Embracing the wild

Definition

The field of wilderness medicine grew out of the need to provide care to persons who were far from urban resources, frequently in austere settings. It addresses the unique conditions of wilderness environments, such as high altitude or extremes of temperature, and their physiologic and pathophysiologic effects. Wilderness medicine has grown to encompass a broader range of settings, not just those traditionally thought of as wilderness. Wilderness medicine can therefore be described as the practice of medicine in settings with any of the following: 1) extreme or uncontrolled environmental conditions; 2) absent, inadequate, or otherwise scant resources; and 3) substantial time delay in transport to or arrival of definitive care.^5,6 Under this definition, WM scenarios would include challenges like those health care professionals face working in remote medical outposts in the Northwest Territories or during disasters such as the wildfire that swept through Slave Lake, Alta, in May 2011.

To appreciate this definition, one needs to examine the 3 key elements of wilderness medicine, as each element creates increased risk to either the patient or the first responder (or both):

• Environment refers to how natural elements and human factors affect patient physiology to cause a medical problem, make a developing problem worse, or make a pre-existing problem unstable. Examples of natural factors include meteorological, aquatic, or terrestrial extremes, while human factors include, but are not limited to, remote communities, expeditions, and armed-conflict zones.

• Resources refers not only to the difficulties of working in a limited-resource setting but also to the need to determine which resources are most functional in specific, unique circumstances. In difficult settings, the ideal treatments dictated by standards of care might not be deemed practical once the necessary equipment’s weight, size, functionality, availability, and appropriateness⁷ have been considered. Inherent to this concept is a strong emphasis on improvisation.⁸

• Time refers to delayed access to definitive medical care, which occurs owing to distance, logistics, or hazards.⁷

This definition of WM does not depend on any particular setting or circumstance. Instead, it extends the scope of WM far beyond a typical wilderness setting, applying whenever any of these 3 features influences care.

Unique competencies

The scope and variety of WM takes it beyond any single field; although it overlaps closely with family medicine, it also shares elements with emergency medicine, sports and exercise medicine, trauma surgery, orthopedics, public health, travel medicine, and veterinary medicine.⁸ The wilderness medicine practitioner (WMP), who could be from any health care profession, must integrate the science and art of these diverse disciplines in order to optimize patient care. Furthermore, circumstances might require a WMP to reach beyond his or her traditional medical role and draw upon skills typically assigned to paramedics, nurses, or other health care professionals.⁹ These skills include triaging, formulating a diagnosis and treatment plan in the field, starting intravenous infusions, administering medication, and transport and evacuation, to name a few. Finally, owing to the unconventional settings in which WMPs find themselves, they need expertise in survival, navigation, search and rescue, and incident command systems^6,10 (Figure 1). Ultimately, the WMP maintains competencies that create a unique practice of medicine.

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Figure 1

Wilderness medicine comprises a unique body of knowledge from a wide cross-section of competencies

Clinical practice perspective

Diverse practitioners in Canada deliver WM. They include providers living and working in remote environments—physicians and nurses in rural or remote communities or medical outposts, and paramedics working in rural environments where transport times are measured in hours, if not days. There are dedicated organizations whose practices are largely wilderness-based: the military, the coast guard, and search and rescue groups. For these WMPs, the typical treatment goals used in conventional medical settings are reframed within a WM context. Consider the standard management of an open tibial plateau fracture, which is open reduction and internal fixation, antibiotics, venous thrombosis prophylaxis, and continuing wound care. These interventions would not be realistic if this injury occurred in a resource-poor or remote location. Evacuation to a hospital would be the ultimate goal, but the initial approach would be fracture stabilization, basic wound care, pain management, and prevention of complications while rescue or evacuation efforts were under way. Sometimes, actions that are reflexive in resource-abundant settings, such as withholding oral intake in anticipation of surgery, are impractical in a remote environment.¹¹ In austere circumstances, maintaining patient and rescuer safety with adequate food, fluids, and shelter takes priority. Resourceful WMPs are able to balance medical necessity with the vagaries of the environment, the resources available, and the urgency of treatment when developing a unique management plan. The capacity to do so requires knowledge of how the patient could be affected by the environment, as well as the training and equipment to modify standard treatments as required.

Demographic perspective

According to the Kirby Report,¹² approximately 95% of Canada’s territory is rural, with 30% of the population living in rural or remote areas. A substantial proportion of medical encounters in rural areas would fall into the WM category.¹³ To date, there are few statistics on illnesses and injuries occurring in remote locations. Untapped data sources already exist in Canada, including the Canadian Forces and many other federal and provincial organizations, and additional efforts are needed to examine and publicize these records. A single Canadian epidemiologic study¹⁴ examining morbidity and mortality in mountain rescue incidents in national parks showed that musculoskeletal injuries accounted for most medical issues. The same study indicated that WM settings also experience the typical array of medical conditions seen in urban emergency departments. While we are not aware of any relevant published Canadian studies, American data show that baby boomers, older adults, and younger people alike enjoy adventure activity. As such, there are changes in the risk factors and medical concern profiles of those engaging in outdoor adventure. “Diabetic hikers, post–coronary bypass surgery mountain bikers, and osteoporotic river rafters are now common in recreational areas.”¹⁵ Given the number of people living in rural or remote settings, as well as the trends in population demographics, there is a growing need for health care provision beyond the confines of urban medical facilities.

The Canadian public would also benefit from WM knowledge creation and transfer. For instance, is standard first aid or cardiopulmonary resuscitation training appropriate for persons residing in rural or remote communities, especially as this style of training depends on the support of urban emergency medical services and medical infrastructure?¹¹ Is there a more appropriate model for these communities? We speculate that there are practices and criterion standards that might need to be reevaluated using a WM lens in order to optimize their effectiveness and relevance in resource-poor or remote settings.

Basic medical research perspective

Wilderness medicine offers the opportunity to explore ways in which the environment affects the human condition. Table 1^1–4 displays examples of biomedical research conducted in Canada that have clinical relevance to WM. Beyond its obvious application to those engaging in recreation or work in extreme environments, WM research also has relevance in other areas of medicine (eg, pulmonology and critical care). Future WM research within Canada is limited only by imagination. Important areas for investigation include cold and heat exposure; infectious diseases and animal encounters related to changing environmental conditions (eg, West Nile virus, Lyme disease, invasive venomous species); the physiology of endurance sports; and management of special needs and conditions (eg, diabetes, cystic fibrosis, cancer) far from routine care or in extreme environments.