What
is Wilderness Medicine (Continued)
Relation
to other fields of medicine. Compared to competitive
sports that are held in readily accessible places, wilderness
or remote area activities—such as hiking, climbing,
backcountry skiing, whitewater boating, and hunting—are
generally individual or small group activities, more cooperative
than competitive, but they attract large numbers of participants,
require high levels of fitness and training, and entail
high risk for medical problems. The wilderness sojourner
is usually a highly conditioned athlete. But, the beauty
of the wilderness often lures people in beyond their abilities.
These problems and patient management in the wilderness
have been the concern of medical organizations, such as
the WMS and the National Association for Search and Rescue
(NASAR) and of outdoors organizations, such as Boy Scouts
of America and National Outdoor Leadership School. However,
the major responsibility for managing medical problems has
remained with the participants themselves, backed up by
local search and rescue teams. Recently more competitive
sports are moving off-road, into the backcountry, prompted
by expanding interest in endurance events and the challenge
of rugged terrain. Ultra-marathon runs, mountain bike races,
nordic ski races, and dog-sled races are traversing remote
off-road courses of 100 miles or more during events that
last 24 hours or more. This will increase appreciation for
wilderness medicine; from one perspective, wilderness medicine
may be seen as sports medicine in remote areas.
Wilderness medicine not only overlaps with sports medicine,
but also with emergency medicine, military and occupational
medicine. The physiology of heat illness is the same regardless
of whether it occurs in a foot race or football game, during
a military operation in the desert or jungle, fighting a
fire in the city or forest, or working in a steel mill.
In each instance, management must include initial field
measures, evacuation and transport with transfer to a higher
level of care. It also overlaps with disaster medicine,
where medicine is often practiced in the field, perhaps
under harsh conditions, with minimal supplies and prolonged
evacuation times.
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What
defines wilderness?
While wilderness medicine can be broadly described by its
interests, it is much harder to precisely define, primarily
because wilderness is an elusive concept. The popular concept
of wilderness describes a utopian place of beauty and serenity.
However, the reality is that it can change quickly to a
severe, impersonal and unforgiving environment that can
overpower and destroy. The boundaries of wilderness are
often indistinct. As towns and cities expand, communities
designed for luxury and comfort border rugged undeveloped
mountain and desert areas. Coastal and bayside developments
place dense populations next to a water wilderness. Campgrounds
filled with trailers look more like suburbs. Disasters may
create a wilderness in the midst of a city by destroying
transportation, communication, and health care facilities.
Wilderness emergency techniques are often needed for urban
emergency response. High rise evacuations may utilize rope
rappelling. Fires in wooded suburbs require wildland fire
suppression and survival techniques.
Some define wilderness as isolation from people, yet adventure
travelers to remote areas of the world are usually surrounded
by indigenous people, although farther from transportation,
communication, and medical care than anywhere in our domestic
"wilderness" areas. Another perspective would
be to define wilderness as the lack of medical care. This
would include travel to underdeveloped yet highly populated
areas of the world, disasters that destroy infrastructure
in highly developed areas, as well as our protected roadless
areas.
Medical aspects of wilderness medicine
The medical dimension of wilderness medicine is easier to
define but very broad, including components of physiology,
clinical medicine, preventive medicine, public health, international,
and global health.
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Environmental
physiology is a primary area of study. The entire
spectrum of environmental stress is included: heat, cold,
hypo- and hyperbaria, and altitude. These stresses are investigated
from the perspective of their effect on health, exercise,
work, illness, and injury victims. Exercise capacity is
markedly altered in heat or at altitude, however the body
undergoes unique adaptations to these stresses, known as
acclimatization, to allow functioning in these conditions.
In wilderness medicine the stakes of ignoring the complex
interaction between environmental physiology, exercise physiology
and clinical pathophysiology are higher than winning or
losing a race; they are illness and death. For example,
a human living at sea level, taken in a balloon to an altitude
of 29,000 feet will become unconscious from lack of oxygen
at this high elevation. However, with acclimatization, mountaineers
have climbed to this elevation, without supplemental oxygen,
to stand on top of Mount Everest. This adaptation is not
absolute: even a young fit, acclimatized person may become
seriously ill from environmental stress. Ascending too rapidly
at even moderate altitudes may cause a syndrome of acute
mountain sickness that may progress to life-threatening
problems.
It is also important for medical professionals to understand
the effects of environmental stress on normal physiology
and preexisting illness to advise patients of their risk
in performing wilderness activities. Looking beyond the
risk of persons with heart disease who begin an exercise
program, can a person with known coronary artery bypass,
who exercises moderately at sea level, safely hike or ski
at 10,000 feet, or trek to 18,000 feet? What are the medical
contraindications to scuba diving, which must take into
consideration the hyperbaric environment and the unforgiving
oxygen dependency in this alien environment? Which wilderness
pursuits are safe in pregnancy? Which medications effect
tolerance to environmental and exertional stress?
Environmental hazards.
The clinical interests of wilderness medicine
include other environmental hazards that abound in wild
places—many are found as frequently in populated areas.
Some are common encounters, for example, venomous bites
and stings (from honeybees to jellyfish to rattlesnakes),
poisonous or irritating plants (from poisonous mushrooms
to poison ivy and oak), animal attacks (from dog bites to
bears), and ultraviolet exposure (sunburn to snow-blindness).
Other hazards are cataclysmic, for example, lightening strike
and avalanche. Yet others, microbial hazards, are unseen
but potentially devastating. Infectious diseases commonly
transmitted through outdoor activities or foreign travel
may occur from exposure to insects, animals, or the environment.
Examples include Giardia, Lyme disease, rabies, leptospirosis,
malaria, and many more "exotic" diseases. While
these may be rare in North American cities, only a few are
limited to wilderness areas.
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Each
geographic region or ecosystem has a unique combination
of environmental stress and hazards. Wilderness medicine
takes a comprehensive view to help prepare people for travel
or work in a particular area, such as mountains, desert,
jungle, caves, whitewater, and open water. Our newest wilderness
frontier, outer space, offers an opportunity to apply known
concepts of wilderness medicine with new environmental and
physiologic challenges.
Clinical medicine. Clinical
issues in wilderness medicine include not only knowledge
of hazards listed above, but planning and delivery of health
care in harsh or remote environments. This incorporates
some of the most unique aspects of wilderness medicine.
Expedition medicine is the most obvious example. Equipment
and supplies are severely limited by space, weight, and
by consideration of what can be used in the field. Furthermore,
equipment is limited by reasonable expectations of what
can be accomplished in the field. Treating patients in the
wilderness demands special consideration of environmental
factors. The patient and the health providers must be protected
from environmental extremes and hazards. "Return-to-play"
considerations are magnified in the wilderness where the
decision is whether to allow someone who has suffered an
injury or illness to continue on a trip or to initiate a
lengthy and disruptive evacuation.
Search and rescue are
essential components of wilderness medicine. Heroism must
be tempered by reality and the need to avoid creating more
victims. Helicopters are frequently overrated in their ability
to fly in any conditions, and, thus, dangerously overused.
Search and rescue involves coordination and close interaction
between emergency medical technicians (EMTs and paramedics),
guides, and those with technical skills such as climbers,
pilots, and physicians. Evacuation may take extended periods
of time (hours to days), during which clinical problems
must be actively managed, not merely stabilized as in urban
protocols. This reliance on paramedical and non-medical
personnel creates interesting problems in training and medical
control. As a result, Wilderness EMT programs have developed
with new treatment protocols that allow more advanced intervention
than urban protocols designed for short transport times.
These proposed treatment standards can also be useful in
remote rural areas that experience longer transport times.
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The
clinical interests of wilderness medicine extend beyond
wilderness environments. Ironically, some environmental
problems are seen much more commonly in urban areas, (hypothermia
and heat illness) or in suburbs (submersion and lightening
strike) than in wilderness areas. Urban and university medical
centers may be evacuation, referral, and research centers
that see serious environmental problems occur in outlying
areas.
Preventive medicine.
Although providing care in the wilderness is an exciting
concept, wilderness medicine should primarily be preventive
medicine. It is much easier to prevent these problems than
to treat them in remote areas. Observing basic safety rules
of alpine or desert travel and understanding environmental
stresses would prevent many wilderness injuries and avoid
survival situations.
How do people get in trouble in the wilderness? Sometimes
it is an unexpected random event like an avalanche or an
animal attack or a sudden injury. But even these can usually
be prevented with knowledge, conditioning, skills, and a
cautious approach. More often, a combination of errors or
misjudgments cause problems: getting lost when venturing
into the wilderness and failing to carry basic gear; continuing
to travel in a storm despite fatigue and cold rather than
stopping to secure shelter, warmth, and food while still
capable of functioning; allowing oneself to become dehydrated,
metabolically exhausted, and ill from rapid altitude gain,
which then causes an accident.
Preventive medicine requires epidemiologic research to determine
the common causes of problems, then a focused educational
program to provide the knowledge needed to avoid the problems.
Simple facts like the need for ventilation of cooking stoves
would prevent carbon monoxide deaths that occur from cooking
in tents during a storm. Popular, but fallacious remedies
that find their way into public literature, such as treating
snake envenomation with electric shock, must be scientifically
evaluated and debunked. But those most in need of education
are usually the ones who will not read or listen. The most
effective programs are likely to be guided wilderness experiences
for youths and adults with a focus on safety.
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A
most difficult task is to prepare someone mentally for a
stressful and threatening wilderness experience. Given the
inherent isolation of wilderness and the risk of becoming
lost or being stranded by severe weather, medical problems
are often inseparable from survival problems. The ability
to successfully manage unexpected adversity may be an innate
individual characteristic or one that can be developed by
repeated experiences in the wilds. The psychology of wilderness
survival is fascinating, because accounts abound of individuals
similar in all measurable ways who face the same survival
challenge, yet one survives and the other dies. Perhaps
it is analogous to sports psychology; those willing to push
themselves through pain may fit a profile, yet in groups
with identical measurable physical characteristics and training,
one will be the winner.
Medicolegal issues.
Unfortunately, wilderness medicine cannot escape the medicolegal
concerns that plague medical practice. Our society is moving
away from the concept of self-responsibility and self-reliance
to the belief that any misfortune can be blamed on someone
else and that it is the responsibility of some agency to
rescue any individual in trouble. As a result, our parks
are being plastered with signs at every turn warning visitors
of obvious dangers. Wilderness travelers ignore these warnings
or knowingly venture into a storm, yet fully expect to be
rescued at great public expense and risk to the rescuers.
Those injured or killed seek compensation from the land
management agency or from the group that organized the trip,
even if the adverse event was a known risk yet unforeseeable
event.
Whereas "Good Samaritan" rules apply to health
professionals rendering aid on chance encounter, they do
not apply to health professionals who are designated as
trip medical officer, and the medical limitations imposed
by the wilderness environment are not appreciated by trip
members. Medical malpractice insurance coverage for expeditions
or wilderness trips is not available to most physicians,
so given the constant threat of malpractice lawsuits from
trip participants or their families, most doctors now choose
not to be a trip physician. Ironically, this leaves many
remote group ventures without any medical care. Manufacturers
of sporting safety gear, such as climbing equipment, face
such high liability insurance premiums that some have stopped
manufacturing the products.
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Public
health. There are public health considerations
in wilderness medicine. The wilderness has long been extolled
for its benefits to body and soul. Wilderness can offer
an appreciation of the vastness and power behind the universe
that creates a spiritual perception for many. Wilderness
experiences can be an invaluable educational and maturational
tool, especially for young people. Experiences such as whitewater
boating and summiting a mountain are exhilarating. Besides,
the demand for each individual to travel under his/her own
power, to face the changing elements, and to be creative
in managing daily tasks creates physical and mental strength.
Group experiences can create tight bonds among participants
and be an ideal setting for studying issues of group dynamics
and leadership.
Policy issues. Where
public health and strong feelings are involved, policy issues
arise. Given the important benefits of wilderness, it should
be made more accessible to physically challenged persons.
This does not mean paving roads into the wilderness, although
it may mean some wheelchair accessible paths. Primarily
it means programs that encourage and help handicapped persons
experience the wilderness on its own terms.
The lack of judgment and personal responsibility of wilderness
travelers with the resultant cost of rescue has led to the
proposal of no-rescue zones. Certain wilderness areas would
be posted with advisories that travelers enter at their
own risk, helicopters (and possibly search teams) will not
enter. Given the current legal climate in the U.S., this
concept is unlikely to win support. However, in certain
high-risk areas, wilderness travelers may be asked to post
a bond to cover the costs of rescue.
Environmentalism and global health.
An environment so attractive is ripe for exploitation. Through
advertising, products such as tobacco, alcohol, and automobiles
try to link their products with wilderness activities. This
abuse of image is perhaps not as important as the depredation
of the environment itself. Although environmentalism is
not the primary focus of wilderness medicine, it must be
a concern to all medical fields. Medicine is affected by
the loss of rain forest that destroys species before they
can be tested for, their medicinal value. Concurrent loss
of indigenous cultures means that there will be no traditional
healers to identify plants that have been used empirically
for centuries. Medicine should be concerned with the potential
increase in skin cancer from decreasing ozone protection,
and with the poisoning of air, water, and soil with chemical
and radioactive toxins.
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International
health. International health is another global
concern of wilderness medicine. Practicing medicine in underdeveloped
areas shares many similarities to providing care in the
wilderness, including limited supplies and diagnostic capabilities,
the need to improvise, and knowing what can reasonably be
accomplished. Unfortunately, medical practice in many parts
of the world (many of the same areas that are popular among
wilderness adventure travelers) involves diseases of poor
sanitation, crowded living conditions, and inadequate nutrition,
with care compromised by minimal medical resources. Even
in a scientific forum, discussion of these maladies will
inevitably include political connotations. If nothing else,
health issues in other parts of the world give practitioners
from developed countries a perspective on their own health
care system and health problems, many of which result from
luxury and surfeit rather than hardship and scarcity. Ironically,
in a vicious cycle, the same socioeconomic conditions that
threaten health of the locals, threaten the existence of
the "wilderness" that we seek when traveling to
these areas. Population and economic pressures result in
encroachment into wild areas and environmental depredation
of the water and air. Pollution causes further health risks,
limited not only to the locals, but to all of us on this
ever shrinking planet.
International travel to remote areas is now very popular.
Although remote by standards of communication, transportation
and health care, the areas are home to indigenous peoples.
The health of local peoples directly affects traveler's
health. Endemic infections such as malaria and enteric illness
are passed by mosquitos or contaminated food and water to
outside travelers.
Unique Aspects of Wilderness Medicine.
Aside from its focus on medical problems and practice in
remote environments, there are several things that make
wilderness medicine a unique discipline. It is an inclusive
field that incorporates not only primary care providers,
but every other medical specialty—from dermatologists
to trauma surgeons to infectious disease specialists. Its
also incorporates rescue personnel and wilderness guides
who usually must provide the first line of medical care
and have the best opportunity to educate the public in wilderness
safety. Wilderness medicine is also unique in its dependence
on clinical judgment. Even the most basic diagnostic equipment,
such as a blood pressure cuff, is not likely to be available
in the wilderness. Finally, wilderness medicine is unique
in its reliance on improvisation. One must utilize whatever
supplies or materials are available; it is impossible to
have optimal equipment to manage all situations. Non-medical
equipment must often be used for splints, airway control,
or other medical purposes. Any medical equipment and medications
carried should have multiple uses to be efficient.
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Development
of Wilderness Medicine: Wilderness Medical Society.
Should wilderness medicine evolve as its own field, even
though few, if any, will actually practice exclusively within
the field? Given the breadth and depth of wilderness medicine,
how should the field be developed and promoted to benefit
both health professionals and the public? Consideration
of these questions led to the formation of the Wilderness
Medical Society.
The founders of the WMS noted that none in the medical community
was looking comprehensively at solutions to medical problems
in remote areas. Knowledge of environmental physiology and
illness was scattered throughout the medical literature.
Little was being taught in medical schools or postgraduate
training programs concerning care outside the hospital.
Individuals and organizations that lead groups into the
wilderness each found their own medical advisors and developed
their own level of preparedness, but had nowhere to get
expert consensus advice. The public is at the whim of lay
writers that do not always check their information carefully,
promoting dramatic but ineffective remedies and inaccurate
information.
Their response was an organization based on the following:
"The mission of the WMS is to encourage, foster, support
and conduct activities or programs that may improve the
knowledge and well-being of its membership and the general
public in matters related to wilderness medicine. The purpose
of the Society is to establish an organization composed
of qualified physicians, allied specialists, and other qualified
individuals that will concern itself with matters related
to wilderness medicine and the benefits, health, safety,
and care of individuals in the wilderness."
So, with a mission primarily focused on education and research,
the WMS has undertaken the following tasks: 1) to assemble,
collate, analyze, and interpret information from dispersed
sources; 2) to act as a clearinghouse for information; 3)
to act as a referral resource for information and experience;
4) to help develop rational programs and solutions for care
in the wilderness; 5) to help debate issues in wilderness
use and medical rescue; and 6) promote association and networking
of like-minded colleagues.
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To
accomplish these, the WMS has developed programs in the
following areas:
1) Education. This effort has primarily focused on
health professionals, with the idea that they would, in
turn, educate the public through their involvement in various
aspects of wilderness medicine. Professional conferences
form the foundation of the educational effort. However,
direct public education now is being approached through
public seminars. Publications include an educational quarterly
newsletter, Wilderness Medicine Letter, and a peer-reviewed
quarterly medical journal Wilderness Medicine & Environmental
Medicine, that attempt to concentrate wilderness medicine
information and research. A bibliography of wilderness medicine
is maintained as a reference source. Educational presentations
(available in PowerPoint® or in slide format) on topics
in wilderness medicine were developed as a teaching aid
for lectures to professional and public groups, and medical
school and postgraduate training programs.
2) Expert Referral. A databank of members’ expertise
is maintained to use for referral when media need accurate
information or expert commentary on issues involving wilderness
medicine. This also will serve as a physician referral network
for up-to-date information to help with patient-care problems
and a speaker's bureau.
3) Standards. Wilderness Medical Society Practice
Guidelines for Wilderness Emergency Care, 2nd edition (Guilford,
CT: The Globe Pequot Press; 2000) addresses controversial
clinical issues to aid hospital and pre-hospital practitioners
with problems that have elicited more opinion than fact.
4) Research. The WMS offers several seed-money research
grants, mostly for medical students and graduate students
in health or biologic sciences with the intent of stimulating
interest through research early in their careers. Eventually,
identifying outside sources of funding will allow an expanded
research program.
5) Policy and Environmentalism. Although difficult
for a small society to undertake because of the financial
requirements, policy issues should at least be debated so
that intelligent opinions can be devised, allowing members
to work through their own contacts and organizations. It
was difficult for the WMS to limit consideration to individuals
in the wilderness without the broader perspective of how
the health of human beings and the health of the wilderness
may be inextricably linked; environmental health issues
are a natural starting point to approach policy. Thus an
Environmental Council was formed to investigate health effects
of environmental degradation and devise educational strategies
to influence other health professionals and, where possible,
public agencies or officials.
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The
health professionals and other leaders in wilderness travel
who are involved in the Wilderness Medical Society are a
very dynamic and engaging group. Each contributes his/her
own special expertise and interests to the field, as well
as the enthusiasm and energy for wilderness endeavors. Ultimately,
wilderness medicine provides an opportunity to combine their
medical professions and interests with their passion for
the wilderness.
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