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For several years, I have had the privilege to contribute to the “Tech” column in Wilderness Medicine Magazine. I have searched for “game changers” that impact wilderness patient care and expand our capabilities in resource-deprived wilderness environments. Focused on identifying technological novelties and cutting edge opportunities, my aim has been to pursue the same standards of care we hold to in the practice of front-country medicine. 

Looking back at my own journey of training, education, and practice, I recall an AWLS course I took nearly 20 years ago. We were completing a discussion on the tools to include in your backcountry kit. I was admonished to consider that the most important ingredient to our backcountry medical kit was not a fancy new gadget in the top of our pack, but that the most amazing piece of “tech” laid between our ears.

With that said, I look at the recent context of the pandemic, the retreat of an entire population into the outdoors, an increase of backcountry recreationalists, and the highest avalanche mortality year on record. The historic significance of what we have collectively endured will never be forgotten. As our minds ponder the impact of what has been lost, I can’t help but think of that “greatest piece of tech” that has helped us move through this period of time—the human brain.

The human brain is able to process calculations at speeds of up to 60 bits per second and even though computers and artificial intelligence (AI) are sometimes eclipsing our processing speeds, they lack the ability to use reason and logic, to learn, to overcome and to problem-solve. Expertly crafted, the brain utilizes chemical neurotransmitters and hormone regulation to enact amazing potential from the rest of the body. The sympathetic and parasympathetic components of the nervous system work in a dichotomous marriage of harmony to maintain homeostasis. Connected to the cranial nerves and the peripheral nervous system, the power of the brain is augmented to engage with all the elements of medical knowledge and technology covered in previous iterations of this column. In many ways, it is the gatekeeper, the rule maker, and the chief instrument in the practice of wilderness medicine. Yet, like an ophthalmoscope with dead batteries, or an ultrasound without a screen, the brain is not without limitations. It is not impervious to injury or stress.

Indeed, the influences of physiological and environmental stressors can render an impairment that cannot only inhibit the practice of medicine but also threaten personal care and safety. As we consider this amazing piece of technology, some time will be dedicated in reviewing two elements of concern that not only pose a threat to our patients but also to us as the wilderness medical provider. These elements include: environment and trauma.

It doesn’t require a long meditation on the acronym AEIOUTIPS to ascertain the many components of the environment that can affect our brain. Exposure to allergens, infection, or overdose from environmental toxins are all a consideration. Add to this group the effects of altitude, heat, cold, the presence or absence of adequate hydration and you have a group of several environmentally mediated threats to our central piece of technology—the brain.

When considering the associated effects of trauma, multiple confounding elements are revealed. Typically, our thoughts on trauma lean in on our understanding of physical trauma—those issues related to a singular event, like falling from an inadequately protected pitch of climbing or being caught in an avalanche/whitewater event. These, and other physically traumatizing events, are easy to conceptualize as a threat to our brain. What often escapes our consideration, however, is the trauma of survival—the process of stress injury formation which also renders our cognitive processes impaired. 

The requirements of adequate cognition are not to be understated. Without adequate function, our ability to care for ourselves and others would not be possible. In closing out this brief reflection on the amazing design of our brain and the threats to its survival, I will lay out a couple of practical considerations to mitigate injury and prolong cognitive function even when threats of impairment are present.

1) Helmets: I wear them for everything. I have a healthy quiver of them for each outdoor event I would consider. As a medical director and provider in the field, I’m typically the first to put it on and last to take it off, hopefully serving as a role model for others. Unfortunately, I’ve slipped on ice—even in the parking lot. On my bike, I’ve been hit by a car only a block from home.

Image Source: Designsoak.com

You never know if that easy class 3 whitewater rapid, that easy 5.8 pitch with unforeseen rocks from above, or the bike ride with your child will present a risk to your noodle. If I want to keep my head in the game, my helmet will always be in place.

2) Peripherals: While the hip bone may be connected to the knee bone, the brain is connected to everything else. What I mean by that is: My fingers can palpate, but what if they can’t “sense?” My eyes carry the image to my brain, but what if they can’t “see?”. You get the picture. Covering the peripherals includes all the elements that feed my brain signal. This means sunglasses, gloves, ear protection are all going to be included in my protective measures for my brain to optimally process accurate data from the patient and the environment.

3) Hydration: Not too much, not too little. The heat, the cold, and the altitude all have an effect on the body. While there are many physiological processes at work as a result of these environmental pressures, inadequate or improper hydration is one common element that can drastically alter my neurological status. While nothing in this article is meant to replace a lecture in wilderness medicine, an emphasis on proper hydration and electrolyte management is key to maintaining my neuro mojo.

4) Toxins: While dead batteries may not cause cognitive impairment, there are a host of other metabolic influences that can lead to reduced proficiency and clarity of thought. The list is wide and broad but it goes without saying that alcohol, recreational substances, sleep deprivation (to name a few) can all have a toxic effect on the brain that may easily impair our psychomotor function. As wilderness medicine providers, it may be easy to “toss one back” at the end of your long day of rafting, but consider your overall responsibilities to the group in the event things go awry.

CImage Source: Mentalfloss.com

5) Memory: This final consideration is a two-fold discussion. The exposure to stress injury in wilderness trauma is a risky proposition not just for the patient but also the provider. Stress Injury Formation has been widely discussed and is finally receiving some well-deserved attention. For more a definitive concept review, consider reading the chapter “Psychological First Aid and Stress Injuries” in the text, "Wilderness EMS" (Hawkins SC, ed. Wolters Kluwer, 2017) or checking out various podcasts on the topic by organizations such as WMS, MRA, PMR, and the AAC. The presence of stress injury formation poses a threat to anyone participating in life, its hurdles, and its trauma. Faced with the challenges of patient care in austere environments and with limited resources, providers suffering stress injury formation may find task completion, differential diagnosis formation, and other elements of patient care difficult to accomplish. Psychological First Aid practiced with patients and peers is an excellent mitigation strategy for stress injury formation. “Preloading” your mental game with scenarios and mental rehearsals may also be helpful to limit stress injury formation and help insure you and your brain are at the top of your game in wilderness patient care.

The concept of preloading goes beyond Psychological First Aid. The full effects of the environment, physiological exhaustion, and stress injury may indeed culminate into cognitive collapse where functional capacity is limited. Anticipating this problem and creating safeguards has become a habit of mine as I try to protect my mental tech from languishing in the backcountry. This may look like the simple extra steps of preloading your GPS with the waypoints to get you home. For my team (Portland Mountain Rescue), it meant the development of medical protocols so that when stress is upon us, we can fall back on the algorithms of care that escape us when our brains are taxed. From a technical standpoint, I even developed a “Quick Reference Card” (QRC) project that covers all the rescue basics from knots and rigging to patient care. Having these cues has become paramount in keeping myself, my team, and our patients safe when our cognitive capacity is impaired by the multitasking elements of a rescue.

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So, suffice it to say, your most important resource might be forgotten if it wasn’t attached. Alas, it surely can’t be found in your pack, or on any Top-10 Gear List for 2021. But, it does work offline, better than the 1000 apps you downloaded for the journey. So, study hard and stay ready my friends.

 

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