Wilderness Medicine

Preparing for Patients Who Go to Extremes

By Tonia Twichell

(May 2014) Jay Lemery, MD, compares his work in the emerging field of wilderness medicine to adding a room onto the ancient house of medicine.

Building that room looks like a long-term project for Lemery and fellow advocates because the dimensions of wilderness medicine are complex, encompassing much more than the predictable terrain of mountains, rivers, deserts and jungles.

Wilderness medicine also claims outer space, diving/hyperbaric medicine, extreme sports, climate change, and disaster and humanitarian assistance. By gathering together these disparate interests, wilderness medicine offers a way to keep people safe in unfamiliar or dangerous surroundings.

“So many things were pigeonholed,” says Lemery, an associate professor of emergency medicine. “Snake bites, bear attacks, hypothermia, hypoxia — no one place was owning all these things. And no one place was teaching situational awareness or how to come prepared or what to do if someone does get injured.”

Wilderness medicine has developed nationally as more people embrace adventure travel and sports, and as the field expands in new directions. Anchored in a smattering of departments of emergency medicine around the country, wilderness medicine includes such specialties as immunology, infectious disease, public health, pharmacology, pediatrics, sports medicine, physical medicine, traumatology, family medicine and internal medicine.

Richard Zane, MD, chair of the Department of Emergency Medicine, prefers an expanded name for the field: wilderness, austere, expedition and environmental medicine.

“It’s a mouthful, I know,” he says. “But the term wilderness medicine evokes images of Cub Scouts and campers. What we’re talking about is what happens when you take humans from one place and put them in another environment. Or it can be how to prepare the population when the environment around them is changing.”

The discipline has found a natural home at the University of Colorado School of Medicine in part because of state attraction to outdoor sports exploration and recreation enthusiasts — and the inevitable injuries and rescues that follow.

Lemey's close ties to the Wilderness Medicine Society — he is president of the Salt Lake City-based organization — have put the field on a fast track at CU, with courses and trips for medical students and undergraduates, fellowships, a massive online open course (MOOC) and continuing medical education travel.

Most classroom experiences are held outdoors in locales as close as Estes Park and Moab, and as far-flung as Costa Rica and Alaska. Emergency scenarios are staged, but there have been real broken bones, extreme weather scares and cases of altitude-induced pulmonary edema.

Lessons vary by location and can include triage, building a litter, avalanche and fast water rescue, ropes work, insect and animal bites, hypothermia, frostbite and manufacturing medical equipment from ordinary items.

“It used to be that you could say you’re a doctor, sign onto a trip and go as the physician with no training at all,” says Tracy Cushing, MD, MPH, who volunteers with Colorado Outward Bound, teaching best practices to guides. “There’s more of an expectation now that you’ll be certified in travel medicine and have at least some level of advanced training.”

At the Wilderness Medicine Society, Cushing is on a committee establishing guidelines for wilderness medicine topics like prevention and/or treatment of frostbite, acute altitude illness, eye injury and illness, and epinephrine usage.

“Say that someone wants to climb Everest,” says Cushing, an assistant professor of emergency medicine. “Our hope is that they or their physician will pull up our guidelines and follow them.”.

“It was clear from being there and the stories we heard afterward that scores of the people had no business being there,” says Lemery. “You can’t just show up.”

Such basics as putting the right things in your backpack and keeping your feet dry often are ignored.

“You know what the biggest killer is in developing countries?” he asks. “Cars. You’re going to be in cars with no seatbelt, no airbags. So what do you do? First-time travelers who grew up in the OSHA world often don’t have situational awareness.”

Wilderness medicine training can prepare health practitioners and lay people alike.

“Everyone wants to be helpful in a disaster,” says Cushing, who relied on her wilderness medicine skills while working on the Hopi Reservation and in Nepal where patients were often hours away from a hospital. “You may go somewhere and plan on treating cholera and dengue, but do you know how to purify water or set up your own tent? You might deliver 100 babies a day, but if you can’t take care of yourself, you’ll just be another patient.”

Lemery predicts that increasingly destructive natural disasters will make wilderness medicine training pertinent even in large urban centers

“For example, most of the world does not have MRIs and cat scans, so we emphasize the importance of the physical exam, which has eroded in U.S. medical school,” Lemery says.

During hurricanes, blackouts and other emergencies, urban physicians can find themselves making a diagnosis without technology.

“You need to think about ‘What if the hierarchal structure was gone and you had to deviate. What would you do then?’”

CU offers an array of wilderness medicine opportunities including continuing medical education trips around the world, fellowships, undergraduate and medical student electives and a massive open online course (MOOC ) .See the list of choices by clicking on the Wilderness Medicine story at MedSchool.UCDenver.Edu/CUMedToday/feature