Future Considerations 2

I have been giving the concept of travel medicine, wilderness medicine and remote medicine a bit of thought lately.  Building on my previous post that discusses some of the “overlap” between these fields of medicine, I wanted to look at some specific examples and build my case for the statement that these specialities are converging, or should be converging, into one field.

One of my favorite books “Field guide to wilderness medicine” discusses some things that I consider more likely to be found in a tropical medicine manual, such as malaria.  Malaria is a disease that, I consider, largely preventable, in an educated and prepared traveler.  Is this a “wilderness medicine” issue or a “travel/tropical medicine” issue?  I see this these as very, very similiar.

Treatment of acute issues, while outdoors, such as a dislocated shoulder or ankle injury cannot be prevented with a vaccine or chemoprophylaxis.  At least not that I know of!  These types of injuries are considered more “emergency medicine” problems than travel medicine…even though it may have taken place during a holiday trip.  Now, having said that, a good number of emergency medicine physicians might have trouble diagnosing and treating a venomous bite, due to their geographic region of practice.  My point is that this is new “thing called wilderness/travel/expedition medicine” is and should be emerging as a very unique skill set!

Pre-travel consultation should include a review of immunizations, risk of exposures and a good knowledge of the geographical areas the person is headed.  Travel medicine at it’s finest.  Now, the problem comes into play when the members of that trip/expedition run into problems of an acute nature, while away.  The fractured ankle, acute dehydration or trauma are some of these examples. 

As with buying a house, location is everything in medicine.  Access to some really fancy imaging equipment and 24/7 specialist consultation is wonderful.  Trust me, I work at a facility with ALL this.  What about that 25 year old female with acute, right lower quadrant pain?  A pregnancy test could be a literal “life saver” at that point.  I think it takes a very creative and unique health care provider to work with limited resources and support.  This is exactly the nature of wilderness and remote medicine.  “Doing the best you can with what you have” is a common saying I have heard.  This is not emergency medicine at a fully staffed level 1 trauma center.

To me, the “ideal” expedition medicine healthcare provider will be able to conduct a pre-travel risk assesment, advise on vaccines and immunizations, communicate with primary care providers of the “patients/adventurers” and competently deal with acute issues while at their location, then ensure proper follow-up or even rescue, as needed.  Whew…that is a lot and I am sure I am leaving things out!

There are currently several paths for further education in these areas, but all are in their “individual areas”.  Wilderness medicine fellowships exist with Stanford and now, Harvard being two fine examples.  Diploma courses in travel and tropical medicine are available and I have to mention my personal favorite: Tulane SPHTM .  I have completed the program at Tulane and I did receive education in “wilderness medicine” but nothing compared to parasitology, virology and the like.  The Diploma in Mountain Medicine, offered in Europe, is another example of “wilderness” heavy medicine and even search and rescue components!  Australia has a fantastic program for Rural and Remote Medicine, involving what looks like a decent overlap with wilderness medicine.

Has any of these programs managed to blend all of the qualities necessary for the “ideal” expedition/travel/wilderness medicine doc?

Maybe I still believe that the “specialist/generalist” model of skills is ideal for this type of thing, at least as initial training.  But, where to go for an all encompassing training program for advanced study in these areas that allows us to provide total care for our “patients/adventurers”, including pre, during and post adventure care?  There is my rub…

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