college

Experiencing medicine
without the bells and whistles

Pamela Aird
Aaron Orkin
Michael Gora

In August 2005 we were pleased to be among a group of medical students from across Ontario who participated in Canada’s first wilderness medicine elective. Although wilderness medical practice is typically associated with rural, remote, or extreme environments, this elective exposed us to important and universally applicable aspects of high-quality medical practice.

How many students ever learn how to properly move someone who has a suspected spinal injury? Indeed, our training seems to begin at the hospital doors, even though our lives as physicians extend far beyond those doors. Few medical students or physicians are trained in basic first response to medical emergencies. Without the extraordinary diagnostic equipment and drugs in the emergency department or the back of an ambulance, without a host of other medical professionals to assist, how many medical students (indeed, how many physicians) are trained to manage a serious medical emergency?

Trauma or emergency scenarios with extreme shortages of supplies, diagnostic equipment, or personnel can emerge suddenly and unexpectedly even in densely populated areas. In terms of medical resources, a “virtual wilderness” can emerge in any location. Natural disasters, wars, or acts of terrorism can suddenly change a community with a tertiary care hospital into a medical wilderness. Practice in underdeveloped communities also requires more medical improvisation skills. Similar situations can unfold suddenly on an airplane, in the middle of a traffic jam, or on an afternoon jog.

With this in mind, the wilderness offered us a unique opportunity to apply newly acquired medical knowledge to situations outside the hospital or clinic. We focused on thorough hands-on patient assessment and practical management plans, without the aid of advanced equipment. We learned that basic patient assessment is the fundamental tool for evaluating the sick or injured. In addition, we learned to manage patients under suboptimal conditions, which greatly improved our ability to manage them in pristine hospital emergency departments. Learning to run intravenous catheters in the dark or at subzero temperatures, to carry patients a few hundred yards, to extricate them from cars, and to consider the complexities of arriving on a multiple-casualty disaster scene has given us a new perspective on hospital-based medicine and an effective general approach to patient management, especially for emergency practice. Learning to properly manage a severe laceration or compound fracture in the woods certainly makes managing a similar scenario in the emergency department far easier. We can now approach a safe, well lit, and well supplied hospital or clinic or a nursing staff and triage system as wonderful luxuries in medical practice and can appreciate them as such.

The course was offered by the Canadian chapter of Wilderness Medical Associates (WMA). This well respected international organization has taught courses to police, firefighters, military personnel, the outdoor industry (including Outward Bound, the National Outdoor Leadership School), and search-and-rescue organizations for decades in the United States and since 1995 in Canada. Now WMA is beginning to teach courses to physicians, residents, and medical students.

Students from the Michael DeGroote School of Medicine at McMaster University in Hamilton, Ont, spearheaded the project with WMA to develop a curriculum suitable to the learning goals of participants. Students from the University of Western Ontario in London, the University of Toronto, and Queen’s University in Kingston were also involved, creating an exciting opportunity for students from various schools and various medical pedagogic traditions to learn together.

The course began with an overview of the respiratory, circulatory, neurologic, integumentary, and musculoskeletal systems. This basic physiology was then integrated into a study of environmental topics, such as thermoregulation, altitude medicine, and submersion events. Finally, practical rescue techniques (including swift-water and high-angle rescue, and safe patient transportation and extrication methods) were incorporated. Appropriate management of trauma (specifically, fractures in the extremities and spine) was discussed and practised with minimal resources. Aspects of health care that might be taken for granted in the confines of a hospital, such as personal safety of health care workers, were explored alongside medical assessment and treatment. We were taught not only by a physician, but also by an emergency medical technician, a flight paramedic, a firefighter, and trained search-and-rescue personnel. They offered us insight into wilderness medicine from several perspectives. We developed a broad understanding of the many professions involved in crisis management and emergency medicine and a renewed respect for the unique expertise of these various professionals.

It is perhaps most important that this elective has given us an important perspective on the social responsibilities of physicians in an emergency situation. Regardless of specialty, physicians are often called upon to assist in emergencies. While most physicians might hope that they are never on an airplane when the captain calls for a physician, many have a story about when they have had to act in their professional capacity, often far outside their own discipline and with few resources immediately available.

While this elective certainly did not train any of us to be wilderness medicine experts, it provided us with the foundation for acting effectively, professionally, and practically under some fairly extreme conditions. Having taken this course, we are now able to appreciate our responsibility to serve our community as physicians and to ensure that our training, regardless of specialization, remains generally applicable. After all, what use is a medical degree if you cannot offer a basic response to a broken leg at a community hockey game?

Ms Aird, Mr Orkin, and Mr Gora are medical students at McMaster University in Hamilton, Ont. They participated in the wilderness medicine elective, initiated its creation, and were instrumental in planning and organization.