242 wilderness medicine

7/25/2019 242 Wilderness Medicine

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What’s in Your Medical Kit

Expedition Cruise Ship Doc

Training with the Marines

Location Devices

Volume 24, #2

S p r i n g 2 0 0 7



Volume 24, Number 2 Spring 2007

Ask the Experts Roundtable:Location Devices

Mike McDonald,

Dale Atkins, Ken Zafren MD,

Rocky Henderson, Howard Paul

Page 19

Off the Beaten Path:Expedition Cruise Ship Doc

Yvonne Lanelli and Pierre

Guibor, MD

Page 8

Backcountry Medicine: What’s in Your Kit?

Timothy Platts-Mills, MD

Page 5

2nd Battalion of the 1stMarine Regiment

Training OperationsFred Trayers, LT MC USN

Page 12

Cover: Dr. Guibor hiking

in the valley of

the Geysers,

Kamchatka, Russia© Yvonne Lanelli



+ WHAT’S NEW + EDITORIAL

Wilderness Medicine A quarterly magazine published by the

Wilderness Medical Society

Christopher Van ilburg, MD............Editor

Jonna Barry........................Managing Editor

Larry E. Johnson, MD, PhD................................Assistant Edito

Seth C. Hawkins, MD................................Associate EditorGeorge Rodway, PhD, CRMP..............................Associate Edit

Karl Neumann, MD.............Editor Emeritus

Contributing Editors:

Jolie Bookspan, PhD

Yvonne Lanelli

Debra Stoner, MD

Contributors:

Cristopher Benner, PA-C

Andrew (Woody) Bursaw, MS4

Christian Sloane, MD

Email submissions and comments to:

Christopher Van i lburg: [email protected]

& Jonna Barry: [email protected]

Wilderness Medicine (ISSN 1073-502X) is published quarterl y in Janu

April, July, and October by the Wilderness Medical Society,810 E 10

Street., PO Box 1897, Lawrence, KS 66044

Tel: 800-627-0629. Periodicals postage paid at

Lawrence, KS and additional mailing offices.

Annual subscription rate: $55.

POSTMASTER:

Send address changes to the Wilderness Medical Society,

810 E 10th Street., PO Box 1897, Lawrence, KS 66044.

Requests to reprint Wilderness Medicine in whole or in part must

submitted to www.copyright.com.

© 2007 Wilderness Medical Society. All rights reserved.

Printed on recycled paper in the USA.

Te goals for Wilderness Medicine magazine are to:

1. Provide timely information regarding WMS

news and activities;

2. Provide a forum for the exchange of ideas and knowledge

regarding wilderness medicine, and regarding WMS, and

3. Promote active membership involvement

through solicitation and publication of

members’ articles and photographs.

Joyce Lancaster, Executive Director

Jason Gilbert, Association Manager Wilderness Medica l Society 810 E 10th Street, PO Box 1897

Lawrence, KS 66044 Tel: 800-627-0629Int’l: 785-843-1235

Email: [email protected]

Send address changes andrequests for back issuesto the address above.

Send advertising inquiries to:Rhett Dubiel:

[email protected].

+ BOARD OF DIRECTORS

Te 2007 WMS Board of Directors

Eric L. Johnson, MD, WMS President

Luanne Freer, MD, Past-President

Colin Grissom, MD, Treasurer

Chris Moore, MD, Secretary

Andrew “Woody” Bursaw, MS4Nat’l Student Representative

Tom DeLoughery, MD

Tony Islas, MD

Kimberly Johnson, MD, PhD

Shean Phelps, MD, MPH

James A. Wilkerson III, MD

Standing Committees

Finance and AuditColin Grissom, MD, Chair

Nominating CommitteeLuanne Freer, MD, Chair

Ongoing Recommended Committees

Awards Blair Erb, MD, Chair

CME James A. Wilkerson III, MD andKimberly Johnson, Co-Chairs

Environmental Council Kimberly Johnson,MD, Chair

Executive Board Eric L. Johnson, MD, Chair

FAWM Shean Phelps, MD, MPH, Chair

Membership Tony Islas, MD, Chair

Publications George Rodway,PhD, CRNP, Chair

Research Colin Grissom, MD, Chair

Student Services Andrew “Woody” Bursaw, MS4

Wilderness MattersEric L. Johnson, MD ..................................4

Student Elective UpdateChristopher Sloane, MD .............................7

Member ProfilesSam Schimelpfenig, MD ...........................15

Book ReviewsSeth C. Hawkins, MD, editor ...................16

Search and Rescueon Mt. Hood Photo EssayChristopher Van ilburg, MD ...................18

ICAR - IKAR - CISA Statement:Avalanche Rescue Devices

and Systems .....................................22

CALL FOR:Board Member Nominations ...22

Fit to be Wild:A New Look at Old WildernessMedicine for Traveler’s Diarrhea

Jolie Bookspan, PhD ................................23

Dispatches:Mountain Medicine

Conference, ArgentinaKen Zafren, MD ......................................26

From the PA’s Desk Cristopher Benner, PA-C, MMSc ...............28

Cliff Notes Andrew “Woody” Bursaw, MSA .................29

CALL FOR:WMS Award Nominations .........29

Conference Calendar ...................30

CALL FOR: Abstracts 2007 ................................30


http://slidepdf.com/reader/full/242-wilderness-medicine 4/324 WILDERNESS MEDICINE // Spring 2007

+ WILDERNESS MATTERS Eric L. Johnson, MD, President, WMS

Make plans to attend the WMS SummerConference and Annual Meeting in Snowmasat Aspen, Colorado, July 21 – 25, 2007.

Visit www.wms.org for conferencedetails and registration.

Springtime is always a time for me to clean up post-winter season andlook for the annual renewal that comes with this seasonal cycle. It’s timeto put away the telemark skis and ice-climbing gear, and break out theroad bike, rock gear, and tennis racket. For those who reside in otherparts of the country or world, this may seem very foreign, however inIdaho we are very much tied to the seasons. For your society, it is muchthe same with the administration putting away 2006 year-end financialsand the winter meeting, and looking forward to the upcoming eventsand activities.

Te WMS completed a successful society meeting in Park City, Utah inMarch, and my many thanks to Dr. Colin Grissom for acting as Program

Chair. Besides great didactics, this meeting offered Level 1 avalanchecertification and the Advanced Wilderness Life Support course. If youmissed this opportunity in 2007, stay tuned as plans are in the works tooffer another Winter Meeting in Park City in 2008.

During the month of February, the annual ritual of reading the emailsfrom the Wilderness Medicine Student Rotation held in ennessee offersan amazing tale of the trials and tribulations of medical student wildernesseducation. om Kessler does a wonderful job in coordinating this effort,and I am envious of the opportunity these young physicians have. Itis to be applauded and supported. I am also humbled by these youngupcoming wilderness docs, as their bios are filled with broad experiencesand interests that took me years to develop and discover…if they are anyindication of future WMS members, the Society is in good hands.

As we turned the calendars to 2007, WMS rolled out revised guidelinesfor the achievement of Fellow through the Academy of WildernessMedicine. Tese revised guidelines have taken months to evolve andinclude not only wilderness didactic credits as before, but awards creditfor wilderness experiences, volunteer work, WMS committee work,research and the like. I encourage all members to check out the newguidelines at www.wms.org. My thanks to Dr. Shean Phelps, JasonGilbert, and Dr. ony Islas for all their efforts in developing thisprogram. Of note, at the upcoming Annual Meeting in July, we areexcited to be acknowledging our first group of Wilderness MedicineFellows at the Awards Ceremony!

We’re all looking forward to the Society’s Annual Meetinbeing held in Snowmass CO July 21st-25th, 2007. Checout the WMS website for program details and onlinregistration. Dr. Luanne Freer, Program Chair, has ptogether a must-attend wilderness meeting. Besides gre

didactics, hands-on workshops, and fun activities, it is yosociety’s “work” meeting that includes Committee meetinand your Board of Directors meeting. For me, it is alwaystime to see old friends and meet many new ones. Te WMBanquet night features the Awards Ceremony (Master Ceremonies our own Dr. Blair Erb) and evening speakeDr. Mark Plotkin. I encourage all members to attend.

For those wishing for a fall season overseas learninexperience, the World Congress of Wilderness anMountain Medicine held in Aviemore Scotland Octob3rd-7th will be what you need to attend. Co-sponsoreby the WMS and the International Society of MountaMedicine (ISMM), the pre-conference day as well conference didactics offers world-class speakers and activitie

Please see www.wms.org for all details. I registered on-line and it took aof 5 minutes. I have not been to Scotland in the fall, but am assured bmy colleagues across the pond that I will not be disappointed.

Te WMS continues to seek out ways to better serve our membershiand I have noted a few already. Streamlining the Fellow process, offeringreat educational opportunities, ensuring an efficient administratiostructure, seeking out active Board and Committee memberencouraging student involvement, liaison with like-minded corporaand national/international organizations and many others is what yoBoard is focused on. If you have any additional thoughts or ideas, yousociety wishes to hear them!

As always, I encourage all to follow our theme to “combine yoprofession with your passion.” Let us know how best we can improvyour society and remember wilderness matters.

You may contact Dr. Johnson at [email protected].

WMS Summer Conferencein the HEART of the Rockies!


http://slidepdf.com/reader/full/242-wilderness-medicine 5/325WILDERNESS MEDICINE // Spring 2007

+ BACKCOUNTRY MEDICINE Timothy Platts-Mills, MD

Te ideal expedition medical kit would weigh nothing yet containeverything found in a well-stocked Emergency Department. ButEmergency Departments are heavy, and finding a balance between theRay Jardine (the “light is right” backpacking guru) approach and theCarolinas MED-1 truck is not simple. Although no “best” medical kitexists, once trip length and participants reach a critical mass, some keyitems need to come along. Tis article describes 40 of the most usefulmedicines and supplies to bring into the backcountry and presentsprinciples that apply to both small and large expedition medical care. Arecommended reading list is provided for those wanting to learn more.

Preparation, Organization,and Communication

Although not part of the kit, these represent the surest and lightest way to stay healthy. Study the area you’re traveling to, learn aboutthe problems others have encountered, and anticipate the injuriesand illnesses you will have to treat. If trekking in the tropics, reviewthe CDC recommendations for vaccinations and malaria prophylaxis.Identify team members’ medical problems and substance dependenciesand be prepared to address them. Encourage team members to readythemselves physically. Wilderness medical problems often stem fromfailures in leadership and communication; a fancy medical kit is not asubstitute for either. eams should have clearly defined objectives andagreed upon alternative plans if hazardous weather or illness occurs.

Although you may travel sans cell phone, they’re now a standard safetydevice for U.S. backcountry travel. Outside the U.S., satellite phonesmay be appropriate. Waterproof paper and pencil weigh little and can

be critical when trying to find a lost team member or recruit help for asearch and rescue party.

Foot Care and Skin CareUnless you are sea kayaking or orbiting Mars, you will be on your feet,and eventually they will hurt. Ask team members to tell you immediatelyif they have any foot discomfort. I drain blisters with a small incision,cover them with cyanoacrylate tissue adhesive (Dermabond), cover thedried adhesive with mole skin, cover the mole skin with duct tape, andput Vaseline over the duct tape to decrease friction between the footand the footwear. Tere are lots of other ways to do this, but you need aplan. A petroleum-based antibiotic ointment serves as a lubricant andis useful for the treatment of superficial skin infections.

Essential in most environments – sunscreen, lip protection, andsunglasses. At altitude, at sea, and on snow an extra pair of sunglassesfor every two team members is recommended.

Respiratory ProblemsEpinephrine is an essential medication because of its role in anaphylaxistreatment. Te recommended dose for adults is 0.3 mg (0.3 ml of1:1000) intramuscularly. Te EpiPen can deliver this dose, but it’s bulky,painful when injected, and only provides a single dose. An alternative—bring a 1 mL vial of 1:1000 epinephrine (3 doses). Pack albuterolinhalers to treat asthma and bronchospasm associated with cold,altitude, or respiratory illness. Intramuscular epinephrine may be used

for the treatment of severe asthma. Asthmatics should continue theirroutine medications and carry a burst dose of oral prednisone, typically60 mg for 5 days. A 7-day course of levofloxacin (Levaquin) 500 mg isappropriate treatment for those with fever and respiratory complaintsconsistent with pneumonia. Oxymetazoline nasal spray (Afrin) and a

non-sedating antihistamine with pseudoephedrine such as Claritin-Dtreat congestion. Oxymetazoline applied to a small piece of cotton woolor tissue paper also serves as anterior packing for nose bleeds. Troatlozenges quiet coughs and are particularly appreciated at high-altitudeand in cold environments.

Altitude Illnesses Altitude illness treatment depends on three drugs. Acetazolamide(Diamox) 250 mg orally twice a day both prevents and treats acutemountain sickness. Dexamethasone (Decadron) 8 mg intramuscularlyfollowed by 4 mg injections every 6 hours treats high altitude cerebraledema. Oral prednisone is an acceptable dexamethasone substitute,but an injectable steroid is preferable due to altered mental status andvomiting in many with cerebral edema. Nifedipine (Procardia) 10-20

mg orally every 6 hours is the drug of choice for high altitude pulmonaryedema. Supplemental oxygen should also be given if available.

WoundsTe key to wound care in the backcountry is cleansing and hemostasis.Use clear flowing water to wash wounds initially; the bacterialconcentrations are likely to be lower than on the skin. Tereafter, aplastic water bottle with a hole or a 20 ml syringe with an 18-gaugeneedle can be used for high-pressure irrigation. Wound closureprevents further contamination and controls bleeding, but is usuallynot essential and is inappropriate for puncture or dirty wounds. An Acewrap works well as a compression bandage and keeps the wound clean.



issue adhesive closes small cuts. A skin stapler or suture kit may beappropriate. Reasonable choices for suture are 3-0 and 4-0 vicryl and 4-0and 5-0 nylon. Several 0-silk sutures are useful for the repair of backpackstraps and tents. A sharp-tipped knife aids in splinter removal. reatinfected wounds or those with crushed tissue, gross contamination, orexposed tendon or bone with cephalexin (Keflex) 500 mg every 6 hours.Fashion splints out of insulation pads and duct tape.

Abdominal Complaints

Tere are a few bad belly problems common enough to consider thatcannot be definitively addressed in the backcountry. Abdominal painand fever, not obviously due to gastroenteritis, requires antibioticsand evacuation. Levofloxacin 500 mg once a day and metronidazole (Flagyl) 500 mg four times a day are appropriate. Pregnant trekkers

with abdominal pain also require evacuation; bring a urine pregnancytest. Both urinary infections and traveler’s diarrhea can be treated withlevofloxacin. For symptomatic treatment of gastrointestinal complaintsbring prochlorperazine (Compazine) 25 mg suppositories, antacidpills, docusate sodium (Colace), bismuth subsalicylate (Pepto-Bismol),loperamide (Imodium), and hydrocortisone hemorrhoid cream (Anusol HC). Analgesia and Central

Nervous System Treatmentsraveling solo, you might forgo pain medications, but if you’re responsiblefor an expedition you need to have options. Ibuprofen (Motrin) 600mg tabs and oxycodone and acetaminophen (Percocet) 5/325 mgtabs will cover most situations. Use intramuscular morphine for those

with major injuries. Remember, large narcotic doses cause respiratorydepression.

Injectable lorazepam (Ativan) treats seizures, agitation, and alcohol withdrawal, and works synergistically with oxycodone and morphine tocontrol pain. Caffeine 200 mg tabs are useful for caffeine withdrawalheadaches and during long drives or prolonged rescues, but areunnecessary if you have coffee.

MiscellaneousFluconazole (Diflucan) 150 mg orally treats vaginal candidiasand athlete’s foot. Insect repellant containing DEE repels fliand mosquitoes. A mixture such as Cavit is useful for filling cavitieCiprofloxacin ophthalmic drops (Ciloxan) treats bacterial infectioof the eye and corneal ulcers associated with contact lens use. Whetraveling with older individuals, carry aspirin 325 mg tabs to treat chepain. Nitroglycerine and furosemide (Lasix) tabs should be brought fpatients with congestive heart failure and are important in the treatme

of severe high-altitude pulmonary edema. Intravenous start kiintravenous fluids, tube thoracostomy equipment, and advanced airwequipment may be appropriate for large groups with a base camp.

im Platts-Mills is a senior resident in Emergency Medicine in Fresno, California. He than

Dr. Michael Burg for assistance in preparing this article and Dr. Matt Lewin for insights in

providing medical care in remote settings .

Recommended Reading1. Wilkerson JA. Medicine for Mountaineering and Other Wilderness Activities, 5th ed. Seattle WA: Te Mountaineers Books; 2001.

2. Zell SC, Goodman PH. Wilderness preparation, equipment, and medical

supplies. In: Auerbach PS, ed. Wilderness Medicine, 4th ed. Philadelphia, PA:

Elsevier Inc; 2001:1662-1685.

3. Lentz M et al. Mountaineering First Aid, 4th ed. Seattle WA: Te

Mountaineers Books; 1996.

4. Vonhof J. Fixing Your Feet, 2nd ed. Manteca, CA: Footwork

Publications; 2001.

5. Forgey WW. Wilderness Medical Society Practice Guidelines for WildernessEmergency Care. Old Saybrook, C: Te Globe Pequot Press; 1995.

Communication:

1. Cell or satellite phone

2. Waterproof paper and pencil

Foot and Skin Care:

3. Petroleum-based antibiotic cream

4. Duct tape

5. Mole skin

6. Cyanoacrylate tissue adhesive

7. Sunscreen

8. Lip protection

9. Sunglasses

Respiratory:

10. Epinephrine 1 mg (1:1000) in vials

11. Albuterol inhaler

12. Oxymetazoline nasal spray 0.05 percent

13. Loratadine/pseudoephedrine 10 mg tabs

14. Throat lozenges

Altitude Illness:

15. Acetazolamide 250 mg tabs

16. Dexamethasone injectable solution

17. Nifedipine 10 mg tabs

TOP 40 ITEMS FOR A BACKCOUNTRY MEDICAL KIT

Wounds:

18. High-pressure irrigation device

19. Ace wrap

20. Suture kit

21. Knife

22. Cephalexin 500 mg tabs

Abdominal Complaints:

23. Urine pregnancy test

24. Levofloxacin 500 mg tabs

25. Metronidazole 500 mg tabs

26. Calcium carbonate antacid

750 mg tabs27. Bismuth subsalicylate

250 mg tabs

28. Docusate sodium

100 mg tabs

29. Prochlorperazine

25 mg suppositories

30. Loperamide 2 mg tabs

31. Hydrocortisone hemorrhoidal

2.5 percent cream

Analgesia and Central

Nervous System Treatments:

32. Ibuprofen 600 mg tabs

33. Oxycodone/acetaminophen 5/325 mg tabs

34. Morphine sulfate injectable

35. Lorazepam injectable

36. Caffeine 200 mg tabs

Other:

37. Fluconazole

150 mg tabs

38. Insect repellant

containingDEET

39. Cavit 7 gm tube

40. Syringes and

needles for

intramuscular

injections

Photo courtesy of ender Corporation and Adventure Medical Kits. www.tendercorp.com



February 19, 2006: Te 2007 elective is well underway. As I writethis I am here to spend a week with Dr. om Kessler and his interna-tional crew of 24 students at Camp Wesley Woods in the Great SmokyMountains. Tey are all having a great time. Tis truly is a great oppor-

tunity for the students. For daily updates and a chronicle of the entireexperience, from start to finish, go online and check our new “Blog.”Te link is http://blog.wms.org.

The best way to learn is by doing,

and that maxim is certainly followed

for our wilderness medicine training.

The students have submitted a brief update:

“Te best way to learn is by doing, and that maxim is certainly followedfor our wilderness medicine training. For our first scenario, we were hik-ing after lunch when two of us decided to race down a steep incline.

After tripping over a root, I was face down on my belly at the bottom ofthe hill, precariously resting on some branches inches over the creek. Myback was hyper-extended and everything hurt. We had spent the morn-ing practicing spinal immobilization, so the task of my teammates wasto assess the scene of the accident and to get me to safer ground with mypossible spinal cord injury. My awkward position didn’t make it easy forthem, and luckily one of the rescuers noticed a sharp stick right next tomy ribs, which would have made rolling me much more painful. Eventhough this was our first day of intense scenario training, we took it seri-ously and did a great job.

In our short time here, we have had quite a few unique lectures aboutbear encounters, mushroom toxicity, planning a medical trip to Mars,creative rehydration methods, and the history of the Great SmokyMountains, among many others. However, I am sure we would all agreethat our favorite part of the course is getting outside and getting dirty.On our second day here, we did just that. We learned about search andrescue by tracking Lt. Col. Jeff Wadley through the woods here at ourhome base – Camp Wesley Woods. We took turns tracking a path leftby a theoretical missing person, sometimes even on our hands and kneesthrough the brush. Of course, we stored the information for what is sureto be a rescue scenario later in the course.

We have spent our first week discussing topics that many of us are fa-miliar with, but the emphasis now is on what we may encounter in a

wilderness setting and what we can do with the problem outside thecomfortable confines of the well-stocked emergency department or in-

tensive care unit. Whether it is the country road loop 5 minutes fromhome that some of us run every day or mile 1,345 of the Appalachianrail, we are thinking about and practicing what we can do to preventthe need for any wilderness medicine and how we can get people safelythrough an unforeseen tragedy.

Most of us have not been in a classroom for over a year now but we havebeen in the emergency room, operating room, wards, and clinics learning

while doing. Tis rotation is a truly unique opportunity for us both toget back into the classroom and to get our hands dirty at the same time.

We are looking forward to learning a lot more and testing our knowledgein a wide range of scenarios, topped off by our own planned 4-day back-packing journey in the Great Smoky Mountain National Park.”

Tanks to the many WMS members and volunteers who have made thiselective possible. Without your assistance, this elective simply would notbe the excellent experience that it is. A special thanks to Jason Gilbertand the staff at the WMS offices who have worked tirelessly to makesure the elective went off without a hitch.

About the electiveTe elective is held in February in the Great Smoky Mountains atCamp Wesley Woods, just outside of Knoxville, N. Te course is a

well balanced mix of didactics, small group sessions, and hands-on,scenario-based learning in an outdoor setting. Tere is an extendedhike practicum. Leadership training is integrated through the course.Te Wilderness First Responder Curriculum is integrated through the

month and successful completion of the course allows students to takethe WFR certification test (for an extra fee). A comprehensive syllabus, written by recognized leaders in the field of wilderness medicine is givento each participant. Academic credit is provided by the Uniformed Ser-vices University of the Health Sciences (USUHS) through an ongoingmemorandum of understanding.

Many of you have emailed, asking about plans for next year. Wehope to have dates finalized soon for the 2008 elective. Checkthe website in April for updated dates and application materials:www wms.org/academy/elective.asp.



Y v o n n e L a n e l l i a n d P i e r r e

G u i b o r , M D

CRUISE SHIP DOCTOR — WILDERNESS MEDICINE AT SEA

Photos by Yvonne Lanelli



I was snorkeling with twelve expedition cruise ship

passengers on Belize’s White Reef. Suddenly the

divemaster yelled, waved his arms and pointed down.

A 42-year-old female passenger lay flat on the sandy

bottom. I took a deep breath and free-dove 30 feet. . . .

If the phrase “cruise ship doctor” conjures images of partying Love Boat-style mega-liners, a stint on an expedition cruise vessel will blow thatcliché higher than a whale’s spout.

“It’s wilderness medicine at sea,” says WMS member Pierre GuiborMD. In his eighth year as expedition cruise ship physician, he has

sailed both small and large cruise lines from the Arctic Circle toSouth America. Currently, he serves as Cruise Medicine andSurgery Consultant for Clipper Cruise Lines.

Expedition cruise vessels typically carry 120 passengers and80 crew. Te ship’s doctor functions alone—without nurse,labs, X-ray or specialty consults—in remote locales such asRussia’s Kamchatka Peninsula, Galápagos, the South Pacific,

or Belizean reefs.

“WHERE AM I?” She was seizing. I grasped her under her chin, pushed off thebottom and kicked hard to the surface, emerging next to the panga

[small skiff]. Te captain and mate pulled her 90-pound limp,cyanotic body aboard. I jerked off my fins and mask and leaped

up the panga’s ladder. She was not breathing, had no pulse and herstomach was distended. I performed one abdominal thrust. Water

gushed over the bottom of the panga. Laying her on her back, I clearedher airway with my fingers. She was still unconscious, not breathing

and pulseless. I gave her two mouth-to-mouth breaths and started cardiac

PERFORMING UNDER PRESSURE—CAN YOU DO IT?

Without labs, x-rays, EKG, nurse, or specialty consults,

the expedition ship doctor reverts to the basics, “much

like what we learned in medical school.” Most crucial:

taking a thorough exam and history. “Document date and

time of accident or onset of illness, signs and symptoms,

allergies, medications, previous illnesses, and surgeries.

Take blood pressure, pulse, respirations, and temperature

on every patient, no matter the symptoms, diagnosis,

or treatment.”

Fortunately, cases such as the seizing snorkeler are rare.

“I see mostly GI episodes and sore throats with coughing.

I clean minor wounds, give IM tetanus toxoid boosters,

suture lacerations, and treat minor muscle aches and

strains of passengers who didn’t work out prior to their

expedition. And I stress the merits of hand washing!”

Severe trauma aboard ship is uncommon. However, “be

ready to handle a tension pneumothorax or hemothorax

with an emergency chest tube. Review cardio-pulmonary

resuscitation (CPR) techniques. Take ACLS (Advanced

Cardiac Life Support) or ATLS (Advanced Trauma Life

Support) courses.”

Obtaining medications in exotic foreign locations presents

challenges as well. Before leaving the U.S., Dr. Guibor

emails the doctor currently onboard and determines

which meds he should bring with him, in concurrence with

the medical director of the cruise line. “But,” he cautions,

“when doctors from different countries bring their favoritemeds, unfamiliar brands cause confusion.” Passengers

themselves cause confusion as well. “They stockpile all

their meds in one bottle instead of in individually labeled

ones. When asked, many can’t remember the name of the

meds, dosage, frequency—even the MD who prescribed

them!” Possible solution—a pre-cruise form listing meds,

dosages, frequency, and prescribing doctor. “And it would

be extremely helpful to have a copy of a recent EKG.”



compressions. After 30 seconds—which seemed like 30 minutes—shecoughed and started breathing on her own. Her pulse returned. Her colorwent from dark blue to pink in one minute. She opened her eyes and said,“Where am I?”

Dr. Guibor’s efforts had just begun. Onboard the cruise ship, he plungedinto emergency evacuation efforts that he had initiated by radio fromthe panga, mobilizing the ship captain, first officer, hotel manager,cruise director, Belize agent, the ship’s U.S. office, and the patient’sinsurance company. In the patient’s cabin, Dr. Guibor re-warmed her,performed a complete physical exam—during which she denied a priorhistory of seizures—and started two large bore IVs in each arm withRingers Lactate.

Tirty minutes later, evacuation began. Dr. Guibor, the patient, and hermother bounced across the waves in the little open outboard panga tothe small city of Dendriga, Belize. “I kept her warm with blankets and

jackets.” Night fell. When the panga stuck on a sandbar, the crew andcaptain jumped out and pushed it over. Onshore, they transferred to theship agent’s Suburban. It was 10 PM. “We drove from Dendriga over anunpaved road to Belize City.” During the entire trip, “I kept my indexand middle finger on her radial pulse, the IVs open and ran O2 with anasal cannula—until the O2 ran out. I attached AED pads for cardiacmonitoring—and in case a shockable cardiac event occurred. We werefortunate; she didn’t seize during transport. ”

At 6 AM, they arrived at the Belize City Medical Clinic. “Beforeboarding the ship I had already checked out this facility, anticipating anemergency.” Te patient remained there on IV Dilantin for two moredays before flying back to the U.S. by commercial carrier.

Dr. Guibor, who returned the ship once she had beeadmitted, followed-up afther return to the U.S. “Shehad no recurrence of seizureIt’s been over four years anI’m still in contact with heChristmas cards and emails.” THAT’S WHY THEY (DON’T)PAY ME THE BIG BUCKSSmall expedition cruiship doctors are usually nsalaried. So why trade 3 to

weeks of your valued offitime for a stint of wildernemedicine at sea?

I stood on top of the highetemple in the Mayan ruins

ikal. Te steamy Guatemalan jungle spread below me. Howler monkeboomed. Something red—a scarlet macaw maybe?—flashed in thdistance. I had just climbed five stories of steep stone stairs and listened

expert naturalists and historians. A few hours earlier I’d been bouncing ovthe jungle canopy in a little plane. Spanning over 400 years in less than day—priceless.

Cruise lines usually provide complimentary air transportation, cruiexperience, and shore excursions to the ship doctor. Te doctocompanion or spouse may also receive the cruise but is responsible fohis/her air transportation to and from the ship plus shore excursionSince most small expedition ship’s cruises range from $6,500 to $15,00per person, this translates into a sizable compensation package.

In addition, the ship doctor—on his/her own—can research and arranpre- or post-cruise travel. Dr. Guibor, a NAUI Dive Instructor anDivers Alert Network Referral Physician, often schedules scuba divin

before and after his assignment. Being a professional diver jokingearned him the ship doctor title when his vessel struck an uncharted roand he “doctored the ship.” “On scuba, I evaluated and photographepuncture damage to the hull. Ten I helped repair it!”

Intangibles also keep Dr. Guibor at sea. “Tere are rewards for makinaccurate decisions rapidly, much like combat,” says the former U.Marine. “Some of us with military service vicariously enjoy the sexperience that we had in the past.” As in the military, he enjoys workin

with ship officers who are consummate professionals, forming friendshithat continue after the voyage ends.

But it isn’t all happy outcomes and Christmas cards.

“Downsides are isolation and uncertainty of your diagnosis and treatmeplan for serious patients. If the condition worsens and you made aincorrect patient management decision, you are solely responsible. Shistock limited medical supplies, including oxygen. If you run out, yocan’t call Walgreen’s.” AN ADVENTURE FOR THE INTREPIDPacking his duffle for the next assignment, he reflected, “Smaexpedition ship duty is much different from large cruise ship duty. Yopractice medicine under unusual circumstances, challenge yourself bophysically and mentally, participate as a professional mariner providin

MORE THAN SICK CALL

The ship doctor also forms part of the ship’s documents

department. “The mandated Center for Disease Control

(CDC) Gastrointestinal Upset Log is an important statement

of wellbeing aboard the ships, whether in U.S. or International

waters.” The ship doctor takes regular water samples and

maintains the water sampling log testifying to the absence

of E. coli. When a health issue affects a crew member or

passenger, the doctor and hotel manager coordinate specific

hygiene awareness or ship cleaning procedures. If an illness—

usually diarrhea episodes—requires cabin isolation, the doctor

coordinates with the hotel manager, captain, and first officer.



the best care possible to passengers and crew for whom you’re their onlyresource—and experience some of the most remote parts of the world.Te rewards are not so much financial but rather providing the service.Consider the currency, ‘Job well done, Doctor!’”

He closed the duffle. “Being a ‘team player’ on a small ship delivers greatrewards. Would you like to find out?”

CHAIN OF COMMAND AND PEOPLE SKILLS

Unlike a hospital setting, the ship’s doctor frequently finds him/herselflow in authority except when medical issues are in question. Balancingmedical concerns with ocean-going operations requires tact—pluscommon sense and basic seamanship.

“Most Captains consider medical issues, unless life threatening, to besecondary. Learn the chain of command, such as the first officer whothen communicates with the Captain if needed.”

Te ship is an isolated, self-contained community at sea. eamworkis essential. “A team consensus builder uses skills that enable the teammembers to arrive at the same conclusions for problem solving andcorrective measures. Rather than forcing an issue in an authoritativemanner, the effective ship doctor is low key, avoiding heavy-handed

directives.” Dr. Guibor summons all his tact when advising passengersthat treatment will involve “isolation in their cabin for several days oftheir expensive voyage”!

Clipper Cruise Line specializes in small cruise shipexpedition-type experiences in remote areas of Alaska,Russia, Japan, Asia and South Pacific, aboard the ClipperOdyssey. The ship doctor must be able to handle a multitudeof general medical problems and consider a number ofsolutions, with limited alternatives/supplies available.

Flexibility, availability and affability, with a teamworkattitude, are important factors for this position.Daily sick-call hours and emergency availability topaxs and crew members.

Ship doctor applicants should have the following:1) Current US State Licensure & CV; 2) Copy photo pagepassport; 3) ACLS or equiv.; 4) Good general health/positiveattitude; 5) Available for 3-6 weeks tour of duty. Preferencegiven to past ship physician experience and/or military service.Computer skills essential.

EM, FM, IM or Surg preferred. No labs, xray or nurseavailable. Contracts provide Med. Liab. Insur., air/landtravel to and from ship, and cruise itinerary for doctorand comp cruise for companion.

DO YOU HAVE WHAT IT TAKES?Qualifications for expedition cruise shipdoctors vary for each ship.

Generally, requirements include:• Active state medical license• Current passport• ACLS, ATLS, or equivalent• Good general health and flexible attitude

• Availability for a 3 to 6-week tour of duty.Experience in Emergency Medicine, Family Practice,General Surgery, or Internal Medicine is a plus.“You’ll be suturing small wounds.”

Additional preparation for a ship doctorposition might include:

• Membership and attending conferences oforganizations such as the Wilderness MedicalSociety (WMS) or International Society of TravelMedicine (ISTM)

• Keeping physically and mentally fit with regularactivities, i.e. hiking, swimming, etc.

• Networking with other cruise ship physicians with

experience aboard the same ship• Planning pre- or post-excursions to derive the utmost

from your remote travel

• Staying optimistic!

CRUISE SHIP PHYSICIANS

Pierre Guibor, MD, PA

Cruise Medicine & Surgery Consultant

Email: [email protected]

Office: 201-392-3438

www.intrav.com

Dr. Guibor examines a polar bear skin (Ursus maritimus)drying in the Arctic summer sun on the rocky beach at LittleDiomede, Alaska. Villagers explained that a hunting party had

found the polar bear trapped on the island when the northernice pack moved out early, perhaps due to global warming.



injuries received in combat or training. Medical care is complicated bthe fact that military operations are frequently conducted in austeenvironments. Tere are almost always limits in personnel, equipmenand transportation, which sometimes make managing routine patienfar more challenging. If there were ever a “classic” example of wildernemedicine, it can be seen in the care of a Marine Corps small unoperating in the field.

2nd Battalion of the 1st

Marine Regiment

TRAINING OPERATIONS

Fred Trayers, LT MC USN2nd Battalion, 1st Marines

Assistant Battalion Surgeon

An M1A1 Abrams tank fires it s main gun.

With the Marines Awesome…absolutely awesome. Tere’s no other way to describe theraw power of the 120mm smoothbore cannon of an M1A1 AbramsMain Battle ank. I stood 10 feet behind this steel monstrosity when itsmain gun roared again. Despite wearing a flak jacket with armor plates,Kevlar helmet and ear protection, the shock wave almost knocked me offmy feet with its massive overpressure, and I was engulfed in a cloud ofdust and smoke. Tis was hardly what I expected to be doing 6 monthsafter completing my internship!

Serving with the United States Marine Corps as a physician is a uniqueexperience. Te Marine Corps falls under the Department of the Navy,

which provides the Marines with their medical support. Tis includesall levels of healthcare providers from physicians to Hospital Corpsmen,

who are equivalent to U.S. Army Medics. Te career path of a Navyphysician is different than that of a civilian counterpart. After graduation

from medical school, Navy physicians complete an internship in theusual fashion. However, following internship, most Navy physicians willbe assigned as “General Medical Officers” for 2 to 3 years, providingmedical support directly to the fleet. Tis “GMO tour” as it is called,may be as a Flight Surgeon, Undersea Medical Officer, ship’s doctor, orit could be with the Marines.

Te medical issues for a Marine infantry battalion are interesting, to saythe least. Te patient population consists mostly of young men who arein generally excellent health. Tere are two general categories of medicalproblems: Te majority consists of preventive medicine issues, minorinjuries, and acute illnesses: the types of things that would be seen at alocal acute care clinic. Te second category consists of wounds or other

Photos by Fred raye

Te 2nd Battalion / 1st Marines Battalion Aid Station(BASP at 29 Palms, California).



For four weeks last spring, the 2nd Battalion of the 1st Marine Regimentconducted training operations in Victorville, California, and theMarine Corps Air-Ground raining Center in 29 Palms, California.Te training operations were crucial in preparing the battalion for itsupcoming deployment to the Western Pacific, and medical training wasan important element to the overall training package.

Victorville is home to the former George Air Force Base. Instead ofcompletely abandoning the facility, however, it has been transformedfor use in Military Operations in Urban errain (MOU) training.Te hundreds of buildings that used to be base housing are perfect totrain Marines to operate in the type of environments that are commonin modern warfare. Te battalion conducted task-specific trainingbefore proceeding to integrated platoon-, company-, and battalion-sized operations. Medical training was specifically addressed. In orderto provide the highest level of intensity and realism, a Hollywoodproduction company was hired to support the training. Special effectstechnicians, makeup artists, and actors are used to create a highly realistictraining simulation for the Marines and Corpsmen.

In our scenario, the Marines were gathered in a parking lot in the centerof the MOU town. Tey are receiving an otherwise unremarkablelecture on basic first aid when a passing Humvee detonates an improvisedexplosive device (IED). A huge but harmless explosion startles everyoneto action. Te Humvee swerves off the road and hits a secondary IED asit comes to rest alongside one of the buildings. When the dust settles, thescreams of our actors can be heard as they call out for help.

Te Marines immediately deploy and move towards the casualties. Teyset security and establish a defensive perimeter. Te buildings are clearedto ensure no hostile forces lie in wait to inflict further casualties on ourforces. Simultaneously, under the direction of the Navy Corpsmen, theMarines tend to the grievous wounds of the victims. Te Hollywoodmakeup effects are gory, with eviscerated bowels, mangled bones, andshredded tissue bathed in large quantities of bright red “blood.” oachieve the highest level of realism and shock, many of the actors areamputees. Imagine the look of surprise and horror when a Marine opensthe Humvee door to find the victim splattered in blood and sees twobloody stumps where the legs should be!

Te basic level of medicaltraining for the Marinesi s ca l led “Combat

Lifesavers” which followsthe Prehospital raumaLife Support (PHLS)guidelines. A militaryspecific version of theseguidelines have been

1. Return fire /take cover

2. Direct/expect

casualty to remainengaged as combatant,if appropriate

3. Direct casualty tomove to cover/applyself-aid if able

4. Try to keep casualtyfrom sustainingadditional wounds

BASIC MANAGEMENT PLAN FOR CARE UNDER FIRE:

5. Massive Hemorrhage:Stop life-threatening externalhemorrhage if tactically feasible

6. Airway Management: Position changes,airway adjunct or cricothyroidotomy

7. Respirations: Consider tensionpneumothorax and decompress if required

8. Circulation: Assess for unrecognizedhemorrhage and control

9. Hypothermia: Minimize casualty’sexposure to elements / maintainprotective gear if feasible

Marines applytourniquets

and give first-aid to asimulated

casualty.

An actor/amputeeawaits the arrivalof Combat Lifesavertrained Marinesafter a simulatedIED blast.(Photo by Daniel DeAndrade)

Marines andCorpsmen tendto the chestwound and armamputation of thesimulated casualty.

After a simuluated IED blast, an actress/double amputeeis found ejected from a Humvee.



developed, which differs slightly from traditional civilianprotocols. Te most notable difference is that medicalcare is only provided if it is tactically feasible to do so.In a combat environment, accomplishing the missionand avoiding additional casualties are of the utmostimportance. Another interesting difference is that thetraditional ABCDs of trauma care are modified slightlythrough use of the acronym MARCH, which stands forMassive hemorrhage, Airway, Respirations, Circulation,

and Hypothermia. Tis sequence of trauma life supportis tailored to suit the more commonly seen mechanismsof injury and environmental circumstances of combat.

Te most dangerous and challenging aspects ofproviding medical care to the Marines falls on theshoulders of the U.S. Navy Corpsmen. Corpsmen areenlisted sailors who work in all areas of Navy medicine,in many different roles. Among the Marines, however,Corpsmen have a special role in that they are assigned

directly to combat units. Tis means that in addition to their medicalresponsibilities, Corpsmen will face the same tremendous challenges astheir Marines during training and combat. Initial Corpsman training isroughly equivalent to that of an EM-Basic curriculum. Corpsmen are

frequently called upon to do far more, and will address the daily routinemedical problems of their Marines, as well as be the primary medicalprovider during combat operations. On an almost daily basis, I amhumbled by the ability and courage of these Corpsmen, many of whom

wear Purple Hearts and other awards for valor, which they have earnedby caring for their Marines under the most horrifying circumstances.

Military medicine is unique but extremely rewarding. Te sacrificesmade by the young men and women who serve in the armed forces areinspiring, and it has been a privilege to take care the medical needs ofthese individuals and their families.

Recommended Reading1. National Association of Emergency Medical echnicians.PHLS Prehospital rauma Life Support: Military Version (6th Ed.).Philadelphia, P:Mosby; 2007.

2.Yevich S, et al. S pecial Operations Forces Medical Handbook. Jackson, WY:eton NewMedia; 2001.

3. Peters JM, Fansler JR. Not On My Watch: Te 21st Century Combat Medic. Bloomington, IN:Authorhouse; 2007

4. Bradley J. Flags of Our Fathers. New York, NY:Random House; 2006.

L rayers is a Battalion Medical Officer with 2nd Battalion, 1st Marines. After this to

of duty, he plans to apply for continued residency training in Emergency Medicine at Nav

Medical Center, San Diego.

Corpsmen: (L to R) HM3 Sean Phinney, HM3 JuanGalarza, HN Daniel Lee, and HM3 Joshua Salyer.



+ MEMBER PROFILES Sam Schimelpfenig, MD

Graeme Walker is at the endof his post-graduate training forgeneral practice/family medicinein Scotland. He developed aninterest in wilderness medicine

while at medical school, and hisattendance at the 1999 WMS WorldCongress in Whistler had a majorinfluence on his subsequent careerdevelopment. Since medical school,he has been fortunate to have beenable to combine his medical career

with regular freelance work as an

expedition leader in a variety ofcountries around the world, and thisyear he stepped foot on his seventhcontinent while working as ship’sdoctor on a cruise to Antarctica.He continues his active interest in

wilderness medicine while at homein the highlands of Scotland, as avolunteer member of DundonnellMountain Rescue eam.

A member of the Wilderness Medical Society since2002, Dr. Vidal Haddad Jr., has been activelyinvolved in research on aquatic animals andtoxicology for several years. He completed medicalschool in Brazil in 1983 and afterwards specialized

in dermatology. He also obtained a PhD from theFederal University of Sao Paulo in Brazil. He is amember of the Brazilian Society of Dermatology

where he serves as a peer reviewer for the official journal of the society, as well as a member of theBrazilian Society of oxicology. He has servedas the chairman of several aquatic dermatologysymposiums and has received numerous awards forhis research in the field of aquatic dermatology. Heis the author of several books on Brazilian aquaticand poisonous animals and maintains a websitededicated to the treatment of venomous Brazilianaquatic animals.

Dr. William Karesh is a veterinarian whodirects the Field Veterinary Program of the WildlifeConservation Society. Tis program serves to fill theneed for health-related services and technical advicefor field biologists, conservation organizations,and government agencies around the world. Dr.Karesh has also served as the Director of WildlifeConservation at the Woodland Park Zoo in Seattle,and as veterinarian at the San Diego Zoo and the

Wild Animal Park in California. His main interest ison the practical problems raised by the interactionsof people and wildlife. Dr. Karesh is the author ofthe critically acclaimed book Appointments at the Endof World: Memoirs of a Wildlife Veterinarian (WarnerBooks, 1999, 2006). Wilderness Medicine magazinefeatured his article on gorillas in the Congo (Vol21:3; 20-22, located on the web at http://www.wms.org/pubs/newsletter.html).

Sheryl Olson, RN, currently works as a flight nurse in Colorado.She grew up in Wyoming, which fostered her interest in the greatoutdoors. Later, she began teaching skills in winter emergency care

while working with the Ski Patrol in Breckenridge, Colorado andhas continued to teach since then. She has been actively involvedin teaching EM courses, CPR and ACLS courses, and also atannual WMS conferences covering helicopter rescue and evacuation,

wilderness improvisation skills, and children’s courses on survival,navigation, and first aid. Her current project involves organizing a

Wilderness Medicine Adventure Course in ibet and China in thesummer of 2007.



To the Ends of the Earth:Adventures of anExpedition PhotographerGordon Wiltsie

W.W. Norton, New York , 2006Clothbound, 224 pages, $35 USISBN-13:978-0-393-06028-7

Gordon Wiltsie is considered one ofthe world’s preeminent “expeditionphotographers,” a term he prefers

to “adventure photographer.” In o the Ends of the Earth, the readeris treated to Gordon’s talents in every conceivable way – both artistic

with his photography, and literary with the prose that accompaniesthe images.

Te photographs tell stories, so they are not always spectacular posterimages suitable for reproduction and hanging on a wall of art. Rather,they represent the action, support the stories, and guide one throughthe tales of adventure. I am largely in favor of this method, becauserather than being enticed to quickly flip through the book and become

Te gourmet—Vienna’s Heurigers, Singapore’s street food—and thdrinker—whisky distilleries and wineries. Even the party-goer—RioCarneval, New Orleans’s Mardi Gras. And, not to be left out, thfisherman—Li River, Nuku’alofa—and the wildlife observer—polbear safari, Masai Mara migration. Te scuba diver—Roatan, Ya

And the outré —Count Dracula’s castle, Amsterdam’s Red Light Distric And, yes, wilderness adventurer—bicycling, climbing, caving, bung jumping, elephant riding! And 962 more.

Covering every continent, 1,000 Places . . . includes the obvious (thParthenon, Panama Canal) and not-so-obvious (Costa Rica’s Manu

Antonio National Park). Special indexes will guide you to ten areas particular interest including “Glories of Nature” (Sun Yat-Sen Classic

Chinese Garden, Great Barrier Reef) or ultra-pricey “Great Hotels anResorts” (Raffles, Sweden’s Ice Hotel). And 955 more.

Its 974 pages add over 2 pounds to your backpack, so unless you’re doinall 1,000 in one marathon adventure, copy selected logistic details tocoupla pages and leave the tome at home.

Ballooning over Albuquerque, cruising the Nile. . . .

Reviewed by Yvonne Lanelli, Alto, New Mexico

1,000 PLACES TO SEE BEFORE YOU DIE: A Traveler’s Life ListPatricia Schultz

Workman Publishing, New York, 2003Softcover, 974 pages,$18.95 US, $28.95 CANISBN-10-:0-7611-0484-4

Moonlight caressing the aj Mahal.rekking Machu Pichu. Exploring Anasaziruins at Canyon de Chelly. Welcoming the

New Year in imes Square or the summer solstice in Stonehenge.

Sharpen your pencil and start marking off 1,000 Places to See BeforeYou Die. Patricia Shultz’s New York imes bestselling Life List challengestravelers, real and armchair. Tere is something for literally everyone.Te historian—medieval castles, Tanksgiving at Plymouth Plantation.Te literary—Stratford-upon-Avon. Te art lover—Louvre, Moscow’ssubway system. Not to mention the religious pilgrim—Christmas inBethlehem, Omayyad Mosque. Also the shopper—Dubai’s Gold Souk.Te golfer—St. Andrews—and skier—New Zealand’s Alps, Utah’s

Wasatch. Oh, yes, and the war buff—Normandy’s D-Day beaches.

breathless in wonder of monumental portraiture, the reader must moback and forth from words to photos, to understand how the threahave been woven into tales. Tis is a book to be read over a period

weeks, or even months, because you will find yourself expending a bit emotional energy in the process.

It is skewed towards cold environments, like the Arctic Ocean, beginninand ending that way, but in his accounting of an expedition to Per

Wiltsie hints that there can be gratification in staying warm. I am fearfthat the sub-zero places he might take me would be too hard on thaging adventurer. However, with someone as talented and extraordina

as Gordon Wiltsie allowing me to stay in an armchair and soak in thexperience, I feel much better about the future.

If you appreciate the wilderness and wish to inspire yourself to becommore adventurous, or just understand the motivations and trials those who have already committed themselves to expeditions into th

wild, this is a book that you should read, and have your children reas well. Gordon Wiltsie has created a wonderful book, and I highrecommend it.

Reviewed by Paul S. Auerbach, MD, Los Altos, California



In 1965, a young couple from California became “landedimmigrants” and traveled to Bella Coola, British Columbia, tolive in a small community surrounded by the vast wildernessof the Chilcotin Plateau. Tis book is the account of living in a

community similar to a hundred years ago, with kerosene lights, wood heat, and home-made entertainment. Although they lived in a small town and had the advantages of a store,a vehicle, and nearby relatives, the influence of the wilderness around them was intense.Tey stayed for about two years, had two children, then decided that they could not raise afamily there and returned to California.

Te stories are charming and also vividly describe bear encounters in yards and along

streams as well as the injuries common among loggers and workers in fish canneries. Tereis a special account of women’s experiences of “cabin fever,” feeling isolated and apart fromsupport of family and friends in the winter, with limited understanding from the men intheir lives. Interestingly, it was not unusual for women to check into the local hospital for acouple of weeks to get a break from household responsibilities when this happened.

Tis book is not like the heavy accounts of Canadian wilderness travel in A Death in theBarrens or Going Inside, both of which describe long canoe voyages. It is, however, a funread, especially for those who imagine living more simply in a wilder place.

Reviewed by Susan Snider, MD, Spruce Pine, North Carolina

For 46 days, Mike Pewtherer and Mark Elbroch lived off the

land—facing the day-to-day struggle of meeting their body’sneed for warmth, water, and food. o do this, they improviseda myriad of tools and containers, slept in leaf insulated shelters,drank untreated water, and killed a variety of animals with sticksand stones. Teir book, Wilderness Survival, captures the reality

of their journey as they challenge learned wilderness living skills in a long-term setting.

Wilderness Survival is actually two books in one: Mike Pewtherer’s essays on basic survivalskills interlaced with Mark Elbroch’s diary of their 46-day adventure. I was able to readMark’s story without technical jargon bogging things down and yet when needed, I couldrefer to Mike’s essays for clarity on skills Mark mentioned. I found this to be a breath offresh air!

Although writings on wilderness living skills are always of interest, the candor found in

Mark’s diary is what captured my attention. His words relay a harsh reality that contrasts with a modern adventurer’s fantasy. Te text is filled with stories of unrelenting mosquitoes,rain, hypothermia, diarrhea, yearning for familiar meals and sweets, and a rollercoaster ofemotions including a heartrending cry after killing a young deer. I encourage you to pickup a copy and share the adventure.

Reviewed by Paul Greg Davenport, Stevenson, Washington

Wilderness Survival: Living off the Land with theClothes on Your Back and the Knife on Your BeltMark Elbroch and Mike PewthererRagged Mountain Press, Camden, ME, 2006Softcover, 288 pages, $15.95 USISBN: 0-07-145331-8

Voyagers of the ChilcotinCarolyn FoltzBooksurge Publishing, Charleston, SC, 2007

Softcover, 214 page, $14.95 USISBN 0-9650963-0-0



Search and Rescue on Mt. Hood

hese images are froWM ’s Editor Dr. Vailburg’s collect ioof the search. For detai led account the 10-day miss ionread Mountain RescDoctor, forthcomin

from St. Martins Prein November 2007.

December 7, 2006 three climbers left il Jane railhead to ascent the rugged, remoNorth Face Gully on Oregon’s Mt. Hoo

Te next day, one of the largest and most intense storms of thdecade, one that would later leave 1.5 million people withopower, hit Oregon’s highest peak. Te Hood River Crag Ra

are the mountain rescue team that initially responded to thdistress call on December 10 and coordinated one of thlargest searches in many years, one that would gain headlinnews as far away as Australia.

Photos by Christopher Vanilburg



Te nation, and many parts of the rest of the world, watched the Mt.Hood search in December 2006 unfold. We all were disheartened withthe end of the story. At Wilderness Medicine we felt we should clarifya common question that appeared in the lay media: why didn’t theseclimbers have a rescue beacon? We asked experts to clarify the differencesamong the commonly used location devices: personal locator beacons,avalanche transceivers, the RECCO system, and the Oregon-specific

Mt. Hood Locator. While technically not a locator search, two high-profile searches in Oregon, the Kim search in the Oregon Coast Range inNovember and the Mt. Hood search in December, both used computertechnology to determine which cell phone towers their cell phones werecommunicating with, thus narrowing the search. We asked search andrescue experts to explain the different devices.

Keep in mind, no device is foolproof: batteries die, electronics fail if theyget dropped or wet, and sometimes we just forget how to operate them,the user manuals can be a thick as a novel. Also, these devices requireproper training, routine practice, and plenty of experience. Nothing, ofcourse, substitutes for common sense and good judgment. Ed.

P e rsona l L oca tor B eacons Mike McDonald of Douglas County (Colorado) Search and Rescue eam

Personal Locator Beacons (PLB) are distress beacons intended for peopleinvolved in land-based outdoor activities. Tere are similar beacons foraviators and mariners. All three types of beacons transmit radio signalsthat are detected by 12 earth-orbiting satellites.

Te satellites relay the signals to ground stations that process the signalsto determine beacon location and ownership, and alert search and rescue(SAR). Tis is an international program with 63 ground stations locatedin 27 countries. Another 13 countries without ground stations areparticipants in the program.

Beacon location is determined by the frequency shift in the receivedsignal as the satellite passes the beacon (Doppler shift). It takes severalsatellite passes over some time, possibly hours, to get a relatively accuratelocation. o eliminate this problem, some beacons transmit coordinatesfrom an external or internal GPS (Global Positioning System) receiver.Te coordinates are transmitted to the ground stations through thesatellites, so an accurate location is known in the time it takes the system

to process the signals; there are geostationary satellites that “see” an entirehemisphere at once, so this can be a matter of minutes. PLBs sold in theU.S., but not necessarily elsewhere, also transmit a low-power homingsignal so that SAR forces can locate the beacon once they reach thesatellite provided location.

Each beacon transmits a unique identifier. If the beacon is registered withthe proper authority (National Oceanic and Atmospheric Administration,NOAA, in the U.S.) the ground station computers match the identifier

with the registration database. A report is generated with the beaconowner’s contact information, emergency contact information, and,of course, location. SAR then begins attempting contact. If a beacondetected in one country has an identifier belonging to another, thesecond country is automatically contacted so the registration databasecan be queried. If the beacon is unregistered, the report contains only thecountry code, location, and beacon information.

Te registration system in the U.S. is accessed via the internet, so abeacon owner can update contact information as often as necessary.Te form has space for comments and some users input trip itineraries.

Although U.S. law requires PLBs to be registered, many are not. For aPLB to provide the maximum benefit it needs to be registered.

As with any tool, there are caveats for PLB usage. Unlike beaconsfor aviation and maritime use that can be automatically activated ina crash or sinking, PLBs require three separate manual operations to



Avalanch e Transc e i v e rsDale Atkins, Colorado Avalanche Center

Avalanche rescue transceivers are the best tool for companions tolocate a buried friend. Costing typically between $300 and $400+,the transceivers are strongly recommended for all who play and workin avalanche terrain. Strapped to the torso and usually worn under the

outer-most layer of clothing the transceiver is a small electromagneticinduction device (about the size of one’s hand) that transmits a constantsignal when turned on. Te device should be turned on at the start of aday’s adventure and then turned off at the end of the day. When a memberof the group is buried in an avalanche, all remaining companions switchtheir devices to “receive” and begin to search for the signal. Once thesignal is detected the searcher can hone in on the signal by following theflux lines of the sending unit’s magnetic field. Te last few meters aresearched in a grid-style pattern with the final pinpointing done with acollapsible probe pole (like a tent pole) or ski pole.

Te first transceiver, the Skadi, became available in 1968 and was thoughtto be a tool for professionals, such as ski patrollers, snow rangers, andplow drivers, but not for the general public. Tese first devices like all of

today’s avalanche rescue transceivers work on the principle of a simpletransformer. Te sending unit creates a magnetic field that is producedby an electrical current pulsed in a coil around a small ferrite rod. Inthe presence of a receiving unit (magnetic coupling) a current is created(induced) in the receiving unit creating a detectable signal. In the early1980s European manufacturers settled upon a standard frequency:457 kHz. Te U.S. adopted this higher frequency—the internationalstandard—in 1996.For over 30 years searchers could only listen to changes in volume asthe signal indicator. In the late 1990s the introduction of “digital”transceivers with multiple receiving antennas greatly improved the ease-of-use. Digital units capture the pulsed signal, transform it to digital data,

interpret the signal information with a microprocessor, and then presethe data visually. Most of today’s transceivers use distance displays andirectional arrows to guide a companion to his buried friend.

Avalanche transceivers in the hands of practiced users, along with a proand shovel, are the best tools to locate a buried companion. Howevedespite their acknowledged superiority as a companion rescue tool, thtransceivers’ success is mediocre. Since the first use of a transceiver find a buried victim in the U.S. in 1974 (through 2006), many movictims have been found dead (98) than alive (65). Te reason is simplmost users are not well practiced to be fast enough to save a life. Lookindeeper into the data offers a glimmer of optimism. Since 2000 whe

digital transceivers began to dominate the market, the mortality rate subjects found by transceiver plunged from 70 percent to 50 percenExperts attribute this statistically significant drop to the improved easof-use with digital transceivers. Even with this dramatic improvement survival, the statistic is also a sobering reminder that using transceivedoes not guarantee survival for the buried avalanche victim.

R ECCO Ken Zafren, Alaska Mountain Rescue Group and WMS

Te RECCO Avalanche Rescue System (Lidingö, Sweden) is a tool this widely used by organized rescue groups worldwide for rapid location buried avalanche victims. RECCO uses a harmonic radar detector to finreflectors that are permanently attached (usually by the manufacturer)

clothing and gear used by skiers, snowboarders, and participants in oth winter sports. Teir use requires no training or other action on the paof the person venturing into avalanche terrain other than using clothinor equipment with reflectors. Te reflectors are inexpensive, don’t ubatteries, and weigh less than 4 grams (about 0.15 ounces). Te use the RECCO system does not interfere with other methods of locatinburied victims, including avalanche transceivers or search dogs. Becauof the high frequency it uses, RECCO allows direct and very accuralocation of the reflectors, minimizing time spent probing to find thexact location of the victim.

Photo courtesy of RECCO Avalanche Rescue System

Photo courtesy of RECCO Avalanche Rescue SystemPhotos by Christopher Vanilburg

be activated. Tis means the user, or someone in the party, must havesufficient mental and physical capabilities to activate the beacon. TePLB needs to be located where it has a reasonably clear view of the sky.For GPS equipped beacons this is even more important because the PLBmust be able to receive GPS signals. PLB users also need to understandthat although the beacon may be detected within minutes of activation,it may take search and rescue many hours to reach the area. Despitethese issues, when properly used, PLBs and their aviation and maritimecounterparts can be truly life-saving devices.



10 ESSENTIALS OF BACKCOUNTRY TRAVEL

RECCO does not replace avalanche transceivers, which are the mosteffective method of finding buried avalanche victims while they are stillalive and can be used by the victim’s own party for rapid location andrescue. However, RECCO provides a complementary method for findingthe victims in a timely manner once organized rescue arrives on the scene.

With the increasing use of cell phones to notify rescue organizations andthe increasing availability of snow machines and helicopters, RECCOhas increasing potential to find live avalanche victims. A large portionof backcountry activity takes place close to developed ski areas, where

the RECCO detectors are available and from where they can be rapidlybrought to an avalanche site. Te current generation RECCO detector weighs 1.6 kg (3.5 lbs) and is very portable. Te detector can be usedeasily from a helicopter or by a rescuer on foot. Te system’s range is over200 meters through air and 20 meters through snow. In North America,the RECCO system is used by over 100 ski resorts, helicopter skiingoperations, and mountain rescue groups. Te RECCO Avalanche RescueSystem website (recco.com) has more information about the RECCOSystem as well as a very useful introduction to avalanche safety.

Mounta i n L ocator Un i tRocky Henderson, Portland (OR) Mountain Rescue

Te Mountain Locator Unit is a solution to a particular problem. In

1986, the Oregon Episcopal School tragedy on Mt. Hood inspireda tremendous amount of energy toward preventing such an accidentagain. Nine people lost their lives partly because rescue teams could notfind their snow cave in time. Te solution that was selected was an

adaptation of wildlife tracking technology. In order to implementthe system, a special law exempting the manufacturer from tort liabilityhad to be passed in the Oregon legislature. Due to FCC and otherregulatory challenges the MLU is only available and legal to be usedon Mt. Hood.

Te system consists of transmitters that are rented to climbers andsensitive directional receivers used by search teams. You cannot buy anMLU. Local climbing shops and a motel at Government Camp rent

them for $5 per weekend. Te climber is instructed on how to activatethem in case of an emergency. Te important thing to remember aboutMLU’s is that when they are activated no one is listening. Tey send apulsing radio signal on the VHF band. Upon notification that you aremissing and that you have an MLU, searchers are able to pinpoint yourlocation in extreme mountain weather and environment. Te transmitterhas a sealed-in battery that will keep transmitting for literally monthsafter activation. Te range the searchers can hear the signal depends onall the factors that affect radio waves such as terrain, body shielding, andantennae position. It has been tested and detected up to 20 miles awayfrom aircraft receivers.

It has proven to be an effective solution to a real problem but is not thesolution to all SAR situations.

C e l l Phones and P ersonal Rad iosHoward Paul, Mountain Rescue Association

A cellular phone can save enormous time in reporting an emergency.However, do not depend upon a cell phone by itself—batteries die,coverage frequently is intermittent or nonexistent, and you are still

without help. You must be prepared to recognize, prevent and deal withbackcountry emergencies without a cellular phone or a radio. Know first-aid, how to use a map and compass; understand weather and its danger;carry the “10 Essentials” of backcountry travel.

1. Extra food & water

2. Extra clothing

3. Map

4. Compass

5. Flashlight + extra

batteries & bulb

6. Sunglasses & sunscreen

7. Matches in a waterproof container

8. Fire starter or candle

9. Pocket knife or utility tool

10. First-aid kit

Photo by Christopher Vanilburg



WMS BOARD MEMBER JOB DESCRIPTION

H Define and pursue the mission of the WMS and safeguard the values of the organization.

H Select, monitor, support, evaluate and compensate the Executive Director.

H Establish long-term direction through oversight of and participation in strategic planning.

H Promote financial viability through budget and financial oversight, fund developmentand investment management.

H Maintain and continuously improve the services of the WMS.

H Monitor the effectiveness of significant organizational programs and take action where appropriateto improve, modify, or eliminate such programs as necessary to maintain excellence.

H Oversee and promote positive relationships with liaison organizations.

H Promote and maintain positive external relationships with the community and other wilderness,healthcare, and environmental organizations.

+ CALL FOR NOMINATIONS TO SERVE ON THE WMS BOARD OF DIRECTORS

Te WMS nominations committee is looking for members interested in stepping up their commitment to the WMS by serving on its Board of DirectoIf you are interested in being considered, please send by email a list of your special qualifications and a written statement itemizing what you feel you cabring to the board and why you should be considered. Deadline for nominations is May 1, 2007, send to [email protected].

H Oversee effective governance, including Board recruitment, selection and orientation,board education, and self-evaluation and effective function and structure.

H Act with the highest integrity to advance the best interests of the WMS and achieve its mission.

H Oversee fundraising and participate in fund development through personal contributions.

H Set policies for the WMS.

H Serve as advisor for the Executive Director

H Bring at least one corporate sponsor to the WMS.

H During his/her term or before taking a seat on the Board, each Board member shouldbecome a life member of the WMS.

H Each Board member is expected to attend (in person or by phone conference) a minimum of50% of annual scheduled Board meetings, and may not be absent from 2 consecutive meetings of the Boar

Internationale Kommission für Alpines Rettungswesen IKAR Commission Internationale

de Sauvetage Alpin CISA International Commission for Alpine Rescue ICAR

ICAR - IKAR - CISA Statement

(Avalanche Rescue, Terrestrial Rescue

and Medical Commissions)

Avalanche Rescue Devices and SystemsKranjska Gora, Slovenia

October 14, 2006

Considering the ongoing development of avalanche safety devices in recent years the above commissions of ICAR–IKAR-CISA

update their statement of 1999 concerning these devices and systems by highlighting the following points:

A. Most people trigger their own avalanche and this can result in death.

The best way not to be caught is to not trigger an avalanche.

If caught, preventing burial is the best way to stay alive. B. The best way to avoid avalanche accidents is prevention, including information (avalanche bulletins),

knowledge, experience, awareness, and caution.

C. If caught, some safety systems/devices may increase one’s chances of survival. Survival depends upon quick rescue.

The efficiency of the transceiver in combination with probe and shovel, and of airbag systems has been proven.

At this time support for other systems is based upon personal opinion and case reports.

However, no device or system guarantees against either injuries to or death of avalanche victims.

D. All rescue systems require training and practice.

E. For organized rescue early notification is essential, e.g., by mobile phone, satellite phone, or radio — wherever possible.

F. To be equipped with a transceiver or at least a transponder, e.g., the RECCO system, renders organized rescue more efficient



The use of probotcs,whch are benecal bactera

and yeasts, datesback thousands of years.

raveler’s diarrhea is common in visitors to tropical areas and duringexpeditions to wilderness locations. It is inconvenient and sometimes

uncomfortable, with abdominal pain, dizziness, and nausea. Whileantibiotics are often used to treat some kinds of traveler’s diarrhea, thereare other time-honored options. In deciding the best treatment, severalissues need to be considered.

Some of the gastrointestinal illnesses (GI), like E. coli, can be made worse with antibiotics. Killing the bacteria can sometimes cause releaseof large amounts of the Shiga toxin. Antibiotics also wipe out the GItract’s “good bugs” along with the bad. Without the beneficial flora thatnormally live in the GI tract, normal nutritional and immunogenicproducts in your body are not made, and the organisms responsiblefor several illnesses can proliferate. An example is antibiotic-associatedClostridium difficile (C. difficile ) colitis, an infection of the colon thatoccurs primarily among patients exposed to antibiotics. More than three

million C. difficile infections occur in hospitals in the U.S. each year. Itis estimated that 20,000 C. difficile infections now occur each year in theU.S. outside the hospital. Antidiarrheal medicines, such as loperamide, sometimes help, but insome situations are not recommended for particular infectious sourcesof diarrhea, because they may keep infectious bacteria in contact withthe gastrointestinal tract for longer periods of time. For example, someauthorities recommend loperamide for non-invasive bacterial infections(generally marked by no fever and no blood), but withholding loperamidefor invasive bacterial infections (generally marked by fever and bloodin stool).

Antacids and proton pump inhibitors (PPIs), drugs to reduce acidproduction in the GI tract and to treat ulcers and reflux, can also allow

ingested infectious organisms to grow in your stomach. Stomach acid isnecessary to kill unhealthy germs and food-borne infection. A known riskfactor for gastroenteritis is using PPIs like Nexium, Prilosec, Prevacid,Zoton, Inhibitol, and others.1-3

Long-term PPI-induced acid suppression in conjunction withHelicobacter pylori (H. pylori ) colonization may promote developmentof atrophic gastritis, a well-accepted step in the progression togastric cancer. 4

Use of PPIs add to the confusion in making the differential diagnosis,as side effects of PPIs may include diarrhea, abdominal pain, andnausea. Diarrhea is also a side effect of antibiotics, which may havebeen prescribed prophylactically to prevent traveler’s diarrhea. It is easy

to confuse these symptoms for a infectious mechanism, and then addmedicines that further the cycle of problems. What are some possiblealternative treatments?

A New Look at Old Wlderness Medcne for Traveler’s DarrheaJolie Bookspan, PhD

P h o t o b y J o n n a B a r r y

FiTto be WiLD:



Photo by Rhonda Mart

WILDERNESS MEDICINE // Spring 2007

Tme-Honored MedcneOne effective remedy for traveler’s diarrhea, historically used in manysocieties, is eating fermented food. Te use of “probiotics,” which arebeneficial bacteria and yeasts, dates back thousands of years. People inancient civilizations, from Mongolian nomads to Babylonian royalty,drank soured milk, and Asiatics ate fermented beans and vegetablesto stop gastrointestinal illness. Russian and Mongolian military troopscampaigning across vast distances ate sauerkraut, which is fermentedcabbage, for scurvy prevention and against diarrhea. Sauerkraut is aversion of kimchi, Korean fermented cabbage that was brought to theeutonics with the Mongols and other wandering tribesmen who hadcontact with the Orient. Modern ConfrmatonTe Lancet recently published a study by researchers from Johns HopkinsUniversity who concluded that probiotics effectively treat acute diarrheaand antibiotic-associated diarrhea in adults and children. Several probiotic

strains were evaluated, including Saccharomyces boulardii, Lactobacillusrhamnosus GG, Lactobacillus acidophilus, Lactobacillus bulgaricus, andothers. Te researchers urged eating probiotic-containing food whentraveling, especially internationally.5 Other major studies support thatprobiotics prevent and reduce duration of acute diarrhea in adults andchildren. 6,7

Germ inhbtng FoodsCabbage may be an accepted antibacterial for stomach ulcers, nowknown associated with the gastrointestinal bacteria H. pylori. Clinicaltrials indicate that some types of probiotics also help control severaldiseases, such as ulcerative colitis, reflux, and irritable bowel.8

Many foods have been long usedagainst fungal + worm infestations

Fermented vegetables like kimchi are nutritious in themselves, plproduce nutrients that beneficial lactobacteria need to thrive and produantibacterial action. wo top foods for promoting beneficial bacteria aninhibiting unhealthy bacteria are cabbage and onions. Broccoli sprouhave been found to specifically reduce H. pylori. Seasoning food wiraw crushed garlic and fresh ginger root may inhibit strains of H. pyloE. coli, Staphylococcus, and Streptococcus, without harming beneficidigestive bacteria.

Several spices have bacteria-inhibiting properties: garlic, allspice, anoregano have been found to have action against “bad” bacteria, followby thyme, cinnamon, tarragon, and cumin. Capsicum, such as chiliand other hot peppers, have moderate antimicrobial action. White anblack pepper, ginger, anise seed, celery seed, and lemon and lime juifollow. Researchers at the University of Kansas found that garlic, clovecinnamon, oregano, and sage kill E. coli.9-12 Research in Mexico h

found the spice oregano to be more effective than prescription druagainst Giardia.13,14

In addition to antibacterial properties, many foods have been long useagainst fungal and worm infestations. Te World Health Organizatiorecommends crushed garlic, curry, and cloves for their specific ant

worm properties, confirmed in studies15, and the anti-worm propertiof coconut.16,17



References:

1. Cunningham R, Dale B, Undy B, Gaunt

N. Proton pump inhibitors as a risk factor for

Clostridium difficile diarrhoea. J Hosp Infect.

2003 Jul;54(3):243-5.

2. Dial S, Delaney JA, Barkun AN, Suissa

S. Use of gastric acid-suppressive agents and

the risk of community-acquired Clostridium

difficile-associated disease. JAMA . 2005 Dec

21;294(23):2989-95.

3. Canani RB, Cirillo P, Roggero P, Romano C,

Malamisura B, errin G, Passariello A,

Manguso F, Morelli L, Guarino A. Terapy

with gastric acidity inhibitors increases

the risk of acute gastroenteritis and

community-acquired pneumonia in children.

Pediatrics. 2006 May;117(5):e817-20.)

4. Peek RM. Helicobacter pylori and

Gastroesophageal Reflux Disease. Curr reat

Options Gastroenterol. 2004 Feb;7(1):59-70.

5. S. Sazawal, G. Hiremath, U. Dhingra, P.

Malik, S. Deb, R. Black. Efficacy of probiotics in

prevention of acute diarrhoea: a meta-analysis of

masked, randomised and placebo-controlled trials.

Lancet Infect Diseases. 2006;6:374-382.

6. Sur D, Bhattacharya SK. Acute diarrhoealdiseases—an approach to management. J Indian

Med Assoc. 2006 May;104(5):220-3.

7. Yan F, Polk DB. Probiotics as functional food

in the treatment of diarrhea. Curr Opin Clin

Nutr Metab Care. 2006 Nov;9(6):717-21.

8. Chande N, McDonald JW, MacDonald JK.

Interventions for treating collagenous colitis.

Cochrane Database Syst Rev. 2006 Oct 18;(4):

CD003575.

9. akikawa A, Abe K, Yamamoto M,

Ishimaru S, Yasui M, Okubo Y, Yokoigawa

K. Antimicrobial activity of nutmeg against

Escherichia coli O157. J Biosci Bioeng.

2002;94(4):315-20.

10. Burt SA, Reinders RD. Antibacterial

activity of selected plant essential oils against

Escherichia coli O157:H7. Lett Appl Microbiol.

2003;36(3):162-7.

11. Elgayyar M, Draughon FA, Golden DA,

Mount JR. Antimicrobial activity of essential

oils from plants against selected pathogenic and

saprophytic microorganisms. J Food Prot. 2001

Jul;64(7):1019-24.

12. De M, Krishna De A, Banerjee AB.

Antimicrobial screening of some Indian spices.

Phytother Res. 1999 Nov;13(7):616-8.

13. Ponce-Macotela M, Rufino-Gonzalez

Y, Gonzalez-Maciel A, Reynoso-Robles R,

Martinez-Gordillo MN. Oregano (Lippia

spp.) kills Giardia intestinalis trophozoites in

vitro: antigiardiasic activity and ultrastructural

damage. Parasitol Res. 2006 May;98(6):557-60.

Epub 2006 Jan 20.

14. Ponce-Macotela M, Navarro-Alegria I,

Martinez-Gordillo MN, Alvarez-Chacon R. In

vitro effect against Giardia of 14 plant extracts.

Rev Invest Clin. 1994 Sep-Oct;46(5):343-7.

15. Soffar SA, Mokhtar GM. Evaluation of the

antiparasitic effect of aqueous garlic (Allium

sativum) extract in hymenolepiasis nana

and giardiasis. J Egypt Soc Parasitol. 1991

Aug;21(2):497-502.

16. Giove Nakazawa RA. raditional medicine

in the treatment of enteroparasitosis.

Rev Gastroenterol Peru. 1996 Sep-

Dec;16(3):197-202.

17. Chowhan GS, Joshi KR, Bhatnagar HN,

Khangarot D. reatment of tapeworm infestation

by coconut (Co-cos-nucifera) preparations.

J Assoc Physicians India. 1985 Mar;33(3):207-9.

In Russia, a lacto-fermented beverage called kvass has long been madefrom old rye bread. It tastes like beer but is not alcoholic and can bepurchased in modern supermarkets packaged just like soda. Kvass wasused by peasants, military, and even the Czars. Another kvass made frombeets was made during war times and taken during travel to protectagainst infections. Ancient Iraqis and Egyptians made similar drinks frombread. Fungus-fermented teas have long been used throughout Russia,China, Japan, Poland, Bulgaria, Germany, and Southeast Asia (calledchainyi grib in Russia, kombucha in Asia, and elsewhere as teeschwamm

or teewass, wunderpilz, cajnij, fungus japonicus, and hongo, whichmeans “mushroom”). Australian aborigines lacto-fermented grains andlegumes to make a bubbly, sour drink that modern Australians call“wholegrain.” South American Native Indians fermented several drinksthey say prevent digestive problems including diarrhea. In Africa, lacto-fermented munkoyo was made from millet or sorghum (sorghum beer)and given to babies to stop infection and diarrhea. Missionaries (andothers) suppressed munkoyo in favor of commercial soft drinks. What To Do – Smple and inexpensve FoodFor serious cases, seek medical attention to determine the pathogenand proper course of treatment. Most of the time, traveler’s stomach isnot a medical emergency. Several things may lessen, prevent, andalleviate outbreaks.

Instead of soda, try kvass. Instead of antacids and antibiotics for traveler’sstomach pain, it is healthier and often as effective or more effectiveto use cabbage, cabbage juice, and fresh sauerkraut. ry apple cidervinegar diluted in a little water. Squeeze lemons and limes on fruit andvegetables, and add to drinks and blender shakes. Add balsamic vinegarto salads. Soothe an uncomfortable stomach with fresh ginger. For thegas of traveler’s stomach, season food with cardamom, coriander, fennel,or cumin. For traveler’s diarrhea, try kimchi, tempeh, and sauerkraut.

Eat fermented vegetables like fresh pickle (fermented, not vinegarcucumbers), sauerkraut (fermented cabbage), fermented chutney,tempeh, oncham, and kimchi. Season with spices like garlic andcurry. Look for fermented food with live cultures. Many products kill

the cultures through heating, processing, and packaging. Use fresh-made sauerkraut, not pasteurized or canned. Te packaging processdeliberately removes helpful nutrients and living cultures createdthrough fermentation so that the lids don’t blow off. Tere are “quick”sauerkrauts made with vinegar; the vinegar is fermented, but the cabbageisn’t. o get real fermented cabbage, check the label for sauerkraut madefrom cabbage, water, and salt, with no vinegar. Although “probiotics” areoften expensively packaged in supplements, you can have the benefitsfrom inexpensive simple foods.

What To Do – Smple and inexpensve ContanersDishwashing techniques in hiking camps and expedition kitchenshave been found to be a cause of many cases of wilderness and high-altitude gastroenteritis.

One time-honored method is not to use dishes. Find or bring large leaveslike banana, spinach, grape leaves, chards, and other greens to wrapfoods for cooking, and use for sturdy plates and napkins. Te leavespack lighter and flatter than dishes. Make pronged vegetable roasters

from long, narrow stems and branches. Cut lengths into simple spoons,spatulas, and chopsticks. Return them to the earth when finished. Don’tdestroy living trees, and keep your impact low. It’s healthier for you andthe wilderness. Old Ways Are NewPeople go to the wilderness to get back to nature, then often eat nogreens or healthy foods, add to litter with disposable containers, lug pilesof dishware, and add bleach into the environment from disinfectingdishwashing technique. Fermented food is health food for you, for theenvironment, and portable convenience food. Use healthy foods for asimpler life and better health.

Dr. Bookspan and her husband live half of each year in Southeast Asia and have previously lived

in Mexico, eating and drinking local food and water, successf ully using these techniques. More on

fermented food and healthy nutrit ion for home and t ravel can be found in Dr. Bookspan’s new

book Healthy Martial Arts ( www.DrBookspan.com/books).

Photo by David Barry



altitude on the nervous system, emphasizing his research on oxidatistress and oxygen free radicals. Dr. Marco Maggiorini from Zurictalked about the effect of hypoxia on the central nervous system fromclinical point of view.

Since almost nobody in Argentina would dream of eating dinner befo9 PM, our schedule seemed quite relaxed. Te only problem was that osleep. In a previous era, everyone took a siesta, but now they still eat laand get up at what we would consider a normal hour. Te first two houof the afternoon session were devoted to work in hostile environmentconditions—altitude and cold—and the effects of solar radiation. Tsession included a talk on medical screening for high altitude workeand a presentation on the effects of EICA and altitude-related illness o

work performance. o a large extent, EICA workers are a self-selectegroup. Tis makes it difficult to do research concerning their fitnesEICA workers who cannot tolerate this exposure do not continue

work. At the same time, there is great concern about the long-terhealth effects of EICA.

Te final session concerned psychosocial health of high altitude workeropics included living standards and quality of life at high altitudmining camps, recreation for workers at remote sites, effects of EICon family life of the workers, and the benefits of physical activities fEICA workers. Te final talk concerned the effects of work rotations othe quality of life of the workers. Te speaker was Dr. Acacia Aguirre,Spanish doctor who lives in Boston.

Te next day of the Congress began with a session devoted to altitudDr. Bailey spoke first about the pathophysiology of Acute MountaSickness (AMS) and High Altitude Cerebral Edema (HACE). DBailey discussed the deleterious effects of oxygen free radicals in hypoxi

Attempts to use sacrificial antioxidants such as Vitamin C have be

unsuccessful, since these turn out to be quenched by free radicals. DBailey suggested a new approach using antioxidant catalysts.

from an airplane approaching Santiago and continuing on to Mendoza,Chile, are spectacular. Flying into Santiago from the north provides alook at the high Andes from the west. Aconcagua, the highest mountainin the Western Hemisphere is the pinnacle, but there are many otherpeaks above 6000 meters (about 20,00 feet).

Te Argentina Society of Mountain Medicine (SAMM) invited meback to Argentina, in December 2006, to speak at their 3rd Congress ofMountain Medicine and to help teach the first Basic Mountain MedicineDiploma Course for Doctors to be given in the Americas. Tis course ispart of the curriculum that leads to the Diploma in Mountain Medicineapproved by the Medical Commissions of the UIAA (InternationalFederation of Mountaineering Associations) and ICAR (InternationalCommission for Mountain Rescue). As a member of the ICAR MedicalCommission, I helped design this course.

After landing in Mendoza, the two-hour drive to San Juan took usthrough an arid landscape with little vegetation and ever-more distantviews of the high mountains until we reached the oasis town of San Juan

with its vineyards. Northern Argentina is known for its wine. My friendsfrom San Juan insist that the wine from San Juan is better than thatfrom Mendoza, but my friends from Mendoza hold exactly the oppositeopinion. Although I am no expert, both seemed excellent.

Te first session concerned chronic intermittent altitude exposure (EICAfrom its Spanish name – Exposición Intermittente Crónica a la Altitud).Tis theme is very topical in Argentina and in neighboring Chile,because thousands of people work at high altitude mines but live at ornear sea level. After a welcome by Dr. Carlos Pesce, the chairman of theCongress, Dr. Daniel Jimenez from Santiago, discussed the advantagesand disadvantages of different schedules and the effects of EICA onhypertension, diabetes, and obesity. Dr. Jean-Paul Richalet, from Paris,

who has studied EICA extensively in Chile, discussed the physiologicalchanges associated with intermittent altitude exposure. Dr. ConxitaLeal from Barcelona discussed contraindications to altitude exposure.Te first half of the morning concluded with Dr. Nora Vainstein fromBuenos Aires discussing the approach to cardiac risk factors in workersundergoing EICA. Te general conclusion of these talks was that EICAcan be quite stressful, especially to the cardiovascular system. Many

workers are eliminated during the initial trial period, but the long-term effects on workers who undergo EICA over a period of years isnot known.

Te second part of the morning focused on neurological changes ataltitude. Dr. Damian Bailey from Wales discussed molecular effects of

Mountain Medicine in Argentina– December 2006

Dr. Maggiorini emphasized the possible

role of brain hypoxia in producing HAPE

and discussed the mechanism by which

PDE-5 inhibitors may act in preventing

and treating HAPE.

+ DISPATCHES Part I – The 3rd Congress of the Argentina Society of Mountain Medicine – San Juan, Argentin

Ken Zafren, MD Photos by Ken Zafre

Te views



and a film showing its history followed, of course, by wine tasting. Te

next stop was a champagne manufacturing operation located in a cave, with tasting of the unfinished product, but not the bottled final product. After this, we went to two lakes formed by dams and then to lunch at – Iam not making this up – a Howard Johnson Resort, by the shore of thesecond lake. Fortunately the food was Argentine style. Te last stop of the day, the Sarmiento house, was by far the mostinteresting. Domingo Sarmiento (1811-1888) was a provincial governorand later the President of Argentina, from 1868-1874, and an educator.He had a great interest in elementary education, which he championedin Argentina. Tere were placards with pithy quotes here and there onthe old furniture which Sarmiento himself had used. He was clearly farahead of his time. o paraphrase one of the quotes, he believed that:the degree of progress of a civilized culture could be judged by the role

of women.

After returning to the hotel, my friend from San Juan, Julio Claudeville,invited me to dinner at his house. Dr. Claudeville was the medicaldirector of the Veladero mine, near San Juan when I met him in Arica,at the 2000 World Congress of Mountain Medicine. Dr. Claudevilleremains very interested in mountain medicine and mountain rescue.Te Veladero mine is located at 3800 meters (12,500 feet) not far fromSan Juan. Te miners, who live at and around San Juan at 500 meters(1640 feet) reach the mine by a 6-hour drive on a dirt road throughuninhabited country. Dr. Claudeville has had to learn about EICA andrescue from necessity. He organized the system of medical care for themine and also for the road, where each transport bus carrying miners hasat least one trained first responder and carries medical equipment. Tere

have been some crashes near San Juan where these buses have been firston the scene and have rendered aid.

On the drive to his house, Julio told me about a crash involving his twochildren, an 11-year-old boy and a 16-year-old girl, which occurred last

winter. Te car in which they were riding with another family memberoverturned on a mountain road in Chile. Te first witness to the accident

was a mining engineer from a nearby mine. He called the mine for aidand a truck with medical equipment and personnel responded. Anambulance came and took the three victims to the local hospital. Tefirst Julio knew about this was when the man called him to say that hischildren were injured and in the hospital. He told him that he woulddo everything for them that a father would do until Julio could come tothe town in Chile. Until Julio arrived, this man had no idea that Julioalso worked for a mine and that he was a doctor. Te children have sincemade a full recovery and the son still calls the man from time to time,remembering his kindness. For me, at least as important as the medicinein mountain medicine was the chance to make friends from aroundthe world.

Part II to be continued in the next issue of Wilderness Medicine.

Dr. Zafren is an emergency physician, having practiced emergency medicine in Anchorage,

Alaska since 1994. He is Past-President of the Alaska Chapter of the American College of

Emergency Physicians and served several terms on the WMS Board of Directors. He also hold a

faculty appointment in the Department of Surgery, Division of Emergency Medicine at Stanford

University Medical Center, Stanford, California.

Next, Dr. Maggiorini spoke on the subject of High Altitude PulmonaryEdema (HAPE). Dr. Maggiorini is a member of the group carrying outresearch on HAPE using subjects who are known to be susceptible toHAPE (HAPE-Susceptibles or just HAPE-S). Tese subjects neverthelessrepeatedly ascend to the Margherita Hut at 4559 meters (about 15,000feet) on Monte Rosa, in order to be studied. He emphasized the possiblerole of brain hypoxia in producing HAPE and discussed the mechanismby which PDE-5 inhibitors, such as sildenafil and tadalafil, may act inpreventing and treating HAPE. Following these two excellent speakers, I

gave a presentation on conditions at altitude not related to AMS, HACE,or HAPE, in which I emphasized a host of neurological conditions. Anyneurological condition that occurs at sea level can, of course, also occur ataltitude. Some conditions may be exacerbated or unmasked by hypoxia.

Te following session dealt with physical and intellectual performance ataltitude. Dr. Maggiorini discussed acclimatization, Dr. Richalet coveredoxygen enrichment for EICA workers, and Dr. Leal discussed womenat altitude. Although oxygen enrichment may be a great advantagefor EICA workers there are some theoretical disadvantages, includingslowing of acclimatization. Te main reason that it is not used, however,is the perception by the mining companies as too expensive.

Te afternoon theme was sleep and fatigue at altitude. Dr. Jorge Lasso

from Santiago, demonstrated the utility of oxygen enrichment duringsleep in EICA workers. Tis is quite effective in abolishing periodicbreathing, but costs more than acetazolamide, which has similar effects.Tere were two talks concerning somnolence and fatigue in drivers andanother talk about the quality of sleep at altitude.

he day’s final session covered nutrition, oxidative stress, andantioxidants at altitude. Tree of the talks concerned nutrition anddigestive disturbances at altitude. Dr. Bailey gave a fascinating talk aboutoxidative stress at altitude. Although we know that too little oxygen isnot a good thing, Dr. Bailey’s research showed that too much oxygenin cells can lead to increased generation of oxygen free radicals. Tiseffect seems quite paradoxical. Dr. Claus Behn from Santiago also gavea talk on the same subject with a different point of view. He showed

some positive results from antioxidant supplemenation. Dr. Behn is agreat exponent of mountain medicine in Chile. He was the organizerof the World Congress of Mountain Medicine in 2000 at Arica, Chile.Most of the Chilean doctors in the mountain medicine course studiedunder Dr. Behn and credited him with fostering their interest inmountain medicine

Te following morning was devoted to organization of medical servicesin remote areas. As the first speaker of the day, I covered care of criticalpatients in remote areas and air medical evacuation. Te following talks

were about trauma care and rescue. I was spirited away by the five othernon-South American invited speakers who had arranged a tour of thearea by minivan. Tis featured a tour of a local winery, with a museum



Following is ainterview of KristinPeterson, a familypractice PA inColorado who

works seasonally asa medical providerin Antarctica. Sheand her husbandalso run KatabaticConsulting, acompany providingspecial environmentmedical consulting.

Q: What is life like in Antarctica?A: McMurdo Station is on an island just off the coast of Antarcticaand we share the island with an active volcano, Mt. Erebus. Itlooks like a mining town, with heavy equipment and huge fuelcontainers and cargo all over the place. But if you look beyond

the town across the sea ice to the continent you can see mountainsand glaciers. At McMurdo we live in dorms and everyone has atleast one roommate. Everyone eats in a huge dining hall. When weare not working, there is actually much to do. Tere is a gym forsports, a weight room, a bouldering cave, a bowling alley and,of course, three bars. Tere is a recreation department whose

job is to get folks out to experience Antarctica. It defeatsthe purpose of being there if you do not get out cross- country skiing or hiking. In addition, we all havemultiple non-medical duties. We may do thingslike shovel snow, assist with landing cargo flights,and help keep equipment running.

Q: What medical facilities and equipmentdo you have available?

A: At McMurdo Station they have everything they need to treat apatient there or to stabilize a patient for medevac to Christchurch,New Zealand, about 2,000 miles to the north. Tere are two PAs,two civilian MDs, a military flight surgeon (MD), a physicaltherapist, physical therapist assistant, x-ray tech, lab tech, dentist,flight nurse, and administrative nurse. Tere is x-ray, ultrasound, alab and tele-medicine with the University of exas Medical Branch.

At field camps, however, the situation can be quite different. Atfield camps I am the only medical provider and responsible foreveryone’s medical needs. I often had oxygen, basic trauma gear,and plenty of medications, including narcotics and antibiotics. Imay or may not have a cardiac monitor. My “medical station” is

often a small table in a corner. Te most important thing I haveis my brain.

Q: What is it like to practice medicinein such a remote location?

A: Te responsibility is enormous when you are the only medicalprovider there. I go through possible scenarios in my head, all thetime. I made sure I knew everyone’s medical history. I was on call24 hours a day and needed to be prepared to respond quickly. Mybiggest worries were usually the science groups that came to camp

with someone who had a medical waiver. Tat meant they did not

have to pass the physical but were allowed to come to a very remotelocation anyway. Often it was someone with a cardiac history, so we

would meet to discuss physical restrictions and the need to check inoften with me. I always informed them that a medevac flight to ourfield camp was minimum of five hours, so the chance of survival due

to a cardiac event decreased significantly.

Q: What was your most challenging medicalexperience in Antarctica?

A: My first season at McMurdo Station we had an across-the-continent medevac. A crew member on a research ship off thecoast on the other side of the continent suffered a stroke. He washelicoptered off the ship to a field camp where he was stabilized.From there he was flown to South Pole Station where bad weathergrounded him overnight. Te South Pole Station is not a goodenvironment for a stroke patient because it is at an altitude of 9,300feet. He was then flown in an LC 130 plane to McMurdo Station

where again bad weather grounded him for another night. I caredfor him that night and he was able to speak and kept asking for

cigarettes! In the morning, he suddenly lost consciousness. Weintubated him and placed him on a ventilator and medevaced himto New Zealand, where he was pronounced brain dead. Te wholeexperience brought home to me how life is harsher “on the ice.”Definitive care is days, not hours, away. Something you may survive

in the U.S. you may not survive in Antarctica. I always give asafety lecture at the field camps. I go through a whole scenario

and time line from time of injury to treatment at the fieldcamp, to the arrival of a medevac flight, to its arrival

at McMurdo. From there the patient may need togo on to New Zealand. Tis may take as much as

24 hours, weather depending. I let people mull thatover and hopefully everyone stays safe. Bottom line: you

are more likely to die from trauma or medical problems in

Antarctica than you would in the U.S.

Q: Would you go back?A: Yes, I plan to return in a few years. My husband, a paramedic, andI have our own company, Katabatic Consulting, where we providespecial environmentmedical consulting.So for us going to

Antarctica was not aone-time experience.It is part of our lives.

We love it.

Cris is a WMS member

and the Director of the

Coalition of Outdoor

Medicine Phys ician

Assistants (COMPAS).

He can be contacted at

[email protected].

o learn more about

COMPAS visit www.

wildernessmedicinepa.org/.

+ FROM THE PA’S DESK Cristopher Benner, PA-C, MMSc



Tis is my fourth andfinal Cliff Notes articleas the WMS StudentRepresentative. It has beena good year and I leave theposition in a time of growth,both for the Society as a

whole and for the studentgroups. I continue to get

weekly emails from studentsinterested in starting new

WMS Student InterestGroups on their campusesand from new studentleaders of established SIGs.Tis is very encouragingas it tells me that the

interest in wilderness medicine is increasing and becoming muchmore mainstream than it was a few years ago when I first learned of it.Keep those emails coming!

At this time I would like to introduce the incoming WMS Student Rep: Jamie Karambay ([email protected]). Jamie is currently a 3rd-year medical student at Albany Medical College and has been very activein the WMS during his medical education. He even helped start up anew MedWar race near his school. I’m sure he will do a great job as yournext rep and couldn’t leave the position in more capable hands.

Lastly, I want to make a few announcements.1) Dr. Paul Auerbach’s newest edition of the textbook, WildernessMedicine, 5th edition (Mosby) is scheduled to be released

March 23, 2007.

2) Several WMS conferences are stil l available this year: Snowmass,CO, Summer Conference (July 21–25, 2007), and the InternationalConference in Aviemore, Scotland (October 3–7, 2007). If you areinterested in sharing lodging or travel arrangements, post a messageon the WMS student message boards at http://wms.academy.sk/

Have a great spring and stay active! Woody

+ CLIFF NOTES Andrew (Woody) Bursaw, WMS Nat’l Student Rep.

+ WMS AWARDS CALL FOR NOMINATIONS

Awards for outstanding contributions to wilderness medicine will bepresented to respective recipients at the Awards Banquet during the

Wilderness Medicine Conference and Annual Meeting, at SnowmassColorado, July 21-25, 2007.

Tis is a call for nominations for the awards that include: SimpkinsService Award, Research Award, Education Award, Bowman AssociateMember Award, Founders Award, and the Auerbach Award. Te

World Congress (Erb) Award, will be presented at the World CongressMeeting in Aviemore, Scotland, this October 3-7, 2007.Specifically, these awards define:

1. Dian Simpkins Service Award: Given in recognitionof outstanding service to thefunction and operation ofthe WMS.

2. Research Award: Givenin recognition of outstandingresearch pertinent to the field of

wilderness medicine.

3. Education Award: Givenin recognition of outstandingcontributions in education tostudents, members, or the publicin the field of

wilderness medicine.

4. Warren D. Bowman AssociateMember Award: Given to anassociate member or allied healthprofessional for outstandingcontributions in support servicesfor wilderness medicine.

5. Founders Award: Givenin recognition of outstandingcontributions to the principlesand objectives of wildernessmedicine as envisioned bythe founders.

6. Paul S. Auerbach Award: Te Auerbach Award is given to aphysician or PhD recommendedby Dr. Auerbach, the AwardsCommittee and/or by pastor present members of theBoard of Directors. It is givenin recognition of sustainedsignificant clinical or servicecontributions to wildernessmedicine, preferably with serviceto the Society. Te Board ofDirectors confirms the selection.It takes into account integrity,ingenuity, effort, humility,selflessness, and serves as a sourceof inspiration for others.

7. Blair Erb World CongressInternational Award: Since wilderness knowsno boundaries, the Societymaintains relationships withindividuals and organizations

representing countries, groups,academic societies, operationalsocieties, and centers involved in

wilderness medicine. Outstandingcontributions by such individualsor organizations are eligible forrecognition through this award.

WMS Award nominations should be sent to: Joyce Lancaster, Director, Wilderness Medical Society

810 East 10th • Lawrence, Kansas 66044 • [email protected]



CONFERENCE

CALENDAR

Wilderness Medicine Conference & Annual Meeting July 21 - 25, 2007 Snowmass, Coloradowww.wms.org

WMS & Affiliated* Conferences 2007-2008

When What Where Info

Mar. 16–21, 2007 WMS Winter Specialty Meeting on Mountain Medicine CME/FAWM Park City, UT www.wms.org

Mar. 16-21, 2007 Advanced Wilderness Life Support (by AdventureMed & Univ. of Utah SOM) Park City, UT awls.org/index.htm

Mar. 21-25, 2007 Wilderness Advanced Life Support/ Expeditionary Medicine (by Wilderness Medicine Outfitters) Denver, CO wildernessmedicine.org

Mar. 21-25, 2007 Wilderness Advanced Life Support™ (Wilderness Medical Associates) Thunder Bay, Ontario, Canada www.wildmed.ca/

Mar. 27-31, 2007 Wilderness Upgrade for Medical Professionals (by WMI-NOLS) Tucson, AZ www.nols.edu/wmi/courses/

Apr. 18-24, 2007 Wilderness Advanced Life Support™ (by ICE-SAR Rescue & Wilderness Medical Assc.) Gufuskalar, Iceland http://wildmed.com/Schedule/

Apr. 19 (6 wks), 2007 Wilderness First Responder (by Wilderness Medical Outfitters) Dodge City, KS wildernessmedicine.org

May 5-9, 2007 Wilderness Advanced Life Support™ (by Montana Family Practice & Wilderness Medical Assc.) Red Lodge, MT http://wildmed.com/Schedule/

May 9-12, 2007 Advanced Wilderness Life Support (by AdventureMed and U of Utah SOM) Moab, UT awls.org/index.htm

Jun. 2-10, 2007 Wilderness First Responder (by Wilderness Medicine Outfitters) Elizabeth, CO wildernessmedicine.org

Jun. 7-15, 2007 Wilderness First Responder (by Wilderness Medicine Outfitters) Elizabeth, CO wildernessmedicine.org

July 21-25, 2007 Wilderness Medicine Conference & Annual Meeting Snowmass, CO www.wms.org

Aug. 2-14, 2007 Wilderness First Responder (by Wilderness Medicine Outfitters) Elizabeth, CO wildernessmedicine.org

Aug. 8-12, 2007 Wilderness Advanced Life Support™ (by Emergency Preparedness Systems & Wilderness Medical Assc.) Greenbay, WI http://wildmed.com/Schedule/

Aug. 27-Sept. 8, 2007 Dolma Valley Trek and Central Tibet Tour (WildernessWise) Tibet wildernesswise.com

Sept. 23-28, 2007 Fly-Fishing CME Adventure (Mountain Medicine Seminars) Northern California wilderness-medicine.com

Sept. 26-28, 2007 Northeast Medicine CME Conference (NY-Presbytarian Dept. of Emergency Medicine/Cornell University) Ithaca, NY nypemergency.org/wilderness/

Oct. 3-7, 2007 World Congress 2007: Mountain and Wilderness Medicine Aviemore, Scotland www.wms.org

Nov. 1-15, 2007 African Wildlife Safari CME Adventure (Mountain Medicine Seminars) CME/FAWM Mt Kilimanjaro, Africa wilderness-medicine.com

Jan. 20-27, 2008 Cousteau So. Pacific CME Adventure (Mountain Medicine Seminars) CME/FAWM Fiji Islands Resort wildernessmedicine.com

Jan. 27-Feb 8, 2008 Explore Patagonia CME Adventure (Mountain Medicine Seminars) CME/FAWM Argentina/Chile wilderness-medicine.com

April 7-25, 2008 Mt. Everest Base Camp CME Trek Kathmandu (Mountain Medicine Senimars) CME/FAWM Kathmandu/Khumbu Region/Nepal wildernessmedicine.com

For the most recent updates, always be sure to check the Wilderness Medical Society website, www.wms.org

*Organizations that afliate with the WMS are granted permission to advertise as offering course content that is accepted

for credit by the WMS Academy’s Registry of Wilderness Medicine Practitioners and Fellowship Program and agree to

allow their names to be listed on the WMS website as an afliated organization.

For more information regarding the Fellow and Registry Program for the Academy of Wilderness Medicine

visit wms.org. Want to see your program or conference in our calendar? Afliate with WMS! Visit the Academy

website wms.org/academy For the most recent updates, be sure to check the Wilderness Medical Society

website www.wms.org.

Abstracts are being accepted for the Annual Meeting and Summer

Wilderness Medical Conference (July 21-25, 2007). Abstract presentations

will feature original research covering the spectrum of wilderness

medicine. The opportunity to learn about new approaches, advances

in medical technology, and epidemiologic studies is unique. Abstracts

for oral and poster presentations are invited and are peer-reviewed.Abstract application forms are available online at www.wms.org under

“Research” and then “Abstract Submission.” The deadline for the receipt

of abstracts for the Summer Wilderness Medical Conference and Annual

Meeting is May 15, 2007. All accepted abstracts will be considered for

publication in the Society’s journal, Wilderness & Environmental Medicine.

CALL

FOR

ASTRACTS



WMS

WILDERNESS

MEDICINE

CONFERENCE &

ANNUAL MEETING

Snowmass, Colorado

July 21-25, 2007

wms.org

WMS & ISMM

MOUNTAIN AND

WILDERNESS

MEDICINE

WORLD CONGRESS

2007

Aviemore, Scotland

October 3-7, 2007

worldcongress2007.org.uk

www.wms.org

+ SAVE THESE DATES!



Volume 24, No. 2Summer 2007

Wilderness Medical Society810 E 10th, PO Box 1897Lawrence, KS 66044www.wms.org

We invite youto attend our special 2007 program that surpasses others in education, recreation, and value for your time and money.With the growing popul arity of wilderness act ivities there’s a tremendous need for quality wilderness medicineeducational programs. This year’s conference meets the challenge of providing new knowledge and basic informationand skills needed for safe wilderness adventures and travels.

EDUCATION, INSPIRATION,

RECREATION, RELAXATION,

RENEWAL…& COMMUNITY.

You will find all of this and more at the 23rd Annual Meeting

and Summer Conference of the Wilderness Medical Society,

July 21 – 25, 2007, in spectacular Snowmass , Colorado.

A potential of 51 educational credits for FAWM!

A potential of 39 AMA PRA Category 1 CMEs!

PLUS an additional 17.5 AMA PRA Category 1

CMEs for AWLS certification course!

242 wilderness medicine

Documents