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Last December we lost a huge advocate for and explorer of the wilderness. As many of you already know, Doug Tompkins died in a sea kayaking accident on Lake General Carrera in Chile. The tragedy of his untimely death can still provide an opportunity for education in the hopes of avoiding other tragedies of this nature. 

Doug exemplified what Luanne Freer likes to call the "Three P's" of life - Profession, Passion, and Philanthropy. His profession evolved from his love of the wilderness, having started Esprit clothing and then The North Face clothing companies in San Francisco in the 1960s. In fact, the North Face motto is "Never Stop Exploring." His passion throughout life was always focused on his love of nature and the wilderness. From an early age, Doug was drawn to Chile and Argentina. Combining the proceeds from his successful profession and his passion for the wilderness, he targeted philanthropic acquisition of large pieces of land to create national parks in Chile and Argentina. He was truly a remarkable individual. 

But Doug died young, at age 72, and in a tragic way. Which leads me to our dual passions in the WMS - where the wilderness intersects with medicine. As members of the WMS, we are able to mix Luanne Freer’s "Three P's" - health care providers (profession), wilderness (passion), and contributing back to our communities (philanthropy, to the WMS and educating and providing for others).

Doug and Kris Tompkins, the day before his death. Photo by Malinda Chouinard

On General Lake Carrera in the center of Chile, December 8, 2015 started out as a beautiful sunny day with barely any wind. This lake is nestled in the Chilean Andes, and is well known for its turquoise blue waters and huge marble rock formations.

The six individuals were on day three of a five-day, 50 mile segment in two two-person kayaks and two single kayaks, traveling from Puerto Sanchez to Puerto Ibanez.

Each day had seen progressively greater winds. As they left their secluded bay where they had camped, the winds progressively increased, more than on prior days. By 10:30 A.M., after the group had committed to the day’s section, surrounded by cliffs with nowhere to beach, the winds were gusting to 50 mph, with cross winds from the north contributing to make things more chaotic. Waves up to six feet were noted, coming from multiple directions. In short order, Doug's two-person kayak (shared with Rick Ridgeway, Patagonia's VP of environmental affairs) capsized approximately 600 feet from shore, perhaps related to a malfunctioning rudder. Unable to right the kayak, being pushed further from shore, and now in 3°C water (38°F) without wetsuits or drysuits, the men abandoned the boat in an attempt to swim to shore. What ensued was a challenging rescue, involving heroic efforts on the part of the other four adventurers. By 10:43 A.M. the first rescue call was put out and a private helicopter was deployed. It took two hours to finally bring Tompkins to shore, at which point he was unconscious. By 1:30 P.M. he had arrived via helicopter to Coyhaique Hospital, approximately 75 miles to the north, where his core body temperature measured 19°C (66°F). Despite attempts to rewarm and resuscitate him, he was pronounced dead at 6:30PM, five hours after his arrival at the hospital. National Geographic wrote this excellent review of the events that transpired.  

While deaths are always a cause for sadness, some in particular offer us an opportunity to pause, reflect, and perhaps learn in the hopes of avoiding such tragedies. There are multiple lessons here (see PEEPS vs. SWISS CHEESE MODEL), but the 38°F water was an environment with little margin for error. It provides an opportunity for a more in-depth look at the signs and symptoms of hypothermia and the learning we can do in response to Tompkins' death. For an even greater and more scientific review, please see the Wilderness Medical Society Practice Guidelines for the Treatment of Hypothermia.

There are several definitions of hypothermia, but it is most commonly defined as a core body temperature of less than 35°C, a mere two degrees below normal body temperature of 37 degrees. Mild hypothermia is defined as 32-35°C (90-95°F); moderate as 28-32°C (82-90°F); and severe below 28°C (82°F). Mechanisms of heat transfer include:

1. Radiation (transfer of heat via electromagnetic waves)

2. Conduction (transfer of heat via direct contact between two objects)

3. Convection (heat transfer between a body and a moving gas or liquid, typically air or water)

4. Evaporation (heat transfer via the change from a liquid state to a gas state, typically sweat; more significant in hot climates)

When immersed in cold water, conduction is responsible for essentially 100 percent of heat loss. A small amount of heat could be lost above the water in windy conditions due to convection. Radiation would be a minority player. Evaporation, as the last form of heat transfer, would only be significant above the water line if clothing or skin/hair is wet and exposed to air. In Tompkins’ situation, the most influential defense would have been a significant thermal barrier insulating him from the cold water, such as a drysuit with clothing beneath, or a wetsuit.

SIGNS AND SYMPTOMS

With mild hypothermia, the victim’s defense mechanisms are still intact. Uncontrollable shivering typically occurs. The body's sympathetic nervous system kicks in causing peripheral vasoconstriction. This decreased blood flow to the periphery decreases heat loss, and shunts warm blood to the core, preserving heat for vital organs. Mental status may be impaired, and increased breathing and heart rate may be observed. Urinary frequency may occur, due to increased blood flow to the kidneys (increased cardiac output, peripheral vasoconstriction).

With moderate hypothermia, blood pressure, heart rate, cardiac output, and respiratory rate all decrease. Mental status continues to deteriorate, pupils may appear dilated, and muscle rigidity may occur. At this stage life-threatening cardiac arrhythmias, such as ventricular fibrillation or pulseless electrical activity, may occur.

Severe hypothermia manifests with a worsening of the above symptoms. Victims will be unresponsive with unreactive pupils. Profound hypotension, apnea, and severe bradycardia may occur. Even with a functioning heart, a palpable pulse may not be present. At this stage, life threatening cardiac arrhythmias, such as ventricular fibrillation, pulseless electrical activity, or cardiac arrest may occur. Despite this situation, it is still sometimes possible to resuscitate these individuals with slow and careful warming. Remember, in general, “no one is dead until they are warm and dead.” Decreased basal metabolic rate may play a major role in preserving end organ function.

If patients are still conscious they will exhibit poor decision-making - "Leave me alone. I'm OK." Sometimes individuals will start taking clothes off (paradoxical undressing) as the ability to peripherally vasoconstrict becomes limited and warm blood is allowed from the core to the periphery. This results in a transient feeling of warmth and further heat loss ensues.

It is interesting to note that intentional hypothermia is frequently used to preserve end organ function during certain medical procedures (for example long cardiopulmonary bypass for certain cardiac and aortic artery procedures, some neurosurgery operations, or traumatic brain injury). 

TREATMENT

In mild hypothermia, it is possible to quickly arrest the drop in body temperature. The victim should be removed from the cold environment and brought to shelter to avoid further heat loss. Wet clothes should be replaced with dry clothing. Patients should be wrapped in blankets and a vapor barrier, making sure to cover the head to minimize further heat loss. The question often arises whether it is better to give a cold soda or hot tea. Calories are the correct answer, as the volume of warm liquid compared with the volume of the body is negligible. However, warmed nutrition with calories is best. In contrast to moderate hypothermia, limited exercise may be considered to stimulate heat generation.

With moderate hypothermia, the victim is cold enough that thermogenesis from shivering is minimal or absent, so therapy must be escalated and active rewarming is necessary. In addition to treatment noted for mild hypothermia, wrap these victims with warmth - hot water bottles, commercial heat packs, placed around the head, neck, chest, armpits and groin. Skin-to-skin contact from a normothermic individual can facilitate conductive heat transfer as well. Preparations for transport to a hospital environment for active rewarming should occur as quickly as possible.

Severe hypothermia is a true medical emergency. These individuals need immediate transport to definitive hospital care. In-hospital rewarming can involve extracorporeal membrane oxygenation or cardiopulmonary bypass. If immediate evacuation is not possible, heat application to the upper torso surface areas in a sleeping bag can be potentially lifesaving. 

With moderate to severe hypothermia, the cardiac conduction system becomes more and more fragile. Movement should be minimized and very gentle. Abrupt movement has been noted to precipitate cardiac arrhythmias such as ventricular fibrillation. The situation can be further complicated as victims may have barely palpable pulses (palpate carotid pulse in preference to distal extremities), severe bradycardia, and essentially appear dead. Premature CPR can even precipitate arrhythmias. Warm intravenous fluids may help stabilize the cardiac conduction system, but are seldom available in remote settings. 

With moderate to severe hypothermia, the cardiac conduction system becomes more and more fragile. Movement should be minimized and very gentle. Abrupt movement has been noted to precipitate cardiac arrhythmias such as ventricular fibrillation. The situation can be further complicated as victims may have barely palpable pulses (palpate carotid pulse in preference to distal extremities), severe bradycardia, and essentially appear dead. Premature CPR can even precipitate arrhythmias, including ventricular fibrillation or cardiac arrest. Before starting chest compressions, the care provider should spend 60 seconds checking for a pulse and/or respiration. Warm intravenous fluids may help stabilize the cardiac conduction system, but are seldom available in remote settings.

The following chart is from the Wilderness Medical Society Practice Guidelines for Hypothermia and can be a useful resource, summarizing the above treatments. 

Wilderness Medical Society Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2014 Update

One should also consider other diagnoses, as severe hypothermia may mimic other conditions, such as stroke or even death.

While Tompkins’ death occurred in frigid waters, hypothermia can also occur in warm climates, as evidenced by the occurrence of annual deaths in Florida in the United States. The following chart gives estimated survival times in cold water. 

(http://www.coldwaterbootcamp.com/pages/1_10_60v2.html), Gordon Giesbrecht, Ph.D. FAsMA

Hypothermia is generally a preventable illness but may still occur despite our best precautions. Doug Tompkins’ death was truly a tragedy. It’s easy to look in the rear view mirror and play armchair quarterback – big winds, no wetsuit or drysuit, old gear? But these adventurers had much experience. And to be fair, five of the six members in the party survived physically unscathed. 

It is now beholden on the survivors to charge on in Doug's memory, with the force of five, living for six. While Doug Tompkins will be missed, his legacy survives in some of the world's biggest and largest and most beautiful parks. Thanks Doug!
So get out there, enjoy the wilderness, manage risk as best you can, and prepare for what might go wrong. And read the article SWISS CHEESE MODEL vs PEEPS! 

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