Wilderness and Environmental Medicine, 6, 3-10 (1995)

EDITORIAL

What is wilderness medicine?

Introduction

What is wilderness medicine? Brief definitions are not adequate. Wilderness medicine must be described not only by its written content, but by its activities and, increasingly, by the endeavors of the Wilderness Medical Society (WMS), the only organization developed specifically to address the future of the field. The perspective of most WMS members is shaped by focal expertise and regional issues. A shared comprehensive perspective is necessary for effective program development. It is my hope that a broad discussion of the interests of wilderness medicine will expand members' interests and involvement, enhanc­ing the possibilities for action.

Relationship to other fields of medicine

Although wilderness medicine shares many interests and methods with other specialties, such as sports medicine and emergency medicine, it incorporates a unique spectrum of topics and special perspective that validate it as a distinct field of study.

From one perspective, wilderness medicine may be seen as care of the athlete in remote areas. Compared to competitive sports played in readily accessible places, wilderness, or remote-area activities (such as hiking, climbing, backcountry skiing, white-water boating, and hunting) are more likely to be individual or small-group activities, and cooperative rather than competitive. However, these activities attract large numbers of participants, demand a high level of fitness (which is often lacking), and entail high risk for both common and unusual medical problems. Adequate preparation for wilderness activities and patient management when problems arise in the wilderness have been concerns of a few medical organizations [e.g., the Wilderness Medical Society and the National Associa­tion for Search and Rescue (NASAR)] and of outdoor organizations [e.g., Boy Scouts of America, National Outdoor Leadership School (NOLS)], but the major responsibility for managing medical problems has remained with the participants themselves, backed up by local search and rescue teams. Recently, more competitive sports have moved off-road and into the backcountry, prompted by expanding interest in endurance events and the challenges of rugged terrain. Ultramarathon runs, mountain bike races, nordic ski events, and dog sled races traverse remote courses of 100 miles or more during events that may last more than 24 h. This may increase appreciation for wilderness medicine and help to organize medical services to support wilderness activities.

Wilderness medicine not only overlaps with sports medicine, but also with emergency, military, occupational, and travel medicine and international health. The pathophysiology of heat illness is similar, regardless of whether it occurs in a foot race or in the Grand Canyon, during a military operation in the desert or jungle, fighting a fire in the city or forest, or working in a steel mill. In each instance, management must include initial field measures, evacuation, and transport to a higher level of care. Wilderness medicine shares with emergency medicine the concepts of urgent intervention, stabilization, prehospital

1080-6032 © 1995 Chapman & Hall

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care and transportation, concern with the entire spectrum of medical problems, and reliance on clinical judgment. It shares with military medicine an intense interest in environmental stresses and hazards, field management, and mobile response. Likewise, in disaster medicine, medical care is routinely provided in the field under adverse conditions with minimal supplies and prolonged evacuation times. Wilderness medicine also relies heavily on pre hospital care response systems and search and rescue.

Where is wilderness medicine practiced?

Wilderness medicine focuses on medical problems and treatment in remote environments, but it should not be literally interpreted as medicine within the boundaries of a defined wilderness area. There are a few medical clinics in wilderness settings and others within national park boundaries. However, most wilderness medical problems are seen by medical practitioners in rural and resort communities. In fact, some environmental problems are seen much more commonly in urban areas (e.g., hypothermia and heat illness) or in suburbs (e.g., submersion and lightning strike). The boundaries of wilderness are often indistinct. As development expands, communities designed for luxury and comfort border rugged undeveloped mountain and desert areas. Coastal and bayside developments place dense populations next to a water wilderness. Campgrounds filled with trailers look like suburbs. Urban and university medical centers may be evacuation, referral, and research centers for serious environmental problems that originate in outlying areas.

Geographic boundaries and the absence of people may define "wilderness," but they do not define wilderness medicine. Natural disasters may create a wilderness in the midst of a city by destroying transportation, communication, and health care facilities. International travelers to remote areas of the world are usually surrounded by indigenous people, although they often remain farther from transportation, communication, and medical care than anywhere in our domestic "wilderness" areas. Practicing medicine in underdeveloped areas shares many similarities with providing care in the wilderness, including limited supplies and diagnostic capabilities and the need to improvise.

Unique aspects of wilderness medicine

Apart from its focus on medical issues in remote environments, several aspects make wilderness medicine unique. It is an inclusive field that incorporates not only primary care providers but every other medical specialty-from dermatologists to trauma surgeons to infectious disease specialists. It also incorporates rescue personnel and wilderness guides, who often provide the first line of medical care and have the best opportunity to educate the public about wilderness safety. Wilderness medicine is distinct in its disproportionate dependence on basic clinical judgment. Even the most rudimentary diagnostic equipment, such as a blood pressure cuff, is not likely to be available in the wilderness. Finally, wilderness medicine is unique in its reliance on improvisation. One must utilize whatever supplies or materials are available; it is rare to have optimal equipment to manage most situations. Medical equipment and medications carried should have multiple uses. Non­medical equipment must often be adapted for medical purposes.

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Medical aspects of wilderness medicine

The medical dimension of wilderness medicine is easier to define but very broad, including components of physiology, clinical medicine, preventive medicine, public health, interna­tional and global health (Table 1 ).

Environmental physiology

This is a primary area of study. The entire spectrum of environmental stressors is included: heat, cold, hypobaria, hyperbaria, and altitude. These stresses are investigated from the perspective of their effects on health, exercise, ability to work, illnesses, and injuries. In the wilderness, the stakes of ignoring the complex interaction among environmental physiol­ogy, exercise physiology, and clinical pathophysiology are illness or death.

Table 1. Content of wilderness medicine

Environmental influences Hazards to health Physiologic effects on human performance and health

Environmental health disorders Heat illness Hypothermia Frostbite Altitude illness Barotrauma Submersion

Health risks of specific environments Mountain Desert Jungle Marine Aerospace Subterranean

Health risks from flora and fauna Toxicology Animal attack

Infectious diseases Traditional medicine in remote environments

Wilderness trauma Medical limitations to wilderness travel

Geographic (travel medicine) Medical services in wilderness setting

Search and rescue Organization of wilderness medical services Expedition medical planning

Global health issues Liability in wilderness medicine Education in wilderness medicine

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Acclimatization is a unique and particularly fascinating aspect of environmental physiol­ogy. Exercise capacity is markedly altered in heat or at altitude; however, the body undergoes the remarkable adaptations of acclimatization to these stresses in order to allow functioning in these conditions.

Equally important to wilderness medicine are the effects of environmental stresses on preexisting conditions. Medical professionals must be able to advise patients of their risks while performing wilderness activities. Can the person with known coronary disease and prior coronary artery bypass who exercises moderately at sea level safely hike or ski at 10,000 ft, or trek to 18,000 ft? Is scuba diving contraindicated for all asthmatics? Which wilderness pursuits are safe in pregnancy? Which medications affect tolerance to environ­mental and exertional stress?

Environmental hazards

The clinical interests of wilderness medicine include a broad array of environmental hazards. Some are fairly common and easily identified, such as venomous bites and stings (from honeybees to jellyfish to rattlesnakes), poisonous or irritating plants (from poison­ous mushrooms to poison ivy and oak), animal attacks (from dog bites to bears), and ultraviolet exposure (from sunburn to snowblindness). Other hazards, such as lightning strike and avalanche, are unforeseen and cataclysmic. Microbial hazards are invisible but potentially devastating. Infectious diseases commonly transmitted through outdoor activi­ties or foreign travel may occur from exposure to insects, animals, or the environment. Examples include giardiasis, Lyme disease, rabies, leptospirosis, malaria, and other "exotic" diseases.

Humans continue to extend recreation and occupational activities into more severe and remote areas. Each geographic region or ecosystem has a unique combination of environ­mental stress and hazards. The newest wilderness frontier, outer space, will extend unique environmental and physiological challenges.

Clinical medicine

Clinical issues in wilderness medicine include planning and delivery of health care in harsh or remote environments. These generate some of the most extraordinary issues in wilderness medicine.

Expedition medicine is a good example. Equipment and supplies are severely limited by space and weight. Further limitations are imposed by consideration of what can rationally be used in the field and by reasonable expectations of what can be accomplished. The environment itself may affect treatment decisions. The patient and the health providers must be protected from environmental extremes and hazards. Safety of rescuers takes precedence over patient care decisions, to avoid creating more victims. "Return-to-play" considerations are magnified in the wilderness, where the difficult decision that must be made when someone has suffered an injury or illness is whether to allow him to continue on a trip or to initiate a lengthy and disruptive evacuation.

Search and rescue

Search and rescue (SAR) is an integral component of wilderness medicine. SAR involves coordination and close interaction between emergency medical technicians, paramedics, guides, and persons with technical skills such as climbers, pilots, and physicians. Evacua­tion may take extended periods of time (hours to days), during which clinical problems

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must be actively managed, not merely stabilized as they are under urban protocols. This creates interesting problems in training and medical control. As a result, wilderness EMT programs have developed with new treatment protocols that allow more advanced intervention than is allowed with short transport times. Some procedures that may need to be performed in the field by rescue personnel include reduction of dislocations and realignment of fractures, releasing spinal immobilization, and placement of bladder catheters.

Preventive medicine

Although providing care in the wilderness is an exciting concept, wilderness medicine should also incorporate prevention, as it is much easier to prevent these problems than to treat them in remote areas. Effective prevention strategies require epidemiologic informa­tion on medical problems in the wilderness, an understanding of how these problems occur, and effective methods of education. Wilderness medicine still offers many opportu­nities for basic epidemiologic research.

How do people get into trouble in the wilderness? Sometimes it is an unexpected chance event like an avalanche, animal attack, or sudden injury. But, a cautious approach combined with judgment and skill can even prevent many of these problems. More often, a combination of errors or misjudgments cause problems; for example: getting lost when venturing into the wilderness and failing to carry minimal equipment; continuing to travel in a storm despite fatigue and cold rather than stopping to secure shelter, warmth, and food while still capable of functioning; or allowing oneself to become dehydrated, metabolically exhausted, and ill from rapid altitude gain. The beauty of the wilderness often lures people beyond their physical abilities and psychological capacity to handle problems. Observing basic safety rules for wilderness travel, knowing physical limits, and understanding environmental stresses would prevent many wilderness injuries and avoid survival situations.

Some solutions are simple, like the necessity to ventilate cooking stoves to prevent carbon monoxide deaths in tents or snow caves. However, the best way to disseminate the necessary information to persons with the most need is more problematic.

Survival situations and the psychology of wilderness medicine

Given the inherent isolation of wilderness and the risk of becoming lost or stranded by severe weather, medical problems are often inseparable from survival problems. The popular concept of wilderness is a utopian place of beauty and serenity. However, the reality is that it can change quickly to a severe, impersonal, and unforgiving environment that can overpower and destroy. The most difficult task is to prepare someone mentally for a stressful and threatening wilderness experience. The ability to successfully manage unexpected adversity may be an innate individual characteristic or one that can be developed by repeated experiences in the wilds. Accounts abound of individuals similar in all measurable ways who face the same survival challenge, yet some survive and others die.

Medicolegal issues

Unfortunately, wilderness medicine cannot escape the medicolegal concerns that plague medical practice. Our society is moving away from the concepts of self-responsibility and self-reliance to the belief that it is the responsibility of some agency to rescue any individual in trouble. As a result, our parks are being plastered with signs at every turn,

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warning visitors of obvious dangers. Wilderness travelers may ignore these warnings or knowingly venture into a storm, yet fully expect to be rescued at great public expense and risk to the rescuers. Those injured or killed seek compensation from the land management agency or from the group that organized the trip, even if the adverse event was a known risk yet unforeseeable event.

Whereas Good Samaritan rules apply to health professionals rendering aid during a chance encounter, they do not apply to health professionals who are designated as the trip medical officer. However, medical malpractice insurance coverage for expeditions or wilderness trips is not available to most physicians. Given the constant threat of malprac­tice lawsuits from trip participants or their families, most doctors now choose not to be a trip physician. Ironically, this leaves many remote group ventures without any prearranged medical care. Similarly, manufacturers of sporting safety gear, such as climbing equipment, face such high liability insurance premiums that some have stopped manufacturing their products. Therefore, safety equipment may become prohibitively expensive or unavailable.

Public health

Wilderness experiences should be encouraged for their public health benefit. The wilder­ness has long been extolled for its benefits to body and soul. Wilderness can evoke a spiritual perception of the vastness and power behind the universe. Wilderness experi­ences can be an invaluable educational and maturational tool, especially for young people. The demand for each individual to travel under his own power, to face the changing elements, and to be creative in managing daily tasks creates physical and mental strength. Experiences such as white-water boating and attaining a mountain summit provide "natural highs." Group experiences can create tight bonds among participants and be an ideal setting for studying issues of group dynamics and leadership.

Policy issues

Given the important benefits of wilderness, it should be made more accessible to physically impaired persons. Although this may mean some wheelchair-accessible paths, it does not mean paving roads into the wilderness. More importantly, it means supporting programs that encourage and help handicapped persons to experience the wilderness on its own terms.

The lack of judgment and personal responsibility of wilderness travelers with the resultant cost of rescue has led to the proposal of no-rescue zones. Certain wilderness areas would be posted with advisories that travelers enter at their own risk; helicopters (and possibly search teams) would not enter. Given the current legal climate in the United States, this concept is unlikely to win support. However, considerable controversy has been generated by the proposal that in certain high-risk areas or for high-risk activities, such as climbing on Mt. Denali, wilderness travelers should be asked to post a bond or pay high user fees to cover the costs of rescue.

Environmentalism and global health

An environment so attractive is ripe for exploitation. Through advertising, products such as tobacco, alcohol, and automobiles try to link their products with wilderness activities. But this abuse of image is not as important as depredation of the environment itself. Although environmentalism is not the primary focus of wilderness medicine, it must be a concern to all medical specialties. Medicine is affected by the loss of rainforest that

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destroys species before they can be tested for their medicinal value. Concurrent loss of indigenous cultures means that there will be no traditional healers to identify plants that have been used empirically for centuries. Medicine should be concerned with the potential increase in skin cancer from decreasing ozone protection and with the poisoning of air, water, and soil with chemical and radioactive toxins.

International health

International health is another global concern of wilderness medicine. In addition to providing exceptional opportunities to practice wilderness medicine, there are policy issues. In reality, medical practice in many parts of the world (often the same areas that are popular among wilderness adventure travelers) involves diseases of poor sanitation, crowded living conditions, and inadequate nutrition, with care compromised by minimal medical resources. Even in a scientific forum, discussion of these maladies will inevitably include political connotations.

Ironically, the same socioeconomic conditions that threaten the health of local people threaten the existence of the "wilderness" that one seeks when traveling to these areas. Population and economic pressures result in encroachment into wild areas and environ­mental depredation of the water and air. Pollution causes further health risks, limited not only to the locals but to all persons on this planet. The health of local peoples directly affects travelers' health. Endemic infections such as malaria and enteric illness are passed by mosquitos or contaminated food and water to outside travelers.

Development of wilderness medicine: Wilderness Medical Society

The founders of the WMS noted that no organization in the medical community was looking comprehensively at solutions to medical problems in remote areas. Publication of research in environmental physiology and illness was scattered throughout the medical literature. Little was being taught in medical schools or postgraduate training programs concerning care outside the hospital. Individuals and organizations that were leading groups into the wilderness and the physicians giving them medical advice had nowhere to get expert consensus advice. The public was at the whim of lay writers who did not always check their information carefully, promoting dramatic but ineffective remedies and inaccurate information.

The response was an organization based on the following:

The mission of the WMS is to encourage, foster, support and conduct activities or programs that may improve the knowledge and well-being of its membership and the general public in matters related to wilderness medicine.

The purpose of the Society is to establish an organization composed of qualified physicians, allied specialists, and other qualified individuals that will concern itself with matters related to wilderness medicine and the benefits, health, safety, and care of individuals in the wilderness.

With a mission primarily focused on education and research, the WMS has undertaken the following tasks: (1) to assemble, collate, analyze, and interpret information from diverse sources; (2) to promote and support research; (3) to act as a referral resource for information and experience; (4) to help develop rational programs and solutions for care in the wilderness; (5) to help debate issues in wilderness use and medical rescue; and (6) to promote association and collaboration of like-minded colleagues.

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To accomplish these, the WMS has developed programs in the following areas: 1. Education. This effort has primarily focused on health professionals, with the idea

that they would, in turn, educate the public through their involvement in various aspects of wilderness medicine. Professional conferences form the foundation of the educational effort. The WMS is now developing a program for direct public education, starting with public seminars. But public education will require even greater creativity than professional education; those most in need of education are usually the ones who will not read or listen.

Publications include an educational newsletter (Wilderness Medicine Letter) and a peer-review medical journal (Wilderness and Environmental Medicine) that attempt to concentrate wilderness medicine information and research. A Bibliography of Wilderness Medicine is maintained as a reference source. Educational slide sets on topics in wilderness medicine were developed as a teaching aid for lectures to professional and public groups. The slide sets also make materials available for teaching these topics in medical schools and postgraduate training programs.

2. Expert referral. A databank of members' expertise is being developed for several purposes. Media need referral to accurate sources of information or expert commentary on issues involving wilderness medicine. This databank can also serve to organize a speaker's bureau and initiate a physician referral network for help with patient care problems.

3. Standards. Management guidelines addressing controversial clinical issues have been published to help hospital and prehospital practitioners manage problems that have elicited more opinion than fact.

4. Research. The WMS offers several seed-money research grants for medical students and graduate students in health or biologic sciences with the intent of stimulating interest through research early in their careers. Another grant is now available to WMS members. Eventually, identifying outside sources of funding will allow expanded research support.

5. Policy and environmentalism. Although difficult for a small society to undertake because of the financial requirements, policy issues should at least be debated so that intelligent opinions can be formed, allowing members to work through their own contacts and organizations. Because the health of human beings, the health of the environment, and the existence of wilderness are inextricably linked, an Environmental Council has been formed to work with environmental health issues. This group will focus on health effects of environmental degradation and devise educational strategies to influence other health professionals, and, where possible, public agencies or officials. Much of their efforts will be through a larger association of similarly concerned medical professionals and organizations, the National Association of Physicians for the Environment (NAPE).

6. Providing an association. At a minimum, the Wilderness Medical Society provides for association, interaction, and opportunities for participation of interested persons to advance this field. The health professionals and others who are involved in the Wilderness Medical Society are a diverse but very dynamic and engaging group. Each contributes his/her own special expertise and interests to the field, as well as their enthusiasm and energy for wilderness endeavors. Ultimately, wilderness medicine provides an opportunity to mix professional interests with a passion for the wilderness.

HOWARD D. BACKER, MD Emergency and Sports medicine, Kaiser Permanente Medical Group, Hayward,

California, USA. Past president, Wilderness Medical Society