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The Expedition Medicine Committee is meeting with expeditionary medicine practitioners to put together the Cowboy Coffee interview series to learn more about the ups and downs of expedition medicine. Our first meeting was with Dr. Lara Phillips. Dr. Phillips was in Nepal completing her Wilderness Medicine Fellowship at Massachusetts General Hospital during the earthquake in April of 2015. She is now on the faculty at Thomas Jefferson University in Philadelphia, PA, and is one of the course directors for the BreckWild Wilderness and Environmental Medicine elective for medical students.

How did you first get involved with expedition medicine, or how would you recommend a newcomer get started in expedition medicine?

There are many ways to get involved in expedition medicine. If there is a particular climate or environment that you like to work in, seeking out expedition medicine in that area is key. For example, if you are a diver, getting involved with DAN [Divers Alert Network] is an option. Different organizations, including the WMS, offer a variety of trips in different environments. Many of these offer credit for continuing medical education as well as networking opportunities. Wilderness medicine conferences are also a good way to gain expertise. Post-residency fellowships in wilderness medicine are also available across the country, many which have an extensive dedicated field component. As you become more experienced within wilderness medicine, opportunities to teach at conferences or during CME expedition trips may arise.

What types of expeditions are you involved with?

During my Wilderness Medicine fellowship at MGH, I had the opportunity of traveling to Nepal and working in a high altitude clinic for three months. I was in Nepal when the 2015 earthquake hit, and I was involved in disaster relief. Some of the responsibilities included working on mobile medical team units and traveling to rural areas to provide needed relief. Currently, I help direct BreckWild (Breckenridge Wilderness and Environmental Medicine Elective) which is run in conjunction with the Sidney Kimmel Medical College [Philadelphia, PA] and the Wilderness Medical Society. The first two weeks are held in Breckenridge, Colorado followed by a fun backcountry expedition portion in Utah.

Backcountry portion of BreckWild, April 2018

How often are you on expedition? What do you do when you’re home?

Currently, I am in the field about one month out of the year (for BreckWild). While at home in Philadelphia, I work as an emergency medicine physician at Thomas Jefferson University Hospital. I work clinically about 60% of the time, and about 40% of the time I am doing other educational or administrative duties with the medical school. I am the faculty advisor for the Wilderness and Disaster Medical Society at Sidney Kimmel Medical College. I help plan and participate in events with our students. We have an annual ice climbing trip and biennial regional Mid-Atlantic Student Wilderness Medicine Conference. My newest activity is working with the Regional Response Health Collaboration Program in responding to COVID-19 outbreaks in local care facilities in PA.

Could you tell us about any near misses or big learnings you’ve had?

While working at the high-altitude clinic in Nepal, I had a patient who suffered what I suspected was a large hemorrhagic stroke. We had no imaging or lab work available, but clinically his GCS was 3. We had to decide whether not to transport him to Kathmandu's main hospital. Though we knew his prognosis was poor, it felt uncomfortable to just send him back to his home. We had no palliative therapies available in the clinic. However, sending him to Kathmandu would require a helicopter transport and significant financial burden to the family. In addition, we were afraid the patient would then not be with his family at the time he passed away. We discussed options with the family and their response was the same, "Whatever you think doctor." With difficulty performing this patient-centered discussion, we ultimately opted to send the patient to Kathmandu. I regret this decision and wish I had felt more comfortable managing his palliative care in the village. Today, I still feel responsible for not allowing the patient to die in the comfort of his own home with his family.

Post earthquake mobile medical response team with IMC, May 2015, Gorka district, Nepal

Arriving to the High-Altitude Clinic March 2015, Manang, Nepal

What’s been your best trip? Worst trip?

During fellowship, after hiking to the clinic in Manang [Nepal] (arguably one of the best expeditions!), the last day ended with an absolutely horrible gastroenteritis. There was no running water (pipes were frozen in the village) and the limited availability of hand hygiene may have been the culprit. I was giving the first educational lecture of the season to hikers and had to leave mid-lecture to vomit. Unfortunately, the only place to throw up was the floor squat toilet, and since there was no running water, it basically froze on top of the ice-lined porcelain, leaving my poor team with frozen popsicle vomit solidified in the outhouse for the next several days. I basically stayed in my room for the next 24 hours filling up vomit basins with nowhere to empty them. With the severity of vomiting, I assumed it was B. cereus.

My best trip is a tie between the hike to Manang and the 2018 BreckWild elective. The Himalayas have a beauty and magic about them one must experience in person, but the 2018 BreckWild was pretty special. It was my husband’s birthday mid-trip when I found out I was pregnant with our second child. This time it was happy vomiting only!

How do you prepare for each expedition?

It depends on the expedition. Having your own personal medical kit is key. In general, you also want to communicate and coordinate with your group members to try to reduce redundancy in items while you're packing. Having knowledge of your group members and their medical needs ahead of time is also important. You should know where you're traveling, and the closest hospital available as well as the capabilities of that hospital. You should know how you would emergently transport someone out of the field at different points during your expedition. Be aware of weather conditions and other unpredictable factors.

What is your role during the expedition?

For BreckWild, as one of the directors, our primary goal is to design and execute the curriculum for the students’ educational experience. We prepare different stimulations in scenarios ahead of time as well as learning objectives and critical actions we expect the students to achieve. We are accompanied by guides who assist us for logistical support and safety.

Are your participants generally well prepared? What do you do to get them ready?

In general, our students are well prepared. Prior to going out on the expedition, they have two weeks of didactics that teach not only core wilderness medicine concepts, but also skills needed in the backcountry. They also have hands on navigation exercises and meet with our guiding staff ahead of time to learn other skills such as route planning, meal preparation, and strategic packing.

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The second in our series of interviews with ExpedMed practitioners