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Making a case for wilderness medicine education

Simon, R. Bryan RN, CNOR, FAWM

doi: 10.1097/01.NURSE.0000415304.66150.ce
Feature: PROFESSIONAL GROWTH

Even if you're not an outdoor enthusiast, knowledge of wilderness medicine can come in handy if you ever have to care for someone who becomes injured or sick in the middle of nowhere.

R. Bryan Simon, a former U.S. Army infantry officer and Army Ranger, is a wilderness medicine lecturer and instructor in the United States and overseas. He has acted as a consultant to outdoor guiding companies, participated in rescues both here and abroad, and currently serves as Board Chair of the Appalachian Center for Wilderness Medicine and on the membership committee of the Wilderness Medical Society. Mr. Simon is also a traveling cardiothoracic OR nurse who works with his wife Deb throughout the United States.

The author has disclosed that he has no financial relationships related to this article.

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I DON'T REMEMBER the motorcyclist's name, but I'll never forget him. We crossed paths between life and death on a beautiful late spring day in North Cascades National Park in Washington State. I was with my wife and friends, enjoying the amazing scenery of the region. Driving up a short incline toward a mountain pass, we watched helplessly as the man lost control of his motorcycle on a gravel-filled turn and collided with the guardrail at the edge of a cliff. We immediately pulled over and attempted to help him, but it was no use. He died on a lonely stretch of road far from the nearest hospital.

Despite my extensive nursing knowledge and years of education, the care I could provide was limited. I'd read about wilderness medicine, but until that day I hadn't considered my need for it. My feeling of helplessness led me to correct that deficiency and ultimately made me a better nurse.

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What's wilderness medicine?

The most commonly accepted definition of wilderness medicine is the practice of medicine where definitive care is more than 1 hour away, resources are limited, and care must be continued over an extended period.1 Wilderness medicine means caring for injured or sick people in the middle of nowhere without the clinical resources found in a hospital setting, often under adverse environmental conditions.

Other names for wilderness medicine include expedition medicine and medicine for the outdoors. Two closely related and often overlapping fields include disaster medicine and humanitarian medicine.

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Why learn about wilderness medicine?

Many nurses who aren't avid backpackers, climbers, boaters, or outdoor enthusiasts are skeptical about their need to learn about wilderness medicine. But you don't have to be participating in these activities to encounter a wilderness medicine situation.

Almost weekly, we read about deadly disasters: a hurricane on the Gulf Coast, tornadoes in the Midwest and Southeast, a terrorist bombing in Europe, or an earthquake, tsunami, and nuclear contamination in Japan. If a natural disaster hit your hometown, would the hospital and government be able to provide adequate care for the population? This is when wilderness medicine can be useful.

While large-scale disasters create situations outside of our daily practice, other more common situations also require us to adapt and improvise. Consider a car crash in a remote area or a sudden winter storm that strands motorists. Could you survive a night in a snowbound car or care for a person injured in a motor vehicle crash with the first-aid kit in your car?

Those in our community and nation expect nurses and other healthcare professionals to have the knowledge, skill, and foresight to handle extreme situations. Our neighbors won't understand that our specialized skills may not translate to emergency care, or that we've practiced solely in an OR, a cardiac catheterization lab, or dialysis unit for years. They expect us to assess for trauma, splint a fracture, or resuscitate a drowning victim regardless of our specialty training. Studying wilderness medicine will help prepare you to provide aid in areas where you don't normally practice.

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What do you learn?

The study of wilderness medicine ranges from exposure to environmental extremes and management of traumatic injuries to disinfection of water supplies and identification of edible and medicinal plants. Some courses address a wide range of topics; others focus on specific subjects, such as diving or aquatic-related injuries or conditions specific to high altitudes and mountain travel. Some of the topics most useful to nurses include preparation of medical kits for cars, the backcountry, and travel overseas; assessment and improvisational management of a patient far from care; and anaphylaxis protocols.

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Wilderness medicine in practice

The motorcyclist who died is never far from my mind when teaching or learning about wilderness medicine. If I encounter a similar situation, I'd now know exactly what to do: I'd apply the basic tenets of wilderness medicine. The first step of wilderness medicine, scene safety, is rarely a part of regular practice. In this case, I would have asked one friend to go up the road and stop or slow vehicles approaching the crash scene. The next step, primary assessment, is similar to patient assessment in our daily practice. In the wilderness, this step is essential to focus limited resources on the situation at hand. Our chief concerns are these:

  • A: Airway
  • B: Breathing
  • C: Circulation
  • D: Disability (neurologic assessment)
  • E: Environment

I would have gone through these steps for the motorcyclist to ensure each was adequate to support life, and if I found one lacking, I would have intervened immediately.

The one portion of the initial assessment unique to wilderness medicine is the focus on E: Environment. Environmental factors or current conditions could cause more harm to both the patient and the rescuers. Examples of these environmental factors include temperature, lightning, and geographical hazards such as an avalanche zone, forest fire, or falling rocks.

In the next step, the secondary survey, the rescuer gathers more facts about the patient, including a history of the incident, the patient's medical history, and changes in mental status and pain.2

The example presented here is based on a short synopsis of the standard used during the Advanced Wilderness Life Support (AWLS) courses. This course is provided by AdventureMed, licensed by the University of Utah and accredited by the Wilderness Medical Society. Other courses offer variations of this assessment that are equally effective. In my own practice, I've combined different techniques according to the situation.

I've used my knowledge in many different situations and have been thankful for it. I've stabilized and arranged for air evacuation of a trekker in the Annapurna region of Nepal, been the first responder to a climber who fell in West Virginia, and cleaned and dressed wounds of a fellow traveler while on a riverboat in the Amazon.

While these examples aren't part of the normal routines of daily life, I've also used my knowledge of wilderness medicine in less-exotic locales to stabilize the cervical spine of a car crash victim outside of my home, remove a tick from my nephew's arm, and clean and dress my cousin's foot when she cut it on a seashell while vacationing at the beach.

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Tapping resources, gaining knowledge

For a nurse interested in the field of wilderness medicine, many resources are available at little or no cost. These include textbooks, Internet sites and discussion groups, and both nonprofit and for-profit businesses that offer courses for the public and for healthcare professionals.

Wilderness Medicine is the most comprehensive textbook on the subject.3 Its author, Dr. Paul Auerbach, is an expert in the field and an active participant in ongoing research and practical applications of wilderness medicine throughout the world, most recently in Haiti.4 Other books, such as the Oxford Handbook for Expedition and Wilderness Medicine by Chris Johnson and colleagues or NOLS Wilderness Medicine by Tod Schimelpfenig, are valuable to interested learners.5,6 Some resources focus on particular elements of wilderness medicine, such as high altitude and mountaineering medicine.

Many nonprofit organizations in the United States focus on increasing knowledge, promoting research, and advancing the practice of wilderness medicine. The largest, the Wilderness Medical Society, is a leader in the promotion of education, research, and healthcare. This society offers many avenues of learning, including the Academy of Wilderness Medicine, which nurses can attend. Students must complete a core curriculum that includes a broad base of wilderness medicine classes as well as required experience. Then the candidate is evaluated and earns the designation Fellow in the Academy of Wilderness Medicine (FAWM).7

The Appalachian Center for Wilderness Medicine (ACWM) is a regional organization. The mission of this organization, for which I currently serve as a director and board chair, is “to promote quality medical care in limited resource (“wilderness”) environments.”8 ACWM attempts to fill unmet needs within the Southeast United States in the realm of wilderness medicine by working with various hospitals and organizations. In the past year, ACWM has partnered with nonprofit organizations to conduct outdoor safety courses, worked with a nonprofit organization for climbers and the National Park Service to address climbing injuries in the New River Gorge, W.Va., and educated hundreds of outdoor enthusiasts in wilderness medicine by contributing speakers to events in the Southeast United States.

A host of other organizations offer formalized courses and training. Some of these include the Wilderness Medicine Institute of the National Outdoor Leadership School (NOLS), Wilderness Medical Associates (WMA), and Stonehearth Open Learning Opportunities (SOLO).For more information, see How do courses stack up?

Several certifications are available. Many organizations offer Wilderness First Aid courses, available to the public, that usually consist of a weekend of study. The Wilderness First Responder (WFR) consists of roughly 40 hours of study conducted over 1 week. Although it's intended for the public, the WFR also focuses on teaching outdoor leaders such as rock climbing instructors, river rafting guides, and summer camp counselors. This course usually includes a substantial hands-on training period and CPR training.

For healthcare professionals, certifications include Wilderness Advanced Life Support (WALS), AWLS, Wilderness EMT, and the Wilderness Upgrade for the Medical Professional (WUMP).

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Being prepared

The study of wilderness medicine is well worth the pursuit. Not only will it broaden your skill set, it will also enhance your ability to deal with a crisis situation far from the comfort zone of your own clinical area.

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How do courses stack up?

Here are just a few of the schools and courses for learning about wilderness medicine.

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National Outdoor Leadership School (NOLS)

NOLS teaches wilderness medicine courses through their Wilderness Medicine Institute. These courses range from the introductory-level Wilderness First Aid and continue to the more advanced Wilderness EMT and Wilderness Upgrade for the Medical Professional (WUMP). These courses are taught at various times and locations across the United States and abroad. See http://www.nols.edu/wmi/courses/.

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Wilderness Medical Associates (WMA)

WMA teaches wilderness and travel medicine courses that range from wilderness first aid and travel medicine first aid to the Wilderness Advanced Life Support course. WMA, which has offices in Maine and Canada, routinely offers courses throughout the United States and the world. See http://www.wildmed.com/.

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Advanced Wilderness Life Support (AWLS)

The AWLS course was originally developed by the University of Utah School of Medicine. The course is now administered by AdventureMed and is taught throughout the United States. Course content is focused on the medical professional. See http://www.awls.org/.

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Stonehearth Open Learning Opportunities (SOLO)

SOLO courses range from the beginner level (wilderness first aid) up to advanced courses such as their search and rescue course. It also offers specialty courses for personnel attending missionary trips. See http://www.soloschools.com/.

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REFERENCES

1. Duff J, Gormly P. First Aid and Wilderness Medicine. 10th ed. Cumbria, UK: Cicerone Press; 2007.
2. Auerbach PS, Della-Giustina D, Ingebretsen R. Advanced Wilderness Life Support. 3.1 ed. Salt Lake City, UT: AdventureMed; 2007. http://www.splashinglight.com/wildmed/awls/awls_text.pdf.
3. Auerbach PS. Wilderness Medicine. 6th ed. Philadelphia, PA: Mosby Saunders; 2011.
4. Auerbach PS. Dispatches from Haiti. Wilderness Med. 2010;27(2):5–11. http://wms.org/magazine/272.pdf.
5. Johnson C, Anderson S, Dallimore J, Winser S, Warrell DA. Oxford Handbook of Expedition and Wilderness Medicine. Oxford, UK; New York, NY: Oxford University Press; 2008.
6. Schimelpfenig T, National Outdoor Leadership School (U.S.). NOLS Wilderness Medicine. Mechanicsburg, PA: Outdoor Leadership School and Stackpole Books; 2006.
7. Wilderness Medical Society. Welcome to the Academy of Wilderness Medicine. http://wms.org/fawm/default.asp.
8. Appalachian Center for Wilderness Medicine. About us. ACWM Mission. http://www.appwildmed.org/about.html.
© 2012 Lippincott Williams & Wilkins, Inc.