Wilderness Medicine FromAdvance For Nurses April, 2012
Fifteen health care professionals- a diverse group of nurses, paramedics and a physician’s assistant- came from mostly urban environments for an intensive three and a half days in early November to be certified as Wilderness Advanced Life Support providers. It was the class for people looking to help the sick and injured in the outdoors. It was a class for those wanting a new look at medicine outside of the hospital and ambulance. It was not a class for those who did not want to get dirty.
“Wilderness medicine is defined as two hours or more from definitive care,” said Dr David Johnson, Emergency Physician at Central Maine Medical Center, who was teaching the class, along with Jim Morrissey a tactical paramedic with the FBI SWAT team out of San Francisco and Medical Health Operational Area Coordinator for Alameda County. Both have written books on the topic. Wilderness Medical Associates teaches several courses on medicine away from the hospital. In addition to the WALS class, which is designed for nurses, paramedics and physician’s assistants, there is also a Wilderness EMT course for BLS personnel. “Whether or not you want to be or not, you’re the doctor. What you know intuitively, the others have no clue. You make decisions. You have to and that’s your job” Johnson said.
Koala Hines , RN at Children’s Hospital and Research Center in Oakland was a student at the four and a half day class. “I want to be able to do everything and I defiantly be able to do things when there is no one around,” she said. She also loves the outdoors, a common theme of the participants. Colin Arnold, a firefighter - paramedic in East Bay wanted to get out of his comfort zone. “We are really good when we have the tools we normally have like cardiac monitors and all sorts of fancy equipment. If you don’t have the equipment you feel inadequate or unprepared so this is an opportunity to advance the assessment skills.”
During the lecture portion, Dr Johnson expanded on what the students already knew, but got them to think of themselves in a wilderness setting. Take frostbite. Everyone knew the best thing was to put the affected area in warm water for a slow thaw. But stop and think. Will someone have that much warm water when working a ski patrol? What if in the long transit that water became cold again? A photo of frostbite that had been thawed and refrozen in transit drew groans even from veteran nurses and paramedics.
Wound care went beyond the direct pressure and bandaging. As advanced life support providers, they should consider prophylactic antibiotics for wound care and appendicitis. “Five percent of wounds get infected in the emergency department,” Johnson said, adding ships and tents- places common for wilderness medicine – can be environments for MRSA.
One could almost call it minimalist medicine. “I hope they take away is the ability to do good assessments and be clear with their problem lists and not muddy up with their extraneous information. You need to have a good idea is this person is sick or not sick?” Johnson said. Yes, an injury could look bad, but Johnson showed many slides and asked the question “Is this an emergency?” In a situation of traveling light with few resources, such decisions may need to be made on who needs to be transported immediately and who can wait. Later that day, the class knew they would be making those decisions.
Today would be the night simulation and the scattered showers of earlier were becoming more and more regular. It was time for the instructors to take a step back and let the students use the knowledge they had gained from to make decisions on what to take when heading out into the wilderness. Does it make sense to put the wheel on the Stokes evacuation basket before heading out or put the wheel on when would you find the patient? What drugs and equipment would be most helpful and what would just add more weight? The different backgrounds now with a common knowledge of outdoor medicine were all working, thinking and providing input. RN Jessica Redford could not contain herself. “This is so exciting!” she said, with a childlike grin and gleam in her eyes.
The most valuable pieces of equipment the class would be using would not be carried in backpacks or stretchers but carried between their ears. “Stick to the plan. That will get you through” Johnson said to the group.
At 6:30 PM, the simulation began. The sun set some twenty five minutes earlier and the overcast day was now a steady rain. The students were divided into “hasty teams”- those who traveled lightest, got to the patients first and managed immediate life threats- and “medical teams” who carried more equipment and supplies, including equipment for evacuation. The students were then given the scenario – a biological research team went to the woods to study the golden salamander. A flash flood went through the valley and no one had heard from them.
Down the trail they met a terrified woman saying the group had been caught in a flood and the other three were in the valley and hurt. She was walking and talking and only had a twisted ankle so the team pressed forward. The darkness, rain, mud, plus a drop off kept the rescuers mindful to not become victims.
At 6:48 pm the hasty team met chaos. One man was screaming in pain down by the creek with an obvious broken tibia and hip displacement. A woman was doing CPR on the unconscious professor and said she had been for the last hour. “Can someone help me?!?” she yells at the rescuers as they were still assessing the scene. Two were in the hasty team and they had three patients. Paramedic Jenna Graham called in on the radio for the others and then began taking over CPR. Revery Barnes stayed with the injured man. Temperatures were in the mid-50s, not terrible, but enough that wet clothes could lead to hypothermia along with the injury.
About five minutes later, more help arrived. The patient was given morphine; splinted and stabilized enough to move him up the hill closer to the Stokes basket. At 7:12 the patient was loaded and ready for transport. The decision was made to stop CPR on the professor and that the woman performing CPR was ok to walk out. It was a reminder to the students that tough decisions need to be made where calling for another ambulance is not an option. Heading up the muddy trail the students were in full team mode. “Rock ahead” and “does anyone need to change places?” was the conversation for the uphill trek by flashlight and headlamps to the command post. The best advice for walking in the mud was “dig in!” No one fell.
At 7:33, the patient was in the building. Rain gear came off and it was time for a debriefing. It was record time according to Johnson – just under an hour- that the team made it to the command post. The team applauded. And “team” now seemed a more descriptive word for a group of health professionals from nursing, EMS, big cities and small towns who just succeeded outside of the hospital and, more importantly, outside of their comfort zones.