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.