Wilderness Medicine Updates

Ep. 24 - Airway Management in Austere Environments with Dr. Nicholas Weinberg

• Patrick Fink • Episode 24

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In this episode of Wilderness Medicine Updates, Dr. Patrick Fink discusses airway management in austere situations with Dr. Nicholas Weinberg. They explore two cases published in the Wilderness Medicine Journal, detailing the decision-making processes in managing critically injured patients. Dr. Weinberg shares his background in emergency and wilderness medicine, and highlights the importance of flexibility and the application of basic life support techniques in the wilderness. The episode emphasizes the significance of understanding the limitations and capabilities of the available tools in wilderness settings.

Links

WEM Article

Photo: Ledge from the fallen climber

Photo: Himalayan clinic resuscitation

Connect with Dr Weinberg: Nicholas.E.Weinberg@hitchcock.org

Timeline

00:00 Introduction and Overview

00:26 Meet Dr. Nicholas Weinberg

01:48 Dr. Weinberg's Background and Career

03:55 Case Introduction: The Climbing Accident

05:38 On-Scene Response and Initial Assessment

08:11 Airway Management and Rescue Coordination

11:05 Patient's Condition and Medical Interventions

18:34 Patient's Recovery and Conclusion

21:01 Reflecting on a Remarkable Case

21:30 Discussing the Second Case

22:59 Experiences in Wilderness Medicine

25:24 Challenges and Strategies in Remote Medical Care

30:31 Managing Airway in Austere Environments

37:42 Advice for Aspiring Wilderness Physicians

42:24 Concluding Thoughts and Listener Shoutouts

As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.

Connect with us by email at wildernessmedicineupdates@gmail.com.

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Patrick Fink MD:

Hello and welcome back to Wilderness Medicine Updates the show for providers at the edges. I'm your host, Dr. Patrick Fink. Today we're gonna talk about airway management in austere situations, and we're gonna use a real life case. I'm pleased to have Dr. Nicholas Weinberg join us today to discuss a case that he published in the Wilderness Medicine Journal. Look in the show notes for a link to that and some pictures related to the case. I'm excited to bring this material to you because I feel like these situations of high acuity patients where you're making consequential decisions with advanced interventions are not all that common in wilderness medicine. Search and rescue, we just have a low volume of similar cases, and so it's useful to be able to learn from one another. To hear about someone's thought process, why they made certain decisions, even if maybe you don't agree with them in all points. Not saying that, that's how I feel about Dr. Weinberg. Dr. Weinberg is an emergency physician at Dartmouth Medical Center and an assistant professor at Dartmouth's Geisel School of Medicine. He serves as the assistant director of Dartmouth's Wilderness Medicine Fellowship, and he has practiced expedition and wilderness medicine around the world. Notably, Dr. Weinberg just returned from a patrol on the National Park Service high altitude patrol on Denali, and he is known for his extensive experience in Mountain and Wilderness Rescue Medicine. Without further ado, I want to bring you straight into my conversation with Dr. Weinberg. I hope you enjoy. Why don't, why don't we just start with how do you tell people what you do and, and where does wilderness medicine fit into your career?

Nick Weinberg:

So I am an emergency physician, at Dartmouth Hitchcock Medical Center, and I'm at the medical school at Dartmouth an assistant professor, and I'm an assistant director of our wilderness medicine fellowship here. And also I, I am involved in ultrasound as well. I did an ultrasound fellowship. So I kind of wear two hats here. And I, before medical school I was a

Patrick Fink MD:

medical appointments.

Nick Weinberg:

a mountain guide ski patroller, ski instructor, offshore sailor bum dirt bag traveler. And then I went kind of back to, I went to medical school after I was in a climbing accident many years ago with a friend of mine and. I evacuated him with some basic woofer training, and had this epiphany that I wanted to do wilderness medicine. I went to a conference in Steamboat many years ago,

Patrick Fink MD:

So.

Nick Weinberg:

most of the folks there were emergency medicine physicians that worked part-time in the ER and did lots of other cool stuff. So they said, yeah, it's great. You can do emergency medicine and work part-time in the ER and then do wilderness medicine stuff. in your other time. So that was kind of my goal going back. And then I worked I went to medical school in Vermont, university of Vermont. And then I worked in the community hospital in the Adirondacks and upstate New York for a few years and which allowed me to do a lot of wilderness medicine stuff. I worked in Nepal for the Hi Himalayan Rescue Association. I did patrols on Denali. I worked on a, a ship that sails around the world a square rigor as the physician crossing the Indian Ocean for four months. So I did a bunch of stuff like that

Patrick Fink MD:

So I did a bunch of stuff like that and then

Nick Weinberg:

academics,

Patrick Fink MD:

to get back, back

Nick Weinberg:

fellowship, in Boston at Mass

Patrick Fink MD:

into Austin and.

Nick Weinberg:

up in New Hampshire at Dartmouth. Yeah, that's kind of abbreviated version of my story.

Patrick Fink MD:

Great. Well, I was really happy to see the two cases that you published in Wilderness and Environmental Medicine.'cause I think these kinds of cases are useful for learning purposes, but the frequency of these high acuity cases is relatively low in any given. Rescue outfit or or SAR group. So it's hard to chase them down and get'em out there in a HIPAA compliant format. And so when I saw this paper come across my desk, I was like, I gotta find this guy. So

Nick Weinberg:

Yeah,

Patrick Fink MD:

let's start with, with.

Nick Weinberg:

and it was kind of an unusual paper to publish and we were kind of threading the line of, you know, HIPAA compliance and, you know, I think we, we were compliant. And, and actually the falling climber you know, she reached out to me. I can tell you this is an interesting part of the story actually and gave me permission to publish this and to help other people learn from this experience. So,

Patrick Fink MD:

That's awesome. Well, let me just start with the first paragraph of this case and then I'll have you lead us in.

Nick Weinberg:

sure.

Patrick Fink MD:

In the White Mountains of New Hampshire, a rock climber and her thirties and her partner scrambled Unroped through Class five technical terrain. To reach a crag, the climber slipped and fell approximately 12 meters or 40 feet. Down a loose gully onto a steep exposed ledge. A nearby pair of climbers, including an emergency physician, heard the fall followed by calls for assistance. The EP had technical climbing experience and training in mountain rescue. He scrambled up the ledge to access the victim. Meanwhile, his partner used a cell phone to call for medical assistance and organized a team of nearby climbers to perform a litter rescue. So let's just get it out there, right up front. You are the emergency physician in this case, right?

Nick Weinberg:

I am. Yeah.

Patrick Fink MD:

Can you walk us through the moment when you first arrived on this scene? What, what did you see? What was going through your mind as you approached this woman?

Nick Weinberg:

Yeah. So

Patrick Fink MD:

Yeah, so

Nick Weinberg:

at

Patrick Fink MD:

you know, I was climbing at this.

Nick Weinberg:

climbing area in New Hampshire. And I heard this loud thud sound that if you have ever heard the

Patrick Fink MD:

Never heard

Nick Weinberg:

falling, it's the sound that you never forget. And I immediately. Knew that it was a bad event and that someone had fallen pretty far just from the sound of it. But then I didn't hear any noises

Patrick Fink MD:

didn't hear any noise.

Nick Weinberg:

was just a tree that fell in the woods. Sometimes you hear a random tree fall and then like a minute later we heard calls for help and then knew that someone was pretty badly injured. So you know. Being a physician experienced and trained in mountain rescue, I wanted to assist. and so I climbed up to this ledge that the, that she, this patient was on and kind of found her there. So she had fallen and was basically kind of down headfirst on this ledge. and she was breathing, but, but really wasn't

Patrick Fink MD:

But

Nick Weinberg:

her

Patrick Fink MD:

really wasn't

Nick Weinberg:

Which was pretty dramatic. I mean, we

Patrick Fink MD:

pretty dramatic. I mean, we learn a lot

Nick Weinberg:

in emergency medicine, and it's pretty rare that to have someone

Patrick Fink MD:

Rare.

Nick Weinberg:

no airway reflex and she really didn't have any airway reflex. So it, it was kind of like basic first aid stuff that you're taught in wilderness first aid courses. And you know, I did a, a jaw thrust. and opened her airway and her partner was with

Patrick Fink MD:

And her partner with

Nick Weinberg:

shaken up. Not really very functional. So we kind of calmed him down

Patrick Fink MD:

her,

Nick Weinberg:

him. And then I realized that she was gonna require a technical rescue'cause it was on this exposed ledge up on a steep hillside. so, I figure I made the decision to

Patrick Fink MD:

I made the decision

Nick Weinberg:

Her there. After we had kind of talked her partner down and kind of calmed him down a bit and then taught him how to do a jaw thrust and he was able to do that effectively, so I felt that my skills would be better

Patrick Fink MD:

be better.

Nick Weinberg:

kind of running this rescue and getting the right resources that we would need for this particular rescue.

Patrick Fink MD:

What did it take to get to that ledge? How, what kind of terrain was between you and there?

Nick Weinberg:

was kind of some, some moderate scrambling, maybe kind of 5, 5, 5, 6 climbing terrain. I don't know if you're a climber, but,

Patrick Fink MD:

Mm-hmm. Yeah.

Nick Weinberg:

so I mean if, if, know, it was a little bit exposed,

Patrick Fink MD:

was a little bit exposed, but

Nick Weinberg:

An experienced climber it wasn't. I I was comfortable kind of soloing

Patrick Fink MD:

mm-hmm.

Nick Weinberg:

Yeah.

Patrick Fink MD:

And were there any concerns about either your security or the patient's security on the ledge, like

Nick Weinberg:

The ledge

Patrick Fink MD:

proximity to the edge potential for an additional

Nick Weinberg:

she was on this kind of

Patrick Fink MD:

Yeah.

Nick Weinberg:

ramp where it was not an ideal place to kind of package her and kind of initiate care, and so I wanted to, the first thing I wanna do is move her down to this lower ledge. A few feet down where there was more space to work work with, and it was less exposed.'cause I obviously didn't want someone else, you know, to create additional victims. So, so we,

Patrick Fink MD:

And did you do that during your.

Nick Weinberg:

so we, we a, a bunch of us basically beamed her down to this other ledge. Yeah.

Patrick Fink MD:

Okay, so you then descend off of the ledge to start coordinating rescue for her?

Nick Weinberg:

Yeah. So then,

Patrick Fink MD:

Yeah.

Nick Weinberg:

the, the partner kind of, well, we left him kind of holding her in a jaw thrust position immobilizing her. And then my climbing partner who didn't have any medical experience.

Patrick Fink MD:

Any medical

Nick Weinberg:

organized a rescue, a, a team of litter carriers, essentially, of other climbers. And also called for nine one one on his cell phone. And then I scrambled down, to eventually down to a parking area where I met the. EMS crew that was first on scene and I, I used to work in a community

Patrick Fink MD:

I used to work

Nick Weinberg:

in, near this

Patrick Fink MD:

near

Nick Weinberg:

and I

Patrick Fink MD:

area.

Nick Weinberg:

paramedic who was on, who was a, also a climber. So it was very convenient and I basically told him story and that that explained that this woman probably needed, you know, to be intubated and needed RSI meds. So he, we basically packed up all of their RSI

Patrick Fink MD:

Up

Nick Weinberg:

and brought it up to this ledge. So it's a pretty unique scenario where we were

Patrick Fink MD:

where we were

Nick Weinberg:

from the

Patrick Fink MD:

far enough from the road that.

Nick Weinberg:

and lowers, but close enough that you know that that street paramedics, well it is a rural area, but, but the paramedics could make it up there.

Patrick Fink MD:

Mm-hmm.

Nick Weinberg:

that's what made it kind of an

Patrick Fink MD:

How, how long do you think it was between did it take to leave the patient, get the paramedic, come back?

Nick Weinberg:

Probably. 45 minutes, maybe 30 to

Patrick Fink MD:

Okay.

Nick Weinberg:

Yeah,

Patrick Fink MD:

Yeah. And when you returned to that ledge with the paramedic, did you appreciate any change in her condition at that point?

Nick Weinberg:

wasn't, was about the same. Really still

Patrick Fink MD:

Mm-hmm.

Nick Weinberg:

her airway. Her very low GCS basically unresponsive to even painful stimuli.

Patrick Fink MD:

Yeah, so I, I think for the emergency physicians listening, that tells a, a pretty stark story. But for, for those maybe with less medical training, what was going through your mind about the nature of her injuries and what you might be facing?

Nick Weinberg:

Yeah, I mean the, so she

Patrick Fink MD:

Yeah,

Nick Weinberg:

and the way

Patrick Fink MD:

tell.

Nick Weinberg:

landed up kind of upside down headfirst. I was very concerned about C-spine injuries, which she ended up having. Several cervical spine fractures unstable fractures. And she ended up being neural, neurologically intact in terms of c-spine injury, but she had several unstable c-spine fractures. And then she ended up having subdural, subarachnoid hemorrhages and intraparenchymal bleeds as well. So yeah, my biggest concern was,

Patrick Fink MD:

My biggest concern.

Nick Weinberg:

immobilization. You know,

Patrick Fink MD:

Mm-hmm.

Nick Weinberg:

she, we were able, we kind of controlled her airway by just a jaw thrust and that was working.

Patrick Fink MD:

Yeah. I guess with that sustained, altered mental status, it's telling you that she has a pretty significant head injury.

Nick Weinberg:

Yeah.

Patrick Fink MD:

I, I imagine that if I had been in your place, I would've had some concern that she could herniate, she could deteriorate. You know, you might be coming back to an even worse situation or someone who's died while you were gone.

Nick Weinberg:

Yeah. That definitely. But fortunately, she, she maintained degree of stability even though she was obviously very sick. Yeah. So.

Patrick Fink MD:

So it sounds like as you were returning, you were thinking through how you wanted to manage her airway. What factored into your decision to pursue rapid sequence intubation versus an LMA, sticking in an oral airway and continuing bag valve masking?

Nick Weinberg:

Yeah. I mean, I, I

Patrick Fink MD:

Yeah, I mean.

Nick Weinberg:

in most wilderness situations you're not gonna have RSI available. And it's, it's not gonna be an option. You know, you'll have maybe an, an oral airway but since,

Patrick Fink MD:

But

Nick Weinberg:

since it was kind of a unique case in that it was remote but not remote enough

Patrick Fink MD:

not remote.

Nick Weinberg:

you know, a LS crew from being on scene essentially. So we had a lot more resources than you might have in a lot of other scenarios. We had the experience and skill level to do RSI and I knew that paramedic, I trusted him. He knew me, we'd worked together. So, and I knew that it was gonna be technical carry out with some lowers and that, you know, an LMA wouldn't be ideal since you really needed an airway. Were able to do RSI and we had a suction device. We had meds, RSI meds and sedation meds, and we had oxygen as well.

Patrick Fink MD:

Mm-hmm.

Nick Weinberg:

And we had, we had backups,

Patrick Fink MD:

All had backup

Nick Weinberg:

So it, it seemed like a reasonable choice given the situation.

Patrick Fink MD:

given how abed and out of it she was.

Nick Weinberg:

Yeah.

Patrick Fink MD:

And the potential for blood or, or vomitus in the airway, did you consider not paralyzing her?

Nick Weinberg:

Yeah, that, that was my

Patrick Fink MD:

Yeah.

Nick Weinberg:

concern was that she would have blood or secretions in the airway and that we would be out here with a mechanical suction device and not able to intubate her. And there were secretions and blood in her airway, but we were able to quickly suction it out and it ended up being a non-issue. But yeah, that, that could have been, you know, a, a point where things could have turned for the worse into different circumstances for sure.

Patrick Fink MD:

Yeah. When I imagine myself in your shoes, I'm, I'm feeling apprehension about paralyzing this patient because of the. You know, obviously suboptimal patient positioning. You know, this patient is not on a gurney up at your sternal height where you're gonna be able to get a great angle into the larynx. And yeah, I, I got a little puckered just thinking about it.

Nick Weinberg:

yeah. I don't, I, I guess, I don't know. Yeah. The other thing was paramedics are used to intubating people on the floor lying down, you know, so. So he, my, my, the, my colleague, the paramedic who was there, was very comfortable doing this. And, and I, I wanted him to intubate since, you know, he, they don't get too intubated as often as we do, so, and I was there as kind of a backup, so I kind of walked him through it. But yeah, it's,

Patrick Fink MD:

But yeah.

Nick Weinberg:

you know, it, it worked. The, the other thing was she was otherwise young and healthy and, you know. Didn't, I didn't think she would be a difficult airway, and she wasn't so based on her anatomy and age.

Patrick Fink MD:

Thinking your way down the airway algorithm, did you have things to perform? A Cracko thyroid otomy if you needed to?

Nick Weinberg:

I don't We did. I don't, I don't know if the paramedics have a, had a CRI kit. They might, but I, I honestly can't remember. They, they might've.

Patrick Fink MD:

Okay, so then you've got this patient intubated despite the fact that she had blood in her airway and manual suction, which almost never seems to work.

Nick Weinberg:

Work actually.

Patrick Fink MD:

the,

Nick Weinberg:

Situation.

Patrick Fink MD:

that's, that's great. That's like the first time I've ever heard of that. Every, every time It is like one of those squeeze ones

Nick Weinberg:

Yeah.

Patrick Fink MD:

where you have to like

Nick Weinberg:

It

Patrick Fink MD:

it. Yeah. It never

Nick Weinberg:

I've ever used one of those in a real scenario, and it worked surprisingly

Patrick Fink MD:

you. You got your one that like, never, ever, ever have worked for me.

Nick Weinberg:

I, I

Patrick Fink MD:

regardless, so you've got the tube in.

Nick Weinberg:

all, they're all these like cheap fans you can get on Amazon. I want, like, I, they must have like battery powered suction devices now. That could be very powerful. Anyway. Something to think about.

Patrick Fink MD:

That's often like a, a terrible YouTube ad. It is like this device will blow up the internet and it's like some tiny little vacuum cleaner like that. Maybe that's all you need.

Nick Weinberg:

Yeah. Well, I mean, stuck whenever I'm, you know, setting up for an intubation with the residents I'm, and suction is all, is the most important thing in my mind, you know, making sure it's there and

Patrick Fink MD:

Yeah.

Nick Weinberg:

Yeah.

Patrick Fink MD:

If you can't see, then

Nick Weinberg:

Yeah.

Patrick Fink MD:

that makes everything nearly impossible. So how did you secure the endotracheal tube?

Nick Weinberg:

We had tape and just, yeah. The, the paramedics had kind of all their, kind of let them do their thing. I was there kind of

Patrick Fink MD:

mm-hmm.

Nick Weinberg:

them and of, yeah, being the point person,

Patrick Fink MD:

Okay,

Nick Weinberg:

I let them the small stuff like sharing the tube the way they do it. Yeah.

Patrick Fink MD:

so then you eventually get her packaged into a litter. She needs at least like one technical lower off this ledge.

Nick Weinberg:

Yeah.

Patrick Fink MD:

did you continue to ventilate her during that process?

Nick Weinberg:

Yeah. So we, I mean, we

Patrick Fink MD:

Yeah.

Nick Weinberg:

attendance that were bagging her while she was being lowered. So which worked it wasn't, it was steep, but it wasn't a vertical lower, I would say it was maybe. 50 degrees, 50 to 60 degrees Rocky

Patrick Fink MD:

So did you have multiple attendants on the litter then? Okay. Yeah, that's that's helpful.

Nick Weinberg:

yeah.

Patrick Fink MD:

Okay. And then you, you mentioned some of her injuries, so she had unstable cervical spine injuries, multiple varieties of intracranial hemorrhage.

Nick Weinberg:

Yeah.

Patrick Fink MD:

How did she end up doing clinically?

Nick Weinberg:

She, she also had a BAS skull fracture. It was mostly kind of from the C spine up where her injuries, but they were very severe. And so she, so eventually we carried her down and transferred her to Dart, which is the name of our Air medical service at Dartmouth. and they landed in nearby field and flew her to Dartmouth to our hospital, and she was evaluated as a trauma patient, admitted to the surgical ICU, and she had a

Patrick Fink MD:

And she had it very complicated.

Nick Weinberg:

She was in a pento barb because of increased ICP. She was on like continuous EEG monitoring. She was cranked and pegged. and basically, so this is actually a good story. I remember one of my residents was rotating in the ICU and I would talk to'em about her getting updates. And I, I guess the teams were continually trying to convince the family to withdraw care. Because her

Patrick Fink MD:

Oh.

Nick Weinberg:

was that poor. And eventually she got, she went back to where she got transferred back to her home state and was cranked and pegged in a, a nursing facility for several months. And I kind of assumed that was it. And she would be in this persistent vegetative state, et cetera. and her one day when I was working in the ed, her mother came to me like found me in the ER and was very grateful'cause she thought I had, you know, saved her daughter's life, et cetera. Anyway, so I, I, I stayed in touch with her mother. anyway, about six months after this, I kind of had forgotten about her. I got a text from her, from the patient basically saying. Explaining what had happened to her and thanking me for saving her life. And I said, wow, this, this text is fairly coherent. Like there was one little typo, I think. so and so she ended up having an amazing recovery and, and was functional and she sent me a picture of her, like playing guitar. And I, last I heard she was writing a, a book or a memoir about her experience. So a happy ending to the story. Yeah. Which is which on

Patrick Fink MD:

Yeah. It's all,

Nick Weinberg:

I think.

Patrick Fink MD:

yeah, everything about this case is, is remarkable. And I don't think it was hyperbole to say that having someone with your combination of skillsets on the scene was incredibly fortunate for her.

Nick Weinberg:

yeah. Yeah. I, I guess

Patrick Fink MD:

Yeah.

Nick Weinberg:

Yeah.

Patrick Fink MD:

Well, it's always nice to have someone say thank you. That doesn't happen all day, every day.

Nick Weinberg:

that often in the er.

Patrick Fink MD:

Great. Well, I, I'd like to, I think we have time to move on to the second case if you're open to that

Nick Weinberg:

Yeah.

Patrick Fink MD:

the, the two cases together do raise the question like, are you a terrible black cloud? On every expedition you go on.

Nick Weinberg:

I don't think so actually.'cause I, I, just got back from a month on Denali doing rescue work and this was my third season up there. And it was actually very light in terms of SARS and, and stuff. There was a lot of frostbite'cause it was very cold, but there were not a lot of

Patrick Fink MD:

Mm-hmm.

Nick Weinberg:

Bad falls. So I, I think I used to be more of a black CRA cloud, but now I don't know. It's, it's

Patrick Fink MD:

You've, you've punched that card.

Nick Weinberg:

Yeah. Yeah. Although I have, I have had quite a bit, quite a few accidents once I was climbing in the Gunks, which is a climbing area in New York state kind of a similar episode where a climber fell right next to us. A 40 foot lead fall and was all, was basically hanging upside down, unresponsive, not protecting his airway. And I, I, we, we kind of evacuated him as well. He ended up getting intubated and flown and had severe head injuries as well. So, I don't know, maybe I am a black cloud. Maybe you don't wanna be climbing next to me, I guess is the moral of the story.

Patrick Fink MD:

Or maybe you do. It's hard. It's hard to say.

Nick Weinberg:

I think the more

Patrick Fink MD:

All right, well let.

Nick Weinberg:

you know, a

Patrick Fink MD:

And

Nick Weinberg:

of people ask

Patrick Fink MD:

you know a lot of people,

Nick Weinberg:

like how to get interested in wilderness medicine. And I think, you know, I ironically,

Patrick Fink MD:

you know, I ironically, I, I.

Nick Weinberg:

that day and I was supposed to be at some conference. A wilderness medicine conference and I went, decided to go climbing instead. And then that event ended up happening kind of serendipitously. And so I, I think what I tell people is like, if the more you get outside and do things, the more you will end up in situations where you have to offer care or rescue people. So the, I guess my, my advice to, to young people interested in wilderness medicine is to. Just get out and recreate and spend a lot of time doing things'cause you'll end up getting pulled into rescues. And I think as, as

Patrick Fink MD:

I think.

Nick Weinberg:

physician, people, just, whether you want to or not, they will look up to you and you will end up kind of being the leader in these rescues often. So, which is kind of cool.

Patrick Fink MD:

Yeah, it is. I mean, it's a, it's a very pertinent skillset in that we're used to being, you know, kind of the leader of the team and assuming the, the risk and the decision making, which are the two elements that people are most willing to just hand off in, in one of those rescue situations.

Nick Weinberg:

Yeah. Well, I, I think we're comfortable. We're, we're so UI think we take for granted actually how much risk we manage on a day-to-day basis in the ed,

Patrick Fink MD:

Mm-hmm.

Nick Weinberg:

So in these situations. A lot of other people are incapacitated, but for us, you know, this, we just have one patient, you know, compared to what a busy day in the ed, you can have 40 patients that you are responsible for. So, I mean, us, these, the, like, that scenario is, is not, actually not that challenging for what we're trained to do, you know?

Patrick Fink MD:

Right. The challenge is just the limited tool set, which on the flip side is also dramatically simplifies the decision making.

Nick Weinberg:

Yeah, and that's, that's I

Patrick Fink MD:

Yeah.

Nick Weinberg:

we decided to write this paper was because, you know, you, you have limited resources and basically you do the best with what you can. And in some ways it's less stressful because you have options to choose less potential pathways. You kind of just, just doing the best you can. It's, it's a different

Patrick Fink MD:

when you're,

Nick Weinberg:

care and I think that was kind of the one of the main reasons I wanted to write the papers because it is a different standard of care and just it out there that it's okay to function at a different standard of care from what we're used to in the ed.

Patrick Fink MD:

mm-hmm.

Nick Weinberg:

I don't know

Patrick Fink MD:

Well, let me introduce this second case and, and we can work through it and see the contrast. During a snowstorm, a guide escorted a middle-aged tracker on horseback from the village of Buche at 4,940 meters or 16,000 feet to the Himalayan Rescue Association Clinic in Che. Am I saying that right?

Nick Weinberg:

got it. Perfect.

Patrick Fink MD:

Che Che Nepal. The Trekker had a Glasgow coma score of nine and was Tachypnic. Her guide told the two emergency physicians at the clinic that the trekker likely had high altitude cerebral edema. She had spent the previous day in her room at a lodge with a headache. She had no reported respiratory symptoms. She had no known significant past medical history and had been at altitude before without problems. Where I wanna start with this one is I think folks should look at the paper in the show notes and see the picture of the room that you're working in. Can you set the stage for us what this clinic looks like?

Nick Weinberg:

Yeah, sure. So the Himalayan Rescue Association is a nonprofit that's based in Catman du Nepal. And their initial clinic was in this region, which is the Kubu region, which is the Everest Valley. Which is a very popular, it's the most popular area in Nepal for trekking and obviously for climbers as well. And it was first developed in the seventies because they were seeing a lot of unnecessary morbidity and mortality in that region, mainly from altitude, illness that could have been prevented. And so the, this was developed, the first clinic was in Farge, which is at 14,000 feet roughly. And it's a small clinic in a, it's a small stone basically with some solar electricity. And that's about it. And it's basic in terms of resources.

Patrick Fink MD:

Pretty basic.

Nick Weinberg:

there's some oxygen tanks, there's a monitor, oxygen concentrators. an EKG machine, there's no imaging, there's

Patrick Fink MD:

No imaging, limited medication,

Nick Weinberg:

supplies

Patrick Fink MD:

basically whatever supplies,

Nick Weinberg:

the years. And they also have another clinic

Patrick Fink MD:

they also have another clinic.

Nick Weinberg:

region on the Anaperna Circuit Trek. There's a pass that people go over that's 17,000 feet and a lot of Reers get altitude illness there. So the main reason there is to prevent altitude, illness, and reers there. and they take volunteer physicians for about. Four months, three to four months in the fall and spring seasons. So I did

Patrick Fink MD:

Okay.

Nick Weinberg:

there and it, it happens to

Patrick Fink MD:

Yeah, the, the.

Nick Weinberg:

probably the best place in the world to see and treat altitude illness. If you're interested, I'll put a plugin for the HRA. Yeah, it's a fun time too.

Patrick Fink MD:

The, the picture really looks like you're in a kind of crummy room of a hostel, and there's two, two beds and there's a monitor and what looks like a climber's oxygen tank sitting on the bed. And you guys are both wearing like knitted caps, like it's not heated and it's cold in there.

Nick Weinberg:

Yeah, it's, it's very

Patrick Fink MD:

Yeah.

Nick Weinberg:

and that was towards the end of the season in, I think it was November. It, it gets quite cold up there. And I was in the middle of the night actually. I was basically running a code in my long underwear, which was kind of funny. And only time I've run a code in my long underwear. But we were, there's this, this giant bell school bell that they have out, it's front of the door and people ring it. And so we were sleeping in the middle of the night and someone rang the bell and then we, I opened the door and there's this woman that looked like she was literally dying and she was, and she was on horseback. And then as soon as we walked her over to a bed, she syncopize and basically went into a PA arrest.

Patrick Fink MD:

Yeah. So what were you thinking at that moment in terms of what might be going on with her? Don't, don't ruin the punchline quite yet as to what is actually going on, but.

Nick Weinberg:

So, well,

Patrick Fink MD:

So.

Nick Weinberg:

the, the, the Nepali guide that was with her basically said, oh, she. She has, she has hate and has, you know, that's what, that was his diagnosis. and you know, basic, most things at altitude are altitude related until proven otherwise. So kind of everything else in the diagnosis of exclusion. So most of the time, whatever these people come in with, it's usually related to the altitude and when they go down, when they descend. Whatever symptoms they had seemed to go away. It's kind of like a dialysis patient where whatever symptoms they come in with seem to get better when they get dialyzed. You know similar with altitude, illness, they get better when they go down. So, you know, our, our first assumption was this is, you know, you had, has, or something like that, or hape and has is the most likely cause. And her, her oxygen saturation was unmeasurable, so we kind of assumed it was hape and haze and they can often be. commitment together. The only thing is she had clear lung sounds, which was a big clue what she ended up having.

Patrick Fink MD:

Mm-hmm.

Nick Weinberg:

Yeah.

Patrick Fink MD:

Yeah. How did, how did your initial suspicions guide your initial interventions?

Nick Weinberg:

So we, we just kind of empirically treated her for hape and hace, so we put her on oxygen and we gave her I am dexamethasone. didn't give her Nifedipine. Then we basically bagged her. She didn't, she, she did regain pulses, but she didn't really perk up that much. And one thing about ha, which is how to pulmonary edema is they often, and this is often a board exam question, they often get rapidly better with oxygen. And that can be used diagnostically too. Unlike someone with pneumonia that is still gonna stay pretty sick and hypoxic people with hate because it's this inappropriate pulmonary vasoconstriction. As soon as you put them on oxygen, they get rapidly better, and that didn't happen to her. So that raised our suspicion that there was something else going on.

Patrick Fink MD:

Talk to me about how, so she, you do CPR for a bit, you get pulses back, which is sort of remarkable in and of itself in someone who's got PEA and maybe just hypoxic versus intracranial cause of her arrest. She then doesn't have great initial respiratory effort. How were you thinking about managing her airway, both over the, you know, the next hour or two, and then looking forward through her potential evacuation?

Nick Weinberg:

Yeah, well,

Patrick Fink MD:

Yeah.

Nick Weinberg:

thing, one other clue to the diagnosis is that she syncopize with exertion. And then once we kind of stopped exerting her, she did slowly get better and then regained kind of weak pulses. And she, she did slowly improve in terms of her, her mental status. but she still remained basically abcu all the whole night. And then the next morning she was a lot more awake and alert. being on oxygen all night. so, you know, we still thought there was probably a component of, of tape involved, which there may have been.

Patrick Fink MD:

And what tools did you have to manage her airway, and how did you opt for one over the other?

Nick Weinberg:

Yeah. So I mean, we had oxygen tanks, oxygen concentrators, masks. There was an assortment of endotracheal tubes that had been brought and left there. There had been some anesthesiologists who had worked there. There was a couple LMAs, A BVM, there's no, no ventilator. And, and just kind of a hodgepodge. I, I don't, I don't know if, if, if you do expedition medicine you end up using kind of a hodgepodge of stuff like that. Sailboat. I worked on that tall ship. It was random stuff that people from all over the world had brought different doctors over the years. So that's also kind of fun, is like you kind of what you have. But there was, there was a storm. We knew we weren't gonna be able to fly her out for at least 24 hours. So the thought of intubating her and then just bagging her for to 48 hours before we could fly her out just didn't seem that appealing. And she was very sick, but was kind of somewhat stable at this sick level. So we, we kind of made the decision to just watch and wait. And again, you know, we were the only, she was

Patrick Fink MD:

You know.

Nick Weinberg:

in, if you were in a busy er, you would, would just intubate her and move on. Right? And they, she'd go upstairs to the nicu. but we had the option to kind of monitor her closely. so, we made the decision not to intubate her. And, you know, both the point

Patrick Fink MD:

You.

Nick Weinberg:

was that both of these patients, if you presented them to any. Standard emergency department in a developed country would get promptly intubated. And we could have managed them differently based on, based on the context.

Patrick Fink MD:

Right. So you, you didn't feel like you wanted to be up all night bagging this patient or potentially through the following day, even maybe employing the guide or whomever else to, to bag

Nick Weinberg:

and also we didn't have

Patrick Fink MD:

and.

Nick Weinberg:

like we, I don't think we had any RSI meds. We didn't have sedation meds. You kind of, I mean intubating someone is a commitment. Once you intubate them, you're committing to, you know, maintaining them as sedated, which with the other patient, the climber, we could do that. And I knew that we were gonna get her down to a helicopter who could, you know, get her to a TER care care center. So,

Patrick Fink MD:

Mm-hmm.

Nick Weinberg:

yeah.

Patrick Fink MD:

So by the following morning, she's a little bit more alert. Was she able to give you any additional history that helped you better understand what had happened?

Nick Weinberg:

the, the, the following afternoon, I would say by the following afternoon she could actually talk to us and she said, yeah, she didn't have hi a headache at all. And that basically she'd been in her, in her tent for a couple days, and then became really short of breath.

Patrick Fink MD:

So she ends up being flown by a helicopter to a hospital in Cat Mandu. And what did they find there?

Nick Weinberg:

So they, they worked her up and they ended up scanning her chest with a CT and found that she had bilateral massive pulmonary emboli and she.

Patrick Fink MD:

she had any history of clots? Do you know?

Nick Weinberg:

Yeah. And she flew back to Austria and ended up doing well, is what I heard.

Patrick Fink MD:

It's another case that seems so improbable because cardiac arrest in the setting of massive pulmonary embolism doesn't usually turn out well, let alone in this austere setting.

Nick Weinberg:

Yeah. Yeah, well, I, and, and I think the fact that, that she kind of syncopize and arrested with ambulation, that's kind of a big clue in retrospect. You know, I, I always have the residents kind of ambulate people if you're thinking about a PE because they often get more symptomatic with ambulation. And she got very symptomatic, obviously, she went into a arrest, so you know that. But, but so she, she

Patrick Fink MD:

Yeah, so.

Nick Weinberg:

enough that, you know, she, she made it through and and got better overnight.

Patrick Fink MD:

So you do a nice job in this, in this paper, there's a great table that I would refer our readers or listeners to. Talking about the different airway interventions, everything from a recovery position up through endotracheal intubation, and a crike. And looking at the advantages and disadvantages of, of both of those, of, of, of each of those interventions. What strikes me is it's primarily an issue of once you commit to the airway, what do you have to do to maintain it?

Nick Weinberg:

Yeah.

Patrick Fink MD:

that seems like kind of a, a critical point in both of these cases.

Nick Weinberg:

Yeah. And that's something that I don't think we have to really worry about in, in the ed, in in our, our home environments because there's always gonna be a respiratory therapist who appears and kind of manages everything, gets the vent set up, and then get eventually transferred to the ICU. in these wilderness settings you don't have that. So you really have to kind of think. Carefully about, you know, what the, the, the ramifications of your, of your actions, I think, and how you're gonna manage this patient after you intubate them. So, yeah.

Patrick Fink MD:

you had a, a senior resident who's graduating and they're saying, Dr. Weinberg, I'm spending my next year up in, up in the Himalaya, or I'm, I'm doing multiple patrols on Denali. How would you brief them or, or give them a mental framework for how to take them ER skills and apply them to that setting?

Nick Weinberg:

Hmm. Where do I begin? Yeah, I think I, I think one of the main reasons we

Patrick Fink MD:

I think one of

Nick Weinberg:

was to

Patrick Fink MD:

the.

Nick Weinberg:

teach people to be flexible and to maybe about things and not just follow blindly, you know. But I often get, have residents, junior residents, that are so eager to intubate because someone's altered. And, know, again, like I said, that that

Patrick Fink MD:

You know, again, like I said, that.

Nick Weinberg:

and convenient in the hospital, but, but in a wilderness setting, it may not be the best decision. And I, if basically I, I wanted to write this

Patrick Fink MD:

Basically I wanted to write the papers so that

Nick Weinberg:

situations, they, could kind of set a standard of care that where there is no standard of care actually, and, and know, that standard of care is, is kind

Patrick Fink MD:

standard.

Nick Weinberg:

is, fluid and can vary. But depending on where you are and what situ, you know, what situ situation you're in and what resources you have. So I guess the, the biggest I would teach people is to be flexible and not, not jump down. To, you know, jump into following an algorithm.

Patrick Fink MD:

What was the setting of your community hospital that you worked in? Was that critical access?

Nick Weinberg:

I've worked in a few different,

Patrick Fink MD:

I worked few different.

Nick Weinberg:

critical access hospitals. I worked in a busy community hospital in upstate New York, with very sick patient population without access to a lot of access to primary care. And so that I kind of, and then I also worked in a small community critical access hospital in, in New Hampshire as well. And I think of those helped prepare me a little bit for, you know, os year settings where you don't have as many resources you have in a busy academic center.

Patrick Fink MD:

Yeah, I hear you talking about all the resources you have at Dartmouth and, and I was thinking to myself about our practice site in Madris, Oregon, which is a critical access hospital, that it's pretty, pretty small, pretty under-resourced overall, and I was thinking about the fact that. Yeah, we have four hospitals in the region and, and Madris is one of them, and it's a, it's single coverage. On the MD side, we have an a PP during, during the daytime, but pretty limited number of nurses and lower experience with high acuity patients overall, but a pretty sick patient population with patients from the Warm Springs Indian Reservation and we're along a a highway corridor. And that, that kind of site, I think is a great stepping stone after a residency in an academic center where you have all of the resources. Because as soon as you're thrust into that situation, you realize how much you had farmed out mentally to, to the respiratory therapist, to the

Nick Weinberg:

Right.

Patrick Fink MD:

experienced trauma nursing staff, and all of a sudden you need to know how to set up the arterial line, pressure bag or run the vent or what have you.

Nick Weinberg:

Yeah, I,

Patrick Fink MD:

Yeah,

Nick Weinberg:

a, I

Patrick Fink MD:

I,

Nick Weinberg:

I gave a grand rounds a few

Patrick Fink MD:

I gave a.

Nick Weinberg:

on, on wilderness medicine just'cause so many people would come up to me asking me how to get into it. And I have a couple slides on that topic where. Basically you're the nurse, you're the tech, you're the EKG tech you know, you're the respiratory therapist. So it it, it's useful to just practice doing, get comfortable doing all these other things that you don't usually do as a physician if you are gonna be in remote areas, especially in a, in a clinic like that, in Nepal where you do have some resources you have to, you're expected to place IVs and. Put the EKG leads on that sort of thing. So it's all stuff that you can learn pretty easily, but it can be pe people can be caught off guard if they're not prepared for that.

Patrick Fink MD:

Definitely it's, you could, you could easily become task saturated in those things if you were unfamiliar and, and learning them in real time. Task saturated, even if you suddenly realize you have to do direct laryngoscopy, you don't have your video scope and you haven't done that since your anesthesia rotation in.

Nick Weinberg:

Yeah, totally.

Patrick Fink MD:

Well, Dr. Weinberg, I appreciate you talking through these two cases with us. I'm gonna have the. Airway management paper in the show notes for people to have access to. And I'd encourage them to read it even after listening to this because I think the analysis and some of the literature review on, for example supraglottic Airways in comparison to intubation in the pre-hospital environment is really useful. And it's a very concise well-structured summary of that. If folks want to hear more from you or connect with you. Where are you? Are you on social media? Do you have other things that we can point to?

Nick Weinberg:

I, I'm not really on social media actually. I'm happy to you, you can give my email out. I'm happy to like field emails from people. Yeah, but I, I, I don't have a, a blog or a webpage.

Patrick Fink MD:

Okay. We'll, we'll put your academic email in the show notes if folks wanna reach out with questions

Nick Weinberg:

happy.

Patrick Fink MD:

and.

Nick Weinberg:

happy to give people advice if, you know, if they want to get interested in, in wilderness medicine and don't know kind of where to go, to jump into it. I'm happy to, to give advice. Awesome.

Patrick Fink MD:

Awesome. Well, I really appreciate your time. The listeners of this show are very appreciative and courteous, at least in the interactions I've had with them. So hopefully you'll get some nice thank yous from them as well, and I'd love to have you back on some time maybe to talk about the. The climbing accident that, that brought you into medicine.

Nick Weinberg:

Yeah, I did. Definitely. I'm happy to, happy to chat anytime. It was really fun chatting with you.

Patrick Fink MD:

That's it for this episode of Wilderness Medicine Updates. I hope you enjoy that conversation with Dr. Weinberg and that you're able to take away some learnings or at least some mental simulation of a couple interesting cases. I do encourage you to look at the paper, which is in the show notes and makes a good read as it does break down the pros and cons of different airway management techniques in austere situations. And I think it's worth thinking about, in the situations where you commonly operate, what tools do you have available to you and what are you actually capable of doing? And for how long? Because that is gonna drive the care that you can deliver to a patient and the decisions you make about how you manage them. I, in my education for our ski patrollers, for example, like to harp on the fact that really it is that basic life support care. That can actually make a difference for patients. And so just like Dr. Weinberg said, probably the biggest thing that he did for the patient in that first case was to do a jaw thrust open the airway, a very simple maneuver that he can teach a climbing partner on a cliff side, but that in and of itself is a lifesaving maneuver. Those basic, basic tools are the things that we can fall back on time and time again. And then if you're in the right place at the right time, like Dr. Weinberg was, can deliver some of that advanced care from the emergency department to the cliff side. I wanna give a couple shout outs I've been hearing from Bruce Petty and Hako Sak. Thanks for reaching out. I appreciate the communication. You guys are awesome. I hope that you enjoyed the podcast, and if you did, please give it a five star rating. On iTunes, on Spotify, that helps us get out to more people. This passion project that I hope delivers benefit, the more people it can reach, the better. So tell your friend, your colleague, a doc, a nurse, a paramedic. Tell your mom, I think your mom might like this podcast. Until next time, you can connect with us on social media. Now, there is an Instagram, there's a blue sky. The information's in the show notes as well, or you can find it on the Buzzsprout page. James Hanson is our media manager and he does an awesome job in his free time. So thanks to you, James. Until next time, I'm your host, Patrick Fink. Stay fit, stay focused, and have fun.

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Patrick Fink MD, FAWM

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Dr. Nicholas Weinberg

Guest