

No, this is themed.

This is a themed.

I did that introduction for you.

You did.

And then I feel like you kind of lost the plot.

I did lose the plot.

I forgot.

Sorry.

Justin, you know something that can happen when you're climbing a mountain.

I do, Sidney.

And you already know.

Oh, Lord.

It's come off in the boot.

Oh, Lord.

That's right, Justin.

Frostbite.

Frostbite is a good topic to talk about for a couple of reasons.

One, it's February.

It's still cold here.

It's a little more temperate now.

Y'all, we had a few weeks here that I know in some of the colder climes probably wouldn't faze you but hachi machi there was a few weeks here where it did not get above freezing and i thought i was going to die and it i mean it yes it got extremely cold we had uh a snowstorm then an ice storm and then more snow and then it stayed below freezing down into single digits for like a week and so nothing could melt so we were just sort of encased in ice for a long time and i think because of the kind of medicine i practice i am now much more acutely aware of the temperature because many, most of my patients are unsheltered.

And so they, so I think about it a lot more, which is a good reminder, I think, for all of us that there are, you know, that we're, we're lucky to be inside if we are.

And it is also a good reminder that frostbite still happens.

One of the issues with frostbite, Justin, that we're going to get into is one, I think that unless you are someone who is in a position where you're vulnerable to it, like you're because of your life circumstances, you may encounter it, you're not going to think about it.

You probably don't really know what exactly is happening

or how what to do about it if it does.

And on the medical end, there's definitely a lack of,

I don't want to say aware, awareness is fair among a lot of physicians because we don't see it a ton.

I would also say among the populace, and this, I do feel like I kind of show my butt a little bit sometimes by trying to speak for the common man in terms of their ignorance, but I feel like frostbite is one of those things that's enough a part of the popular imagination that I often hear it like tossed about without people seeming to really know.

I'm absolutely including myself in this group as to what frostbite actually is.

Because sometimes your hands.

Get a kid's hands cold enough to go numb and they will be convinced that they have frostbite.

And we say that, right?

Like even as our girls were going out to play in the snow, I would be like, now if you start to hurt, come inside so you don't get frostbite, which that's, there, that's a common class.

And I have absolutely no idea why.

That's like a class.

I have no clue why you're like, because as I say it, that if you are in the medical field or if you had a parent who was in the medical field, this is a common thing.

I will say things that are so flippant, like if the tip of your nose starts hurting, it might fall off.

So come inside.

That is such a doctor mom thing to say.

Like I own it.

I realize that.

Like more concerned parents would be like, only go outside for so many minutes and, you know, whatever.

And I'm like, you know, if your fingers start hurting, come inside.

No, but I don't think a lot of people know.

And I think because of the kind of medicine I practice, I think about frostbite a lot and I'm very aware and I'm looking for it and I'm educating my patients.

There is still a lot of education that we need to do to get people to be more aware, to prevent frostbite just because of the awareness, to come seek help quicker and to prevent more tissue damage, more amputations that

can occur from frostbite.

So I think it's good to talk about because

it's an area where education is needed, both on the doctor and patient end.

And there was a new medication approved for frostbite just last year.

So fairly recent.

The first FDA approved medication for frostbite.

Is it topical or intravenous?

Intravenous.

Interesting.

Yes.

Yeah.

We'll get into what it is.

And what an interesting question.

So first of all,

frostbite, the first case that we knows about, that we knows about, what is that, that we know about?

The first case we knows about frostbite comes from, must have been 1648, my uncle.

What happened?

5,000 years.

5,000 years ago in this very hamlet.

In the Andes, they found a mummy.

There was Andes place out there near the farm.

They found evidence of frostbite in a mummy.

B.S.

I don't believe it.

Why?

I don't think they did.

They did.

Man, it's a mummy, man.

No way.

It's also, I think that's one of those things where that's like an easy win.

I feel like if you're looking for how old is a disease,

like some sort of medical condition that is just because you got too cold, obviously that has existed as long as humans have existed, right?

Like there was no way there was a long time before anybody got cold enough.

Like humans were around for thousands of years before they got frostbite.

No, of course, frostbite is as old as humanity because it results from prolonged exposure to freezing temperatures.

And certainly throughout human history, there have been many occasions where we have had prolonged exposure to freezing temperatures.

Let's talk about what it is first before we talk about the history of it.

What do you think frostbite is, Justin?

You might, if you just guess, you might be right.

Okay.

Well, I mean, guess.

Here's what I think: I think that you're,

it is a period of time after which the flesh is

like

cold enough that blood can't reach it.

And so without the blood, the skin on the outside dies.

That's pretty smart.

That's so you got okay.

There are, there are two things that are happening in Frostbite, and you basically got it.

I'm glad our audience doesn't know

the pleasure that you looking at me and saying it was pretty smart fills me with.

I'm glad that I'll go to my grave with that secret.

Go on.

So first of all, there is an aspect where your tissues are kind of freezing.

I mean, they're freezing.

Ice crystals are forming outside the cells, drawing fluid out of your body cells.

So there's actual freezing of your tissue.

And I think that you're also, if I had to guess, you're seeing,

I'm not sure if sublimation would be the right word here, but you're seeing, because of the freezing, moisture pulled out of the tissue, right?

And pulled into the atmosphere, right?

Oh, into the ice crystals that are forming.

Like in a condensation, like with a similar process that happens with drink condensing or with freeze-drying, the moisture is being pulled out of the thing and

forming on the outside.

And if you pull all the moisture, if you pull all of the fluid out of a cell, it will dry up and die.

Right.

So there's tissue damage happening.

And also, there's like ice crystals in the tissue.

And then also there is the blood flow part.

That's the other piece you mentioned that is important to understanding why frostbite happens and also has been really critical for us to understand better to try to treat frostbite more effectively.

So the other thing that happens is blood carries oxygen, right?

So if blood stops flowing to an area, it also gets deprived of oxygen.

Right.

Ischemia is the word for that.

And then that's another kind of damage that is going to happen to the tissue at this point because first we've got ice crystals, dehydrating cells, tissue damage.

second lack of oxygen cells can't breathe tissue damage so you've got like you've got a couple different mechanisms that are happening when you are exposed to cold temperatures there is uh there's a specific thing your body does called the hunting reaction and it's like the blood vessels alternate between dilating and constricting.

And the reason they're doing that is it's trying to continue to pump blood, oxygen in the blood, pump oxygen to all the different tissues in your body and also warm them through the blood flow.

So,

when you get vasodilation, a blood vessel dilates, gets bigger, it warms that area.

But you need all your areas warmed when you're outside in the cold.

So, you get this like cycling through.

The blood vessels get tighter and then they open more.

So, more blood, less blood, as they continue to, as you pump blood to different parts of your body.

Eventually, that hunting reaction can stop if you're cold for long enough.

And then that's when you get areas of tissue death because now you've got areas where the blood vessels are constricted and they stay constricted.

So you are basically talking about

the sort of like old adage that, not I guess an adage, but the common wisdom that

heat is lost through your head.

Like the hat is very important because all the heat will escape through the head without a hat there.

Well, not all of it, but yes, you do lose

through the top of your head.

Your unexposed parts, right?

So you got to have a hat there to keep the heat in your body.

Because otherwise it'll all leave through your head.

And then you've got to start thinking about like amount of blood flow to different areas.

So some areas of our body have lots of different blood flow to it, right?

Like lots of, they're large and they've got lots of vascular input.

Muscles, like my muscle, like my biceps and stuff.

Then if you think about like the extremities, how many blood vessels could possibly get to the tips of your fingers, the tip of your nose, the tips of your toes?

It's just a smaller space, right?

So the amount of blood, the amount of blood flow is restricted already.

These are the areas that are most vulnerable to frostbite.

Fingers, nose, fingers, toes, tip of the nose.

It's also the tip of your ears, but that doesn't fit in my rhyme.

You could probably rework it.

Yeah.

But fingers and toes and tip of the nose.

I was thinking about, that would be a helpful mnemonic to remember a case of frostbite, but then it occurs to me that like, should you experience frostbite, you'll probably be well aware of where you are experiencing frost.

Well, it hurts.

Yeah.

No, and and but that's why you see those areas most vulnerable.

They're also typically the areas that are most likely to be exposed, right?

Like most of us are walking around with like a shirt on or pants on, covering, covering your fingers, you know, if you don't have gloves, that becomes an issue.

Keeping your toes warm.

It seems like, well, isn't everybody wearing shoes?

Well, how thick are they?

Are your feet submerged in some sort of, are they in the snow?

Are they in the ice?

Are they cold?

And then your nose, I think, and ears are a little more obvious if you don't have proper coverage of your face, you know, and it's cold enough.

So you get why these areas.

So anyway, you get a lack of blood flow.

The blood vessels tighten and you're getting a lack of blood flow.

You're getting tissue damage from the ice crystals.

And then you can also get little blood clots that start forming inside these little blood vessels from the slowed blood flow.

Like the blood gets so slow that it starts to clot.

And so then what you get what we call microthrombi, which are these tiny little blood clots, which further block blood flow to these areas.

You also, because then now you have blood clots and you've got slowed, you've got tissue damage, now you're getting inflammation.

Inflammation is your body's response to an injury.

So something's damaged.

We'll send a bunch of inflammatory things, factors to this area.

And because of that, you get swelling and edema, so swelling of the tissues, which causes more tissue damage.

So it's this sort of cascade of events.

There's actually stages in it.

There's like your pre-freeze phase where you are exposed to the freezing temps, okay?

And everything's getting cooled down, but you're not actually damaged yet.

Then there's this freeze thaw where the ice crystals start to form.

The blood vessels are still doing the like constricting, dilating, constricting, dilating kind of thing, and you get all the cellular damage.

Then you get the part where the blood stops flowing.

that's either clogged off or just stop.

And then you get the ischemic phase where there's just, there's no blood, there's no oxygen, everything's damaged, and everything starts dying.

And as you progress through these stages, obviously the injury can become more severe.

So for the person experiencing frostbite, it would go from that initial, like,

this, you know, my fingers are hurt, are like pale, they're hurting, they're really cold,

there's pain, and then it progresses to a numbness.

And then you start becoming aware, like, I don't feel like I can't feel my fingers, I can't feel my toes.

And then eventually to these where you can start seeing the visible damage, blisters start to form as the tissue on top is dead.

And then especially if you've been rewarming and refreezing, that's really dangerous.

And then you can start getting like, I think what we think of as like classic frostbite is like the black extremities, like your fingers are turning black, your toes are turning black, and then you worry about them falling off.

That's like the most advanced.

That is not typical of frostbite, right?

Like there are stages of frostbite long before that, but certainly it can progress to that.

And that's called necrosis tissue death.

And then things can

come off or you may have to take them off.

I do think it's important as we talk about what frostbite is to talk about what frostbite isn't.

There is frost nip.

Frost nip.

And I think this is just a little bit.

Yeah.

And so when you talk about like your kids come in and their hands are pale and cold and you're like, ah, do they have frostbite?

They probably have frost nip.

I mean, hopefully not.

They probably are just cold.

But like, if it has progressed to anything, most of it is frost nip.

And you may have experienced frost nip.

If you are someone who has been outside for a long period of time, if you do work outside, if you didn't wear your gloves.

That wasn't a you.

Okay.

That wasn't a you, adjusting you to me.

That was the

yeah, everyone.

You may have experienced you.

Adjustin may not have experienced frost nip.

It's the whitening of your skin, the paling, I should say, of your skin.

It's gotten paler.

It's become numb, but it reverses, right?

Like you go inside, you warm up your hands, you know, you rub them together, you hold a warm cup of cocoa or whatever, hold them near the fire, all the whatever quaint thing, whatever lovely scene you want to paint, you warm your fingers back up and then they feel fine, okay?

That's not frostbite.

You experience frost nip, much more common.

Important to know about frostbite in case you mistake one for the other, but generally not a big deal.

There's also trench foot.

Have you heard of trench foot?

Yeah.

Heard of trench foot.

Do you know what trench foot is?

Okay.

What I, let me tell you again what it is.

It's like frost.

It's just like you're, it's hyper-pruniness.

So like if you get pruning in the tub, that's one thing.

But trench foot is when your foot is pruning for like days.

That's actually, okay.

Yeah.

It's so you're exposed to wet, cold conditions for a very long time, but not freezing.

That's what differentiates trench foot from frostbite is frostbite is, it has to be a freezing temperature you've been exposed to because the damage that is resulting is freezing.

Trench foot is not freezing, but it is definitely wet, cold conditions.

And it does look like

I have seen quite a bit of trench foot.

I see trench foot.

Everyone's so tired of the bragging on this shit.

I'm not bragging.

I think part of what I do is raise awareness about things that maybe you thought were like old-fashioned, like esoteric sort of medical ideas.

Like we talked about with whooping cough.

I don't know that everybody knew that whooping cough is still a thing.

Yeah.

Right.

Okay.

Well, now trench foot is still a thing.

I see it a lot.

I see trench foot way more than I see frostbite.

And it is from, you know, people who are wearing shoes and socks for like days on end.

There's a reason we're supposed to take our socks off at night.

And if we are not in a, you know, place in our life where we can safely do that or where the environment allows us to do that, that's bad for your feet.

So they do look really pruny and wrinkly.

Like you've been in the bathtub way, way, way, way, way too long.

That is kind of what it looks like.

And it's the same idea.

You've damaged the nerves and the blood vessels from this prolonged exposure to wet and cold.

There's also chill banes, which can come from exposure to wet, cold, again, non-freezing conditions.

And sometimes that can be mistaken for frostbite because you can form things like blisters with that too.

Again, this is a different condition.

But it's important.

I think that probably ER doctors see this.

Well, not probably, certainly ER doctors can see this.

Or like urgent cares.

But then there are a lot of us in the medical profession who, if you're not like me and you don't work in a shelter for people experiencing homelessness, you might not encounter a lot of these things.

And so differentiating between them is really important.

And then also knowing what we can do about it.

That's the next big step.

What have we done about it through history?

What have we learned?

And what do we know to do about it now?

Because I think...

If you don't know what to do about it,

then you might just think we should amputate everything.

And it's it's a little more complex than that.

So I'm going to tell you that.

But first, we've got to go to the billing department.

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All right, Sid, sorry about that interruption from us.

So I want to, why, what have we learned about frostbite through the years?

As you may imagine, a lot of like the early medical writing about frostbite, came from the military.

Frostbite really used to be a condition that we associated with people in the military, with armies, with, you know, I mean, that was where we kind of assumed we would see frostbite.

This is really not true now, but a lot of what we learned about comes from that.

So like most famously, if we go back to

Napoleon's surgeon,

LeRay, Dr.

LeRay, famous surgeon, kind of came, I'm sure we've talked about him on the show before, kind of came up with like the first MASH units.

Like

that like the the precursors to that were inventions of LeRay.

So, very famous surgeon, lots of technique, lots of understanding of surgical procedure came from him,

but also

was

responsible for how we used to treat frostbite, came up with the first methods to treat frostbite.

So, LeRay, obviously, with Napoleon, you know, marching through cold areas for very long periods of time, saw a lot of frostbite, saw a lot of soldiers with, you know, injured toes and hands from frostbite and noticed that if these soldiers then took their frozen digits and warmed them by the fire very quickly, that then what would follow is necrosis.

So they would turn black and fall off, necrosis and tissue death.

And he did many amputations for this, right?

Like that was the, that was the treatment.

If it turns black, cut it off.

Right.

But you don't necessarily, on that note, in case you're interested, you don't necessarily have to cut it off.

It can fall off on its own, but you have to monitor for infection because if it's infected, you don't want to just leave it.

That's something, yeah.

But but anyway, so that so did a lot of amputations, but also noticed that and kind of made this association that I think that it is this rapid rewarming that's causing the damage.

Now, let me just go ahead and say right now, that is not true.

And that is not how we treat frostbite anymore.

In case you've been listening to this episode, just like fast forwarding like, okay, okay, okay, but how do I treat it?

Right.

Like, this is not the end.

So please don't, we changed this.

But at the time, the common knowledge or the common wisdom is that you need to rewarm the limb or whatever slowly.

And the way that LeRay actually did it was with snow.

So you would, you would coat the hand or toes or whatever in snow

and then slowly rewarm, very slowly rewarm.

This

really, this concept that we needed to very slowly rewarm the limb has permeated medical thought for, I mean,

I mean, hundreds of years after this.

That there would be a

shock if we did it too fast.

Well, and this is based, this is the other piece of it that we, that we really haven't talked about.

So like the tissue damage that occurs from the lack of blood flow can be amplified from the rewarming.

So you can get what's called a re-perfusion injury, which

it's exactly like it sounds.

So perfusion.

What do you think it sounds like?

Well,

okay.

Sometimes I lose track of what.

Okay.

It's exactly what it sounds.

It's just a perfusion situation.

Okay.

Perfusion meaning blood flow.

Okay.

So you didn't have perfusion.

Now re-perfusion has occurred.

And with re-perfusion, an injury.

results.

And it is as the blood flow returns and you've got like all of these little clots and inflammatory factors and all this kind of stuff, you can have even more damage to the tissues at this point.

Okay.

So he was observing that.

But the thing is

that was going to happen.

Right.

Right.

So he was attributing the necrosis to the fire, to the rewarming, where like the damage has been done.

It was not from that.

So

what we know nowadays is that there is a reason to rewarm things more quickly.

But it took us a long time to figure that out.

And because of

LeRay's observations and this recommendation that you very slowly rewarm limbs, him using snow, for many, many years through a lot of military campaigns, that was exactly what people did.

They very slowly rewarmed their limbs and then

probably ended in an amputation at some point.

And that's why, you know, I'm talking about like a surgeon was the precursor for this.

It was a surgical.

condition is what the thought was.

Either you won't do anything or you'll cut something off.

There wasn't really a lot of anything anything in between that right um

and if you look back like to world war ii there were only like just the german army there were 150 000 limb amputations performed due to frostbite wow so um in the u.s army there were 91 000 so a lot of a lot of amputations resulting you know because we just didn't know what else to do for it yet.

There were some studies that had been done in the USSR back in the 1930s that looked at like, I'm not sure that this slow rewarming is really the best thing.

Let's try.

And maybe make a lot of sense.

Maybe we should do it more rapidly.

And they actually found some protocols at the time, some rapid rewarming protocols that the evidence was starting to show like, yeah, this might actually be better.

But nobody really read it until many, many years later when it was translated into other languages.

Like at the time, it was just sort of the USSR did these studies.

They had this knowledge and it kind of stopped there, stopped at the borders of the USSR.

So

throughout World War II, we really weren't able to benefit from that knowledge.

We finally figured a lot of this out in the early 60s.

Now, before I get into what we do about Frostbite now and how we figured that out, Justin, when

you have your own story, theatrical story about Frostbite.

It's an incredible story.

No, it's not like worth.

It's okay.

There's a play called Terra nova written by ted talley that's about a journey to the south pole it's a the sort of race to the south pole that was conducted by robert falcon scott and an englishman and roald almundson who was uh a norwegian and this is one of the most famous examples of frostbite in history by the way all my frostbite research talked about it but you know more about it than me so i want to let you know well i don't know if i know more about it than you i played amundsen when i was in college so i think that this period of time is really fascinating and it is a play where when I mentioned earlier,

well, actually, Sydney, I'm kind of excited because I've prepared a brief scene for you.

And if I could just have a moment.

Oh, okay.

Here you go.

I thought this was such a rare treat.

We never get to do this on Sawbones, is to have a sort of like theatrical component, right?

Because we both are

theater people, right?

So

the longer page is the first page of it.

And Wilson was the doctor on the expedition.

So he was the one who was reporting to Scott, who was leading this expedition, which, by the way, the context of this is Roald Amundsen and Scott were racing to the South Pole.

Amundsen beats

after being the first.

Maybe he's Amundsen is definitely the first person who got to the North Pole where it is verified.

There are other people that have claimed to it before him.

But then he is definitely the first person to the South Pole.

He beats Scott by five weeks.

And on their way back from the pole, after they discover this, they miss a...

It's not their fault.

There is a sled dog company that Scott and his party were supposed to connect with that was not there despite his orders.

And it was also much, much, much colder than they had anticipated, like negative 40 degrees.

It was miserable.

So the expedition fell apart.

They all died.

One thing that's interesting about Scott, his party, they did, they failed to reach the South Pole.

They failed to, I'm going to cry.

They failed to reach the South Pole.

They kept their spirits together somehow on the way back.

They all died.

But amongst their possessions was a fossil.

And it was the first fossil that had been discovered on that continent.

And that fossil allowed them to prove that Antarctica had been part of the mega continent

that had been part of the Pangea because they had discovered this fossil that was among their corpses.

That's that's some metal science for you, man.

So, okay, you're gonna play Wilson.

Okay.

Okay, and I'm gonna play Scott.

And we're talking about Oates,

who that's who Jason played, but he's not doing well.

It doesn't seem no.

Oates is having, like many of them, having a really, a really tough time.

But this is a scene

where Scott is asking about Oates State, and Wilson, the doctor, is reporting to it.

Now, I played Amundsen, Amundsen, so I don't know what I'm going to be able to bring to this role.

I'm not going to bring my Norwegian accent, obviously, to it.

So, you know, bear with things.

Okay.

So, start with Bower.

I'll give you your cue.

Bowers, he's fainted.

Okay.

This is about Oats.

You ready?

He's fainted.

Lord, his toes have come off in the boot.

Yeah.

Okay.

So they were all pretty British.

Oh, I can't do a British accent.

Well, we'll try.

Okay, ready?

He's fainted.

Lord, his toes have come off in the boot.

This is the greatest moment of my life.

I would ask that it continue.

No, I can't do it.

I saw that.

That's the greatest moment of my life.

Please continue.

Why would you deny me?

Medical kit.

Is your phone on during the greatest moment of my life?

No, it was yes.

Sorry.

Scott hands the kit to Wilson, who removes a vial and syringe and prepares an injection.

The narrator is American, I decided.

I can give him an injection of morphine.

That's about it.

I don't know.

Please, you gotta stop editorializing.

Just be in the role, honey.

Why'd you make him a child?

Use it on the stage.

He can't do any accent.

Scott helps him to roll up Oates's pant leg and underlegging, exposing blackened flesh.

Wilson injects the thigh.

There, I don't think there's much feeling from the knee down.

The pain is gangrene creeping into the thigh muscles.

What were his chances?

If I keep him pumped full of morphine, he might be able to hovel another week, only because he's as strong as a bull.

Another man would have collapsed days ago.

After that, I don't know.

Perhaps if he were on the sledge, if we had the strength to pull it.

But what are his chances?

He hasn't any, not a hope.

Even if we carry him?

This kind of decay is irreversible.

If we tried to carry him, the effort, weak as we are, could kill us all.

It's a horrible thing to say, but we were lucky with Evans.

With Titus?

He's already slowed us down so badly.

Well, if he doesn't die within the next few days, we're going to be in a very desperate position, Robert.

Does he know it?

In his heart, perhaps.

But you know Titus.

He'll march until he drops.

Wilson, um,

how much opium is in your kit?

Hmm, in tablets, 120 of opium, and one vial of morphine, enough to last him perhaps ten days.

I wasn't thinking of Titus at the moment.

That's 30 tablets each, and the morphine.

That's enough for a lethal dose if you took it all at once, isn't it?

I'm not even going to listen to this.

So,

did they take all the morphine or did they just die?

You'll have to come to my production of Terra Nova to find out.

My one man.

I think this is really well reflective though of the understanding.

I mean, first of all, like the, it's well represented, the swelling and then the toes that have already fallen off, which does happen.

And then they talk about it's irreversible.

I mean, that's, it's a good representation of it.

And at that point, like, you weren't going to be able to control the infection that would set in.

That's very sad.

It is.

It's, it's very sad.

And they were, it's an interesting like journey.

Scott has got, I'm not a, I'm not obviously an expert in

any of this, but it's interesting.

Scott has been sort sort of like he was hailed as a hero when it first happened and then there was a time period where people kind of re-examined and were like well maybe he was a little bit foolhardy and led these guys to their deaths and then it's been another like very modern wave of like actually it seems like he was doing his best he got kind of a bad break so it's been kind of like back and forth so that's humanity it is it's a it's a fascinating uh time it's a really good play too if you ever get a chance to see it it's great

Well, we learned more about Frostbite too late for these guys, unfortunately.

But in the 60s uh there was a doctor william mills who did a lot of research in anchorage alaska um establishing a rapid rewarming protocol for frostbite which we now know is better because every hour that you delay treatment for frostbite results in 28 more tissue death.

So there is a there's a reason why we Loray was was wrong.

We didn't want to do the snow slow rewarming process.

Basically, we want to put the extremity, whatever is frostbitten, into a circulating water bath that is held between 104 and 107 degrees Fahrenheit.

That's 40 to 42 degrees Celsius if you are in most of the world other than here.

So really warm.

And they usually nowadays like to do this kind of thing in a burn center.

Frostbites treated, it's very similar to a burn.

I know it seems counterintuitive.

One's really hot, one's really cold, but the tissue damage is pretty similar.

It's not because you're talking, here's how I get the way of thinking about it, though.

You're basically talking about freezer burn.

I mean, it's like it is the same process, right?

We're referring to it by different names, but really that idea of like the outside being damaged by the freezing and

that outside being damaged.

Like we're talking about freezer burn just for human beings.

It's worse to say that.

And there is, and there is a slightly, most of what I'm talking about in terms of frostbite is a result of atmospheric frostbite.

You're out in a cold place.

There is also like contact frostbite.

If you can imagine touching an extremely cold

thing

flip did it for us in a Christmas story.

We know what contact frostbite is.

You lick the flagpole.

So there you go.

So there's also, and that's slightly different.

Now, most of what I am caring for is, well, actually, I can't think of any cases of contact frostbite.

I am taking care of people who are outside in the cold too long.

And

now we know that we want to rewarm faster.

Ideally, you're going to be treated inside some, like I said, inpatient in a hospital, in a burn center.

You can have

inside being the in being the operative preposition.

You're inside somewhere.

Although, as I was thinking about this, like I could easily get like a sous V situation going, I feel like at Harmony House.

You got to stop bragging.

Again, your ability to sousie human hands is cool, but like.

Well, can you, can sous V hold it at that low of a temperature?

Yeah.

Yeah.

What kind of temperature?

104 to 170 degrees.

Oh, absolutely.

Fahrenheit.

I mean, you're, that is like

jacuzzi temperature.

That's what I'm saying.

That's like the jacuzzi.

Well, I want something.

I could, I could.

Do you want a jacuzzi?

Well, I don't have room for a jacuzzi at any house.

That would be a cool shelter for people experiencing homelessness.

If it's just like this and this is our jacuzzi.

No, but I could make a little sous vide bath, I feel like, and help treat frostbite better.

This has inspired me.

Like, I've learned about this, and I'm like, oh, I could, I could maybe do this.

Let's get this going better.

Because we want to rewarm things.

And then the other thing with Frostbite, and this is where this new medication comes into play.

So we have known for a while that you can use clot busters in some cases of frostbite.

So we know that blood clots are part of it.

And we have medicines that are in this class called thrombolytics.

They break up.

They lydic.

They lice.

Lytic means break up.

And thrombus is a clot.

So they break up clots.

And there's a whole bunch of drugs like that that we could probably be using to better effect.

But honestly, we don't think about it a lot.

We see frostbite and we're like, ooh, you're going to lose that.

And I don't, and part of that is when people present.

Part of it is I have, I have only a couple of people who I can think of who came in and said, like, I think I just got frostbite.

Most of what I see is I had, I got this injury last week and here's the result.

You know what I mean?

Right.

So I,

unfortunately, by the time I'm seeing it, I couldn't do this.

But if you are seeing it fast enough, you can give medications that might break up clots.

And specifically, there's a brand new drug called Eliprost, which was just approved by the FDA last year.

It's the first drug approved specifically for frostbite.

They've already used this before in things like raynodes, which is a specific disorder that's totally unrelated to frostbite, but similarly causes your blood vessels to close up and cut off blood supply briefly to an area.

Same idea, to open up these blood vessels.

That's basically what this medication would do, open back up blood vessels to limit the tissue damage that's occurring, right?

So it's really cool that there's a medication out there.

Now, it's an IV thing.

It's an injection.

It's not something that I can have on hand, like in a shelter, but it's a, it's a really important thing for doctors to be aware of because if you are in an ER and you see an acute case of frostbite, you may be able to save a limb and we could reduce the number of amputations that are performed.

Or the sort of like, what I see more often is this kind of passive auto amputation attitude like, well, there's nothing I can do for that finger.

You're not going to, it's going to fall off.

Be prepared.

And then people are just sent out to, which is a lot to cope with, by the way.

Like, you're like, that toe or finger is going to fall off at some point.

Just deal with it.

And it's especially a lot to cope with if you're someone who lives maybe, you know, either outside, you're camping, or you're trying to stay in abandoned houses.

And so you're not able to necessarily keep everything as clean as you would like to.

Like, that's a really intimidating thing to leave people with.

So if there are drugs and methods that we can use to salvage that tissue,

obviously that would be ideal.

And then the goal would be that we can we can see a day where we reduce the number of amputations.

There was there has always been this sort of adage in medicine that like

frostbite in January, surgery in June,

that eventually that's the, like, that's what's going to happen.

And this is a really exciting area of medicine where maybe we're paying more attention to frostbite and we can find better ways of managing it.

So we don't necessarily have to lose digits.

And it's also very painful.

The whole rewarming process is extremely painful.

That's something to remember.

If you're going to engage in any of this, like I was talking about, like a sous vide water bath, that's that's a painful thing.

So, if there are things we can do to limit that, that would be fantastic.

As you may imagine, one last note about frostbite.

The demographic of who gets frostbite now has shifted dramatically through the ages.

The military.

Well, the military specifically has a lot.

I mean, like they have spent a lot of time and effort preventing frostbite in their soldiers.

Like they have gear specifically so they don't lose their fingers and toes, right?

That they have the ability to do that.

What we now see, as opposed to people in the military getting frostbite, much more often we see

people who are experiencing homelessness, people who are severely mentally ill, people who have various substance use disorders, where like maybe because you're under the influence of a substance, you're not able to make the best decision or you pass out outside or something like that, something that would prohibit you from getting in out of the cold for some reason.

So we definitely have seen that demographic shift, as well as it can always happen in people who engage in extreme outdoor adventures.

I don't know.

Was it a sport?

Triple X, people like that.

Adventure sports.

Adventure sports.

Extreme expenses.

Yeah, I mean, certainly that's always a risk.

If you are not properly suited up for those things,

they love the risk.

They love it.

Protect your fingers, toes, and tip of your nose.

Protect your ears and come in out of the cold.

I guess I'll tell you, like I tell my kids, if they're starting to hurt or go numb, you want to warm those things up and be aware of it in the healthcare profession because this new drug is out.

There's more we could do, and this rapid rewarming, we could maybe save some fingers and toes.

And I sent you a link on this SUV thing.

I think it's got legs.

Folks, I have terrible news.

After I did the best adder eat of my life, I had decided to reset my goals on doing the best podcast episode I've ever done in my life.

And I'll be darned if I didn't just go ahead and do that first time out, first shot.

So now I don't know what I'm going to do.

I'm going to have to think about it because I'm obviously in my prime and there's nowhere to go but down.

Thanks to the taxpayers for the use of their song Medicines is the intro and outro of our program.

And thank you to you for listening.

That's going to do it for us.

Until next time, my name is Justin McElroy.

I'm Sydney McElroy.

As always, don't drill a hole in your head.

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