Handling The Big Chill
by Dr. Mo Lerner

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What do I have in common with Mary Pickford, Jim Carrey, Keanu Reeves, and Paul Schaeffer? I'm a Canadian. Although some of my First Nations friends refer to me affectionately as the Great White Buffalo, even I have agonized over the bitterly cold winter we have experienced this year in the Great White North. Because a larger body usually burns more energy during activity, sweating and heat dissipation are a must.. We get rid of body heat in four ways. If one stands still, some of the heat simply radiates from the body. Sweating is the most efficient means of heat loss by evaporation, and adding a little breeze to the environment increases this effect by convection. If you take the plunge in cool bath you may lose heat quickly by conduction of directly to the water.

While it is true that large people have more insulation and often prefer cooler ambient temperatures, extreme cold can be quite uncomfortable and even dangerous.

Consider what happens when taking a walk in a cool spring rain. If you are wearing cotton clothing (such as jeans) which retain moisture against your skin, you are much more likely to become chilled by virtue of the process of evaporation. Add a brisk wind as well as the fact that you are not wearing a hat, and you can become seriously hypothermic. You can lose up to one third of your body heat through the structures in your head and neck alone because the blood vessels and appendages like ears and noses are so superficial and exposed. The wisdom of generations of grandmothers who advocated wearing something on your head is vindicated.

Winter temperatures mean further danger. In my travels I have noticed an interesting fashion trend especially amongst young people in cold climates. They wear scanty and tight fitting clothing above the waist. It may even be more troublesome for large people who wish to conform to this style but can't find appropriate apparel. I have often seen the disastrous consequences in my work as an ER physician. Frostbitten fingers and ears are more common than people believe. Higher altitudes extend the danger because of lower oxygen levels in the thinner atmosphere where tissues become more easily damaged.

Since walking is one of the best forms of exercise for people of all sizes it makes sense to be properly attired for a stroll in the great outdoors. Wear several layers of loose fitting clothing. Air between the layers acts as efficient insulation and can be removed if a cool morning mist turns to hot weather in the afternoon. In winter, cover your head, hands and especially your ears.

Chiblains
Chiblains, an old English term (chil=cold, blains=sore), is an example of the mildest form of cold damage. The skin swells and becomes reddened as the body's repair system tries to achieve damage control. The end result is a rough, red, dry dermis. It usually resolves uneventfully in warmer months.

Cold Feet
Cold feet are especially a problem in large or diabetic individuals. Trench Foot seems a somewhat archaic term eliciting visions of World War I soldiers with their feet constantly emerged in the cold muddy environs of the trenches. But the present trend of canvass slip-on or high top basketball sneakers as everyday apparel can create the same effect, especially when walking in slush or snow. Feet that are exposed to prolonged conditions of sweat, moisture and cold, especially if immobile for extended periods can produce the same effect. The problem presents in stages. First, feet are cold and pale, In a few days insidious swelling, a hot prickly sensation followed by redness, blisters and pain sets in. Feet remain extremely pain sensitive to repeated cold exposure which serves as the body's warning not to risk any more damage. Treatment involves wearing protective dry clothing and applying soothing moisturizing lotion especially at night.

Frostbite
In the event that you are caught in the extremes of cold for lengthy periods, seek shelter. If parts of your body become numb with cold there are important concepts to consider. Cold makes blood vessels of skin shrink. Cold blood can turn to a sort of sludge which must work its way through shrunken pipes and the combined effect is lack of vital fuel for tissues. In extreme situations cells become crystallized or "freeze dried" (just like in the television commercials describing coffee separating from liquid and impurities into a "finer" instant blend). Eventually the skin can become similar to meat which gets freezer burn in the cooler after prolonged improper exposure. Once in a warmer environment, painful blisters may appear as the body rushes fluid and inflammatory cells to clean up the damage. Later, if the damage is irreparable, skin becomes hard, black and--over several weeks or months--mummified like wood. I once had an indigent patient who cut off his mummified fingers and seemed surprised when he learned that, they would not grow back. Never allow skin to thaw and then refreeze. Contrary to old folklore, rubbing with snow or ice will simply do more damage to already compromised tissue. Treatment involves rapid rewarming in a bath. Don't risk further burn damage to skin by exposure to a hot metal radiant source. If you have a thermometer, the ideal temperature of a bath in these circumstances is approximately 43 degrees Centigrade (about the temperature of a warm cup of coffee). Avoid boiling water. Emersion should cause a brief warm tingly sensation and relief within thirty seconds. It is also useful to add some liquid antiseptic soap. Be gentle with tissues. Avoid rubbing or bumping frostbitten hands or feet against the side of a bath.

Don't break blisters. The fluid in the bleb is a protectant and healing agent. After several minutes in the bath, dry the skin gently and pad with cotton or fluffy towelling. Most importantly, seek medical attention as soon as possible. Several new experimental drugs are being trialed to help restore circulation and avoid permanent damage.

Strange Brew
There is a myth about cold and alcohol propagated by the of image of the faithful St. Bernard dog sporting a barrel of brandy on its collar. Alcohol, drugs, and extreme cold do not mix. Not only does alcohol dilate the skin's blood vessels leading to rapid heat loss, but intoxication leads to impairment of judgement and irrational action in a cold environment.

Motley Crew
Large people can have other problems with cold. A malfunction of the thyroid and/or adrenal glands can cause a slow-down of metabolism leading to weight gain, sluggishness, and a persistent feeling of coldness.

There is also a condition that is demonstrated by intermittent bouts of cold pale fingers and toes called Raynaud's Phenomenon. Often the problem is idiopathic, i.e., no one knows why some get it. The mildest form usually affects young women and is more of a nuisance than a danger. The process is similar to what happens when your arms or legs are bent in such a fashion that not enough blood can get to then and they "go to sleep".

The chemical adrenaline, associated with many processes in our bodies, notoriously causes constriction of blood vessels with decreasing nutrient flow to skin.

The tiny vessels of the fingers and toes go into spasm when something triggers adrenaline in the area. The most common cause is exposure to cold which causes the blood vessels to shrink in order to preserve warm blood for more important deeper structures and other parts of the body. In some people, strong emotion can be the instigating factor.

Those affected may notice a classic sequence; the fingers or toes suddenly become tingly, followed by cool, then pale motley skin because there isn't a lot of blood in the area. Fingers may even become blue since any blood that remains in the area lacks oxygen, attaining the same color as spent blood in your veins.

A more serious situation occurs if the cause is related to actual damage to vessels, such as in previous trauma, hardening of the arteries, or high blood pressure. In these cases the skin gradually becomes thin, shiny and painful.

Treatment involves keeping the hands and feet warm especially when going out, and possibly the use of sedatives if strong emotions cause these symptoms in the first place. Drugs that decrease high blood pressure or that block "adrenaline surges" are sometimes prescribed. In really severe cases the nerves that control the release of adrenaline can be cut. The only problem with this last technique is that the body is too good at adapting, and symptoms often return in a few years.

Panic
If your hands and feet are cold or tingly don't panic--most of the time this is simply due to hyperventilation . This occurs when we get nervous or excited. We usually breathe too fast which causes us to blow off too much carbon dioxide. This, in turn, makes the little blood vessels constrict and the lack of circulation causes local nerves to start tingling. For hyperventilation, lie down, be calm and breathe into a paper bag. This will recycle some of the carbon dioxide so the tingling will stop.

As spring approaches and we venture out into the cool moist air we shouldn't be complacent about cold exposure. Be wise, be well and take care. ß



Heretic Physician