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Posts Tagged ‘Wilderness Medicine’

OK- enough (for now) of the photo documentation of my past month of explorations!  While I am keen to write more about the environment, wildlife, and general experience of my last month in Utah, it’s time for me to get back to the reality of a med student and think (and write) about medicine.

 

A number of schools (and programs) offer Wilderness Medicine electives for medical students, but I chose (and was fortunate to get a spot in) the elective offered by UMass Medical School.  A few things drew me to this program.  First- it has been running for 20 years, so I initially suspected they were doing something right.  Second- many Wilderness Medicine courses are taught in classrooms with field trips and forays “into the wild” for practical experiences.  The UMass course is taught in the wild. With the exception of our first day of lecture, conducted in a hotel meeting room, all our lectures were done outside on snow, in boats, on beaches, or sitting in the desert.  Thirdly- we got to experience three different environments in the course of three weeks.  A few other courses are taught in the wild, but they are taught in a single environment.  Utah gave us access to three, very different, environments (as shown in my previous posts: alpine, river, and desert).

 

This was our main classroom in the alpine section.  We'd just arrived and are taking a quick break before setting camp, but this area was left open and we would congregate here for lectures.

This was our main classroom in the alpine section. A classmate snapped this shortly after we arrived when we were taking a quick break before setting camp, but this area was left open and we would congregate here for lectures. 

 

When I initially described this course to friends and acquaintances, many suggested that this course was basically Outward Bound for doctors.  The answer, I suppose, is yes and no.  There was certainly a lot of medical learning done in this class, but we also gained life skills that will not only help us in future endeavors in the wild but will also give us confidence as we go forward in our medical careers.  Broadly, it taught us to have confidence in our decisions and to use what we have available to do the best that we can.  I’m unlikely to ever have to improvise a splint in the Emergency Room, but knowing that I can, and having that confidence, will carry me and my classmates a long way as we progress to interns, residents, and one day attending physicians.

 

As you might expect, the medical topics that we covered were married to the environments and activities we were doing.  Before heading out on our first big trek we had a thorough lecture on blister pathophysiology, prevention, and treatment. Once in the alpine, we promptly learned about hypothermia, and how to create a hypowrap to help someone with hypothermia.  We learned about frostbite and non-freezing cold injury, as well as thermal burns, sunburns, and sun blindness.  While in the mountains, we also discussed various problems that occur at high altitude.

 

A lot of injuries in the wild are orthopedic, so we had multiple sessions on splinting, immobilizing, and caring for these injuries.  We also learned various lifts, rolls, and carries, utilizing minimal equipment- since you don’t always have a backboard and a team of people to help you.  Along those lines, we learned just how difficult it is to litter carry someone out of a bad situation (you need about 18 people to go 1 mile, and it will take you a LONG time).

 

It's not what you would do in a hospital setting, but how do you get someone with a potential cervical-spine injury free after you’ve just dug them out of an avalanche slide? Stabilize their neck with their arms and drag them! (And kudos to our instructors.  Not only did they dig a deep snow cave for us to locate with avalanche beacons, but one of the brave residents agreed to be buried down there for one of our “scenarios”. I wish I could have seen the look on my face when we realized there was a person 5 feet under the snow!)

It’s not what you would do in a hospital setting, but how do you get someone with a potential cervical-spine injury free after you’ve dug them out of an avalanche slide? Stabilize their neck with their arms and drag them. (And kudos to our instructors. Not only did they dig a deep snow cave for us to locate with avalanche beacons, but one of the brave residents agreed to be buried down there for one of our “scenarios”. I wish I could have seen the look on our faces when we realized there was a person ~5 feet under the snow!)

 

 

The slope that we dug our patient out of- the instructors made the scenarios very realistic while keeping everyone safe.

The slope that we dug our patient out of- the instructors made the scenarios very realistic while keeping everyone safe.

 

Injuries in every settings... here I’m sporting a mid-humeral splint fashioned out of a camping chair (in the rain and on the river).

Injuries in every settings… here I’m sporting a mid-humeral splint fashioned out of a camping chair (in the rain and on the river).

 

A number of dermatologic conditions occur in the wild, so we discussed their various etiologies.  We also discussed methods of wound management, including wounds caused by snakebites, insect stings, and mammalian injury.  (On that note, during our time in the desert our group spotted rattlesnakes, scorpions, and a black widow spider.)

 

A trio of beasties spotted on our trip.

A trio of beasties spotted on our trip.

 

Many of the topics we covered are much more likely to be encountered in the wilderness than in a clinical setting, but some topics are ever-present in any setting.  Anaphylaxis and allergies can occur at any time, and while you may acquire tick-borne illnesses or infections diarrhea in the wild, the incubation time for many of these mean that they frequently present at a primary care office.  Nonetheless, these were topics we covered on this course, frequently harking back to the “bible” of wilderness medicine: Wilderness Medicine written by Paul Auerbach.

 

Thus far I’ve mainly focused on the didactic portion of the course, but much of the learning took place in “scenarios”.  I’ve never participated in simulation medicine, save for the standardized patients we get on our OSCE (Objective Structured Clinical Exam) at the end of most clerkships. While at first it can be awkward to “practice” medicine on people that you know are acting, once you get into the part it is a wonderful way to learn.

 

The beauty (and perhaps the terror?) of our scenarios was that our instructors would let us “play it out” in the field.  In clinical settings, while students may participate in discussions about patient care, they are never in the driving seat.  In our wilderness scenarios we were allowed to make the decisions and deal with the consequences.  At times this was frustrating (can’t I just ask the Wilderness Fellow standing over my shoulder what I should do), but it also allowed me to make mistakes that will stick with me for years to come.  For example, if a “helpful” stander by hands your patient some food, make sure they’re not allergic to it before they take a bite (that’s how a painful case of sun blindness can progress into life threatening anaphylaxis).

 

The scenarios also allowed (or I should say made) students make decisions about evacuation. Do we evacuate the patient? How? Can they walk? Do they need a litter? Do they need cervical-spine protection? Do we leave now or hunker down for the night and head out tomorrow? What’s the best evacuation route? Could a rescue team get a helicopter in here? A snowmobile? Maybe we should send runners to a ranger station? Where’s the closest location we can get cell phone reception?

 

The scenarios progressed with our wilderness medicine knowledge, as well as our knowledge of Incident Command Structure (ICS).  There were twelve medical students in our class, and when we had a scenario with one patient, it would be easy to have “too many cooks in the kitchen”.  On the other hand, when we had three patients, we could quickly run out of hands as people were relegated to “safety officer”, “equipment”, “communications”, and if the scenario necessitated it “runners” leaving the scene to make contact with civilization.

 

All in all, the medical education side of this course was excellent.  Some of the medicine was a review, but it was a much-needed review and one that frequently found we students (who are trained to practice medicine in well-stocked hospitals with multiple imaging modalities at our fingertips) asking “what do we have that we can use” and “how can we do what we need to get done”.

 

Medically, this class was a reminder of quite how much we’ve learned about medicine in the last few years.  It also emphasized that frequently there is no “right way” to handle a situation and your best guess and best efforts may save the day. We were also reminded of the reality that sometimes there is nothing you can do to save a life… and that is an important lesson to learn as well.

 

 

Not a bad place for a lecture...

Not a bad place for a lecture…

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I have spent only 5 of the last 25 nights in a bed (4 different beds, to be precise). At this point I feel a touch claustrophobic in bathrooms and feeling clean is certainly a novelty.  My Wilderness Medicine elective is over and I have had an exceptional visit in Moab (more on that in another post). Tomorrow I head to the mountains of Colorado for one last stint in the wilderness before heading back to New Jersey where I will start a radiology elective on June 3rd.  From a month in the wilderness to an elective spent in dark, windowless rooms- the change in environment couldn’t get much more extreme (which is saying a lot, coming from someone who has gone from alpine camping to desert camping in the course of 3 weeks).

 

This is the final installment of “Pic of the Day”, at least for the Wilderness Medicine Elective.  I may not be able to resist a “Pic of the Day, Moab edition”… we shall see.

 

For the desert portion of the course we headed to Canyonlands National Park, specifically The Needles District of the park.  We spent 4 nights in 3 different sites, hiking up to 12 miles a day with heavy packs.  I found this portion of the course the most physically demanding, but at the end of the day it was unquestionably my favorite section.

 

I’ll write details in future posts, but for now: Pic of the day- desert edition.

 

Day 1- Canyonlands

 

The geology of Canyonlands (actually, the geology of much of Utah) is stunning and fascinating.  This is in the needles are, near Lost Canyon, where we spent our first night in the park.

The geology of Canyonlands (actually, the geology of much of Utah) is stunning and fascinating. This is in the Needles District, near Lost Canyon, where we spent our first night in the park.

 

Day 2- Perspective

 

Looking back at Lost Canyon as we hike out to Elephant Canyon, our next campsite. From many vantage points in the park you could see the snow capped La Sal Mountains.

Looking back at Lost Canyon as we hike out to Elephant Canyon, our next campsite. From many vantage points in the park you could see the snow capped La Sal Mountains in the distance.

 

Day 3- Druid Arch.

 

Before we packed hiked our big packs out to Chesler Park, we took an early morning park out to Druid Arch.

Before we hiked our big packs out to Chesler Park, we took an early morning hike out to Druid Arch.

 

Day 4- The Joint Trail

 

Probably one of the coolest trails I have every hiked, winding through a narrow slot canyon.

One of the coolest trails I have every hiked, The Joint Trail winds through a narrow slot canyon.

 

 

Day 5- Sunrise and out.

 

We left camp at 4am for the 3+ hour hike out.  I led the group of 19 by head lantern for 2 hours before stopping on a bluff to watch the sun rise around 6am.  Pre-dawn hikes are something I will be adding to my repertoire.

We left camp at 4am for the 3+ hour hike out. I led the group of 19 by head lamp for 2 hours before stopping on a bluff to watch the sun rise around 6am. Pre-dawn hikes are something I will be adding to my repertoire.

 

I did not expect to fall in love on this trip, but I have certainly fallen in love with the desert.  I don’t know when I’ll be back, but I hope it is soon…

 

Chesler Park.

 

Chesler Park

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My Wilderness Medicine elective has officially come to a close. In the last three weeks I’ve experienced three very different environments (alpine, river, and desert) and learned lots of pre-hospital medical care for emergencies that arise in the wilderness.  I have quite a bit to write about, but I liked doing a “pic of the day” for the alpine session, so before I get to a thorough write up of the course I’ll post a “pic of the day” for the river and desert portions.

 

While the course is over, my adventure hasn’t come to an end.  I’m currently taking 2 weeks of vacation time to visit with my best friend, first spending more time in Utah in and around Moab and then heading back to her home in Boulder Colorado.  I hope to get some good writing in during this time… we shall see!

 

Without further ado- “pic of the day” river style!

 

Day 1- We started our adventure at the Sand Wash put in on the Green River where we camped, sans-tent, under the stars…

 

Camping under the stars.

Camping under the stars.

 

Day 2- Over the next 5 days we travelled ~87 miles down the Green River, passing through Desolation Canyon and Gray Canyon.  We saw a few different areas with petroglyphs, presumed to be from Fremont people.

 

Petroglyphs carved into "desert varnish", which according to the river guides (and wikipedia) is at least partially made of manganese.

Petroglyphs carved into “desert varnish”, which according to the river guides (and wikipedia) is at least partially made of manganese.

 

Day 3- Sun rising on the cliffs of Desolation Canyon.  This pic is a bit deceiving, as we actually had more “bad” weather than good.  I suppose we should consider ourselves lucky that we got to experience rain in the desert, but getting hammered with more than a third of the area’s average annual rainfall over 4 days could get a bit demoralizing!

 

A great view by which to enjoy your morning coffee...

The morning view from our campground. A great view by which to enjoy your morning coffee…

 

 

Day 4- Please allow me two pics for this day- I couldn’t chose just one (it would be easy to pick a gorgeous landscape for each day, but there really was a lot more to see).

 

The view from another campground...

The view from another campground…

 

Equipment at an abandoned ranch. During our float down the river we saw abandoned ranches, old mines, and even an old moonshine distillery.

Equipment at an abandoned ranch. During our float down the river we saw abandoned ranches, old mines, and even an old moonshine distillery.

 

 

Day 5- At the end of the day we would gather around a fire recapping the day, telling jokes, and marveling at where we were.  Off the grid, without technology or the distraction of modern society, it was wonderful to decompress.

 

Social gathering place and hot spot for heating evening beverages.

Social gathering place and hot spot for heating evening beverages.

 

Day 6- Our last day of camp was spent just below Rattle Snake Rapids (I loved going to sleep to the sound of rapids).  We were pampered on this portion of the trip, being taken care of by river guides- renaissance men of the modern age.  They’re guides, chefs, handymen, naturalists, historians, and fascinating individuals… I hope to reconnect with some when I return to Moab.

 

The nomadic life, with a new campground each night, was great- especially when gear was being floated down the river and not packed on our back!

The nomadic life, with a new campground each night, was great- especially when gear was being floated down the river and not packed on our back!

 

I’ll post some pics from the desert section when I get a chance!

 

——-

 

And for the skeptics, who question whether there was any medical learning on this trip…

I’ll write more on the medical learning in a future post, but here you can see me rocking an improvised humeral fracture splint… in a torrential downpour (thank goodness for Gortex!)

I’ll write more on the medical learning in a future post, but here you can see me rocking an improvised humeral splint… in a torrential downpour (thank goodness for Gortex!)

 

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If you read my last post, you’ll know that I’m currently away in Utah on a Wilderness Medicine elective.  I’ve just come back from the first evolution, the alpine section, and have one night in Salt Lake City before hitting the road tomorrow morning to head to the Green River and Desolation Canyon to take on the next portion of the course.

 

I certainly don’t have time for a thorough write-up of the last week, but I thought I’d give a quick “pic of the day” from the last week to give you an idea of what I’ve been up to.  The pics certainly can’t show all the learning that’s been going on- while there is certainly a large component of this course that many would consider recreation, I think I’ve learned more practical medical skills in the last week than I have in quite some time.  Sure- I don’t know when I’ll next be using an avalanche beacon or when I’ll next use an ice axe to “self arrest“on the side of a cliff, but the skills of dealing with medical emergencies is non-hospital settings and with limited means is certainly important.

 

Without further ado (and because I don’t have much time…)

 

T-minus 1 day… I went shopping.  I knew I wouldn’t be enthusiastic about much of the food available on our trip, so I packed a significant personal stash to keep me going (I ate more nuts in the last week than I have in the last few months).  I also rented double plastic boots, snowshoes, and an ice axe from REI.

 

Yes- I packed a stick of butter and a jar of coconut oil up the mountain... And if I never eat cold, unseasoned, packages of salmon again, it will be too soon

Yes- I packed a stick of butter and a jar of coconut oil up the mountain… And if I never eat cold, unseasoned packages of salmon again, it will be too soon

 

Day 1- The hike up.  I’ve never hiked in snowshoes with a big pack before, so why not add in dragging a loaded sled to the process! Our group of 20 (12 students, 4 residents, 2 fellows, and 2 attendings) hiked up to our site near Lower Red Pine Lake in the Wasatch Mountains.

Wool was definitely my friend on this trip, starting on day 1. Can you spot the avalanche beacon I'm wearing?

Can you spot the avalanche beacons?

 

Day 2- Water. Our group was broken into 4 teams of students and residents, and each day we had different tasks. On our second day my team was in charge of water, which we filtered from this lake.

It is incredibly peaceful out on the lake pumping water (at least when it was warm enough the water didn't freeze within minutes in the tubing.

It is incredibly peaceful out on the lake pumping water (at least when it was warm enough that the water didn’t freeze almost instantly in the tubing).

 

 

Day 3- Snow.  Yeah… this happened. A good 6” of “dust on crust”.

Fresh pow

Fresh pow

 

Day 4- Home. This tent was my home for 6 days. I shared it with two other medical students, and with overnight temps dipping  into the teens (F) I got very familiar with the workings of my 0o mummy bag.

 

Our camp was quite impressive- 7 tents, a double kiva with dug out benches and tables beneath, and a kitchen dug into the snow pack.

Our camp was quite impressive- 7 tents, a double kiva with dug out benches and tables beneath, and a kitchen dug into the snow pack.

 

 

Day 5- Hike day. On our last full day we hiked up to the ridge leading to the false summit of Pfeifferhorn. The views were stunning.

View

 

Day 6- Out.  This morning we woke at 6 to pack camp and head back to civilization.  My feet won’t miss the heavy double-plastic boots, but I will definitely miss these mountains.

Out

 

I plan to write more about the actual medical aspects of this course, but for now I hope you enjoy these pics!

 

And for those that see the t-shirt picture and think this was a warm-weather hike, this is how I was dressed most mornings in camp.  

 

Cold

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Into the Wild

No- this isn’t another post about books (though I did enjoy the book of this title by Jon Krakauer and I love the soundtrack by Eddie Vedder).  Rather- I wanted to let you all know what I will be up to for the next few weeks.

 

Wilderness Medicine is, well, kind of what it sounds like- providing acute medical care in various outdoor environments.  Being an outdoor person, this was an area of medicine I’ve been rather interested in exploring.  My school doesn’t offer a Wilderness Medicine elective but many schools do, and they generally welcome students from other schools.

 

A number of months ago I set to, looking at a number of Wilderness Medicine electives offered by other schools and organizations.  There are quite a few options, but one, run my U Mass, really caught my eye.

 

I should interject at this point to say that, due to the timing of my PhD defence, I started the clinical years of medical school half a year off schedule with most students. Unfortunately, that meant that when I started looking at wilderness electives, I was a bit behind the eight-ball timing wise.

 

A number of months ago I sent an e-mail to the organizers of the U Mass Wilderness Medicine elective enquiring if they took students from other schools.  They replied, kindly informing that they did but that the course usually fills up a year in advance (and it runs from the end of April for three weeks).  Somewhat disappointed, I set up my schedule for the remainder of fourth-year medical school, sans wilderness medicine elective.

 

Fast forward to three and a half weeks ago when, out of the blue, I got an e-mail from the program coordinator asking me if I was still interested in the Wilderness Medicine elective.  After some frantic shuffling of my schedule I was able to say yes, and have been hustling to get myself prepared ever since.

 

Bags are packed and I'm ready to go (both under 50lbs, though I'm getting close).

Bags are packed and I’m ready to go (both under 50lbs, though I’m getting close).

 

Tomorrow morning I leave New Jersey to head to Salt Lake City (and to think- I was there less than 3 months ago).  After spending a couple days meeting up with friends and seeing the sights of SLC, I meet up with the students, residents, fellows, and faculty who will be participating in the Wilderness Medicine elective.

 

The main reason I was particularly interested in the U Mass elective was because it is a 3 week elective taught almost exclusively IN the wilderness (unlike some other programs that do a lot of classroom-based learning and then have excursions into remote areas).

 

The elective is broken up into 3 components, an alpine section, a river section, and finally a desert section.  In each we receive faculty taught lectures, participate in scenarios, and hear (and give) student lectures (my topic is diarrhea and communicable diseases).  I’ll write more when I return, but this is what I know for now.

 

The alpine section

 

We head up into the Wasatch Mountain range where we set up a base camp that we will be living in for the next 6 days.  We snowshoe in with all our gear (apparently about 50lbs in our packs, plus pulling sleds, and then camp on snow for the next 5 nights.  Here we learn how to live in the alpine environment, the basics of mountaineering, avalanche training, how to lift and move patients with spinal injuries, as well as attend lectures on topics relevant to the alpine environment.

 

The river section

 

After snowshoeing out of the mountains we have a day to recover in Salt Lake City before heading to the Green River for the river section of the course.  Over the next 5 days we raft down the river (camping on the banks each night) and learn about water-associated injuries (drowning, of course), as well as other injuries and illnesses that occur in the bush, including fractures (and improvised splints), dislocations, wilderness dermatology, mammalian injuries, and evacuations.

 

After a transition day in Moab (where we can apparently opt to participate in outdoor activities of our choice, or perhaps enjoy a needed day of R&R), we then head to the desert portion of our course.

 

The desert section

 

Having had a chance to check out Moab, we head to Canyonlands National Park.  Here, we hike into the desert (in smaller groups, so as to decrease our impact), and set up camp for 4 days.  We meet daily for lectures on topics such as snakebites, heat illness and injuries, communicable diseases, wilderness toxicology, and other relevant topics while also learning skills such as orienteering and mass casualty training.

 

Throughout the course, in addition to many lectures, we participate in 12 “scenarios” which further train us for practicing medicine in the wild.  There will be 12 medical students, 4 residents, and 2 Wilderness Medicine fellows, as well as faculty.

 

I’ll be interested to see what happens when it comes to camp dinners.  They asked if anyone had “dietary restrictions”, with a special shout-out to vegetarians.  While I’ll be willing to eat things that I usually don’t consume (rice and beans, for example), I really hope I’ll be able to largely avoid processed foods, grains, and vegetable oils… we shall see.  I’m also a little nervous that I’ll get some foul looks for my choice of footwear.  The packing list suggests bringing hiking boots (or maybe hiking shoes) for the desert and river portion: I have neither, and imagine that trying to get some and break them in would not be a good idea (not to mention that I am kind of opposed to thick soled heavy hiking boots). Instead, I have my minimalist trail running shoes and my vibrams… I’ve climbed a 13er in Colorado with them, hopefully I can hack it carrying a heavy pack!

 

Up Matterhorn in Colorado, happy in my VFFs.

Up Matterhorn in Colorado, happy in my VFFs.

 

So there you have it- starting Monday morning (maybe sooner) I’ll be off the radar for large chunks of time (though you wouldn’t know I was on the radar with the frequency of my blog posts).  When the course is done, my best friend will be picking me up in SLC and I’ll be heading back with her to Colorado for a vacation before coming home to start a radiology elective in June.  On the way back to Colorado we plan to spend a couple days in Arches National Park- since I’m sure my appetite for the outdoors won’t yet be sated.

 

More posts to come!

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