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. 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 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.
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.
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…
principleintopractice 