Freer: Wilderness Medicine Not Something You Learn in School | Guest Commentary
Jun 06, 2007
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“Wilderness settles peace on the soul because it needs no help; it is beyond human contrivance. Wilderness is a metaphor for unlimited opportunity.” – E.O. Wilson People ask me all the time – what is it that you do? Exactly, what is wilderness medicine? It is easy to imagine a physician in a jungle caring for a patient with malaria or on top of a mountain caring for a snowblind climber, and that, for sure, is wilderness medicine. But I have also practiced wilderness medicine in the urban street, and I could not rely on much of what I learned in medical school. On the scene of a motor vehicle crash when all resources were overwhelmed, with no skilled help and very little equipment, a couple of jackets, a seatbelt and a scrap of plywood became an immobilization device. This is wilderness medicine as much as a clinic in the depths of the woods; it is the practice of medicine, using a knowledge base (much of which is anecdotal and unscientifically derived), in inopportune and often hazardous surroundings, requiring the art of improvisation….and I haven’t yet begun to really describe the discipline. Over a decade ago, I graduated from emergency medicine residency training in Washington, D.C., and left for my very first job in a small seasonal hospital in Yellowstone National Park. I thought I knew all I needed to know to practice medicine in a remote setting. I had half of it right. I had the proper didactic instruction on injuries and illnesses that arise in the wilderness. I had yet to learn how to create a femoral traction splint out of a couple of tree branches, or how to take care of patients when all resources are overwhelmed, when equipment is either not present or no longer available, when there are no consultants to lean on, when a grizzly bear attacks and the rescuer is worried if he or she is next, when communications are on the fritz, or when lightning is striking near the rescue scene. In short, I had yet to learn how to function when all of my familiar hospital surroundings were gone and I was in the middle of nowhere…with no book to read to tell me what to do next. I am still in the process of being educated; it is a lifelong endeavor. But here is what I’ve learned so far…. A good wilderness medicine physician can come from most any training background, but must possess skills and knowledge in a variety of disciplines: emergency management of illnesses and injuries, pediatrics, anesthesia, orthopedics, obstetrics and gynecology, infectious disease, sports medicine, disaster and military medicine, to name a few. Much of this learning is done in the physician’s “free” time and a dedication to ongoing learning outside the realm of their routine practice is the norm. He or she must be educated about the health risks of specific environments, such as mountain, desert, jungle, marine, aerospace, and subterranean, among others. The influences of the environment on global health issues are within the domain of wilderness medicine curricula, as are environmental health disorders: heat illness, hypothermia, frostbite, altitude illness, barotrauma and submersion injury. A properly prepared wilderness medicine physician should have a working knowledge of health risks from flora (e.g. toxic and injurious plant species) and fauna (e.g. animal bite wounds and zoonoses) and how to prevent illness and injury from contact with both. Recognizing indigenous infectious diseases that may affect travelers to a region is an important piece of a wilderness medicine practice. Expedition and travel medicine are popular subdisciplines in wilderness medicine; understanding how to evaluate, protect, and provide care for a patient traveling to medically underserved areas is an ever-expanding course within the domain of wilderness medicine. A trained wilderness medicine physician may be called on to supervise an emergency response service or search and rescue team in a remote setting. He or she may direct and/or provide medical care for unusual types of injuries sustained in the wilderness (e.g. climbing, dive, avalanche, lightning, and animal attack injuries, to name a few.) What we are told about wilderness medicine is often anecdotal and perhaps unscientific. To that end, members of the medical community interested in research have abundant opportunities to make a real contribution to the knowledge base of wilderness medicine. Wilderness and Environmental Medicine, a peer-reviewed and indexed journal, is in its 15th year of publication, promoting the growth of scientific research on topics relevant to wilderness medicine. Lastly and perhaps most importantly, wilderness medicine physicians are called upon to share their expertise to educate not only their patients, but other physicians, ancillary health care providers, and the lay public on safe and healthy travel in the wilderness. Much of what causes a person to fall ill or become injured in austere environments is preventable with a bit of well-timed and well- informed education. Having spent a great deal of my time over the past years attending conferences sponsored by the Wilderness Medical Society, along with my experience working and living in Yellowstone, I have had the opportunity to learn a great deal. In the spring of 2003 I embarked on an adventurous mission to set up a medical clinic at Mt. Everest base camp (5350m) in Nepal, intent on practicing all that I had learned. I carefully itemized the medical supplies, and carried in the proper medications to treat everything from altitude illness to the infectious diseases we would likely encounter. Splints, a portable hyperbaric chamber, and even a battery-powered oxygen concentrator were among the yak- loads of clinic supplies delivered to our tent in the clouds. I felt prepared for just about anything. Then, in quick succession, the generator malfunctioned and could no longer charge our batteries for oxygen or radios, the foot pedal that inflated the hyperbaric chamber broke, the intravenous fluids froze in the tubing en route to the ill patient, and the injectable medications froze solid. All of this, and as the glacier melted one day, we found the floor of the clinic tent was under water. It would be dishonest of me to say that my feathers weren’t a little ruffled. But adaptability and improvisation are keys to making it in the wilderness. Soon, with some help and a little duct tape (a staple item in the pack of any experienced wilderness medic), I was able to master the wiring of electrical equipment in order to be powered by solar panels, throw a hot water bottle into an insulated cooler to keep medications from freezing, and turn a bystander into an IV fluid warmer by placing the bag inside his down jacket. My Sherpa assistant engineered a diversion run-off stream to drain the growing pond under our clinic. I survived, (as did my patients!) in the shadow of Mt. Everest, for two months in the most austere environment in which I have ever had the opportunity to work. So, what is wilderness medicine? For me, time will tell. I have been practicing in the wilderness for over a decade and I still find myself searching for a concise answer. But there’s nothing concise about it. The real joy is that I plan to continue to look for that answer for the rest of my life. Herein lies the opportunity for anyone who seeks to understand and practice wilderness medicine – to combine your profession with a passion for the unknown and the wild. Luanne Freer, M.D., is an emergency physician and past president of the Wilderness Medical Society. She has lived in and served as medical director for Yellowstone National Park for the past 15 years and serves on the advisory boards for the National Park Service the National Ski Patrol. In 2003 she founded and continues to direct the non-profit Everest Base Camp Medical Clinic for the Himalayan Rescue Association, the subject of two documentaries, including the BBC production, Everest ER.