"Life in Practice"
A Podcast created by KPSR physicians for our KPSR colleagues
"Life in Practice"
Life in Practice: Episode #1: Wilderness Medicine
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Episode #1 features an interview with Dr. Tate Higgins, A KP Ed doc who shares his stories and tips for caring for patients in unusual and sometimes harsh environments
I am Dr. Adrian Silver.
SPEAKER_01And I am Dr. Prabrip Kord.
SPEAKER_03Welcome to Life in Practice, where we explore the far edges of medicine and the depths of the human mind. One month we journey into the fascinating, the unexpected, and the sometimes unbelievable stories from our colleagues.
SPEAKER_01The next we focus on mental health and wellness, helping you care for yourself and those around you.
SPEAKER_03Welcome to episode number one. Today we're venturing off the beaten path, quite literally, into the world of wilderness medicine. Joining us today is Dr. Tate Higgins, a physician whose work takes him far from the comfort of exam rooms to the wild and great outdoors. Welcome, Tate. Thanks for being here.
SPEAKER_00My name is Tate Higgins. I'm a physician here at Kaiser, Emergency Medicine Physician. I've been with Kaiser Santa Rosa for one year. My residency was at Stanford University. I'm here today to talk about some wilderness medicine. Background, kind of what led me to medicine in general was actually through wilderness medicine. So it's a specialty within the house medicine or a little corner that I'm really passionate and interested in. I was a river guide and a mountain guide in my 20s. I was teaching college English and working in the summers outdoors as a professional expedition leader. And through that, I was interested in gaining some more medical training in order to take care of people on bigger, longer, more extreme trips, international work. And so I did a wilderness EMT course with a group called Knowles, the National Outdoor Leadership School, and left that course really excited about applying wilderness medicine skills and also excited about just taking care of patients in general. Started working as an EMT and eventually started teaching wilderness medicine and spent the next oh almost 10 years doing a combination of guiding wilderness trips, working as an EMT and teaching wilderness medicine. And then through that, I got to meet some really interesting emergency medicine physicians who encourage me to look into pursuing more into a non-traditional path. Came back to medicine after 10 years in the backcountry and now really interested in continuing to combine those two things.
SPEAKER_03So in your experience over those years, what was the first time that you felt like you needed to use your skills out in the woods and in the field?
SPEAKER_00I was thinking about some memorable experiences and rescues, and I think about it in a couple of different ways, defining what it is and how we apply it. And one is time. And so when we think about wilderness medicine, it's extended patient contact time. And then the other is having to improvise equipment, the other is having to make independent decisions. Often you're out there on your own. You don't get to call a specialist, you don't get to call for backup as easily. And then I think about the environment. Wilderness medicine, the environment is always a factor. It's never neutral and it's never ideal. And then the final big one that we really think about in wilderness medicine is prevention to anticipate and prevent injuries and illness. And so the reality is we spend a lot of time training and a lot of energy prepping and a lot of energy anticipating injury and illness early and preventing it. I had the unique opportunity early in my wilderness medicine work to work in Nepal. And so I got to guide treks in Nepal at high altitude to Everest Base Camp. I've never climbed Everest, I haven't been past base camp, but I got to go many times to base camp and lead folks in that high altitude environment. And that's the place where I had one of my first kind of crashing patients that we had to manage overnight that needed an emergency helicopter evacuation. So we had a patient that came down with a high altitude pulmonary edema in a tea house and just on the edge of Mount Everest up in the Himalayas. And uh that's a that's my first emergency helicopter Evac where I was the wilderness medicine provider, making those decisions, improvising situation, dealing with the environment.
SPEAKER_03Can you go into some detail about how you managed that? And did it feel like you had the supplies that you needed?
SPEAKER_00You never have enough. Foundations of wilderness medicine are taking pre-hospital foundations and applying them to austere environments. And the things that we learn in front country medicine, check your vitals, doing full assessments, managing ABCs. It's the same foundations that you would use in a pre-hospital setting anywhere, but then you have this extra challenge of time and environment and improvising. For this particular case, we had a patient that had progressive shortness of breath on exertion, started developing a productive cough. We were traveling at altitude. So we had prepped the team and our equipment for possible high-altitude illnesses. And so high altitude pulmonary edema is a big one that we're on the lookout for. We had spent the day going up to about 17,000 feet. And then our sleeping altitude, which is a big factor in altitude illness, was over 15,000 feet in the couple of nights around this presentation. But luckily, we were prepared with some basic things like a pulse ox. We had access to oxygen, which is unique in the wilderness. But because we were on this altitude environment, and we had a Gamov bag, which is a portable hyperbaric chamber that can be used to treat high altitude illness. So luckily we were prepared the best we could be. What we didn't have was electricity, monitoring, nursing staff. We had a first aid kit that was big that had some basic medications, including the ones we needed for altitude. But we rallied the team and we gathered some help with my staff that was there with me. And we took shifts monitoring the patient by hand and feeling a pulse and using a watch and using a finger pulse ox. And then luckily the patient did well overnight, and then we were able to arrange for a helicopter evacuation early the next day.
SPEAKER_02So couldn't you just have brought them down to a low altitude? Isn't that the cure for most high altitude issues?
SPEAKER_00Yeah, it's a good point. Going to lower altitude is what they needed. You're feeling sick at altitude, or you have a sick patient. We assume the altitude is a factor. Of course, everything else happens to altitude too. But the treatment for altitude illness is to remove the altitude, which means to descend. And our big life threats at altitude are fluid and swelling in the brain, high altitude cerebral edema. Patients that have balance problems or severe headaches or mental status changes need to go down right away. And then we have lung problems, high altitude pulmonary edema, which is shortness of breath, dyspnea, hypoxemia. Those patients also gotta go down.
SPEAKER_03It's kind of random, right? It can happen regardless of your age or your exercise ability. Although I imagine if you're older, those situations are probably all that much more difficult to treat.
SPEAKER_00You're exactly right. And it seems to be driven mostly by genetics, as far as if we can account for all the other variables. We know that certain things put you at higher risk. So the faster you climb and the higher you go quickly, the higher risk of developing one of these illnesses or life threats. But being fit probably make you enjoy your trip more, but it's not gonna protect you from the physiology of high altitude.
SPEAKER_03Was that the craziest environment that you've worked in or where you've had to provide care?
SPEAKER_00I think high altitude is one of the really interesting, unique environments in wilderness medicine. The high altitude environment is one of the most challenging because it just the terrain being in the high mountains, the challenge of evacu, the unpredictability, and then of course you have the extreme weather.
SPEAKER_03So for those of us that are not wilderness trained, but do a lot of hiking and being in the backcountry, what do you think is the most essential things that you should have with you? And then as a physician, what do you think are the most important things to be able to help others?
SPEAKER_00Yeah, great question. I think spending a little time before you go on a trip, even if it's just for a day, to think about what could go wrong, are we prepared for it? What equipment do we need? So just having that pause before leaving the house goes a long way. And then I think everybody that's doing any significant time outdoors or anyone that wants to assume a role of taking care of emergency situations in outdoors should have some training. There's great conferences around the country. They're always either at a beautiful place to ski in the winter or a beautiful place to hike and recreate in the spring and summer. There's a group called Wilderness in Travel Medicine that does conferences around that a lot of the Santa Rosa Kaiser Docs have been to. There's a Wilder Medicine Society, and I think engaging in the thought process a little bit and thinking about like how I would take care of a situation. So playing that what if game before you leave. And then it comes down to some basic first aid supplies, some basic survival supplies, and then a plan to either get out of there or to communicate if you need to call for help. But I think the way we can boil it down is that you should have one. The first aid kit has to be customized to the trip, the people, the length. There's no perfect first aid kit. And so a lot of times what I think works well is to find like a commercial first aid kit that's in a container that's the right size and has some things that you like in it from REI or online or wherever, and then bring it home, open it up. There's gonna be some stuff in there that's not useful to you. There's gonna be things missing, and then you can customize it for your needs. It's interesting as a physician, we start thinking about first aid kits in the wilderness and pre-hospital medicine. And we have all this training and skill set, and we start thinking about the what-if scenarios, and it's really easy to start building a first aid kit that is huge and unpractical.
SPEAKER_02You need your yeah, I was just thinking like portable crash, right?
SPEAKER_00The reality is you're not you can't bring everything, you can't bring the crash car, you can't bring all the medicines, you can't bring all the splinting supplies. Even as my training has advanced and my experience has advanced, my first aid kit has gotten smaller, it's gotten more efficient. And part of that is time and experience, and then realizing what we can actually do in the backcountry. When I think about it as a physician, I think about what are the things that I can't improvise that are important to treat, like a life threat, something that I could reverse. So you mentioned epi. Having epinephrine is a one of the few medications in a wilderness setting that could be life-saving. If I'm on an international trip and don't have access to a pharmacy, and I'm gonna be in an environment where I'm worried about infections and I'm gonna be out for days or weeks, then opens up this whole other category of do we need to be carrying medicines to treat common infections. But my personal first aid kid, just to keep it simple, I think um ABCs is where I start, like airway breathing, circulation. And so do I have the ability to manage airway and breathing and control bleeding? And most of that, to be honest, is more skills and training than equipment. Like some barrier devices, protection, gloves, masks, those would be great to have. But airway management in a backcountry setting is positioning. And if you can get good head positioning, you can probably take care of it. And I carry NPAs and OPAs to help with that. And then it's all the CPR stuff we learn rescue breathing and chest compressions. And the reality is if you're doing chest compressions in a wilderness setting, the survival rate, with the exception of like cold water drowning in an otherwise healthy person, the survival's like very unlikely. And but bleeding control is a big one. And so when I think about circulation, I think about do I have the ability to control bleeding? And this goes back to training. There's a great course called Stop the Bleed that talks about how to manage life-threatening bleeds. And it's uh, I think it's a two or four hour course that people can keep an eye out for. It's offered locally. The things we mostly deal with in the backcountry setting are cuts, scrapes, sprains, strains, environmental stuff, minor stuff that if we have some equipment, we may be able to make patients more comfortable. So have a first aid kit and think about what you're gonna use it for and realize that you can't have every single medicine and every single band-aid.
SPEAKER_03That makes a lot of sense. I think what you said in the very beginning, which is just to think about where you're going. How long are you gonna be out there? From my experience in Colorado, people would go out and have really inadequate clothing. They wouldn't realize that even if it's 80 degrees outside, you know, and in low altitude, when you get to the top of a mountain, it can be hailing, snowing, lightning. So I think that it's such a good point for everybody that wants to get involved in this. Like you said, the basics and being prepared and having different scenarios in your head that you can prepare for, having extra food, extra clothing, things like that. Because I imagine many of the things that happen out there are because people are not adequately prepared for it.
SPEAKER_00Yeah, it's so true. And lots of our classic rescue stories always starts with I was just going for the afternoon. So I didn't bother bringing my rain jacket, or I was just doing this. And so it's often those shorter trips, those day hikes that turn into an unexpected night out. Yeah, I think anytime you're leaving the front country, even if you're hiking Taylor Mountain, if you're just going, you should just have a brief check-in about what if? What happens if I break my leg at the end of this trail because a rock rolls funny? And what would I do? I hate having my cell phone in the backcountry, but I'll often just turn it off, put it in a zip like bag, and put it in the bottom of my backpack.
SPEAKER_03So I noticed the last time I was hiking, I saw there's now a feature on the phones where you can actually link to a satellite if you don't have cell service in an emergency situation. That was new to me. I hadn't realized that because there's so many remote places you don't get cell coverage.
SPEAKER_00That's right. The newer iPhones, I think the last couple models have a feature where you can get some basic satellite communication, even if you don't have tower reception and you can at least usually get some text out. And so, yeah, thinking about communication was really important.
SPEAKER_02I mean, that can be absolutely life-saving.
SPEAKER_00There's times where if there's a big injury or illness in the backcountry, then you do your best on scene. But what you really need is an evacuation, and that's the ability to initiate help in evacuation, is often the difference in life and death. And uh so some sort of communication device is really important. And the iPhone is great with the satellite. There's the spot devices, there's Garmin, a couple of different companies have options, but that's another just what if. Okay, what is our communication device if we need it?
SPEAKER_03Are you planning on doing any other expeditions? And do you ever bring people with you? Because if they sound amazing.
SPEAKER_00I definitely plan in more expeditions and get outside as much as possible. This year I was lucky enough. I went down to Patagonia to Chile and I got to teach wilderness medicine CME to a group of physicians who were down there doing some of the world's best whitewater rafting and multi-sport adventures. And I got to go help out at a wilderness medicine conference in Santa Fe this year with Wilderness and Travel Medicine, which was great. My plan is to try to continue to teach wilderness medicine and to get out and do as many expeditions as I can. Keep uh ear out and eye out for opportunities and keep doing trips is the key.
SPEAKER_03That's awesome. Thank you so much, Tate, for taking the time to talk to us today about wilderness medicine. I will definitely be looking up some of those conferences, which sound incredible. For everyone listening today, I hope this was as enjoyable for you as it was for me hearing from Tate about his experiences as a wilderness medicine doc. And stay tuned for our next episode, which will feature Papri talking about mental health and wellness. This has been Life in Practice.