Volume 27, Number 2 - Wilderness Medical Society
Volume 27, Number 2 - Wilderness Medical Society
Volume 27, Number 2 - Wilderness Medical Society
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SPRING 20<br />
10<br />
<strong>Volume</strong> <strong>27</strong>, <strong>Number</strong> 2<br />
Dispatches from Haiti<br />
MSF Surgical Mission: Congo<br />
Why <strong>Wilderness</strong> Medicine?<br />
$12.50 US
WilDerneSS<br />
MeDiCAl<br />
SoCietY<br />
Mark your 2010 calendars<br />
for these upcoMing<br />
WMs conferences<br />
Photo by Peter Kummerfeldt<br />
WMS AnnuAl Meeting &<br />
CMe ConferenCe<br />
Snowmass, Colorado<br />
July 23-28, 2010<br />
Photo by Paul Auerbach<br />
WMS trAvel, Dive & MArine<br />
MeDiCine ConferenCe<br />
The Westin Ka’anapali Resort & Spa<br />
October 30 – November 3, 2010<br />
Lahaina, Maui, Hawaii<br />
These activities have been planned and implemented in<br />
accordance with the Essential Areas and Policies of the<br />
Accreditation Council for Continuing <strong>Medical</strong> Education through<br />
the <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong>. The <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong><br />
is accredited by the ACCME to provide continuing medical<br />
education for physicians.<br />
REGISTER ONLINE<br />
WMS.org/conferences<br />
or call 801.990.2988<br />
for up-to-date info<br />
COMBINING YOUR PROFESSION<br />
WITH YOUR PASSION
EditorIAL STAFF<br />
SPRING 2010 INSIDE<br />
<strong>Wilderness</strong> Medicine<br />
A quarterly magazine published by the<br />
<strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong><br />
Christopher Van Tilburg MD, FAWM, Editor<br />
Jonna Barry Managing Editor<br />
Larry E. Johnson MD, PhD, Assistant Editor<br />
Seth C. Hawkins MD, FAWM, Senior Editor<br />
Debra Stoner MD, FAWM, Associate Editor<br />
George Rodway PhD, CRNP, Publications<br />
Committee Chair<br />
Contributing Editors<br />
Nancy Pietroski PharmD<br />
Sam Schimelpfenig MD<br />
Research Editors<br />
Tracy Cushing MD<br />
Matt Hamonko MD<br />
Marion McDevitt MD<br />
Editors Emeritus<br />
Edward Geehr MD, 1984-1986<br />
Howard Backer MD, 1986-1991<br />
Eric A. Weiss MD, 1991-1994<br />
Karl Neumann MD, 1994-2002<br />
WMS Editorial Office & Advertising Sales<br />
Jonna Barry<br />
1505 N Royer St<br />
Colorado Springs, CO 80907<br />
Tel: (719) 330-7523<br />
Fax: (801) 705-1483<br />
Email submissions to editor@wms.org<br />
Design & layout:<br />
CoPilot Creative<br />
1301 W. Colorado Ave.<br />
Colorado Springs, CO 80904<br />
copilotcreative.com<br />
<strong>Wilderness</strong> Medicine (ISSN 1073-502X) is<br />
published quarterly in January, April, July, and<br />
October by the <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong>, 2150<br />
South 1300 East, Suite 500, Salt Lake City, Utah.<br />
Periodical postage paid at Salt Lake City, Utah and<br />
additional mailing offices. Annual subscription<br />
rate: $55. POSTMASTER: Send address changes<br />
to the <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong>, 2150 South<br />
1300 East, Suite 500, Salt Lake City, Utah.<br />
Submit request to reprint <strong>Wilderness</strong> Medicine in<br />
whole or in part to copyright.com.<br />
©2009 <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong>. All rights<br />
reserved. Printed on FSC-certified paper.<br />
<strong>Wilderness</strong> Matters........................................................................................... 4<br />
Colin Grissom MD, FAWM<br />
Dispatches from Haiti....................................................................................... 5<br />
Paul S. Auerbach MD, MS, FACEP, FAWM<br />
Off the Beaten Path: Surgical Mission with MSF in the Congo......... 12<br />
Michael Hauty, MD, FACS<br />
Why <strong>Wilderness</strong> Medicine?............................................................................ 16<br />
Rob Hart RN, FAWM<br />
Nosebleeds in the Backcountry................................................................. 18<br />
Sam Schimelpfenig, MD, FAAP<br />
Mount Hood SAR Operations....................................................................... 19<br />
Christopher Van Tilburg MD, FAWM<br />
Great Gear for Work and Play: Urbaneering with cyclocross....... 20<br />
Christopher Van Tilburg MD, FAWM<br />
What’s in Your Pack?....................................................................................... 21<br />
Greg Natsch MD<br />
Advanced <strong>Wilderness</strong> Life Support New Zealand-Style....................... 22<br />
Martin Watts MB ChB, FACEM<br />
Book Reviews..................................................................................................... 24<br />
<strong>Society</strong> Matters................................................................................................ 25<br />
News and Announcements<br />
Members in the News<br />
2010 Student Elective Update<br />
Tom Kessler MD and Scott Newton<br />
Cliff Notes......................................................................................................... 29<br />
Cathy Chamberlin<br />
2010 WMS Recognition Awards.................................................................... 29<br />
Conference Calendar.................................................................................... 31<br />
On the cover: Dr. Paul S. Auerbach carries a Haitian boy on his shoulders to a surgery clinic,<br />
where one of the boy’s fingers will be amputated. Photo courtesy of Chuck Liddy/The News &<br />
Observer ©2010.<br />
NOTE: Claims for copies lost in the mail must be received within 90 days (180 days foreign) of the<br />
issue date to ensure replacement at no charge.<br />
©2010 <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong>. All rights reserved. Printed on FSC-certified paper.<br />
The goals of <strong>Wilderness</strong> Medicine magazine are to:<br />
1. Provide timely information regarding WMS news and activities.<br />
2. Provide a forum for exchange of ideas and knowledge regarding wilderness, environmental, and<br />
travel medicine.<br />
3. Disseminate wilderness medicine information to the wilderness, outdoor, and travel community.<br />
The <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong> makes no representations<br />
regarding the legal or medical information provided by the<br />
individual authors in <strong>Wilderness</strong> Medicine magazine.<br />
WILDERNESS MEDICINE // Spring 2010<br />
3
WILDERNESS MATTERS Colin Grissom MD, FAWM, President WMS<br />
2010-2011 WMS board of directors<br />
One of the important responsibilities of the<br />
<strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong> (WMS) is to<br />
establish standards of medical care in remote<br />
settings. One of the goals of my tenure as<br />
President is to increase the visibility of the<br />
WMS by making WMS Practice Guidelines<br />
for <strong>Wilderness</strong> Emergency Care (Guilford,<br />
CT: Globe Pequot; 2006) more widely<br />
available. Credit for establishment and<br />
revision of the published WMS Practice<br />
Guidelines for <strong>Wilderness</strong> Emergency Care goes<br />
to former WMS President Dr. Bill Forgey.<br />
WMS Practice Guidelines for <strong>Wilderness</strong><br />
Emergency Care is the only existing consensus<br />
recommendations specifically for wilderness<br />
medicine practitioners. This is invaluable in<br />
a resource-limited environment where the<br />
Practice Guidelines adjust the standard of care<br />
to consider limited resources and lengthy<br />
delays before reaching definitive care.<br />
At the 2009 WMS winter meeting at The<br />
Canyons in Park City, Utah a consensus<br />
guideline was created on the treatment of<br />
frostbite. A committee of experts led by WMS<br />
Board member Dr. Scott McIntosh of the<br />
University of Utah reviewed the literature<br />
and created a manuscript with evidence-based<br />
grading on the treatment of frostbite. The<br />
intention is to submit this manuscript for<br />
publication in <strong>Wilderness</strong> & Environmental<br />
Medicine journal. This update to our<br />
Practice Guidelines follows two other similar<br />
manuscripts currently in preparation: one on<br />
epinephrine treatment of anaphylaxis led by<br />
Dr. Jay Lemery of Cornell University in New<br />
York City; and the other on prevention and<br />
treatment of high altitude illness led by Dr.<br />
Andrew Luks of the University of Washington.<br />
The process for creating Practice Guidelines for<br />
the WMS has evolved into the objective of<br />
publishing them in the peer reviewed medical<br />
literature, thus making them available on<br />
PubMed searches in the electronic medical<br />
literature. Previously the Practice Guidelines<br />
has been available only in book form.<br />
Having WMS Practice Guidelines available<br />
in the electronic medical literature and<br />
searchable in PubMed will increase the<br />
availability of WMS Practice Guidelines for<br />
use and reference. This will further the goal<br />
of having the WMS maintain its position as<br />
the primary resource for standards on medical<br />
care in wilderness settings.<br />
Consistent with the goal of making the WMS<br />
a member-driven organization, involvement<br />
of WMS members is encouraged as more<br />
WMS Practice Guidelines are revised using the<br />
consensus committee method. WMS members<br />
who submit proposals for lectures or workshops<br />
at meetings will be leading candidates for the<br />
consensus-committee-generated WMS Practice<br />
Guidelines in respective areas. Our goal over<br />
time is to establish and publish WMS Practice<br />
Guidelines in all wilderness medicine areas.<br />
This will maintain the position of the WMS<br />
as the premier organization in wilderness<br />
medicine.<br />
Executive Board<br />
Colin Grissom MD, FAWM, President<br />
Loren Greenway PhD, FAWM,<br />
Chief Executive Officer<br />
Tony Islas MD, FAWM, President-Elect<br />
Eric L. Johnson MD, FAWM, Past President<br />
Jay Lemery MD, FAWM, Secretary<br />
Members at Large<br />
Paul S. Auerbach MD, MS, FAWM, Emeritus<br />
D. Cristopher Benner PA-C, FAWM<br />
Brad Bennett PhD, WEMT, FAWM<br />
Catherine Chamberlin, Student Representative<br />
Lance Ferguson MD, FAWM<br />
Scott McIntosh MD, FAWM<br />
Chris McStay, MD<br />
George Rodway CRNP, PhD<br />
COMMITTEES<br />
Academy Oversight Committee Chair<br />
Loren Greenway PhD, FAWM<br />
Awards Committee Chair<br />
Ken Zafren MD<br />
Continuing <strong>Medical</strong> Education Chair<br />
Hill McBrayer MD<br />
Conference Committee Chair<br />
Loren Greenway PhD, FAWM<br />
Education Committee Chair<br />
Jay Lemery MD, FAWM<br />
Finance and Audit<br />
Tony Islas MD, FAWM<br />
Disaster Medicine Committee Chair<br />
Joy Crook MD<br />
Environmental Council Chair<br />
Lynn Yonge MD, FAWM<br />
International Medicine Committee Chair<br />
Tracy Cushing MD<br />
Membership Committee Chair<br />
D. Cristopher Benner PA-C, FAWM<br />
Nominations Committee Chair<br />
Eric L. Johnson MD, FAWM<br />
Publications Chair<br />
George Rodway PhD, CRNP<br />
Research Council Chair<br />
Tom DeLoughery MD, FAWM<br />
Student Services Chair<br />
Catherine Chamberlin MS4<br />
Web Development Chair<br />
Jim Ingwersen<br />
ADMINISTRATIVE OFFICE<br />
Loren Greenway PhD, FAWM, CEO<br />
Loren@wms.org<br />
Teri Howell, Administrative Director<br />
Teri@wms.org<br />
<strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong><br />
2150 South 1300 East, Suite 500<br />
Salt Lake City, UT 84106<br />
Email: wms@wms.org<br />
Tel: 801-990-2988<br />
Fax: 801-990-2987<br />
Jim Ingwersen, IT Director<br />
jim@wms.org<br />
1837 Austin Bluffs Pkwy Ste 200<br />
Colorado Springs, CO 80918<br />
Tel: 719-492-2200<br />
4 WILDERNESS MEDICINE // Spring 2010
Dispatches froM Haiti<br />
Paul S. Auerbach, MD, MS, FACEP, FAWM<br />
On Tuesday, January 12, 2010 the worst earthquake in more<br />
than 200 years struck 16 miles from Port-au-Prince, Haiti.<br />
An estimated 3 million people were affected by the quake. In<br />
a country routinely referred to as the poorest in the western<br />
hemisphere, the devastation was dramatic and widespread. The<br />
relief effort has been and continues to be historic. An International<br />
<strong>Medical</strong> Corps team made up in part of Stanford doctors<br />
and nurses arrived on the scene soon after the earthquake.<br />
This is wilderness medicine at its most stark, leaving many<br />
who were first to arrive to describe the situation as “practicing<br />
Civil War medicine” in the 21st century. The following<br />
was adapted from Dr. Paul Auerbach’s blog at healthline.com/<br />
blogs/outdoor_health.<br />
WILDERNESS MEDICINE // Spring 2010<br />
5
First Days in Haiti…<br />
I can now access the Internet, so am going to try to begin to post from<br />
Haiti. Under the auspices of International <strong>Medical</strong> Corps, we have been<br />
here working very hard now for four full days. Much more has happened<br />
than I could possibly relate, so I will try to hit the highlights. Each day<br />
is more difficult than the last.<br />
The decision to travel to Haiti to assist with medical relief following<br />
the earthquake was at the same time easy and difficult. It was easy,<br />
because how could anyone be aware of such misery and suffering and<br />
not volunteer to help, but difficult because it was intimidating.<br />
My good friend Bob Norris, MD from Stanford was asked to pull<br />
together a team for IMC. I joined a group with Bob, Ian Brown, MD,<br />
and Anil Menon, MD, all Stanford emergency physicians, and Stanford<br />
nurses Gaby McAdoo, Heather Tilson, Julie Racioppi, and Jon Gardner.<br />
I flew out on Thursday and was routed on Friday morning through the<br />
Dominican Republic. I was hoping to continue on to Haiti that day, but<br />
that was not possible because of air traffic control and the situation at<br />
the destination airport. We eventually chartered a bus and required an<br />
all night drive to get to Port-au-Prince.<br />
The scene on our arrival into Port-au-Prince was intense. Most of the<br />
buildings were crushed or damaged, and there were large crowds milling<br />
on the streets and surrounding relief trucks. We watched waves of people<br />
scramble over the rubble to obtain food and supplies. Just when we<br />
despaired about how we were going to find the hospital, a helpful police<br />
escort maneuvered us through wreckage-filled streets to the University<br />
Hospital, which had become the center of medical activity. Nearly the<br />
entire population of PAP was by now living on the streets in massive,<br />
enlarging tent cities.<br />
The hospital grounds were packed with patients, and the immediate and<br />
constant emotion was and remains a sense of urgency. There are hundreds<br />
of patients, with constant cries of distress, and a regular smell of death.<br />
However, there is also hope, and an enthusiastic growing collection of<br />
volunteers from many nations, including International <strong>Medical</strong> Corps,<br />
Doctors Without Borders, Partners in Health, Hope for Haiti, Canadian<br />
Red Cross, Norwegian Red Cross, Swiss governmental humanitarian aid<br />
surgeons, and many others. It is a team effort and will continue to evolve<br />
with the enormous need.<br />
We are caring for incredibly brave people, who are suffering under the<br />
most adverse of circumstances. Yet, they all have time to say how much<br />
they appreciate the help and to thank us. We are treating fractures,<br />
massively infected wounds, some infested with maggots, disfiguring<br />
injuries, and tetanus, while in the midst, babies are being born. We<br />
cannot do everything, and sometimes can do nothing, because there<br />
are individual situations that are beyond our control. We know that<br />
tomorrow morning we will wake up, go out, and do the best we can to<br />
relieve the suffering.<br />
6 WILDERNESS MEDICINE // Spring 2010
Photo by Eric Holden.<br />
January 20…<br />
Today we were awakened by a 5.9 earthquake. We rushed to the hospital<br />
to discover that the patients who had been inside the hospital during the<br />
night had fled outdoors and many new patients had entered the grounds.<br />
Even though some of the buildings were inspected by engineers and felt<br />
to be safe, neither the patients nor the staff would agree to reenter them.<br />
Worse yet, by the middle of the day, the air temperature was in the low<br />
90s and the ground temperature closer to 100 degrees. There were too<br />
few tarpaulins and tents to cover the patients. Without sufficient shade<br />
or fluid replacement, the patients deteriorated rapidly, and we began to<br />
diagnose heatstroke, as well as cases of tetanus and gangrene.<br />
On the bright side, an entire battalion of soldiers came to the hospital to<br />
aid us. They provided security and added much-needed manpower and<br />
supplies. In addition, the USNS Comfort hospital ship arrived to accept<br />
patients, and we were able to transfer 53 of our sickest patients, which<br />
gave us more time with the remaining patients at the hospital.<br />
My heart is racing.<br />
I’m determined to get this<br />
information to you.<br />
January 21…<br />
We are receiving reinforcements from all directions, especially from<br />
International <strong>Medical</strong> Corps and from many other NGOs. The U.S.<br />
military continues to provide protection, supplies, transportation,<br />
medical assistance and most important, peace of mind. They never shirk<br />
a task when we need their help.<br />
We continue to triage, operate on and otherwise treat approximately 700<br />
patients, with injuries that will change their lives forever. We have seen<br />
countless amputations, disfigurements and open fractures. The medicine<br />
is intense, but we are up to the task most of the time. It is quite hot<br />
outside and there is little time to eat, drink or go to the bathroom, so<br />
by the end of the day we are quite tired and usually dehydrated. But we<br />
do not complain, because by comparison, the earthquake victims are<br />
so disadvantaged.<br />
WOW. We just suffered a serious aftershock. Right now as I am writing<br />
this post. The building just shook and everyone ran outside. I’m sitting<br />
here and continuing to write. Is this emotional progress? My heart is<br />
racing. I’m determined to get this information to you.<br />
Tomorrow I will be spending most of my day working to help structure<br />
interactions within the entire medical compound, to identify all the<br />
resources and to be certain that everyone working can find out how<br />
to get assistance. I’m splitting my time now between clinical care and<br />
administration.<br />
Let me share a typical story of a patient. She’s a small 3-yearold<br />
who had the side of her face crushed by falling rubble.<br />
Her ear and cheek were mangled and abraded. When I<br />
found her in the crowd a few days ago, I brought her to<br />
a team of Swiss surgeons that debrided the wound and<br />
administered antibiotics. Today the infection has progressed<br />
and it’s also apparent that she may have a broken femur and<br />
be developing a compartment syndrome in her leg. Her swollen face has<br />
distorted features, but she’s a brave little girl. We will do all we can for<br />
her. She lies in a tent with a young boy with a spinal cord injury, children<br />
with missing limbs and burn victims. This is not easy to watch and not<br />
easy to write, but it’s real. Thank goodness we have gotten to the point<br />
where we have enough staff to examine every patient at least once a day.<br />
The surgeries continue, and we have a dialysis setup for kidney failure<br />
patients and those with crush injuries, a central storehouse for medical<br />
supplies, and a small blood bank. The Norwegian Red Cross is putting<br />
up tents as fast as they can get them shipped here. We are hoping to soon<br />
have adequate staff to transition to a full 24-hour operation.<br />
Much is improvised – traction, splints, beds – but we are seeing the<br />
supply chain begin to catch up. Many new patients, like gunshot victims,<br />
are not directly earthquake-related, but we have not yet seen the “second<br />
wave.” We know it’s coming.<br />
Photo by Eric Holden.<br />
WILDERNESS MEDICINE // Spring 2010<br />
7
January 22…<br />
There was incredible activity today at the University Hospital. We<br />
suffered through more aftershocks and had to permanently evacuate a<br />
large building, so once again patients were outside in the brutal heat.<br />
Under tarps and rapidly deployed tents, we treated them with fluids and<br />
attended to their now week-old wounds.<br />
The days are nonstop from dawn to dusk. I have assumed a role to help<br />
organize the operation, including the logistics of water, food, sanitation,<br />
operating room needs, and schedules. I’ve been coordinating volunteers,<br />
arranging for shelter, caring for orphans, and interfacing with the<br />
military. The enormity of suffering is beyond comprehension, but we are<br />
learning to deal with it and move forward. I’ve learned as much as I have<br />
contributed, so that I will be prepared for the next days and the future.<br />
The people with whom I’ve worked, from Haiti and all other nations,<br />
have been remarkable. We are becoming a family.<br />
Today’s story is about a 5-year-old survivor of a week beneath the rubble.<br />
He was pulled from the ground and came to our team emaciated,<br />
dehydrated, frightened and confused. Our doctors and nurses gently<br />
hydrated him and started him on the road to recovery. With so many<br />
people affected, there will be many such stories, but for each tale with a<br />
happy ending, there are thousands with a tragic outcome.<br />
January 23…<br />
We saw a lot of progress today. The surgeons are seeing a decrease in the<br />
number of patients that need emergency surgery for crush injuries and<br />
fractures, but that doesn’t mean that we are anywhere near a point where<br />
less-than-massive resources are needed. There are still countless broken<br />
bones, deformities, facial injuries, and burns. We are encountering the<br />
sequelae of the initial surgeries that were performed in non-optimal<br />
settings. These mostly include infections that require wash-outs of<br />
wounds and revisions of the prior surgeries. This is to be expected in<br />
our situation.<br />
The hospital campus is evolving into a decent structure. We now have a<br />
central pharmacy, three operating rooms for adults, one operating theatre<br />
(within a tent, as are most facilities) for children, and arrangements<br />
for childbirth, children, postoperative patients, and emergency triage<br />
assessments. These are crowded and extremely busy areas, staffed by<br />
dedicated volunteer physicians, nurses, and technicians.<br />
I spoke with a young woman today, a dancer in Haiti who lost part of<br />
one of her legs. She was brave and doing her best to cope. I told her<br />
that she will dance again, and that she will be a much better dancer<br />
on one leg than I could ever be on two. She smiled and squeezed my<br />
hand. These are such special people. I have not seen one seriously injured<br />
victim complain.<br />
I am now officially tasked to coordinate the medical activities of all the<br />
non-governmental agencies within the compound, so I am working on<br />
medicine, essential services like water, food, and sanitation, integration<br />
between services, creation of satellite pharmacies, placement of physicians<br />
and other volunteers, and many other activities. I have never worked so<br />
hard, but have also never been more focused. My job is to make the<br />
situation improve every day for these people and for this country. The<br />
IMC team and other international volunteers inspire me to go after this<br />
mission with great determination.<br />
The Stanford Emergency Medicine team that responded to Haiti under the<br />
auspices of International <strong>Medical</strong> Corps included: (seated, left to right) Ian<br />
Brown, MD; Jonathan Gardner, RN; Heather Tilson, RN; Paul Auerbach,<br />
MD; Gaby McAdoo, RN; Julie Racioppi, RN; (standing left to right) Robert<br />
Norris, MD; Anil Menon, MD. Photo courtesy of Paul Auerbach.<br />
Arm wound post debridement. Photo by Eric Holden.<br />
8 WILDERNESS MEDICINE // Spring 2010
January 24…<br />
January 25…<br />
It was incredibly hot today on the grounds of the hospital. Fortunately,<br />
we have erected sufficient tents to accommodate all of the patients. We<br />
estimate that we have more than 600 patients on the grounds now,<br />
either in tents or living in a communal central area we call “the forest.”<br />
While there has been considerable progress, we have a way to go with<br />
communications (no phones yet), sanitation, information distribution,<br />
acquisition of key equipment, and development of social services like<br />
mental health.<br />
We continue to have new patients enter the compound, including<br />
nearly 100 emergency patients today. We are receiving patients referred<br />
from the countryside and other hospitals. The operating rooms are busy<br />
with orthopedic and wound care, skull fractures, hand surgery, facial<br />
reconstruction, and the like. Neurosurgery is still not ready to go at<br />
this facility.<br />
The Swiss have a pediatric surgery service next to our pediatric area.<br />
The tent ward is full of children with multiple amputations and severe<br />
injuries. There is no candy coating this – their lives will never be the<br />
same. A half a block away, when the wind shifts, it smells of death from<br />
bodies buried in the rubble of the nursing building. We have learned<br />
to adapt, to walk past this place and<br />
wrinkle our noses. We no longer need<br />
to wear facemasks.<br />
To facilitate progress, we have selected a<br />
chief of surgery and a nursing director,<br />
and have identified sufficient staff to<br />
cover the nights as well as the daytime.<br />
I have to sneak away now and again<br />
from my organizational duties to see patients and be a doctor. There<br />
are many doctors here to help, and we are grateful to have them. The<br />
emphasis now is to quickly transition this medical center back to its<br />
rightful owners.<br />
The city has been flattened, but the people are now picking up the<br />
pieces. We notice a decrease in the amount of garbage in the streets, and<br />
vendors are selling small amounts of fresh produce and cooked meat.<br />
The food drops appear to have been successful.<br />
I found someone willing to trade a hotel room shower for a medical<br />
consultation. Even though there was no hot water and almost no water<br />
pressure, it was the most wonderful shower I have ever taken.<br />
At the end of our 9th full day working at the University Hospital in<br />
Haiti, a functioning hospital has emerged.<br />
Our tent E.R. saw nearly 300 patients today, and we are preparing to<br />
see more than 500 tomorrow in what are essentially two rooms. To keep<br />
the place running, we are not only doctors, but also electricians, masons,<br />
and plumbers.<br />
I find myself beginning to lose my physical endurance. Everyone is<br />
getting tired…I can see it in the faces of the people with whom I have<br />
worked for many days. Each day brings new crises of capacity, supplies,<br />
sudden patient influx or something else. We have been with many of our<br />
same patients now for more than a week and have come to know them,<br />
so bad outcomes and deaths affect us a lot.<br />
The media frenzy is beginning to die down. Four days ago, you couldn’t<br />
avoid a camera or reporter being there to document your activity. If<br />
that brings resources to Haiti, I am all for it. I have been disappointed,<br />
however, in some of the innuendos. Let me tell you the truth – everyone<br />
is working incredibly hard, getting along, cooperating, and there are very<br />
few controversies. We have the operating rooms coordinated, a way to<br />
care for orphans, and simple<br />
paper medical records. Our big<br />
problem is space, but USAID<br />
[United States Agency for<br />
International Development]<br />
just brought us three big tents<br />
tonight, which is a huge relief.<br />
The city has<br />
been flattened,<br />
but the people are now picking up the pieces.<br />
I visited many of the patients I<br />
know this afternoon, just to touch their hands or wipe their foreheads,<br />
and encourage them. Many are missing a leg or arm, and have lost<br />
many relatives. Think about how life has changed for them and about<br />
what you might do to make it a bit better for them. Please pick a relief<br />
organization and make a donation. It truly makes a difference.<br />
Tent City... the beginning.<br />
Photo by Eric Holden.
January 26…<br />
On the 10th full day in Haiti, we find ourselves at the transition point<br />
where we must carry out our duties, but begin to transfer responsibility<br />
to the persons who will assume our roles when we depart. Some of our<br />
team has begun to “hit the wall.” These old muscles are aching for sure.<br />
However, each time I walk past a young Haitian child who has lost a<br />
limb, yet still smiles and tries to give me a wave, I am energized. It will<br />
be very difficult to leave, but I know that within a few days, we must get<br />
our batteries recharged.<br />
The hospital complex is really taking shape now. Tents are everywhere<br />
and all filled with patients. We have arranged for electricity and<br />
sanitation. We have oxygen bottles and new stretchers. Yet, we are still<br />
missing critical sterilization equipment for surgical instruments, modes<br />
of transportation, phones, and sufficient supplies to call this a complete<br />
medical operation.<br />
Some of my new friends from other NGOs have begun to rotate out,<br />
and I miss them already. We have become close “under fire,” in a way<br />
that is not possible in any other venue. We would trust each other with<br />
our lives.<br />
Three of us shared a common experience today, individually, as we<br />
walked down the road past the crushed nursing school and towards the<br />
Swiss surgery tent. We all noticed for the first time a beautiful flowering<br />
bougainvillea that had been completely overlooked when we marched,<br />
heads down, along what was only a week ago a thoroughfare of death.<br />
We smelled the cooking from the street, and walked past tents of injured<br />
persons singing, trying to be happy, and attempting to begin to get back<br />
to normal.<br />
Our group has befriended the young 5-year-old boy who was pulled<br />
from the rubble after a week. He comes to visit us, and clings to the nurse<br />
who was most attentive to him during his resuscitation. His parents were<br />
killed and he is an orphan. He is like thousands of children in Haiti now.<br />
The orphanages are full or filling and reconstruction cannot possibly<br />
occur fast enough to avoid enormous tent cities.<br />
January <strong>27</strong>…<br />
We’ve been here working at the University Hospital in Port-au-Prince<br />
for nearly 2 full weeks, and it has shaped up. The care being delivered<br />
is remarkable given the circumstances since the earthquake. There are<br />
two operating rooms running 4 beds each, a tented medical unit for<br />
our sickest patients, a fully stocked pharmacy, an increasing laboratory<br />
testing capability, and more tents. Still, this is not a hospital as we<br />
have them in the U.S. It is a medical facility under tents, and the<br />
conditions are not sterile. While the situation is improving, and we<br />
have optimism that it will continue to improve, for the patients who<br />
have suffered bad injuries, they are certainly not completely out of<br />
the woods.<br />
I find myself going back to visit a few patients, like the young professional<br />
dancer who lost her leg. She was returned to the O.R. today for a revision<br />
of her stump, so was postoperative and asleep when I saw her. In the<br />
crowded tent, she was covered with flies, so I sat by her for a while and<br />
fanned them away with a small notebook. In another tent, I watched a<br />
mother bathe an emaciated infant. The baby will not make it through<br />
the next two days. One tent over, a woman shouted out in pain during<br />
childbirth.<br />
The garbage is being picked up, and we should have upright portable<br />
bathrooms tomorrow. That is a triumph towards which I have struggled<br />
for days. Once again, the U.S. military showed its compassion<br />
and coordination when nearly 50 patients were evacuated to more<br />
advanced care.<br />
Yesterday the generator went out for many hours, so we could not run<br />
the O.R., or so I thought. A team of resourceful surgeons wore their<br />
headlamps and made it through some of their cases.<br />
Tomorrow we will finalize coordination of sanitation, electrical lines,<br />
tent placement, number of physicians needed through the next 2 weeks,<br />
and how to accelerate the return of Haitian physicians and nurses. There<br />
is much work to be done.<br />
We got word today that we may be going home soon. I have mixed<br />
feelings about that. It will be difficult to leave, but all signs point to it<br />
approaching the right time. Emotionally, I am OK, but my legs are a bit<br />
wobbly. I wake up as tired as I was when I went to sleep. The patients<br />
here deserve fresh legs.<br />
January 28…<br />
We found out today that we ship out tomorrow. There is an incredible<br />
amount of work to be done here – we have only contributed to the first<br />
phase of what is necessary. I cannot remember the details of much of<br />
what we did the first 3 days, when we were functioning on hyper-drive<br />
in a battlefield setting. My recollections become detailed after the third<br />
day, when we were able to see only four or five patients at a time, and we<br />
stopped triaging amputees to the operating room.<br />
Teams of non-Haitian surgeons have left to go home, because the<br />
operations to be performed now are largely orthopedic and plastic<br />
surgery, as well as specialty cases. Sadly, there are scores of patients with<br />
spinal fractures who are paralyzed, and little can be done for them this<br />
far out from the initial injury. Children continue to reach out to us. I<br />
10 WILDERNESS MEDICINE // Spring 2010
82nd Airborne preparing for a food drop.<br />
Photo by Eric Holden.<br />
had a small child who is a triple amputee offer me his cracker with his<br />
remaining hand. One can only pray that the memories he carries of this<br />
tragedy are erased swiftly, that he is assisted in his rehabilitation, and that<br />
his life improves. All of these will, of course, be hard to achieve.<br />
I visited one of my favorite patients, the young woman who danced<br />
ballet professionally before she lost her leg below the knee. Today, she<br />
was bright and alert, and gave me a big smile when I walked to the side<br />
of her stretcher bed within a very hot tent. She motioned me to come<br />
closer, and we exchanged contact information. I will do what I can to<br />
stay in touch with her.<br />
Many of our interpreters are living outside in former parks in enormous<br />
congregations of people. I gave my tent to one of these persons and am<br />
distributing everything that might be useful to victims of the earthquake<br />
and to medical persons who have just arrived to take over from those<br />
leaving to rest or return home. There are plenty of medical supplies – the<br />
Haitian people need shelter, food, and water. Soon, they must begin to<br />
rebuild and take what was a feeble economy and turn it into something.<br />
This will be a gargantuan undertaking.<br />
It became time today for me to hand over the reins to Dr. Solomon<br />
Kuah, who will assume my role as the medical coordinator of the NGO<br />
activity. I said goodbye to many persons with whom I have become close<br />
under the most challenging circumstances. In a meeting of the leadership<br />
present, I told them that I have never been so proud to be among such<br />
an incredible collection of talent and dedication. Then I allowed myself<br />
to be infused with 9 liters of IV fluid so that I could get vertical and walk<br />
out under my own power.<br />
WILDERNESS MEDICINE // Spring 2010<br />
11
Off the Beaten Path<br />
Surgical Mis<br />
with MSF in the<br />
12 WILDERNESS MEDICINE // Spring 2010
sion<br />
Congo<br />
Michael Hauty<br />
MD, FACS<br />
Photos courtesy of Michael Hauty<br />
The<br />
team was tightly squeezed into a white<br />
Toyota Land Cruiser making its way over<br />
a poorly maintained dirt road in eastern<br />
Democratic Republic of Congo (DRC).<br />
We were bound for the regional district<br />
hospital: Hopital General Referent-Rutshuru.<br />
The operations of the hospital have been<br />
a joint venture between the Congolese<br />
Ministry of Health and the French section<br />
of Medecins sans Frontieres (MSF), aka<br />
Doctors Without Borders, since 2005. The<br />
team, an international collection of health<br />
care providers, was leaving our residential<br />
compound for a busy day tending the needs<br />
of a traumatized local population.<br />
Dr. Michael Hauty with fellow<br />
"Rwandan warriors."<br />
WILDERNESS MEDICINE // Spring 2010<br />
13
Team members included internists from Great Britain, an OB/Gyn<br />
from Syria, surgeons from the DRC, India and the USA, a physical<br />
therapist from Switzerland, and a mid-wife from France. The ride was<br />
bumpy and dusty but the view of the spectacular Virunga National Park,<br />
quite possibly the most magnificent collection of designated parkland<br />
on the planet, made for a rewarding commute. The sprawling military<br />
compound of the region’s UN peacekeeping force, MONUC (Mission d'<br />
Organization des Nations Unis de Congo), and the teeming IDP (internally<br />
displaced people) camp along the route served as reminder of the current<br />
status in North Kivu province. The combination of unimaginable natural<br />
resources, a distant and ineffective national government and repeated<br />
iterations of the Hutu/Tutsi conflict had set the stage for a conflict with<br />
largest loss of life since WWII, some 5.4 million people.<br />
I was once again in the field with MSF, on my fifth surgical mission to<br />
French-speaking Africa. Attracted by the possibility of providing medical<br />
care independent of the mind-numbing machinations of the current<br />
medico-business environment in the U.S. and compelled by the plight<br />
of the Congolese population, especially the women and children, I soon<br />
realized the upcoming month would be far busier and more demanding<br />
than any in recent memory.<br />
In terms of combining my profession with my passion, few experiences<br />
measure up to a mission with MSF. Travel to locales not accessible to<br />
tourists, living conditions similar to a rustic summer camp, and a daily<br />
routine which tests medical resourcefulness and surgical ingenuity are all<br />
components of a typical mission. HGR-R’s daily census approached 300<br />
beds. The two-room operating theater saw 700-800 interventions each<br />
month. Patients slept two or three to a bed while receiving antibiotics<br />
for malaria, typhoid fever, and other tropical ailments. Nearly 300 live<br />
births, some 40% via C-section, occurred monthly. All of which is<br />
relatively standard for an African district hospital.<br />
What makes the Congo unique and the site of such an immense and<br />
sustained international humanitarian effort is the chronicity and extent<br />
of violence. The DRC, known<br />
as Zaire under the long rule<br />
In terms of combining my profession<br />
with my passion, few experiences<br />
measure up to a mission with MSF.<br />
of Mobutu Seso Seko and<br />
earlier as the Belgian Congo,<br />
under the brutal colonial yoke<br />
of Belgium and its mining<br />
companies, is the second<br />
largest (after Sudan) of the<br />
sub-Saharan African countries and home to some 65 million citizens.<br />
It serves as the global poster country for extreme sexual violence against<br />
women perpetuated by the genocidiares who fled Rwanda after the<br />
atrocities of 1994 and the breeding ground for bizarre militias such<br />
as the Mai-Mai. The bulk of the trouble resides in the eastern part of<br />
the immense country, far from the population and economic centers<br />
of Kinshasa and Kisangani. Here beneath the towering volcanic peaks<br />
of the Virunga and the densely forested habitat of the endangered<br />
mountain gorilla, tragedy strikes the mostly rural populace with tiresome<br />
regularity.<br />
An alphabet soup of armies – FARDC (Forces Armees de la Republique<br />
Democratique de Congo [National Army of the DRC], CNDP<br />
(Congres National pour la Defense du Peuple [Titso rebels]), and FDLR<br />
(Forces Democratiques de Liberation du Rwanda [Hutu rebels]) – rule the<br />
region and each has been blamed for atrocities. The young “soldiers” are<br />
armed with counterfeit Kalashnikov rifles and ancient grenade launchers,<br />
but undisciplined and rarely paid. Even during the prolonged lulls in<br />
combat, violence is inflicted on citizens as banditry and armed looting<br />
prevail. As the hundreds of hospital employees are known to be well paid,<br />
they are frequently targets of such crimes. Two weeks before my arrival,<br />
an operating room nurse was killed during a robbery. On my third<br />
call night, a maternity nurse was brought to the Salle d’Urgence with a<br />
gunshot wound to the abdomen. The hospital had constructed a separate<br />
building to deal with the 20 plus victims of rape and sexual violence who<br />
presented each week. This situation necessitated a mammoth workload<br />
for the surgical service above and beyond that imposed by the stream of<br />
fractures, burns, and abscesses seen daily.<br />
The intensity of the work and our cloistered existence fostered a strong<br />
camaraderie among the team members. Our activities were tightly<br />
proscribed by the tense security situation. Hiking the forests was<br />
not permitted due to the dangers posed by land mines and potential<br />
kidnappings by the militias. We were allowed to leave the compound<br />
only in pairs and during daylight hours. Even then our routes were<br />
limited to a 1.5 kilometer stretch of the town’s major road. For exercise<br />
we resorted to the occasional jog around the field of an adjacent school<br />
and weekend pickup matches of volleyball and soccer. Nonetheless, time<br />
passed rapidly. Before I knew it the logisticians were arranging car and<br />
driver for my 250 kilometer return to the relative calm and order of<br />
Kigali, Rwanda and several days as a regular tourist. Yet with the long<br />
call nights, mosquito netting, and abdominal cramps soon behind me, I<br />
knew I’d be eager to return to the field by next year.<br />
MSF is approaching its fortieth birthday and with its multi-billion<br />
dollar annual budget and thousands of employees and volunteers from<br />
all corners of the globe, it is a key player in the world of international<br />
humanitarian aid. We see<br />
ourselves as members of<br />
a movement rather than<br />
as cogs in an immense<br />
and bureaucratic<br />
organization. In<br />
addition to physicians,<br />
lab techs, physical<br />
therapists, nurses, and water and sanitation engineers, among many<br />
others, are regularly deployed. Postings vary in length according to<br />
position but range from six weeks to six months. Volunteers receive a<br />
salary, generous per-diem, travel expenses, and a full benefit package. Do<br />
yourself and the world a favor and check out their websites at: msf.org<br />
and doctorswithoutborders.org. An intense desire to help is spreading<br />
through American universities and medical schools. Global health<br />
programs abound. If time with MSF isn’t your cup of tea, a myriad of<br />
other organizations await your donation of talent and expertise.<br />
Dr. Hauty is a general surgeon in Hood River, Oregon. For a detailed account of his<br />
time in the Congo with MSF check out his blog at: http://hauty-congo.blogspot.com.<br />
To facilitate more time outdoors he has morphed into a part-time “acute care surgeon”<br />
(surgical hospitalist).<br />
14 WILDERNESS MEDICINE // Spring 2010
Garden of "Villages des Mamas" set off<br />
from the rest of the hospital to house<br />
victims of sexual violence.<br />
Orthopedic ward with<br />
ancient traction devices.<br />
Children of Kiwanja.<br />
Mural for public-awareness campaign<br />
against sexual violence in Goma, DRC.
Why <strong>Wilderness</strong><br />
Medicine?<br />
Rob Hart RN, CEN, FAWM • Photo by Rob Hart<br />
We are surrounded by wilderness medicine. It swims around us on<br />
vacation, it lurks in the dark corners of our garage, it’s tethered to a<br />
pole near the REI store, and it strides across the busy parking lot of<br />
the Starbucks. It seems to find us, wherever we are, and with as little<br />
equipment as we could possibly need.<br />
So, how do we cope with such a specter? What can we, as medical<br />
professionals, do to advance our skills in an environment filled with fire<br />
ants, rabid monkeys, swiftly moving snow, thin air, lightning, tropical<br />
genital rashes, torrential diarrhea, and a rainbow of poison-dart frogs?<br />
We start by acquiring a case of high-grade duct tape, flexible Steri-Strips,<br />
and Super Glue. We sign up for a few WMS conferences, preferably the<br />
ones associated with skiing or climbing or some other enjoyable sport<br />
we could use as a write-off. We become card-carrying members; commit<br />
to memory the content of the Journal – inspired by the writers, the<br />
research, and the colorful stories. We ingest the knowledge of those who<br />
have screwed up before us, so that during some backcountry epic, we can<br />
excrete the functional solution to any malady – traumatic or medical –<br />
that could be served to us.<br />
A surgeon I know used to say this: “See one. Do one. Do one right.<br />
Teach one.” I would expand on that and add, “Do one right a bunch<br />
of times, then teach one.” This, I believe, is where the speakers at the<br />
annual conferences are lecturing from. They are seasoned veterans of<br />
screwing up. Their knowledge of craft is built on the plight of many<br />
disasters. They have survived so that their wisdom can be passed on to<br />
others – others who will then go out into the world, be sought out by<br />
their own epic adventure, and be put to the test. It’s the great circle<br />
of learning: we make mistakes, we learn, we grow, we teach others to<br />
avoid mistakes.<br />
16 WILDERNESS MEDICINE // Spring 2010
Nature, however, is a cruel prankster.<br />
Just when you think that you have mastered the art of wilderness<br />
medicine, a feral squirrel is flung into a roaring campfire by a visiting<br />
clan of German climbers who have spent the good part of a day devising<br />
a rodent-sized trebuchet. The squirrel, now engulfed in a healthy<br />
flame, leaps from the fire (which burns as bright as a small star from<br />
the magnesium Volkswagen cylinder head which was thrown in on a<br />
double-dog-dare) and rockets itself into the nearest open tent. Strangely<br />
enough, there is alcohol inside the tent, along with a pair of climbers<br />
about to toast their victorious ascent of More Monkey than Funky. Patron<br />
Silver, it turns out, is just as flammable as a Wal-Mart tent or unwashed<br />
dreadlocks. Instantly the tent burns away, temporarily eclipsing the<br />
campfire quasar, and leaving two stunned climbing bums spanking<br />
embers and charcoal from their heads, screaming and dancing as if they<br />
were on a talent show, and yielding a pair of top quality burn patients.<br />
The collective of equally intoxicated bystanders act quickly by beating<br />
out the insidious hair fire with a lawn chair – wrestling style – and drops<br />
one of them into the dirt, unconscious.<br />
Burn patient, closed head injury, suspect cervical injury, scalp wound,<br />
airway potential, intoxication, distracting injuries, remote location –<br />
now this wilderness medicine!<br />
And there you stand, beer in hand, with thoughts of CT orders, fluid<br />
resuscitation, transfer paperwork, and the life-saving tetanus status<br />
flowing through your brain like a mudslide. You process the spontaneous<br />
event quickly; there is duct tape in the glove box, a film can of outdated<br />
Vicodin in your pack, a wrinkled Sam Splint harvested from a fractured<br />
snowboarder under your seat, a few potentially clean shirts padding your<br />
camera, a partially smashed pill which looks like it might be Zofran, and<br />
26 potentially lethal assistants. It’s not quite enough to build a functional<br />
helicopter, but it might be just enough to get the writhing squirrel-attack<br />
victims to a local hospital.<br />
Love your craft. Learn as much as you can. Become a member of the<br />
WMS and plan some trips around the conferences. Seek out the lecturers<br />
who have gray hair or no hair at all, for they will be the ones with divine<br />
wisdom. The wisdom that can only be achieved through years of travel;<br />
of mistakes, both grand and slight; of learning and teaching the work<br />
that he or she has authored, and expanding the works of others; of doing<br />
a thing wrong, and a few right; impassioned practitioners exploiting the<br />
mileage God has given to few humans.<br />
Lastly, ingest the wisdom and art of improvisation, cultivate the ability<br />
to see beauty in the face of adversity - and most of all, appreciate the<br />
flashpoint of premium tequila.<br />
Rob Hart, RN, CEN, FAWM, works at a Level II trauma center in Boise, Idaho. When<br />
he is not at work in the trenches, he operates his fine art photography business (hartimages.<br />
com) and coordinates climbing and trekking adventures.<br />
WILDERNESS MEDICINE // Spring 2010<br />
17
ild Med 101:<br />
Nosebleeds in the Backcountry<br />
Sam Schimelpfenig, MD FAAP<br />
Photo by Rob Hart<br />
N<br />
Nosebleeds, also known as epistaxis, are very common, and most<br />
people will get one at one time or another. Although the bleeding can<br />
be impressive, it rarely causes any serious problems. The source of the<br />
bleeding is most often the anterior portion of the nasal septum, from<br />
a region rich in superficial blood vessels called the Kiesselbach Plexus.<br />
Most of the bleeding from this area is due to drying of the nasal mucosa<br />
which tends to occur in hot, dry climates, and during the winter months<br />
when home heating lowers the relative humidity indoors. However, in<br />
the wilderness setting, trauma (even mild) may contribute epistaxis.<br />
Morbidity from epistaxis is low, and typically results from underlying<br />
medical conditions that contribute to the nosebleed. Thus, in a wilderness<br />
setting, it is important to make sure the patient does not have any serious<br />
illnesses that could be of concern. Medications such as aspirin and other<br />
blood-thinning agents will inhibit the clotting process and make control<br />
of a nosebleed more difficult.<br />
The simplest way to treat a nosebleed is to gently squeeze the soft parts<br />
of the nose against the nasal septum; application of pressure to the hard<br />
nasal bones will not help control bleeding. Pressure is applied until the<br />
nosebleed stops, which can occasionally take as long as 10 to 15 minutes.<br />
Often a cold pack if available may help. The patient should lean slightly<br />
forward so that blood does not drip down the back of the throat. Tilting<br />
the head back may prevent blood from getting on the patient’s clothing,<br />
but the blood will then drain down the back of the throat into the<br />
stomach, where it typically causes nausea and vomiting.<br />
Occasionally, a nosebleed will need to be packed to control the bleeding.<br />
The myriad of methods for nasal packing available in an emergency<br />
department are not typically carried in a first aid kit; but packing can<br />
be improvised with Vaseline gauze or sterile gauze. Vaseline impregnated<br />
gauze is preferable as it easier to remove without causing additional<br />
trauma and bleeding. If only dry sterile gauze is available, try applying a<br />
topical antibiotic cream to the gauze so it easier to apply and remove.<br />
The packing should be gently applied from the anterior to the posterior<br />
portion of the nostril using forceps or a similar device. Packing can also<br />
be applied to the opposite nostril to provide additional compression of<br />
the nasal septum. The packing should be inserted as far as possible into<br />
the nostril, but not so far that it cannot be easily removed. A common<br />
mistake is to apply packing to the nasal opening only, where it simply<br />
serves as a plug and not a source of pressure against the bleeding vessel.<br />
The packing should be removed as soon as possible to avoid developing<br />
a serious infection, ideally in less than 48 hours, and the patient should<br />
be started on a prophylactic antibiotic.<br />
If available, constricting nasal sprays such as Afrin or Neo-Synephrine<br />
can be used as directed in conjunction with packing to help control a<br />
nosebleed. An expedition first aid kid may carry some of the commercial<br />
nasal packing devices typically used in a clinic or emergency department<br />
setting (e.g. Merocel nasal tampon, Rapid Rhino nasal tampon).<br />
If available, they should be placed in the nostril according to the<br />
accompanying directions. Again, the packing should be removed as soon<br />
as possible and the patient started on an oral antibiotic to help prevent<br />
infection. The patient should be counseled on not exerting, straining, or<br />
sneezing over the next 24 – 48 hours, as this may precipitate a rebleed.<br />
Epistaxis should rarely be a cause for concern in the backcountry; but<br />
if the bleeding cannot be controlled or there is a medical history that<br />
is of concern, the patient should be evacuated. Also, if the nosebleed<br />
was a result of trauma or the patient also has an altered mental status,<br />
control of the bleeding is an important part of making sure the airway<br />
is properly managed. Typically, epistaxis that requires packing to achieve<br />
hemostasis should be followed up by an otolaryngologist.<br />
18 WILDERNESS MEDICINE // Spring 2010
Mount Hood<br />
SAR Operations<br />
On December 9th, 2009, three climbers<br />
ascending Mount Hood’s treacherous Leuthhold<br />
Couloir were reported missing. Dr. Van Tilburg’s<br />
mountain rescue team, Crag Rats, of Hood River,<br />
Oregon, was dispatched along with Portland<br />
Mountain Rescue, and American <strong>Medical</strong><br />
Response’s Reach-and-Treat Team stationed in<br />
Government Camp. Late in the day, one body<br />
was recovered. In the days following, the search<br />
was limited due to extreme avalanche danger. At<br />
press time, two climbers remained missing.<br />
Photos by<br />
Christopher Van Tilburg MD, FAWM<br />
11:00 am Ascending Triangle Moraine, before<br />
turning back shy of the summit due to high<br />
avalanche danger, below freezing temps,<br />
double digit wind gusts, and 50-foot visibility.<br />
2:40 pm Scarfing turkey sandwiches, staying<br />
warm, packing gear.<br />
8:00 am Summit team at Timberline<br />
Lodge, jittery.<br />
1:30 pm Redeployed to Illumination<br />
saddle and built a deadman anchor.<br />
3:00 pm Traversing in a white-out above<br />
Mississippi Head cliffs, in the “Mount Hood<br />
Triangle,” good thing for GPS.<br />
4:30 pm Long ride down, the day’s ice<br />
starting to melt.<br />
2:00 pm Rope raising<br />
system inside the ping<br />
pong ball – sky and snow<br />
undistinguishable.<br />
9:00 am Snowcat ride to 8,470 feet,<br />
freezing rain.<br />
10:10 pm Search called off for tomorrow due<br />
to avalanche danger, turn off 4 am alarm.<br />
10:00 am Wind picks up, temperatures<br />
plummet: no country for a soft shell.<br />
2:15 pm Raising the SKED with the Portland<br />
Mountain Rescue “Hogsback Kit.”
for Work and Play Christopher Van Tilburg MD<br />
Urbaneering with cyclocross<br />
When I lived in the city, I sought out wild places in every nook<br />
and cranny of the urban megapolis. Trail running was my<br />
connection to the landscape. Kayaking, cycling, rock climbing,<br />
and buildering (climbing the university brick buildings) were all<br />
readily available from campus. Despite now living in a small<br />
mountain town, my urbaneering skills (as in, outdoor adventure<br />
sports in the city) just broadened to include the wild and crazy<br />
sport of cyclocross (a high-speed off-road criterion with some<br />
running and a scosh of mud).<br />
Photos by Christopher Van Tilburg<br />
Coaxed unexpectedly into a race by a friend, I pulled into the lineup<br />
with no prior experience, using my girlfriend’s shoes (one size too small)<br />
and by friend’s bike (once size too big). The mass start was disorientating<br />
as I careened across a horse pasture, slid into a gully, peddled frantically<br />
through a muddy canyon, and emerged in a field. Note to reader: a<br />
key part of cyclocross is barreling down a hairpin mud slope, jumping<br />
off your bike, hucking it on your shoulder, bounding over an obstacle,<br />
running up a mud bank still with bike, and sliding back on the saddle.<br />
All this joy comes in five, 2-mile laps around a fairground, equestrian<br />
center, park, or any other spot of urban green space. Make that urban<br />
brown space: did I mention the mud? At one race in the rain, a halfdozen<br />
6-inch-deep, 10-foot-long puddles the color of a double nonfat<br />
latte developed. We rode through them without pause, getting doused<br />
with frigid brown goodness. One slope was so muddy, I had to put my<br />
hand down in 6-inch-deep goo to climb the hill.<br />
This vintage sport—started in Europe in the early 1900s when cyclists<br />
added wide knobby tires to their road bikes to negotiate foul-weather—<br />
has gone high tech and urban. Races have the festiveness of a tailgate<br />
party, replete with cheering crowds, clanging cowbells, and tachycardia<br />
into the mid-triple digits. But don’t be fooled: anyone can ride cyclocross.<br />
Beginners and kids. Tandems, unicycles, and single speeds.<br />
The best part: the bikes are multifunctional. They are similar to road<br />
bikes, with burly mods. They zip through tight turns with a short<br />
wheelbase, bound over rocks with a high-clearance bottom bracket,<br />
run tubeless knobbies to minimize pinch flats, and sport old-school<br />
mud-shedding cantilever brakes. The workhorse cyclocross stallion<br />
will do double-duty as an overnight touring mount (add panniers), a<br />
randonneuring steed (aka long-distance cycling), a daily commuter (add<br />
fenders and flashing light), or wet-weather trainer (keep your carbon<br />
roadie in the garage). Except for true mountain bike trails, these bikes<br />
are built to tackle urban bike/ped paths, dirt or gravel backroads, or, yup,<br />
muddy low-tech singletracks.<br />
So, go get dirty.<br />
20 WILDERNESS MEDICINE // Spring 2010
What’s in<br />
Your Pack?<br />
We invite you to send in five<br />
things you couldn’t do without<br />
in your pack.<br />
Dr. Natsch is currently the Chief, Bureau of Emergency<br />
<strong>Medical</strong> Services for the Missouri Department of Health and<br />
Senior Services. He has been involved with EMS for over 35<br />
years, 30 as a paramedic.<br />
Dr. Greg Natsch shares his<br />
can’t-do-without-gear:<br />
My Camelbak Hydration system (built into all my<br />
packs) goes without saying, but these are my<br />
“American Express” items… I don’t leave home<br />
without them. With me at all times.<br />
1. Cap<br />
2. Good prescription sunglasses. Good for<br />
all conditions.<br />
3. Swiss Army knife – all the tools you could want.<br />
4. Global Positioning System (GPS).<br />
5. Smartphone – loaded with medical references,<br />
maps, emergency beacon, camera, and music<br />
for sanity.<br />
VISIT WWW. MMMEDICINE. COM FOR MORE INFORMATION<br />
MATTERHORN<br />
MOUNTAIN MEDICINE<br />
Zermatt, Switzerland<br />
July 14-17, 2010<br />
Join the faculty of Mountain and Marine Medicine for<br />
our 4th annual High Altitude and Mountain Medicine<br />
conference! This interactive course is designed for<br />
physicians, nurses, EMT's, health providers, climbers<br />
and mountain sports enthusiasts. Join us for an incredible<br />
educational event at the base of the Matterhorn!<br />
Guided climbs and adventures offered by:<br />
Suntoucher<br />
M o u n t a i n G u i d e s<br />
THIS ACTIVITY HAS BEEN PLANNED AND IMPLEMENTED IN ACCORDANCE WITH THE ESSENTIAL AREAS AND POLICIES OF THE ACCREDITATION COUNCIL FOR CONTINUING MEDICAL<br />
EDUCATION THROUGH THE JOINT SPONSORSHIP OF THE WILDERNESS MEDICAL SOCIETY AND SUNTOUCHER MOUNTAIN GUIDES. THE WILDERNESS MEDICAL SOCIETY IS ACCREDITED BY<br />
THE ACCME TO PROVIDE CONTINUING MEDICAL EDUCATION FOR PHYSICIANS. THE WMS DESIGNATES THIS EDUCATIONAL ACTIVITY FOR A MAXIMUM OF 23 AMA PRA CATEGORY 1 CREDITS TM .<br />
EACH PHYSICIAN SHOULD ONLY CLAIM CREDIT COMMENSURATE WITH THE EXTENT OF THEIR PARTICIPATION IN THE ACTIVITY.
Advanced <strong>Wilderness</strong> Life Support<br />
New Zealand Style<br />
AWLS participants<br />
enjoy a short break for<br />
a hot drink, a photo<br />
opportunity, and to<br />
take in the magnificent<br />
alpine scenery.<br />
For those looking for some of the most beautiful and varied wilderness<br />
areas in the world to explore, New Zealand is worth more than a<br />
passing glance. This lovely South Pacific nation provides some of the<br />
most awesome and exciting wilderness experiences on earth. Tramping<br />
through unique native bush, temperate forest or high alpine areas is just<br />
the start. The country offers fantastic climbing and wonderful water<br />
sports including rafting and kayaking on white water, lake and sea.<br />
Winter time is also no time to rest, with skiing, snowboarding and ice<br />
climbing available for all. The country itself is a magnet for outdoor<br />
enthusiasts and adventure sports adrenaline seekers from around the<br />
globe. It is therefore quite appropriate that New Zealand recently hosted<br />
one of the first Advanced <strong>Wilderness</strong> Life Support (AWLS) courses run<br />
outside of America, and the first ever in Australasia.<br />
The courses were hosted by the Southland <strong>Wilderness</strong> Medicine Group<br />
and were based in the Adventure Sports capital of New Zealand,<br />
Queenstown in the impressive Central Otago Lakes District. Aside from<br />
breathtaking scenery Queenstown provides easy access to New Zealand’s<br />
lake and alpine adventure playgrounds.<br />
The Advanced <strong>Wilderness</strong> Life Support courses were overseen by lead<br />
instructor, Dr Rich Ingebretsen MD PhD, on his first visit to New Zealand,<br />
assisted by trainee instructors who had recently attended AWLS courses<br />
in the United States. The standard AWLS core curriculum was taught on<br />
the courses together with some local content relevant to the Australasian<br />
environment, specifically cold water immersion issues (common in New<br />
Zealand) and Australasian snake and spider bites. Didactic lectures were<br />
held at the Crowne Plaza convention centre against the backdrop of<br />
Lake Wakatipu and the Remarkables Mountains. The practical teaching<br />
component of the course was held up in the mountains overlooking the<br />
22 WILDERNESS MEDICINE // Spring 2010
AWLS Instructor Cory Kreutzer<br />
demonstrates a single person roll<br />
on a casualty while protecting the<br />
cervical spine from further injury.<br />
AWLS Instructor Dr Martin Watts<br />
demonstrates spinal immobilization<br />
techniques on a trauma victim in the field<br />
using improvised materials (in this case SAM<br />
Splint, duct tape, and backpack).<br />
AWLS students evacuate a<br />
casualty on a makeshift litter. Lake<br />
Wakatipu and New Zealand’s<br />
Southern Alps form a wonderful<br />
backdrop.<br />
town and lake near the Coronet Peak ski field. Spring weather helped with a diet<br />
of sunshine and light breezes to make this one of the world’s premier classrooms!<br />
Practical scenarios on the final day were undertaken by the students on the shores<br />
of Lake Wakatipu before the inevitable AWLS exam.<br />
Such was the interest in the AWLS courses that further courses are now planned<br />
for New Zealand for 2010. The enthusiasm of the participants was such that<br />
several of those attending were further encouraged to continue their studies<br />
towards their Fellowship in the Academy of <strong>Wilderness</strong> Medicine.<br />
<strong>Wilderness</strong><br />
Advanced<br />
Life Support <br />
(WALS) 36 CECBEMS CEUs<br />
Designed for medical professionals<br />
by medical professionals.<br />
<strong>Wilderness</strong> <strong>Medical</strong> Associates is the world leader in<br />
wilderness and remote medical training. We offer the<br />
courses needed to respond to emergency situations,<br />
whether in the backcountry or an urban area in crisis.<br />
MAY 25 - 28<br />
Mt. Destinations - Santa Fe, NM (for attendees of WMS conference)<br />
406-522-9038 www.mountaindestinations.com<br />
JUNE 26 - 30<br />
Northern Cairn - Grand Haven, MI<br />
866-221-8176 www.northerncairn.com<br />
AUGUST 31 - SEPTEMBER 3<br />
<strong>Medical</strong>Officer.net - Crested Butte, CO<br />
970-<strong>27</strong>5-4999 www.medicalofficer.net<br />
SEPTEMBER 13 - 17<br />
Mayo Regional Hospital - Dover-Foxcroft, ME<br />
207-564-8401 x207 www.mayohospital.com<br />
The courses listed are accepted for credits by the<br />
WMS Academy’s Registry of <strong>Wilderness</strong> Medicine<br />
Practitioners and Fellowship Program. For more information<br />
and additional courses please visit our website.<br />
WMS member Martin Watts is an Emergency Medicine Specialist and Clinical Director of<br />
Emergency Medicine in Southland, NZ. He is part of the Southland <strong>Wilderness</strong> Medicine Group<br />
who was responsible for organizing New Zealand’s first AWLS courses in 2009.<br />
Photographer Dr. Justin Venable is an Advanced Trainee in Emergency Medicine and an<br />
expedition physician for Himalayan Rescue Association and the NZ Representative to International<br />
Mountaineering and Climbing Federation <strong>Medical</strong> commission<br />
1-888-WILDMED www.wildmed.com<br />
WILDERNESS MEDICINE // Spring 2010<br />
23
REVIEWS<br />
High Crimes: The Fate<br />
of Everest in an Age<br />
of Greed<br />
Michael Kodas<br />
New York, NY: Hyperion; 2008<br />
Softcover, 384 pages, US $15.99<br />
ISBN-10: 1401309844,<br />
High altitude mountaineering has long been noted to have the potential<br />
to bring out the most noble as well as the most sordid characteristics in its<br />
participants. Like any human activity that tends to place individuals in<br />
extreme circumstances, climbing on the earth’s greater ranges will place<br />
unusual demands on a person’s mental and physical capabilities – and<br />
not all rise to the challenge in the most gracious fashion. Michael Kodas’<br />
High Crimes: The Fate of Everest in an Age of Greed details many of the less<br />
gracious recent deeds for which the world’s highest peak is unfortunately<br />
becoming well-known. The ugly side of human nature seems all too<br />
present in this work, and while the “tell-all” nature of the book will<br />
not appeal to some readers of mountain literature, I believe most will<br />
find it an engrossing read. It’s an attention-grabbing combination of<br />
sickening examples of poor mountaineering behavior intermixed with<br />
just enough worthy and highly respectable conduct to keep one’s interest<br />
on the page and wondering “yikes, what next?” In many respects Mt.<br />
Everest has become (and will probably continue to be) the quintessence<br />
of the “ultimate” challenges a cross-section of humankind will always<br />
seek. However, after reading High Crimes, the reader might just<br />
begin to wonder if such a mantle for Everest has somehow helped to<br />
create a high altitude Circus Maximus that seems an anathema to the<br />
old-school mountaineer.<br />
George W. Rodway, PhD<br />
Salt Lake City, Utah<br />
We would like to know<br />
what you’re reading!<br />
To contribute a book review to WM magazine,<br />
visit wms.org/publications/magazine for<br />
book reviewer guidelines.<br />
The Accidental Explorer:<br />
Wayfinding in Alaska<br />
Sherry Simpson<br />
Seattle, WA: Sasquatch Books; 2008<br />
Hardcover; 240 pages, US $23.95<br />
ISBN-10: 1570615373<br />
ISBN-13: 978-1570615375<br />
How do you find yourself in any wilderness intent on losing you? Read<br />
Sherry Simpson’s compilation of essays about her Alaskan adventures<br />
and you will start your next trip exploring your mind and soul as much<br />
as your surroundings.<br />
This refreshing collection of essays chronicles an inexperienced Alaskan<br />
adventurer as she sets out to discover her homeland and herself. The<br />
ten narrations describe her explorations of destinations such as famed<br />
Glacier Bay to an unidentified, secretive coastline trek. Certain to appeal<br />
to history aficionados she weaves narrations from historic explorers into<br />
her stories. Whether she travels with companions or alone, Simpson’s<br />
mind shuttles between self promulgation and adoration at her foibles and<br />
accomplishments. But the one engaging current that fuels and unifies<br />
you through the course of this book is the author’s charming humor.<br />
Simpson hosts a wit that guides her self-doubts into a courageous and<br />
enthusiastic path of becoming an adventurer.<br />
In these stories you won’t find the usual gear lists and how-to notes.<br />
What you will find is encouragement to use a navigation device that<br />
needs no batteries or power backup but still comes in a sturdy case. A<br />
devise that sits squarely on our shoulders but one we so often forget to<br />
use….our minds. This book meanders through the mind and soul of the<br />
author as much as the face of Alaska’s landscape and offers a refreshing<br />
outlook on outdoor adventures.<br />
How well does Simpson describe each setting and bring her reader on<br />
site as she struggles through the remote landscapes? Very well, because<br />
even when I read this book ensconced on a tropical beach the author’s<br />
poetic prose blew the icy wilds of Alaska across my skin. Step away from<br />
the “how to” books and into one that melts the physical, spiritual and<br />
mental truths of adventure into a true wilderness experience.<br />
Debra Stoner MD, FAWM<br />
Northumberland, PA<br />
24 WILDERNESS MEDICINE // Spring 2010
SOCIETY MATTERS<br />
News & Announcements<br />
HUMANITARIAN RELIEF GRANT<br />
Humanitarian relief<br />
Grant 2010<br />
Dear WMS Member,<br />
The humanitarian catastrophe in Haiti this past January<br />
has resonated with us all. Many of us responded through<br />
donations of time or money, and others through relief<br />
efforts on the ground. There have been worse disasters<br />
in history, but few that have struck with such cruelty<br />
upon a fragile society with no reserves.<br />
For several years, the <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong> has<br />
embraced disaster response and global medical outreach<br />
as cross-over disciplines. They are environments that<br />
challenge caretakers to provide best-practice care in<br />
austere and unpredictable environments. So with the<br />
challenges of Haiti fresh on our minds, we would like<br />
to continue the growth of our <strong>Society</strong> by providing a<br />
meaningful contribution to the field of humanitarian<br />
relief. A new, annual research grant in this field<br />
sponsored by the WMS will provide for a sustainable,<br />
long-term focus on these issues, within the highest<br />
academic traditions of our <strong>Society</strong>.<br />
As a non-profit, member-supported <strong>Society</strong>, we now<br />
seek to endow such a grant, and we would like your<br />
help with the following:<br />
• Donation of items to be auctioned at the WMS<br />
Annual Meeting in Snowmass, Colorado this<br />
July. 100% of the proceeds from the auction will<br />
go to directly support the WMS Humanitarian<br />
Relief Grant.<br />
• Direct monetary tax-deductable donations to help<br />
fund the grant. We welcome donations of any size.<br />
• Help us with recruitment of corporate sponsors<br />
who could provide direct donations and/or<br />
matching funds.<br />
The <strong>Society</strong>’s leadership believes this is an important<br />
new initiative. Not only are we focusing our expertise<br />
in the direction of a growing and inadequately studied<br />
area of medicine, but we are also adding value to our<br />
membership. We can think of no better mission for a<br />
medical society than to stay focused on those in need,<br />
and we hope you'll help in this quest.<br />
With appreciation,<br />
Tony Islas & Jay Lemery<br />
Snowmass Conference Co-Chairs<br />
The <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong><br />
Partners with Global Rescue<br />
The <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong> has partnered with Global Rescue in order to ensure the<br />
safety of <strong>Society</strong> members on expeditions and otherwise traveling to the world’s most<br />
remote locations. “The life-saving value of Global Rescue memberships can’t be overstated,”<br />
opines WMS CEO Loren Greenway.<br />
“There are many reasons to plan ahead for medical advice, evaluation, assistance, and<br />
evacuation,” the co-founder of WMS, Paul Auerbach, MD, wrote in an article about Global<br />
Rescue. “Furthermore, in this time of security risks up to and including armed conflict,<br />
kidnapping, and terrorism, one must be aware of how to get help quickly and reliably,<br />
because during or immediately after the event is not the time to begin planning.”<br />
Global Rescue is an emergency services company that provides best-in-class medical,<br />
aeromedical evacuation, and security services to travelers worldwide, and is the only such<br />
provider that performs field rescues. The company regularly airlifts climbers from the<br />
Himalayas, hunters from Africa, and skiers from the Alps and the Andes. Global Rescue<br />
also works with some of the world’s largest companies to protect their employees from<br />
health, safety, and security threats around the globe.<br />
Recent examples of Global Rescue’s work include evacuating an injured skier from<br />
Bariloche, Argentina, rescuing a safari client from Mozambique, and dispatching a special<br />
operations team to Africa to protect and prepare to evacuate Americans from a country<br />
experiencing civil unrest. For more information, visit www.globalrescue.com.<br />
Auction Info…<br />
We need to hear from you by<br />
JUNE 1st in order to include your<br />
item(s) in the auction.<br />
The WMS will host a silent auction<br />
after the Haiti presentation by Dr.<br />
Paul Auerbach at the WMS Annual<br />
Meeting in Snowmass, Colorado this<br />
July. All proceeds will go to directly<br />
support the WMS Humanitarian<br />
Relief Grant.<br />
Michelle Johnson and Pauli Ingwersen<br />
have graciously agreed to coordinate<br />
the auction. For your auction item(s),<br />
please email a description of your<br />
item or items and an estimate value<br />
to Pauli Ingwersen at pauli@wms.org.<br />
Artwork, unique jewelry, weekend<br />
get-aways at a cabin, float or raft<br />
trips, fly fishing lessons, wine, books,<br />
equipment of all kinds are just a few<br />
ideas to get you started.<br />
Donations:<br />
We'll take—and appreciate—<br />
donations of any size!<br />
Merchandise:<br />
The WMS will have limited<br />
edition, specially designed WMS<br />
Humanitarian Relief Grant 2010<br />
merchandise to encourage your<br />
support. This merchandise will be<br />
available during the Snowmass<br />
Conference and our website wms.org<br />
after the conference.<br />
Corporate or<br />
Matching Donations:<br />
Please contact Dr. Loren Greenway<br />
(loren@wms.org) if you know of a<br />
company or business that would help<br />
support us through direct matching or<br />
outright donations.<br />
Also…<br />
Although the WMS Humanitarian<br />
Relief Grant will be open for<br />
proposals involving any area of the<br />
world, for our inaugural grant, we<br />
will only be accepting proposals<br />
specifically addressing Haitian<br />
relief efforts. The size of our grant<br />
disbursement will depend on the<br />
success of our fundraising.<br />
WILDERNESS MEDICINE // Spring 2010<br />
25
SOCIETY MATTERS<br />
Grant Winners<br />
The <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong> is keenly interested in fostering<br />
awareness and appreciation among healthcare professionals and scientists<br />
for the research of health-related concerns in outdoor and wilderness<br />
activities. The Charles S. Houston and Research-in-Training Awards are<br />
selected on a competitive basis to provide funding for a research project<br />
in the field of wilderness medicine. The Charles S. Houston Award is<br />
for medical students and the Research-in-Training Award is for residents<br />
and fellows of an accredited graduate medical education program or<br />
doctoral candidates working towards a PhD. The Herbert N. Hultgren<br />
Award is for members of the WMS. The 2010 Winners of the WMS<br />
Research Awards and their areas of research are:<br />
Charles S. Houston Award ($6000): Gabriel Willman MD, University<br />
Eye Hospital and Institute for Ophthalmic Research, Department for<br />
Ophthalmology, University of Tübingen, Germany. Research Project:<br />
Functional and structural analysis of ophthalmological changes caused<br />
by high altitude in relation to Acute Mountain Sickness.<br />
Herbert N. Hultgren Award ($5000): Matthew Sanborn MD,<br />
University of Pennsylvania Department of Neurosurgery. Research<br />
Project: Developing An Animal Model for High-Altitude Cerebral<br />
Edema for in vivo Testing of Cerebral NO Activity.<br />
Research-in-Training Award ($4000): Peter Byers MD, Eastern Virginia<br />
<strong>Medical</strong> School Department of Emergency Medicine. Research Project:<br />
A Novel Approach to Killing Ixodes scapularis and Dermacentor andersoni<br />
Ticks in Humans.<br />
2010 winter conference in<br />
park city, Utah<br />
The Winter Conference in Park City was packed full with workshops,<br />
plenary sessions, skiing, boarding, and fun fun fun! And as it turned<br />
out…it does have the Greatest Snow on Earth!<br />
Attendees commented on the expansive program, excellent<br />
speakers, and exciting workshops (especially those on the<br />
mountain). We were fortunate to have many of the celebrated<br />
experts in wilderness medicine disciplines on our faculty, as<br />
well as new stimulating speakers, topics, and workshops.<br />
Dr. David Shlim, our distinguished<br />
banquet speaker, gave a presentation<br />
entitled Limitless Compassion based in<br />
part on the book he co-authored with<br />
Chokyi Nyima Rinpoche Medicine<br />
Dr. Peter Hackett and Compassion: A Tibetan Lama’s<br />
Guidance for Caregivers (Summerville,<br />
MA: Wisdom Publications; 2004). Dr. Shlim<br />
concluded our winter conference by beautifully<br />
articulating how to encompass compassion into<br />
our encounters with our patients and in our<br />
everyday life.<br />
Plan now on attending the WMS Winter<br />
Conference in Park City FEBRUARY 2011!<br />
Dr. David Shlim<br />
Call for Abstracts: 2010 WMS Annual<br />
Summer Meeting<br />
The <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong> is pleased to announce the call for<br />
abstracts for the <strong>27</strong>th Annual Meeting of the <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong>,<br />
July 23-28, 2010 in Snowmass, Colorado.<br />
The abstract session will focus on recent research covering the entire<br />
spectrum of <strong>Wilderness</strong> Medicine. Submissions should be limited<br />
to research presentations. Abstracts may be submitted for both oral<br />
and poster presentations using the specific format described below.<br />
Abstract submissions must be received by June 15, 2010.<br />
Posters should be no larger than 3-feet high by 6-feet long. Boards for<br />
presenting posters will be available at the meeting. Authors are encouraged<br />
to be by their poster for viewing during their day of presentation. Oral<br />
presentations will be 10 minutes with 5 minutes for questions.<br />
All accepted abstracts will be considered for publication in <strong>Wilderness</strong> &<br />
Environmental Medicine.<br />
The Abstract Application (cover sheet, abstract form and a sample<br />
abstract) are available at wms.org/research/abstract_applic.asp.<br />
Member Get-A-Member Award<br />
You still have time! The Awards Committee announced a new award<br />
to be given at the Annual Meeting in Snowmass. This award challenges<br />
members to bring new members into the WMS—and it has some great<br />
benefits. One regular member and one student member who recruit<br />
the most new members (regular members/associates/students) will<br />
receive free registration to the Annual Meeting and a copy of Dr. Paul S.<br />
Auerbach’s seminal textbook <strong>Wilderness</strong> Medicine.<br />
Call for Authors<br />
The WMS is in the process of developing a Community Education<br />
Lecture Series similar to the professional Educational Lecture Series<br />
already available at wms.org. This new series is designed for the wilderness<br />
medicine provider who wants to teach the general public. Many of your<br />
favorite content friendly topics are being developed in a format for the<br />
lay person with no wilderness medicine knowledge.<br />
If you are a WMS member with experience or interest in a wilderness<br />
medicine topic and interested in authoring a lecture for the Community<br />
Education Series, contact: Dr. Debra Stoner, deb.stoner@gmail.com.<br />
Educational Lectures<br />
If you are not familiar with the WMS Educational Lecture Series,<br />
you able to review some samples by logging into the Member area<br />
(wms.org/members/memberlogon.asp), then look for “free sample”<br />
under Announcements on your Member’s home page. These are readyto-use<br />
PowerPoint presentations with complete lecturer’s notes on<br />
these topics: Hazardous Marine Life, Wild Animal Attacks, Accidental<br />
Hypothermia, <strong>Wilderness</strong> Dermatology, <strong>Wilderness</strong> Ophthalmology,<br />
Submersion Injuries, Diarrhea from Foreign and <strong>Wilderness</strong> Travel,<br />
Surviving a <strong>Wilderness</strong> Emergency, Current Concepts in Dive<br />
Medicine, Field Water Disinfection, Frostbite and Cold Injuries, High<br />
Altitude Medicine, Venomous Snakebite Management, and Venomous<br />
Arthropods. Other topics such as Lightning Safety, Orthopedic Injuries,<br />
Heat Illness and Women’s Health are in development.<br />
26 WILDERNESS MEDICINE // Spring 2010
Members in the News<br />
Kenneth W. Kizer, one of the original<br />
founders of the WMS, was recently<br />
elected to the National Academy of Public<br />
Administration. A long time member of<br />
the Institute of Medicine of the National<br />
Academy of Sciences, Dr. Kizer now joins<br />
a group of only about a dozen persons<br />
ever to have been elected to both of these<br />
national honorary bodies. Dr. Kizer has<br />
been repeatedly selected as of the “100<br />
Most Powerful People in Healthcare” by<br />
Modern Healthcare magazine. He is the<br />
former Under Secretary for Health in<br />
the U.S. Department of Veterans Affairs (1994-1999) and is currently<br />
President, CEO and Chairman of Medsphere Systems Corporation.<br />
Based in Aliso Viejo, CA, Medsphere is the leading commercial provider<br />
of open source information technology for the health care industry.<br />
Dr. Jolie Bookspan and<br />
husband Paul Plevakas shared<br />
the Master Instructor of the<br />
Year Award at the November<br />
2009 International Black Belt<br />
Hall of Fame. Dr. Bookspan<br />
taught a seminar on training<br />
ergonomics for higher<br />
performance and flexibility<br />
during the day events. Hundreds of top martial artists, teachers, and<br />
Grandmasters attended from all over the world. The event was held in<br />
Pittsburgh, Pennsylvania.<br />
Mr. Plevakas (Paul Sensei) runs their karate dojo in Philadelphia. Dr.<br />
Bookspan is 4th degree black belt and former undefeated full contact<br />
martial artist and Headmaster of the Academy of Functional Exercise<br />
Medicine (AFEM).<br />
You can meet Dr. Bookspan (and take one of her fitness classes!) at the <strong>27</strong>th WMS <strong>Wilderness</strong> and<br />
Mountain Medicine Conference and Annual Meeting in Snowmass, Colorado, July 23-28, 2010.<br />
See their book Healthy Martial Arts on DrBookspan.com/books.<br />
<strong>Wilderness</strong> Medicine CME<br />
In the Backcountry of<br />
Yellowstone National Park<br />
Program Supports<br />
10 hours of AMA PRA Cat 1 CME &<br />
10 hours of WMS FAWM Credit<br />
September 3-6, 2010<br />
For more information contact<br />
gmatthews59718@gmail.com or visit<br />
www.yellowstonepacktrips.com/cme.html<br />
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing <strong>Medical</strong><br />
Education through the sponsorship of the <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong> and Yellowstone Pack Trips. The <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong>is accredited by the<br />
ACCME to provide continuing medical education for physicians. The <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong> designates this educational activity for a maximum of 10<br />
AMA PRA Category 1 Credits TM. Each physician should only claim credit commensurate with the extent of their participation in the activity.<br />
WILDERNESS MEDICINE // Spring 2010<br />
<strong>27</strong>
SOCIETY MATTERS<br />
Student Elective 2010<br />
Tom Kessler, MD<br />
Since 2003 the WMS has<br />
sponsored and staffed an<br />
elective in wilderness medicine<br />
geared toward medical<br />
students as a clinical rotation,<br />
but also open to other clinical<br />
students (physician assistants<br />
and nurse practitioners)<br />
and residents. With the<br />
cooperation of Camp Wesley<br />
Woods, Townsend, Tennessee,<br />
costs for room and board are kept as modest as possible in a setting ideal<br />
for the elective. In addition, the Smoky Mountain area and proximity<br />
to Maryville and Knoxville provide many opportunities to broaden the<br />
experience.<br />
But the volunteer faculty gives the experience its unique breadth and<br />
depth. With no more than modest travel support, these experienced<br />
experts find the reward of interacting with motivated adult learners<br />
sufficient to offer their knowledge, experience, and values. It would be<br />
impossible to have the strong program without such volunteers, and we<br />
are indebted to them.<br />
We would like to thank the following people for making this year’s<br />
Student Elective another great success. You all made this possible…<br />
• Camp Wesley Woods staff,<br />
including Director David Leech,<br />
Anna Kendra, Matt, Adam, and<br />
Joe David Bradley<br />
• Kirk Harris, Fred Baty, Lisa<br />
Burchfield, Bryan Rowell,<br />
Nathan Osborn – the<br />
prehospital faculty<br />
• Chuck Hestor, law<br />
enforcement ranger<br />
• Phil Bertram, MD<br />
• Great Smoky Mountain<br />
Heritage Center, Kathy<br />
Prince and Richard Way<br />
• Blount County Sheriff’s Office,<br />
Captain Jeff Burchfield and<br />
Officer Rodney Holloway with<br />
Bryan Rowell<br />
• Kurt Smith, MD<br />
• Jeff Wadley, Civil Air<br />
Patrol officer<br />
• David Keitz, MD<br />
• Jim Suozzi, MD<br />
• Jack Gotcher, MD<br />
• Laura Helfman, MD<br />
• Andrew Morgan, PA<br />
• Rob Worthing, MD<br />
• Chris Calvert, MD<br />
• Chris Pannucci, MD<br />
• Neal Pollock, PhD<br />
• Chris Moore, MD<br />
• Mel Otten, MD<br />
A Student’s Reflections<br />
on the 2010 Elective<br />
Scott Newton MS4<br />
This past February, eighteen medical students, two residents, and one PA<br />
student lived at Camp Wesley Woods near the Great Smoky Mountains<br />
National Park in Tennessee to study topics in <strong>Wilderness</strong> Medicine. A<br />
diverse faculty, including physicians, paramedics, National Park rangers,<br />
and local law enforcement officers, gave lectures, led discussions, and<br />
directed hands-on scenarios where students had the opportunity to<br />
employ the skills and knowledge they acquired in a simulated setting.<br />
The course concluded with a student-organized 4-day backpacking trip<br />
inside the Great Smoky Mountains National Park.<br />
Topics in the first week included pre-hospital care, food and water<br />
procurement in the wilderness, and common ailments faced by<br />
international and wilderness travelers. Students received hands-on<br />
training in initial management of patients in the field, with a particular<br />
emphasis on adapting standard first responder techniques to use in<br />
remote locations. Hands-on scenarios included evaluating and treating<br />
a patient who had suffered a fall and then safely transporting the patient<br />
away from the scene over rough terrain. Training officers from the<br />
Blount County Sheriff’s department gave a hands-on demonstration of<br />
a variety of firearms.<br />
“Folding this into my existing medical knowledge expands the scenarios<br />
where I could be of use,” said Nicole Ingram, medical student from Texas<br />
Tech. “I feel like we could be dropped into the middle of nowhere with<br />
nothing but a pocketknife and a match and make it back home.”<br />
“As long as we’re not wearing any cotton!” added Lindsay Merry, medical<br />
student from University of Manchester, UK.<br />
Topics for the remainder of the month included high altitude medicine,<br />
search and rescue skills, water and river sports, plant toxins, and<br />
management of soft tissue injuries and trauma. The hands-on scenarios<br />
continued and increased in difficulty, pushing students to the extent of<br />
their ability and knowledge. Students also gave short presentations on<br />
topics of their own choosing, ranging from identification of edible plants<br />
to treatment of hypothermia.<br />
Scott Newton is a 4th-year medical student at Albany <strong>Medical</strong> College in Albany,<br />
New York and graduated from the University of Washington in Seattle with a BA<br />
in Spanish.<br />
To contact the elective directors, please<br />
go to WMSelective.org, or email Dr. Chris<br />
Sloane: csloane@ucsd.edu<br />
28 WILDERNESS MEDICINE // Spring 2010
CLIFF NOTES Catherine Chamberlin MS4<br />
<strong>Wilderness</strong> Medicine Electives<br />
It is that time of year – 2nd-year medical students are dreaming about<br />
being out of the classroom, 3rd years are trying to plan their 4th (and<br />
best) year of medical school, and 4th years are trying to squeeze in that<br />
last adventure before residency.<br />
In the past few weeks I have received several emails asking about<br />
<strong>Wilderness</strong> Medicine elective opportunities. To start, check out the<br />
Student Interest Groups (SIG) website where there is a long list of<br />
WM electives, including field-based and international opportunities<br />
(wms.org/studentgroups/sig_web_site/sigelective.htm)<br />
If you are looking for an elective in a remote area, check out Indian<br />
Health Service or AHEC (Area Health Education Centers). I would also<br />
recommend looking at the WMS directory (membership required for<br />
access) to find physicians located in your area of interest.<br />
Here’s a letter I received from a friend and fellow wilderness medicine<br />
4th-year medical student, Jeremy Brudevold, who did just that…<br />
As a student interested in wilderness medicine I find myself<br />
preoccupied with searching for my next big adventure. Even<br />
in the midst of interviewing for an Emergency Medicine Residency<br />
position, I cannot help but take time to explore what the<br />
wilderness has to offer. This past December my sister was married<br />
in Maui, Hawaii. When I found out the wedding location,<br />
I knew it would not only be a great opportunity to spend time<br />
celebrating with family, but also a time for me to search for a new<br />
exciting adventure.<br />
I began my search by sending emails to all of the WMS<br />
members in Hawaii to see what opportunities were available<br />
during my time in Maui. It did not take long for me to receive<br />
an email from Dr. Clayton Everline, who has not only started a<br />
wonderful non-profit organization (TheWavesofHealth.org), but<br />
is also an active WMS member on Maui. He informed me that<br />
the world’s best women surfers would be in Maui competing at<br />
the Billabong Pro Maui surfing event. Dr. Everline was very helpful<br />
and accommodating, and since I was an eager medical student<br />
seeking to lend a hand, he invited me to join him in providing<br />
medical care to the participants.<br />
When I arrived at Honolua Bay the view alone made the<br />
journey well worth it. The contestants’ athleticism and determination<br />
to capture each wave was amazing, and I could not help<br />
but think of how fortunate I was to be a part of it all. As the<br />
event was winding down, I spent some time with Dr. Everline,<br />
who taught me about many different aspects of surfing medicine.<br />
Having spent most of life in the Midwest, my exposure to surfing<br />
was somewhat limited to say the least. As I sat watching the<br />
waves crash against the reef, I was humbled and intrigued by the<br />
power of the ocean, and I knew one day I would be back.<br />
Letters such as these serve as a continuous reminder of the spectrum<br />
of opportunities that exist in <strong>Wilderness</strong> Medicine. If you know of any<br />
wilderness medicine electives to post on the SIG website, please email<br />
me at wmsstudentrep@gmail.com.<br />
2010 WMS Recognition Awards<br />
The WMS Awards Committee, chaired by Dr. Ken Zafren, invites you<br />
send your suggestions for nominees of members and non-members<br />
who you believe are worthy of the <strong>Society</strong>’s recognition. The winners<br />
will be honored at the 2010 Summer Conference and Annual Meeting<br />
in Snowmass, Colorado. The award categories are listed below:<br />
Dian Simpkins Service Award. Given in recognition of outstanding<br />
service to the function and operation of the <strong>Society</strong>.<br />
Education Award. Given in recognition of outstanding contributions in<br />
education to students, members, or the public in the field of <strong>Wilderness</strong><br />
Medicine.<br />
Founders Award. Given in recognition of outstanding contribution to<br />
the principles and objectives of <strong>Wilderness</strong> Medicine as envisioned by<br />
the <strong>Society</strong>’s founders.<br />
Research Award. Given in recognition of outstanding research pertinent<br />
to the field of <strong>Wilderness</strong> Medicine.<br />
Warren D. Bowman Award. Given to an associate member or an allied<br />
health professional for outstanding contributions in education to students,<br />
members, or the public in the field of <strong>Wilderness</strong> Medicine.<br />
The Awards Committee believes that your participation will significantly<br />
expand the depth of reach for the awards program. Members in all of the<br />
membership categories are eligible to make a nomination. The Awards<br />
Committee will give full consideration to all those named. In support of<br />
your nomination please include:<br />
Nominator: Your name, member number, and contact information<br />
Nominee: 1) Award for which you are nominating him/her; 2) full<br />
name and contact information; 3) awards, recognition, degrees; 3)<br />
experience, accomplishments, and memberships; 4) your personal<br />
support statement<br />
Email your nomination(s) with supporting information to Dr. Ken<br />
Zafren: zafren@alaska.com. We look forward to your participation in<br />
helping the WMS to award our worthy colleagues with these honors.<br />
VISIT WMS.ORG TO:<br />
Register For The Summer<br />
Conference July 23-28, 2010<br />
Update Your Profile<br />
Renew Your Membership<br />
Check Out Our Store!<br />
WILDERNESS MEDICINE // Spring 2010<br />
29
Dagala Thousand Lakes Trek<br />
Himalayan Kingdom of Bhutan<br />
Continuing <strong>Medical</strong> Education<br />
October 7-22, 2010<br />
www.AndesMountainGuides.com/cme<br />
MOUNTAIN GUIDES<br />
WILDERNESS MEDICAL SOCIETY<br />
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing <strong>Medical</strong> Education through the joint sponsorship of the<br />
<strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong> and Andes Mountain Guides. The <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong> is accredited by the ACCME to provide continuing medical education for physicians. The <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong><br />
designates this educational activity for a maximum of 16 AMA PRA Category 1 Credits TM. Each physician should only claim credit commensurate with the extent of their participation in the activity.
2010 conference calendar & affiliated conferences*<br />
WHEN WHAT WHERE<br />
Apr 16 - 18, 2010 St. Luke's Hospital <strong>Wilderness</strong> <strong>Medical</strong> Conference (SLTC) Skytop, PA<br />
Apr 18 - 24, 2010 Desert Medicine Training Course (EM/UK) Namibia<br />
Apr 21-5, 2010 <strong>Wilderness</strong> Upgrade for the <strong>Medical</strong> Professional (WMI/NOLS) Sausalito, CA<br />
Apr 28-May 2, 2010 <strong>Wilderness</strong> First Responder (WTC) Southwest Rescue, Durango, CO<br />
May 1-9, 2010 <strong>Wilderness</strong> First Responder (WTC) University of Michigan, Ann Arbor, MI<br />
May 4-12, 2010 <strong>Wilderness</strong> First Responder (WTC)<br />
Southern Utah Univ, Bryce Canyon<br />
Nat. Park, UT<br />
May 5-7, 2010 Advanced <strong>Wilderness</strong> Life Support (AWLS) Moab, UT<br />
May 8-15, 2010 Sailing in British Columbia Expedition for <strong>Medical</strong> Professionals (WMI/NOLS) Conway, WA<br />
May 9-13, 2010 <strong>Wilderness</strong> Upgrade for the <strong>Medical</strong> Professional (WMI/NOLS) Kyle B. Brown, Ames, IA<br />
May 9-13, 2010 <strong>Wilderness</strong> First Responder/WEMT Module (WTC)<br />
Alaska Pacific University, Anchorage,<br />
AK<br />
May 15-16, 2010 <strong>Wilderness</strong> Medicine for the Professional Practitioner (WMI/NOLS) Sausalito, CA<br />
May 15-23, 2010 <strong>Wilderness</strong> First Responder (WTC)<br />
Oklahoma State University, Stillwater,<br />
OK<br />
May 24-June 1, 2010 <strong>Wilderness</strong> First Responder (WTC) University of San Diego, San Diego, CA<br />
May 25-28, 2010 <strong>Wilderness</strong> Advaned Life Support (WMA) Santa Fe, NM<br />
May 29-June 2, 2010 <strong>Wilderness</strong> First Responder, WEMT Module (WTC) WMTC Classroom, Winthrop, WA<br />
June 5-13, 2010 WFR/WEMT (WMO) Elizabeth, CO<br />
Jun 25-<strong>27</strong>, 2010 Advanced <strong>Wilderness</strong> Life Support (AWLS) Mt. Rainier, WA<br />
July 3-11, 2010 WFR/WEMT (WMO) Elizabeth, CO<br />
July 9-17, 2010 Rafting the Main Salmon Expedition for <strong>Medical</strong> Professionals (WMI/NOLS) Driggs, ID<br />
July 10-17, 2010<br />
Sea Kayaking in Prince William Sound Expedition for <strong>Medical</strong> Professionals<br />
(WMI/NOLS)<br />
Palmer, AK<br />
Jul 16-18, 2010 Advanced <strong>Wilderness</strong> Life Support (AWLS) Queenstown, New Zealand<br />
Jul 23-28, 2010 WMS Annual Meeting and CME Conference Snowmass, CO<br />
Aug 7-15, 2010 WFR/WEMT (WMO) Elizabeth, CO<br />
Aug 8-12, 2010 8th World Congress on High Altitude Medicine and Physiology (ISMM) Arequipa - Peru<br />
Aug 29 - Sep 5, 2010<br />
Backpacking in the Wind River Range Expedition for <strong>Medical</strong> Professionals<br />
(WMI/NOLS)<br />
Lander, WY<br />
Aug 31-Sep 3, 2010 <strong>Wilderness</strong> Advaned Life Support (WMA) Crested Butte, CO<br />
Sept 3-6, 2010 Yellowstone Pack Trips (WPT) Yellowstone National Park, WY<br />
Sep 17-19, 2010 Expedition Medicine National Conference (ExpedMed) Washington, DC<br />
Sep 18-19, 2010 <strong>Wilderness</strong> Medicine for the Professional Practictioner (WMI/NOLS) Cullowhee, NC<br />
Sep 19-<strong>27</strong>, 2010 Expedition for <strong>Medical</strong> Students and Residents (WMI/NOLS) Conway, WA<br />
Oct 6-9, 2010 Advanced <strong>Wilderness</strong> Life Support (AWLS) Moab, UT<br />
Oct 7-22, 2010 Dagala Thousand Lakes Tour with CME (AMG) Bhutan<br />
Oct 2010 Diving and Marine Medicine Training Course (EM/UK) Bandar Khairan, Oman<br />
Oct 16-23, 2010 Backpacking in the Galiuros Expedition for <strong>Medical</strong> Professionals (WMI/NOLS) Tucson, AZ<br />
Oct 30-Nov 3, 2010 WMS Dive, Marine and Travel Medicine Conference (WMS) Lahaina, Maui, HI<br />
For the most recent updates, registration, and links be sure to check the <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong> website www.wms.org. *Organizations<br />
that affiliate with the WMS are granted permission to advertise as offering course content that is accepted for credit by the WMS Academy’s<br />
Registry of <strong>Wilderness</strong> Medicine Practitioners and Fellowship Program (FAWM) and agree to allow their names to be listed on the WMS website as<br />
an affiliated organization. For more information regarding the FAWM program visit WMS.ORG.<br />
AMG = Andes Mountain Guides<br />
AWLS = Advanced <strong>Wilderness</strong> Life Support<br />
EM/UK = Expedition Medicine, UK<br />
ISMM = International <strong>Society</strong> of<br />
Mountain Medicine<br />
SLTC = Luke's Trauma Center<br />
WMA = <strong>Wilderness</strong> <strong>Medical</strong> Associates<br />
WMI/NOLS = <strong>Wilderness</strong> Medicine Institute/National<br />
Outdoor Leadership School<br />
WMO = <strong>Wilderness</strong> Medicine Outfitters<br />
WMS = <strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong><br />
WPT = <strong>Wilderness</strong> Pack Trips<br />
WTC = <strong>Wilderness</strong> Training Center<br />
WILDERNESS MEDICINE // Spring 2010<br />
31
Vol. <strong>27</strong>, No. 2<br />
SPRING 2010<br />
<strong>Wilderness</strong> <strong>Medical</strong> <strong>Society</strong><br />
2150 South 1300 East, Suite 500<br />
Salt Lake City, UT 84106<br />
wms.org<br />
<strong>27</strong> TH WMS<br />
WILDERNESS MEDICINE<br />
CONFERENCE &<br />
ANNUAL MEETING<br />
WILDERNESS &<br />
MOUNTAIN MEDICINE<br />
SNOWMASS, COLORADO<br />
JULY 23-28, 2010<br />
REGISTER ONLINE<br />
WMS.ORG/conferences<br />
or call 801.990.2988<br />
for up-to-date info<br />
COMBINING YOUR PROFESSION<br />
WITH YOUR PASSION