What You Learn Outside
Introductions
My name is N. Stuart Harris. I am at Mass General Hospital and have been here since 1999. I completed my Emergency Medicine residency training here in 2003, and started as faculty immediately after. I started the wilderness medicine fellowship program in 2005.
What is wilderness medicine?
Wilderness medicine is the provision of resource-limited medicine under austere conditions. It can take place anywhere: in remote wilderness areas, but also after natural/ human disasters in cities, and throughout the developing world every day. In each of these settings, you have access to the history and physical exam that we've depended on in medicine for the last 2400 years, but you don't have many of the things that we very much take for granted in the front country. You may not have labs, you may not have imaging, you may not have other diagnostic modalities.
Another aspect of WM training we teach (which I think people are sometimes lost to) is how critical the ‘resource-limited’ aspect of WM is. Wilderness Medicine operates where there is a lack of ability to provide some of the most basic things we take for granted in emergency departments: that they're clean, heated or cooled, lit, and have clean, running water with the ability to flush away your sewage. Those are all things that are critical to providing clinical care. In an emergency department, you don't have to think about them-- somebody else is already doing it for you. We see the aftereffects of the failure of this skill set in the introduction of cholera to Haiti by well-meaning, but insufficiently trained/careful providers after the earthquake. Cholera now kills many more Hatians than were helped by these ‘rescuers.’ Being a capable ‘camper’ saves lives. A lot of the places where we are active, being able to keep somebody warm, dry, and safe from an environmental standpoint is a significant part of patient care.
You also practice in an urban environment. Could you talk about how the different fields enhance one another between urban, rural, and wilderness environments?
My day-job (and night and weekend job) is emergency medicine. I work in an urban Level I trauma center. In the year before the pandemic, we saw roughly 113,000 patients. We have pretty much everything you could want as far as diagnostic and therapeutic options. The academic practice of wilderness medicine teaches durable, transferable skills that can still inform patience care in an urban Boston Harvard hospital. My argument, which I think is playing out, is that wilderness medicine teaches a recapitulation of what good medicine is. A good doctor is a portable creation.
Wilderness medicine focuses on that interaction between a care provider and a patient. The caregiver is directly engaging, getting a good history, and performing a good exam. They're making a diagnosis on the basis of what they’ve heard and felt, and on their ability to think. In a busy hospital/ emergency department, too often, you see computers rolled in between doctor and patient. It's a literal barrier, but it's also an emotional and intellectual barrier between physicians and patients. If you are a care provider and you're typing away trying to get a note done while you are talking to a patient, they are keenly aware you are not paying as much attention as you could. Narrative is the diagnostic engine of medicine. Through listening and storytelling, we provide diagnosis and treatment.
As much as anything, wilderness medicine keeps humanism in medicine and tries to keep that fundamental bond between patient and care provider front and center. It may only be a 3, 4 or 5 minute interaction between you and the patient, but in it you are making eye contact and engaging with the patient. You don’t provide healing to a patient by looking at them, but by listening to them. Good medicine is practiced when we’ve listened and thought well enough to have a clear idea of the diagnosis being sought and being ruled out before the diagnostic armamentarium of medicine is unleashed. Paying attention and listening carefully to the patient in front of you ultimately provides for time-efficient, cost-efficient medicine. Wilderness medicine experience helps to make sure the patient remains at the center of care.
How does wilderness medicine translate to urban settings?
First, a lot of our research is based on hypoxia: how the body responds to low oxygen states. We typically study this by going to high altitude. People sometimes ask, "well, you're in Boston. It's at sea level, so why do you care about altitude?"
We care because hypoxia related issues are what's going to kill the vast majority of our patients. At sea level, sometimes it's an organ system at a time, like a heart attack or stroke. Other times, like trauma or sepsis, it's a whole body's inability to deliver oxygen sufficiently to the cells. All of those are problems of oxygen delivery. So, if we can better understand the life threat of low-oxygen states (hypoxia), we're going to be a lot better at treating the people who show up in standard emergency departments, even at sea level.
Part of the way we're doing that is by looking at how different organ systems within the body respond, like the lungs. A lot of our early work on ultrasound was trying to figure out how the body responded and how the edema that collects in the lungs occurs. Increasingly, we are working with some local world-class scientists to look all the way down to the organelle level: how does the mitochondria, the little powerhouses of the cell, respond to those low-oxygen states? On the treatment side of things, research has a huge capacity with mouse models, genomics, metabolomics, and other methods for looking at beautiful science, way beyond my abilities. I offer an interface between the mice and the bedside. They had some really interesting findings published looking at Leigh's syndrome, which is the most common pediatric neurological disease due to mitochondrial dysfunction. They found that low oxygen states were protective, and even reversed some of the underlying problems, which in some ways is counterintuitive. This is interesting, but we need to translate this into human communications.
That intersection between the bench and the bedside and demanding environments, especially hypoxic environments, is what we do all the time. We've done it for more years than I care to admit now. That's part of what we do.
As far as how wilderness medicine seeks to improve all medical care, we've had our wilderness medicine course for senior medical students for the last 15 years: Medicine in the Wild. I team-teach the course with the National Outdoor Leadership School (NOLS). I was a student there, then an instructor. I'm on the board now. NOLS uses the wilderness and the wild in a way that I think is very helpful for developing doctors. Medicine in the Wild is a 28 day course in the heat and cold of the wilderness mountains of New Mexico, teaching wilderness medicine skills. We are also teaching physicians how to be teachers, which we don't always do a very good job of in medicine. Too often in medical education, we assume that if you know something, you can teach it. This is often not true. The wilderness course also teaches leadership skills. The standard progression is from being a medical student, to being an intern, to resident, to becoming an attending. Each one of those roles comes with very specific responsibilities which sometimes we don't make as clear to people as we could in school, so my course does it outside.
Now we've got graduates who came in as medical students and now have been in practice as attendings for years. They say, "What I learned out there about how to get a good history and engage with a patient, is what I return to when things are going sideways. Get back to the basics. It's about asking, how do I approach this? A, B, C, D." That's a skill that can be easier to teach in the wilderness. In a busy ED or a busy ICU, things are whistling and belling and alarming. For teaching purposes, having a more straightforward process can provide a structure that, as things get busier and are not making sense, emphasizes the universal simplicity that underlies complex problems. For the most part, human physiology is very simple: air goes in and out, and blood goes round and round. If you can keep that in mind when things are getting really complex, if you've got the basics covered, it helps. That's something wilderness medicine teaches.
What does your team usually look like in wilderness medicine?
It completely varies, depending where we go. A large part of our clinical training over the years has been in the Everest Base Camp area. We work with our partners, the Himalayan Rescue Association. We are usually there for about three months, or a little bit longer, in the Spring or Fall, for the typical Everest climbing season. The summer closes down for the monsoons and the winter closes down because, well, it's the winter! We are typically there, embedded with the HRA. We provide care to a lot of the locals in the valley that drains the southern side of Everest. It can be absolutely standard emergency medicine. It can be obstetrics, lacerations, pneumonia, or anything else. Then, about half the population is people who are climbers, trekkers, or Sherpa there for the expeditions on Everest. Because of this, we also see a lot of altitude sickness. It's a great place to study altitude illness: how the body responds to low oxygen states.
Are your projects usually short-term? What does sustainability look like in wilderness medicine?
Some of our work is very episodic. If we are providing medical support for climate research centers in Alaska or Siberia, we might have a 2-6 week period that we are active in the field. We are also working on a lot of our longitudinal longevity, which is on training individuals that can then go forth. The continuity is within the training of the individual. They each make and do different things.
We are also working on some longer-term projects with NOLS, with the Woodwell Climate Research Center, and with the native Alaskan population up in Northwest Alaska. There, we offer teaching support and clinical care, and pursue research opportunities. Those are ways that we try to build in a longer-term response through sustainable changes. We are not in the business of setting up healthcare systems in remote areas, but the underlying thought is that we go to where patients are in need. This contrasts with current models, which are set up so that if you are sick, you have to go to a hospital or clinic. We believe healthcare is a right. That if patients are underserved, we’re responsible for getting the professional to them. We need to go to where the patients are and provide care for the patients there. We've got work to do before we can hope to see permanent operations in different places.
With that in mind, what's the difference between wilderness medicine and rural medicine?
Being a little flip, I think if you can drive there, it's rural. In wilderness medicine, you typically can't. We can also use “resource limited under austere conditions” to define wilderness medicine. As Congress defined in 1963, wilderness areas are places that have no roads. You can't have mechanized equipment there. We practice in Denali and other places recognized by the government as “Wilderness Areas,” but a large portion of our work is in the developing world and in other places where there may be basic roads but no medical care. For the most part, just because you are in a rural area doesn't mean you don’t have power, clean water, facilities, or other resources. Taking care of sick patients in rural locations can make for an extraordinarily challenging practice, but by comparison, it sounds pretty good when you're in a wilderness area with someone who is sick, with none of those resources.
How do people get involved with wilderness medicine? What does certification look like?
There are a bunch of different ways to get involved! I like to joke that wilderness medicine is a great gateway drug for people interested in medical practice, because you can take a two-day course as a student with no medical background at all and get to lay hands on another human in scenarios and get an introduction to what providing medical care is all about: the archetypal interaction between two human beings. Additional training can include 28+ day wilderness EMT trainings. The apex of WM training would be someone who is a board eligible or board certified emergency physician who then decides to do one or two years' wilderness medicine fellowship like we offer. There is a whole range of different commitments of time, and levels of expertise that are available. A defining quality of wilderness medicine is that it is very easy to enter, but it is an infinitely distensible space.
