Wilderness Medicine

Why is the issue of epinephrine so controversial and confusing?  To carry epi or not to carry epi?  The prime deciding factor should be making a sound medical decision - while keeping the potential legal implications in mind.  This article discusses questions to consider if your outdoor program carries or is considering carrying epinephrine.  Located on pages 8-10.

People who live, work, travel and recreate in the outdoors have specialized medical training needs that may not be adequately met by traditional first aid programs. They care for patients in remote locations, in challenging weather, with questionable communication and support, limited equipment, and may need to make independent decisions on patient care and transport. As a result, medical and outdoor specialists developed wilderness medicine courses in an attempt to meet these needs. Initially, the content for these courses was written independently and was opinion based. Subsequently, the content has evolved based on evidence and experience. This process has led to a consensus about content and scope of practice (SOP) among the training organizations whose directors created the document. History of WFA and WFR SOP Development Around 2005 numerous open public sessions at several annual WMS meetings had discussion on aspects and areas of SOPs for Wilderness First Aid (WFA) and Wilderness First Responder (WFR). All who chose to participate were encouraged to be there and speak. While many were interested, only a few signed on to work on the WFA project of five years and the following five years on the WFR project. An informal group of wilderness medicine course providers emerged and have been working diligently and collegially to discuss course content for the WFA and WFR programs. These include: Aerie, Desert Mountain Medicine, NOLS Wilderness Medicine Institute, SOLO, Wilderness Medical Associates, Wilderness Medicine Outfitters, and Wilderness Medicine Training Center. We are interested in content that is practical and realistic for our students. Our discussions range from specific techniques such as femur traction splints to broader discussions on the relevance of mental health and medical topics in these courses. We engage in these conversations as we lead, interact, recreate and serve with those who seek wilderness medicine training; the outdoor recreationist, trip leaders, search and rescue groups, disaster response teams, humanitarian relief organizations and wilderness education programs. By participating in committees and attending meetings and conferences, we network with groups such as the Wilderness Risk Managers, American Red Cross, Boy Scouts of America, Association of Outdoor Recreation and Education and the National Association of EMS Physicians, as well as the many outdoor organizations that seek relevant and practical wilderness first aid training for their participants and trip leaders. The results of these collegial conversations have been increasing consistency in curriculum content and the writing of two documents describing, in this group's opinion, broad guidelines for minimum curriculum content for WFA and WFR. The WFA document was published in 2010 and revised in 2013 with publication in the Wilderness and Environmental Medicine Journal. http://www.wemjournal.org/article/S1080-6032(13)00147-6/pdf Everyone who volunteered for the current draft WFR SOP was accepted to work on the project which was done with a multitude of discussion by emails and phone calls. Numerous drafts were sent out and reviewed. Those who felt strongly on a point were heard in detail. Some points were agreed to in a cooperative manner in order to keep the project moving forward.

Wilderness medicine (WM) education is desired in Primary Care Sports Medicine fellowship training. Due to the COVID-19 pandemic and travel restrictions, a virtual wilderness medicine boot camp was created to share a WM experience with learners across the United States. A previously led in-person WM boot camp was converted to lecture format and delivered through video conference. This covered information relevant to WM and the sports medicine certification exam. A post intervention survey was completed by 79.5% of participants (128/161). Participants rated the virtual experience positively. Both fellows and faculty felt the virtual boot camp adequately taught WM topics (fellows [5(4-5)], faculty [5(55)], P<0.01). Both felt the virtual experience was sufficient over an in-person boot camp (fellows [4(2.75-4)], faculty [4(4-5)], P<0.01). Due to the ongoing COVID-19 pandemic, it is important to rethink teaching strategies to optimize the opportunities for learners. To date, this is the largest boot camp recorded in the literature. This was a safe and cost effective way to ensure that requirements for a WM experience were met. This virtual course could be adjusted to fit learning objectives of any specialty and tailored to accommodate any level of learning.

Despite the growth of wilderness medicine in general, some
EMS systems, even in areas with high outdoor activity
usage, are ill-prepared to respond to wilderness emergencies.
Underfunding, jurisdictional issues, undertraining, and
lack of attention can all contribute to a meager formal
rescuer response during your next wilderness emergency.
By law all EMS personnel, whether in the front country
or backcountry, must operate under the medical oversight
of a licensed physician. However, until now there has
been no specific training for physicians to provide this
type of oversight.

Elders are the only people we can look towards to learn how to live and more so, how to die - for in showing us the beauty and grace in dying, they teach us how to live life fully with meaning and purpose. When we cast elders aside as no longer of use, a burden on society, we communicate to the rest of humanity that we are only valuable to a certain point in our lives, and then no more.  We risk sending a message to future generations that what is important about you and your life is not who you are, but rather is what you do and how you contribute, in an economic fashion, to the rest of society. 
I come from a generation who mistakes time for money and money for love – and we never have enough love.  My generation is confused as to what is most important right now; which I believe is the patient, listening ear you lend to others to hear their stories, the time you give which helps others feel seen, and the equal rights you are willing to fight, which reminds us all the importance of humanity and its ultimate value = love.  What is not most important, if at all, is the wealth, monetary items, or material possessions we leave behind. Sadly, I spent the first 25 years of my adult life not understanding this illusion.
This research and its autoethnography method provides me with a unique technique to research, experience, and write about the phenomena of growing old and the experience of becoming an elder for my community.  All of which provide me with a deeper understanding of how I mirror the society I am a part of through my actions and behaviors. This research project not only illuminates my personal experiences in ceremony as I ponder this next phase of my life, it also illustrates the power of contemplative silence, rituals, and connection to nature for any willing participant. This is just the beginning for a new life long practice for me. 

C. Raymond Greene (1901Greene ( -1982 was a man of many talents. After graduating from medical school in 1927, he spent a decade in general practice. He subsequently became heavily involved in the emerging specialty of endocrinology and went on to gain considerable recognition in the treatment of thyroid disorders before eventually becoming involved in the world of medical publishing. Aside from Greene's mainstream vocational and intellectual pursuits, from boyhood he nurtured a passionate interest in mountaineering-first in his native Great Britain, and then the European Alps, and ultimately in the high Himalayas. His involvement in landmark climbs, such as the successful Kamet venture in 1931 and Everest attempt in 1933, earned him a place in the pantheon of Himalayan explorers and mountaineers and stimulated Green's interest in high altitude physiology and medicine. He made notable additions to the literature on this subject in publications such as Nature and Journal of Physiology. Apart from his remarkable life achievements in the areas of medicine, mountaineering, and publishing, Greene was perhaps best remembered by those close to him (and by contemporary readers who are devotees of his writing) as a peerless storyteller with a sardonic sense of irony.

High-altitude athletes and adventurers face a number of environmental and medical risks. Clinicians often advise participants or guiding agencies before or during these experiences. Preparticipation evaluation (PPE) has the potential to reduce risk of high-altitude illnesses in athletes and adventurers. Specific conditions susceptible to high-altitude exacerbation also important to evaluate include cardiovascular and lung diseases. Recommendations by which to counsel individuals before participation in altitude sports and adventures are few and of limited focus. We reviewed the literature, collected expert opinion, and augmented principles of a traditional sport PPE to accommodate the high-altitude wilderness athlete/adventurer. We present our findings with specific recommendations on risk stratification during a PPE for the high-altitude athlete/adventurer.

"Background: Emergency medicine and wilderness medicine are close by kind of technical skills, because of their infrequent use. Treatments often need intra venous access to start. Depending of patient clinical statement, care should be quick and safe. Intra-venous access is usual. But, now, intra-osseous access gains in popularity in case of difficult venous access. Does medical technician often choose it? How and why is it used?
Methods: This study offers to compare intra-venous access and intra-osseous access in wilderness conditions like canyoning or caving by in-situ simulation. Users should answer to a questionnaire and give feedback about materials used by a Likert scale. 13 medical doctors were questioned after rescue camp in Pyrenees Mountains.
Results: Even if the time to success in the two accesses is the same, intra-osseous access seems to be quicker, easier and safer according to the users in case of emergency.
Conclusion: In-situ simulation is a good tool to test new materials or new care organization in real conditions. It is high fidelity simulation in healthcare.

Introduction : La médecine d’urgence et la médecine en milieu périlleux se ressemblent par leurs difficultés de réalisation de certains gestes techniques, étant donné leur rareté ou bien leurs conditions de réalisation. La prise en charge d’une victime nécessite souvent la pose d’une voie veineuse afin de pouvoir entreprendre une thérapeutique. Suivant l’état clinique du patient ou bien en fonction du milieu dans lequel est arrivé l’accident, il faut agir rapidement et sûrement. La voie intra-osseuse est une alternative à la voie veineuse périphérique dite classique dans ces situations particulières. Mais est-elle souvent choisie ? Quelle est la performance des soignants lors de sa pose ? Quel est le ressenti des utilisateurs ?
Méthode : Cette étude propose à des sauveteurs en milieu périlleux de comparer, dans un environnement hostile comme la spéléologie ou le canyoning, la pose d’une voie intra-osseuse avec une voie veineuse périphérique sur simulateur. Ils doivent exprimer leur ressenti par rapport aux deux méthodes sur une échelle de Likert. Treize médecins en stage de médecine de montagne dans les Pyrénées françaises ont répondu au questionnaire.
Résultats : Il semble que la pose de la voie intra-osseuse est réalisée dans les mêmes délais que la voie veineuse périphérique mais que la voie intra-osseuse est ressentie plus rapide, plus facile et plus sûre et elle serait préférée en cas d’urgence en milieu périlleux.
Conclusion : La simulation in situ, en dehors des laboratoires, sur les lieux même d’exercice des professionnels de santé est un outil formidable pour tester l’organisation des soins ou une nouvelle technique, tout en évoluant dans un contexte d’apprentissage haute fidélité."

A cultural system an embodiment of the range of activities, social conflicts, and moral dilemmas that individuals are compelled to engage in as they go about negotiating everyday events that confront them in their lives.  A collective worldview reflects specific philosophies or belief systems concerning how the world works, the place of humans within it, and thus, how these individuals should live their lives. Our current dominant worldview is called anthropocentrism, that is, our activities and behaviors place humans at the center of this world and a value system that all else exists as utilitarian value for the human consumer experience.
This modern worldview is reflected in those individual decisions and actions we each take as we navigate our daily dilemmas. Behaviours and value systems based on profit, growth, and consumption reflect a worldview that is fundamentally economic in nature.  This economic engine, which dominates Western society and the global economy, reflects a belief system which rationalizes that individual acts of self-interest somehow serve the common interests of society as a whole.  Perhaps best summed up by Bill McKibben (2007) when he says “it is perhaps the central assumption of the world we live in: you can tell who I really am by how I spend” (p. 30).
If all this were good for us, why are we less satisfied with life despite our growing wealth, financial independence, and increased security?  Could it be that happiness pursued through material possessions and indulgence of sensual pleasures and avoidance of sensual pain isn’t happiness at all, but rather is a distraction from our truer sense of self and collective identity? Could it be that the daily threat of annihilation be it environmental, nuclear, political, financial, or other acts of violence are a result of our anthropocentric lifestyle?  Perhaps it is in the dehumanization of a competitive capitalistic society which narrows our vision to material gains and, as a result, we are confused about our true identity in the larger scheme of things and thus unhappy?
Either way, the obvious growing discomfort with our lifestyle is throwing us into an identity crisis of authenticity. While this can be a good catalyst for transformation, we have created defense mechanisms to keep our anxiety at bay through a multitude of distractions such as watching television, the internet and social media, mobile technology, gaming, alcohol and drug abuse, or retail therapy.  Adding to the ease of distractions around us is the social pressure of conformity and enculturation which provides us an easy escape from our existential quest.
Where do we go to safely challenge our worldviews that we each hold individually?  How do we begin a journey that starts with our self and how we show up in the world around us individually and collectively?  Indigenous wisdom proposes that when community is too serious, is suffering and anxious, that we stop and go into ceremony.  It is critical that we step out of the frenetic life we are living, reconnect with one another, and re-member ourselves in the world we are a part of, not separate from.  We are a modern world in need of an initiation.

Introduction Our project follows community requests for health service incorporation into conservation collaborations in the rainforests of Papua New Guinea (PNG). This protocol is for health needs assessments, our first step in coplanning medical provision in communities with no existing health data. Methods and analysis The study includes clinical assessments and rapid anthropological assessment procedures (RAP) exploring the health needs and perspectives of partner communities in two areas, conducted over 6 weeks fieldwork. First, in Wanang village (population c.200), which is set in lowland rainforest. Second, in six communities (population c.3000) along an altitudinal transect up the highest mountain in PNG, Mount Wilhelm. Individual primary care assessments incorporate physical examinations and questioning (providing qualitative and quantitative data) while RAP includes focus groups, interviews and field observations (providing qualitative data). Given absence of in-community ...

The management of trauma has evolved significantly over the last 40 years. Seminal to this process was the development in Nebraska of a concept of trauma management that was promulgated as Advanced Trauma Life Support (ATLS). It has achieved global support and is considered by many to be the acme in trauma management. Every participant in an ATLS course remembers that an aviation accident in rural Nebraska was responsible for the nascence of the program but very few know the details of the crash. February 17, 2016, was the 40th anniversary of the accident. This article extracts the details of the flight, the crash, the search, the extrication, the reception at the nearby rural hospital, and the injuries from both the official report and the published, personal records of survivors of the crash. The effect of ATLS can be debated elsewhere and its future questioned. However, the article concludes by highlighting the fortitude and resilience of the human spirit that were demonstrated that night under incredible circumstances.

To provide guidance to clinicians, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the out-of-hospital evaluation and treatment of victims of accidental hypothermia. The guidelines present the main diagnostic and therapeutic modalities and provide recommendations for the management of hypothermic patients. The panel graded the recommendations based on the quality of supporting evidence and the balance between benefits and risks/burdens according the criteria published by the American College of Chest Physicians. The guidelines also provide suggested general approaches to the evaluation and treatment of accidental hypothermia that incorporate specific recommendations.

In the past two decades, Chile has developed intense mining activity in the Andes mountain range, whose altitude is over 4,000 meters above sea level. It is estimated that a workforce population of over 55,000 is exposed to high altitude hypobaric hypoxia. The miners work under shift systems which vary from 4 to 20 days at the worksite followed by rest days at sea level, in a cycle repeated for several years. This Chronic Intermittent Hypoxia (CIH) constitutes an unusual condition for workers involving a series of changes at the physiological, cellular and molecular levels attempting to compensate for the decrease in the environmental partial pressure of oxygen (PO 2 ). The mine worker must become acclimatized to CIH, and consequently undergoes an acute acclimatization process when he reaches the worksite and an acute reverse process when he reaches sea level. We have observed that after a period of 3 to 8 years of CIH exposure workers acclimatize well, and evidence from our studies and those of others indicates that CIH induces acute and chronic multisystem adjustments which are eff ective in off setting the reduced availability of oxygen at high altitudes. The aims of this review are to summarize fi ndings of the physiological responses to CIH exposure, highlighting outstanding issues in the fi eld.

To provide guidance to clinicians about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the prevention and treatment of acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE). These guidelines present the main prophylactic and therapeutic modalities for each disorder and provide recommendations for their roles in disease management. Recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches to the prevention and management of each disorder that incorporate these recommendations.

Endurance events are increasing in popularity in wilderness and remote settings, and participants face a unique set of potential risks for participation. The purpose of this article is to outline these risks and allow the practitioner to better guide the wilderness adventurer who is anticipating traveling to a remote or desert environment.

Endurance events are increasing in popularity in wilderness and remote settings, and participants face a unique set of potential risks for participation. The purpose of this article is to outline these risks and allow the practitioner to better guide the wilderness adventurer who is anticipating traveling to a remote or desert environment.

Expedition teams without accompanying medical professionals traveling overseas from the United Kingdom frequently carry medical kits containing Prescription Only Medicines (POMs). Access to safe, basic POMs whilst on expedition is important, as the quality and availability of medicines in-country may not be acceptable and delay in treatment may be hazardous. At present there is no published guidance relating to drug acquisition and administration in these situations. In the UK, a number of different practices are currently in use, with uncertainty and medico-legal concerns currently hampering safe and efficient provision of POMs on overseas expeditions. A guideline is proposed for the management of prescription only medications in an expedition setting.

To provide guidance to clinicians about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the prevention and treatment of acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE). These guidelines present the main prophylactic and therapeutic modalities for each disorder and provide recommendations for their roles in disease management. Recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches to the prevention and management of each disorder that incorporate these recommendations.

BACKGROUND: The current study aimed to elucidate the protective role of combined fenugreek and a-tocopherol against cadmium induced histopathological changes in the testes. MATERIALS-METHODS: Thirty adult male albino rats divided into three equal groups 10 rats each. Group I is the control group. Group II received 5 mg/kg/ day cadmium chloride. Group III received 5 mg/kg/day cadmium chloride and 150 mg/kg/day fenugreek and 100 mg/kg/ day of a-tocopherol. The treatment of all groups was done by oral gavage for 60 consecutive days. The testes were removed and subjected to histopathological and ultrastructure study. RESULTS: Rats exposed to cadmium showed severe histopathological changes in the testicular spermatogenic series, many vacuoles and multinucleated giant cells. Treatment with fenugreek and a-tocopherol partially improved the morphological changes, reduced tissue damage and rebuilt of the spermatogonia layer. CONCLUSIONS: Fenugreek and a-tocopherol might represent a promising medicinal combination to ameliorate the toxic effects of cadmium exposure.

While most climbers are not medical professionals, climbers are well disposed to dealing with situations that require focus and psychological strength. Transitioning these skills to an emergency situation can speed treatment and evacuation of an injured partner.

A profile of the recent genesis of the Sub-Faculty of Expedition Medicine into a Faculty of Expedition and Wilderness Medicine of The Australasian College of Tropical Medicine is presented. Information is given on aims, structure, professional grades of membership, and the various activities of the Faculty, including publications and scientific meetings.