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Volume 24, #2

Spring 2007

Whats in Your Medical Kit?

Expedition Cruise Ship Doc
Training with the Marines
Location Devices

Volume 24, Number 2 Spring 2007

Dr. Guibor hiking
in the valley of
the Geysers,
Kamchatka, Russia
Yvonne Lanelli

Backcountry Medicine:
Whats in Your Kit?
Timothy Platts-Mills, MD
Page 5

2nd Battalion of the 1st

Marine Regiment
Training Operations
Fred Trayers, LT MC USN
Page 12

Off the Beaten Path:

Expedition Cruise Ship Doc

Ask the Experts Roundtable:

Location Devices

Yvonne Lanelli and Pierre

Guibor, MD
Page 8

Mike McDonald,
Dale Atkins, Ken Zafren MD,
Rocky Henderson, Howard Paul
Page 19


+ Board of Directors + EDITORIAL

Wilderness Matters

The 2007 WMS Board of Directors

Eric L. Johnson, MD...................................4

Eric L. Johnson, MD, WMS President

Student Elective Update

Luanne Freer, MD, Past-President

Christopher Sloane, MD..............................7

Member Profiles
Sam Schimelpfenig, MD............................15

Book Reviews
Seth C. Hawkins, MD, editor....................16

Search and Rescue

on Mt. Hood Photo Essay
Christopher Van Tilburg, MD....................18

Colin Grissom, MD, Treasurer

Chris Moore, MD, Secretary
Andrew Woody Bursaw, MS4
Natl Student Representative
Tom DeLoughery, MD
Tony Islas, MD
Kimberly Johnson, MD, PhD
Shean Phelps, MD, MPH

ICAR - IKAR - CISA Statement:

Avalanche Rescue Devices
and Systems. ....................................22

James A. Wilkerson III, MD

Board Member Nominations....22

Finance and Audit

Colin Grissom, MD, Chair

Fit to be Wild:
A New Look at Old Wilderness
Medicine for Travelers Diarrhea
Jolie Bookspan, PhD .................................23

Mountain Medicine
Conference, Argentina

Standing Committees

Nominating Committee
Luanne Freer, MD, Chair
Ongoing Recommended Committees
Awards Blair Erb, MD, Chair
CME James A. Wilkerson III, MD and
Kimberly Johnson, Co-Chairs

Ken Zafren, MD.......................................26

Environmental Council Kimberly Johnson,

MD, Chair

From the PAs Desk

Executive Board Eric L. Johnson, MD, Chair

Cristopher Benner, PA-C, MMSc................28

Cliff Notes
Andrew Woody Bursaw, MSA..................29

WMS Award Nominations..........29
Conference Calendar....................30
Abstracts 2007................................30

FAWM Shean Phelps, MD, MPH, Chair

Membership Tony Islas, MD, Chair

Wilderness Medicine
A quarterly magazine published by the
Wilderness Medical Society
Christopher Van Tilburg, MD............Editor
Jonna Barry........................Managing Editor
Larry E. Johnson, MD, PhD................................Assistant Editor
Seth C. Hawkins, MD................................Associate Editor
George Rodway, PhD, CRMP..............................Associate Editor
Karl Neumann, MD.............Editor Emeritus
Contributing Editors:
Jolie Bookspan, PhD
Yvonne Lanelli
Debra Stoner, MD
Cristopher Benner, PA-C
Andrew (Woody) Bursaw, MS4
Christian Sloane, MD
Email submissions and comments to:
Christopher Van Tilburg:
& Jonna Barry:
Wilderness Medicine (ISSN 1073-502X) is published quarterly in January,
April, July, and October by the Wilderness Medical Society, 810 E 10th
Street., PO Box 1897, Lawrence, KS 66044
Tel: 800-627-0629. Periodicals postage paid at
Lawrence, KS and additional mailing offices.
Annual subscription rate: $55.
Send address changes to the Wilderness Medical Society,
810 E 10th Street., PO Box 1897, Lawrence, KS 66044.
Requests to reprint Wilderness Medicine in whole or in part must be
submitted to
2007 Wilderness Medical Society. All rights reserved.
Printed on recycled paper in the USA.
The goals for Wilderness Medicine magazine are to:
1. Provide timely information regarding WMS
news and activities;
2. Provide a forum for the exchange of ideas and knowledge
regarding wilderness medicine, and regarding WMS, and
3. Promote active membership involvement
through solicitation and publication of
members articles and photographs.

Publications George Rodway,

PhD, CRNP, Chair
Research Colin Grissom, MD, Chair
Student Services Andrew Woody Bursaw, MS4

Joyce Lancaster, Executive Director

Jason Gilbert, Association Manager
Wilderness Medical Society
810 E 10th Street, PO Box 1897
Lawrence, KS 66044
Tel: 800-627-0629
Intl: 785-843-1235
Send address changes and
requests for back issues
to the address above.
Send advertising inquiries to:
Rhett Dubiel:

+ WILDERNESS MATTERS Eric L. Johnson, MD, President, WMS

Were all looking forward to the Societys Annual Meeting
being held in Snowmass CO July 21st-25th, 2007. Check
out the WMS website for program details and online
registration. Dr. Luanne Freer, Program Chair, has put
together a must-attend wilderness meeting. Besides great
didactics, hands-on workshops, and fun activities, it is your
societys work meeting that includes Committee meetings
and your Board of Directors meeting. For me, it is always a
time to see old friends and meet many new ones. The WMS
Banquet night features the Awards Ceremony (Master of
Ceremonies our own Dr. Blair Erb) and evening speaker,
Dr. Mark Plotkin. I encourage all members to attend.

Springtime is always a time for me to clean up post-winter season and

look for the annual renewal that comes with this seasonal cycle. Its time
to put away the telemark skis and ice-climbing gear, and break out the
road bike, rock gear, and tennis racket. For those who reside in other
parts of the country or world, this may seem very foreign, however in
Idaho we are very much tied to the seasons. For your society, it is much
the same with the administration putting away 2006 year-end financials
and the winter meeting, and looking forward to the upcoming events
and activities.
The WMS completed a successful society meeting in Park City, Utah in
March, and my many thanks to Dr. Colin Grissom for acting as Program
Chair. Besides great didactics, this meeting offered Level 1 avalanche
certification and the Advanced Wilderness Life Support course. If you
missed this opportunity in 2007, stay tuned as plans are in the works to
offer another Winter Meeting in Park City in 2008.
During the month of February, the annual ritual of reading the emails
from the Wilderness Medicine Student Rotation held in Tennessee offers
an amazing tale of the trials and tribulations of medical student wilderness
education. Tom Kessler does a wonderful job in coordinating this effort,
and I am envious of the opportunity these young physicians have. It
is to be applauded and supported. I am also humbled by these young
upcoming wilderness docs, as their bios are filled with broad experiences
and interests that took me years to develop and discoverif they are any
indication of future WMS members, the Society is in good hands.
As we turned the calendars to 2007, WMS rolled out revised guidelines
for the achievement of Fellow through the Academy of Wilderness
Medicine. These revised guidelines have taken months to evolve and
include not only wilderness didactic credits as before, but awards credit
for wilderness experiences, volunteer work, WMS committee work,
research and the like. I encourage all members to check out the new
guidelines at My thanks to Dr. Shean Phelps, Jason
Gilbert, and Dr. Tony Islas for all their efforts in developing this
program. Of note, at the upcoming Annual Meeting in July, we are
excited to be acknowledging our first group of Wilderness Medicine
Fellows at the Awards Ceremony!


For those wishing for a fall season overseas learning

experience, the World Congress of Wilderness and
Mountain Medicine held in Aviemore Scotland October
3rd-7th will be what you need to attend. Co-sponsored
by the WMS and the International Society of Mountain
Medicine (ISMM), the pre-conference day as well as
conference didactics offers world-class speakers and activities.
Please see for all details. I registered on-line and it took all
of 5 minutes. I have not been to Scotland in the fall, but am assured by
my colleagues across the pond that I will not be disappointed.
The WMS continues to seek out ways to better serve our membership,
and I have noted a few already. Streamlining the Fellow process, offering
great educational opportunities, ensuring an efficient administration
structure, seeking out active Board and Committee members,
encouraging student involvement, liaison with like-minded corporate
and national/international organizations and many others is what your
Board is focused on. If you have any additional thoughts or ideas, your
society wishes to hear them!
As always, I encourage all to follow our theme to combine your
profession with your passion. Let us know how best we can improve
your society and remember wilderness matters.
You may contact Dr. Johnson at

WMS Summer Conference

in the HEART of the Rockies!
Make plans to attend the WMS Summer
Conference and Annual Meeting in Snowmass
at Aspen, Colorado, July 21 25, 2007.
Visit for conference
details and registration.

+ Backcountry Medicine Timothy Platts-Mills, MD

The ideal expedition medical kit would weigh nothing yet contain
everything found in a well-stocked Emergency Department. But
Emergency Departments are heavy, and finding a balance between the
Ray Jardine (the light is right backpacking guru) approach and the
Carolinas MED-1 truck is not simple. Although no best medical kit
exists, once trip length and participants reach a critical mass, some key
items need to come along. This article describes 40 of the most useful
medicines and supplies to bring into the backcountry and presents
principles that apply to both small and large expedition medical care. A
recommended reading list is provided for those wanting to learn more.

Preparation, Organization,
and Communication

Although not part of the kit, these represent the surest and lightest
way to stay healthy. Study the area youre traveling to, learn about
the problems others have encountered, and anticipate the injuries
and illnesses you will have to treat. If trekking in the tropics, review
the CDC recommendations for vaccinations and malaria prophylaxis.
Identify team members medical problems and substance dependencies
and be prepared to address them. Encourage team members to ready
themselves physically. Wilderness medical problems often stem from
failures in leadership and communication; a fancy medical kit is not a
substitute for either. Teams should have clearly defined objectives and
agreed upon alternative plans if hazardous weather or illness occurs.
Although you may travel sans cell phone, theyre now a standard safety
device for U.S. backcountry travel. Outside the U.S., satellite phones
may be appropriate. Waterproof paper and pencil weigh little and can
be critical when trying to find a lost team member or recruit help for a
search and rescue party.

Foot Care and Skin Care

Unless you are sea kayaking or orbiting Mars, you will be on your feet,
and eventually they will hurt. Ask team members to tell you immediately
if they have any foot discomfort. I drain blisters with a small incision,
cover them with cyanoacrylate tissue adhesive (Dermabond), cover the
dried adhesive with mole skin, cover the mole skin with duct tape, and
put Vaseline over the duct tape to decrease friction between the foot
and the footwear. There are lots of other ways to do this, but you need a
plan. A petroleum-based antibiotic ointment serves as a lubricant and
is useful for the treatment of superficial skin infections.
Essential in most environments sunscreen, lip protection, and
sunglasses. At altitude, at sea, and on snow an extra pair of sunglasses
for every two team members is recommended.

Respiratory Problems

Epinephrine is an essential medication because of its role in anaphylaxis

treatment. The recommended dose for adults is 0.3 mg (0.3 ml of
1:1000) intramuscularly. The EpiPen can deliver this dose, but its bulky,
painful when injected, and only provides a single dose. An alternative
bring a 1 mL vial of 1:1000 epinephrine (3 doses). Pack albuterol
inhalers to treat asthma and bronchospasm associated with cold,
altitude, or respiratory illness. Intramuscular epinephrine may be used

for the treatment of severe asthma. Asthmatics should continue their

routine medications and carry a burst dose of oral prednisone, typically
60 mg for 5 days. A 7-day course of levofloxacin (Levaquin) 500 mg is
appropriate treatment for those with fever and respiratory complaints
consistent with pneumonia. Oxymetazoline nasal spray (Afrin) and a
non-sedating antihistamine with pseudoephedrine such as Claritin-D
treat congestion. Oxymetazoline applied to a small piece of cotton wool
or tissue paper also serves as anterior packing for nose bleeds. Throat
lozenges quiet coughs and are particularly appreciated at high-altitude
and in cold environments.

Altitude Illnesses

Altitude illness treatment depends on three drugs. Acetazolamide

(Diamox) 250 mg orally twice a day both prevents and treats acute
mountain sickness. Dexamethasone (Decadron) 8 mg intramuscularly
followed by 4 mg injections every 6 hours treats high altitude cerebral
edema. Oral prednisone is an acceptable dexamethasone substitute,
but an injectable steroid is preferable due to altered mental status and
vomiting in many with cerebral edema. Nifedipine (Procardia) 10-20
mg orally every 6 hours is the drug of choice for high altitude pulmonary
edema. Supplemental oxygen should also be given if available.


The key to wound care in the backcountry is cleansing and hemostasis.

Use clear flowing water to wash wounds initially; the bacterial
concentrations are likely to be lower than on the skin. Thereafter, a
plastic water bottle with a hole or a 20 ml syringe with an 18-gauge
needle can be used for high-pressure irrigation. Wound closure
prevents further contamination and controls bleeding, but is usually
not essential and is inappropriate for puncture or dirty wounds. An Ace
wrap works well as a compression bandage and keeps the wound clean.

Tissue adhesive closes small cuts. A skin stapler or suture kit may be
appropriate. Reasonable choices for suture are 3-0 and 4-0 vicryl and 4-0
and 5-0 nylon. Several 0-silk sutures are useful for the repair of backpack
straps and tents. A sharp-tipped knife aids in splinter removal. Treat
infected wounds or those with crushed tissue, gross contamination, or
exposed tendon or bone with cephalexin (Keflex) 500 mg every 6 hours.
Fashion splints out of insulation pads and duct tape.

Abdominal Complaints

There are a few bad belly problems common enough to consider that
cannot be definitively addressed in the backcountry. Abdominal pain
and fever, not obviously due to gastroenteritis, requires antibiotics
and evacuation. Levofloxacin 500 mg once a day and metronidazole
(Flagyl) 500 mg four times a day are appropriate. Pregnant trekkers
with abdominal pain also require evacuation; bring a urine pregnancy
test. Both urinary infections and travelers diarrhea can be treated with
levofloxacin. For symptomatic treatment of gastrointestinal complaints
bring prochlorperazine (Compazine) 25 mg suppositories, antacid
pills, docusate sodium (Colace), bismuth subsalicylate (Pepto-Bismol),
loperamide (Imodium), and hydrocortisone hemorrhoid cream
(Anusol HC).

Analgesia and Central

Nervous System Treatments


Fluconazole (Diflucan) 150 mg orally treats vaginal candidiasis

and athletes foot. Insect repellant containing DEET repels flies
and mosquitoes. A mixture such as Cavit is useful for filling cavities.
Ciprofloxacin ophthalmic drops (Ciloxan) treats bacterial infections
of the eye and corneal ulcers associated with contact lens use. When
traveling with older individuals, carry aspirin 325 mg tabs to treat chest
pain. Nitroglycerine and furosemide (Lasix) tabs should be brought for
patients with congestive heart failure and are important in the treatment
of severe high-altitude pulmonary edema. Intravenous start kits,
intravenous fluids, tube thoracostomy equipment, and advanced airway
equipment may be appropriate for large groups with a base camp.
Tim Platts-Mills is a senior resident in Emergency Medicine in Fresno, California. He thanks
Dr. Michael Burg for assistance in preparing this article and Dr. Matt Lewin for insights into
providing medical care in remote settings.

Recommended Reading
1. Wilkerson JA. Medicine for Mountaineering and Other Wilderness Activities,
5th ed. Seattle WA: The Mountaineers Books; 2001.

Traveling solo, you might forgo pain medications, but if youre responsible
for an expedition you need to have options. Ibuprofen (Motrin) 600
mg tabs and oxycodone and acetaminophen (Percocet) 5/325 mg
tabs will cover most situations. Use intramuscular morphine for those
with major injuries. Remember, large narcotic doses cause respiratory
Injectable lorazepam (Ativan) treats seizures, agitation, and alcohol
withdrawal, and works synergistically with oxycodone and morphine to
control pain. Caffeine 200 mg tabs are useful for caffeine withdrawal
headaches and during long drives or prolonged rescues, but are
unnecessary if you have coffee.

2. Zell SC, Goodman PH. Wilderness preparation, equipment, and medical

supplies. In: Auerbach PS, ed. Wilderness Medicine, 4th ed. Philadelphia, PA:
Elsevier Inc; 2001:1662-1685.
3. Lentz M et al. Mountaineering First Aid, 4th ed. Seattle WA: The
Mountaineers Books; 1996.
4. Vonhof J. Fixing Your Feet, 2nd ed. Manteca, CA: Footwork
Publications; 2001.
5. Forgey WW. Wilderness Medical Society Practice Guidelines for Wilderness
Emergency Care. Old Saybrook, CT: The Globe Pequot Press; 1995.


1. Cell or satellite phone
2. Waterproof paper and pencil
Foot and Skin Care:
3. Petroleum-based antibiotic cream
4. Duct tape
5. Mole skin
6. Cyanoacrylate tissue adhesive
7. Sunscreen
8. Lip protection
9. Sunglasses
10. Epinephrine 1 mg (1:1000) in vials
11. Albuterol inhaler
12. Oxymetazoline nasal spray 0.05 percent
13. Loratadine/pseudoephedrine 10 mg tabs
14. Throat lozenges
Altitude Illness:
15. Acetazolamide 250 mg tabs
16. Dexamethasone injectable solution
17. Nifedipine 10 mg tabs

18. High-pressure irrigation device
19. Ace wrap
20. Suture kit
21. Knife
22. Cephalexin 500 mg tabs
Abdominal Complaints:
23. Urine pregnancy test
24. Levofloxacin 500 mg tabs
25. Metronidazole 500 mg tabs
26. Calcium carbonate antacid
750 mg tabs
27. Bismuth subsalicylate
250 mg tabs
28. Docusate sodium
100 mg tabs
29. Prochlorperazine
25 mg suppositories
30. Loperamide 2 mg tabs
31. Hydrocortisone hemorrhoidal
2.5 percent cream

Analgesia and Central

Nervous System Treatments:
32. Ibuprofen 600 mg tabs
33. Oxycodone/acetaminophen 5/325 mg tabs
34. Morphine sulfate injectable
35. Lorazepam injectable
36. Caffeine 200 mg tabs
37. Fluconazole
150 mg tabs
38. Insect repellant
39. Cavit 7 gm tube
40. Syringes and
needles for

Photo courtesy of Tender Corporation and

Adventure Medical Kits.


February 19, 2006: The 2007 elective is well underway. As I write

this I am here to spend a week with Dr. Tom Kessler and his international crew of 24 students at Camp Wesley Woods in the Great Smoky
Mountains. They are all having a great time. This truly is a great opportunity for the students. For daily updates and a chronicle of the entire
experience, from start to finish, go online and check our new Blog.
The link is

The best way to learn is by doing,

and that maxim is certainly followed
for our wilderness medicine training.
The students have submitted a brief update:
The best way to learn is by doing, and that maxim is certainly followed
for our wilderness medicine training. For our first scenario, we were hiking after lunch when two of us decided to race down a steep incline.
After tripping over a root, I was face down on my belly at the bottom of
the hill, precariously resting on some branches inches over the creek. My
back was hyper-extended and everything hurt. We had spent the morning practicing spinal immobilization, so the task of my teammates was
to assess the scene of the accident and to get me to safer ground with my
possible spinal cord injury. My awkward position didnt make it easy for
them, and luckily one of the rescuers noticed a sharp stick right next to
my ribs, which would have made rolling me much more painful. Even
though this was our first day of intense scenario training, we took it seriously and did a great job.
In our short time here, we have had quite a few unique lectures about
bear encounters, mushroom toxicity, planning a medical trip to Mars,
creative rehydration methods, and the history of the Great Smoky
Mountains, among many others. However, I am sure we would all agree
that our favorite part of the course is getting outside and getting dirty.
On our second day here, we did just that. We learned about search and
rescue by tracking Lt. Col. Jeff Wadley through the woods here at our
home base Camp Wesley Woods. We took turns tracking a path left
by a theoretical missing person, sometimes even on our hands and knees
through the brush. Of course, we stored the information for what is sure
to be a rescue scenario later in the course.

We have spent our first week discussing topics that many of us are familiar with, but the emphasis now is on what we may encounter in a
wilderness setting and what we can do with the problem outside the
comfortable confines of the well-stocked emergency department or intensive care unit. Whether it is the country road loop 5 minutes from
home that some of us run every day or mile 1,345 of the Appalachian
Trail, we are thinking about and practicing what we can do to prevent
the need for any wilderness medicine and how we can get people safely
through an unforeseen tragedy.
Most of us have not been in a classroom for over a year now but we have
been in the emergency room, operating room, wards, and clinics learning
while doing. This rotation is a truly unique opportunity for us both to
get back into the classroom and to get our hands dirty at the same time.
We are looking forward to learning a lot more and testing our knowledge
in a wide range of scenarios, topped off by our own planned 4-day backpacking journey in the Great Smoky Mountain National Park.
Thanks to the many WMS members and volunteers who have made this
elective possible. Without your assistance, this elective simply would not
be the excellent experience that it is. A special thanks to Jason Gilbert
and the staff at the WMS offices who have worked tirelessly to make
sure the elective went off without a hitch.
About the elective
The elective is held in February in the Great Smoky Mountains at
Camp Wesley Woods, just outside of Knoxville, TN. The course is a
well balanced mix of didactics, small group sessions, and hands-on,
scenario-based learning in an outdoor setting. There is an extended
hike practicum. Leadership training is integrated through the course.
The Wilderness First Responder Curriculum is integrated through the
month and successful completion of the course allows students to take
the WFR certification test (for an extra fee). A comprehensive syllabus,
written by recognized leaders in the field of wilderness medicine is given
to each participant. Academic credit is provided by the Uniformed Services University of the Health Sciences (USUHS) through an ongoing
memorandum of understanding.
Many of you have emailed, asking about plans for next year. We
hope to have dates finalized soon for the 2008 elective. Check
the website in April for updated dates and application materials:


Yvonne Lanelli and Pierre Guibor, MD


Photos by Yvonne Lanelli




Without labs, x-rays, EKG, nurse, or specialty consults,
the expedition ship doctor reverts to the basics, much
like what we learned in medical school. Most crucial:
taking a thorough exam and history. Document date and
time of accident or onset of illness, signs and symptoms,
allergies, medications, previous illnesses, and surgeries.
Take blood pressure, pulse, respirations, and temperature
on every patient, no matter the symptoms, diagnosis,
or treatment.

I was snorkeling with twelve expedition cruise ship

passengers on Belizes White Reef. Suddenly the
divemaster yelled, waved his arms and pointed down.
A 42-year-old female passenger lay flat on the sandy
bottom. I took a deep breath and free-dove 30 feet. . . .
If the phrase cruise ship doctor conjures images of partying Love Boatstyle mega-liners, a stint on an expedition cruise vessel will blow that
clich higher than a whales spout.
Its wilderness medicine at sea, says WMS member Pierre Guibor
MD. In his eighth year as expedition cruise ship physician, he has
sailed both small and large cruise lines from the Arctic Circle to
South America. Currently, he serves as Cruise Medicine and
Surgery Consultant for Clipper Cruise Lines.
Expedition cruise vessels typically carry 120 passengers and
80 crew. The ships doctor functions alonewithout nurse,
labs, X-ray or specialty consultsin remote locales such as
Russias Kamchatka Peninsula, Galpagos, the South Pacific,
or Belizean reefs.


She was seizing. I grasped her under her chin, pushed off the
bottom and kicked hard to the surface, emerging next to the panga
[small skiff]. The captain and mate pulled her 90-pound limp,
cyanotic body aboard. I jerked off my fins and mask and leaped
up the pangas ladder. She was not breathing, had no pulse and her
stomach was distended. I performed one abdominal thrust. Water
gushed over the bottom of the panga. Laying her on her back, I cleared
her airway with my fingers. She was still unconscious, not breathing
and pulseless. I gave her two mouth-to-mouth breaths and started cardiac

Fortunately, cases such as the seizing snorkeler are rare.

I see mostly GI episodes and sore throats with coughing.
I clean minor wounds, give IM tetanus toxoid boosters,
suture lacerations, and treat minor muscle aches and
strains of passengers who didnt work out prior to their
expedition. And I stress the merits of hand washing!
Severe trauma aboard ship is uncommon. However, be
ready to handle a tension pneumothorax or hemothorax
with an emergency chest tube. Review cardio-pulmonary
resuscitation (CPR) techniques. Take ACLS (Advanced
Cardiac Life Support) or ATLS (Advanced Trauma Life
Support) courses.
Obtaining medications in exotic foreign locations presents
challenges as well. Before leaving the U.S., Dr. Guibor
emails the doctor currently onboard and determines
which meds he should bring with him, in concurrence with
the medical director of the cruise line. But, he cautions,
when doctors from different countries bring their favorite
meds, unfamiliar brands cause confusion. Passengers
themselves cause confusion as well. They stockpile all
their meds in one bottle instead of in individually labeled
ones. When asked, many cant remember the name of the
meds, dosage, frequencyeven the MD who prescribed
them! Possible solutiona pre-cruise form listing meds,
dosages, frequency, and prescribing doctor. And it would
be extremely helpful to have a copy of a recent EKG.


Dr. Guibor, who returned to

the ship once she had been
admitted, followed-up after
her return to the U.S. Shes
had no recurrence of seizures.
Its been over four years and
Im still in contact with her,
Christmas cards and emails.



Small expedition cruise

ship doctors are usually not
salaried. So why trade 3 to 6
weeks of your valued office
time for a stint of wilderness
medicine at sea?


The ship doctor also forms part of the ships documents
department. The mandated Center for Disease Control
(CDC) Gastrointestinal Upset Log is an important statement
of wellbeing aboard the ships, whether in U.S. or International
waters. The ship doctor takes regular water samples and
maintains the water sampling log testifying to the absence
of E. coli. When a health issue affects a crew member or
passenger, the doctor and hotel manager coordinate specific
hygiene awareness or ship cleaning procedures. If an illness
usually diarrhea episodesrequires cabin isolation, the doctor
coordinates with the hotel manager, captain, and first officer.

compressions. After 30 secondswhich seemed like 30 minutesshe

coughed and started breathing on her own. Her pulse returned. Her color
went from dark blue to pink in one minute. She opened her eyes and said,
Where am I?
Dr. Guibors efforts had just begun. Onboard the cruise ship, he plunged
into emergency evacuation efforts that he had initiated by radio from
the panga, mobilizing the ship captain, first officer, hotel manager,
cruise director, Belize agent, the ships U.S. office, and the patients
insurance company. In the patients cabin, Dr. Guibor re-warmed her,
performed a complete physical examduring which she denied a prior
history of seizuresand started two large bore IVs in each arm with
Ringers Lactate.
Thirty minutes later, evacuation began. Dr. Guibor, the patient, and her
mother bounced across the waves in the little open outboard panga to
the small city of Dendriga, Belize. I kept her warm with blankets and
jackets. Night fell. When the panga stuck on a sandbar, the crew and
captain jumped out and pushed it over. Onshore, they transferred to the
ship agents Suburban. It was 10 PM. We drove from Dendriga over an
unpaved road to Belize City. During the entire trip, I kept my index
and middle finger on her radial pulse, the IVs open and ran O2 with a
nasal cannulauntil the O2 ran out. I attached AED pads for cardiac
monitoringand in case a shockable cardiac event occurred. We were
fortunate; she didnt seize during transport.
At 6 AM, they arrived at the Belize City Medical Clinic. Before
boarding the ship I had already checked out this facility, anticipating an
emergency. The patient remained there on IV Dilantin for two more
days before flying back to the U.S. by commercial carrier.



I stood on top of the highest

temple in the Mayan ruins of
Tikal. The steamy Guatemalan jungle spread below me. Howler monkeys
boomed. Something reda scarlet macaw maybe?flashed in the
distance. I had just climbed five stories of steep stone stairs and listened to
expert naturalists and historians. A few hours earlier Id been bouncing over
the jungle canopy in a little plane. Spanning over 400 years in less than a
Cruise lines usually provide complimentary air transportation, cruise
experience, and shore excursions to the ship doctor. The doctors
companion or spouse may also receive the cruise but is responsible for
his/her air transportation to and from the ship plus shore excursions.
Since most small expedition ships cruises range from $6,500 to $15,000
per person, this translates into a sizable compensation package.
In addition, the ship doctoron his/her owncan research and arrange
pre- or post-cruise travel. Dr. Guibor, a NAUI Dive Instructor and
Divers Alert Network Referral Physician, often schedules scuba diving
before and after his assignment. Being a professional diver jokingly
earned him the ship doctor title when his vessel struck an uncharted rock
and he doctored the ship. On scuba, I evaluated and photographed
puncture damage to the hull. Then I helped repair it!
Intangibles also keep Dr. Guibor at sea. There are rewards for making
accurate decisions rapidly, much like combat, says the former U.S.
Marine. Some of us with military service vicariously enjoy the sea
experience that we had in the past. As in the military, he enjoys working
with ship officers who are consummate professionals, forming friendships
that continue after the voyage ends.
But it isnt all happy outcomes and Christmas cards.
Downsides are isolation and uncertainty of your diagnosis and treatment
plan for serious patients. If the condition worsens and you made an
incorrect patient management decision, you are solely responsible. Ships
stock limited medical supplies, including oxygen. If you run out, you
cant call Walgreens.


Packing his duffle for the next assignment, he reflected, Small

expedition ship duty is much different from large cruise ship duty. You
practice medicine under unusual circumstances, challenge yourself both
physically and mentally, participate as a professional mariner providing

the best care possible to passengers and crew for whom youre their only
resourceand experience some of the most remote parts of the world.
The rewards are not so much financial but rather providing the service.
Consider the currency, Job well done, Doctor!

Dr. Guibor examines a polar bear skin (Ursus maritimus)

drying in the Arctic summer sun on the rocky beach at Little
Diomede, Alaska. Villagers explained that a hunting party had
found the polar bear trapped on the island when the northern
ice pack moved out early, perhaps due to global warming.

He closed the duffle. Being a team player on a small ship delivers great
rewards. Would you like to find out?


Unlike a hospital setting, the ships doctor frequently finds him/herself

low in authority except when medical issues are in question. Balancing
medical concerns with ocean-going operations requires tactplus
common sense and basic seamanship.
Most Captains consider medical issues, unless life threatening, to be
secondary. Learn the chain of command, such as the first officer who
then communicates with the Captain if needed.
The ship is an isolated, self-contained community at sea. Teamwork
is essential. A team consensus builder uses skills that enable the team
members to arrive at the same conclusions for problem solving and
corrective measures. Rather than forcing an issue in an authoritative
manner, the effective ship doctor is low key, avoiding heavy-handed
directives. Dr. Guibor summons all his tact when advising passengers
that treatment will involve isolation in their cabin for several days of
their expensive voyage!


Qualifications for expedition cruise ship
doctors vary for each ship.

Generally, requirements include:

Active state medical license
Current passport
ACLS, ATLS, or equivalent
Good general health and flexible attitude
Availability for a 3 to 6-week tour of duty.
Experience in Emergency Medicine, Family Practice,
General Surgery, or Internal Medicine is a plus.
Youll be suturing small wounds.
Additional preparation for a ship doctor
position might include:
Membership and attending conferences of
organizations such as the Wilderness Medical
Society (WMS) or International Society of Travel
Medicine (ISTM)
Keeping physically and mentally fit with regular
activities, i.e. hiking, swimming, etc.
Networking with other cruise ship physicians with
experience aboard the same ship
Planning pre- or post-excursions to derive the utmost
from your remote travel
Staying optimistic!


Pierre Guibor, MD, PA
Cruise Medicine & Surgery Consultant
Office: 201-392-3438

Clipper Cruise Line specializes in small cruise ship

expedition-type experiences in remote areas of Alaska,
Russia, Japan, Asia and South Pacific, aboard the Clipper
Odyssey. The ship doctor must be able to handle a multitude
of general medical problems and consider a number of
solutions, with limited alternatives/supplies available.

Ship doctor applicants should have the following:

1) Current US State Licensure & CV; 2) Copy photo page
passport; 3) ACLS or equiv.; 4) Good general health/positive
attitude; 5) Available for 3-6 weeks tour of duty. Preference
given to past ship physician experience and/or military service.
Computer skills essential.

Flexibility, availability and affability, with a teamwork

attitude, are important factors for this position.
Daily sick-call hours and emergency availability to
paxs and crew members.

EM, FM, IM or Surg preferred. No labs, xray or nurse

available. Contracts provide Med. Liab. Insur., air/land
travel to and from ship, and cruise itinerary for doctor
and comp cruise for companion.


2nd Battalion of the 1st

Marine Regiment
Training Operations
Fred Trayers, LT MC USN
2nd Battalion, 1st Marines
Assistant Battalion Surgeon

An M1A1 Abrams tank fires its main gun.

With the Marines

Awesomeabsolutely awesome. Theres no other way to describe the
raw power of the 120mm smoothbore cannon of an M1A1 Abrams
Main Battle Tank. I stood 10 feet behind this steel monstrosity when its
main gun roared again. Despite wearing a flak jacket with armor plates,
Kevlar helmet and ear protection, the shock wave almost knocked me off
my feet with its massive overpressure, and I was engulfed in a cloud of
dust and smoke. This was hardly what I expected to be doing 6 months
after completing my internship!

Photos by Fred Trayers

injuries received in combat or training. Medical care is complicated by

the fact that military operations are frequently conducted in austere
environments. There are almost always limits in personnel, equipment,
and transportation, which sometimes make managing routine patients
far more challenging. If there were ever a classic example of wilderness
medicine, it can be seen in the care of a Marine Corps small unit
operating in the field.

Serving with the United States Marine Corps as a physician is a unique

experience. The Marine Corps falls under the Department of the Navy,
which provides the Marines with their medical support. This includes
all levels of healthcare providers from physicians to Hospital Corpsmen,
who are equivalent to U.S. Army Medics. The career path of a Navy
physician is different than that of a civilian counterpart. After graduation
from medical school, Navy physicians complete an internship in the
usual fashion. However, following internship, most Navy physicians will
be assigned as General Medical Officers for 2 to 3 years, providing
medical support directly to the fleet. This GMO tour as it is called,
may be as a Flight Surgeon, Undersea Medical Officer, ships doctor, or
it could be with the Marines.
The medical issues for a Marine infantry battalion are interesting, to say
the least. The patient population consists mostly of young men who are
in generally excellent health. There are two general categories of medical
problems: The majority consists of preventive medicine issues, minor
injuries, and acute illnesses: the types of things that would be seen at a
local acute care clinic. The second category consists of wounds or other



The 2nd Battalion / 1st Marines Battalion Aid Station

(BASP at 29 Palms, California).

For four weeks last spring, the 2nd Battalion of the 1st Marine Regiment
conducted training operations in Victorville, California, and the
Marine Corps Air-Ground Training Center in 29 Palms, California.
The training operations were crucial in preparing the battalion for its
upcoming deployment to the Western Pacific, and medical training was
an important element to the overall training package.
Victorville is home to the former George Air Force Base. Instead of
completely abandoning the facility, however, it has been transformed
for use in Military Operations in Urban Terrain (MOUT) training.
The hundreds of buildings that used to be base housing are perfect to
train Marines to operate in the type of environments that are common
in modern warfare. The battalion conducted task-specific training
before proceeding to integrated platoon-, company-, and battalionsized operations. Medical training was specifically addressed. In order
to provide the highest level of intensity and realism, a Hollywood
production company was hired to support the training. Special effects
technicians, makeup artists, and actors are used to create a highly realistic
training simulation for the Marines and Corpsmen.

The Marines immediately deploy and move towards the casualties. They
set security and establish a defensive perimeter. The buildings are cleared
to ensure no hostile forces lie in wait to inflict further casualties on our
forces. Simultaneously, under the direction of the Navy Corpsmen, the
Marines tend to the grievous wounds of the victims. The Hollywood
makeup effects are gory, with eviscerated bowels, mangled bones, and
shredded tissue bathed in large quantities of bright red blood. To
achieve the highest level of realism and shock, many of the actors are
amputees. Imagine the look of surprise and horror when a Marine opens
the Humvee door to find the victim splattered in blood and sees two
bloody stumps where the legs should be!

After a simuluated IED blast, an actress/double amputee

is found ejected from a Humvee.

The basic level of medical

training for the Marines
is called Combat
Lifesavers which follows
the Prehospital Trauma
Life Support (PHTLS)
guidelines. A military
specific version of these
guidelines have been

Marines apply
and give
first-aid to a

Basic Management Plan for Care under Fire:

1. Return fire /
take cover

2. Direct/expect
casualty to remain
engaged as combatant,
if appropriate

In our scenario, the Marines were gathered in a parking lot in the center
of the MOUT town. They are receiving an otherwise unremarkable
lecture on basic first aid when a passing Humvee detonates an improvised
explosive device (IED). A huge but harmless explosion startles everyone
to action. The Humvee swerves off the road and hits a secondary IED as
it comes to rest alongside one of the buildings. When the dust settles, the
screams of our actors can be heard as they call out for help.

5. Massive Hemorrhage:
Stop life-threatening external
hemorrhage if tactically feasible

6. Airway Management: Position changes,
airway adjunct or cricothyroidotomy
7. Respirations: Consider tension

pneumothorax and decompress if required

3. Direct casualty to
move to cover/apply
self-aid if able

8. Circulation: Assess for unrecognized

hemorrhage and control

4. Try to keep casualty

from sustaining
additional wounds

9. Hypothermia: Minimize casualtys

exposure to elements / maintain
protective gear if feasible

An actor/amputee
awaits the arrival
of Combat Lifesaver
trained Marines
after a simulated
IED blast.

(Photo by Daniel DeAndrade)

Marines and
Corpsmen tend
to the chest
wound and arm
amputation of the
simulated casualty.



developed, which differs slightly from traditional civilian

protocols. The most notable difference is that medical
care is only provided if it is tactically feasible to do so.
In a combat environment, accomplishing the mission
and avoiding additional casualties are of the utmost
importance. Another interesting difference is that the
traditional ABCDs of trauma care are modified slightly
through use of the acronym MARCH, which stands for
Massive hemorrhage, Airway, Respirations, Circulation,
and Hypothermia. This sequence of trauma life support
is tailored to suit the more commonly seen mechanisms
of injury and environmental circumstances of combat.
The most dangerous and challenging aspects of
providing medical care to the Marines falls on the
shoulders of the U.S. Navy Corpsmen. Corpsmen are
enlisted sailors who work in all areas of Navy medicine,
in many different roles. Among the Marines, however,
Corpsmen have a special role in that they are assigned

Corpsmen: (L to R) HM3 Sean Phinney, HM3 Juan

Galarza, HN Daniel Lee, and HM3 Joshua Salyer.

directly to combat units. This means that in addition to their medical

responsibilities, Corpsmen will face the same tremendous challenges as
their Marines during training and combat. Initial Corpsman training is
roughly equivalent to that of an EMT-Basic curriculum. Corpsmen are
frequently called upon to do far more, and will address the daily routine
medical problems of their Marines, as well as be the primary medical
provider during combat operations. On an almost daily basis, I am
humbled by the ability and courage of these Corpsmen, many of whom
wear Purple Hearts and other awards for valor, which they have earned
by caring for their Marines under the most horrifying circumstances.
Military medicine is unique but extremely rewarding. The sacrifices
made by the young men and women who serve in the armed forces are
inspiring, and it has been a privilege to take care the medical needs of
these individuals and their families.



Recommended Reading
1. National Association of Emergency Medical Technicians.
PHTLS Prehospital Trauma Life Support: Military Version (6th Ed.).
Philadelphia, P:Mosby; 2007.
2.Yevich S, et al. Special Operations Forces Medical Handbook. Jackson,
WY:Teton NewMedia; 2001.
3. Peters JM, Fansler JR. Not On My Watch: The 21st Century Combat
Medic. Bloomington, IN:Authorhouse; 2007
4. Bradley J. Flags of Our Fathers. New York, NY:
Random House; 2006.
LT Trayers is a Battalion Medical Officer with 2nd Battalion, 1st Marines. After this tour
of duty, he plans to apply for continued residency training in Emergency Medicine at Naval
Medical Center, San Diego.

+ MEMBER Profiles

Sam Schimelpfenig, MD

Sheryl Olson, RN, currently works as a flight nurse in Colorado.

She grew up in Wyoming, which fostered her interest in the great
outdoors. Later, she began teaching skills in winter emergency care
while working with the Ski Patrol in Breckenridge, Colorado and
has continued to teach since then. She has been actively involved
in teaching EMT courses, CPR and ACLS courses, and also at
annual WMS conferences covering helicopter rescue and evacuation,
wilderness improvisation skills, and childrens courses on survival,
navigation, and first aid. Her current project involves organizing a
Wilderness Medicine Adventure Course in Tibet and China in the
summer of 2007.

A member of the Wilderness Medical Society since

2002, Dr. Vidal Haddad Jr., has been actively
involved in research on aquatic animals and
toxicology for several years. He completed medical
school in Brazil in 1983 and afterwards specialized
in dermatology. He also obtained a PhD from the
Federal University of Sao Paulo in Brazil. He is a
member of the Brazilian Society of Dermatology
where he serves as a peer reviewer for the official
journal of the society, as well as a member of the
Brazilian Society of Toxicology. He has served
as the chairman of several aquatic dermatology
symposiums and has received numerous awards for
his research in the field of aquatic dermatology. He
is the author of several books on Brazilian aquatic
and poisonous animals and maintains a website
dedicated to the treatment of venomous Brazilian
aquatic animals.

Dr. William Karesh is a veterinarian who

directs the Field Veterinary Program of the Wildlife
Conservation Society. This program serves to fill the
need for health-related services and technical advice
for field biologists, conservation organizations,
and government agencies around the world. Dr.
Karesh has also served as the Director of Wildlife
Conservation at the Woodland Park Zoo in Seattle,
and as veterinarian at the San Diego Zoo and the
Wild Animal Park in California. His main interest is
on the practical problems raised by the interactions
of people and wildlife. Dr. Karesh is the author of
the critically acclaimed book Appointments at the End
of World: Memoirs of a Wildlife Veterinarian (Warner
Books, 1999, 2006). Wilderness Medicine magazine
featured his article on gorillas in the Congo (Vol
21:3; 20-22, located on the web at http://www.wms.

Graeme Walker is at the end

of his post-graduate training for
general practice/family medicine
in Scotland. He developed an
interest in wilderness medicine
while at medical school, and his
attendance at the 1999 WMS World
Congress in Whistler had a major
influence on his subsequent career
development. Since medical school,
he has been fortunate to have been
able to combine his medical career
with regular freelance work as an
expedition leader in a variety of
countries around the world, and this
year he stepped foot on his seventh
continent while working as ships
doctor on a cruise to Antarctica.
He continues his active interest in
wilderness medicine while at home
in the highlands of Scotland, as a
volunteer member of Dundonnell
Mountain Rescue Team.



To the Ends of the Earth:

Adventures of an
Expedition Photographer
Gordon Wiltsie
W.W. Norton, New York , 2006
Clothbound, 224 pages, $35 US
Gordon Wiltsie is considered one of
the worlds preeminent expedition
photographers, a term he prefers
to adventure photographer. In To the Ends of the Earth, the reader
is treated to Gordons talents in every conceivable way both artistic
with his photography, and literary with the prose that accompanies
the images.
The photographs tell stories, so they are not always spectacular poster
images suitable for reproduction and hanging on a wall of art. Rather,
they represent the action, support the stories, and guide one through
the tales of adventure. I am largely in favor of this method, because
rather than being enticed to quickly flip through the book and become


YOU DIE: A Travelers Life List
Patricia Schultz
Workman Publishing, New York, 2003
Softcover, 974 pages,
$18.95 US, $28.95 CAN
Moonlight caressing the Taj Mahal.
Trekking Machu Pichu. Exploring Anasazi
ruins at Canyon de Chelly. Welcoming the
New Year in Times Square or the summer solstice in Stonehenge.
Sharpen your pencil and start marking off 1,000 Places to See Before
You Die. Patricia Shultzs New York Times bestselling Life List challenges
travelers, real and armchair. There is something for literally everyone.
The historianmedieval castles, Thanksgiving at Plymouth Plantation.
The literaryStratford-upon-Avon. The art loverLouvre, Moscows
subway system. Not to mention the religious pilgrimChristmas in
Bethlehem, Omayyad Mosque. Also the shopperDubais Gold Souk.
The golferSt. Andrewsand skierNew Zealands Alps, Utahs
Wasatch. Oh, yes, and the war buffNormandys D-Day beaches.



breathless in wonder of monumental portraiture, the reader must move

back and forth from words to photos, to understand how the threads
have been woven into tales. This is a book to be read over a period of
weeks, or even months, because you will find yourself expending a bit of
emotional energy in the process.
It is skewed towards cold environments, like the Arctic Ocean, beginning
and ending that way, but in his accounting of an expedition to Peru,
Wiltsie hints that there can be gratification in staying warm. I am fearful
that the sub-zero places he might take me would be too hard on this
aging adventurer. However, with someone as talented and extraordinary
as Gordon Wiltsie allowing me to stay in an armchair and soak in the
experience, I feel much better about the future.
If you appreciate the wilderness and wish to inspire yourself to become
more adventurous, or just understand the motivations and trials of
those who have already committed themselves to expeditions into the
wild, this is a book that you should read, and have your children read
as well. Gordon Wiltsie has created a wonderful book, and I highly
recommend it.
Reviewed by Paul S. Auerbach, MD, Los Altos, California

The gourmetViennas Heurigers, Singapores street foodand the

drinkerwhisky distilleries and wineries. Even the party-goerRios
Carneval, New Orleanss Mardi Gras. And, not to be left out, the
fishermanLi River, Nukualofaand the wildlife observerpolar
bear safari, Masai Mara migration. The scuba diverRoatan, Yap.
And the outrCount Draculas castle, Amsterdams Red Light District.
And, yes, wilderness adventurerbicycling, climbing, caving, bungee
jumping, elephant riding! And 962 more.
Covering every continent, 1,000 Places . . . includes the obvious (the
Parthenon, Panama Canal) and not-so-obvious (Costa Ricas Manuel
Antonio National Park). Special indexes will guide you to ten areas of
particular interest including Glories of Nature (Sun Yat-Sen Classical
Chinese Garden, Great Barrier Reef) or ultra-pricey Great Hotels and
Resorts (Raffles, Swedens Ice Hotel). And 955 more.
Its 974 pages add over 2 pounds to your backpack, so unless youre doing
all 1,000 in one marathon adventure, copy selected logistic details to a
coupla pages and leave the tome at home.
Ballooning over Albuquerque, cruising the Nile. . . .
Reviewed by Yvonne Lanelli, Alto, New Mexico

Wilderness Survival: Living off the Land with the

Clothes on Your Back and the Knife on Your Belt
Mark Elbroch and Mike Pewtherer
Ragged Mountain Press, Camden, ME, 2006
Softcover, 288 pages, $15.95 US
ISBN: 0-07-145331-8
For 46 days, Mike Pewtherer and Mark Elbroch lived off the
landfacing the day-to-day struggle of meeting their bodys
need for warmth, water, and food. To do this, they improvised
a myriad of tools and containers, slept in leaf insulated shelters,
drank untreated water, and killed a variety of animals with sticks
and stones. Their book, Wilderness Survival, captures the reality
of their journey as they challenge learned wilderness living skills in a long-term setting.
Wilderness Survival is actually two books in one: Mike Pewtherers essays on basic survival
skills interlaced with Mark Elbrochs diary of their 46-day adventure. I was able to read
Marks story without technical jargon bogging things down and yet when needed, I could
refer to Mikes essays for clarity on skills Mark mentioned. I found this to be a breath of
fresh air!
Although writings on wilderness living skills are always of interest, the candor found in
Marks diary is what captured my attention. His words relay a harsh reality that contrasts
with a modern adventurers fantasy. The text is filled with stories of unrelenting mosquitoes,
rain, hypothermia, diarrhea, yearning for familiar meals and sweets, and a rollercoaster of
emotions including a heartrending cry after killing a young deer. I encourage you to pick
up a copy and share the adventure.
Reviewed by Paul Greg Davenport, Stevenson, Washington

Voyagers of the Chilcotin

Carolyn Foltz
Booksurge Publishing, Charleston, SC, 2007
Softcover, 214 page, $14.95 US
ISBN 0-9650963-0-0
In 1965, a young couple from California became landed
immigrants and traveled to Bella Coola, British Columbia, to
live in a small community surrounded by the vast wilderness
of the Chilcotin Plateau. This book is the account of living in a
community similar to a hundred years ago, with kerosene lights, wood heat, and homemade entertainment. Although they lived in a small town and had the advantages of a store,
a vehicle, and nearby relatives, the influence of the wilderness around them was intense.
They stayed for about two years, had two children, then decided that they could not raise a
family there and returned to California.
The stories are charming and also vividly describe bear encounters in yards and along
streams as well as the injuries common among loggers and workers in fish canneries. There
is a special account of womens experiences of cabin fever, feeling isolated and apart from
support of family and friends in the winter, with limited understanding from the men in
their lives. Interestingly, it was not unusual for women to check into the local hospital for a
couple of weeks to get a break from household responsibilities when this happened.
This book is not like the heavy accounts of Canadian wilderness travel in A Death in the
Barrens or Going Inside, both of which describe long canoe voyages. It is, however, a fun
read, especially for those who imagine living more simply in a wilder place.
Reviewed by Susan Snider, MD, Spruce Pine, North Carolina



Search and Rescue on Mt. Hood

Photos by Christopher VanTilburg

December 7, 2006 three climbers left Tilly

Jane Trailhead to ascent the rugged, remote
North Face Gully on Oregons Mt. Hood.
The next day, one of the largest and most intense storms of the
decade, one that would later leave 1.5 million people without
power, hit Oregons highest peak. The Hood River Crag Rats
are the mountain rescue team that initially responded to the
distress call on December 10 and coordinated one of the
largest searches in many years, one that would gain headline
news as far away as Australia.
These images are from
WMs Editor Dr. Van
Tilburgs collection
of the search. For a
detailed account of
the 10-day mission,
read Mountain Rescue
Doctor, forthcoming
from St. Martins Press
in November 2007.



The nation, and many parts of the rest of the world, watched the Mt.
Hood search in December 2006 unfold. We all were disheartened with
the end of the story. At Wilderness Medicine we felt we should clarify
a common question that appeared in the lay media: why didnt these
climbers have a rescue beacon? We asked experts to clarify the differences
among the commonly used location devices: personal locator beacons,
avalanche transceivers, the RECCO system, and the Oregon-specific
Mt. Hood Locator. While technically not a locator search, two highprofile searches in Oregon, the Kim search in the Oregon Coast Range in
November and the Mt. Hood search in December, both used computer
technology to determine which cell phone towers their cell phones were
communicating with, thus narrowing the search. We asked search and
rescue experts to explain the different devices.
Keep in mind, no device is foolproof: batteries die, electronics fail if they
get dropped or wet, and sometimes we just forget how to operate them,
the user manuals can be a thick as a novel. Also, these devices require
proper training, routine practice, and plenty of experience. Nothing, of
course, substitutes for common sense and good judgment. Ed.

Personal Locator Beacons

Mike McDonald of Douglas County (Colorado) Search and Rescue Team

Personal Locator Beacons (PLB) are distress beacons intended for people
involved in land-based outdoor activities. There are similar beacons for
aviators and mariners. All three types of beacons transmit radio signals
that are detected by 12 earth-orbiting satellites.
The satellites relay the signals to ground stations that process the signals
to determine beacon location and ownership, and alert search and rescue
(SAR). This is an international program with 63 ground stations located
in 27 countries. Another 13 countries without ground stations are
participants in the program.

Beacon location is determined by the frequency shift in the received

signal as the satellite passes the beacon (Doppler shift). It takes several
satellite passes over some time, possibly hours, to get a relatively accurate
location. To eliminate this problem, some beacons transmit coordinates
from an external or internal GPS (Global Positioning System) receiver.
The coordinates are transmitted to the ground stations through the
satellites, so an accurate location is known in the time it takes the system
to process the signals; there are geostationary satellites that see an entire
hemisphere at once, so this can be a matter of minutes. PLBs sold in the
U.S., but not necessarily elsewhere, also transmit a low-power homing
signal so that SAR forces can locate the beacon once they reach the
satellite provided location.
Each beacon transmits a unique identifier. If the beacon is registered with
the proper authority (National Oceanic and Atmospheric Administration,
NOAA, in the U.S.) the ground station computers match the identifier
with the registration database. A report is generated with the beacon
owners contact information, emergency contact information, and,
of course, location. SAR then begins attempting contact. If a beacon
detected in one country has an identifier belonging to another, the
second country is automatically contacted so the registration database
can be queried. If the beacon is unregistered, the report contains only the
country code, location, and beacon information.
The registration system in the U.S. is accessed via the internet, so a
beacon owner can update contact information as often as necessary.
The form has space for comments and some users input trip itineraries.
Although U.S. law requires PLBs to be registered, many are not. For a
PLB to provide the maximum benefit it needs to be registered.
As with any tool, there are caveats for PLB usage. Unlike beacons
for aviation and maritime use that can be automatically activated in
a crash or sinking, PLBs require three separate manual operations to


be activated. This means the user, or someone in the party, must have
sufficient mental and physical capabilities to activate the beacon. The
PLB needs to be located where it has a reasonably clear view of the sky.
For GPS equipped beacons this is even more important because the PLB
must be able to receive GPS signals. PLB users also need to understand
that although the beacon may be detected within minutes of activation,
it may take search and rescue many hours to reach the area. Despite
these issues, when properly used, PLBs and their aviation and maritime
counterparts can be truly life-saving devices.
Photos by Christopher VanTilburg

Photo courtesy of RECCO Avalanche Rescue System

interpret the signal information with a microprocessor, and then present

the data visually. Most of todays transceivers use distance displays and
directional arrows to guide a companion to his buried friend.
Avalanche transceivers in the hands of practiced users, along with a probe
and shovel, are the best tools to locate a buried companion. However,
despite their acknowledged superiority as a companion rescue tool, the
transceivers success is mediocre. Since the first use of a transceiver to
find a buried victim in the U.S. in 1974 (through 2006), many more
victims have been found dead (98) than alive (65). The reason is simple:
most users are not well practiced to be fast enough to save a life. Looking
deeper into the data offers a glimmer of optimism. Since 2000 when
digital transceivers began to dominate the market, the mortality rate of
subjects found by transceiver plunged from 70 percent to 50 percent.
Experts attribute this statistically significant drop to the improved easeof-use with digital transceivers. Even with this dramatic improvement in
survival, the statistic is also a sobering reminder that using transceivers
does not guarantee survival for the buried avalanche victim.

Avalanche Transceivers


Dale Atkins, Colorado Avalanche Center

Ken Zafren, Alaska Mountain Rescue Group and WMS

Avalanche rescue transceivers are the best tool for companions to

locate a buried friend. Costing typically between $300 and $400+,
the transceivers are strongly recommended for all who play and work
in avalanche terrain. Strapped to the torso and usually worn under the
outer-most layer of clothing the transceiver is a small electromagnetic
induction device (about the size of ones hand) that transmits a constant
signal when turned on. The device should be turned on at the start of a
days adventure and then turned off at the end of the day. When a member
of the group is buried in an avalanche, all remaining companions switch
their devices to receive and begin to search for the signal. Once the
signal is detected the searcher can hone in on the signal by following the
flux lines of the sending units magnetic field. The last few meters are
searched in a grid-style pattern with the final pinpointing done with a
collapsible probe pole (like a tent pole) or ski pole.

The RECCO Avalanche Rescue System (Liding, Sweden) is a tool that

is widely used by organized rescue groups worldwide for rapid location of
buried avalanche victims. RECCO uses a harmonic radar detector to find
reflectors that are permanently attached (usually by the manufacturer) to
clothing and gear used by skiers, snowboarders, and participants in other
winter sports. Their use requires no training or other action on the part
of the person venturing into avalanche terrain other than using clothing
or equipment with reflectors. The reflectors are inexpensive, dont use
batteries, and weigh less than 4 grams (about 0.15 ounces). The use of
the RECCO system does not interfere with other methods of locating
buried victims, including avalanche transceivers or search dogs. Because
of the high frequency it uses, RECCO allows direct and very accurate
location of the reflectors, minimizing time spent probing to find the
exact location of the victim.

The first transceiver, the Skadi, became available in 1968 and was thought
to be a tool for professionals, such as ski patrollers, snow rangers, and
plow drivers, but not for the general public. These first devices like all of
todays avalanche rescue transceivers work on the principle of a simple
transformer. The sending unit creates a magnetic field that is produced
by an electrical current pulsed in a coil around a small ferrite rod. In
the presence of a receiving unit (magnetic coupling) a current is created
(induced) in the receiving unit creating a detectable signal. In the early
1980s European manufacturers settled upon a standard frequency:
457 kHz. The U.S. adopted this higher frequencythe international
standardin 1996.
For over 30 years searchers could only listen to changes in volume as
the signal indicator. In the late 1990s the introduction of digital
transceivers with multiple receiving antennas greatly improved the easeof-use. Digital units capture the pulsed signal, transform it to digital data,



Photo courtesy of RECCO Avalanche Rescue System

RECCO does not replace avalanche transceivers, which are the most
effective method of finding buried avalanche victims while they are still
alive and can be used by the victims own party for rapid location and
rescue. However, RECCO provides a complementary method for finding
the victims in a timely manner once organized rescue arrives on the scene.
With the increasing use of cell phones to notify rescue organizations and
the increasing availability of snow machines and helicopters, RECCO
has increasing potential to find live avalanche victims. A large portion
of backcountry activity takes place close to developed ski areas, where
the RECCO detectors are available and from where they can be rapidly
brought to an avalanche site. The current generation RECCO detector
weighs 1.6 kg (3.5 lbs) and is very portable. The detector can be used
easily from a helicopter or by a rescuer on foot. The systems range is over
200 meters through air and 20 meters through snow. In North America,
the RECCO system is used by over 100 ski resorts, helicopter skiing
operations, and mountain rescue groups. The RECCO Avalanche Rescue
System website ( has more information about the RECCO
System as well as a very useful introduction to avalanche safety.

Mountain Locator Unit

Rocky Henderson, Portland (OR) Mountain Rescue

adaptation of wildlife tracking technology. In order to implement

the system, a special law exempting the manufacturer from tort liability
had to be passed in the Oregon legislature. Due to FCC and other
regulatory challenges the MLU is only available and legal to be used
on Mt. Hood.
The system consists of transmitters that are rented to climbers and
sensitive directional receivers used by search teams. You cannot buy an
MLU. Local climbing shops and a motel at Government Camp rent
them for $5 per weekend. The climber is instructed on how to activate
them in case of an emergency. The important thing to remember about
MLUs is that when they are activated no one is listening. They send a
pulsing radio signal on the VHF band. Upon notification that you are
missing and that you have an MLU, searchers are able to pinpoint your
location in extreme mountain weather and environment. The transmitter
has a sealed-in battery that will keep transmitting for literally months
after activation. The range the searchers can hear the signal depends on
all the factors that affect radio waves such as terrain, body shielding, and
antennae position. It has been tested and detected up to 20 miles away
from aircraft receivers.

It has proven to be an effective solution to a real problem but is not the

The Mountain Locator Unit is a solution to a particular problem. In solution to all SAR situations.
1986, the Oregon Episcopal School tragedy on Mt. Hood inspired
a tremendous amount of energy toward preventing such an accident C e l l P h o n e s a n d P e r s o n a l R a d i o s
again. Nine people lost their lives partly because rescue teams could not Howard Paul, Mountain Rescue Association
find their snow cave in time. The solution that was selected was an
A cellular phone can save enormous time in reporting an emergency.
Photo by Christopher VanTilburg
However, do not depend upon a cell phone by itselfbatteries die,
coverage frequently is intermittent or nonexistent, and you are still
without help. You must be prepared to recognize, prevent and deal with
backcountry emergencies without a cellular phone or a radio. Know firstaid, how to use a map and compass; understand weather and its danger;
carry the 10 Essentials of backcountry travel.


1. Extra food & water
2. Extra clothing
3. Map
4. Compass
5. Flashlight + extra

batteries & bulb
6. Sunglasses & sunscreen
7. Matches in a waterproof container
8. Fire starter or candle
9. Pocket knife or utility tool
10. First-aid kit



ICAR - IKAR - CISA Statement

(Avalanche Rescue, Terrestrial Rescue
and Medical Commissions)
Avalanche Rescue Devices and Systems
Kranjska Gora, Slovenia
October 14, 2006

Internationale Kommission fr Alpines Rettungswesen IKAR Commission Internationale

de Sauvetage Alpin CISA International Commission for Alpine Rescue ICAR
Considering the ongoing development of avalanche safety devices in recent years the above commissions of ICARIKAR-CISA
update their statement of 1999 concerning these devices and systems by highlighting the following points:
A. Most people trigger their own avalanche and this can result in death.
The best way not to be caught is to not trigger an avalanche.
If caught, preventing burial is the best way to stay alive.
B. The best way to avoid avalanche accidents is prevention, including information (avalanche bulletins),
knowledge, experience, awareness, and caution.
C. If caught, some safety systems/devices may increase ones chances of survival. Survival depends upon quick rescue.
The efficiency of the transceiver in combination with probe and shovel, and of airbag systems has been proven.
At this time support for other systems is based upon personal opinion and case reports.
However, no device or system guarantees against either injuries to or death of avalanche victims.
D. All rescue systems require training and practice.
E. For organized rescue early notification is essential, e.g., by mobile phone, satellite phone, or radio wherever possible.
F. To be equipped with a transceiver or at least a transponder, e.g., the RECCO system, renders organized rescue more efficient.

+ Call for nominations to serve on the WMS

Board of Directors!

The WMS nominations committee is looking for members interested in stepping up their commitment to the WMS by serving on its Board of Directors.
If you are interested in being considered, please send by email a list of your special qualifications and a written statement itemizing what you feel you can
bring to the board and why you should be considered. Deadline for nominations is May 1, 2007, send to
WMS Board member job description
H Define and pursue the mission of the WMS and safeguard the values of the organization.
H Select, monitor, support, evaluate and compensate the Executive Director.
H Establish long-term direction through oversight of and participation in strategic planning.
H Promote financial viability through budget and financial oversight, fund development
and investment management.
H Maintain and continuously improve the services of the WMS.
H Monitor the effectiveness of significant organizational programs and take action where appropriate
to improve, modify, or eliminate such programs as necessary to maintain excellence.
H Oversee and promote positive relationships with liaison organizations.
H Promote and maintain positive external relationships with the community and other wilderness,
healthcare, and environmental organizations.



H Oversee effective governance, including Board recruitment, selection and orientation,

board education, and self-evaluation and effective function and structure.
H Act with the highest integrity to advance the best interests of the WMS and achieve its mission.
H Oversee fundraising and participate in fund development through personal contributions.
H Set policies for the WMS.
H Serve as advisor for the Executive Director
H Bring at least one corporate sponsor to the WMS.
H During his/her term or before taking a seat on the Board, each Board member should
become a life member of the WMS.
H Each Board member is expected to attend (in person or by phone conference) a minimum of
50% of annual scheduled Board meetings, and may not be absent from 2 consecutive meetings of the Board.

Photo by Jonna Barry

Fit to be Wild:

A New Look at Old Wilderness Medicine for Travelers Diarrhea

Jolie Bookspan, PhD

Travelers diarrhea is common in visitors to tropical areas and during

expeditions to wilderness locations. It is inconvenient and sometimes
uncomfortable, with abdominal pain, dizziness, and nausea. While
antibiotics are often used to treat some kinds of travelers diarrhea, there
are other time-honored options. In deciding the best treatment, several
issues need to be considered.

Antacids and proton pump inhibitors (PPIs), drugs to reduce acid

production in the GI tract and to treat ulcers and reflux, can also allow
ingested infectious organisms to grow in your stomach. Stomach acid is
necessary to kill unhealthy germs and food-borne infection. A known risk
factor for gastroenteritis is using PPIs like Nexium, Prilosec, Prevacid,
Zoton, Inhibitol, and others.1-3

Some of the gastrointestinal illnesses (GI), like E. coli, can be made

worse with antibiotics. Killing the bacteria can sometimes cause release
of large amounts of the Shiga toxin. Antibiotics also wipe out the GI
tracts good bugs along with the bad. Without the beneficial flora that
normally live in the GI tract, normal nutritional and immunogenic
products in your body are not made, and the organisms responsible
for several illnesses can proliferate. An example is antibiotic-associated
Clostridium difficile (C. difficile) colitis, an infection of the colon that
occurs primarily among patients exposed to antibiotics. More than three
million C. difficile infections occur in hospitals in the U.S. each year. It
is estimated that 20,000 C. difficile infections now occur each year in the
U.S. outside the hospital.

Long-term PPI-induced acid suppression in conjunction with

Helicobacter pylori (H. pylori) colonization may promote development
of atrophic gastritis, a well-accepted step in the progression to
gastric cancer. 4

Antidiarrheal medicines, such as loperamide, sometimes help, but in

some situations are not recommended for particular infectious sources
of diarrhea, because they may keep infectious bacteria in contact with
the gastrointestinal tract for longer periods of time. For example, some
authorities recommend loperamide for non-invasive bacterial infections
(generally marked by no fever and no blood), but withholding loperamide
for invasive bacterial infections (generally marked by fever and blood
in stool).

Use of PPIs add to the confusion in making the differential diagnosis,

as side effects of PPIs may include diarrhea, abdominal pain, and
nausea. Diarrhea is also a side effect of antibiotics, which may have
been prescribed prophylactically to prevent travelers diarrhea. It is easy
to confuse these symptoms for a infectious mechanism, and then add
medicines that further the cycle of problems. What are some possible
alternative treatments?

The use of probiotics,

which are beneficial bacteria
and yeasts, dates
back thousands of years.


Photo by Rhonda Martin

Time-Honored Medicine

One effective remedy for travelers diarrhea, historically used in many

societies, is eating fermented food. The use of probiotics, which are
beneficial bacteria and yeasts, dates back thousands of years. People in
ancient civilizations, from Mongolian nomads to Babylonian royalty,
drank soured milk, and Asiatics ate fermented beans and vegetables
to stop gastrointestinal illness. Russian and Mongolian military troops
campaigning across vast distances ate sauerkraut, which is fermented
cabbage, for scurvy prevention and against diarrhea. Sauerkraut is a
version of kimchi, Korean fermented cabbage that was brought to the
Teutonics with the Mongols and other wandering tribesmen who had
contact with the Orient.

Modern Confrmation

The Lancet recently published a study by researchers from Johns Hopkins

University who concluded that probiotics effectively treat acute diarrhea
and antibiotic-associated diarrhea in adults and children. Several probiotic
strains were evaluated, including Saccharomyces boulardii, Lactobacillus
rhamnosus GG, Lactobacillus acidophilus, Lactobacillus bulgaricus, and
others. The researchers urged eating probiotic-containing food when
traveling, especially internationally.5 Other major studies support that
probiotics prevent and reduce duration of acute diarrhea in adults and
children. 6,7

Germ Inhibiting Foods

Cabbage may be an accepted antibacterial for stomach ulcers, now

known associated with the gastrointestinal bacteria H. pylori. Clinical
trials indicate that some types of probiotics also help control several
diseases, such as ulcerative colitis, reflux, and irritable bowel.8



Fermented vegetables like kimchi are nutritious in themselves, plus

produce nutrients that beneficial lactobacteria need to thrive and produce
antibacterial action. Two top foods for promoting beneficial bacteria and
inhibiting unhealthy bacteria are cabbage and onions. Broccoli sprouts
have been found to specifically reduce H. pylori. Seasoning food with
raw crushed garlic and fresh ginger root may inhibit strains of H. pylori,
E. coli, Staphylococcus, and Streptococcus, without harming beneficial
digestive bacteria.
Several spices have bacteria-inhibiting properties: garlic, allspice, and
oregano have been found to have action against bad bacteria, followed
by thyme, cinnamon, tarragon, and cumin. Capsicum, such as chilies
and other hot peppers, have moderate antimicrobial action. White and
black pepper, ginger, anise seed, celery seed, and lemon and lime juice
follow. Researchers at the University of Kansas found that garlic, cloves,
cinnamon, oregano, and sage kill E. coli.9-12 Research in Mexico has
found the spice oregano to be more effective than prescription drugs
against Giardia.13,14

Many foods have been long used

against fungal + worm infestations.
In addition to antibacterial properties, many foods have been long used
against fungal and worm infestations. The World Health Organization
recommends crushed garlic, curry, and cloves for their specific antiworm properties, confirmed in studies15, and the anti-worm properties
of coconut.16,17

In Russia, a lacto-fermented beverage called kvass has long been made

from old rye bread. It tastes like beer but is not alcoholic and can be
purchased in modern supermarkets packaged just like soda. Kvass was
used by peasants, military, and even the Czars. Another kvass made from
beets was made during war times and taken during travel to protect
against infections. Ancient Iraqis and Egyptians made similar drinks from
bread. Fungus-fermented teas have long been used throughout Russia,
China, Japan, Poland, Bulgaria, Germany, and Southeast Asia (called
chainyi grib in Russia, kombucha in Asia, and elsewhere as teeschwamm
or teewass, wunderpilz, cajnij, fungus japonicus, and hongo, which
means mushroom). Australian aborigines lacto-fermented grains and
legumes to make a bubbly, sour drink that modern Australians call
wholegrain. South American Native Indians fermented several drinks
they say prevent digestive problems including diarrhea. In Africa, lactofermented munkoyo was made from millet or sorghum (sorghum beer)
and given to babies to stop infection and diarrhea. Missionaries (and
others) suppressed munkoyo in favor of commercial soft drinks.

What To Do Simple and Inexpensive Food

For serious cases, seek medical attention to determine the pathogen

and proper course of treatment. Most of the time, travelers stomach is
not a medical emergency. Several things may lessen, prevent, and
alleviate outbreaks.
Instead of soda, try kvass. Instead of antacids and antibiotics for travelers
stomach pain, it is healthier and often as effective or more effective
to use cabbage, cabbage juice, and fresh sauerkraut. Try apple cider
vinegar diluted in a little water. Squeeze lemons and limes on fruit and
vegetables, and add to drinks and blender shakes. Add balsamic vinegar
to salads. Soothe an uncomfortable stomach with fresh ginger. For the
gas of travelers stomach, season food with cardamom, coriander, fennel,
or cumin. For travelers diarrhea, try kimchi, tempeh, and sauerkraut.
Eat fermented vegetables like fresh pickle (fermented, not vinegar
cucumbers), sauerkraut (fermented cabbage), fermented chutney,
tempeh, oncham, and kimchi. Season with spices like garlic and
curry. Look for fermented food with live cultures. Many products kill
the cultures through heating, processing, and packaging. Use freshmade sauerkraut, not pasteurized or canned. The packaging process
deliberately removes helpful nutrients and living cultures created
through fermentation so that the lids dont blow off. There are quick
sauerkrauts made with vinegar; the vinegar is fermented, but the cabbage
isnt. To get real fermented cabbage, check the label for sauerkraut made
from cabbage, water, and salt, with no vinegar. Although probiotics are
often expensively packaged in supplements, you can have the benefits
from inexpensive simple foods.
Photo by David Barry

What To Do Simple and Inexpensive Containers

Dishwashing techniques in hiking camps and expedition kitchens

have been found to be a cause of many cases of wilderness and highaltitude gastroenteritis.
One time-honored method is not to use dishes. Find or bring large leaves
like banana, spinach, grape leaves, chards, and other greens to wrap
foods for cooking, and use for sturdy plates and napkins. The leaves
pack lighter and flatter than dishes. Make pronged vegetable roasters
from long, narrow stems and branches. Cut lengths into simple spoons,
spatulas, and chopsticks. Return them to the earth when finished. Dont
destroy living trees, and keep your impact low. Its healthier for you and
the wilderness.

Old Ways Are New

People go to the wilderness to get back to nature, then often eat no

greens or healthy foods, add to litter with disposable containers, lug piles
of dishware, and add bleach into the environment from disinfecting
dishwashing technique. Fermented food is health food for you, for the
environment, and portable convenience food. Use healthy foods for a
simpler life and better health.
Dr. Bookspan and her husband live half of each year in Southeast Asia and have previously lived
in Mexico, eating and drinking local food and water, successfully using these techniques. More on
fermented food and healthy nutrition for home and travel can be found in Dr. Bookspans new
book Healthy Martial Arts (
1. Cunningham R, Dale B, Undy B, Gaunt
N. Proton pump inhibitors as a risk factor for
Clostridium difficile diarrhoea. J Hosp Infect.
2003 Jul;54(3):243-5.
2. Dial S, Delaney JA, Barkun AN, Suissa
S. Use of gastric acid-suppressive agents and
the risk of community-acquired Clostridium
difficile-associated disease. JAMA. 2005 Dec
3. Canani RB, Cirillo P, Roggero P, Romano C,
Malamisura B, Terrin G, Passariello A,
Manguso F, Morelli L, Guarino A. Therapy
with gastric acidity inhibitors increases
the risk of acute gastroenteritis and
community-acquired pneumonia in children.
Pediatrics. 2006 May;117(5):e817-20.)
4. Peek RM. Helicobacter pylori and
Gastroesophageal Reflux Disease. Curr Treat
Options Gastroenterol. 2004 Feb;7(1):59-70.
5. S. Sazawal, G. Hiremath, U. Dhingra, P.
Malik, S. Deb, R. Black. Efficacy of probiotics in
prevention of acute diarrhoea: a meta-analysis of
masked, randomised and placebo-controlled trials.
Lancet Infect Diseases. 2006;6:374-382.
6. Sur D, Bhattacharya SK. Acute diarrhoeal
diseasesan approach to management. J Indian
Med Assoc. 2006 May;104(5):220-3.
7. Yan F, Polk DB. Probiotics as functional food
in the treatment of diarrhea. Curr Opin Clin
Nutr Metab Care. 2006 Nov;9(6):717-21.
8. Chande N, McDonald JW, MacDonald JK.
Interventions for treating collagenous colitis.
Cochrane Database Syst Rev. 2006 Oct 18;(4):
9. Takikawa A, Abe K, Yamamoto M,
Ishimaru S, Yasui M, Okubo Y, Yokoigawa
K. Antimicrobial activity of nutmeg against

Escherichia coli O157. J Biosci Bioeng.

10. Burt SA, Reinders RD. Antibacterial
activity of selected plant essential oils against
Escherichia coli O157:H7. Lett Appl Microbiol.
11. Elgayyar M, Draughon FA, Golden DA,
Mount JR. Antimicrobial activity of essential
oils from plants against selected pathogenic and
saprophytic microorganisms. J Food Prot. 2001
12. De M, Krishna De A, Banerjee AB.
Antimicrobial screening of some Indian spices.
Phytother Res. 1999 Nov;13(7):616-8.
13. Ponce-Macotela M, Rufino-Gonzalez
Y, Gonzalez-Maciel A, Reynoso-Robles R,
Martinez-Gordillo MN. Oregano (Lippia
spp.) kills Giardia intestinalis trophozoites in
vitro: antigiardiasic activity and ultrastructural
damage. Parasitol Res. 2006 May;98(6):557-60.
Epub 2006 Jan 20.
14. Ponce-Macotela M, Navarro-Alegria I,
Martinez-Gordillo MN, Alvarez-Chacon R. In
vitro effect against Giardia of 14 plant extracts.
Rev Invest Clin. 1994 Sep-Oct;46(5):343-7.
15. Soffar SA, Mokhtar GM. Evaluation of the
antiparasitic effect of aqueous garlic (Allium
sativum) extract in hymenolepiasis nana
and giardiasis. J Egypt Soc Parasitol. 1991
16. Giove Nakazawa RA. Traditional medicine
in the treatment of enteroparasitosis.
Rev Gastroenterol Peru. 1996 SepDec;16(3):197-202.
17. Chowhan GS, Joshi KR, Bhatnagar HN,
Khangarot D. Treatment of tapeworm infestation
by coconut (Co-cos-nucifera) preparations.
J Assoc Physicians India. 1985 Mar;33(3):207-9.



+ DISPATCHES Part I The 3rd Congress of the Argentina Society of Mountain Medicine San Juan, Argentina

Mountain Medicine in Argentina

December 2006

The views

from an airplane approaching Santiago and continuing on to Mendoza,

Chile, are spectacular. Flying into Santiago from the north provides a
look at the high Andes from the west. Aconcagua, the highest mountain
in the Western Hemisphere is the pinnacle, but there are many other
peaks above 6000 meters (about 20,00 feet).
The Argentina Society of Mountain Medicine (SAMM) invited me
back to Argentina, in December 2006, to speak at their 3rd Congress of
Mountain Medicine and to help teach the first Basic Mountain Medicine
Diploma Course for Doctors to be given in the Americas. This course is
part of the curriculum that leads to the Diploma in Mountain Medicine
approved by the Medical Commissions of the UIAA (International
Federation of Mountaineering Associations) and ICAR (International
Commission for Mountain Rescue). As a member of the ICAR Medical
Commission, I helped design this course.
After landing in Mendoza, the two-hour drive to San Juan took us
through an arid landscape with little vegetation and ever-more distant
views of the high mountains until we reached the oasis town of San Juan
with its vineyards. Northern Argentina is known for its wine. My friends
from San Juan insist that the wine from San Juan is better than that
from Mendoza, but my friends from Mendoza hold exactly the opposite
opinion. Although I am no expert, both seemed excellent.
The first session concerned chronic intermittent altitude exposure (EICA
from its Spanish name Exposicin Intermittente Crnica a la Altitud).
This theme is very topical in Argentina and in neighboring Chile,
because thousands of people work at high altitude mines but live at or
near sea level. After a welcome by Dr. Carlos Pesce, the chairman of the
Congress, Dr. Daniel Jimenez from Santiago, discussed the advantages
and disadvantages of different schedules and the effects of EICA on
hypertension, diabetes, and obesity. Dr. Jean-Paul Richalet, from Paris,
who has studied EICA extensively in Chile, discussed the physiological
changes associated with intermittent altitude exposure. Dr. Conxita
Leal from Barcelona discussed contraindications to altitude exposure.
The first half of the morning concluded with Dr. Nora Vainstein from
Buenos Aires discussing the approach to cardiac risk factors in workers
undergoing EICA. The general conclusion of these talks was that EICA
can be quite stressful, especially to the cardiovascular system. Many
workers are eliminated during the initial trial period, but the longterm effects on workers who undergo EICA over a period of years is
not known.
The second part of the morning focused on neurological changes at
altitude. Dr. Damian Bailey from Wales discussed molecular effects of



Ken Zafren, MD

Photos by Ken Zafren

altitude on the nervous system, emphasizing his research on oxidative

stress and oxygen free radicals. Dr. Marco Maggiorini from Zurich
talked about the effect of hypoxia on the central nervous system from a
clinical point of view.
Since almost nobody in Argentina would dream of eating dinner before
9 PM, our schedule seemed quite relaxed. The only problem was that of
sleep. In a previous era, everyone took a siesta, but now they still eat late
and get up at what we would consider a normal hour. The first two hours
of the afternoon session were devoted to work in hostile environmental
conditionsaltitude and coldand the effects of solar radiation. This
session included a talk on medical screening for high altitude workers
and a presentation on the effects of EICA and altitude-related illness on
work performance. To a large extent, EICA workers are a self-selected
group. This makes it difficult to do research concerning their fitness;
EICA workers who cannot tolerate this exposure do not continue to
work. At the same time, there is great concern about the long-term
health effects of EICA.
The final session concerned psychosocial health of high altitude workers.
Topics included living standards and quality of life at high altitude
mining camps, recreation for workers at remote sites, effects of EICA
on family life of the workers, and the benefits of physical activities for
EICA workers. The final talk concerned the effects of work rotations on
the quality of life of the workers. The speaker was Dr. Acacia Aguirre, a
Spanish doctor who lives in Boston.
The next day of the Congress began with a session devoted to altitude.
Dr. Bailey spoke first about the pathophysiology of Acute Mountain
Sickness (AMS) and High Altitude Cerebral Edema (HACE). Dr.
Bailey discussed the deleterious effects of oxygen free radicals in hypoxia.
Attempts to use sacrificial antioxidants such as Vitamin C have been
unsuccessful, since these turn out to be quenched by free radicals. Dr.
Bailey suggested a new approach using antioxidant catalysts.

Dr. Maggiorini emphasized the possible

role of brain hypoxia in producing HAPE
and discussed the mechanism by which
PDE-5 inhibitors may act in preventing
and treating HAPE.

Next, Dr. Maggiorini spoke on the subject of High Altitude Pulmonary

Edema (HAPE). Dr. Maggiorini is a member of the group carrying out
research on HAPE using subjects who are known to be susceptible to
HAPE (HAPE-Susceptibles or just HAPE-S). These subjects nevertheless
repeatedly ascend to the Margherita Hut at 4559 meters (about 15,000
feet) on Monte Rosa, in order to be studied. He emphasized the possible
role of brain hypoxia in producing HAPE and discussed the mechanism
by which PDE-5 inhibitors, such as sildenafil and tadalafil, may act in
preventing and treating HAPE. Following these two excellent speakers, I
gave a presentation on conditions at altitude not related to AMS, HACE,
or HAPE, in which I emphasized a host of neurological conditions. Any
neurological condition that occurs at sea level can, of course, also occur at
altitude. Some conditions may be exacerbated or unmasked by hypoxia.
The following session dealt with physical and intellectual performance at
altitude. Dr. Maggiorini discussed acclimatization, Dr. Richalet covered
oxygen enrichment for EICA workers, and Dr. Leal discussed women
at altitude. Although oxygen enrichment may be a great advantage
for EICA workers there are some theoretical disadvantages, including
slowing of acclimatization. The main reason that it is not used, however,
is the perception by the mining companies as too expensive.
The afternoon theme was sleep and fatigue at altitude. Dr. Jorge Lasso
from Santiago, demonstrated the utility of oxygen enrichment during
sleep in EICA workers. This is quite effective in abolishing periodic
breathing, but costs more than acetazolamide, which has similar effects.
There were two talks concerning somnolence and fatigue in drivers and
another talk about the quality of sleep at altitude.
The days final session covered nutrition, oxidative stress, and
antioxidants at altitude. Three of the talks concerned nutrition and
digestive disturbances at altitude. Dr. Bailey gave a fascinating talk about
oxidative stress at altitude. Although we know that too little oxygen is
not a good thing, Dr. Baileys research showed that too much oxygen
in cells can lead to increased generation of oxygen free radicals. This
effect seems quite paradoxical. Dr. Claus Behn from Santiago also gave
a talk on the same subject with a different point of view. He showed
some positive results from antioxidant supplemenation. Dr. Behn is a
great exponent of mountain medicine in Chile. He was the organizer
of the World Congress of Mountain Medicine in 2000 at Arica, Chile.
Most of the Chilean doctors in the mountain medicine course studied
under Dr. Behn and credited him with fostering their interest in
mountain medicine
The following morning was devoted to organization of medical services
in remote areas. As the first speaker of the day, I covered care of critical
patients in remote areas and air medical evacuation. The following talks
were about trauma care and rescue. I was spirited away by the five other
non-South American invited speakers who had arranged a tour of the
area by minivan. This featured a tour of a local winery, with a museum

and a film showing its history followed, of course, by wine tasting. The
next stop was a champagne manufacturing operation located in a cave,
with tasting of the unfinished product, but not the bottled final product.
After this, we went to two lakes formed by dams and then to lunch at I
am not making this up a Howard Johnson Resort, by the shore of the
second lake. Fortunately the food was Argentine style.
The last stop of the day, the Sarmiento house, was by far the most
interesting. Domingo Sarmiento (1811-1888) was a provincial governor
and later the President of Argentina, from 1868-1874, and an educator.
He had a great interest in elementary education, which he championed
in Argentina. There were placards with pithy quotes here and there on
the old furniture which Sarmiento himself had used. He was clearly far
ahead of his time. To paraphrase one of the quotes, he believed that:
the degree of progress of a civilized culture could be judged by the role
of women.
After returning to the hotel, my friend from San Juan, Julio Claudeville,
invited me to dinner at his house. Dr. Claudeville was the medical
director of the Veladero mine, near San Juan when I met him in Arica,
at the 2000 World Congress of Mountain Medicine. Dr. Claudeville
remains very interested in mountain medicine and mountain rescue.
The Veladero mine is located at 3800 meters (12,500 feet) not far from
San Juan. The miners, who live at and around San Juan at 500 meters
(1640 feet) reach the mine by a 6-hour drive on a dirt road through
uninhabited country. Dr. Claudeville has had to learn about EICA and
rescue from necessity. He organized the system of medical care for the
mine and also for the road, where each transport bus carrying miners has
at least one trained first responder and carries medical equipment. There
have been some crashes near San Juan where these buses have been first
on the scene and have rendered aid.
On the drive to his house, Julio told me about a crash involving his two
children, an 11-year-old boy and a 16-year-old girl, which occurred last
winter. The car in which they were riding with another family member
overturned on a mountain road in Chile. The first witness to the accident
was a mining engineer from a nearby mine. He called the mine for aid
and a truck with medical equipment and personnel responded. An
ambulance came and took the three victims to the local hospital. The
first Julio knew about this was when the man called him to say that his
children were injured and in the hospital. He told him that he would
do everything for them that a father would do until Julio could come to
the town in Chile. Until Julio arrived, this man had no idea that Julio
also worked for a mine and that he was a doctor. The children have since
made a full recovery and the son still calls the man from time to time,
remembering his kindness. For me, at least as important as the medicine
in mountain medicine was the chance to make friends from around
the world.
Part II to be continued in the next issue of Wilderness Medicine.
Dr. Zafren is an emergency physician, having practiced emergency medicine in Anchorage,
Alaska since 1994. He is Past-President of the Alaska Chapter of the American College of
Emergency Physicians and served several terms on the WMS Board of Directors. He also hold a
faculty appointment in the Department of Surgery, Division of Emergency Medicine at Stanford
University Medical Center, Stanford, California.



+ From the PAs Desk Cristopher Benner, PA-C, MMSc

Following is a
interview of Kristin
Peterson, a family
practice PA in
Colorado who
works seasonally as
a medical provider
in Antarctica. She
and her husband
also run Katabatic
Consulting, a
company providing
special environment
medical consulting.

Q: What is life like in Antarctica?

A: McMurdo Station is on an island just off the coast of Antarctica

and we share the island with an active volcano, Mt. Erebus. It

looks like a mining town, with heavy equipment and huge fuel
containers and cargo all over the place. But if you look beyond
the town across the sea ice to the continent you can see mountains
and glaciers. At McMurdo we live in dorms and everyone has at
least one roommate. Everyone eats in a huge dining hall. When we
are not working, there is actually much to do. There is a gym for
sports, a weight room, a bouldering cave, a bowling alley and,
of course, three bars. There is a recreation department whose
job is to get folks out to experience Antarctica. It defeats
the purpose of being there if you do not get out cross
- country skiing or hiking. In addition, we all have
multiple non-medical duties. We may do things
like shovel snow, assist with landing cargo flights,
and help keep equipment running.

Q: What medical facilities and equipment

do you have available?
A: At McMurdo Station they have everything they need to treat a

patient there or to stabilize a patient for medevac to Christchurch,

New Zealand, about 2,000 miles to the north. There are two PAs,
two civilian MDs, a military flight surgeon (MD), a physical
therapist, physical therapist assistant, x-ray tech, lab tech, dentist,
flight nurse, and administrative nurse. There is x-ray, ultrasound, a
lab and tele-medicine with the University of Texas Medical Branch.
At field camps, however, the situation can be quite different. At
field camps I am the only medical provider and responsible for
everyones medical needs. I often had oxygen, basic trauma gear,
and plenty of medications, including narcotics and antibiotics. I
may or may not have a cardiac monitor. My medical station is
often a small table in a corner. The most important thing I have
is my brain.

Q: What is it like to practice medicine

in such a remote location?
A: The responsibility is enormous when you are the only medical

provider there. I go through possible scenarios in my head, all the

time. I made sure I knew everyones medical history. I was on call
24 hours a day and needed to be prepared to respond quickly. My
biggest worries were usually the science groups that came to camp
with someone who had a medical waiver. That meant they did not



have to pass the physical but were allowed to come to a very remote
location anyway. Often it was someone with a cardiac history, so we
would meet to discuss physical restrictions and the need to check in
often with me. I always informed them that a medevac flight to our
field camp was minimum of five hours, so the chance of survival due
to a cardiac event decreased significantly.

Q: What was your most challenging medical

experience in Antarctica?
A: My first season at McMurdo Station we had an across-the-

continent medevac. A crew member on a research ship off the

coast on the other side of the continent suffered a stroke. He was
helicoptered off the ship to a field camp where he was stabilized.
From there he was flown to South Pole Station where bad weather
grounded him overnight. The South Pole Station is not a good
environment for a stroke patient because it is at an altitude of 9,300
feet. He was then flown in an LC 130 plane to McMurdo Station
where again bad weather grounded him for another night. I cared
for him that night and he was able to speak and kept asking for
cigarettes! In the morning, he suddenly lost consciousness. We
intubated him and placed him on a ventilator and medevaced him
to New Zealand, where he was pronounced brain dead. The whole
experience brought home to me how life is harsher on the ice.
Definitive care is days, not hours, away. Something you may survive
in the U.S. you may not survive in Antarctica. I always give a
safety lecture at the field camps. I go through a whole scenario
and time line from time of injury to treatment at the field
camp, to the arrival of a medevac flight, to its arrival
at McMurdo. From there the patient may need to
go on to New Zealand. This may take as much as
24 hours, weather depending. I let people mull that
over and hopefully everyone stays safe. Bottom line: you
are more likely to die from trauma or medical problems in
Antarctica than you would in the U.S.

Q: Would you go back?

A: Yes, I plan to return in a few years. My husband, a paramedic, and

I have our own company, Katabatic Consulting, where we provide

special environment
medical consulting.
So for us going to
Antarctica was not a
one-time experience.
It is part of our lives.
We love it.

Cris is a WMS member

and the Director of the
Coalition of Outdoor
Medicine Physician
Assistants (COMPAS).
He can be contacted at
To learn more about
COMPAS visit www.

+ CLIFF NOTES Andrew (Woody) Bursaw, WMS Natl Student Rep.

This is my fourth and
final Cliff Notes article
as the WMS Student
Representative. It has been
a good year and I leave the
position in a time of growth,
both for the Society as a
whole and for the student
groups. I continue to get
weekly emails from students
interested in starting new
WMS Student Interest
Groups on their campuses
and from new student
leaders of established SIGs.
This is very encouraging
as it tells me that the
interest in wilderness medicine is increasing and becoming much
more mainstream than it was a few years ago when I first learned of it.
Keep those emails coming!


At this time I would like to introduce the incoming WMS Student Rep:
Jamie Karambay ( Jamie is currently a 3rdyear medical student at Albany Medical College and has been very active
in the WMS during his medical education. He even helped start up a
new MedWar race near his school. Im sure he will do a great job as your
next rep and couldnt leave the position in more capable hands.
Lastly, I want to make a few announcements.
1) Dr. Paul Auerbachs newest edition of the textbook, Wilderness
Medicine, 5th edition (Mosby) is scheduled to be released
March 23, 2007.
2) Several WMS conferences are still available this year: Snowmass,
CO, Summer Conference (July 2125, 2007), and the International
Conference in Aviemore, Scotland (October 37, 2007). If you are
interested in sharing lodging or travel arrangements, post a message
on the WMS student message boards at
Have a great spring and stay active! Woody

1. Dian Simpkins Service
Award: Given in recognition
of outstanding service to the
function and operation of
the WMS.
2. Research Award: Given
in recognition of outstanding
research pertinent to the field of
wilderness medicine.
3. Education Award: Given
in recognition of outstanding
contributions in education to
students, members, or the public
in the field of
wilderness medicine.

Awards for outstanding contributions to wilderness medicine will be

presented to respective recipients at the Awards Banquet during the
Wilderness Medicine Conference and Annual Meeting, at Snowmass
Colorado, July 21-25, 2007.

4. Warren D. Bowman Associate

Member Award: Given to an
associate member or allied health
professional for outstanding
contributions in support services
for wilderness medicine.

This is a call for nominations for the awards that include: Simpkins
Service Award, Research Award, Education Award, Bowman Associate
Member Award, Founders Award, and the Auerbach Award. The
World Congress (Erb) Award, will be presented at the World Congress
Meeting in Aviemore, Scotland, this October 3-7, 2007.
Specifically, these awards define:

5. Founders Award: Given

in recognition of outstanding
contributions to the principles
and objectives of wilderness
medicine as envisioned by
the founders.

6. Paul S. Auerbach Award: The

Auerbach Award is given to a
physician or PhD recommended
by Dr. Auerbach, the Awards
Committee and/or by past
or present members of the
Board of Directors. It is given
in recognition of sustained
significant clinical or service
contributions to wilderness
medicine, preferably with service
to the Society. The Board of
Directors confirms the selection.
It takes into account integrity,
ingenuity, effort, humility,
selflessness, and serves as a source
of inspiration for others.
7. Blair Erb World Congress
International Award:
Since wilderness knows
no boundaries, the Society
maintains relationships with
individuals and organizations
representing countries, groups,
academic societies, operational
societies, and centers involved in
wilderness medicine. Outstanding
contributions by such individuals
or organizations are eligible for
recognition through this award.

WMS Award nominations should be sent to: Joyce Lancaster, Director, Wilderness Medical Society
810 East 10th Lawrence, Kansas 66044




Wilderness Medicine Conference & Annual Meeting

July 21 - 25, 2007 Snowmass, Colorado

WMS & Affiliated* Conferences 2007-2008





Mar. 1621, 2007

WMS Winter Specialty Meeting on Mountain Medicine CME/FAWM

Park City, UT

Mar. 16-21, 2007

Advanced Wilderness Life Support (by AdventureMed & Univ. of Utah SOM)

Park City, UT

Mar. 21-25, 2007

Wilderness Advanced Life Support/ Expeditionary Medicine (byWilderness Medicine Outfitters)

Denver, CO

Mar. 21-25, 2007

Wilderness Advanced Life Support (Wilderness Medical Associates)

Thunder Bay, Ontario, Canada

Mar. 27-31, 2007

Wilderness Upgrade for Medical Professionals (by WMI-NOLS)

Tucson, AZ

Apr. 18-24, 2007

Wilderness Advanced Life Support (by ICE-SAR Rescue & Wilderness Medical Assc.)

Gufuskalar, Iceland

Dodge City, KS

Apr. 19 (6 wks), 2007 Wilderness First Responder (by Wilderness Medical Outfitters)
May 5-9, 2007

Wilderness Advanced Life Support (by Montana Family Practice & Wilderness Medical Assc.)

Red Lodge, MT

May 9-12, 2007

Advanced Wilderness Life Support (by AdventureMed and U of Utah SOM)

Moab, UT

Jun. 2-10, 2007

Wilderness First Responder (by Wilderness Medicine Outfitters)

Elizabeth, CO

Jun. 7-15, 2007

Wilderness First Responder (by Wilderness Medicine Outfitters)

Elizabeth, CO

July 21-25, 2007

Wilderness Medicine Conference & Annual Meeting

Snowmass, CO

Aug. 2-14, 2007

Wilderness First Responder (by Wilderness Medicine Outfitters)

Elizabeth, CO

Aug. 8-12, 2007

Wilderness Advanced Life Support (by Emergency Preparedness Systems & Wilderness Medical Assc.)

Greenbay, WI

Aug. 27-Sept. 8, 2007

Dolma Valley Trek and Central Tibet Tour (WildernessWise)


Sept. 23-28, 2007

Fly-Fishing CME Adventure (Mountain Medicine Seminars)

Northern California

Sept. 26-28, 2007

Northeast Medicine CME Conference (NY-Presbytarian Dept. of Emergency Medicine/Cornell University)

Ithaca, NY

Oct. 3-7, 2007

World Congress 2007: Mountain and Wilderness Medicine

Aviemore, Scotland

Nov. 1-15, 2007

African Wildlife Safari CME Adventure (Mountain Medicine Seminars) CME/FAWM

Mt Kilimanjaro, Africa

Jan. 20-27, 2008

Cousteau So. Pacific CME Adventure (Mountain Medicine Seminars) CME/FAWM

Fiji Islands Resort

Jan. 27-Feb 8, 2008

Explore Patagonia CME Adventure (Mountain Medicine Seminars) CME/FAWM


April 7-25, 2008

Mt. Everest Base Camp CME Trek Kathmandu (Mountain Medicine Senimars) CME/FAWM

Kathmandu/Khumbu Region/Nepal

For the most recent updates, always be sure to check the Wilderness Medical Society website,
*Organizations that affiliate with the WMS are granted permission to advertise as offering course content that is accepted
for credit by the WMS Academys Registry of Wilderness Medicine Practitioners and Fellowship Program and agree to
allow their names to be listed on the WMS website as an affiliated organization.


For more information regarding the Fellow and Registry Program for the Academy of Wilderness Medicine
visit Want to see your program or conference in our calendar? Affiliate with WMS! Visit the Academy
website For the most recent updates, be sure to check the Wilderness Medical Society

Abstracts are being accepted for the Annual Meeting and Summer
Wilderness Medical Conference (July 21-25, 2007). Abstract presentations
will feature original research covering the spectrum of wilderness
medicine. The opportunity to learn about new approaches, advances
in medical technology, and epidemiologic studies is unique. Abstracts
for oral and poster presentations are invited and are peer-reviewed.
Abstract application forms are available online at under
Research and then Abstract Submission. The deadline for the receipt
of abstracts for the Summer Wilderness Medical Conference and Annual
Meeting is May 15, 2007. All accepted abstracts will be considered for
publication in the Societys journal, Wilderness & Environmental Medicine.





Snowmass, Colorado
July 21-25, 2007


Aviemore, Scotland
October 3-7, 2007



Education, inspiration,
recreation, relaxation,
renewal& community.

A potential of 51 educational credits for FAWM!

You will find all of this and more at the 23rd Annual Meeting

A potential of 39 AMA PRA Category 1 CMEs!

and Summer Conference of the Wilderness Medical Society,

PLUS an additional 17.5 AMA PRA Category 1

CMEs for AWLS certification course!

July 21 25, 2007, in spectacular Snowmass, Colorado.

We invite you

to attend our special 2007 program that surpasses others in education, recreation, and value for your time and money.
With the growing popularity of wilderness activities theres a tremendous need for quality wilderness medicine
educational programs. This years conference meets the challenge of providing new knowledge and basic information
and skills needed for safe wilderness adventures and travels.

Volume 24, No. 2

Summer 2007
Wilderness Medical Society
810 E 10th, PO Box 1897
Lawrence, KS 66044