Extreme Medicine

Pushing the Boundaries of Health Care

By Laura Freeman

2009_extreme1A hospital can be such a comforting place to work. Dozens of highly trained colleagues are on call in case of an emergency, and a barrage of high-tech hardware is ready to help save the day. But when the nearest hospital is hundreds—or millions—of miles away, the margin for error disappears. From a cramped silo to the limitless reaches of space, these professionals know what it’s like to practice medicine on the edge.

Into the Wild

When Beth Phillips, M.D., is doing rounds in the emergency department at UAB Hospital, she is never without her stethoscope. Out in the field, she leans on another tool: duct tape.

“With duct tape you can splint an ankle or even close a wound,” says Phillips, the director of UAB’s new Wilderness Medicine Education Program, which offers weekend courses at state parks and other locations across the country. Participants can earn certification in Advanced Wilderness Life Support.

The training includes many situations likely to be encountered in the Southeast—such as falls, lightning strikes, snakebites, and boating injuries—and some that are not, such as avalanche survival and rescue. Phillips has taught dive medicine to medical students and she hopes to add high-angle and swift-water rescue training.

“It can be frustrating to have the skills to provide care, but be in a situation where you don’t have the tools to use those skills,” she says. “Our course teaches health professionals how to improvise using what is at hand. You may have to stabilize a fracture or find a way to close a wound without a suture kit. Then you may have to improvise a litter to get the patient where help can reach you.”

Sugar

A key aspect of the training is tempering the health professional’s instinctive desire to take quick action. The most important rule in wilderness medicine, Phillips says, is to assess the situation before reacting to it. “Never let yourself or someone else become a second victim,” she says. “The patient is depending on you to stay safe and be able to help.”

Phillips became interested in wilderness medicine after taking a mountain rescue and rappel course in the Cumberland Mountains as an EMS volunteer in Sewanee, Tennessee. Experience has taught her to always be prepared when she heads into the woods. Her own backpack contains “a compass with a reflective back, a cell phone and a whistle to help people find you, moleskin for blisters, a light space blanket, and a basic first-aid kit, plus a splint if I have space—and always duct tape and safety pins. You never know when you’re going to have to MacGyver it.”

Getting Out of a Jam

Squeezing into a dark, grimy pipe in search of a trapped worker, confined-space rescue specialists know they face the very real possibility of meeting death at the end of the tunnel.

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“Confined-space rescues are inherently dangerous to the rescuer,” says Alan Veasey, director of the Workplace Safety Training Program in UAB’s Center for Labor Education and Research. “Several years ago, the National Institute for Occupational Safety and Health found that up to 60 percent of the people who died in confined-space incidents entered for the purpose of rescuing others.”

Veasey’s job is to make sure that doesn’t happen to his trainees. “We teach firefighters, police, rescue teams, and industrial employees who work in confined spaces how to be part of the solution and avoid becoming part of the problem,” he says.

The problem is that many accident scenes are so narrow that rescuers only have room for themselves and whatever equipment they can push in front of them. “Sometimes we may only be able to reach a foot to determine whether a person is alive, assess their condition, and begin treatment and extraction,” says Veasey.

When the atmosphere is toxic or low in oxygen, or when there is no room for CPR, or a fire threatens, the top priority is getting the victim out. If time is less critical, says Veasey, the focus shifts to preventing further injury.

“After assessing the airway, breathing, and circulation, we stabilize and package the victim and immobilize them on a backboard if there is a risk of spinal injury,” he explains.

The modern landscape is riddled with confined spaces that can become lethal hazards: industrial hoppers, silos, wells, telecommunications vaults under city streets, and endless miles of piping and sewers. Emergencies involving tanker trucks on highways and tank cars on railways often involve both tight quarters and potentially toxic chemicals. Because that combination is common, many participants in the confined-space classes also enroll in the Workplace Safety Training Program’s hazardous-materials courses.

“One of the rescue teams we trained had to use what they learned in both classes to rescue a victim from a sewer and decontaminate both the victim and themselves,” Veasey says.

Crossing the Skies

It is certainly better equipped than a sewer pipe or open field, but the cabin of UAB’s flying ambulance, a Cessna Citation 550 Bravo, is not the ideal spot for treating a medical emergency, either.

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“Weather can be a factor, although less so with the plane than in a helicopter,” says Michael Catenacci, M.D., medical director of UAB’s Critical Care Transport (CCT) team, which maintains a fleet of ground-based ambulances in addition to its speedy jet unit.

Running into bumpy air at 20,000 feet in the confines of the Citation doesn’t make caring for critically ill patients any easier. The team tries to handle necessary procedures before takeoff, but they must be ready to respond if patients need help on their way to UAB Hospital.

“We occasionally have to perform procedures in the back of the plane, such as endotracheal intubation, obtaining arterial blood gases, and starting intravenous lines,” says Catenacci. “The ambulances and medical jet are really mobile intensive care units outfitted with the latest in portable ICU equipment, including mechanical ventilators and a mobile laboratory. We bring specialized equipment if necessary, such as aortic balloon counterpulsation pumps and left ventricular assist devices.”

The medical inventory occasionally includes UAB experts who travel with the team to deliver their unique skills in a remote setting. “On one trip, we flew to a small hospital to help out a surgeon whose patient had an unusual complication during an operation,” Catenacci recalls. “The UAB surgeon stabilized the patient, and we flew back to our surgical intensive care unit. The patient ended up doing well and had a good outcome. It is a great service to work with because we see many unusual cases.”

The Final Frontier

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Modern health care is so sophisticated that few patients are beyond the reach of medical help—even if they are millions of miles from their home planet. Several years ago, NASA asked noted trauma surgeon Norman McSwain, M.D., an alumnus of the School of Medicine at UAB, to help design a medical training program for American astronauts. Space crews are using the program now and will take it with them on the agency’s upcoming mission to Mars.

“Just about anything that can happen on Earth can happen in space, and then some,” says McSwain. “In addition to the illnesses and injuries you might see here, the medical officer will be dealing with the physics and physiology of space.” When you can’t count on gravity, something as simple as starting an IV takes special equipment. In a place where no particular way is up, motion sickness and altered balance are frequent problems. Blood volume quickly begins to fall, and fighting muscle atrophy and bone loss takes daily resistance workouts. Even getting along with people in a confined space for extended periods can be a test of mental health.

Despite the unique challenges of space, the basic principles of frontier medicine still apply out on the final frontier. “If there’s an emergency, the medical officer can get advice from the ground, but he won’t be able to go get more equipment or more medicine,” McSwain says. “He’ll have to deal with it using what he has on board.”