Wild Side of Medicine
Medical decisions:
Field warming of frostbite By Tod Schimelpfenig, WMI Curriculum Director
made this decision, for real, in the field. Once tissue is frozen, damage is done. Thawing is the next critical phase, which, practically, might be slow warming in armpits or on a friendly belly but ideally is rapid and by warm-water immersion. Frostnip, the freezing of the outer skin layer, is not the problem. If you see the white, waxy patch on nose, ears, or fingers, and it’s only the surface, warm it immediately. It will burn, sting, and eventually heal. If it’s a deeper injury, you have a decision to make. Once the underlying cause is corrected— be it exposure, hypothermia, wet or inadequate insulation, dehydration, or poor nutrition—most frostbite will spontaneously thaw. Trying to keep it frozen is difficult and will likely only increase the damage. The ideal thawing technique is rapid warming in a warm water bath at 37°C to 39°C (98.6watch: Watch the NOLS bootie system video for 102.2°F). Practically, with more tips on keeping your feet warm to prevent the frozen ends of the fingers frostbite. You can also find this video by searching and toes we commonly see “winter warmth” at NOLS.TV.
One of the Wilderness Medicine Institute’s (WMI) most important wilderness medicine curriculum themes is the NOLS leadership skill of judgment and decision-making. When we perform first aid in town, we don’t often make critical decisions. Our care is simple. We can quickly and easily get the patient to the doctor. In the wilderness, our care may not be so simple, and transport decisions have real consequences. New questions arise: How sick or injured is this person? How quickly do they need to see a doctor? What is the risk of the evacuation to the patient, rescuers, and expedition mates? Might my treatment decision cause harm to the patient? The decision of whether or not to thaw frostbite in the field is a prime example of judgment with consequences. I know. I’ve
Decision-making skills
in the field, a warm armpit or belly often will suffice. However, if the frostbite is extensive or accompanied by hypothermia or other serious medical problems, it may be safer to keep the part frozen until it can be thawed once, and well. It is essential to avoid a freeze-thawfreeze cycle, which produces tremendous tissue damage. This is the decision I faced: to thaw or to walk. I kept my toes—solid as a rock, numb as wood, cold as ice, and white as a sheet—frozen for hours. I walked six miles and found prompt transport to a hospital, where rapid warming in water, and a bit of luck, saved my toes. This tough decision is best made with a sound understanding of the consequences of freeze-thaw-freeze, the dangers of prolonging the frozen state, and the reality that thawed tissue is not only sensitive and easily damaged but also difficult to ski on, in the case of toes. Better yet, the tough decision is best avoided with outdoor skill competence, another NOLS leadership skill. Real Life Drama
informed a nonprofit’s survival By Steven Cutting, Patagonia Mountaineering ‘97
For the last eight years, I have been living and working in Japan at a school called the Asian Rural Institute (ARI), which teaches sustainable agriculture and leadership to community leaders from developing countries. The school is located in northern Japan, so we were shaken up and damaged by the earthquake. We also had to deal with the fact that our beautiful organic farm has been contaminated with radioactive Caesium from the Fukishima Nuclear Power Station. In the weeks after the earthquake, I found myself frequently recalling my NOLS Patagonia Mountaineering Course. These two experiences, more than anything else in my life, demonstrated to me the awesome forces of nature and just how small we humans and all our endeavors on this Earth are. I also began to realize just how much of my “unanticipated” NOLS learning was coming into play. More than the river-crossing techniques,
crampon lessons, or the even our Tyrolean traverse, it was the mental and psychological trials of that course that shaped me as a leader. We are not always in control, rational decisions are sometimes disappointing, plans change—these are just a few of the hard-won lessons. In Patagonia, we ran into obstacle after obstacle, each slowing us down and diminishing our goal of crossing the ice field and taking a toll on the group’s motivation. In the same way, at ARI the damaged buildings, ruined land, and the threat that we would no longer be able to continue our way of life weighed heavy on the hearts of staff. We had to seriously consider canceling our upcoming nine-month training program. Being a non-profit, there was a high risk that such a decision would result in massive loss of funding and permanent closure of the school. This meeting brought me back to the day our NOLS group sat in a circle on the ice and
made the unpleasant decision to turn back rather than pursue our goal of traversing the ice field. It was a deeply disappointing day. Difficult decision making is a part of mountaineering, a part of leadership, and a part of life. At ARI, however, we were able to employ a bit of creative thinking and hold the first three months of training at an alternate location. It took a lot of work, but it allowed us to sustain our program. In a similar spirit of experimentation, we are working to decontaminate our soil with radiation-absorbing plants and by processing contaminated bio-matter through a bio-gas system with a xyolite filter. To me, this is not at all different from the scenario in Patagonia when we got one person safely to the other side of a glacial river to set up a Tyrolean by building a boat of Therma-rests, sleds, and empty fuel containers. For more information about the ARI, check out http://www.ari-edu.org/english/index.html Fall 2011 27