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. 25 - Tree Well Burial Study / Wilderness Med Careers AMA with Zack Majd
In this episode of Wilderness Medicine Updates, host Patrick Fink breaks down a recent research paper on the differences between simulated avalanche burial and tree well burial, analyzing the findings and their implications for skiers and outdoor rescue personnel.
We then transition to a special Q&A session with pre-med student Zack Majd, tackling questions about forming a career in wilderness medicine. Patrick discusses the necessary educational paths, the benefits and limitations of fellowships, and the essentials of wilderness medical training. Additionally, the episode highlights upcoming educational events and provides practical advice on wilderness medical gear, psychological support techniques, and the integration of wilderness medicine with other medical disciplines. A must-listen for anyone interested in advancing their career in the field of wilderness medicine.
Links:
Kanaan NC, Abdul Cader J, Krakker J, Beasley H, Grissom CK, McIntosh SE. Simulated Avalanche vs Tree-Well Burial Effects on Human Physiology. Wilderness & Environmental Medicine. 2025;36(3):361-367. doi:10.1177/10806032251337476
Van Tilburg C, Paal P, Strapazzon G, et al. Wilderness Medical Society Clinical Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents: 2024 Update. Wilderness & Environmental Medicine. 2023;35(1_suppl):20S-44S. doi:10.1016/j.wem.2023.05.014
Fink PB, Wheeler AR, Smith WR, et al. Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update. Wilderness & Environmental Medicine. 2024;35(2):198-218. doi:10.1177/10806032241248422
EP. 21 - Snow Immersion Suffocation
Chapters:
00:00 Introduction and Episode Overview
00:43 Upcoming Events in Wilderness Medicine
Part 1
02:07 Tree Well Burials vs. Avalanche Burials
05:36 Study Findings and Analysis
08:23 Limitations and Implications of the Study
Part 2
11:21 Q&A: Careers in Wilderness Medicine
12:48 Zach's Journey and Career Questions
20:35 Balancing Wilderness Medicine with Other Careers
26:05 Pathways to Wilderness Medicine
30:32 Debating the Value of Wilderness Medicine Fellowships
32:21 Personal Experience with Wilderness Medicine Fellowship
34:29 Research in Wilderness Medicine
37:05 Essential EMS Gear for Wildland Firefighters
39:19 Prioritizing Care in Wilderness Settings
47:31 Psychological First Aid in Wilderness Medicine
50:49 Preparing for Wilderness Medicine Challenges
53:55 Future of Wilderness Medicine
57:33 Signoff
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Hello and welcome back to Wilderness Medicine Updates the show for providers at the edges. I'm your host, Patrick Fink. Today we're gonna do something a little different. This episode is a two-parter. In the first segment, I'm gonna discuss a recent paper on the physiology of simulated avalanche burial versus simulated tree well burial. And then in the back half of the show, I'm gonna flip the script and become the interviewee. We're gonna be answering some questions about what it looks like to make a career in wilderness medicine. Before we jump in, I want to bring to your attention a few events. The first is that the International Committee on Alpine Rescue, or IAR Annual Congress is coming to the US for only the second time ever this year, and will be taking place at the Snow King Resort in Jackson, Wyoming from October 7th to the 12th. If you're a member of a rescue outfit, this is a great opportunity to hear about the cutting edge, new ideas and high quality standard practices in rescue and wilderness medicine. You can learn more about that and register at www.icartwentytwentyfivejacksonhole.org. Link is in the show notes if you're in the Pacific Northwest region that I call home. Wilderness Medicine updates, listener Hako, stop Sack. A King County paramedic and member of Mount Hood's Storied. Crag. Ratts rescue team. Brought up another great educational opportunity. Hako is helping to organize the Pacific Northwest Mountain Medicine Symposium. This is a conference that's dedicated to rescue techniques and medical care in mountain environments. This is a one day event in Seattle, Washington, and it's on Saturday, October the 25th. There's a morning practical session on hypothermic cardiac arrest, and an afternoon of talks with great speakers. You can learn more and register at PW Mountain rescue medicine symposium.org. Again, links for both of these educational opportunities are in the show notes. Now, without further ado, let's talk about Tree Well Burials. Today we're gonna look at a new paper in Wilderness and Environmental Medicine published online just in September, 2025 by Nicholas Canon Etal. This article is freely available and I'd encourage you to grab the link in the show notes and see the figures and read it yourself. Full disclosure, I know several of the authors and one of the senior authors was my fellowship director at University of Utah, but I was attracted to this article before I even realized that. So I don't think I have a bias there. But if I do now, you know, first some background snow immersion suffocation, also called non avalanche snow burial. Is different from avalanche burial. These burials happen when ski resort or backcountry travelers fall headfirst into tree wells or deep powder snow, and they're unable to extract themselves and they die of asphyxia. Little is really known about the physiology of these kinds of burials as to date, there have only been a few case reports and small simulation studies. If you wanna learn more about the subject as a whole, check out my episode 21 on snow immersion suffocation, where we take a deep dive on the subject. The important difference to understand about tree well burial compared to avalanche burial is that generally tree well, victims are positioned head down and don't usually have an air pocket near the face because of snow falling in around them. Accordingly, they usually die quite quickly from hypoxia and prolonged survival in that setting is exceedingly rare. To better understand how tree well burial affects victims in comparison to avalanche burial. The authors in this paper conducted a simulation study using 14 healthy volunteers aged 18 to 60. All participants were placed in a simulated position in which they were buried in a avalanche position and a tree well position. They were buried in both positions and a minimum of three days happened between these two events, before they were placed in the second position of the 14. Two of them didn't return for a second burial and one had equipment failure, so they essentially analyzed just 11 of these volunteers who had complete data on both sides. Now the avalanche position was essentially a seated reclined position in a snow pit with the back at 60 degrees. The tree well burials were faced down, so lying essentially the legs parallel to the ground and torso inclined downwards by 60 degrees, head down into the snow. The tree. Well, patients were buried in snow with a target density of 10 to 20%, and the avalanche patients with a density of 40 to 50% to replicate the snow density experienced falling an avalanche versus the loose snow of a tree. Well, they all wore a one piece Gore-Tex suit, a light hat insulated helmet, face masks, goggles, and gloves, and their choice of long underwear. To be able to study their breathing. Participants breathe through an Avalon device that draws inspired air from near the chest and expires that air towards their backs and using an insert in the device. The researchers monitored their respiratory rate, tidal volume, tidal CO2 inspired oxygen pressure, and they also used a finger pulse oximeter to measure heart rate and oxygen saturation. As well as a swallowed esophageal capsule that measured their core temperature. In both of the simulated settings, the researchers targeted a 60 minute burial and burials were terminated. If participants requested or if they reach predetermined endpoints such as a core temperature less than 35 degrees Celsius, or an oxygen saturation, less than 85%. So what did they find? In the Avalanche Group, eight of 11 participants completed the whole 60 minutes. The other three terminated, one requested at 48 minutes. One reached a core temperature less than 35 degrees Celsius at 51 minutes, and one had oxygen desaturation less than 85% at 55 minutes. In the tree. Well, group seven of the 11 completed the full 60 minutes. Three participants terminated early two of them for anxiety or distress, and one for difficulty breathing in contrast to the avalanche group. The meantime, determination was just 14.6 minutes. Among those who quit, one participant was terminated at 58 minutes for an oxygen saturation. Less than 85% in the Avalanche burials, the mean temperature change. Core temperature change was a decrease of just less than one degree across the study compared to 0.58 degrees in the tree well group, which means that they were cooling 1.42 times faster in the avalanche burial group. Oxygen saturation decreased faster in the tree well group when oxygen saturation was normalized for burial time. The oxygen saturation decreased 10.9 times faster in the tree well group than in the Avalanche group. There was no statistically significant difference observed between the two groups for heart rate, respiratory rate, or end tidal carbon dioxide. So overall the tree well group showed slower cooling, faster hypoxia, and of those who terminated, they terminated earlier than the Avalanche group. The authors suggest that faster cooling in avalanche burials is likely due to increased snowpack density. In these scenarios, this seems conceptually sound as higher density. Snow is likely to cause more conductive heat loss from the body, whereas the low density snow in the tree well group derives cooling more from convection or to the air, which is a less efficient form of cooling or heat transfer. The faster hypoxia in the tree well group is hypothesized to be related to position. According to the authors, as the lower density snow in this group would be expected to facilitate gas diffusion better. So if it was a gas availability issue, the avalanche victims should get hypoxic faster'cause their snow is more dense. The authors hypothesize that the head down position could create increased pressure on the diaphragm, or that anxiety could cause shallow breathing. The authors highlighted a few limitations of their study, namely a small sample size and the use of simulated burials in only one position per group. Acknowledging that there could be quite a variety of positions associated with these entities, and they also didn't simulate any efforts that someone might be making when they're head down in a tree. Well, kind of struggling to try to get out of there, which could affect their results. So what can we take from this study? Well, I think this study has a pretty huge limitation that the authors don't discuss. It provided some of the best data yet showing less hypothermia and faster hypoxia in tree, well burial victims compared to those buried in an avalanche type setting. This aligns with case report data suggesting rapid death by asphyxiation in tree, well victims, much more so than in avalanche burial victims. The slower rate of cooling also supports the idea that tree, well victims in cardiac arrest are less likely to be victims of hypothermic arrest. Now what about that huge limitation I was just talking about? I think the biggest issue with this study is that the participants used an Avalon. I understand that this makes measuring their respiratory parameters easier, but it also makes it significantly less similar to real burials. The Avalon is a very uncommon and often incorrectly used device, and snow sports users are unlikely to be using one when buried, which really limits the applicability of what we can derive from this study. Burial without an Avalon, I would expect would result in more CO2 accumulation. Which itself has been shown to have an effect on cooling. I would also estimate that both groups would have faster times to hypoxia without the device, and that the higher snow density in the Avalanche burial group could result in more hypoxia for that group, reducing the observed difference between the groups in this study. Second. Well, this is not a limitation. I don't buy the explanation for the hypoxia in the tree. Well, group, the author suggests that shallow breathing or reduce tidal volume during diaphragm, during diaphragmatic compression could be the driver behind that hypoxia. But both of these would be expected to have more of an effect on carbon dioxide than on oxygenation, an effect which they didn't observe. They didn't see changes in CO2. I think it's much more likely that a head down position creates issues with what we call ventilation, perfusion, mismatching. In short, if you flip me upside down, I'll have more blood flow to the upper portions of my lungs'cause they're down. While gravity pulling my lungs up towards my head would increase lung expansion at the lung basis, creating mismatch ventilation and perfusion that. Being inverted in the hole flips the usual top to bottom gradients that we normally see in the ventilated lung. And I would hypothesize that gas exchange efficiency overall would be impaired because humans aren't adapted to prolonged inversion. Still. I applaud the authors on this paper. What I take away from this is that we can reinforce our existing recommendations about tree. Well burials rescue is time critical. Death is overwhelmingly due to hypoxia and prolonged burial is unlikely to result in neurologically intact survival or significant hypothermia. Again, if you wanna learn more, you can take a listen to episode 21 or take a look at the Avalanche and Snow Immersion guideline. I have linked in the show notes, which was authored by our show guest, Chris Tilburg. Now on to part two of the show. Up next, I bring you a q and a with pre-medical student Zach Majd. Zach recently graduated from Pomona College in California and is applying to medical school. Zach approached me with an interest in wilderness medicine and questions about what a career in wilderness medicine could look like. We decided to collaborate and Zach solicited questions on forums across the web about wilderness medicine careers. And I do my best to answer them. If you're a medical student, pre-med studying nursing, you're in a physician associate program and you've been wondering how wilderness medicine could fit into your career, I think we'll have some good answers for you. Let's jump to our conversation.
Patrick Fink:Today we have a different kind of episode. We're gonna do an a MA type episode. For medical trainees and those who are interested in wilderness medicine, and I have joining me here, my friend Zach and Zach contacted me through wilderness medicine updates@gmail.com, which y'all can reach out, as I always say with some questions. And this is where we sit. We're doing a podcast together we're gonna work our way through a series of questions that Zach solicited from the online world. Questions about careers knowledge, practical questions about essentially starting a career in wilderness medicine. What does that look like? And then some kind of miscellaneous questions We'll work through as much as we have time to do. So why don't we start with Zach. Who are you? What do you do?
Zack M:Yeah. First thanks, for having me on. I'm thrilled to be here. My name is Zach. I am a senior at Pomona College, which is a small liberal arts college right outside of la and I'm a pre-med student There. My interest in medicine really started about four years ago. I took a gap year before college, and during that time I spent a semester with Knowles, which for those who don't know, is an outdoor leadership school. During that time I got my EMT and my Wilderness First responder certification over about a month. Then for the next two months, I spent time learning and training on wilderness medicine rescue skills. So it was really a brief introduction to wildness medicine. After that, I've spent some time working in 9 1 1 and transport for EMS, but I was always really interested wilderness medicine and giving emergency care in austere environments. And that kind of led me, as I'm thinking about next steps and going forward in my career, what I wanna do, that led me to reach out to you with the hope of getting more information about wellness medicine and what a career looks like, and that's why I'm thrilled to be here and asking questions and learning today.
Patrick Fink:Fantastic, and you must be finishing school in a month.
Zack M:Yeah, it's the last five weeks of school, which is crazy but exciting too.
Patrick Fink:What's next for you?
Zack M:That's the question. Next is some job before about a year or two before med school. Working as an ER technician or, doing some clinical research. I'm still divided, deciding and applying to different things, but something related to medicine before I really dive in headfirst to medical school.
Patrick Fink:That's wise. It's a big jump, so you want to make sure you're ready.
Zack M:That's what
Patrick Fink:Zach, I'm a little nervous about this podcast'cause I usually don't talk that much. During interviews, so, I'm ready for you to hit me with whatever questions you have.
Zack M:All right. Yeah, this is great for me. I get to ask questions and sit back and let you do all the heavy work. Let's just jump into it. As you know, as you mentioned, I solicited questions and preparation for this podcast across a number of platforms, what people were most interested in, and then I peppered in some of my own questions too. One of the biggest things that came up, when I was asking people is what exactly a career in motorist medicine looks like? One user yox is interested in what exactly is wilders medicine? Specifically is it different from EMS or maybe more tactical medicine?
Patrick Fink:That's a good place to start is just what is wilderness medicine? And actually, if you Google that and go to the Wilderness Medicine Society, you'll see that. There isn't actually a consensus definition, but there's, one that a number of groups have started to use, which is that wilderness medicine is medical care delivered in areas where there are either temporary or permanent geographic challenges that reduce the availability of or requirements for, medical treatment and patient resources. So you're in a setting where the environment is dictating part of the care that you can deliver to the patient. So in that way, it is different from EMS in that you're in a very different setting. I don't have a truck full of supplies. What we have available to us is gonna depend on where we are, are we along an urban boundary, in which case we might be able to bring some of those EMS resources to the patient. Or are we, well into a wilderness area where weather prohibits us from getting advanced resources in there and everything's coming in by ground. It's also pretty different from tactical stuff in that tactical care, and I'm far from an expert on this, but seems to be largely. In the moment when someone is hurt, it's tactical combat casualty care or TCCC, which is basically addressing threats to life while in a hot zone, and then evacuating that patient with a lot more resources available and it focuses pretty heavily on less of the environmental, more penetrating and blunt trauma care. So in wilderness medicine, we're also focused on. Altitude medicine, dive medicine, other aspects of being out in the environment and the things that tend to befall patients in that setting.
Zack M:And I know you mentioned environmental care, how much overlap too with rine medicine is there between sports medicine? So I'm thinking,
Patrick Fink:hmm.
Zack M:Tissue injuries or musculoskeletal, is there any overlap there? Are they completely different? specialties.
Patrick Fink:It's a reasonable question. The theory is sound that there should be some overlap, but the careers are very different. So we definitely treat orthopedic injuries. We treat people who suffered injuries due to sports because people do sports in the outdoors. However, sports medicine is largely at the. Edge of the field, or it's in the clinic. So there's all of the resources of EMS and all of the advanced diagnostic tools that you might have in the clinic, like ultrasound. And the reality of training in these two things, sports medicine and wilderness medicine couldn't be more different from a physician perspective.
Zack M:Okay. great. We've set an idea of what wilderness medicine is, and we also got a lot of questions about how you can get involved in wilderness medicine. So maybe it's best to start you enter medical school and then work the way up. One user hank the Davis. Two, says I'm very interested in wilderness medicine. What can I do early on to secure this career track? You know, maybe before medical school. Are there things to think about getting involved with that can help you if you're interested in this career?
Patrick Fink:So I think first off, it's worth saying that there are. Two different ways to approach a career in wilderness medicine. There is, I'm gonna do something as my day job that is wilderness medicine in some capacity, full-time search and rescue, ski patrol, those capacities. And then there are those who are in healthcare fields who are then giving time and energy on the side. Either way, I think it starts with a passion for being outdoors. It starts with wanting to be outside. There's usually something that you like to do. You're like, I'm a mountain biker, I'm a climber, I'm a boater, I'm a skier. And so you're thinking to yourself, okay, how do I make a career out of climbing, boating, and skiing? That's not being a climbing, boating, skiing guide. That's maybe like a little bit more, I wanna, I want to help people or, or deliver more for the community. So if you have one of those passions for the outdoors. You are trying to figure out a career where you can be outside and, but maybe give back to your community or you want to take it another level intellectually and bring the medical care component in. You're gonna pair that passion for the outdoors with some kind of medical training at whatever level that you wanna operate. That could be. Wilderness First responder, plus love for climbing. Maybe you're more a guide, but you're prepared to respond in the environment. And you can be a volunteer search and rescue member, or maybe you want to be at the EMT level and you're gonna pair that with some technical skills, and you could be part of a reach and treat team. You could be on the ski hill, those kinds of things. Or you could become a nurse paramedic doctor. Pair that with a technical expertise and now you have something to bring to the table. So if you're early in your career, you should look at whatever your passion is and look at taking that one level further. So if you are into rock climbing, go take some rescue courses. Start with partner rescue. It doesn't have to be. Complex team rescue so that you have a higher level of technical proficiency. And then bring in some medical training as well. Start with wilderness first responder. Work your way up to whatever level works for you, and that's a great place to start. And then volunteer as early and as often as possible with your local search and rescue ski clinic,
Zack M:okay. Going back to something you mentioned before with these advanced degrees, and so I think it's a really interesting contrast between people who have day jobs and then people who are working in healthcare and then putting in this extra time. What is the balance for someone like yourself? much time are you spending, maybe in the hospital versus out in these wilderness settings? Does it feel like it's two full-time jobs? Or is it really one job and then, on the side, fun.
Patrick Fink:No, I mean for me, I work full-time in the emergency department of I don't know how many hours per month. At least 120 hours. Actually providing patient care in the emergency department every month and everything that I'm doing. Wilderness medicine on top of that is volunteering my time. It's choosing to spend some of my additional time doing something else, providing trainings and advice for ski patrol, producing this podcast, those sorts of things. There are people whose full-time. Job is doing that is, is being a physician in a wilderness environment that is less common in the United States? It is more common in Europe because here we're cost conscious, and so having physicians flying around on helicopters or being, those primary responders out in the field is less common. So I think the majority of people who are. Physicians, nurses, paramedics, they're working in a context where the majority of their hours are urban, hospital based, ambulance based, what have you, and then giving time on top of that.
Zack M:Okay. This is a question cocktail MD had, and I think it really relates to this. Is there a way to make money in wilderness? Medicine, especially in the United States, if it is such a volunteer, field.
Patrick Fink:Yeah, here's the secret. You're gonna get rich doing wilderness medicine. No, it's, I'm kidding. Unless you're part of a. A team where you're getting paid full time to do that job. Generally speaking, there's not a lot of compensation for being part of wilderness medicine. So for example, a medical director role, you might have a contract with a park or with a group, and that might lead you to some kind of honorarium or thank you optimistically, maybe$10,000 a year. In comparison to what you can make at your day job, no matter what level you're at, it's just not, it's the hours. It doesn't pan out. But here's where the math gets fun, which is that I think diversifying your career brings you career longevity in your primary workspace. So ER medicine is really prone to burnout'cause it's stress we get yelled at or physically assaulted like it is just dealing with all the problems of the healthcare system. Making it 10 years in emergency medicine is a pretty good run. If I am able to diversify my position in medicine, feel like I'm giving back, and I earn myself even one extra year in my specialty, that pays pretty well. If it's three to five years, we're talking about a substantial kind of payback from that. And honestly, I think the reason that people give their time is because it feels really good. It feels good to give back either to SAR groups where you're doing education or to give your own time as part of a rescue service, being part of that team with that objective is it is often the same thing that brought people to medicine.
Zack M:What is the main difference? Or the few differences that really helps prevent that burnout with wilderness medicine? Is it the one-on-one patient? Is it being out in nature? Or for you, maybe not for everyone, but what do you find that helps prevent burnout?
Patrick Fink:When I think about what's hard in my day job is that the work is never done. And we don't get a lot of thank yous. You know, it's just, we're kind of there. We're doing the grind. Very high functioning team. Many of those same elements. But if I volunteer my time and I start teaching with ski patrols, providing education, doing something like this podcast, it gives me a really defined space where I can say, Hey, this is an area where I did good. And I get positive feedback that says people are benefiting from it. And so that to me is really awesome. I can go skiing, mountain biking, whatever I can get outside any day of the week. But doing that in a way that helps serve people is pretty awesome. Being able to be out on the ski hill, enjoying myself, but also respond, provide medical care or advise people who are. Where I was 10 years ago. That stuff feels really good. And as we enter the second half of our careers, that's the kind of thing that sustains you. Because right now it sounds crazy to you maybe that someone would ever think of stopping a career as a doctor.'cause you just climb that field. You climb that ladder, you're like, you're a hoop jumper until you finally land a job after residency. But once you're done jumping hoops, then you're like, all right, I made it. This is it. This was good. It is a good time, don't get me wrong, but like it's, it's a good time to then turn around and, and give back in the same way that all the people helped you get there.
Zack M:Yeah, it is hard to imagine, but I can see what you're saying. You definitely get used to just looking at the next step, but it's good to think about, down the road. Okay, so let's say, you've convinced me, medicine, it offers all these, great benefits and, helps you prolong your career and just, great for health. Great to get outdoors. Thinking about the next steps, medical schools. Is there specific medical schools that you think are more, conducive to wilderness medicine? Is that even a thing someone should be thinking about where they choose to go to medical school or just try to get in somewhere and worry about that after,
Patrick Fink:Getting into medical school is hard. That's probably the single biggest barrier to entering the physician field if you make it through medical school and then you just keep showing up and don't touch anyone inappropriately you will make it through because there's so many people who want to clear that hurdle. Uh, don't envy your position. I've been there. That said are there medical schools that would be better for a career in wilderness medicine, broadly speaking? No. Like there it is. Just no, any medical school is fine. Any paramedic school, any nursing school, anywhere where you can get a good training in medical school, in your primary education, in medicine, you're not gonna be spending a lot of time learning about. Altitude illness, you're gonna be focused on the core stuff that helps you deliver quality care to the greatest number of patients residency maybe, because now you're talking about are, is this a place where do they have a wilderness medicine fellowship, for example? Because if they do, maybe there's more people there who are involved in that and can provide additional education. I went to University of Utah for residency. When there, we had a fellowship, we had fellows, and so we're getting lectures. We had an environmental module on heat, illness, altitude, illness, those kinds of things. And because of our proximity to the mountains, our orthopedic experience was in a ski clinic. We're up like adjacent to the ski hill where you also see exposure related complaints and those sorts of things. An interface with the folks who are working up in the hills. So that's when you might start to derive some benefit from being somewhere along the way though anytime you can be somewhere where you can do your primary thing. Boating, climbing, skiing, running mountain biking. As easily as possible. That's probably something pretty significant to think about'cause you're not gonna have a lot of time. You gotta keep the fire alive and it'll feed you through that process.
Zack M:You mentioned residency being important is the, the majority of wilderness medicine doctors are emergency medicine and they're going through residents emergency medicine. Are there orthopedic physicians, family medicine or other residencies that can still be conducive to wilderness medicine or is it really emergency medicine or nothing?
Patrick Fink:No, you don't have to do em even though it is the best specialty. I don't know whether there are any fellowships which will take. Folks from outside of emergency medicine, mostly because those fellowships are ER based and you're you. They need you to work as an ER attending. That doesn't mean that you can't do wilderness medicine. So trauma surgery, orthopedics, family medicine, sports medicine, internal medicine. It's more about having fundamental knowledge, adding on that wilderness knowledge and then applying it in the field. The Wilderness Medicine Society is a really great kind of clearing house for folks to come in, get some information, and find a place in the field of wilderness medicine. So if you, if say I'm talking to someone who has already gone through all of their training and they say, Hey, I'm super interested in this, great. There's courses you can take, there's learning you can do to kind of take the knowledge that you already have. And take it to the, the wilderness environment. Knowles, you mentioned Knowles. They have a, wilderness medicine for healthcare professionals course. Or you can take the diploma and mountain medicine course through the Wilderness Medical Society and that will teach you both technical rescue as well as kind of wilderness medicine core content and give you a certification on top of just your MDD or what have you. That says, okay, I have some kind of core competency operating in this austere environment. So you really don't have to take the full dive, do the fellowship, like if you wanna do academic medicine and do have that behind you to power research, yeah, you probably should go the EM way and do a fellowship and then plan on working at an academic medical center. But that is a tiny sliver of people who are in wilderness medicine.
Zack M:When I asked, these questions, when I solicited questions, there actually started a little bit of an argument in one of the chats about fellowships illus medicine and how necessary. Having a fellowship or the useful having a fellowship in wilderness medicine was versus a fellowship, in maybe EMS or critical care. And I was wondering if you had any thoughts on that, whether wilderness medicine fellowship is something people should aim for if it's not necessary. What's that about?
Patrick Fink:So I don't think it's necessary. It's great training, and depending on where you do it, you're good. Pretty different experiences. What are people saying when they say useful? Giving you information so you can go become a, medical advisor to someone, or are they saying, will this actually increase my career earnings in comparison to EMS or critical care? That's probably not how you should be making those decisions. Fellowship is almost never a good financial decision. For example, critical care fellowship. I want to be an intensive care doctor. I'm gonna spend two years working like a boatload in the ICU. Getting paid as a resident, and then when I come out, I will make exactly the same amount of money as I would've if I was an ER doctor. Great, okay. But I have some career diversity. It's just a matter of where I wanna spend that time. Same thing goes for an EMS fellowship. You're gonna spend a lot more time doing like fire ridealongs education for EMS, maybe SWAT or tactical EMS. And when you're done, you're now, you're prepared to be a medical director for those kinds of organizations. How are you gonna be spending your time? Is it gonna be at the firehouse? That is just a matter of where you want to be, so you don't need it? I think, I was in accidental wilderness medicine fellow, and by that I mean that I finished my residency around the time that like Covid was winding down. At that time there were no jobs in emergency medicine'cause we had crushed the curve. And with that we had crushed ER physician full-time equivalents within the field. There weren't patients, so there weren't jobs. And I was like, what am I gonna do with my life? I've been thinking about maybe I'll do a fellowship. And my wife's like, a wilderness medicine fellowship. Why don't you do that? That has your name written all over it? And I was like, that's a great idea. Fantastic idea. Terrible financial decision for one year in comparison to like taking a ER job or just trying to piece things together? Probably like thousands of dollars left on the table. Wouldn't trade it. Like the experiences and the connections totally worthwhile. I was spending time in national parks with the Jenny Lake Rangers up in Grand Teton doing technical rescue courses with National Park Service. Total bad asses from Josar down in Canyon lands. Having an awesome time and meeting people throughout the field and getting a sense for operations up and down the chain that now helps inform what I do. And Sure. I've come back to my kind of core competency, which is like a background in ski patrol focus on mountain medicine. But as I reach out and I'm interested in other parts of o other. When I reach out and I need help with medical direction, I need to develop a plan for that. I have contacts through that field who are medical directors up in Jackson Hole, who are training National Park Service employees who have experienced medical directing for wildland fire. And so that becomes super useful. And it's also just a really great group of people. So I wouldn't trade it for the world. I think that choosing a fellowship is an extremely personal decision. For most people, it's a bad financial decision, and so that should not be how that decision is made.
Zack M:About a little while ago. You mentioned, getting into emergency medicine residency for research sake. you talk a little bit about the research that's going on in wilderness medicine? King Cobra 2203 ask, is research a part of wilderness medicine, and if so, what are the active areas of research in the field?
Patrick Fink:Yeah, so there is active research in the field of wilderness medicine. It's at the fringes of knowledge. It can be as simple as, you know, the paper that I reviewed last year where it's saying, Hey, we improvise a lot of things out in the field. Can we take something we already have like a space blanket and use it as a tourniquet? And I'm gonna do an actual research project where we see if we can occlude arterial flow in a limb. Using a space blanket to make a tourniquet. So developing new ways to improvise tools using things we already have. But it may also be kind of on the medical understanding or treatment side of things. So when I had Dr. Ross Hoffmeyer on, he mentioned that, some of these gas anesthetics, like Methoxy, fluorine haven't been well studied at altitude or in the cold. Are we able to use them in those settings? If so, how? How do we need to change our approach? Are they as effective looking at those things and then saying, Hey, are there conditions out there? So for example, high altitude cerebral or pulmonary edema. Poorly understood processes that have limited treatments available to them. Are there other medications that we can use to treat those processes or can we identify people ahead of time on the basis of certain risk factors or with specific tests that say you are at risk for those things and you need prophylactic medications, you need a different altitude, ascent profile, or you just plain shouldn't go above 18,000 feet. Anywhere that there's an edge, there is research, it's mostly being housed at academic institutions, but there are grants available through, for example, the Wilderness Medicine Society and other large organizations like Knowles that collect a lot of data. Also put out research into, for example, you can find data on who gets hurt in the outdoors and how do they get hurt. And a lot of that comes from big operations like Knowles.
Zack M:Switching gears, we've talked a little bit about kind of the career of wildness medicine, getting a little bit more into the weeds. We also got a lot of questions from listeners about, specific techniques and different equipment. Some more, specific than others, but I'll just dive in and we can, weed through these. The first question comes from definitely a dumbass 23, about in the wildland fire world. And they ask what's some worth the weight EMS gear we should have that we might not be considering wildland fires. Do you have any thoughts on specific EMS gear that people don't think about but can be really useful?
Patrick Fink:I don't think I'm gonna blow any minds here.'cause I'm thinking about this guy and he's out doing wildland fire. He has so much to carry. So I think that there's two approaches to this. The first is a systems approach that, like a fire unit should probably have a medic or some something within the incident command structure so that they have medical support and more advanced resources can be delivered where they're needed. But I don't think that, that's this guy's question. The question is, what is the most like high yield stuff that I can carry on my person? That probably doesn't weigh that much and isn't that big. And so that's probably not that different from what my load out looks like just in my vest when I'm patrolling on health, for example, so standard stuff that I try to get all the patrollers to carry is a CPR mask, like an actual mask, not the like little foil nonsense, but one that goes like this. And that has a. One-way valve on it so that no one can vomit in your mouth. With that, some oral and nasal airways, because with those two things, the mask and the airways, I can provide ventilations to like almost anybody for a period of time until something else gets there. So I want to be able to do basic airway management and I want to be able to manage severe hemorrhage. So for me, that looks like two tourniquets. I like the. Windless style tourniquets, and a pressure dressing. So that could be an Israeli style trauma bandage. A bundle of gauze and a swatee tourniquet, plus some good tape and a good pair of trauma shears. Those things are gonna be what, make or break those initial moments in addition to your BLS care. Knowledge and everything that follows after is more just prolonging the care or some more advanced management of those things. But if you can manage critical bleeding and you can manage airway problems or provide CPR, that's gonna be your goal.
Zack M:Great. Once you get up to a patient, bear Rider wants to know how do you prioritize compounding issues and what order do you address them and when does leaving someone in place outweigh getting them out of the austere environment? On this case the ski hill.
Patrick Fink:This is why you need to, before you go out into that wilderness environment. Take a course that gives you a fundamental understanding of how to perform a patient assessment because the basics aren't different. So our priorities remain the same. It's essentially A, B, C, D, E, the classic airway, breathing, circulation, disability, IE, neurological injury and exposure or environment. and some might put C first, CIB, like critical bleeding gets treated before all else. But regardless, that's what we fall back on. So even in the emergency department, when I feel like a situation is getting really complex in my mind I go back to this resident I worked with on my anesthesia rotation who was an anesthesia resident. And he'd be like, is the blood pumping? Is the heart pumping? Is the blood going round and round? Is the air going in and out?'cause if we got those three things, we're doing pretty okay. We can slow down and think. So coming back to those basics of A, B, C, D, and E. Now, when does leaving someone in place outweigh getting them out of the woods? Almost never. There's almost nothing that makes it better to leave someone where they are. And the reason for that is that our, we are constrained in the care that we can deliver by the environment. Our goals generally are to evaluate and stabilize the patient to an extent that we can evacuate them in whatever form. So unless you're unable to move them for some reason, the goal is just stabilize those A, B, C Ds in the most efficient way possible that protects you, your team, and the patient. And then you wanna minimize exposure to the environment and get people out. As soon as possible. And maybe there's times when like you literally can't move a patient, so you're a solo practitioner, your partner just fractured their femur and you have no way to drag or move them. You're probably still gonna approach it the same way, like they're gonna need to stay there until someone is gonna take them out of there. So you're gonna have to stabilize them. And unless you can get comms to the outside world, your next move is gonna be like, here's your fire buddy, I'm gonna go get help. So like our goal is always to get people out and you can get hung up on trying to deliver advanced care. That makes me think of like maybe the one setting, which is the first. 20 to 30 minutes of CPR after a cardiac arrest is one time when we stay in play because we know that the one thing that we can deliver to a patient that will be effective and that we shouldn't mess with is high quality CPR. This is probably obvious'cause you're not gonna extract someone who is functionally dead until you try to, until you try to treat them. But that is one setting. For example, on the ski hill, normally we're like. Get someone in a toboggan, get'em down right? Get'em off the hill, get'em out of the snow. If you go down with a cardiac arrest, we're gonna work you where you are. We're gonna cut your jacket off. We're gonna do all this stuff there for 20 to 30 minutes to see what kind of result we can actually get. We're not gonna mess with that intervention, but generally speaking, you'll do pretty well by doing your a b CDEs and then getting out as soon as possible.
Zack M:You mentioned. CPR And we had a question, a little ironic, maybe a little lighthearted from Serenading, your father who asked, is it even worth starting CPR? But I actually think it's an interesting question because obviously, in the urban settings there's EMS is arriving, so CPR makes a lot of sense, but maybe it's harder to imagine if you're in the back country hours away, whether you would start CPR for some people. What would you say about that? Always start CPR.
Patrick Fink:Not if someone has obvious signs of being dead, like their head is not on their body. They have truncal transection, or their whole body's frozen. That said, that's a little tongue in cheek. I think that probably the root of this question is someone imagining. Starting CPR in an environment where you just don't have an end point and you're like, are we really gonna continue this for hours and hours and hours and hours, and it's just not feasible? That said, my answer is yes. If someone does not have a pulse and is not breathing, the majority of those people deserve at least 20 to 30 minutes of CPR. And there are certain scenarios which are more specific to wilderness medicine where CPR can be uniquely successful. So people who have suffered drowning, people who have been hit by lightning, or people who have had a brief avalanche burial or critical snow burial are people who can be readily resuscitated with CPR people who have suffered a cardiac arrest because of trauma. It's a dire situation that doesn't even work in the front country most of the time. But in our cultures particularly, there's a huge psychological benefit to doing CPR and people almost expect it. So I think it is how we show that we are doing the most for a patient and we just have to have a good understanding of when to stop and in all, but the most hypothermic patients, the answer to that question somewhere around 30 minutes is where if we haven't gotten a good result, we're probably not getting a good result.
Zack M:You also mentioned femur fractures, and I think that's a great place to talk about traction splints. We reached out to Reddit, the ski patrol community. We got a lot of questions about traction splints, and other specialty equipment specifically. How often are traction splints applied properly when they get to the hospital? Do you see, ever see them improperly applied, along with any other specialty equipment people are using?
Patrick Fink:I would say that there's pretty significant variability in how well traction splints and, pelvic binders are applied. And that's, it's like. Organization specific. This is something a hundred percent that like if people train on it, they do it right and if they don't train on it, they do it wrong. So you know, you have to be familiar with the equipment that you have, and you have to be getting it out, and you have to be applying it on each other and have a fundamental knowledge of how to do that. Both of these things, I think are worthwhile. The pelvic binder very clearly worthwhile in situations where someone has significant abdominal pelvic trauma and hypotension, low blood pressure because it can reduce the amount of space inside their broken pelvis that they can bleed into a traction splint for the femur. The data on that is a little bit more variable in that yes, they generally do improve patient pain if they're applied correctly. They likely reduce the potential for bleeding associated with a femur fracture. But there isn't clear data that shows that it improves outcomes long term. So if you're asking that question because you don't want to put on a traction splint, the other thing that I would say to you is it's all about your protocols, baby, because you don't want to be that guy who's the maverick, who's not putting on the traction splint. You don't wanna break the standard of care. If you're asking because you see them applied wrong often, that's a training problem.
Zack M:What about. maybe non-physical, equipment or techniques, I guess is a better way to say it. Are there mental things that found work really well? You mentioned keep, starting CPR can be a psychological benefit to people around. Is there anything that's proven to keep someone fighting, as opposed to just telling them to hang in there. Are there things you use in those on the hill to keep patients morale up as best you can?
Patrick Fink:Yeah, so there is, not probably the way that this person is thinking where you're like, I'm on death's door. Like, don't go into the light buddy. So how do you help? Support a patient without physical or medical interventions. I think the best thing that you can turn to is something called psychological first aid, and that's helping to address the other half of the patient, not just the body, but the mind in the moment. So these tactics have been shown to actually reduce. Pain. If you have someone you know holding your hand, you'll experience less pain. But if you someone have someone you don't know holding your hand, you still experience less pain than if you were just by yourself. This is actually supported by interesting tidbits of evidence. I would encourage you to look at our, pain management in austere. Settings guideline from the Wilderness Medic Medical Society. I'll put it again in the show notes but there's an A, B, CDE mnemonic that we have in there that's adapting psychological first aid to the treatment of patients in a wilderness environment. And it's basically giving them a role in their care as much as possible. A is anchoring attention, acknowledgement, and that's providing the patient with a provider who acknowledges themselves as being like, I'm the one who's gonna take care of you, acknowledges that they're in distress and helps direct their attention. And you move on to B, which is breathing. So encouraging people to breathe in a controlled manner, not rapid, shallow breathing or hyperventilation. We use, both like tactical settings and in. Medicine, things like box breathing. So in for four, hold for four, out for four, hold for four. It's a square to help regulate your central nervous system and help calm you. And then c is for control and cognitive shift. So providing the patient a role that gives them some control over their situation. So maybe they need to help hold this thing on their leg while you address something else, or that gives them. Some decision that they can make small things, you're not like, how do you wanna get outta the woods? But just something that shifts their mindset away from catastrophizing. D is for distract, diffuse, and decrease nociception, which is like pain stimulus. So we're treating pain. And also distracting the patient from their situation by directing their attention elsewhere and diffusing whatever we can from the situation using either empathy or humor. And finally like explanations and expectations, which is like telling them what's gonna happen and what they can expect. So we're gonna be here for the next two hours. 20 minutes from now, we're gonna package you in a litter. That means you're gonna be wrapped up like a mummy and you won't be able to move anything except your face. And we're gonna hook you up to a helicopter. It's gonna be loud. It's gonna be windy, and as soon as you're off the ground, you're gonna start to spin. And that's normal. The flight is gonna be short, but it'll feel like a long time. You might get nauseated, but then once you land, we'll be able to get you out of the letter. Just like explaining these. Unique situations to take the unknown out of it. So that's my best answer to that question,
Zack M:that's a great answer. I hadn't heard about that. A, B, c, D for psychological, treatment. It's really cool. How about for yourself, for the provider? How do you deal with the unique challenges of being maybe the sole provider or one of the only providers in that remote environment? Are there any tactics that you use any. Training or preparation beforehand, or things you'd like to tell yourself when you're going into those settings?
Patrick Fink:I think that the best way to prepare yourself for that setting is to develop a broad base of experience in clinical care. In an urban or a more controlled setting because as soon as you go out into that wilderness environment, you're gonna have fewer resources and more demands on your attention, like addressing environmental concerns or objective hazards in the mountains. So you have to be able to fall back on judgment that you've developed in another setting, and you have to be able to make a bunch of those kind of simpler clinical decisions based on experience rather than using. Limited brain space to address those. You know, when I address the clinical care of a open tib fib fracture, for example, I've evaluated tte open fractures in the emergency department. So I have a standard way that I know to evaluate that limb. I have a standard way that I, might approach a basic reduction and bandaging, and those aren't things that I need to be thinking through, and it allows me to prioritize the care and say, okay, what's number one? Let's make sure that this limb has circulation and that I don't need to perform an emergent reduction. Make sure that there's adequate hemorrhage control, and then we can move on to pain control. I don't have to invent that in the moment.
Zack M:That kind of wraps up our questions about. Techniques and equipment. To wrap up, we've had some other miscellaneous questions that I wanna make sure we get to. One question comes from lower froyo 4 6 2 3, they're wondering how can Willer medicine, search and rescue be applicable on typical EMS or technical rescue? So they're a volunteer search and rescue. Member, and I guess they're wondering about how those two can be combined or integrated together.
Patrick Fink:I think from like a techniques perspective, there's not a lot that you take from the wilderness environment and you take it back into the. The EMS environment, except perhaps that if you are spending your time thinking about what are the important elements of care that I can deliver in an austere environment, what are those things that I'm gonna carry with my, on my person on the fire line? What are the like specific problems that I think are most important to be able to address in those first minutes? And what are the critical tools that I need? You can take that same prioritization. Back into whatever your work context is and better understand what are the critical interventions like we have. I got all the toys in the emergency department. I got all the stuff, I got all the meds. But the same critical components of care that I wanna deliver in the first 10 minutes are gonna be essentially the same. And how I deliver them might just be a little bit more sleek and refined in the emergency department. So I don't find myself improvising tourniquets in the emergency department or improvising splints. But when I think and develop protocols or plans for how to address things in a more challenging environment, it refines my thinking in a way that I think is useful back in my day job.
Zack M:Just to wrap up, where do you see the field of Wilder medicine going in the next maybe 10 to 15 years? Where do you hope it'll go, and then where do you expect it to go?
Patrick Fink:I think that the field is graduating to a higher level of professionalism, and I think what I mean by that is I think maybe 10, 20 years ago, this was basically like a brand new field. It was like the people who got the outdoor ed degree for their bachelor's and then ended up going to medical school, were like, let's invent wilderness medicine. So we can keep doing all the fun stuff that we've always done. We'll do CME courses where we go hiking, and somehow get paid for it. But now there's increasingly large organizations. That are dealing with increasing populations of people going out into wilderness spaces, be that National parks, national Forest, BLM, land ski areas, what have you to deal with that In those increasing demands and increasing burden of rescue response are having to become more professional. They're having to raise their standard of care. They're having to protocolize and they're becoming more and more like. EMS systems in that there's hierarchies of command, incident, command structures, protocols that different, you know, kind of provider levels can operate under. And so I think from a structural perspective, that's where the field is going and the demand for, fellowship trained. Wilderness docks is gonna be driven largely by that. It's national parks wanting medical direction, it's national forests wanting medical direction. The more people that end up in the outdoors, the more spaces there are for people to occupy in the field. I think training wise it's becoming a little bit more refined in that there are now certifications like the Diploma in Mountain Medicine that are internationally recognized that say I am a medical provider who has the chops to be in a technical environment, or at least understand that it can be translated to other countries. People may be looking for more of that. Expeditions try to find a expedition dock, or companies want someone to develop their medical protocols. You're a petroleum company that's doing exploration out in the desert and you need EMTs on site and you need protocols to do wilderness medical treatment. Who are they gonna be looking for? They're gonna be looking for people who've, who have. Specific training in those things?
Zack M:So you expect that it'll, it might become more of a standalone field, or do you think it'll always stay integrated with urban emergency medicine too? 10 years from now there could be a large population of doctors strictly doing wilderness medicine research, or do you think it'll always be contained within
Patrick Fink:I think in general people are probably going to be, in their day jobs still, but the opportunities for formalized roles in wilderness medicine are growing more numerous by the day. With that money to help develop protocols or to, conduct relevant research like that's a slowly growing area that continues to grow as more and more people go outdoors. There's also, the changing technology that could significantly affect the field. For example, the ability to deliver medical supplies using drones or even conduct search using drones with forward looking infrared cameras. The technology that can be brought to bear on this is pretty interesting. I don't think it's gonna replace boots on the ground within the next. Decade. But, it's definitely an interesting growth area.
Zack M:Great. Those are all the questions that we had listed in, and I think I've learned a lot. I hope everyone listening has too. So thank you so much Dr. Fink, for taking the time to answer all these questions and teach us a little bit about the field of wildness medicine.
Patrick Fink:Hey, Zach. My pleasure. That was far too much talking for me in one go. But, if folks have other questions, don't hesitate to send them in. We can put together another MA episode in the future, but hopefully if you're considering a career in wilderness medicine or thinking about augmenting what you already do in medicine with this side of things, that this was helpful or gives you something to chew on if you've been thinking about it, I encourage you just to reach out to whatever your local organization may be. So they're volunteer search and rescue outfits and almost. Every county, across the United States, they're generally sheriff's office space. So reach out to your local sheriff's office. If you're interested in ski patrol and you're not ready to be a professional ski patroller, look at the National Ski Patrol. That's a volunteer organization. Again, nationwide Mountain Rescue Association. There's a lot of umbrella organizations one of my other podcast guests, moose Motlow, said one of the awesome things about the United States. Compared to other places in the world is that if you show up and you have skills and you want to give your time and energy, people are gonna let you in the door and they're gonna start teaching you and giving you experience. The more that you can show up and give, the more you're gonna get.
Zack M:All right, great. Well, I'll have to check out. Those'cause I do love skiing, so maybe I'll, follow in your footsteps.
Patrick Fink:It is pretty fun to throw bombs and ski powder,
Patrick:That's it for this episode of Wilderness Medicine Updates. I'm your host, Patrick Fink. Thank you for taking the time to listen through this. If you are in a health career and thinking about how to fit wilderness medicine into that career, I hope you got something useful out of the show and maybe you learned a little something about Tree Well Immersion as well. Again, don't forget to check out episode 21 if you haven't heard it. Particularly if you're in a snow related profession, an avalanche professional, a ski patroller, or even just a recreational skier or rider, I think it's important information. Once again, I thank you for being a listener of this show. The best way to support this show is to share it with a friend, maybe another ski patrol member, a SAR member, your buddy down the block who's always riding bikes out in the Wilderness Park Ranger. Nurse, medical student, your mom, share with your mom. Another way you can support this show is by giving me a five star rating on iTunes, on Spotify, on Apple Podcasts, on Amazon, whatever. Whatever outlet you use to listen to this show, that helps raise us up in the rankings, raise me up through the search algorithm and deliver this show to more people who might like it. Comments are helpful as well. If you gimme a shout out, I'll shout you out as well, and don't please reach out through Wilderness Medicine updates@gmail.com with any questions or comments. I'd love to hear from you if this show inspired other questions that you might have about wilderness medicine or careers in wilderness medicine. Send those along and at some point we can do a listener q and a session where I answer those questions. You can listen to me ramble on some more if that's what you really want. But that's all I have for today. Until next time, stay fit, stay focused, and have fun.
