Wilderness Medicine

Definition

Wilderness medicine encompasses the prevention, diagnosis, and treatment of injuries and medical conditions that may occur during activities in remote territories.

Purpose

Activities that may require wilderness medicine include backpacking, cross-country skiing, mountaineering, white water rafting, scuba diving, and exploration in undeveloped regions such as deserts or jungles. Wilderness medicine has evolved to deal with situations in which definitive medical care is hours or days away, and in which patients may require quick or extended attention. Wilderness medicine utilizes first aid techniques, but requires additional skills that take into account demanding environments, uncommon threats to health, hazardous or lengthy travel to medical facilities, and difficulties in obtaining food, water, and shelter.

Wilderness medicine uses techniques to assess and treat a variety of conditions and injuries, including:

• wounds and burns
• external and internal bleeding
• cardiac arrest
• head injuries
• spinal cord injuries
• fractures and dislocations
• altitude sickness
• problems from cold and heat
• allergic and anaphylactic reactions
• lightning strikes
• near drowning
• insect, reptile and animal bites
• poisoning
• emergency child birth

Precautions

In wilderness situations caregivers should follow the maxim of first, do no harm. Uninjured members of groups should not attempt rescues that place themselves in danger. People administering first aid or wilderness medicine should remain calm and organized at all times. Only those with experience should administer medications and medical procedures. Injured people should not be moved until they are fully evaluated, or unless environmental conditions are threatening and require immediate shelter.

People with certain medical conditions should avoid travel in the wilderness, which can make existing conditions worse. These conditions include metastatic cancer, peptic ulcers, coronary artery disease, chronic obstructive pulmonary disease, clotting or bleeding disorders, high-altitude sickness, chronic rheumatoid arthritis, chronic severe back pain, and chronic knee and hip joint disease.

Description

The first stage of wilderness medicine begins with an assessment of the injury or condition. Primary assessment is used to quickly determine if a patient is in a life-threatening situation and to provide immediate emergency care. Secondary assessment is the thorough evaluation of a patient after life-threatening circumstances are relieved.

Primary assessment

A rule of thumb for the first steps of primary assessment, recommended by the Wilderness Medicine Institute, is the ABCDE procedure. It stands for Airway, Breathing, Circulation, Disability, and Exposure assessment. First, a patient's airway should be checked by close observation of whether or not air can move in and out and any obstructions to breathing should be alleviated. In unconscious people the tongue can often fall to the back of the throat and block breathing and the head should be tilted back and the lower jaw raised to alleviate the obstruction. If neck or spinal cord injuries are suspected, the head must be handled with extreme care to avoid further injury to the delicate spinal cord. In these cases, the lower jaw can be pulled forward to open the airway. If the neck is severely out of alignment due to an injury or fall, it may be gently realigned to free the airway.

After the airway is cleared and breathing is ensured, a patient's circulation is checked by noting the pulse of the carotid artery, on the neck, the pulse of the femoral artery in the front groin, and by listening to the heartbeat. If pulse is lacking, cardiopulmonary resuscitation (CPR) may be required, which requires chest compression and mouth-to-mouth breathing. Circulation checks include surveying a patient for bleeding. If severe bleeding is present, it should be stopped by direct pressure to the injured area, and by elevating the wound level to the heart if possible.

Disability assessment means checking for damage to the spinal cord, particularly in the cervical region of the neck. Assessment of exposure determines if environmental conditions, such as heat or cold, are immediate threats to a patient's life, which may require actions such as seeking shelter or covering the patient with protective clothing.

Secondary assessment

During this stage, a thorough physical examination of the patient is made from head to toe to determine the extent of injuries or problems. Caretakers performing the assessment should write detailed notes in order to inform physicians or emergency workers later. Patients are thoroughly interviewed to determine the scope of problems and any previous medical issues that might be related. Patients should be spoken to calmly to determine their mental states and how well they respond to stimuli. Vital signs such as heart rate and respiration rate should be noted and monitored. The skin should be carefully observed for injuries, boils, rashes, and discoloration. Red or flushed skin may indicate fever or heat-related conditions, while pale or blotchy skin can point to shock or hypothermia. A bluish tint to the skin may mean a lack of oxygen. Contact lenses should be removed from patients in cold conditions, as they can freeze to the eyes. During secondary assessment the patient should be closely monitored over time until improvement is noted or further treatment decisions are made. At all times in wilderness injuries, shock must be watched for and immediately treated.

Shock

In wilderness situations shock should be suspected after traumatic injuries, significant loss of blood due to internal or external bleeding, extreme loss of fluids from vomiting or diarrhea, heart attacks, and spinal cord injuries. Shock is easiest to alleviate when it is treated early; when not treated properly, it can progress to unconsciousness and death. When the likelihood of shock occurs, patients should be continually monitored and supported.

Symptoms of shock begin with anxiety and restlessness, with increased heart rates and labored, shallow breathing. Shock victims tend to sweat profusely with cool and clammy skin. Thirst and nausea are also symptoms.

Shock is treated in the wilderness by maintaining an open airway for the patient to breathe, by treating any injuries such as bleeding wounds, by reducing pain if possible, and by replenishing fluids. Patients should be kept calm and warm and their feet should be elevated if possible to increase blood flow to the organs. If shock symptoms progress, plans should be quickly made to get help or evacuate the patient.

Evacuation

Evacuation of a patient may be a crucial decision in the wilderness, depending upon the severity of an injury or condition, the difficulty of moving the patient, the time considerations involved, and the availability of outside help. In general if a patient with severe symptoms is not improving despite care then evacuation becomes necessary. The Wilderness Medical Society lists symptoms that require postponing travel or evacuating patients:

• progressive deterioration with symptoms of dizziness, fainting, abnormally slow (bradycardia) or fast (tachycardia) heart rate, labored breathing, poor mental status, progressive weakness, constant vomiting or diarrhea, intolerance of oral fluids, or recurrent loss of consciousness due to head injuries
• debilitating pain
• inability to sustain pace due to medical problems
• passage of blood by mouth or rectum
• symptoms of serious high-altitude illness
• infections that get worse despite treatment
• chest pain that is not musculoskeletal in origin
• psychological status threatening the individual or group

If a patient cannot be moved without risk of further injury, then other members of a party, preferably two or more, should be sent to get outside help. When requesting outside assistance, the safety of incoming rescuers and time constraints should be weighed. Requests for outside help should be made in writing, and include an assessment of the patient and situation as well as a detailed location of the incident. In some regions, helicopter evacuation may be an option, and should be used if an injury is life-threatening.

During evacuation patients must be handled with extreme care, as well as insulated from heat, cold and further injuries. Larger wilderness expeditions may have special devices available for transporting injured members, while smaller parties may have to improvise transporting devices by using backpacks, ropes and other available materials.

Wounds and burns

In wilderness situations wound management strives to stop bleeding, prevent infection, and speed healing. Bleeding from wounds should be controlled by direct pressure. Wounds and burns should be cleaned gently and thoroughly, treated with antibiotic ointment, and covered with bandages to avoid infections. Wounds that have high risks of infections, such as large cuts, open fractures, and animal bites, should be watched closely.

External and internal bleeding

External bleeding should be stopped by direct pressure, such as firmly applying a clean bandage or compress to an open wound. Secondary pressure may be applied to pressure points, such as the large arteries in the upper arm or groin, to slow bleeding. Tourniquets are recommended only in life-threatening situations, as they can cause complications and infections. Symptoms of internal bleeding include dizziness, fainting, rapid heartbeat, weak pulse, shortness of breath, thirst, loss of color, vomiting blood, blood in the feces or urine, and severe pain or swelling in the abdomen. If internal bleeding is suspected, medical help should be sought immediately. With all cases of significant blood loss, shock must be carefully considered.

Cardiac arrest

Cardiac arrest in the wilderness may require CPR, although CPR is less effective in remote regions that lack access to the life support technology that ambulances quickly supply. CPR should be administered to patients who have suffered near drowning, hypothermia, lightning strikes, and drug overdoses. CPR generally should not be administered in the wilderness if it endangers the rescuers, if the time of the cardiac arrest is unknown, if the patient appears to be dead or rigor mortis has set in, or if cardiac arrest was caused by severe trauma or lethal injuries.

Head injuries

Head injuries that do not cause loss of consciousness in the victim are rarely dangerous. Short-term loss of consciousness following head injuries is known as concussion, and these patients should be closely monitored for 24 hours, including waking them every three hours during sleep to check for mental alertness. For head injuries that cause prolonged unconsciousness, the airway and cervical spine must be protected. Severe brain injury is indicated by relapses into unconsciousness, bad headaches, bleeding from the ears, clear fluid draining from the nose, vomiting, persistent disorientation, personality changes, seizures, irregular heartbeat and breathing, and unequal or unreactive pupils. Severe head injuries must be treated by seeking immediate medical help or evacuation.

Spinal cord injuries

If spinal cord injuries are suspected, patients must be immobilized. Some expeditions or rescue teams may carry special splints or vests in their medical kits. If no such equipment is available, spineboards may be fashioned from available materials such as backpacks, poles, or ice axes to prevent unnecessary movement of the injured backbone.

Fractures and dislocations

Wilderness care for fractures recommends immobilization by using splints and slings. If manufactured splints and slings are not available in the medicine kit, they can be improvised by using natural materials, ski poles, ice axes, clothing, or parts of backpacks. In the case of dislocations, standard wilderness procedure is to splint, tape and stabilize the injury in the current position. However, if circulation or nerve function is impaired, or if the injured person is in extreme pain, relocation may be necessary by realigning the injured area. Relocation is most effective if it is done immediately following the injury, before stiffness or muscle spasms set in.

Altitude sickness

Symptoms of altitude sickness include headache, nausea, fatigue, vomiting, and bluish skin. Ataxia, or loss of muscular control and balance indicates more severe altitude sickness. Altitude sickness can occur at altitudes above 8,000 feet. The best prevention of the condition is allowing plenty of time for acclimatization at high altitudes, drinking plenty of fluids, and eating a diet rich in carbohydrates. Aspirin or acetaminophen may be taken, while the drug acetazolamide (Diamox) can relieve symptoms of mild acute mountain sickness (AMS). Other related conditions, which can cause death, are high altitude cerebral edema (HACE), which causes fluid accumulation on the brain, and high altitude pulmonary edema (HAPE), which causes fluid in the lungs. The main treatment for acute mountain sickness is to rapidly descend to lower altitudes. In some cases oxygen may be available to ease symptoms.

Problems from cold and heat

Frostbite is localized tissue damage from exposure to cold, and is remedied by the slow warming of exposed parts, preferably in heated water. Hypothermia is the condition resulting from lowered body core temperature, and is a common affliction in wilderness medicine. Mild hypothermia occurs when the body's core temperature (measured rectally) falls from normal to 95°F (35°C) Fahrenheit. Moderate hypothermia gives temperatures between 90-95°F (32.2-35°C), while severe hypothermia occurs when a body's core temperature falls below 90°F (32.2°C). Symptoms include severe shivering, confusion, apathy, drowsiness, slurred speech, and impaired reflexes, and progresses to the point of unconsciousness.

Even cases of the mildest hypothermia must be cared for closely. Patients in whom hypothermia is suspected should be immediately warmed by gently removing wet clothing and providing dry clothing, blankets and shelter. They should be monitored for body temperature changes. Severe hypothermia cannot be remedied in the wilderness; victims must be immediately and gently evacuated. Warming severe hypothermia victims too quickly is dangerous. Cardiopulmonary resuscitation (CPR) may be initiated on victims of severe hypothermia who have cardiac arrest. In cases of near drowning, hypothermia must always be suspected.

Illness from heat includes heat exhaustion and the more severe heat stroke. Symptoms include confusion, rapid weak pulse, cramps, dizziness, nausea, diarrhea, headache, and high measured temperatures. Sweating may or may not occur, and the skin may be clammy and blotched. The principle treatment for heat illness in the wilderness is immediate cooling of the patient, by providing shade, fanning, sponging and immersion in cold water. Heat exhaustion will correct itself with enough rest and water. Heat stroke is life threatening and requires immediate cooling and rehydration with fluids, preferably intravenous ones. Prevention of heat illness includes proper conditioning, protective clothing, and avoiding dehydration.

Insect, reptile, and animal bites

Wilderness medicine must deal with an array of bites and stings, from bears, snakes, reptiles, spiders, scorpions, bees, fish and ticks. Prevention includes knowledge of the threats in the region being explored, as well as packing appropriate supplies such as bee sting kits for anaphylactic shock and snakebite kits for venomous attacks. The goal of treatment is to stop bleeding, prevent infection, and alleviate envenomation, or exposure to poison. The Sawyer Extractor is a suction tool used to remove snake venom, while the Epipen and Ana-kit are available by prescription for anaphylactic shock due to stings and severe allergic reactions.

Preparation

Knowledge and sound planning can be the difference between success and disaster in the backcountry. Members of extended wilderness outings should undergo thorough examinations by their physicians and dentists prior to undertaking expeditions. People going on wilderness outings should begin in a state of sound physical fitness by undertaking appropriate conditioning programs, as well as becoming acclimatized to special conditions such as altitude or extreme temperatures. Those with medications should be aware of potential side effects and complications, and inform other members of their group. At least two, and preferably all, members of wilderness expeditions should be familiar with first aid, wilderness medicine and rescue procedures. All members of wilderness outings should carry appropriate clothing, equipment, food, water, and first aid supplies. Trip itineraries should be recorded with park rangers or other official services. Means of communication with rescue facilities should be considered in advance in case emergencies arise.

Carrying adequate medical supplies is a crucial preparation for wilderness outings. These supplies will vary depending on the length of the trip and the region. Medical kits should contain basic first aid supplies such as bandages, dressings, pain relievers, water purification tablets, sunscreen, antiseptics, and ointments. Additional medical supplies include antibiotics, medications for gastrointestinal problems, antihistamines and emergency kits for asthma or allergic reactions, snake and insect bite kits, splints, and basic surgical supplies. Extended expeditions or those facing extreme conditions might include intravenous fluids, oxygen bottles for altitude problems, rescue gear and evacuation equipment, and specific medications for regional diseases and infections, such as malaria.

KEY TERMS

Anaphylactic shock— Severe allergic reaction characterized by airway constriction, tissue swelling, and lowered blood pressure.

Cardiac arrest— Heart failure or heart attack.

Dislocation— Displacement of bones at a joint.

Envenomation— Exposure to venom by bites or stings from insects, reptiles, and fish.

Wilderness— Large backcountry areas lacking roads, communication and other modern infrastructure.

Immunizations are a very important preparation for those entering wilderness areas, particularly in Third World countries. Immunizations should be planned as far in advance as possible, as some take several weeks to become effective and others cannot be given together. Some immunizations that may be required, depending on the region, include tetanus, poliovirus, measles, mumps, rubella, cholera, yellow fever, meningococcus, hepatitis, bubonic plague, typhoid fever and rabies. See Resources below for sources of specific immunization information.

Several organizations provide training and certification for various levels of wilderness medicine. The most basic levels of preparation are first aid and first responder certifications, followed by outdoor emergency care (OEC) training. More rigorous training provides the wilderness first responder (WFR), the wilderness emergency medical technician (WEMC), or the wilderness prehospital emergency care (WPHEC) certifications. The most advanced level of wilderness medical certification is search and rescue (SAR) emergency care, which provides expertise in a sophisticated array of rescue techniques and equipment.

Resources

BOOKS

Auerbach, Paul, MD. Medicine for the Outdoors. New York: The Lyons Press, 1999.

ORGANIZATIONS

International Association for Medical Assistance to Travelers (IAMAT). 417 Center St., Lewistown, NY 14092. (716) 754-4883.

U.S. Centers for Disease Control. 1600 Clifton Road NE, Atlanta, GA 30333. (404) 639-1610. 〈http://www.cdc.gov〉. Publishes Health Information for International Travel.

Wilderness Medical Society. PO Box 2463, Indianapolis, IN 46204. (317) 631-1745.

Wilderness Medicine Institute. PO Box 9, 413 Main Street, Pitkin, CO 81241. (970) 641-3572. 〈http://www.wildernessmed.com〉.