The Doctor is Out: Teaching Wilderness Medicine at Georgetown

When they first dissect a frog, or maybe first peer through a microscope, many doctors- to-be begin to dream about a career in medicine, long before they ever apply to medical school. Not Matt Wilson. “I wanted to be a park ranger,” he says with a touch of nostalgic good humor.

As a young boy growing up in Virginia, Wilson participated in myriad outdoors clubs and wilderness leadership activities. As an adult, his career plans evolved and he decided on a career in medicine, attending medical school at the University of Virginia. But he never forgot his first love—the outdoors. Remarkably, he has found a unique way to pursue both passions simultaneously, teaching the wilderness medicine course offered since 2013 at Georgetown School of Medicine.

During the two-week elective, Wilson complements daily lectures with regional outdoor recreational activities run by local professionals. For example, the altitude and climbing emergency lectures are coupled with a trip to the climbing gym, where students participate in supervised climbing with exposure to mountain rescue techniques. The marine and whitewater lectures are followed by a trip to the river rescue station in Cabin John, Maryland and an optional kayaking excursion with a local boat outfitter.

Extreme outdoor recreation is more popular than ever. More than 40 million tourists visit recreation areas above 7500 feet in the American West each year. Hundreds of thousands participate in adventure travel in central and south Asia, Africa, and South America, many traveling to altitudes above 13,000 feet. Most of these activities are enjoyed without injury, but when someone does get hurt, they are a significant distance away from a hospital or clinic.

Wilderness medicine, also known as “austere medicine,” is about caring for people in a resource-limited environment. That may be the wilderness, but the term may also apply to disaster relief, terrorist incidents, or international medical missions. Wilson’s course is accessible to fourth-year students, as they have nearly completed medical school and have largely acquired the skills needed to provide most kinds of care in a typical hospital setting.

“They know how to use state-of-threat treatments and diagnostic tools. Now it’s time to step out of the box,” Wilson says. “We try to get the students to think in a different way. What do you do when the situation is less than ideal? There are things that happen every day in medicine that defy textbook answers.”

“The students learn what is important to do and in what order,” Wilson notes, applying what they already know but in new conditions.

In a wilderness or austere scenario, the challenge is not only diagnosing and treating a problem, but often finding a way to get the victim to a clinical setting in time to prevent further damage or death. A high-angle rescue, for example, requires skills common to mountaineering, not medicine. And in many cases, rapid and safe evacuation is more effective than treatment in the field.

Some of Wilson’s students want to go into emergency medicine (he himself is a board certified emergency medicine physician at MedStar Washington Hospital Center), others envision themselves participating in disaster relief or medical mission activities at some point in their careers, and still others just enjoy outdoor sports and see these skills as a natural complement to pursuing them.

Students complete the course with a capstone group exercise that involves the simulation of various injuries in a wilderness setting. Occasionally the activity brings unplanned excitement, such as when the student acting out a twisted ankle encountered a sizable but non-venomous snake.

In the past three years, the course has been offered in warmer months, so activities have included hiking, rock climbing, and canoeing, with simulated heat stroke and drowning. This year the course will be offered in winter, and will include skiing with simulated fractures, frostbite, and hypothermia.

Some of the students come to the class with great confidence, having participated in outdoor activities most of their lives. Wilson says that they quickly learn how the stress of an injury coupled with the remote setting creates a significant challenge. They may not realize, for example, how quickly cardiac arrest following a lightning strike can be reversed in the field with CPR. And they may hold to the same myths that many do: that the victim remains electrified after the strike and cannot be touched. This is not true and delaying resuscitation in order to triage less severely injured victims can rapidly diminish the chances of successful resuscitation.

Techniques also change over time. The best course of action for a poisonous snake bite, for example, is now to evacuate the victim to a place where anti-venom can be administered as soon as possible—not to cut or otherwise compromise the wound in an attempt to extract the poison. Wild animal attacks, fortunately, are rare and are best prevented in the first place by not engaging a defensive action from an animal, to the extent possible.

Indeed, the most effective strategies focus on prevention: packing a good emergency kit, watching for signs of dehydration, postponing outdoor activities when a thunderstorm is forecast. But enjoying the great outdoors brings a certain amount of risk with it, though probably not, as Wilson points out, “as much as driving on the Beltway.”

In the true Georgetown spirit of women and men for others, Wilson also offers his skills to the National Park Service as operational medical director of the National Capital Region, at the recommendation of Bill Rogers, MD, who preceded him in the position for many years. The area covers Harper’s Ferry in West Virginia to Prince William Forest in Virginia, and everything in between including Rock Creek Park and the National Mall. This means that every year on the Fourth of July, he is downtown coordinating a team to provide care for a million people who gather on the Mall to celebrate and view the fireworks. Known as “mass gathering medicine,” the volunteer crew is prepared to address everything from a drug overdose to a terrorist incident. Wilson and several Georgetown residents help implement National Park Service protocols, working with representatives from the Park Police and a variety of state and federal agencies.

Hours before the Independence Day parade along Constitution Avenue begins, Wilson stands calmly between a red truck labeled “Mass Casualty Unit” and a big white school bus labeled “Medical Ambulance.” Noting the thorough security sweep beginning the previous night and the carefully planned emergency response staging, he shrugs. “It’s really the safest day of the year to be down on the Mall.”

A fleet of air conditioned Metro buses stands by to ameliorate the most common ailment for parade viewers and marching bands: heat stroke. To Wilson, it’s a reminder that “You don’t have to be all that far from a hospital to be in an unusual setting requiring the care of many people at one time.”

Wilson and the multiple medical teams are standing by, ready to assist as the crowds gather to celebrate freedom. And on this day, fulfilling a boyhood aspiration, he takes his place alongside the park rangers.

By Patti North