Wilderness medicine

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Wilderness medicine
SKI PATROL ATTENDS AN INJURED SKIER. CROSSED SKIS INDICATE AN INJURY - NARA - 554256.jpg
Synonymsexpedition medicine, austere medicine, remote medicine
Subdivisions Expedition medicine

Military medicine

Diving medicine

Aviation medicine
Significant diseasesAltitude sickness

dysbarism envenomation heat related illnesses hypothermia

major trauma

Contents

Significant testsPoint of care; Ultrasound, blood tests
SpecialistWilderness Medicine Physician/Clinician

Wilderness medicine is a medical specialty concerned with medical care in remote, wilderness and expedition environments. The specialty includes prior planning, public health issues, a number of sub-specialties as well as responding to emergencies. One modern definition of wilderness medicine is "medical care delivered in those areas where fixed or transient geographic challenges reduce the availability of, or alter requirements for, medical or patient movement resources". [1] [2] [3]

This rapidly evolving field is of increasing importance as more people engage in outdoor activities, with more participants coming from the extremes of age, and with more people engaging in high risk activities. [4]

The exact aegis of wilderness medicine as a specialty is in constant flux to match the requirements of patients underlying wilderness or remote activities. While wilderness medicine is the preferred terminology for this medical speciality in the United States, terminology such as extreme medicine, remote medicine or expedition medicine, are used internationally.

Wilderness medicine overlaps with a number of other medical specialties in terms of knowledge base and scope of practice, these most notable include; Pre-hospital emergency medicine, Military medicine, Humanitarian aid, Disaster medicine and Public health. The future of extreme, expedition, and wilderness medicine will be defined by both recipients and practitioners, and empirical observations will be transformed by evidence-based practice. [5]

Unlike wilderness first aid which is focussed on the provision of immediate care to the sick and injured in a wilderness setting, wilderness medicine has a far broader approach. These include but are not limited to:

Scope

Wilderness medicine is a varied sub-specialty, encompassing skills and knowledge from many other specialties. The specific curricula will vary but an example can be seen in the curriculum [9] [10] for Fellowship in the Academy of Wilderness Medicine (FAWM):

Scope of Practice
Diving and hyperbaric medicine
  • Physics and physiology of depth
  • Dive medicine
  • Dysbarisms and barotrauma
Tropical and travel medicine
High-altitude and mountaineering medicine
Expedition medicine
  • Basic (emergency) field dentistry
  • Expedition planning, pre- and post-expedition responsibilities
  • Camp safety and layout
Survival, field craft and equipment
  • Survival techniques and equipment
  • Water procurement
  • Food procurement
  • Hiking and trekking
  • Foot gear and care of the feet
  • Clothing selection for wilderness survival
  • Land navigation
Search and Rescue
Sports Medicine
  • rock climbing
  • ultramarathons
  • endurance sports
  • kayaking / sailing etc.
Preventive medicine, field sanitation and hygiene
  • Field sanitation and hygiene measures
  • Vector control and barriers
  • Water purification methods
Environmental Medicine
Improvised Medicine
  • Improvised field wound management
  • Improvisational medical techniques in the wilderness
Disaster and Humanitarian Assistance
  • Triage
  • Field hospital provision
  • Malnutrition therapy
Wilderness Emergencies and Trauma Care
  • Pre-hospital patient assessment
  • Pain management in the wilderness setting
  • Emergency airway management
  • Psychological response to injury and stress
  • Management of trauma and injuries
  • Prolonged Field Care (PFC)

Epidemiology

The epidemiology of wilderness medicine is as broad as the patient groups, geography and activities in question. Common risks to many of these are gastointestinal upset, and minor injuries (ankle sprains, fractures, scrapes and lacerations) as well as the rarer and more serious disorders such as major trauma, heat related illnesses and cardiovascular disease (e.g. cardiac arrest). [11] There are also a number of specific wilderness medical emergencies.

Austere environments interdisciplinary interface

Insights from the field of Military Combat Tactical Care (TCCC) interact with wilderness medical practice and protocol development. Moreover, new products and technologies tested in combat are adopted by wilderness medical personnel and vice versa. [12] Experts in wilderness medicine come from various professional groups and specialist backgrounds including the military. More recently, advances in the development of Prolonged Field Care (PFC) guidelines has led to the development of military and civilian PFC courses, [13] such as the international Austere Emergency Care course. [14] [15]

Casualty extrication by road Nepal ambo.JPG
Casualty extrication by road

Notable Individuals

Education

Portable hyperbaric chamber used in altitude sickness Portable hyperbaric chamber.jpg
Portable hyperbaric chamber used in altitude sickness

Few countries provide formal medical accreditation for specialists in wilderness medicine. The credentialing that exists is mostly drawn from professional organisations run for and by wilderness medicine clinicians. As a result, there is a huge variety in the education available for wilderness medicine, with only a few educational institutions specialising in this field. The Wilderness Medical Society is perhaps the oldest and most well established organisation in this area and has established international reach. The Wilderness Medical Society produce the Wilderness & Environmental Medicine journal and administer the Fellowship of the Academy of Wilderness Medicine (FAWM) award. The FAWM was first awarded in 2007 in 28 clinicians (20 men and 8 women). [40] The FAWM continues today and recognised educational activity form a number of providers which provide credit towards the Fellowship. The College of Remote and Offshore Medicine (CoROM) in Malta offers FAWM credit as well as; undergraduate, postgraduate and short courses in wilderness medicine-related topics. [41] and mountain medicine. An extreme medicine master's degree has run in partnership between World Extreme Medicine and the University of Exeter since 2016. [42] There are a number of higher education and specialist qualifications available internationally:

Diplomas
Bachelors
Masters Degrees
Fellowships (Academic)
Fellowships (Contribution to the field)

Applications to Covid-19

As of April 2020, studies and trials are underway that examine the possible benefits of nitric oxide in the treatment of COVID-19. [49] [50] [51] This research is related to the role of nasal breathing in the creation of nitric oxide, which increases oxygen absorption in the lungs. [52] Nitric oxide was also investigated as an experimental therapy for SARS. [53]

Brian Strickland, MD, a fellow in Wilderness Medicine at Massachusetts General Hospital who studies "acute respiratory distress" in high altitudes, is applying this research towards COVID-19. [54] [55] He is currently involved in clinical trials which apply the use of inhaled nitric oxide as a treatment for COVID-19. [56] This approach was inspired by the work of associate professor of Emergency Medicine at the Harvard Medical School N. Stuart Harris, who has been studying the effects of altitude sickness on mountain climbers, such as those who climb Mount Everest. Harris noticed that the consequences of high level altitude sickness on the human body mirrored COVID-19's dysfunctional impact on the lungs. His focus on nitric oxide comes from its role in being able to breathe in high altitudes. [54] [57]

See also

Related Research Articles

<span class="mw-page-title-main">Emergency medicine</span> Medical specialty concerned with care for patients who require immediate medical attention

Emergency medicine is the medical speciality concerned with the care of illnesses or injuries requiring immediate medical attention. Emergency medicine physicians specialize in providing care for unscheduled and undifferentiated patients of all ages. As first-line providers, in coordination with emergency medical services, they are primarily responsible for initiating resuscitation and stabilization and performing the initial investigations and interventions necessary to diagnose and treat illnesses or injuries in the acute phase. Emergency medical physicians generally practice in hospital emergency departments, pre-hospital settings via emergency medical services, and intensive care units. Still, they may also work in primary care settings such as urgent care clinics.

<span class="mw-page-title-main">Emergency medical services</span> Services providing acute medical care

Emergency medical services (EMS), also known as ambulance services or paramedic services, are emergency services that provide urgent pre-hospital treatment and stabilisation for serious illness and injuries and transport to definitive care. They may also be known as a first aid squad, FAST squad, emergency squad, ambulance squad, ambulance corps, life squad or by other initialisms such as EMAS or EMARS.

<span class="mw-page-title-main">Emergency medical technician</span> Health care provider of emergency medical services

An emergency medical technician is a medical professional that provides emergency medical services. EMTs are most commonly found serving on ambulances and in fire departments in the US and Canada, as full-time and some part-time departments require their firefighters to be EMT certified.

<span class="mw-page-title-main">Paramedic</span> Healthcare professional who works in emergency medical situations

A paramedic is a healthcare professional trained in the medical model, whose main role has historically been to respond to emergency calls for medical help outside of a hospital. Paramedics work as part of the emergency medical services (EMS), most often in ambulances. They also have roles in emergency medicine, primary care, transfer medicine and remote/offshore medicine. The scope of practice of a paramedic varies between countries, but generally includes autonomous decision making around the emergency care of patients.

<span class="mw-page-title-main">First responder</span> Trained emergency personnel

A first responder is a person with specialized training who is among the first to arrive and provide assistance or incident resolution at the scene of an emergency. First responders typically include law enforcement officers, emergency medical services members, fire service members and Public Works employees such as Heavy Equipment Operators as well as Public Works Tree Department personnel. In some jurisdictions, emergency department personnel, such as doctors and nurses, are also required to respond to disasters and critical situations, designating them first responders; in other jurisdictions, military and security forces may also be authorized to act as first responders.

<span class="mw-page-title-main">Emergency physician</span> Physician specialized in emergency medicine

An emergency physician is a physician who works in an emergency department to care for ill patients. The emergency physician specializes in advanced cardiac life support, resuscitation, trauma care such as fractures and soft tissue injuries, and management of other life-threatening situations.

<span class="mw-page-title-main">British Columbia Ambulance Service</span> Ambulance service in British Columbia, Canada

The British Columbia Ambulance Service (BCAS) is an ambulance service that provides emergency medical response for the province of British Columbia, Canada. BCAS is one of the largest providers of emergency medical services in North America. The fleet consists of more than 500 ground ambulances operating from 183 stations across the province along with 80 support vehicles. Additionally, BCAS provides inter-facility patient transfer services in circumstances where a patient needs to be moved between health care facilities for treatment. BCAS also operates a medical evacuation program that utilizes both fixed-wing and rotary aircraft.

<span class="mw-page-title-main">New South Wales Ambulance</span> Provider of pre-hospital emergency care in New South Wales, Australia

NSW Ambulance, previously the Ambulance Service of NSW, is an agency of NSW Health and the statutory provider of pre-hospital emergency care and ambulance services in the state of New South Wales, Australia.

<span class="mw-page-title-main">Wilderness medicine education in the US</span>

Wilderness medicine is defined by difficult patient access, limited equipment, and environmental extremes. Today, wilderness or expedition medicine is practiced by Wilderness First Responders, Wilderness EMTs, Remote/Offshore/Wilderness Paramedics, and Physicians on expeditions, in outdoor education, search and rescue, mountain rescue, remote area operations including research, exploration, and offshore oil platforms, as well as tactical environments. In mainland Europe, where mountain rescue is done by paid professionals, there are courses for physicians that help qualify them to be mountain rescue or expedition doctors. Many of these courses lead to an International Diploma in Mountain Medicine, which is recognized by the Union Internationale des Associations Alpinistes.

An wilderness emergency medical technician is an emergency medical technician that is better equipped than other licensed healthcare providers, who typically function almost exclusively in wilderness environments, to better stabilize, assess, treat, and protect patients in remote and austere environments until definitive medical care is reached. Despite the term, wilderness emergency medical technician training is available and geared not just to the emergency medical technician, but also the paramedic, prehospital registered nurse, registered nurse, physician assistant, and medical doctor. After all, without an understanding of the applicable gear, skills, and knowledge needed to best function in wilderness environments, including a fundamental understanding of the related medical issues more commonly faced, even an advanced provider may often become little more than a first responder when called upon in such an emergency. WEMT training and certification is similar in scope to wilderness advanced life support (WALS) or other courses for advanced providers such as AWLS, WUMP, WMPP, and RMAP. Unlike more conventional emergency medicine training, wilderness emergency medicine places a greater emphasis on long-term patient care in the backcountry where conventional hospital care can be many hours, even days, away to reach.

<span class="mw-page-title-main">Emergency medical responder</span> Person who provides out-of-hospital care in medical emergencies

Emergency Medical Responders (EMRs) are people who are specially trained to provide out-of-hospital care in medical emergencies, typically before the arrival of an ambulance. Specifically used, an emergency medical responder is an EMS certification level used to describe a level of EMS provider below that of an emergency medical technician and paramedic. However, the EMR is not intended to replace the roles of such providers and their wide range of specialties.

The following outline is provided as an overview of and topical guide to emergency medicine:

<span class="mw-page-title-main">Wilderness Medical Society</span>

The Wilderness Medical Society was created on 15 February 1983 by three physicians from California, United States — Dr. Paul Auerbach, Dr. Ed Geehr, and Dr. Ken Kizer. It is the largest international non-profit membership organization devoted to addressing wilderness medicine challenges, more specifically defined as "medical care delivered in those areas where fixed or transient geographic challenges reduce availability of, or alter requirements for, medical or patient movement resources". It also publishes Wilderness & Environmental Medicine Journal, Wilderness Medicine Magazine, and Wilderness Medicine Clinical Practice Guidelines.

A wilderness medical emergency is a medical emergency that takes place in a wilderness or remote setting affinitive care. Such an emergency can require specialized skills, treatment techniques, and knowledge in order to manage the patient for an extended period of time before and during evacuation.

Wilderness first aid as an established medical discipline is a relatively new phenomenon compared to the more established field of prehospital emergency medicine. While instructional guidelines for curriculum for prehospital emergency medical care have been standardized by the U.S. federal government, there are no current federal regulations defining scopes of practice for varying levels of wilderness medicine.

<span class="mw-page-title-main">Air medical services</span> Use of air vehicles to transport patients

Air medical services are the use of aircraft, including both fixed-wing aircraft and helicopters to provide various kinds of medical care, especially prehospital, emergency and critical care to patients during aeromedical evacuation and rescue operations.

<span class="mw-page-title-main">Seth C. Hawkins</span> American poet

Seth Christopher Collings Hawkins is an American emergency physician, writer, anthropologist, and organizational innovator. He has made notable contributions to the fields of wilderness medicine, Emergency Medical Services (EMS), and medical humanities. His work has particularly specialized in EMS and wilderness medicine in the southeastern United States, where he is the founder of the Appalachian Center for Wilderness Medicine, the Appalachian Mountain Rescue Team, and the Carolina Wilderness EMS Externship.

<span class="mw-page-title-main">Pre-hospital emergency medicine</span>

Pre-hospital emergency medicine, also referred to as pre-hospital care, immediate care, or emergency medical services medicine, is a medical subspecialty which focuses on caring for seriously ill or injured patients before they reach hospital, and during emergency transfer to hospital or between hospitals. It may be practised by physicians from various backgrounds such as anaesthesiology, emergency medicine, intensive care medicine and acute medicine, after they have completed initial training in their base specialty.

<span class="mw-page-title-main">William R. Smith (physician)</span> American physician

William 'Will' R. Smith, is an emergency physician and wilderness medicine consultant who lectures about integrating combat medicine into wilderness rescues around the world. He started Wilderness & Emergency Medicine Consulting, a company that helps people with pre-trip planning, online medical support, travel medicine in remote areas and provides expert witness testimony in court cases related to wilderness medicine. As medical director for the National Park Service, he oversaw the largest rescue event ever to occur in Grand Teton National Park. He lives in Jackson, Wyoming, where he is an emergency medicine physician at St. John’s Medical Center.

<span class="mw-page-title-main">Prolonged field care</span> Specialized type of medical care

Prolonged field care refers to the specialized medical care provided to individuals who have sustained injuries or illnesses in situations where timely evacuation to a medical facility is delayed, challenging, or not feasible. This concept is applicable in various contexts, including military operations, wilderness emergencies, and disaster response scenarios. Definitions exhibit slight variation, but they convey the same fundamental meaning:

"Field medical care, applied beyond doctrinal planning time-lines"

"Field medical care that is applied beyond 'doctrinal planning time-lines' by a tactical medical practitioner in order to decrease patient mortality and morbidity."

"Prolonged care is provided to casualties if there is likely to be a delay in meeting medical planning timelines"

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