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Scot: Welcome to the "Who Cares About Men's Health" Sideshow. This is a fun little episode we're excited about. Survival tips, fact or fiction. You've heard these before. Don't eat snow, because if you do, it'll make you more dehydrated. To prevent hypothermia, you've got to get in a sleeping bag with somebody else naked. And then this is a good one. After an avalanche, what you should do if you get covered by snow is spit so you know which way to dig to escape. We're going to find out if those are true or not.

My name is Scot Singpiel. On "Who Cares About Men's Health," I bring the BS to the show. And the MD to my BS is Dr. Troy Madsen.

Troy: Hey, Scot. I am so excited for this because I've heard these myths and I want answers.

Scot: And Producer Mitch is in the mix.

Mitch: Hey. I also want to know if I should butter my burns at some point. That's what I keep hearing.

Scot: Oh, okay. Well, our guest, Graham BZ. Is that your last name? BZ? That's what we're calling you.

Dr. BZ: My last name is Brant-Zawadzki, but it's long and terrible, so BZ is much more . . .

Scot: Yeah, it's cool.

Troy: I have to say this, too. Scot has this fear, like this deep fear of mispronouncing people's last names. I was so excited for him to pronounce your last name. And then he just totally glossed over it. So I'm disappointed.

Scot: Well, I didn't even know what it was. Even his email says Graham BZ, so I didn't know what his last name was. I thought, "I don't know." So here we are.

Troy: Made it too easy for you, Scot.

Scot: Anyway, he is an interesting doctor that practices mountain medicine, and that's actually a thing. What exactly is mountain medicine?

Dr. BZ: So mountain medicine is a subset under wilderness medicine, which is a larger umbrella term, and it all refers to medicine in an austere environment. I'm part of the Wilderness Medical Society, and you'd be surprised how hard it is to come up with a good definition for what wilderness medicine really is. But it's basically when we're providing medical care beyond the scope of your typical medical system and infrastructure.

Scot: All right. And I actually went to the WMS, the Wilderness Medical Society website, because I was trying to figure out exactly what it was you did. They have a definition there. "Wilderness medicine, also known as expedition medicine, is a practice of medicine where definitive care is more than one hour away and often days to weeks away. Defined by difficult patient access, limited equipment, environmental extremes. Decision-making, creative thinking, and improvising are required." So does that sound fair?

Dr. BZ: That is fair. I will tell you that I'm part of a committee to currently update that definition. But I think that that pretty much sums it up adequately for now.

Mitch: Graham, when it comes to expedition medicine, all these cool terms, what's some of the cool stuff that you get to do?

Dr. BZ: I think the best teaching case or one of the most influential cases for me was actually we were training some Peruvian mountain guides down in Peru. It's kind of a train-the-trainer model where we go and train the mountain guys and then they go on and train these other folks within their own country.

And the course that I went to, we basically hike into the base of this 18,000-foot peak, and the base camp is at about 15,000, so it's pretty high altitude. And some of these folks flew straight up from Lima, which is sea level, into Cusco and didn't really take the proper precautions in terms of acclimatizing before coming up.

And so one of our cohorts developed pretty severe HAPE, which is high altitude acute pulmonary edema, and required more than just oxygen. So we actually had to deploy what's called a Gamow bag, which is a positive-pressure, kind of an inflatable, almost like a sleeping bag that you kind of crawl into and then pressurize.

We learn about that a lot as students, especially in wilderness medicine, but what we don't learn about is just how much effort it takes to maintain pressure in this bag. Basically, think about using a bike pump, or even a foot pump. You can use both. And you're continuously pumping nonstop for hours to maintain this pressure.

Scot: To keep a person alive?

Dr. BZ: To keep a person alive and to keep this person . . .

Scot: Wow.

Dr. BZ: Yeah. To keep their oxygen saturation up, you're just continuously pumping and pressurizing this bag. And the idea is that you do that to temporize them to a helicopter evacuation, or at least just improve them enough so that they can then get down on their own.

So for about four hours at 2:00 in the morning, we're all just sitting there pumping and keeping this bag pressurized so this person could oxygenate themselves and improve a bit enough to get walked out.

The whole experience was definitely a humbling one. And then trying to get this poor person hiked out to . . . I think it was about a four- or five-mile hike down to where we could actually access a vehicle and then get him out from there.

Scot: And all of that happened because this individual went from sea level to 15,000 feet too fast without actually taking intermediate steps to get their body used to it.

Dr. BZ: Exactly.

Scot: Wow. And how long would that normally take to get used to something like that?

Dr. BZ: So there are different . . . It kind of depends on your strategy. There are different strategies for acclimatization. For the course we were doing, we would recommend up to two weeks to really properly acclimatize. I think taking up to four to six days for that level of transition is kind of the minimum that you'd recommend.

Scot: All right. Let's get to it. Let's get to these myths here, these questions. We're going to throw these out here and I thought maybe we could all just kind of play along. Now, I don't know, Troy, if you know some of these answers since you've got the MD here. Don't participate. But Mitch . . .

Troy: I don't. That's why I want to know the answers. Yeah, these are questions we've talked about and I've heard these, and some of these, I'm really curious.

Scot: All right. So the first one, don't eat snow if you're out in the wilderness and you don't have any water because it'll actually make you more dehydrated. So this is one of those situations maybe you're out, it's wintertime, you've run out of water, you're not near a water source, you're not near your car, and you need to survive. Should you eat snow or not? This says you should not. I think that sounds silly. That's my take. Mitch, what do you think?

Mitch: I guess I don't understand how it would make you more dehydrated. For me, that's the thing. It's water. It's just super cold water, right? What on earth is in the snow that's going to make you more dehydrated?

It's like when coconut water came out. Does anyone remember when the coconut water craze was going? I was doing some volunteer work up at Sundance, and the lady I was working with, she's like, "Oh, coconut water hydrates you better than water." And I'm like, "That doesn't make any sense." So on the flip side, we now have snow and I'm like, "How does it dehydrate you if it's water?"

Troy: Well, this is what I've heard, though, Mitch. The rationale is that the water content of snow is so low, especially here in Utah where it's super dry, that it takes more effort and uses more energy to produce than water, just like putting snow in your mouth, than it really produces water. So that's the rationale I've heard. I don't know if that's true, but that's what I've heard.

Scot: All right. We heard Graham chuckling a couple of times, so we'll see if that's his tell or not. Is that true? True or not?

Troy: Yeah, what's the word?

Dr. BZ: I don't think anyone has ever looked at drinking snow in the Sierras versus Utah and wondered if they're . . .

Mitch: "Is it dryer?"

Dr. BZ: Yeah, exactly. But I think Troy is pretty spot on. So the problem with . . . Snow is mostly air, especially again here in Utah. So you'd need to eat about, I think, 8 to 10 quarts of snow to meet the same amount of just liquid water.

Again, it's much colder the body temperature, so every time you're putting that snow in your mouth, your body is spending energy to melt that snow so that you can drink it, and that burns calories. In the end, it does consume more total body volume water than you actually are receiving for it. So point to Troy. That is right.

Troy: So this is true. I'm going to say I can't take credit for this because I never would've believed it, and then I saw it in a Sundance film. And in this Sundance film, these guys were lost out in the snow, and one guy said to the other guy . . . This guy was super dehydrated. He was like, "You can't eat the snow. It's going to make you more dehydrated. It just takes up too much energy. You can't do it." And I was like, "That's stupid."

Then I thought about it more and I was like, "Maybe it makes sense." It's true. You just don't get a lot of water out of snow. The water content is really low.

Scot: And to make the connection, burning energy requires, in that chemical process, water is what we're saying, right? That's why it uses more water.

Dr. BZ: Correct. That's exactly right.

Scot: Okay. Yeah. Got to go back to my cellular biology class that I never took. So what should you do instead?

Dr. BZ: So what you want to do is you want to find another way to melt the snow that's not using your own body's energy. So if you can heat the snow up in any way, even just leaving it in the sun in a spot where it can be melted, then you can drink the liquid melted snow and that's going to be the best way you can hydrate.

Troy: I'm going to ask this because I know Scot is thinking it. What if you had a container and you filled it with snow and then you peed on the snow?

Scot: What?

Mitch: What?

Troy: And then the warmth from the urine . . . You're going to have some urine in there. Is that just going to be useless? Is it going to be just too . . .

Scot: You pee on the container if you've got the container, and then hopefully the heat transmits.

Troy: I don't know. Do you think it would?

Dr. BZ: That is an excellent question. So it would depend on how dehydrated your urine was to begin with, I think, because dilute urine is . . . You're still going to be able to pull . . . We always get asked this. "Can you drink your urine if you're dehydrated?" And the answer is if you're coming from a hydrated status . . . Well, an answer, I should say. If you're hydrated, you can kind of drink your urine over a couple of cycles before it really starts ruining your kidneys and other things as you're getting more and more distillate.

So if you're pretty hydrated to begin with, that's already urine that you've heated up and you've used those calories already. You might as well put it in the snow and dilute that urine a bit. And if you're in dire straits, I think that's an ingenious way to potentially temporarily hydrate yourself.

Troy: So maybe it would work then.

Dr. BZ: Yeah, I'd say.

Troy: It's better than drinking your urine, it sounds like. At least if you have a big old thing of snow and you can pee in it or . . . I don't know. Again, hypothetical here. I'm not recommending it.

Dr. BZ: I think last resort Hail Mary kind of stuff.

Troy: Yeah, don't do this every time you're out skiing.

Scot: Try to use the sun's energy first, I think, would be a good . . .

Dr. BZ: I was going to say, if you're going to use a container to try to melt snow, you want the back half of that container to be . . . Use dark clothing or something that's reflective so that that energy isn't just passing through the snow. You're kind of trapping heat energy in that container as well.

Scot: Oh, okay. Yeah, that makes sense.

Troy: Kind of dark container or something there. Okay. That makes sense. Yeah.

Scot: All right. Myth number two. To prevent hypothermia, you need to get the person who has hypothermia naked into a sleeping bag, and that body temperature helps warm them up, as opposed to just getting in clothed because you wouldn't be transmitting enough heat. So the question is, is that just a clever pickup line, or is that a legitimate survival strategy, Graham?

Dr. BZ: I don't want to discourage anyone from crawling into a sleeping bag naked with another person, if that's what seems like the right thing to do. But it will help. It'll definitely help warm someone up faster than just putting them in a sleeping bag and clothes by themselves because you're going to help transmit . . . Again, you're going to help heat that sleeping bag and help raise the temperature of that environment faster. So getting into that sleeping bag with that person will definitely help.

The reason we say get in naked is because the way a sleeping bag works is it radiates heat back at you. And if you're wearing a lot of clothes together, then you're kind of trapping heat under your clothes and it's not radiating to that person as effectively.

So technically, yes, that would be the fastest way to warm someone up. Do you need to do that? Probably not. There are, again, other ways to do it. I think putting someone in a sleeping bag with a heated bottle of water or another heat source can act in the same way.

Really, the best thing to do to warm someone up if they're not comatose, if they're still awake and alert, is to use their own body's thermodynamics. So get them active. Get them doing jumping jacks. Get them moving. If they are in the sleeping bag, have them moving up and down and doing kind of snow angels in that sleeping bag as much as possible to help burn calories as well from the inside.

So I hate to say it, but if you're going to be in a sleeping bag with someone, you also want to be active in that sleeping bag.

Troy: There's just so much more to this. This is one of the things I heard too. This is one they teach in Boy Scouts. It's like, "If this ever happens, you have to . . ." It's just like, "Huh, okay."

But it sounds like there are other alternatives and maybe better alternatives, like you said, like a heated water bottle or something like that to really get the job done. But it sounds like it makes sense if you're in that situation and you have to do it.

Dr. BZ: And again, totally naked is probably a bit dramatic. You don't want to be both in a sleeping bag but also covered in all your winter gear. If you're in long johns and underwear, that will be equally as effective.

Scot: All right. Question number three. After an avalanche, if you get trapped in an avalanche, in order to know which way to dig to escape, you should spit because then the spit is going to go down, because that's what gravity does. It pulls things down. Mitch, what do you think? Yes or no?

Mitch: When we were doing our pre-production, it was the first time I've ever heard of this. And I guess I never would have thought to . . . I guess you would get all turned around, but spitting is the last thing I would think of doing to try to figure out which way was up or down. I guess that's my first question. When trapped in an avalanche, do you get tossed around enough that you don't know which way to dig?

Scot: Yeah, hold on that answer, Graham. Let's go to Troy.

Troy: This is one I have heard for years. I don't know if it's also one of those things people just say, but it does make sense. If you're tossed around in an avalanche, you may not know which way is up. And I've heard that if you want to know which way is up, spit, because then if the spit just falls back on your face, you know your face is facing up, and if it falls to one side, you know the other way is up. If it falls straight down, you know that up is back behind your head.

Obviously, there are certain logistical issues if you are trapped in an avalanche, so that's probably the bigger question. But I'm curious, Graham. Is this something you've heard or something you've ever recommended?

Dr. BZ: So I think the bigger question . . . The first question is, can you get tumbled around enough to not know which way is up or down? I've never been in an avalanche, but talking to those who have, the answer is absolutely yes. I mean, if you've ever been just even in a whiteout, you can kind of get vertigo and lose your sense of your body in space. So you can definitely be disoriented like that.

The bigger question is what can you actually do about it. So we talked a bit about how snow is roughly one-tenth the density of water. And that, again, varies by the type of snow and where you are and how dry it is, etc.

But when you think about an avalanche . . . So snow just sitting on the ground is maybe, let's say, one-tenth the density of water. Once that avalanche is set off and all that snow is sliding down the hill and then sets at the bottom, all that snow is now compacted and the density has increased. It's at least doubled. There are some studies that show that it can go significantly more than that. And so that snow is no longer that nice, fluffy Utah powder we like to play in. That is now basically, for all intents and purposes, concrete.

And so even if you knew which way was up or down, the ability to dig yourself out is more or less impossible. Just being under a foot of cubic snow can translate into hundreds of pounds that are on your body.

And so I think a better way to know which way to dig out is if you can move any part of your body, it's probably under the least amount of snow. Or if it's even sticking out of the snow, that's the direction you'd want to go if you can move anything.

But what unfortunately kills a lot of avalanche victims, even those that are only partially buried, meaning that a part of their body is still sticking out of the snow or just very shallow, a shallow burial, is even in a shallow burial, people just can't dig themselves out. They don't have the ability.

Troy: That's an interesting thing too. Graham, I think we often have this image that people get covered in avalanches and they get tossed around and hit trees and rocks and they die from that. I think you kind of alluded to it a little bit there. What percent of people actually die from that versus just die because they're stuck there and they just can't get out?

Dr. BZ: Yeah, that's a great question, Troy. We looked at this locally here in Utah. And what happens is we actually compare a lot of our avalanche data in the U.S. and North America to European data and we see a stark difference in the rates of trauma for that exact reason.

A lot of avalanches in backcountry terrain and the Alps and other parts of Europe happen well above treeline, and so there are a lot fewer obstacles to strike, such as trees, boulders, things like that. And so we see a lot more deaths that are due to purely asphyxiation from suffocation under the snow versus patients here in the U.S. where maybe the rescuers get to them in time but they've suffered severe traumatic injuries, which have led to their decline.

So it's a great question. We see a much higher incidence of trauma with avalanche here in North America than in some other parts of the world.

Troy: Interesting. It sounds like, bottom line, you can spit if you want to spit. Maybe that will let you know which way is up. But it sounds like the more . . .

Scot: Just end up having a wet face.

Troy: Going to have a wet face. Yeah, it's probably not going to help a whole lot. But yeah, I like what you said there about if there's a body part that moves, it's probably by the surface or it's not covered, and if you can move any direction, that's the direction you want to go.

Dr. BZ: Exactly. If you are in that phase where maybe the slide is slowing but hasn't fully set up yet and you can still move any part of your body . . . You've probably heard of this idea of swimming with the avalanche, and that actually has a lot of credence.

We know that larger particles float to the top. If you think of an avalanche, it's kind of laminar flow of particles.

So the same way we call it the Brazil nut effect, that in a bag of nuts the bigger nuts always float to the top, or in granola, the bigger clumps are always at the top. And by the time you're at the end of the bag, it's all the crumbs at the bottom.

The same thing happens in an avalanche. So you want to make yourself as big as possible and you want to try to push all those particles, as many as you can, below you so you can float on top. So if you can do that to stay shallow in the pack, that's great.

And then another thing to do is, as a last resort, try to make as much space around your head to make a pocket of air that you can use to survive longer than you might otherwise.

So one of the things we look for in avalanche rescue to determine if a patient has a better chance of survival is if they have an air pocket around their face or if there's any snow impacted in their mouth. Because if there's snow in the mouth, or what we call an ice mask, where the snow in front of the face is kind of melted and then refrozen and sealed off, then that patient has a lot lower chance of survival because they've had less air to breathe while waiting for rescue.

Troy: So it sounds like just keep moving if you can move.

Dr. BZ: Yeah. Move as much as you can, as long as you can.

Troy: As long as you can, yeah. Hopefully, none of us are ever in that situation.

Scot: It sounds terrifying.

Troy: Absolutely horrible. Yeah, it just sounds awful.

Dr. BZ: I will say that the more I've learned about avalanche safety and snow science, I thought I would be able to use that to go further in the backcountry and do cooler things, and it's had the exact opposite effect. I'm much more conservative than I ever was before I recognized the danger.

Scot: Now that you know.

Troy: I can imagine.

Scot: The danger is more than what the average layperson realizes, then, is what I'm getting from you.

Dr. BZ: Yeah. I think we've made a lot of strides in avalanche science and snow safety, and we have these decision rules people use and what we call obvious clues where people look at terrain features and try to determine what the risk of an avalanche is. And those are all fantastic things.

But I think they also sometimes give people a false sense of security in terms of thinking that they can't be in an avalanche if those rules say that it's safe, but the opposite is true. An avalanche can happen anywhere at any time. I think a lot of us get very lucky when we're recreating in the backcountry, and we think that translates into good choices when it's just the luck that nature provided us that day.

Scot: Graham, thank you so much for coming on the show and using some of your mountain medicine experience to talk us through these rumors, and some good tips there too for any of our listeners that might happen to like to go out and recreate in the backcountry. We sure appreciate you being on the show. Thanks for listening and thanks for caring about men's health.

Dr. BZ: Thank you so much. Thanks for having me.

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