As is often the case, the best new wilderness medicine news is not in the outdoor or the wilderness medicine literature. Instead, it can be found in rigorous studies reported in major peer-reviewed journals. A recent study reported in the Pediatric Infectious Disease Journal is a case in point.
With the recognition that poor personal hygiene, not drinking water, is the real culprit leading to gastrointestinal distress among backpackers, more attention is being paid to hand sanitation. Although good ol' soap and water is the tried and true approach to this, it is not always practical in the backcountry. Lately, a lot of folks have been using alcohol-based hand sanitizers instead. Although I have admired their attention to hygiene, I have wondered if this approach was effective.
A group of French investigators have studied the hand sanitizer intervention in a group with a huge susceptability to hand-to-mouth transmission of gastroenteritis: 5 to 10 year old kids. Basically, the intervention was quite simple. In one school, all students underwent supervised use of hand sanitizers several times a day. In another school, they did not. The numbers of children developing diarrhea and/or vomiting during the study period were compared between the schools. The "intervention" school experienced about half of the number of GI infections as the control school. There were similar differences demonstrated between the schools in doctor visits, days lost from school, and working days lost by parents. There were no complications associated with the use of the gel.
Other studies have looked at the biology of this (effectiveness of gels in killing organisms in the lab) and at the use of the agents in the health care setting. This is the first well-designed trial of such an intervention among laypersons. The results are pretty impressive.
Sure, a French elementary school ain't a trek in the wilderness. Yet, the impressive results in a very high-risk group with very large numbers is compelling. I think that we can rest assured that this approach in the back country is now evidence-based.
The exact citation for the study is: Pediatric Infectious Disease Journal 2010;29(11)994-998.
Tuesday, June 28, 2011
Tuesday, March 29, 2011
What happens in the wilderness, redux
One concern I have long had about the wilderness first responder "movement" has been the disconnect between their content and the actual data speaking to the types of medical events encountered in typical backcountry expeditions. When I discuss this with folks (as at a recent AORE conference), a frequent refrain is that there are not enough good data about such events.
Bull %*#*.
In actuality, there are a number of registries and large series which have been the basis for numerous publications in the peer-reviewed medical literature over the past few decades. Indeed, the database from NOLS has produced three such publications. The fascinating thing about all of these reports is that they are strikingly consistent. In fact, it could be argued that we have had enough such studies.
Now along comes yet another such report, this time from the esteemed outdoor education program at Cornell University ("COE"). Although there is very little in the way of surprises here, this is a particularly well done study which did just about everything right. Ironically, the study is accompanied by an editorial which perfectly illustrates the fact that some folks just don't care about data.
First, the study itself. COE is a large program with an excellent ability to record, capture, and analyze data from its many treks. This report covered a six-year period, with 74,005 participant days. The activities included the usual suspects in such college programs, although there was an inordinate emphasis on climbing walls (nearly two thirds of the participant days). The remainder were more typical: backpacking, mountaineering, natural (rock and ice) surface climbing, various water sports, etc. Overall, the injury/illness rate in this large series was 1.5/1000 participant days. This is extremely close to the rate reported in previous studies from NOLS and Outward Bound. About one-third of these events necessitated evacuation, again a figure consistent with other reports. The distribution of these events was also very similar to a host of similar previous publications. Most (over half) were skin and soft-tissue injuries. There were no deaths, serious injuries, or (see one of my previous blog commentaries) anaphylaxis. There were ten fractures/dislocations, of which three were ankle and one was tib-fib. The other fractures were seemingly trivial: wrist, collarbone, nose and coccycx. The latter ("tailbone") is an injury many of us active folks have probably had without realizing it because of not taking an xray; I rarely if ever radiate someone's pelvis to document this fracture.
In a very thoughtful discussion, the authors of this report comment on the safety culture at COE, as well as their use of such data to inform programing. For example, the number of injuries associated with food preparation (lacerations and burns) has led to some changes in instruction. The authors assert, very correctly, that the pattern and severity of injuries in their outdoor recreation are dwarfed by those of other college sports. All in all, a very nice study. The publication information is: Wilderness and Environmental Medicine; 2010; 21:363-370. You can download a pdf from the journal's website.
The editors of the journal should have left well enough alone. They didn't. When the editors of a medical journal believe that there is something worthy of highlighting in an issue, they occasionally solicit an "editorial" to emphasize the study's importance. Inexplicably, the editors chose a WFR instructor with no apparent background or qualification in epidemiology to editorialize on the study. The editorial was generally lame and ill-informed. For example, the author considered it "surprising" to learn that outdoor recreation injury rates were lower than intercollegiate sports, although this observation has been widely known for decades, first publicized by Project Adventure in their safety studies. More troublesome, the editorialist violated a major rule of an editorial by using it to include unreviewed new data. He somehow turned the discussion around to femur fractures, using a alleged incident from one of his former students to "report" the successful construction of an ad hoc traction splint on a mountaineering trek. He went on to advocate for the teaching of and utilization of this technique.
This is a completely unsubstantiated case report, which has now made its way into the medical literature without peer review--a travesty for a medical journal. Femur traction splints constructed out of sticks, trekking poles, and similar items have been a staple of WFR courses for a long time. When I mention such constructions to trauma surgery colleagues, I generally get a "you've got to be kidding" response. My favorite description of the technique is from the Outward Bound First Aid Handbook: "Improvised traction splints employing ski poles, canoe paddles, and other pieces of equipment are more often architecturally interesting than medically useful." Amen. WFR course time spent on such nonsense teaches students techniques they will probably forget, will never need, and wouldn't work anyway.
Kudos to COE for a very helpful report. Darts to Wilderness and Environmental Medicine for spoiling it with a silly editorial.
Bull %*#*.
In actuality, there are a number of registries and large series which have been the basis for numerous publications in the peer-reviewed medical literature over the past few decades. Indeed, the database from NOLS has produced three such publications. The fascinating thing about all of these reports is that they are strikingly consistent. In fact, it could be argued that we have had enough such studies.
Now along comes yet another such report, this time from the esteemed outdoor education program at Cornell University ("COE"). Although there is very little in the way of surprises here, this is a particularly well done study which did just about everything right. Ironically, the study is accompanied by an editorial which perfectly illustrates the fact that some folks just don't care about data.
First, the study itself. COE is a large program with an excellent ability to record, capture, and analyze data from its many treks. This report covered a six-year period, with 74,005 participant days. The activities included the usual suspects in such college programs, although there was an inordinate emphasis on climbing walls (nearly two thirds of the participant days). The remainder were more typical: backpacking, mountaineering, natural (rock and ice) surface climbing, various water sports, etc. Overall, the injury/illness rate in this large series was 1.5/1000 participant days. This is extremely close to the rate reported in previous studies from NOLS and Outward Bound. About one-third of these events necessitated evacuation, again a figure consistent with other reports. The distribution of these events was also very similar to a host of similar previous publications. Most (over half) were skin and soft-tissue injuries. There were no deaths, serious injuries, or (see one of my previous blog commentaries) anaphylaxis. There were ten fractures/dislocations, of which three were ankle and one was tib-fib. The other fractures were seemingly trivial: wrist, collarbone, nose and coccycx. The latter ("tailbone") is an injury many of us active folks have probably had without realizing it because of not taking an xray; I rarely if ever radiate someone's pelvis to document this fracture.
In a very thoughtful discussion, the authors of this report comment on the safety culture at COE, as well as their use of such data to inform programing. For example, the number of injuries associated with food preparation (lacerations and burns) has led to some changes in instruction. The authors assert, very correctly, that the pattern and severity of injuries in their outdoor recreation are dwarfed by those of other college sports. All in all, a very nice study. The publication information is: Wilderness and Environmental Medicine; 2010; 21:363-370. You can download a pdf from the journal's website.
The editors of the journal should have left well enough alone. They didn't. When the editors of a medical journal believe that there is something worthy of highlighting in an issue, they occasionally solicit an "editorial" to emphasize the study's importance. Inexplicably, the editors chose a WFR instructor with no apparent background or qualification in epidemiology to editorialize on the study. The editorial was generally lame and ill-informed. For example, the author considered it "surprising" to learn that outdoor recreation injury rates were lower than intercollegiate sports, although this observation has been widely known for decades, first publicized by Project Adventure in their safety studies. More troublesome, the editorialist violated a major rule of an editorial by using it to include unreviewed new data. He somehow turned the discussion around to femur fractures, using a alleged incident from one of his former students to "report" the successful construction of an ad hoc traction splint on a mountaineering trek. He went on to advocate for the teaching of and utilization of this technique.
This is a completely unsubstantiated case report, which has now made its way into the medical literature without peer review--a travesty for a medical journal. Femur traction splints constructed out of sticks, trekking poles, and similar items have been a staple of WFR courses for a long time. When I mention such constructions to trauma surgery colleagues, I generally get a "you've got to be kidding" response. My favorite description of the technique is from the Outward Bound First Aid Handbook: "Improvised traction splints employing ski poles, canoe paddles, and other pieces of equipment are more often architecturally interesting than medically useful." Amen. WFR course time spent on such nonsense teaches students techniques they will probably forget, will never need, and wouldn't work anyway.
Kudos to COE for a very helpful report. Darts to Wilderness and Environmental Medicine for spoiling it with a silly editorial.
Saturday, February 26, 2011
Column Resumes
For several years, I wrote a regular column for the magazine of the Adirondack Mountain Club, Adirondac. They were having some financial challenges which caused their page allotment to shrink, so the column has been on hiatus.
The editor has asked me to resume the column in the summer, and I am doing so. As in the past, it will provide advice on the health and safety aspects of outdoor recreation, targeting a lay audience. The initial column will discuss some aspects of canoe safety. The Adirondack Mountain Club does not as yet have an online version of the magazine, but I will post the columns in the Publication area of my website.
The editor has asked me to resume the column in the summer, and I am doing so. As in the past, it will provide advice on the health and safety aspects of outdoor recreation, targeting a lay audience. The initial column will discuss some aspects of canoe safety. The Adirondack Mountain Club does not as yet have an online version of the magazine, but I will post the columns in the Publication area of my website.
Thursday, January 6, 2011
Best Giardia Story Ever
A buddy of mine who works as a college outdoor education instructor recently shared an experience with me. For reasons I will mention later, today is an amazingly appropriate day to bring this up.
My friend related a visit to one of the college's treks by a student instructor from the west. The visitor was appalled to learn that this particular program did not practice universal water treatment during their expeditions. When told that the local instructors had carefully considered things and no longer recommended routine treatment of most Adirondack waters, he commented that it must be because of something unique to New York, since tasting even a drop of untreated water in the American west was "guaranteed" to result in giardiasis. He went on with a litany of reasons why this was to be avoided at all costs, not the least being that giardiasis was essentially incurable, and that those unfortunate enough to acquire it would have it forever--often flaring up any time an offending food was consumed. He treated everything he drank on the trek. No one else did. Everyone was just fine.
Of course, everything about this would be simply silly if it were not for the fact that the person involved is en route to becoming a professional outdoor educator, presumably about to share such nonsense with unsuspecting students. This is hardly a "controversy" anymore; it is difficult to identify any true expert in this field who considers the "treat everything" approach to be necessary or appropriate. Which brings me to the reason why today is a very good time to tell this tale.
A report today (http://www.nytimes.com/aponline/2011/01/05/health/AP-EU-MED-Autism-Fraud.html?_r=2&ref=health) has confirmed once and for all that the original study linking vaccines to autism was not only incorrect, it was fraudulent. The 1998 study, by a British quack named Andrew Wakefield, reported 12 reportedly normal children in whom autism developed as a consequence of the MMR vaccine. The journal in which it was published retracted it long ago because of concerns about its validity, and all of Wakefield's coauthors disassociated themselves with its conclusions. Literally scores of well-designed studies involving thousands of children have been published subsequently, none of which have supported the Wakefield hypothesis. One would think that the concern would have gone away by now.
Sadly, things didn't work out that way. In the nearly 13 years since the Wakefield publication, concern about the MMR vaccine became rampant, leading many families to avoid it. This, in turn, has resulted in a resurgence of measles in the world, with countless preventable deaths. Nonetheless, uninformed "experts" have continued to trump this bogus association, believing a study of 12 patients over well-designed trials with thousands.
Believe it or not, this situation is nearly identical to the current infatuation of some wilderness folks with water-borne giardiasis.
There has been exactly one peer-reviewed scientific study suggesting a link between wilderness water consumption and giardiasis. This report, from 1976, reported that about 2/3 of participants in a camping trip in Utah's Uinta mountains acquired giardiasis. The authors ascribed the outbreak to consumption of surface water.
In subsequent years, it has become clear this this report was incorrect (although certainly not fraudulent--just wrong). Analyzing this incident in light of contemporary knowledge about giardiasis has made it clear that this was an epidemic of food- or hand-to-mouth borne infection. (This is discussed in more detail in a paper available on my website: http://adirondoc.com/publications/water_quality_2004.pdf).
Although no subsequent scientific studies have shown any association between North American wilderness water consumption and giardiasis (or, indeed, any infection), the damage was done with the single 1976 paper, just as it was with Wakefield's 1998 autism/vaccine study. "True believers" such as the student instructor continue to tout misinformation which has been long-since discredited--often embellishing it along the way.
While the damage done by this over 30 year old paper pales in comparison to that of the Wakefield study (I doubt that anyone has died because of it!), it certainly has had negative effects. Most strikingly, the incessant attention to water quality in the backcountry has eclipsed attention to a much more important strategy--hand washing---which probably would have prevented the Utah outbreak! It has created the market for a dizzying array of technologic fixes (filters, "steri-pens", etc) which exist to solve a problem which doesn't exist. It has perpetuated very bad science among folks who aspire to professional careers in outdoor education.
I'll conclude with a "stay tuned". With a couple of colleagues and a student, I am analyzing data from a series of studies we have done examining the colonization of backpackers' hands with (hope you're not eating lunch now) organisms found in FECES. Without giving away the results, let me just suggest that you avoid shaking hands with folks you meet in the wilderness...
My friend related a visit to one of the college's treks by a student instructor from the west. The visitor was appalled to learn that this particular program did not practice universal water treatment during their expeditions. When told that the local instructors had carefully considered things and no longer recommended routine treatment of most Adirondack waters, he commented that it must be because of something unique to New York, since tasting even a drop of untreated water in the American west was "guaranteed" to result in giardiasis. He went on with a litany of reasons why this was to be avoided at all costs, not the least being that giardiasis was essentially incurable, and that those unfortunate enough to acquire it would have it forever--often flaring up any time an offending food was consumed. He treated everything he drank on the trek. No one else did. Everyone was just fine.
Of course, everything about this would be simply silly if it were not for the fact that the person involved is en route to becoming a professional outdoor educator, presumably about to share such nonsense with unsuspecting students. This is hardly a "controversy" anymore; it is difficult to identify any true expert in this field who considers the "treat everything" approach to be necessary or appropriate. Which brings me to the reason why today is a very good time to tell this tale.
A report today (http://www.nytimes.com/aponline/2011/01/05/health/AP-EU-MED-Autism-Fraud.html?_r=2&ref=health) has confirmed once and for all that the original study linking vaccines to autism was not only incorrect, it was fraudulent. The 1998 study, by a British quack named Andrew Wakefield, reported 12 reportedly normal children in whom autism developed as a consequence of the MMR vaccine. The journal in which it was published retracted it long ago because of concerns about its validity, and all of Wakefield's coauthors disassociated themselves with its conclusions. Literally scores of well-designed studies involving thousands of children have been published subsequently, none of which have supported the Wakefield hypothesis. One would think that the concern would have gone away by now.
Sadly, things didn't work out that way. In the nearly 13 years since the Wakefield publication, concern about the MMR vaccine became rampant, leading many families to avoid it. This, in turn, has resulted in a resurgence of measles in the world, with countless preventable deaths. Nonetheless, uninformed "experts" have continued to trump this bogus association, believing a study of 12 patients over well-designed trials with thousands.
Believe it or not, this situation is nearly identical to the current infatuation of some wilderness folks with water-borne giardiasis.
There has been exactly one peer-reviewed scientific study suggesting a link between wilderness water consumption and giardiasis. This report, from 1976, reported that about 2/3 of participants in a camping trip in Utah's Uinta mountains acquired giardiasis. The authors ascribed the outbreak to consumption of surface water.
In subsequent years, it has become clear this this report was incorrect (although certainly not fraudulent--just wrong). Analyzing this incident in light of contemporary knowledge about giardiasis has made it clear that this was an epidemic of food- or hand-to-mouth borne infection. (This is discussed in more detail in a paper available on my website: http://adirondoc.com/publications/water_quality_2004.pdf).
Although no subsequent scientific studies have shown any association between North American wilderness water consumption and giardiasis (or, indeed, any infection), the damage was done with the single 1976 paper, just as it was with Wakefield's 1998 autism/vaccine study. "True believers" such as the student instructor continue to tout misinformation which has been long-since discredited--often embellishing it along the way.
While the damage done by this over 30 year old paper pales in comparison to that of the Wakefield study (I doubt that anyone has died because of it!), it certainly has had negative effects. Most strikingly, the incessant attention to water quality in the backcountry has eclipsed attention to a much more important strategy--hand washing---which probably would have prevented the Utah outbreak! It has created the market for a dizzying array of technologic fixes (filters, "steri-pens", etc) which exist to solve a problem which doesn't exist. It has perpetuated very bad science among folks who aspire to professional careers in outdoor education.
I'll conclude with a "stay tuned". With a couple of colleagues and a student, I am analyzing data from a series of studies we have done examining the colonization of backpackers' hands with (hope you're not eating lunch now) organisms found in FECES. Without giving away the results, let me just suggest that you avoid shaking hands with folks you meet in the wilderness...
Thursday, December 2, 2010
Why mosquitos love us and hate DEET
It's hard to be thinking about mosquitos during the first lake effect event of the season, but maybe it will get you into the mood for summer!
For a long time, I have endorsed the usual understanding of the mechanism by which mosquitos target warm-blooded animals. For quite a while, it has been recognized that there is a complex neurochemical mechanism by which the bugs are attracted to carbon dioxide. From an evolutionary standpoint, this makes a lot of sense: if you are looking for a blood meal, what better way to find it than by going after something which breathes out carbon dioxide? It is also consistent with our backcountry observations. How many times, for example, have you noticed the propensity of these creatures to congregate under the tent fly?
This understanding has also permitted me to pooh-pooh students in my classes who claim that something about their own sweat, soap, or BO is particularly attractive to mosquitos. I have generally dismissed them as whiners, and pontificated that there was no biologic mechanism for such an observation. How could a bug distinguish between Dr. Bronner's and Mountain Suds?
Mea culpa.
Complex modern science has now shown us that the smell detection system of mosquitos is vastly more complicated than we ever could have imagined. In the process, it has also uncovered the biologic explanation for the effectiveness of DEET. Pretty impressive.
The study (by Liu and associates at Vanderbilt) is available online from the journal PLoS Biology (http://www.plosbiology.org/article/info%3Adoi%2F10.1371%2Fjournal.pbio.1000467). The molecular biology here is daunting, and not for the faint of heart. Also keep in mind that the work was done with an African mosquito; it is certainly plausible, however, that similar mechanisms are in place for other species.
These scientists have unraveled the existence of two distinct olfactory signaling pathways in these insects. Each of these pathways (AgOR and AgIR) consists of a family of specific receptors, each of which, presumably, can respond to specific odors. Such responses can be either attractive or repulsive. A specific receptor (AgOR7) appears to be the actual target of DEET; animals in whom this receptor was inactivated by microinjection of specific RNA fragments were no longer affected by DEET.
What can we take away from this elegant science? Carbon dioxide is still a potent attractant for mosquitos, but short of stopping breathing there is nothing we can do about it. DEET works--we know this from a lot of previous behavioral studies, and now we understand it at the molecular level. From a wealth of other studies, we also know that the health concerns of DEET are vastly overblown and can generally be ignored. Mosquitos also seem to be capable of responding to a lot of other olfactory stimuli, but we do not as yet understand what makes something attractive or repulsive.
Bottom line--it is now plausible that certain individuals are more attractive to mosquitos than others. Other than DEET and protective garmets, however, there is little to do other than sucking it up!
For a long time, I have endorsed the usual understanding of the mechanism by which mosquitos target warm-blooded animals. For quite a while, it has been recognized that there is a complex neurochemical mechanism by which the bugs are attracted to carbon dioxide. From an evolutionary standpoint, this makes a lot of sense: if you are looking for a blood meal, what better way to find it than by going after something which breathes out carbon dioxide? It is also consistent with our backcountry observations. How many times, for example, have you noticed the propensity of these creatures to congregate under the tent fly?
This understanding has also permitted me to pooh-pooh students in my classes who claim that something about their own sweat, soap, or BO is particularly attractive to mosquitos. I have generally dismissed them as whiners, and pontificated that there was no biologic mechanism for such an observation. How could a bug distinguish between Dr. Bronner's and Mountain Suds?
Mea culpa.
Complex modern science has now shown us that the smell detection system of mosquitos is vastly more complicated than we ever could have imagined. In the process, it has also uncovered the biologic explanation for the effectiveness of DEET. Pretty impressive.
The study (by Liu and associates at Vanderbilt) is available online from the journal PLoS Biology (http://www.plosbiology.org/article/info%3Adoi%2F10.1371%2Fjournal.pbio.1000467). The molecular biology here is daunting, and not for the faint of heart. Also keep in mind that the work was done with an African mosquito; it is certainly plausible, however, that similar mechanisms are in place for other species.
These scientists have unraveled the existence of two distinct olfactory signaling pathways in these insects. Each of these pathways (AgOR and AgIR) consists of a family of specific receptors, each of which, presumably, can respond to specific odors. Such responses can be either attractive or repulsive. A specific receptor (AgOR7) appears to be the actual target of DEET; animals in whom this receptor was inactivated by microinjection of specific RNA fragments were no longer affected by DEET.
What can we take away from this elegant science? Carbon dioxide is still a potent attractant for mosquitos, but short of stopping breathing there is nothing we can do about it. DEET works--we know this from a lot of previous behavioral studies, and now we understand it at the molecular level. From a wealth of other studies, we also know that the health concerns of DEET are vastly overblown and can generally be ignored. Mosquitos also seem to be capable of responding to a lot of other olfactory stimuli, but we do not as yet understand what makes something attractive or repulsive.
Bottom line--it is now plausible that certain individuals are more attractive to mosquitos than others. Other than DEET and protective garmets, however, there is little to do other than sucking it up!
Wednesday, October 13, 2010
How much "risk" can we tolerate in the wilderness?
This topic comes up a lot among wilderness educators, but I recently came across two seemingly unrelated pieces in the New York Times which provide a very nice context to the discussion.
The first (http://www.nytimes.com/2010/08/27/us/27cuts.html?_r=1&scp=3&sq=fire%20departments&st=cse) describes the angst which is developing in a number of urban areas as budget constraints are challenging city fire and EMS services. The article begins with the tragic story of a two-year-old boy in San Diego who suffered a fatal aspiration at his home. Although there was a fire station near the home, staffing changes in the SDFD led to its being empty at the time of the incident. The police responded to the child's home within five minutes and started CPR, but it took 9 and a half minutes for an ambulance to arrive. The child was pronounced dead at the hospital.
The first (http://www.nytimes.com/2010/08/27/us/27cuts.html?_r=1&scp=3&sq=fire%20departments&st=cse) describes the angst which is developing in a number of urban areas as budget constraints are challenging city fire and EMS services. The article begins with the tragic story of a two-year-old boy in San Diego who suffered a fatal aspiration at his home. Although there was a fire station near the home, staffing changes in the SDFD led to its being empty at the time of the incident. The police responded to the child's home within five minutes and started CPR, but it took 9 and a half minutes for an ambulance to arrive. The child was pronounced dead at the hospital.
Although it is not clear to me that the child would have survived with earlier care (when children survive such incidents, it is almost always because of immediate bystander intervention), the implication of the article was that harm may have been done because the city could not meet up to the "national goal" of a five minute response.
Well, just a minute here.
I am writing this entry at our summer home in the Adirondacks. I probably couldn't get my nearest neighbor here within five minutes. The nearest fire department with EMS service is in a town about 16 miles away, and that is a volunteer operation. Ten times the "national goal" would actually be a pretty good response to our place!
Mind you, this area is by no means "wilderness". There are several hundred homes in the vicinity, with such important services as bars, a gas station, pizza joints, and even a (limited hours) vet clinic. Although we are seasonal users, there are plenty of year-round residents. If any of my neighbors are disturbed that our access to emergency medical services is way outside the national goal, I haven't heard it from them. Indeed, nearly every edition of the local weekly (we also have a paper) carries a letter to the editor thanking the volunteer ambulance crews for something!
Folks who choose to live (or get away) in places such as this generally make very informed decisions. No--we can't call a cab. No--we may not be able to have high-speed internet access. No--if the big one comes some evening, we will not be defibrillated within minutes. On the other hand, we are not awakened by sirens at night, the smells of balsam replace those of exhaust, and we don't worry about walking in the neighborhood. There are plenty of folks living throughout the US in very similar circumstances, and I doubt that many would trade them in order to be assured of a more rapid EMS response.
How does this apply to the wilderness? Just like the person who moves from San Diego, CA to Woodgate, NY is accepting a change in the availability of assistance in emergencies, the user of the wilderness is (or should be) doing so to an even greater degree. Stepping into the backcountry is an experience of inestimable value. It has a downside. The likelihood of surviving major trauma deep in the Five Ponds Wilderness is nil. An identical injury on 42nd Street and 8th Avenue might well be survivable. Sadly, one just can't have it both ways. Take your pick.
This ethic extends to situations well beyond major trauma. Sprain your ankle at the tennis club, and expect your buddy to drive you home and share a beer with you after helping you get some ice. Sprain it on the way down Katahdin and you should expect a pretty rough time; please don't expect a helicopter ride to Bangor. One of my many complaints about the "WFR" movement is that it may contribute to the perception that there is really something which can be done for devastating injury or illness is very remote areas. Usually, there isn't. Accept it.
Which brings me to the other article: http://www.nytimes.com/2010/08/27/opinion/27stroll.html?_r=1&scp=5&sq=wilderness&st=nyt.
This opinion piece, by an attorney, decries the US Forest Service for lack of signage in some wilderness areas, bemoaning the occasonal camper, hiker, or hunter who becomes lost. If one wishes to hike on established and well marked trails, the options in North America are nearly limitless. Yet, if one wants to test the extent of his navigational and wilderness skills in an expansive, truly "unmarked" environment, options in the lower 48 are not many. Indeed, when I teach such skills, I prefer to do so in Alaska. We do not seem to care that a number of skiers choosing black diamond routes will sustain serious, indeed some life-threatening injuries. Why can we not allow the wilderness equivalent of "black diamond" for those of us who desire such experiences?
Backpacking and similar wilderness pursuits, in virtually every database, are extraordinarily safe. Yet, they carry inherent risks which simply cannot be eliminated without significantly devaluing the experience. By giving the impression that we can "manage" these risks out of existence, we do harm in two ways. We provide expectations of safety which cannot be realized. We invite regulatory interventions which ultimately destroy the experiences that we value.
Monday, August 16, 2010
Wilderness Helicopter Evacuations
This has not been a good summer for the medical helicopter industry, or its employees and patients. Crashes in July took the lives of three in Arizona and two in Oklahoma; these brought to four the number of fatal medical helicopter crashes in 2010 alone.
Fortunately, none of these crashes involved wilderness rescues. On the other hand, it is simply a matter of time before a catastrophic incident occurs in the backcountry.
There has been a proliferation in the use of helicopters to provide medical response to wilderness injuries and illnesses in the past few years. Indeed, in this month alone, two such responses occured in the New York Adirondacks. While there may certainly be circumstances in which such an undertaking could be lifesaving, there are others in which this response has been mobilized for a condition which turned out to be trivial. Folks have undergone helicopter evacuations for sprained ankles, broken arms, and similar mishaps which in an earlier time would have been handled with an uncomfortable, but safer, "walk-out". The US Forest Service even dispatched a helicopter to "rescue" two workers who were freaked out by the sounds of wolves howling: http://www.mtexpress.com/index2.php?ID=2005112785
The Federal Aviation Administration has recently (June 8, 2010) recognized medical helicopters as an industry meriting closer regulation and scrutiny. Their fact sheet highlights (without explicitly addressing wilderness use) one of the vulnerabilities in the backcountry setting. The decision to mobilize a helicopter medical mission actually requires the decision of two professionals. First, a medical person (typically on the scene) makes the determination that air evacuation is necessary. Secondly, the pilot makes the determination that the mission is safe.
In urban settings, the first of these decisions is often (although not always) made by individuals with medical training and experience: EMTs, emergency physicians, etc. The system in the backcountry, however, is far less formal. The call for a helicopter rescue may well be initiated by an individual on the scene with minimal training and experience in the assessment of injuries. While one might argue that "when in doubt, err on the side of safety", the above experiences suggest that it is hardly a given that "safety" is served by dispatching a helicopter into wilderness terrain.
This is obviously a very controversial subject, and it currently is informed by very little data and lots of anecdote. With a colleague, I am currently embarking on a study of medical helicopter evacuations in a wilderness area which will include actual disposition of the evacuees--some of the anecdote to which I allude suggests that it is not uncommon for individuals flown out of the woods to be evaluated in the hospital and sent home without admission. When complete, the data from this study may help us develop a more structured process for mobilizing this high-tech and potentially deadly resource in the wilderness.
Fortunately, none of these crashes involved wilderness rescues. On the other hand, it is simply a matter of time before a catastrophic incident occurs in the backcountry.
There has been a proliferation in the use of helicopters to provide medical response to wilderness injuries and illnesses in the past few years. Indeed, in this month alone, two such responses occured in the New York Adirondacks. While there may certainly be circumstances in which such an undertaking could be lifesaving, there are others in which this response has been mobilized for a condition which turned out to be trivial. Folks have undergone helicopter evacuations for sprained ankles, broken arms, and similar mishaps which in an earlier time would have been handled with an uncomfortable, but safer, "walk-out". The US Forest Service even dispatched a helicopter to "rescue" two workers who were freaked out by the sounds of wolves howling: http://www.mtexpress.com/index2.php?ID=2005112785
The Federal Aviation Administration has recently (June 8, 2010) recognized medical helicopters as an industry meriting closer regulation and scrutiny. Their fact sheet highlights (without explicitly addressing wilderness use) one of the vulnerabilities in the backcountry setting. The decision to mobilize a helicopter medical mission actually requires the decision of two professionals. First, a medical person (typically on the scene) makes the determination that air evacuation is necessary. Secondly, the pilot makes the determination that the mission is safe.
In urban settings, the first of these decisions is often (although not always) made by individuals with medical training and experience: EMTs, emergency physicians, etc. The system in the backcountry, however, is far less formal. The call for a helicopter rescue may well be initiated by an individual on the scene with minimal training and experience in the assessment of injuries. While one might argue that "when in doubt, err on the side of safety", the above experiences suggest that it is hardly a given that "safety" is served by dispatching a helicopter into wilderness terrain.
This is obviously a very controversial subject, and it currently is informed by very little data and lots of anecdote. With a colleague, I am currently embarking on a study of medical helicopter evacuations in a wilderness area which will include actual disposition of the evacuees--some of the anecdote to which I allude suggests that it is not uncommon for individuals flown out of the woods to be evaluated in the hospital and sent home without admission. When complete, the data from this study may help us develop a more structured process for mobilizing this high-tech and potentially deadly resource in the wilderness.
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