Outside magazine, April 1999
I've Fallen, and I'm Pretending I Can't Get Up
In the perilous quest to produce state-of-the art wilderness medicine, our writer is just what the doctor ordered
By Ken Kalfus
It was a lovely place to get hurt. I lay on the shore of a thawing lake on which shallow gray puddles reflected a luminescent sky and a stand of woods on the opposite bank. I groaned, the victim of a nasty fall on the ice that had dislocated my right hip.
As if that wasn't bad enough, one of my hiking companions, Harvey Rubin, had somehow fractured his left elbow while trying to prevent my fall, and now he sat a few feet away holding his stricken limb. Compounding the disaster, our three companions on this star-crossed walk in the January woods had sustained injuries almost simultaneously. Christina Sebestyen had suffered an anterior dislocation of the shoulder. Heather Harnly was down with a nasty broken ankle. Worst of all, Kim Newell had apparently fallen from a nearby tree, resulting in a severe cervical-spine injury ù basically a broken neck. I don't know what she had been doing in the tree.
I called out to Kim, who lay flat on her back, motionless and silent.
"How are you?"
"Toast," she replied.
Just then another party of hikers, 15 in all, arrived on the scene. They surveyed the grim tableau with surprising calm. Four of the hikers sauntered over and crouched around me.
"Don't help him!" Harvey cried. "Help me! I'm a full professor!"
"Don't worry, we're medical students," one of them said to me.
"What year?" I gasped.
Christina, meanwhile, was loudly refusing medical attention and cursing with such vehemence that one of her rescuers wondered if she was afflicted with Tourette's syndrome. I moaned louder.
The students quickly checked my vital signs, asked questions about my symptoms, and diagnosed my condition. I screamed as they pulled back on my leg in order to return the hip to its socket, and then I let out extravagant sighs of relief. Now they faced their next task: getting me out of the woods.
First, they conducted what I felt was an overly relaxed discussion about what to do; I whimpered a bit to move them along. The students finally immobilized my legs by "buddy-splinting" them to each other with the hip pads from a backpack. Then they fashioned a stretcher from the backpack's exterior frame, passed ski poles through its straps, and carried me along the trail to a rustic lodge, where I was more or less dumped in the dining room along with my fellow victims in their litters and makeshift bandages.
Without much regard for the sensibilities of the wounded patients, the rescuers then launched into a review of the cases and how they had been handled. The discussion was led by Dr. Kevin McGuire, a second-year orthopedics resident at the University of Pennsylvania, who sat on one of the dining room tables and carefully questioned the students.
Brian Alverson had helped bring in the obstreperous Christina. "We gave her Percocet for the pain," Alverson said.
"You were carrying Percocet in the woods?" McGuire asked skeptically.
"No, she was," Alverson explained. "She said she got it from her gynecologist for bad PMS."
The students assumed more self-critical postures in regard to their treatment of Kim's C-spine injury, which, as she had realized, turned out to be fatal. Though the students had made sure that her airway was not blocked and that she was breathing normally, they neglected to perform the "secondary survey," a head-to-toe examination of her body. Rolling her onto a board without stabilizing her head, they had severed her spinal cord. Oops. The students were particularly embarrassed because most of them were already veterans of the emergency room, where such precautions are a matter of course.
Among the students keenly attending Dr. McGuire's review was Kim herself, happy to be alive. It's not every day that you can participate in your own postmortem.
We had all, needless to say, been faking it. My fellow malingerer, Dr. Harvey Rubin, is a professor of medicine at Penn and was the faculty adviser for this inaugural session of a two-week elective field course in wilderness medicine; Kim and the rest of the victims were all third- and fourth-year medical students at Penn, just like our rescuers. The course was held at the Princeton-Blairstown Center, a 275-acre nature preserve deep in the New Jersey outback near the Delaware River. The point of our little exercise in Method acting (I am not a man with a dislocated hip, I am a dislocated hip) was to give the participants practice in responding to medical emergencies in the wild. The students also heard lectures by visiting faculty, gave their own presentations, plowed through a hefty syllabus, subjected themselves to one another's cooking, and slept barracks-style in two cabins heated by woodstoves. By successfully completing the course, the students earned certificates as "first responders" to outdoor medical emergencies.
Someday one of them may save your own sorry ass.
Wilderness medicine, which has become a hot subspecialty for adventure-minded doc-jocks, is a relatively new discipline. It grew out of the realization that it's one thing to care for the injured in an emergency room, surrounded by the full, gleaming panoply of modern medicine ù or even in a well-appointed field hospital ù and quite another to do it in the outdoors. This insight, and a desire to get closer to "bare-handed medicine," led a pioneering handful of hardy physicians to found the Wilderness Medical Society in 1984. The society now has about 4,000 members, three-quarters of whom are doctors; the rest include emergency medical technicians, guides, and the like. Based in Colorado Springs, the WMS has annual meetings, funds research, and publishes a peer-reviewed journal, Wilderness and Environmental Medicine. The movement is also growing internationally; this August, the World Congress on Wilderness Medicine will convene in Whistler, British Columbia, for its third quadrennial convocation.
More than a dozen American medical schools now offer some wilderness training, primarily in classroom settings. The University of Massachusetts Medical School established the first wilderness medicine field course in 1995, with monthlong expeditions out West; this year med schools at the University of Colorado and Penn have followed suit. As there is something appealing about being a victim without the inconvenience of actually being hurt, I volunteered to join the Penn course as a designated crash dummy. In the space of a few days I would suffer, in addition to my hip injury, an evisceration, a compound radial arm fracture, and a fractured and dislocated ankle. I would take idle pleasure in being carried around on a stretcher under a wide country sky. I'm a bit accident-prone anyway.
The course's guest star was Dr. Bruce Paton, a former WMS president and its current secretary. A 73-year-old retired cardiac surgeon born in India of Scottish parents, who bequeathed him a brogue that has been kept immaculate after more than 40 years in America, Paton is a still-vigorous, still-backpacking elder statesman who flew in from Denver to deliver the keynote address, as well as a talk on chest and abdominal injuries.
Most of the lectures took place in a log building opposite the dining hall, in a room with a stone fireplace, exposed roof beams, and a derelict piano. Paton's keynote talk featured a slide presentation, and the projector's first emission read simply, "PREPARE!" After an overview of all the ways carelessness can prove fatal in the wilderness, Paton moved on to the real meat of the course: improvisation. What the students wanted to know was what to do if the unforeseen happened and they found themselves up the creek ù with a paddle, perhaps, but with little more than a paddle.
Dr. Paton had an answer: duct tape.
As the future doctors of the wild gathered round, Dr. Paton sang the praises of duct tape, and a few other household items. "With a combination of duct tape and safety pins," he declared, "you can do almost anything except brain surgery." Protective shields against snowblindness can be made from duct tape, if it's properly slitted. A safety pin can be attached to the tongue of an unconscious person and then tied to the person's jacket in order to keep his airway open. Ziploc bags can serve in place of rubber gloves. In the event of a sucking chest wound, you (well, not you, but someone who knows what he's doing) can prevent an accident victim's chest cavity from filling with air by cutting off the end of a condom and using it as a one-way valve.
Dr. Paton warned that while medically trained individuals might be nice to have along on expeditions to remote places, they can be medically reckless pains in the butt, too. In 1997, he led a group of 15 doctors up Mount Kilimanjaro. At least a third of them suffered some form of altitude sickness, and two became seriously ill, but none revealed it at the time, fearing that they would be denied the opportunity to reach the summit.
The days flew by, with additional lectures on orthopedic injuries, venomous bites and stings, hypothermia, heatstroke, burns, lightning, dehydration, psychological crises, high-altitude illnesses, ob/gyn emergencies, and drowning. I concluded that the most worrisome typically nonfatal wilderness ailment is HAFE, or high-altitude flatus expulsion. Wilderness Medicine, the course textbook, describes HAFE as "the unwelcome spontaneous passage of colonic gas at altitudes above 3,000 meters. The mechanism has been postulated to relate to the expansion of intraluminal bowel gas at the decreased pressure of altitude."
Fortunately, I wasn't asked to simulate HAFE, but once we began acting our various accident scenarios, my skills as a medical thespian were tested to the limit.
For my broken arm, Dr. McGuire asked me to paint the inside of my arm with stage blood and draw a black circular mark in the center of the wound to signify the bone protruding through the skin. The students found me writhing in pain, my arm bent back awkwardly. They were unable to guess my injury, even after I led them on a round of medical charades. I finally let them peel away my coat and shirt.
"What's that?" asked Rebecca Brown, a fourth-year student. She squinted at the artless gore.
"A broken arm."
"Doesn't look like a broken arm to me."
"It's a broken arm! Believe me, I'm in such pain!"
In a real emergency situation, of course, such an injury would not have been subject to argument, but Dr. McGuire urged the students to take note of what accident victims, even hopelessly confused ones, tell them about their symptoms. Moreover, he said, people tend to repeat their injuries, dislocating the same shoulder they had wrenched trying to perform the same impossible rock-climbing maneuver the year before, and they often know exactly what kind of treatment they need. "Listen to them," Dr. McGuire urged the students. "They know."
In the evenings, the students, who seemed like a remarkably well traveled bunch, gathered around the fireplace in the dining hall, cooked s'mores, and exchanged stories of faraway inconveniences: the worst bus ride, the weirdest bar, the absolutely worst latrine. Most expressed the hope that their careers would allow for occasional rotations in Third World clinics, stints as expedition doctors, or service with relief organizations such as M‰dicins Sans Frontiˆres and the International Committee of the Red Cross.
The visiting docs had their own war stories. While I was being packaged for evacuation during one of the simulations, I heard Dr. McGuire describe one of his encounters with the limits of wilderness medicine. A few years earlier, he'd found himself on Chimborazo, a 20,561-foot extinct volcano in Ecuador, in the middle of the night in subzero temperatures, when a climber with another party lost his grip on an ice wall and fell into a crevasse. By the time Dr. McGuire and his guides retrieved the man from the rocks below, he wasn't breathing, and given his hypothermic condition, it was impossible to check whether his heart was beating. Dr. McGuire tried to resuscitate him, but to no avail. They fabricated a litter from some climbing ropes and a sleeping bag, but the victim was a large, ungainly man and the footing was treacherous, so his legs and arms kept swinging out of the litter. Progress was slow, and the weather worsened. After descending several hundred feet, they determined that the man was definitely dead, and at this point they abandoned the body rather than continue to put their own lives at risk.
Dr. Richard Levitan, an ER physician at Penn's university hospital and an expert on high altitude and cold emergencies, told a real-life tall tale about descending from the summit of the Grand Teton and coming across a group of climbers in a tent, one of whom had just fallen more than 800 feet. The victim was my kind of guy: He had fractured his neck and his back in several places, broken both arms, fractured three ribs, and punctured a lung, whereupon he had managed to walk a mile and a half back to his tent. When Levitan arrived, the man was sitting up and cheerfully conversing with his companions. The doctor tore up the man's sleeping pad to splint his arms and stabilize his neck, and arranged a helicopter rescue for the indestructible outdoorsman.
My own final adventure as an indestructible outdoorsman involved being thrown from a raft while running Class IV rapids and being found miles from the nearest road. The written instructions from Dr. McGuire called for me to tape one of my boots on backward to suggest a fractured ankle, dislocated posterially and externally rotated nearly 180 degrees ù and perhaps to make a fashion statement soon to be imitated across America. I was supposed to have had quite a hard landing, also resulting in a closed fracture of my right elbow and a broken toe for good measure.
Rebecca Brown was unlucky enough to be one of my rescuers again. I could see her suppress a real groan while I voiced a fake one.
"What is it this time?" she asked.
"I'm cold, oh, so cold," I said, in a papery whisper.
It was a plausible enough grievance, given that I was once again writhing on wet ground beneath an overcast sky. But I was also playing for time, since I had completely forgotten the symptoms I was supposed to be manifesting. Was my pulse weak? Did I have sensation in my left leg? Where did it hurt?
I asked if I could take a look at my instructions.
And then, holding the sheet of paper before me, I felt, well, sick. The medical terms flew up at me with the poetry and incomprehensibility of a Zen koan: distal humerus tender, N/V intact. I was overwhelmed by the multiplicity of disaster, the cornucopia of calamity ù the broken bones, the pierced soft tissue, the edemas, the blood clots, the infarctions, all the rest that flesh is heir to, the falls, the collisions, the frostbite. There was only one way out ù and so I ended my career as a wilderness accident victim by going into a simulated state of simulated shock.
Ken Kalfus's second collection of stories, Pu-239 and Other Russian Fantasies, will be published this fall by Milkweed Editions.