Expedition and Wilderness Medicine

Guest post Dr Edi Albert – Associate Professor, Remote and Polar Medicine at the University of Tasmania. Director, Wilderness Education Group

These two nearly synonymous terms refer broadly to the practice of medicine in austere and remote environments. The former term suggests a “journey with a purpose”, whether scientific, humanitarian, or recreational. The latter terms suggests an environment “undisturbed by human activity”. Either way, a pretty cool way to practice medicine.

112It is within this context that we can identify three broad aspects to expedition and wilderness medicine: pre-departure preparation and planning, care of expeditioners (and sometimes local inhabitants) whilst on their travels, and providing education and advice to others (often to those without health-care backgrounds).

Thus, depending upon the types of environment visited, the modes of transport used, and the purpose of the trip, one may find significant overlaps with military medicine, aviation medicine, maritime medicine, travel and tropical medicine, and sports medicine and physiology.

There is an emphasis on environmental medicine and physiology (yep, there’s the “P” word again…it crops up quite a lot I’m afraid!). This may include cold injuries, heat illness, high altitude illness, hyperbaric and diving medicine, and toxinology.

There is an old saying that “if you can’t look after yourself, how can you look after others?” To that end it is extremely important to develop field and rescue skills: meteorology, navigation, survival techniques, rope-skills, and leadership – to name but a few.

Whilst a difficult or complex emergency in the back of beyond will get the interested “LITFL” reader’s adrenaline pumping, mostly expedition and wilderness medicine is about preparation, planning, and prevention. A horrible accident or serious incident (unless it is another group!) could reflect badly on you and the expedition leader, rather than be an opportunity to be a hero. Treatments are mostly simple complaints: gastro-intestinal upset, minor wounds, and the odd febrile illness, but you do need to be prepared for any eventuality.

113No one conventional medical specialty can claim to “own” expedition and wilderness medicine, but in terms of practising effectively it helps to have a broad based training, rather than working in a sub-specialty. You can’t just step out of a hospital or clinic environment and take a conventional set of attitudes, guidelines, protocols, and skill sets with you.

Even in Retrieval Medicine, where the aim is to “bring a hospital standard of care to the patient” it is a very different world from your ED or ward. How much more so when even greater limitations in equipment, pathology, and imaging force you to use just your clinical judgement, and when isolation forces you to reassess your priorities and re-think the risks?

The effective practice of Expedition and Wilderness Medicine requires a large degree of pragmatism and improvisation, the ability to confidently make decisions without all the information you would ideally like to have, and then to act upon them. There’s no point knowing the 101 causes of elevated serum rhubarb if you can’t work out how to move an injured patient out of the rain.

There is an ever increasing body of research, education, and practical opportunities in the field of Expedition and Wilderness Medicine.

Books, Journals, and Internet Resources

The Wilderness Medical Society (WMS) is a US-based international non-profit organisation devoted to wilderness medicine education and research.  The WMS produces the peer-reviewed Wilderness and Environmental Medicine Journal as well as Practice Guidelines and an online Lecture Series.   The International Society for Mountain Medicine focuses on scientific and practical aspects of mountain medicine, and publishes the High Altitude Medicine and Biology journal.

116A choice of two great tomes awaits the avid reader. Not only do they contain just about everything you might want to know, they are heavy enough to hold a tent down in the most severe of storms! Wilderness Medicine, edited by Paul Auerbach is the first of these, and Expedition and Wilderness Medicine edited by Bledsoe, Manyak, and Townes is the other.

If you want something detailed enough as a reference, yet small enough to take with you, then the second edition of the Oxford Handbook of Expedition and Wilderness Medicine would be hard to beat.

If you are after something to fit in your back pocket, or to recommend to non-medical folk, then Pocket Wilderness Medicine and First Aid by Jim Duff and Peter Gormly is probably the pick of the bunch.

There is now a wide array of useful information freely available on the internet. As we develop a series of posts on various topics we will include some specific resources.

But, so you don’t miss out now, here are three that have a broad scope:

  • The Adventure Medic is an online magazine with regular articles, reports, videos (that tend to make one feel inadequate) and a jobs and volunteering section.
  • The Centers for Disease Control “Yellow Book” is updated and published online every two years. It is the best “go to” site for all matters related to travel medicine and health.
  • The Expedition Medical Cell at the Royal Geographical Society has a number of useful resources including free access to the Expedition Handbook, a list of vacancies for expeditions, and information on courses. 

115

Courses and Educational Programs

There are numerous providers of expedition and wilderness medicine courses around the world.  These vary from short first aid courses for the lay person to extensive post-graduate education designed for health professionals.  They are a great way to stimulate or consolidate your interest in expedition and wilderness medicine.  Here are a few to choose from, with a focus on those closest to home.

Australia & New Zealand

“Wilderness First Aid” Courses are provided by:

There are a number of options aimed at health professionals:

United States

In the USA, Wilderness Medicine has become “big business”. Here are just a few options to get you started:

  • The WMS provides the Fellowship of the Academy of Wilderness Medicine based around a core curriculum and experience in wilderness medicine activities, as well as regular conferences.

Wilderness First Responder courses are provided by the following well respected organisations:

  • Wilderness Medicine Institute of NOLS
  • Advanced Wilderness Life Support (AWLS)
  • Wilderness Medical Associates
  • Remote Medical International

United Kingdom

The UK also has various training options and research options. Medex run high altitude research expeditions every few years and started the UIAA-ISSM accredited Diploma in Mountain Medicine, which is now being run by the Royal College of Surgeons in Edinburgh. Various other countries have since started providing this diploma. Perhaps one of the more interesting ways to complete this is via the Mountain Medicine Society of Nepal. Expedition Medicine run various courses based in the UK and other countries.

Jobs and volunteering

Opportunities to work in Expedition and Wilderness Medicine are many and varied. The Adventure Medic and Royal Geographical Society websites mentioned above are good places to start. Like many other aspects of life, networking with like-minded professionals often opens doors that you didn’t know existed.

A career in expedition and wilderness medicine?

Expedition and wilderness medicine unites doctors, nurses, and paramedics through their desire to use their medical skills as a passport for adventure and to regularly challenge themselves professionally out of their comfort zone. There is also a natural bridge to humanitarian medicine and the opportunity to contribute to the health care of the (often poor and underserved) people in whose wonderful landscapes we choose to sojourn.

Don’t expect full time career; see it more as a side line or hobby. Don’t aim to make money out of expedition and wilderness medicine, but find instead that you become enriched in many ways that are far more important.

 

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LITFL Review 228

LITFL review

Welcome to the 227th LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

resizer
Another awesome post on Dr Smith’s ECG blog. A must for anyone who sees patients with chest pain. [CC]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

The Best of #FOAMed Resuscitation <—NEW SECTION!

The Best of #FOAMtox Toxicology

The Best of #FOAMus Ultrasound

  • Ditch the X-Ray for confirming CVL placement using RASS (rapid atrial swirl sign) as discussed by Avila, Dawson and Mallin. [AS]

The Best of #FOAMim Internal Medicine

  • The Louisville Lecture series has added a talk on Epilepsy for the Internist. [ML]

The Best of #FOANed Nursing

The Best of Medical Education and Social Media

  • We’ve all heard the refrain “you can’t trust podcasts (or blog post, etc).” Weingart discusses his thoughts on this, pointing out the need to guide trainees on what sources are good, how to interpret and apply the information and how to seek support for the ideas. [AS]
  • Simon Carley discusses How to Integrate #FOAMed into #MedEd. [SR]

News from the Fast Lane

Reference Sources and Reading List

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Funtabulously Frivolous Friday Five 142

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF…introducing Funtabulously Frivolous Friday Five 142

Question 1

We’ve all heard of Occam’s Razor but what is Hickam’s Dictum or the Anti-razor?

  • A patient can have as many diseases as they damn well please.
  • Occam’s razor can be paraphrased ‘when investigating a patient with multiple symptoms, a single unifying diagnosis should be sought’ Hickam’s Dictum was a response when one single unifying diagnosis is not possible. Dr John Hickam was a faculty member at Duke University in the 1950s. [Reference]
  • Hickam was not the first to question William of Ockham as Walter Chatton a theologian and philosopher (c.1290 – 1343) often sparred with William and came up with the “anti-razor“.
  • Chatton proposed: “Whenever an affirmative proposition is apt to be verified for actually existing things, if two things, howsoever they are present according to arrangement and duration, cannot suffice for the verification of the proposition while another thing is lacking, then one must posit that other thing”. I.e. if occam’s razor does not satisfactorily determine the truth, another explanation is required. [Reference]

 

Question 2

For more philosophy about razors and anti-razors, what is Crabtree’s Bludgeon?

  • Paraphrased: “no set of inconsistent observations can exist that some human intellect cannot conceive a coherent explanation for”. [Reference]
  • Be careful of over-attachment bias to a particular diagnosis.
  • And finally, Occam’s duct tape: “avoiding the simple explanations to make multiple unnecessary assumptions”.

Question 3

In 1816 who used a stiff roll of paper as the first example of a now ubiquitous piece of medical equipment?

  • Rene Laennec (1781-1826) revolutionised the examination of the chest with the first stethoscope.
  • Physicians no longer needed to press their ears against the chests of their patients to auscultate the chest and accurate clincopathophysiological correlation became possible. [Reference]
  • The familiar binaural stethoscope, with rubber tubing going to both ears, was not developed until the 1850s. Regarded as the father of chest medicine, Laennec demonstrated the importance of the instrument in diagnosing diseases of the lungs, heart and vascular systems. Ironically, he died of tuberculosis.
  • The stethoscope song – click on link.

Made of wood and brass, this is one of the original stethoscopes belonging to the French physician Rene Theophile Laennec (1781-1826) who devised the first stethoscope in 1816. It consists of a single hollow tube. The familiar binaural stethoscope, with rubber tubing going to both ears, was not developed until the 1850s. Regarded as the father of chest medicine, Laennec demonstrated the importance of the instrument in diagnosing diseases of the lungs, heart and vascular systems. Ironically, he died of tuberculosis.

Question 4

What is abarognosis?

  • Loss of ability to appreciate the weight of objects held in the hand, or to differentiate objects of different weights.
  • Caused by a lesion of the contralateral parietal lobe. [Reference]

Question 5

Which specialty doctors die the youngest?

  • Emergency Doctors. [Reference]
  • Before you all jump to Dermatology for a few extra years of life (19 to be precise), the study had many faults but interesting none the less. The searched the obituaries for 7 years in the BMJ from 1997 to 2004, so a fairly limited population while the college for emergency medicine was relatively young in the UK (less junior trainees and females to balance the stats, plus only 17 doctors in that cohort). Interesting facts from the study:
  • Cardiologists are not immortal
  • Radiologists die from more neurological pathology…… too much radiation??
  • Higher rate of deaths from accidents in the emergency cohort. Maybe we should stop living life in the fast line at home.

discipline and death

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Research and Reviews in the Fastlane 131

Research and Reviews in the Fastlane

Welcome to the 131st edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Resuscitation, Pre-Hospital/Retrieval Medicine
R&R Hall of Famer - You simply MUST READ this!

Kudenchuk PJ et al. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. NEJM 2016. PMID: 27043165

  • In past iterations of ACLS, drugs played a central role in resuscitation. However, recent years have seen many of them (atropine, vasopressin, epinephrine) take a hit. This article further stresses the limited (if any) role for medications. The study investigators performed a 3-arm, RDCT comparing amiodarone to lidocaine to placebo in refractory VF/VT arrest. The results? No significant difference in survival to discharge or survival with good neurologic outcome between the meds. In a small subgroup (those with witnessed arrest) both amiodarone and lidocaine outperformed placebo but this is simply exploratory data for generating a hypothesis. Even if it turns out to be accurate, there doesn’t seem to be much reason to give the more expensive, more side effect amiodarone over the tried and true, dirt cheap lidocaine.
    Bottom line: Stop focusing on the drugs and keep your attention on maintaining a high-compression fraction + delivering electricity when indicated. (Swaminathan)
  • This high quality study performed by the Resuscitation Outcomes Consortium (ROC) Investigators examined the efficacy of amiodarone and lidocaine in out of hospital cardiac arrest, specifically in patients with pulseless ventricular tachycardia or ventricular fibrillation. Patients were randomized to receive either placebo, amiodarone, or lidocaine. A well done trial with many layers to it, the main finding, in brief, is that no benefit to survival to hospital discharge or favorable neurological outcome was found. Importantly, when the relationship to witnessed arrest was examined, a pre-specified subgroup, a statistically and clinically significant 5% survival advantage with amiodarone and lidocaine was present. While this study likely demonstrates the futility of these drugs for patients after arrival in the ED, their use in the prehospital setting may be beneficial for those whose arrest is witnessed. An important contribution to the resuscitation literature of which we all must be aware. (Fried)
  • Recommended by: Jeremy Fried, Anand Swaminathan
  • Read More: Push Hard and Fast – And Say No to Drugs (ScanCrit)

The Best of the Rest

Research and Critical Appraisal
Ridgeon EE et al. The Fragility Index in Multicenter Randomized Controlled Critical Care Trials. Crit Care Med 2016. PMID: 26963326

  • There is a real danger of fixating on ‘significant’ p-values when interpreting the results of clinical trials. How robust are these ‘significant’ results really? The ‘Fragility Index’ is a useful, simple metric for answering this question.It is the minimum number of patients whose status would have to change from a nonevent to an event that is required to turn a statistically significant result to a nonsignificant result. Following on from Walsh et al, 2014 (see: http://intensiveblog.com/fragility-index-walsh-et-al-2014/), these authors demonstrate that much of the evidence-base in critical care trials is worryingly ‘fragile’: >40% of multi-center RCTs had a Fragility Index of less than or equal to 1! Learn more about ‘The Fragility Index’ here: http://lifeinthefastlane.com/ccc/fragility-index/
  • Recommended by: Chris Nickson

Cardiology, Emergency Medicine
Body R et al. Chest pain: if it hurts a lot, is heart attack more likely? Eur J Emerg Med 2016; 23(2):89-94. PMID: 25340995

  • If a patient is in a lot of pain, does that make it more likely that they are having an MI? According to this prospective data-set (collected for a different study): no. Patients diagnosed with MI rated their pain as 8/10 as compared to an average of 7/10 pain in the patients who ruled out – not diagnostically helpful. Of course, physicians may have been more likely to enroll patients with higher pain scores, which would skew the numbers, much like the research indicating that pain radiating to the right shoulder is more specific than pain radiating to the left shoulder.
  • Recommended by: Justin Morgenstern

Emergency Medicine, Gastroenterology
R&R Hot Stuff - Everyone’s going to be talking about thisBeadle KL et al. Isopropyl alcohol nasal inhalation for nausea in the Emergency Department: A randomized controlled trial. Ann Emerg Med 2015. PMID: 26679977

  • This is a small double-blinded RCT comparing inhaled isopropyl alcohol to saline placebo for short-term relief of nausea in the ED. Although it is hard to believe patients (and possibly investigators) were truly blinded to the odor of isopropanol, this study found isopropanol superior to placebo for improvement of nausea at ten minutes. This effect may be short lived however, as there was no difference in subsequent use of antiemetics between the two groups. In light of recent attention to possible side effects of existing medications, including prolongation of the QT interval with ondansetron, isopropyl alcohol pads offer an intriguing option for short-term relief of nausea in the ED.
  • Recommended by: Meghan Spyres

Neurology, Intensive Care
R&R Landmark paper that will make a differenceJoseph B et al. Traumatic brain injury advancements. Curr Opin Crit Care. 2015; 21(6):506-11. PMID 26539924

  • We are increasingly aware of the role that inflammation plays in development of secondary traumatic brain injury. Several newer strategies aimed at reducing inflammation are highlighted in this review paper. Strong evidence is still pending for most of these treatment strategies but we are awaiting several clinical trials on the use of Glibenclamide, statins, beta blockers, hypothemia and remote ascetic conditioning. Furthermore more tailored treatment of TBI coagulopathy using bedside viscoelastic essays may have profound effects on secondary brain injury.
  • Recommended by: Soren Rudolph

Emergency Medicine, Trauma, Resuscitation
R&R Hot Stuff - Everyone’s going to be talking about this
Patanwala AE et al. Succinylcholine Is Associated with Increased Mortality When Used for Rapid Sequence Intubation of Severely Brain Injured Patients in the Emergency Department. Pharmacotherapy. 2016; 36(1):57-63. PMID: 26799349

  • Should we use succinycholine or rocuronium as our 1st line paralytic in patients with head trauma? This retrospective cohort study found equal overall mortality but a higher mortality rate in patients with more severe head injury if they got succinycholine. This study only shows an association and not causality and will need further prospective studies to elucidate the truth. However, in the absence of better evidence, either agent appears reasonable as the first line but rocuronium has a number of advantages (absence of contraindications, longer paralysis).
  • Recommended by: Anand Swaminathan
  • Read More: Does Succinylcholine Increase Mortality in Severe TBI Patients? (UMEM Education Pearls), Rocuronium vs. Succinycholine (Core EM)

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

The post Research and Reviews in the Fastlane 131 appeared first on LITFL: Life in the Fast Lane Medical Blog.

LITFL Review 227

LITFL review

Welcome to the 227th LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

resizer

The old and new titans of critical care Paul Marik and Rob MacSweeney throw down over the futility of predicting fluid responsiveness in resuscitation. [JS]

Natalie May provides a thought-provoking post looking at our polarised perspectives in the emergency department (although really applies to hospital as a whole). Can we be each be a little kinder, less judgemental, and inclusive this week? [SO]

The Best of #FOAMed Emergency Medicine

  • Amal Mattu and Rick Body talk low-risk chest pain evaluation in the ED. This post via St. Emlyn’s contains full video of their talks from last week. [AS]
  • The usual subscription-based EM:RAP has relaunched its free TV as EM:RAP HD on YouTube. This week, the team highlights tubes for stopping GI bleeds. [AS]
  • PHEMCAST joins in with the sepsis debate but with an interesting prehospital slant and also an insider’s view from Tim Nutbeam who is heavily involved in the UK Sepsis Trust. [SL]
  • A great case discussion from SMACC on a prehospital trauma case led by Brian Burns, great to a hear more than one way to skin a cat from these experts and highlighting the difficulties in critical decision making. [SL]
  • Here is a superb bunch of tips on managing cognitive load as an emergency physician– useful for all physicians really. [SO]

The Best of #FOAMcc Critical Care

The Best of #FOAMus Ultrasound

The Best of #FOAMped Paediatrics

The Best of #FOAMim Internal Medicine

The Best of #FOANed Nursing

The Best of Medical Education and Social Media

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

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