The Epidemiology of Remote and Wilderness Injuries and illnesses

28th October 2020

In the previous articles we have looked at the patterns and distributions of injuries across all civilian settings and also those particularly relevant to hostile events. In this article we will look at the epidemiology of injuries and illnesses in remote environments.

The patterns and distribution of injuries and illnesses in remote environments differs significantly from those in traditional domestic environments as activities in remote or wilderness areas carry with them particular additional or unique hazards including, but not limited to:

• Dangerous activities – by the very nature of being in a remote environment we are likely to be undertaking unfamiliar or higher-risk activities.

• Unfamiliar geography

• Unfamiliar climates and altitudes

• Unfamiliar diet

• Poor sanitation and food hygiene

• Psychological stressors including, but not limited to, isolation, loneliness, monotony, claustrophobia, agoraphobia etc.

• Exposure to a wider range of communicable diseases

• Exposure to a wider range of flora and fauna

• Local cultures and practices

These hazards not only increase the risk of serious injury or illness, but also influence the nature of that injury or illness.  For those working or playing in these environments it is fundamentally important to not only understand how we can mitigate these risks, but also how deal with the consequences.    In addition to the nature of the consequence which might be unfamiliar to us coming from a low-hazard, low-risk, urbanised setting we have the added complications of having to deal with a casualty for extended periods of time and often with limited resources.

Historical Perspective

Wilderness First Aid has developed since the 1970s from a niche subject delivered through a few North American outdoor training providers such as Stonehearth Open Learning Opportunities in Colorado and the National Outdoor Leadership School in Wyoming who saw the importance of recognising the challenges of delivering medical care in wilderness settings.   The first Wilderness Emergency Medical Technician (W-EMT) course – a 4 week course based on the US EMT syllabus complete with state registration was delivered in 1976 to EMTs to help adapt their skills and knowledge when working with search and rescue teams.

The UK was slower to gain traction and a 4 week first aid course just would not work.   The British Association of Ski Patrollers have been running 5 day EMT courses since the 1990s but even this was considered esoteric.   Rescue Emergency Care were the first organisation in the UK to offer first aid training specifically for outdoor environments in the late 1990’s and provided the original “REC” course which offered a progressive pathway of short two-day courses from basic (Level 1) to Expedition (Level 5).  The 16 hour long REC Level 2 course became the defacto outdoor course and pre-requisite to many National Governing Body Awards in the UK and spawned a number of Outdoor First Aid courses, offered by nearly every Awarding Organisation.

Most of these two-day Wilderness or Remote First Aid courses are simply a basic one-day Emergency First Aid at Work course with an additional day on injuries and heat and cold issues. The better courses are contextualised for a remote environment e.g. hours from help rather than minutes.

For the lay person or non-registered healthcare provider there is an increasing range of regulated accredited Pre-Hospital Care courses available on the market such as First Responder, FREC and FPOS which have certain commonalities:

• Aimed at the community first responder or advanced first aider in the workplace

• Usually 4 or 5 days in duration

• Covering most aspects of First Aid at Work with the addition of:

  • Airway management and supplemental oxygen

  • Trauma skills for head, spinal and burns injury

Whilst providing a wider and deeper content, these courses do not prepare individuals for remote environments nor the injuries or illnesses they may encounter.

There are a minority of course which have become known colloquially as “MIRA” courses (after the original Medicine in Remote Area course) which provide candidates with invasive surgical skills such as emergency airways, IV cannulation, intubation and needle decompression.   Many would argue that:

• The skills required to perform these interventions safely are above scope of practice of the lay responder (certainly based on having practiced those skills once and only on a mannequin).

• They are not representative of the skills required for remote or wilderness settings

For those wishing to extend their skills to offer appropriate care in remote environments the choices are Pre-Hospital Care style courses, which are not specific nor necessarily applicable to remote environments, or ‘hostile environment’ training which are questionable in their appropriateness and medical liability.

Evidence review

Below are a selection of data sources which reveal the distribution and severity of injuries and illnesses in remote environments. Between all three of the examples below (1-3) and other supporting literature (4-6) there are common themes which should form the basis of remote medical training.

Royal Geographical Society – Expedition Advisory Board (1)

The Royal Geographical Society is the home to the Expedition Medical Advisory Group with records of over 5,000 expeditions in its collection.   Data collected from 467 expeditions from 1995 to 2000 show a similar range of issues identified

Wilderness Injuries and Illnesses (1992)

From September 1984 to September 1989, a comprehensive safety data base was compiled from all National Outdoor Leadership School wilderness courses conducted in the Western hemisphere accruing in 358,210 person-days of wilderness activities.

The collated data reveals:

Survival and Austere Medicine: An Introduction (2017)

From a lesser known publication, below are the results of one of our author’s experience in the provision of health care in various remote and austere locations (some third world, some first world) to nearly four thousand people over a cumulative 30-month period (spread over 18 years):

Summary

1. Shit happens.   No. Really.   Shit and puke is where it is at. While surgical airways and tourniquets are sexy, the crux of remote healthcare is diarrhoea and other less glamorous issues such as UTIs and skin infections across all literature (1-6) . If you want to be an asset to your expedition or work abroad, put the tourniquet down and know how to look after poorly people, including diarrhoea and vomiting.
   
   

2. Illness is on par with Injury.  Whilst trauma is exciting, and is much easier to deal with, the skills needed to deal with medical casualties are slightly different.   There is a general bias to trauma in terms of Learning Outcomes and Guided Learning Hours attributed to trauma in most Pre-Hospital Care courses.  Dealing with medical conditions requires casualty assessment skills, diagnostic skills and decision making skills.
   
   

3. Medical Issues require medication.   Anyone can walk into a supermarket and buy a wide range of medication to administer to themselves, their children or offer to their friends…but for some reason we think that we cannot talk about medicines on a First Aid course in the UK.  This needs to change.
   
   

4. Trauma is not that traumatic.   Injuries tend to be simple issues, the most common being ankle sprains.   Again, it is rarely spinal injuries and catastrophic haemorrhage and more bites and blisters so the onus should on doing the basics – such as immobilisation and wound care – really well rather than spending a disproportionate amount of time on low -probability, high-severity trauma.
   
   

5. A standard first aid course delivered in the woods is not a remote First Aid course. Whether you choose to attend a Remote First Aid or Prolonged Field Care course with us or with one of our competitors, do your research: If the training providers’ core business is commercial training for corporate or childcare environments in the UK, they are probably not going to be subject matter experts in remote medical issues as well.

References

1. https://www.rgs.org/getattachment/In-the-field/Advice-training/Resources-for-expeditions/Health-and-safety-survey/HSSurvey2002_summary-of-results.pdf/?lang=en-GB
   

2. Gentile DA, Morris JA,  Schimelpfenig T, Bass SM, Auerbach PS.  (1992)  “Wilderness Injuries and Illnesses”.  Annals of Emergency Medicine.  21(7):853-61 
   

3. The Remote, Austere, Wilderness and Third World Medicine Discussion Board Moderators  (2017)  “Survival and Austere Medicine: An introduction”.  3rd edition.
   

4. McLaughlin KA, Townes DA, Wedmore IS, Billingsley RT, Listrom CD, Iverson LD. (2006) “Pattern of injury and illness during expedition-length adventure races”. Wilderness and Environmental Medicine. 2006 Fall;17(3):158-61
   

5. Wiggins CM, Lyon RM (2009) “Expedition medicine: the risk of illness and injury”. Emergency Medicine Journal. 26:28. 318-324
   

6. Twombly SE, Schussman LC. (1995) “Gender differences in injury and illness rates on wilderness backpacking trips”. Wilderness & Environmental Medicine. 6(4). 363-376,