Unique Challenges in Wilderness Medicine

Introduction:

Wilderness medicine is a multi-branched field of medical practice. Medical practice in the wilderness poses varied challenges to the caregiver. Wilderness medicine provides emergency care to an ill or injured person who is suffering a casualty, and hospital care is not available at the moment. However, careful planning, patient assessment, and effective management guidelines should be devised to carry out such challenging medical emergencies. The most common injuries treated by wilderness medicine specialists are soft-tissue lesions, sprains, strains, and lower-extremity fractures. The Wilderness Medical Society (WMS) was founded by three physicians, Dr. Greer, Dr. Auerbach, and Dr. Kizer, from northern California in 1983. This is a non-profit organization and is based in Salt Lake City, Utah, USA (United States of America).

What Are the Fields of Interest Covered Under Wilderness Medicine?

1. Dive Medicine:

• Recreational diving and technical diving are becoming popular globally.

• Decompression illness and barotrauma are related to diving.

• Scientific diving encounters the lowest injury rates.

• Decompression illness is caused by decompression stress followed by nitrogen bubble formation and pro-inflammatory microparticle formation.

• Treatment involves recompression in a hyperbaric chamber, and the use of portable chambers in remote areas has been advocated.

2. High Altitude Care:

• High-altitude travel has witnessed an increased demand in recent times.

• The incidence rate of AMS (acute mountain sickness) is high and is estimated to be 25 per cent in people who go mountaineering.

• High-altitude pulmonary edema (HAPE) and high-altitude cerebral edema (HACE) are identified as potentially life-threatening conditions encountered in high-altitude travel.

• The primary treatment involves the administration of oxygen.

• Pharmacologic management includes Acetazolamide and glucocorticoids for effective management of such conditions.

3. Envenomation:

• Victims’ reactions to envenomation are often self-limiting, but sometimes systemic complications, including coagulopathy or respiratory, can occur due to the neurotoxins released by the venom.

• Some envenomations from Cubozoa jellyfish can cause severe adrenergic surges and cardiovascular collapse.

4. Trauma Care:

• Trauma is the most common reason for morbidities occurring in the wilderness.

• Head injury remains the most common casualty that might occur during hiking, rock climbing, mountain biking, and snow-related activities.

• Wilderness medicine caters to medical care in case of motor vehicle accidents during travel and the ones that occur in remote areas.

• Unfortunately, trauma may be a life-threatening emergency involving multiple systems.

• Advances in cervical spine management and immobilization, opiate-assisted pain control, and invasive procedures are part of trauma care in wilderness medicine.

• Lay providers are taught shoulder reduction techniques to harness effective management of the case.

5. Hyperthermic Care:

• Heat exposure can lead to a wide range of symptoms, from heat cramps to heatstroke, a potential life threat.

• Heatstroke sometimes proves to be fatal, as it is associated with elevated core body temperature accompanied by neurologic dysfunction.

• Heatstroke is a complex process that includes cellular dysfunction, cardiac conduction impairment, release of pro-inflammatory cytokines, intravascular depletion, and subsequent circulatory collapse.

• Removal of heat stress and rapid whole-body cooling is helpful in alleviating encephalopathy, coagulopathy, and multi-organ failure.

6. Frostbite Care:

• Frostbite involves vasoconstriction, ischemia, and intracellular and extracellular ice crystal formation, leading to cell lysis and cell death due to the cooling of the tissues. Reperfusion-ischemia injury is possible, and repeated thawing and refreezing are particularly damaging.

• Basic field care involves administering anti-prostaglandins, controlling pain, and placing protective dressings, and underlying hypothermia should be managed.

• Non-hemorrhagic blister debridement should be done.

• In advanced-care medical facilities, tissue plasminogen activators or prostaglandins/PG analogs can be administered.

• Tissue viability can be determined easily with advanced techniques like magnetic resonance angiography and bone scintigraphy.

7. Avalanche:

• Avalanche victims are at high risk of undergoing hypothermia and suffocation due to the traumatic forces of the snowball.

• Avalanche rescue and resuscitation can be carried out better with a thorough insight into snow burial physiology, including cooling, after drops, and the role of exhaled carbon dioxide.

• Technological advances such as exhaled air diversion devices, flotation devices, and transceivers are designed to lower the risk of avalanche-associated injury and death.

8. Military Medicine:

• Battlefield medicine or military medicine has grown drastically in the past decade, equipped with all the trauma-care casualty guidelines and training.

• Advances in hemorrhage control with the help of tourniquets and hemostatic agents, surgical cricothyroidotomy, intraosseous access, needle decompression, pain management, prophylactic antibiotics, and low-volume field resuscitation have been employed.

9. Travel Medicine:

• Travel medicine deals with the epidemiology of travelers’ diseases, education among the risk group, and an initiative to spread awareness about vaccination. This specialty is gaining popularity as it is an era of easy long-distance travel.

• Malaria is the most common disease of concern in travel medicine, carrying higher morbidity and mortality rates, especially among children.

• Geosentinel monitoring is used to assess disease propagation and assist in management.

10. Search and Rescue Operations:

• Search and rescue operations are conducted under many organizational structures, such as citizen volunteer groups, law enforcement agencies, and in many other localities.

• Participants’ medical training involves basic first aid and wilderness first aid training; classes for wilderness first responders, wilderness emergency medicine technicians, paramedics, as well as for physicians are conducted.

• Search and rescue missions are often used for missing children, recreationists, and individuals with developmental delay, autism, Alzheimer's disease, or dementia.

• Helicopters facilitate rapid identification and evacuation employed under appropriate circumstances.

What Practice Guidelines Does WMS (Wilderness Medicine Society) Follow?

The evidence-based wilderness medical society practice guidelines have been formed and published in several areas of wilderness medicine. The topics addressed are:

• High-altitude illness.

• Frostbite.

• Lightning.

• Eye injuries.

• Epinephrine.

• Use of extrication devices in crevasse rescue.

• Exercise-associated hyponatremia.

• Spine trauma management.

• Heat-related illness.

What Is the Scope of Wilderness Medicine?

1. Professional Organizations:

• The Wilderness Medical Society (WMS) is a pioneer professional organization representing wilderness medicine physicians and other healthcare providers.

• The World Congress in Wilderness Medicine has been meeting every ten years since 1991 to provide a forum for exchanging current ideas and concepts related to wilderness medicine.

• The International Society for Mountain Medicine sponsors the International Hypoxia Symposium and the Congress on High Altitude Medicine and Physiology. The Undersea and Hyperbaric Medical Society, the Divers Alert Network, and the South Pacific Undersea Medicine Society focus on dive medicine.

• The International Society of Travel Medicine (ISTM) was founded in 1988. The organization focuses on travel-related diseases, including immunization recommendations.

• ISTM is involved in the global monitoring of infectious diseases. In collaboration with the Centers for Disease Control and Prevention (CDC), ISTM manages a global surveillance network for infectious diseases to provide real-time data for analyzing evolving disease patterns.

2. Fellowships:

• The purpose of wilderness medicine fellowships is to develop academic leaders in the specialty.

• The fellowship program comprises a research component, a teaching component, and a field component. The course duration will be one year of training, with part-time clinical attending duties and part-time wilderness medicine training.

• The best-known wilderness medicine fellowship is based at Stanford University in Palo Alto, California. There are eight wilderness medicine fellowships associated with emergency medicine residency programs enlisted by Academic Emergency Medicine.

• They are located at Baystate Medical Center, the University of California, San Francisco-Fresno, the Medical College of Georgia, the University of Utah, Massachusetts General Hospital, the University of Colorado, the State University of New York, and Loma Linda University.

• The Madigan Army Medical Center hosts an Austere and wilderness medicine fellowship for military physicians.

3. Master’s Degree:

• The Wilderness Medical Society started its master's degree program in 2009.

• The program offers advanced, post-fellow certification in the chosen sub-discipline within the scope of wilderness medicine.

• The degree comprises a curriculum in education, scholarly activity, and experimental activity.

• Most participants fulfill the requirements of their program within two to five years.

4. Diploma in Mountain Medicine:

• The WMS also provides diploma courses in mountain medicine, certifying academic and advanced skills in mountain rescue techniques in collaboration with the University of Utah and the University of Colorado.

• The course started in 1997.

• The program is open to physicians, nurses, and paramedics who work in or aspire to work in austere environments.

• The skill involves expedition medicine, search and rescue operations, mountain guiding, ski patrol, and mountain recreation.

• Participants must pass written and skills examinations to complete the program.

5. Schools of Wilderness Medicine:

• Stonehearth Open Learning Opportunities (SOLO), Conway, New Hampshire, USA.

• National Outdoor Leadership School, Wilderness Medicine Institute, Lander, Wyoming, USA.

• Wilderness Medical Associates International, Portland, Maine, USA; Haliburton, Ontario, Canada.

• Tsukubamirai, Ibaraki, Japan.

• National Ski Patrol, Lakewood, Colorado, USA.

• Advanced Wilderness Life Support, University of Utah, Salt Lake City, Utah, USA.

• Aerie Backcountry Medicine, Missoula, Montana, USA.

6. Wilderness Research and Grants:

The Wilderness Medical Society offers various grants to support health-related research projects in outdoor and wilderness activities, which are as follows:

• Charles. S. Houston Award.

• Research-in-training award.

• Herbert. N. Hultgren Award.

• WMS adventure travel research grant.

• Peter Hackett- Paul Auerbach research grant.

Conclusion:

Wilderness medicine is reaching new heights in education, research, training, technology, communications, and the environmental streams. With the emerging diverse streams in WMS, many are gaining interest in joining the course. In the upcoming years, more research is required in this field to deepen the understanding of specific techniques performed to enhance better clinical outcomes.