Practicing extreme medicine requires getting acclimated to extreme situations. For a group of second-year medical students at The University of Texas Medical Branch School of Medicine in Galveston, that meant slipping into a 10-foot-deep swimming pool to scuba dive.
“While we were actually in the water, everything was difficult,” said Omar Abdelaziz, a UTMB student.
“Everything” included simple things like moving and trying to regulate the water pressure throbbing in his ears.
“You know how when you go on a plane and get pressure in your ears? It’s like that but more intense really quickly, even in a 10-foot pool,” Mr. Abdelaziz said.
The purpose of scuba diving was not just doing something adventurous, though that’s an enjoyable benefit of learning about extreme medicine, he says. It’s also trying to understand what patients go through when they do extreme activities – like scuba diving, rock climbing, or floating weightless in space.
“I’ve never been scuba diving before, and I didn’t know what the sensation of the air going into the mouth was,” he said. “It’s dryer than normal air because there’s no water in the air tanks. … And when you understand where the patient’s coming from, you can then go on and talk to the patient,” about how to safely do potentially dangerous activities.
Mr. Abdelaziz was one of 18 medical students taking part in a two-week extreme medicine program offered in August through UTMB’s preventive medicine residency department. The main thrust of the class was to help aspiring physicians learn how to cope in austere settings where most or all of the tools of modern medicine are unavailable, says Brian Pinkston, MD, a former director of UTMB’s Aerospace Medicine Center.
“A lot of our medicine is, ‘I don’t have what I need, but what do I have? And how can I use my brain, and how can this suffice? If the prevention doesn’t work, how do I then put something together that is workable?’” said Dr. Pinkston, who taught the course with his wife Cheryl Lowry, MD.
The extreme medicine class also was designed to give medical students a break from the physiology, anatomy, and pathology classes that make up most medical school curricula in the first and second years. And it’s designed to show students the possibilities of what might be an enjoyable – if unorthodox – career in medicine.
Physicians who practice different types of extreme medicine – which is similar to wilderness and expedition medicine – don’t always practice full-time in wild and unreachable places, according to the Wilderness Medical Society, an Austin nonprofit that promotes wilderness medicine training and research. In fact, most physicians who provide care in austere settings work in typical clinic and hospitals settings, but prepare themselves also to provide care while traveling, participating in outdoor sports, or doing philanthropic work in remote environments, the organization says.
Training for extreme situations also turns out to be good medical training because austere environments can crop up in unlikely places, says Luke Husby, DO, an assistant professor at UT Health San Antonio and the school’s director of education for wilderness medicine.
“That could be on a plane,” said Dr. Husby, an emergency physician and member of the Wilderness Medical Society. “Every doctor has had somebody go down [sick] on a plane. You encounter that low-resource [environment] and you have to kick in that fundamental thought about what tools you could use.”
An emerging field
Extreme medicine is as old as first aid. But today it’s an emerging field of medicine that encompasses various medical specialties for a range of human endeavors, including travel, exploration, entertainment, business, disaster relief, and warfare. (See “Taking Medicine to the Extreme,” page 23.)
There are about 20 wilderness medicine fellowship programs across the country, says Renita Fonseca, chief executive officer at the Wilderness Medical Society. Texas does not currently have any wilderness medical fellowships, but the emerging extreme medicine curriculum at UTMB and a wilderness program under development at UT Health San Antonio give medical students and residents a taste of the specialty, she says.
Drs. Pinkston and Lowry arrived at extreme medicine through long careers in military aerospace medicine, which focuses on clinical care and support for crewmembers and passengers in aviation. That population frequently lives and works in remote, isolated areas under great stress, according to the Aerospace Medical Association website.
Aerospace medicine, like other types of extreme medicine, prepares physicians to practice in low-resource environments, and it is a mixture of individual care and population health, says Dr. Pinkston.
For instance, physicians might give pilots a physical to check their fitness for an assignment. But when a new military base is set up, that same physician acts more as a public health official – one of the first people on the ground to figure out where to put latrines and dining areas, and to assess what types of illnesses are likely to arise in that environment, Dr. Lowry explains.
Because they practice a form of preventive medicine, extreme medicine physicians spend most of their time preventing a crisis so that they won’t have to address one, Dr. Pinkston says. For instance, he and Dr. Lowry helped conduct UTMB’s medical reviews of people who go to scientific stations in Antarctica. Because of the extreme cold and difficult weather there, the South Pole station in winter can be more difficult to reach and resupply than the International Space Station, he says. Physicians there must be able to endure the tough conditions while planning and using resources intelligently.
“In Antarctica, you only have so many antibiotics until you can get another shipment,” Dr. Pinkston said. “The best resource that you have is prevention versus using up [medications] that you might not have enough supply of. You have to think of prevention as a tool to save on resources.”
Physicians in those circumstances also must improvise treatments that are normally no problem for modern physicians. Several years ago, a doctor in Antarctica emailed Dr. Pinkston to find out what antibiotic regimen he could use to stabilize a patient with appendicitis for two months until the patient could get to a surgeon. The regimen worked and the patient survived.
UTMB’s two-week medical school class was designed to give students a feel for that kind of medicine by taking them scuba diving, rock climbing, sailing, and to NASA’s neutral buoyancy laboratory. In each case, students learned basic skills – some medical and some practical – designed to make them better doctors in those situations.
“We were given mild exposure [to each situation],” said Gabe Pecha, a UTMB second-year medical student. “For instance, if you’re stuck in the middle of the ocean on a boat, what do you do? What kinds of things do you bring for sea sickness? We also learned how to tie knots and basic knowledge of how sailboats work.”
The students planned a simulated trip to support a humanitarian operation in Brazil, figuring out what types of supplies were most urgent. They also rehearsed treating a patient after a rock-climbing accident, with Dr. Pinkston as the patient, and practiced triaging patients during a natural disaster. And they learned how to treat medical conditions typical of extreme environments, like hypothermia in the cold and getting the bends (decompression sickness) while scuba diving.
“There was lots of pressure, lots of chaos,” Mr. Abdelaziz said. “A lot of [the class] was physiology, the basic med school stuff, while adding the problem-solving layer of not having things available to you and being in a precarious position yourself.”
Prepared for anything
The Wilderness Medical Society as well as several for-profit businesses provide conferences, workshops, and training for physicians looking to learn more about wilderness or extreme medicine. (See “Where to Get Training,” page 25). That kind of training can come in handy when you least expect it, says Dr. Husby at UT Health San Antonio.
Two years ago he visited Jackson Hole, Wyo., to attend a wilderness medicine CME course. One day later, he went to a nearby lake to read a book when he heard two thudding sounds and guttural screams. A hiker had fallen from not one but two cliffs – a roughly 60- to 80-foot fall altogether – and was lying unconscious. Dr. Husby and another man rushed to see what happened.
Dr. Husby said his training told him it would have been dangerously foolish to try to reach the fallen man because of his size and lack of equipment.
“I physically couldn’t get to him,” he said. “I could see right over the edge, but I was too big” to reach him.
Fortunately, the other man was smaller and had climbing equipment, so he managed to get to the fallen hiker, and Dr. Husby talked that man through administering first aid.
“We could barely hear each other, but I was trying to tell him what to do – don’t move him, don’t roll him, try to keep his head straight, open his airways – all the kind of stuff,” he said.
Together they were able to tend to the hiker, alert a park ranger, and get the hiker evacuated to a hospital. His spine was damaged, but he survived.
While it’s hard to be prepared for every eventuality, the UTMB class does get students thinking about what’s most important in an extreme situation. One of the class exercises was to create a “survival kit” out of a normal-sized pill bottle. Mr. Pecha was able to squeeze matches, superglue, fishing line, duct tape, a safety pin, and a rubber band among other things into his kit. Estefania Bazan, another second-year UTMB student, also included contact lenses.
“I can’t see very well, and I’d definitely need those if I was stranded in the wilderness,” she said.
Extreme medicine positions are not as easy to find as those at clinics and hospitals, but physicians with extreme medical training can look forward to a growing job market, Dr. Pinkston says.
“The CIA, the State Department, National Geographic, reality TV shows – all of those have increasing need for those trained in this field, and there are increasing numbers of people with medical conditions who want to go on that adventure travel,” he said. “We need a corps of individuals who have that knowledge who can provide either as expeditionary medical leads or just for counseling.”
To that end, the Graduate School of Biomedical Sciences at UTMB already offers a certificate program in extreme medicine that’s open to anyone with a bachelor’s degree. A master’s level extreme medicine degree program through that school is currently under review by the Texas Higher Education Coordinating Board.
Physicians who take up extreme medicine as a career typically find that the unusual problems it presents help keep them from feeling worn out or unchallenged, Dr. Lowry says.
“It helps prevent burnout,” she said. “If you talk to doctors who are out there practicing in the wilderness, very few of them are actually burned out compared to regular health care providers within a health care system.”
But even physicians who practice traditional medicine can learn a lot from the survival skills and the ability to improvise that extreme medicine demands, Dr. Husby says.
“You need to have those skills and just be comfortable with those skills should something arise,” he said. “Because you’re going to be the de facto leader [in a medical emergency].”
Tex Med. 2019;115(12):20-25
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