Book Review

Wilderness Medicine: Management of wilderness and environmental emergencies

N Engl J Med 1995; 333:1789-1790December 28, 1995

Article

Wilderness Medicine: Management of wilderness and environmental emergencies
Third edition. Edited by Paul S. Auerbach. 1506 pp., illustrated. St. Louis, Mosby, 1995. $157. ISBN: 0-8016-7044-6

Many decades ago, a victim of a mountain-climbing accident was brought into a hospital in the Pacific Northwest. The doctor on duty remarked, “It is a good thing he had the accident right outside the hospital, or he wouldn't have survived.” The mountaineer had fallen on a remote mountain in the Cascades, and the evacuation had taken several days — a testimony to the practice of wilderness medicine long before the term came into use in the 1970s.

The wilderness is shrinking, and access to it is increasing. Climbers on Denali (Mount McKinley) have been known to take out cellular phones on reaching the 6194-m summit and call home. “Heli-hiking” and “flightseeing” are for the weak, wealthy, or infirm.

Wilderness medicine (medicine practiced in settings remote from health care facilities) is a field that grew out of symposia on mountain medicine, aimed at the increasing numbers of people involved in adventure tourism. The field has evolved to encompass a society, multitudes of courses and symposia, international congresses, a journal, sets of teaching slides, and position papers. The editor is one of the founders of wilderness medicine.

The third edition of a book that first appeared in 1983 is welcome. This edition has many new features, as well as time-tested information. Strong editorial oversight has been used in an effort to ensure consistency among the 56 chapters and 93 contributors.

This definitive textbook covers the principles of the subject very well. In essence, “At the heart of wilderness medicine is improvisation, an amazing amalgam of formal medical science integrated with an adventurous twist of creative and commonsense problem solving.”

The readership for this book includes primary care providers in diverse settings throughout the world. The book should be an important reference work in emergency departments, as well as travel- and sports-medicine clinics. Persons teaching aspects of wilderness travel will be well served if they have access to this book, as will trip doctors and nurses.

Many chapters are state-of-the-art summaries, containing historical overviews, current concepts of pathophysiology with the controversies spelled out, a wealth of references, and most important, a range of clinical material to inform good judgment in providing care, whether in the field or on arrival at a medical facility. These chapters cover injuries related to altitude, diving, cold, and heat. The discussion of injuries inflicted by mammals is a rare compendium on this topic and, at 67 pages, the longest chapter. Bites by domestic animals are common, and as habitat encroachment continues, encounters with wild animals and resulting injuries will become more prevalent. One survey suggests that 45 percent of schoolchildren have been bitten by dogs, and 1.2 percent of postal carriers in the United States are bitten by dogs every year. Although encounters with animals concern even rational people, humans are the most dangerous of animals. Table 40-2 shows that over 200,000 individual murders are committed by humans per year worldwide, as compared with a paltry 4520 deaths caused by animals other than snakes, which rank second, accounting for 50,000 deaths annually. Rational approaches to animal bites of many varieties are well covered here.

Atypical for a medical textbook is the chapter called “Wilderness Improvisation,” a takeoff on 101 uses for a safety pin in the wild. This chapter covers such matters as how to improvise an airway. Knowledge of such measures of extemporization will increase the chances of coping with unexpected situations in the field. Readers with extensive wilderness experience will find that some improvisations used successfully in past situations are not discussed. One example is the use of a helicopter rotor for rapid cooling of persons with heatstroke. Also missing is a discussion of the role of sterile technique in extremis.

Liability issues abound in wilderness emergencies. An informative chapter discusses these issues, covering consent and abandonment, as well as the liability of outfitters. The references are to actual cases, and the clinician will find most questions in the gray zone of resolution. A strong chapter on ethics follows and provides useful guidelines.

The book could have been slimmed by scaling down the size of many of the graphs and reducing the duplication of material by cross-referencing. The order of the chapters is haphazard, and the book would have benefited from a grouping of chapters into sections covering such topics as problems related to changes in environmental factors or to plants and animals; survival, search, and rescue; trauma; and contact with other peoples. The summaries at the end of a few chapters (chapters 3, 12, 20, 22, and 26) are good, but their absence in most of the chapters reflects an inconsistency in working with so many authors to cover such a comprehensive range of subjects.

This book will not keep health care providers from attending the many courses on wilderness medicine, but such providers will be well served by this encyclopedic work. In the case of a woman who has undergone coronary-artery bypass grafting and is planning to parasail in Irian Jaya, for example, one can consult the chapters on high-altitude medicine, foreign travel and exotic diseases, jungle travel, and women in the wilderness, which is much easier than rummaging through disorganized course notes.

As our society ages, an increasing number of people with wealth and leisure will plan wilderness trips and will seek pretravel advice, as well as help with problems they encounter afterward. This book of diverse material will serve both tasks well.

Stephen Bezruchka, M.D., M.P.H.
University of Washington School of Public Health and Community Medicine, Seattle, WA 98195-3576