Recently, the Wilderness Medical Society published the latest edition of Wilderness and Environmental Medicine (Vol. 20, No. 2,). This publication contains two articles, one by Dr. William Forgey, the second by Dr. Thomas Welch et. al., both critical of current wilderness medical training offered for the laypublic. We strongly enourage you to read these postings.
A Message from Aerie’s Director
What should we teach and what should we omit?
At Aerie, we are constantly reviewing and revising our curriculum. This is our ethical and legal responsibility, and for this task we rely on our Medical Director, our Board of Advisors, our instructors, current industry standards, and, to a large extent, our students. We watch our students, paying attention to what they learn, how they learn, and what they retain. In this way, our students give us constant feedback on the efficacy of our instruction. This feedback educates our curriculum decision-making and encourages us to distinguish what we can teach from what we should teach. Our instructors are experienced enough and the wilderness medicine industry is sufficiently unregulated that we can teach many advanced skills that we chose to exclude from our introductory courses. Instead, Aerie classes are defined by our emphasis on decision-making and patient assessment, which we most effectively convey through challenging and in-depth, intense scenarios.
In both the medical and outdoor fields, judgment, gained from experience, is the most valuable and difficult skill to either learn or teach. Sound judgment is nearly impossible to package into a cohesive “teaching unit,” and it is difficult to market. The latter point is important to state, because as Aerie’s Director, I am sometimes tempted to make our classes appear as if they will teach everything a perspective student wants and needs to know, providing them skills that look good on paper or in pictures. In my opinion, the wilderness medicine industry falls prey to these temptations too often, giving students the impression that any particular physical skill set, usually the one being offered, will set their students apart in the field and provide the life-saving intervention that their patients might require. As a result, wilderness medicine is often defined by what we do, construct, or administer, rather than by the more crucial skills involved in critical thinking and decision-making. Examples of this include the teaching of certain medication administrations and instruction in advanced skills in introductory courses.
As a critical care paramedic, paramedic instructor and ambulance preceptor, I regularly observe the complications and potential dangers inherent in teaching advanced skill sets to people with little patient-care experience. Often, priorities are lost or at least confused under the stress of a true emergency. For example, after over 1,000 hours of instruction and two years of training, paramedic students will often reach for a medication to administer before fully assessing their patient; they start an IV before checking for a pulse. In large part they do this because they have more trust in doing than in observing. These mistakes are not isolated events but are instead the norm, a part of the learning process. Fortunately, in an urban setting, preceptors are able to step in and redirect. However, by definition, wilderness environments usually preclude such intervention. Aerie students take our classes precisely because they venture into areas where such recourse is not available. It is a wilderness medicine educator’s responsibility to understand this dynamic and provide training that not only increases our students’ potential to help but also minimizes their potential to harm. This issue has significant legal as well as educational implications. For example, the Montana Board of Medical Examiners recently published a Position Paper on wilderness medicine in Montana, warning EMTs that acting outside of current state EMT protocol (which most of these advanced techniques clearly do) is not permitted under state law and may subject the EMT to reproach. We have always taught exactly this at Aerie. While state protocols may not have been written with wilderness care as a consideration, acting outside of the protocols has inherent risk and should only be considered in an educated manner. The more we teach our students that strays from standard protocol, the more risk they may face. Personally, I believe it is extremely difficult for a newly trained student to balance the legal and medical risks and benefits of many of these advanced procedures and that, as educators, we need to understand this challenge and adjust our curricula appropriately.
In addition, I believe that, particularly in the absence of experience, the more physical skills you have at your disposal, the more appealing these skills become and the more likely is their misapplication. This is far more likely when we teach fairly advanced skills to students in 16 or 80-hour classes, or even in a longer Wilderness EMT courses. It is not a matter of whether an individual is capable of learning and performing the skills; my nine year-old daughter is capable of performing almost any advanced physical skill taught in these classes. However, she has yet to develop the judgment necessary to decide when to apply the skills appropriately.
There is little doubt in my mind that certain levels of wilderness medicine training should instruct students in relatively advanced techniques, including medication administration and certain orthopedic procedures such as dislocation reductions. However, these procedures are fairly few and do not define the tenor of Aerie classes. We do not, for example, believe that EMT students, most of whom initially struggle remembering to observe a scene for hazards or clear an airway, should confound their understanding of appropriate medical care with IV insertion, urinary catheter placement or wound suturing.
Although it may be tempting to move in other directions, our collective outdoor, medical and teaching experience always reminds us to focus on priorities, and in wilderness medicine these are the less-than-sexy goals of situational awareness, prevention and patient assessment, all of which form the basis for good decision making. While we teach in some of the most beautiful settings in the world, this is truly what makes an Aerie class unique. Through interactive discussions and challenging scenarios, we try to impart our experience to our students, enabling them to make sound judgments in the most difficult circumstances. Medicine itself is a difficult enough subject to teach and learn. Add to this the complexities inherent in providing care in extended, challenging environments, and there is, in my opinion, no question that wilderness medicine classes need to promote sound decision making, which is infinitely adaptable, over any particular physical skill sets, which are inherently limited, largely impractical, potentially harmful and often distracting to the tasks at hand.
David McEvoy, MS, Critical Care Paramedic
March 1, 2008