Wilderness Medicine Updates
The podcast for medical providers at the edges, bringing you digestible updates at the growing edge of Wilderness Medicine, Wilderness EMS, Search and Rescue, and more.
Wilderness Medicine Updates
Ep. 18 - Ketamine for Wilderness Pain Management with Dr. Christopher Van Tilburg
Ketamine Use in Wilderness Pain Management: An Interview with Dr. Chris Van Tilburg
In this episode of Wilderness Medicine Updates, host Patrick Fink discusses wilderness pain control with guest Dr. Chris Van Tilburg, focusing on the effective use of ketamine. The episode delves into how ketamine serves as a versatile medication for pain management, sedation, and intubation in emergency and wilderness environments.
Dr. Van Tilburg, an expert in wilderness medicine with extensive field experience, shares insights on administering ketamine in challenging rescue scenarios, the limitations and benefits of various medications, and practical considerations for field use. The conversation touches on dose ranges, administration techniques, and patient management during rescues. Additionally, Dr. Van Tilburg talks about his soon-to-be-released book, 'Crisis on Mount Hood: Stories from 100 Years of Mountain Rescue,' celebrating the centennial of the Crag Rats, America's oldest mountain rescue team.
Links
WMS Guideline: Avalanche and Nonavalanche Snow Burial
WMS Guideline: Pain Management in Austere Environments
Chris’s Linktree
Contact Chris through LinkedIn
Preorder Chris’s book “Crisis on Mt Hood”
Chris on Wikipedia
Crag Rats Mountain Rescue
Chapters:
00:00 Welcome and New Year Greetings
00:29 Introducing Today's Guest: Dr. Chris Van Tilburg
03:07 Podcast Shoutouts and Listener Appreciation
03:37 In Conversation with Dr. Chris Van Tilburg
05:58 Challenges of Wilderness Pain Management
09:37 Pain Management Strategies
14:23 Ketamine vs. Other Pain Medications
18:01 Ketamine Dosage and Administration
22:16 Nitty Gritty Tactics: Needle Sizes and Administration
23:02 Intramuscular Injection Sites and Techniques
24:22 Timing and Dosage of Ketamine Administration
25:16 Challenges in Mountain Rescue Situations
27:17 Case Study: Seizure Patient and Ketamine Use
29:18 Considerations for Head Injuries and Ketamine
33:03 Medications in Wilderness Medical Kits
34:02 The Art of Wilderness Medicine
37:54 Protecting Medications in the Field
38:55 Wrapping Up: Upcoming Book and Final Thoughts
As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.
Connect with us by email at wildernessmedicineupdates@gmail.com.
You can pay us a compliment and share the show with a new listener on any popular platform here.
Welcome back to Wilderness Medicine Updates. The show for providers at the edges and happy new year to you all. This is our first episode for 2025. And I'm very happy to be wishing you a happy new year from Bend, Oregon, where we have a ridiculously deep snowpack and somehow haven't really gotten any snow in town. It's pretty nice to live near the mountains and not in them sometimes. Today, I'm super excited to welcome a guest to the show. Chris Van Tilburg. I'm gonna talk to you a little bit about Chris in just a second, but our topic for today is going to be approach to wilderness pain control, and importantly, we're gonna make a deep dive on ketamine. Ketamine is a medication that you may be familiar with because of the news, has killed some celebrities recently, or maybe you've heard of people getting ketamine infusions for treatment resistant depression or substance abuse. Well, for us in the emergency department, ketamine. Is a wonder drug of sorts because it can be used for pain control. It can be used for sedation. It can be used to intubate people. It can be used to control the dangerously agitated, but it has some special features that differentiate it from opioids or NSAIDs and then make it particularly well suited to use in unmonitored or minimally monitored environments, such as out in the wilderness or the search and rescue context. First, a little bit about Chris straight from his Wikipedia page. He's a cool enough doctor to have a Wikipedia page. Chris van Tilburg is an American physician and author specializing in emergency wilderness travel, environmental occupational and public health medicine. He is the author of 11 books on outdoor recreation, wilderness medicine, and international travel. Including a couple of memoirs, one called mountain rescue doctor, wilderness medicine in the extremes of nature and search and rescue a wilderness doctors life and death tales of risk and reward. He has a forthcoming book, which we discuss at the end of this podcast, crisis on Mount hood stories from 100 years of mountain rescue. And that comes from Chris's background as a deployable member of the crag rats, which is a search and rescue team on the North side. Of Mount hood. And I believe that the longest continuously operating search and rescue team in the United States. Chris is also a family medicine trained emergency medicine doc working out of hood river, Oregon, and he's a medical director to a number of mountain rescue and search and rescue teams. And this podcast, you can expect to hear about Chris's approach to search and rescue pain management. You're also going to hear why ketamine is his drug of choice and why we both shy from wilderness use of intranasal medications. We're going to talk about which medications he brings with him on a SAR deployment and which ones he does not and why and so much more. Before we dive in, I also want to thank those of you who have given the podcast a written rating on Apple podcasts, I'm looking at you lions, Leo, Haley, one eight, eight, and my favorite name on there. Sorry to the other two charter spatula. I appreciate the comments that went along with your five star reviews. It really warms my heart and it definitely helps get the This podcast out to other people when you drop those reviews. So thank you. And if you want to be mentioned on the show, keep them rolling. Without further ado, let's jump into my conversation with Dr. Chris Van Tilburg. It's great to have you on the show, Chris, I really appreciate you coming. When someone asks you at a dinner party, what you do, how do you elevator pitch yourself? Cause you have a lot of balls in the air,
Chris Van Tillburg:Well, it's, it's easiest to explain to people that I'm a and wilderness doctor, but of my job now I do administration, administrative medicine. but that's the easiest thing to tell people is kind of encompasses my entire career.
Patrick:but Chris, what's a wilderness doctor.
Chris Van Tillburg:A wilderness physician is generally anybody who's practicing medicine in rural, remote, or wild areas, and for me, that means mostly mountain rescue, but I've also worked in Haiti. I've been to Haiti five times. I've been a cruise ship pilot. Doctor, I've been an expedition doctor but most of my time now is in mountain rescue.
Patrick:Okay. And is that predominantly or exclusively with the crag rats?
Chris Van Tillburg:No, I'm a field deployable member of the Craig rats. Last year I went on 35 missions or something like that. But I'm also field deployable and medical director of Portland mountain rescue, which is those are the two teams that cover mountain hood. Craig rats generally cover the. North and east portal Mountain Rescue covers the south. I'm also a medical director for Clackamas County, SAR and Pacific Northwest SAR. Those are the two ground teams that cover Mount Hood.
Patrick:You're a busy guy. That's a lot of run reviews and training.
Chris Van Tillburg:Well, I got, a great medical lead for every team. So it's, it's fabulous. I got really great help.
Patrick:Awesome. So the reason that I wanted to reach out to you to talk about wilderness pain control, and specifically ketamine, was the expertise that you brought to our group when we were putting together the pain management guideline for the Wilderness Medicine Society. And it seems like you have a particular knack with ketamine, which is where I want to get to eventually. For the purposes of this discussion, let's table the language and you can say remote, austere wilderness when we're talking about like, Well, outside the hospital environment, what do you think of as the challenges of managing pain in those settings that are unique to wilderness or austere settings?
Chris Van Tillburg:Great question. The two probably the two biggest challenges. One is a medical provider issue and one's a patient issue for medical providers. Our biggest challenges. We just can't take very much. Very many up on the table. the mountain or up the trail. We just have a limited space in our pack and we have to make really hard decisions sometimes what we take up the trail. So that is one of the big limitations. The other big limitations is the patient is in a oftentimes in a remote or rural or area and so that Even if we did have equipment up the trail, it just makes delivery of medical care very, very challenging.
Patrick:So, when you're thinking about constraints on your pack, are you thinking about, you know, the range of medications you can bring? Are we talking monitoring equipment? what do you typically have in the hospital that you find that you do not have when you're up on the north side of mount hood, for example?
Chris Van Tillburg:Well, I have a like 40 liter pack. And then I generally in the Alpine, I take an airbag pack. So in that pack, I have to take my personal safety equipment, my spare clothing, food, water, my technical climbing equipment for the South side of Mount Hood. That's going to be like a Petzl RAD line. And. Set of boot crampons and a harness I'm usually wearing. And then. that stuff fills up, you know, most of my pack. And so I have limitations of what I can bring. So typically, I bring a six liter bag zippered pouch that has my advanced life support kit and oftentimes, depending on the situation, I'll bring it. An AED I'll bring a heat blanket or two, and we might spread those out amongst the team members, depending if I'm on the ready, I'm on the hasty team, or if I'm coming after some gears already up the mountain. So, just situationally dependent, but those are the things I bring. I don't bring IV fluids. I don't bring a twelve lead monitor. bring kit, you know, all those things that we have available to us in the emergency department.
Patrick:Okay, so a limited subset Of both medication tools, but then also physical tools. Do you have the capacity to monitor blood pressure and, uh, to monitor oxygenation,
Chris Van Tillburg:I carry a pulse oximeter, which is mostly helpful, I've found. Bringing somebody down the mountain. It's a quick, easy way to, for anybody, any BLS rescuer can glance at the pulse oximeter and say, yeah, we still got a pulse and we still got O2 sat at the appropriate. So it's a great tool to monitor somebody. I don't bring a blood pressure cuff because it's just 1 of the things I've decided, you know, I have to cut something out. I only have 6 liter bags. So it's 1 of the things I just decided, it's, it's useful, but not gonna make, not gonna employ medical decision making that I can't use other tools and skills for.
Patrick:right? When you see a low blood pressure, what are you going to do? You're going to walk out faster.
Chris Van Tillburg:Yeah, right.
Patrick:So when you're thinking about your role as the physician or the medical provider on a technical rescue team, what are your goals when you're, Delivering pain control to a patient. that seems like a really straightforward question, right? You're like to get rid of pain. I want them to have less pain, but everything has a downside to it So what are your considerations when you're thinking about should I use this medication? Should I not will this? Enhance our action here, or is this just gonna impede us?
Chris Van Tillburg:Right. Probably an important goal, maybe not the most important, but an important goal is to make job of the rescuers easier. We had a ankle fracture dislocation. Last summer, four miles up the trail combined with the elbow non dislocation, and it was until I got there, it was just impossible to even move this person, this patient, even get, get that person out of us into a safe zone. We were up by a waterfall. There's water spraying everywhere. So, a really important job of pain control is to make the job, allow the rescuers to do their job.
Patrick:that's like packaging and moving the patient in that setting.
Chris Van Tillburg:Yeah, correct. It was like, they couldn't even move her. For Into a safe spot without paying control, and then we had to move her into the litter and get her down the trail. So, yes yeah, pack moving and packaging.
Patrick:Okay. And obviously there's, you know, kind of multiple levels to pain control that we can apply and we might go straight to higher levels in that setting where someone is clearly in excruciating pain. But can you march me through the levels that you think of in terms of like, this is the lowest level or the base level of care that I've essentially delivered to almost everybody. And then this is how I escalate my. Pain management tactics, depending on what's in front of me.
Chris Van Tillburg:Yeah, I think in my situation, there's really three levels of pain treatment. One is just getting somebody. Immobilizing a fracture or getting them into a litter off the trail, straighten their fractured extremity or immobilizing it. That's probably the quickest and easiest and one of the most essential things to do. And then the next step would be some kind of oral over the counter. And then the third step would be prescription medication.
Patrick:So, immobilization first, because If that broken wrist stops flapping in the wind that addresses a significant pain driver
Chris Van Tillburg:Yeah. And a lot of people, we get them packaged in a litter and they're immediately, the two effects happen. One is kind of alleviates their pain because they're off the ground and they're stabilized. And then it provides a fair bit of anxiety relief because all of a sudden they realize I'm going to be taking care of them in this package. And I got a bunch of rescuers around me.
Patrick:That's an interesting effect to think about kind of ties into the psychological first aid side of things you know, we always talk about trying to Empower the patient or involve them in their care But at times they're perfectly happy to be wrapped up in a blanket and say take it from here
Chris Van Tillburg:Right?
Patrick:I feel safe now
Chris Van Tillburg:Yeah.
Patrick:What is your over the counter pain strategy or oral pain control? What's that level 2 look like?
Chris Van Tillburg:Usually that's, you know, Tylenol is the safest. Ibuprofen is the most ubiquitous. Somebody's usually got that in their pack, or I have both. once in a while I'll use which isn't over the counter, but it's maybe a little bit safer to use than Ibuprofen in some situations. But yeah, it's Tylenol and Ibuprofen.
Patrick:Remind me, is it meloxicam that's in the military pill packs?
Chris Van Tillburg:Yeah, exactly.
Patrick:Okay. For those who aren't familiar, that's like a self administered pain pack that the military uses, which has immediate administration pain meds as well as an antibiotic. So if you sustain some kind of wound in the field, they can treat themselves immediately. Um, so you, you start off with an NSAID and Tylenol of some form, and then let's say that, that lady you've just pulled out from underneath the waterfall with the elbow fracture, the ankle fracture. She's in the litter, she's stabilized, you managed to get her to swallow some NSAIDs. She's still screaming. You clearly would like to kind of March to that next level. What is your first line kind of prescription or show physician level medication?
Chris Van Tillburg:I should mention that sometimes I go straight to the the good drugs. Like, I don't even mess with ibuprofen. Sometimes if somebody's in significant pain, or if I want to make sure I keep them without taking anything by mouth, like I've had that a few times with head injuries, but I only carry. Ketamine and oxycodone. That's all I carry those two things. So if I can't give somebody, I rarely use oxycodone because of. the risk of, respiratory compromise and it just takes longer to work. I usually go right to ketamine.
Patrick:Okay. I think a lot of us on this podcast and people listening, perhaps with an EMS background or saying, where's the fentanyl?
Chris Van Tillburg:Yeah, I don't carry it. I don't carry it for a couple of reasons. One is I can do almost everything with ketamine that I would do with fentanyl two is it's a little. More challenging to carry because of the higher level of controlled substance by the D. E. A. That's kind of a minor issue. Um, and then, um, you know, the side effects of fentanyl are are more pronounced and ketamine. So I don't even I've never carried it. I don't carry it. I just carry ketamine.
Patrick:Those side effects being respiratory depression and potentially altered mental status, depending on the patient.
Chris Van Tillburg:Correct.
Patrick:I have always used fentanyl as a first line, but my, wilderness operational context is usually ski hill medicine. If I've had one issue with it, it's that. Delivering it intranasally is pretty variable in that setting because people's noses are cold and runny and intramuscular fentanyl doses to be effective need to be probably up above 100 micrograms, which means that we're talking about four milliliters plus of a standard mixture of fentanyl. I have been hesitant to use ketamine. I'll admit that. You seem very comfortable, and this is like where I want to dig in a little deeper. Can you anticipate why I would be hesitant to use ketamine?
Chris Van Tillburg:Well, I'm not sure exactly your perspective, but I have some people are hesitant to use it because it hasn't been used as long as a parental opioids. It has it's it's a drug of abuse. So there's all is that stigmata about it. But so is fentanyl. And just, you know, maybe in unfamiliarity with it. I mean, I use it somewhat rarely in the emergency department when I work, or especially at the ski clinic we have a minor or major procedure to do. That's pretty straightforward, but maybe unfamiliarity might be part of it too.
Patrick:Okay, it was unfair to ask you to read my mind. I think, as you know, I'm also an emergency physician, and so I use it a ton in the emergency department,, often in people who have experience with opioids, who have significant pain. It can be opioid sparing in that context, but I'm usually administering it. IV in that setting at a dose range of 1 to 3 milligrams per kilogram, which we don't need to dive too much into the math here today, but it's a relatively low dose. And even at those doses, I occasionally have people who get weird, um, you know, if it's not pushed slowly or hung in a bag, I get people who start experiencing hallucinations. So let's contextualize this a little bit for our audience, because probably a number of them might not have as much familiarity with ketamine as we do. talk with me or explain the dose range that exists within ketamine, how we get from like nothing up to we're using it as an RSI drug.
Chris Van Tillburg:Right. Well, I use it. Pain management dosage. I don't use it yet. The dissociative sedation dosage except the occasion would be at the mountain ski resort clinic where we have a nurse full code card. Sometimes they're there for a difficult shoulder reduction or something or a. you know, pediatric, polys fracture reduction. I may use it, but generally I only use it in a pain dose. I carry a nasal atomizer, but I've never given ketamine intranasally for the exact same issue you've already mentioned.
Patrick:That's kind of variable effect and absorption.
Chris Van Tillburg:Yeah, if somebody's on the side of a mountain shivering and they're cold and they're trying, you're telling them to hold their breath and then snort through their nose. And it's just, I've never done it just for that reason. So I give it. I am, um, and I give, you know, one, two milligrams per kilogram. I am. So, um, a hundred milligrams is pretty safe for most adults for the pain dose. I have had people, okay. Um, not get great pain control with that. I've also had people that are getting slightly loopy and slightly dissociative with that dose. So to err on the side of maybe a little less to start see what happens. The half life is like, in my experience, 30 to 40 minutes. So it's, you know, you got to redose in 30 to 40 minutes or hopefully you're off the mountain.
Patrick:Okay. So I think of ketamine as having basically three dosing ranges. The first being the one that you're trying to stay inside of, which is where it's providing pain control. And then if we get up higher above that, that's probably what we could call the recreational. where people who are abusing this drug are tending to use it for that effect, where at that point people are starting to hallucinate, but have not reached zone three, which I would call dissociative dose ketamine, which is where mind and body are not in relationship with one another. And that's the level at which we use it in the emergency department when we're intubating. So you don't get too much experience with people. starting to have hallucinations when you're giving it at two milligrams per kilogram intramuscularly.
Chris Van Tillburg:I've had it happen once. I give it roughly four to five times a year, either on the mountain or up a trail in a remote location. And so I've had that happen. I had that happen once last year then it wore off and I just backed off on the dose a little bit. But, um, I have that happen with, two milligrams per kilogram.
Patrick:Because when you say two milligrams per kilogram, my mind immediately goes to when ketamine has been studied for management of the dangerously agitated psychiatric patient, the dose range For putting those people down is three to five milligrams per kilogram. So it's really not that much farther away, but it sounds like you don't have a lot of trouble with, strapping people into that litter and getting halfway down towards cloud cap. And they're seeing machine elves or strange hallucinations.
Chris Van Tillburg:Yeah. And that that does pass fairly quickly. And probably I use more like one to one point five milligrams per kilogram. Because basically the formulation I buy it in is, um, one hundred per M. L. And it's in a five M. L. Bottle. So, um, You know, we're not weighing people
Patrick:Right.
Chris Van Tillburg:Sometimes you can ask people what they weigh and sometimes you got to guess probably more often than not, I just give a hundred milligrams. So it's one CC, one ML. It's easy for somebody to help me draw it up. If they're a paramedic or, um, you know, if there's two of us, or sometimes I draw it up and give it to our awesome critical care nurse who's on our team. So, yeah. So oftentimes I just go straight to a hundred milligrams
Patrick:Okay, and for most people, that's going to land between one and two milligrams per kilogram for an adult size human.
Chris Van Tillburg:Right.
Patrick:let's just talk nitty gritty tactics. Obviously, you're going to draw it up with a large gauge needle when you give it. I am what size needle are you caring for that?
Chris Van Tillburg:Well, that's a great question. You know, so typically I carry, two eighteens and two twenty sevens, but I think the last time I used it, which was on a trail up on Mount hood for whatever reason, I couldn't find any 27 gauge needles, so I drew it up with an 18 and gave it an 18. Not the best, but this lady, she was in bad shape and we couldn't even move her at all. So, that's just, but yeah, generally, I like to just carry an 18 and a 27.
Patrick:Yeah, that's a small biopsy. when you're administering it intramuscularly, do you prefer shoulder versus thigh versus glued? Or is it just what you can get access to?
Chris Van Tillburg:I think I've only given it in the shoulder in the deltoid because getting access to any other muscle is very challenging, especially people have lower extremity injuries and you got to take their clothes off. It's pretty easy to somehow get to a deltoid. Um, and so that's where I've always given it.
Patrick:Okay. I'm going to share my non evidence based tactic for the lower extremity, which is most people have pockets. And so you can go through the lining of the pocket into the thigh without Exposing the leg. That's something I came up with when people got tired of me poking holes in their Gore Tex pants. I was just administering it straight through the arcteryx and it made some people a little frosty, but through the pocket works pretty well if you don't have access to the shoulder.
Chris Van Tillburg:That's a great idea. Fabulous idea.
Patrick:Yeah, because that's why we're not giving IV meds, right? Both the fussiness of the IV and because we don't want to expose people. So there's always the side zip on the pants or the pocket where there's the thin nothing material and you can usually find some thigh muscle through there.
Chris Van Tillburg:Yeah, that's a great idea.
Patrick:So when you administer it intramuscularly, how long Before peak effect, generally speaking.
Chris Van Tillburg:In my experience, it's usually pretty quick, five or six, seven minutes, something like that. And then, peaks, in 20 or 30 minutes and then wears off by 40 minutes. So, oftentimes, know, it's two or three hour trail excavation. I'm doing multiple doses.
Patrick:Okay, and do you carry just the single vial of five milliliters?
Chris Van Tillburg:Yep, that's it. So, and then I get home, I waste it and, you know, put a new one in my kit. But yeah, I just carry one, five ml bottle.
Patrick:Okay. How do you decide at that seven to ten minute mark whether or not to up the dose or re dose? Are you just waiting a full twenty to forty minute cycle and saying the next time I dose, I'm going to give more if pain control was not adequate?
Chris Van Tillburg:No, because the rescues in the mountain rescue situation are, you know, I wouldn't say chaotic, but there's so many different things going on. do I have somebody who could keep track of time. I try to have somebody on their phone, either myself or somebody else start a little chart note and just document times, but, you know, we're wheeling the patient down a litter, down the trail. We get to bridge, get the wheel off, haul him across the bridge, put the wheel back on the litter. there's just so many things going on that I just kind of wait till the patient says, Hey, I'm having pain again, which usually happens.
Patrick:Okay, yeah, 20 minutes or even 40 could go by relatively quickly in that setting.
Chris Van Tillburg:Right.
Patrick:you're never really giving say your a hundred milligrams or one milliliter and then 10 minutes later saying, well, that obviously wasn't enough and redosing right then.
Chris Van Tillburg:Uh, I think I've done that maybe once or twice where, know, we've had to redose before 30 or minutes went by. But in general, I just kind of give him the shot and wait five minutes for the edge to go away of the pain. And then we package them. I mean, there's so many other things we got to do. We got to extremity. Package them in a hypothermia wrap, get them in the litter, somebody might be working on the rope raising system, especially if they're up high on the mountain. We got to get them out of the femoral, which is where a lot of people land. And it's about a, you've been up there, it's about
Patrick:Yeah,
Chris Van Tillburg:know, 200 vertical raise to get back to the hogs back. Uh, so there's just so much going on that I don't, it's, not as prescribed as it is in the hospital.
Patrick:the fumaroles on the south side of Mount Hood always reminded me of those things you would see in kids arcades where you like feed a quarter in and it does circles and circles and circles down the drain. It just seems to pull people in no matter where you fall from off the top of the south side of Mount Hood. They just funnel into the fumarole.
Chris Van Tillburg:yeah,
Patrick:Oh, what an awful place to be. So are there patients with whom you would say, ketamine is not the right drug here. I am not going to give you ketamine to manage your pain.
Chris Van Tillburg:well, it does go through my mind. Occasionally. we had a patient who had a generalized tonic clonic seizure right in front of us, seven miles up the trail. And I didn't, I don't carry, benzodiazepine in my kit. So, after. The seizure that we witnessed, was postictal maybe five minutes or so we got her and started bringing her down and three hour ride down in a wheeled, you know, cascade toboggan. And so kind of did think twice. I talked to a pretty skilled paramedic that's on our team about giving that person ketamine for pain because, you know, there's the some reports of it, lowering the seizure threshold and so it's not ideal. But, you know, it's just, those are the kind of some of the decisions that we make in medicine. You make them all the time, right? You're just, uh, weighing risks and benefits. We had a two hour extrication down the trail, so I gave her ketamine. I did think twice about it.
Patrick:Had this patient sustained traumatic injuries?
Chris Van Tillburg:No, was just bouncing around in the litter.
Patrick:Okay. So, I guess, break down for me why you were considering pain control in that setting anyway. Just for the comfort of the ride?
Chris Van Tillburg:Yeah, she was in significant pain, just bouncing around in the litter. We were seven and a half miles up. We had two bridges to get across, one washout. The wheels got to come off for those situations. Um, you know, it's a rugged trail and she was complaining of pain and she said, this is really awful. I don't like this and I'm hurting. So yeah, I was, you know, atrogenic pain, pain caused by the extrication basically. So I talked to her about it and talked to her with my paramedic and I was like, you know, here's the options. I gave her probably a smallish dose, but yeah, that's just pain from just extrication.
Patrick:Yeah. Okay. And then classically, there's the concern about increased intracranial pressure, possibly when we administer ketamine. Um, do you? Hold any concerns about giving it to people who have sustained a head injury. And let's refine that to say, you know, I've hit my head, but I'm not yet altered, you know, because an altered patient, we might hold back or be cautious about administering centrally acting medications because we don't want to make them more altered. We don't want to make them stop protecting their airway or stop. respiring spontaneously, but let's say there's that person who's fallen off the south side of Mount Hood and they took a bouncing ride down to the funeral, hit their head, obviously wearing a helmet, but maybe brief loss of consciousness and that now they're talking to you. Do you have any concerns about ketamine in that patient?
Chris Van Tillburg:Yeah, like I would probably with any altering pain medicine. And I think we've had a couple of those where the,
Patrick:Okay.
Chris Van Tillburg:that's their fentanyl because they carry it. So we have had a couple of situations where that's a consideration. I mean, it's just we got to just weigh the pros and cons. If we just get the patient package in a hypothermia wrap and bundled in the litter, sometimes that's adequate pain control and sometimes it isn't.
Patrick:And I'm presuming you've never seen the mythical side effects of laryngospasm or pronounced hypersalivation when you're administering this pain dose ketamine.
Chris Van Tillburg:No, but we did have a patient. It wasn't my patient, but we did have a patient at the Mountain Hood Meadows Ski Resort Clinic who had a, um, airway compromise because of ketamine, you know, couldn't hold his neck up straight and kinked his head The nurses, the doc on duty straight down his neck and, um, Okay. But yeah, there, there's that case of positional or near asphyxia.
Patrick:And that based on what you said earlier, you were probably giving a higher dose in that setting to facilitate a reduction.
Chris Van Tillburg:Yeah, I think that was a case. It wasn't my patient. It was one of the other docs, but yeah, I think that was the case. it was a joint. Production,
Patrick:And just to quell maybe some of the concerns of the listeners who have less familiarity with ketamine. I mean, one of the reasons that we so love ketamine in the emergency department and elsewhere It has the effect of sedating or dissociating the patient, providing pain control, yet they continue to breathe for themselves, even if you go completely into that dissociative zone. So what you're saying in this patient is they essentially became too relaxed and too sedate and it was a mechanical level obstruction. They, you know, slumped their head and the hose got kinked. But not that they stopped breathing on their own, correct?
Chris Van Tillburg:Yes. A good clarification. That's correct.
Patrick:Yeah, it is such a magical drug for that reason and fairly neutral on the blood pressure if anything like a little bump in the blood pressure in young healthy people when we give it. So those are some significant upsides in comparison to opioids specifically or our other sedating medications Propofol or Versed, for example. I think that's a pretty good march through your approach to ketamine. I'm definitely going to try This intramuscular ketamine. I think I'm going to start in the emergency department using this for pain control to gain some familiarity with how folks look after one to 200 milligrams of intramuscular ketamine. You said you're thinking about adding some benzodiazepines to your kit. Are there other medications that you have tried carrying with you in the past and no longer found useful or ran into problems with them?
Chris Van Tillburg:I don't think so. And I'm giving a talk at the Wilderness Medical Society, Crested Butte Conference on advanced life support kits. So, anybody who attends that will get my full, List of what I bring, but I think, you know, I bring kind of very basic stuff, epi, nitro, aspirin, glucagon, a couple types of antihistamine, one sedating, one non sedating, and decadron, and ketamine. And I think I have some lidocaine too with me, and that's about it. So it's not a huge list, and it's pretty compact. all the meds fit into like a baggie. that's designed like a snack sized Ziploc.
Patrick:It's quite a snack.
Chris Van Tillburg:Yeah. Yeah. you know, the challenge really, as you know, in wilderness medicine is like, especially I realized when we were sitting there doing the, pain management guidelines for WMS, the big challenge is there's multiple things happening. on the side of the mountain or on a trail above a creek. people are cold. It's windy. You're on a dirt trail or on snow and we, can't literally just measure out exactly 2 milligrams per kilogram, for example, or we're just, you know, doing the best we can, as you know, to try to, get somebody. reasonable pain control, even just bring it down to a moderate level from a severe level and then get them packaged and get out of there. Um, so every, there's a lot of things happening at once. And oftentimes, if it's me or our other physician mountain rescuer, or our highly skilled paramedics, we're often doing two jobs because we're maybe, Team lead in medical or we're medical and we're also in charge of putting in a rope anchor just because we have limited resources.
Patrick:Right.
Chris Van Tillburg:we're doing multiple jobs,
Patrick:You don't have the luxury of being the staff physician inserted by helicopter like Dominique Zermatt.
Chris Van Tillburg:right?
Patrick:Which would be fantastic with a big duffel bag full of tools.
Chris Van Tillburg:Yeah,
Patrick:Yeah, it definitely falls into the art of medicine realm where that experience that you've garnered in the emergency department and other care settings over the course of years helps you make those decisions. So it's tough if someone is new to this setting where they're A paramedic who, is just entering a rescue setting, for example, or, even worse, a physician who is just entering a rescue setting. you want more monitoring tools. You feel a little bit naked and you have to fall back on judgment a lot more, which can be challenging. it feels a little bit more vulnerable when you're out in that setting and you're. Actions have more consequence because you have fewer rescue tools available at your disposal, like less ability to manage airway. I don't have a constant cardiac and pulse oximetry monitor. So I would be more than happy to be rescued by you, Chris, with your years of experience.
Chris Van Tillburg:but I think our corollary to that really, you know, really great observation. The corollary is we, the Craig rats, you know, we're the oldest mountain rescue team in the U. S. And we have gone through various cycles of personnel and. Just all of a sudden, three or four years, we have nine ALS rescuers, paramedics, a critical care nurse, three doctors, including me. So we are starting an ALS program, and I leaned on my good friend, A. J. Wheeler from Teton County to sort of put it together. In the ALS program, we are only medication for those ALS might be ketamine. It would be useful to bring other things, but I think the advantages of ketamine were they don't cause respiratory depression, as you mentioned. And, uh, If you err a little bit on the the pain dosing, not, not going to put somebody into a critical state. So there are a number of reasons where I think that will be the only pain medicine we carry. at least when we start, we're just starting this program, so we'll see how it goes.
Patrick:Yeah, that's interesting. We should stay in conversation about that. Not bachelors in the position of trying to expand their ALS program as well Just wanting to deliver a higher level of care to their guests And so going through the same kind of considerations as well. that brings to mind one last question about ketamine, which is, do you think about in terms of the viable operating temperatures, how do you actually protect the physical integrity of that medication in the field?
Chris Van Tillburg:Yeah, I just have it in my ALS kit buried in my pack, but I don't do anything special, for it in the field because usually, we're able to get to a patient in, 1, 2, 3 hours, something like that. So, I just put it in my pack and go and hopefully it doesn't freeze. I suppose if I was worried about it, throw a chemical hand warmer in my ALS kit.
Patrick:so you've never had that vial freeze. Okay. Now most, most of the meds, it seems like, have an operating temperature that is similar to that of a reasonably comfortable human. So, uh, it's, it's always a little bit off label when you're like, I'm gonna take this out in 30 degree temperatures for six hours. Yeah, it's hard to imagine it denaturing in the cold, but I have worried about precipitation, for example, having it come out of solution. Well, I think let's wrap up here. I want you to give us a little blurb about your upcoming book. You have a truly impressive list of your bibliography, not bibliography, your, your opus is extensive. You have written quite a number of books, both pertaining to wilderness medicine and to Travel in the backcountry, backcountry ski and snowboard routes, Oregon. It's really impressive. And I actually, when looking at your upcoming book, I'm quite interested to pick up a copy. Why don't you let us know what, what we have in store.
Chris Van Tillburg:Well, I've been a member of the Craig Rats Mountain Rescue Team based in Hood River, Oregon since, 2000 and, we were the oldest rescue team in the nation formed in 1926, so our, centennial anniversary is coming up next year. I said about, Documenting the 100 year history of the Craig rats. And after, you know, I've been working on this project for 3 or 4 years and after going over it with my agent and my editor, really about a 3rd of it is about the 100 year history of the Craig rats and about 2 3rds of it is the changing landscape of Mount Hood and how, you know, in 2022 during the pandemic, we had this surge of outdoor recreation and it, expanded all of the typical problems we have. So, it's really, it's a history narrative, but also grounded in modern day.
Patrick:So it's a hundred years of rescue history on Mount Hood. from the very early days up to now,
Chris Van Tillburg:Yeah, and the Craig Rats have very detailed archives date back to 1926. I mean, it took me a year just to go through the meeting minutes and news clips and, um, yeah, they, Craig Rats have maintained detailed archives.
Patrick:that's very cool. If our listeners are interested in learning about that or diving into more of your works, where should they connect with you? Where can they find Chris Van Tilburg?
Chris Van Tillburg:Uh, the best way is probably just to go to, um, either Wikipedia or, link tree, has links to my recent articles in an outside magazine, and it has a WMS practice guideline. So my link tree or my Wikipedia page have probably is the best place to start.
Patrick:Perfect. And for the listeners, we'll put those in the show notes. So you don't have to go digging around for those. And he just put in a subtle plug for our wilderness medicine clinical practice guidelines. Chris is the lead author on the avalanche and snow burial. Guideline, but also, as I mentioned earlier, joined us on the pain management in austere settings, which is, it's a tome. it's not an easy read because of the expansiveness of the document. But if you are interested in diving deeper, we have different sections on different medications. And also, I think the kind of general approach to. Pain management in there covers a lot of the art side of what we're talking about here. The many considerations that go into wilderness pain control. So you can look in the show notes to find a link to that as well. It is open access, so anyone can read it. Thank you again, Chris, for joining us. A really. Enjoyed chatting about this and I'm personally looking forward to giving some ketamine to some folks starting tomorrow in the ER for pain control. Going to build my experience around this one.
Chris Van Tillburg:Okay. Good luck. Thanks a lot for having
Patrick:All right, everybody. I hope you enjoyed that conversation with Dr. Chris Van Tilburg. Physician, author, rescuer, mountaineer, athlete. He's an interesting guy. I know Chris from our work together on the Wilderness Medical Society guideline for pain management in the austere environment, but he's also the lead author on the avalanche and snow burial guideline. And both of those are linked down in the show notes as well as links to Chris's personal page on His link tree, his Wikipedia, anything you can want to do to reach out to Chris, as well as the link where you can pre order his upcoming book, I don't get any kickbacks if you order his books, but it looks like an awesome book and he's been going through some really, really cool archives and putting together some awesome history. So I hope you enjoyed our conversation as always. If you have questions, comments, Suggestions for future episodes. Want to delve into things more or just have a personal clarifying question. You want to reach out to me and we can chat about how you are approaching pain management for your search and rescue your ski patrol or just your personal use. Don't hesitate to reach out at wilderness medicine updates at gmail. com right now. I am not on social media with any of this stuff because I just can't handle it. The real world happens elsewhere. So if you want to support the show. Because this is a passion project and I just pay for it out of pocket. We don't have any sponsors yet. The best thing you can do is make sure you are subscribed on your listening platform of choice, be that Apple podcasts or Spotify and whatever platform you're on. Do give us a review. Give us five stars because that helps get this out to other people. It helps get us into that suggestions box where it says, Hey, You listen to this podcast. Maybe you'd like wilderness medicine updates. And if you have another friend, a skier, a climber, a boater, a wilderness traveler, explorer, rescuer, Mountaineer, another athlete, maybe a med student, a PA, a nurse, an EMT paramedic. SAR member, ski patrol member who you know, hasn't heard this podcast and you know, they would benefit from hearing about wilderness pain control or updates to avalanche rescue protocols or the physiology of the buried avalanche victim, or all of the other stuff I'm going to be pushing out this year, share an episode with them and invite them to join the crowd. I really appreciate all the positive feedback that I get from you guys both in person, through the emails, through the reviews. I see all of them and I appreciate all of them and I do reply to all the emails that I receive. So until next time, stay fit, stay focused, have fun.
