Call of the wild: creating a formal wilderness medicine elective for Canadian pre-clerkship medical students.

Wilderness medicine education is interesting to medical students, yet not widely implemented in Canadian medical curricula. We describe a curriculum for a pre-clerkship wilderness medicine elective at a Canadian medical school. Our study reports increased student awareness of career opportunities in wilderness medicine after elective completion, and interest in hands-on learning for wilderness medicine topics. Medical schools may benefit from incorporating feedback from our elective towards a successful wilderness medicine curriculum in their own programs.

La médecine en milieu sauvage est un domaine que les étudiants trouvent intéressant, mais dont l'enseignement est peu répandu dans les programmes d'études médicales au Canada. Nous décrivons le contenu d'un stage au choix de médecine en milieu sauvage offert au pré-externat dans une faculté de médecine canadienne. Notre étude montre qu'à la suite du stage, les étudiants sont mieux informés des possibilités de carrière en médecine en milieu sauvage et qu'ils manifestent un intérêt pour l'apprentissage pratique dans ce domaine médical. Les commentaires recueillis sur notre stage peuvent être utiles à d'autres facultés souhaitant introduire une formation en médecine en milieu sauvage dans leur programme.

Resident Wilderness Medicine Curriculum Consensus Guidelines: Summarization and Recommendations for Resident Rotations in Wilderness Medicine.

INTRODUCTION: Wilderness medicine education is one of the fastest growing facets of both graduate and undergraduate medical education. Currently, there are curriculum guidelines for both student electives and fellowships in wilderness medicine. However, there are no guidelines for resident elective curricula. The student/resident education committee of the Wilderness Medical Society (WMS) convened a task force to develop curriculum guidelines for these electives. METHODS: A survey of previously described core wilderness medicine topics was sent to a cohort of educators involved in wilderness medicine resident electives. They were asked to rank topics on the basis of their importance of being included on a Likert scale. Multivariate analysis of medians was used to distinguish among topics to determine which topics were voted most and least necessary for a curriculum. RESULTS: Of the database members contacted, 35 responded to the survey. The described current state of residency electives was that 16 institutions offered their own elective (46%). For subject preferences, multivariate analysis of scoring distribution medians demonstrated a significantly higher pattern of responses (P<0.01) for subjects with a median of 3 (must include) than for the lowest-scoring subjects that had a median of 1 (can include). Every topic was rated "must" by at least 1 respondent. Topics were further subdivided into an educational framework reflecting a common approach to education of wilderness medicine fellows focusing on education, leadership, knowledge, and skills. CONCLUSIONS: There was a wide variety in the ranking of topics; however, there were multiple topics on which a consensus for inclusion was reached. These topics are organized and presented here as a suggested curriculum by the student/resident education committee of the WMS.

Wilderness Medicine Curricula in United States EMS Fellowship, Emergency Medicine Residency, and Wilderness Medicine Programs.

OBJECTIVE: Wilderness Medicine (WM) focuses on care delivered in austere or resource-scarce environments. The Accreditation Council for Graduate Medical Education (ACGME) requirements and core content for Emergency Medicine (EM) residency and Emergency Medical Services (EMS) fellowship in the United States (US) include some WM topics that are covered to varying degrees in these programs. Furthermore, there are no ACGME-approved WM fellowships or specific curricula. Different training programs may develop WM content and curricula that differ significantly, leading to variations in WM competencies and training. In 2009, the American College of Emergency Physicians (ACEP) Wilderness Medicine Section created a Fellowship Subcommittee and Taskforce to develop a standardized curriculum and core content for EM-based WM fellowships. However, to date, EMS fellowship and EM residency WM curricula in the US content have not been analyzed for consistency with the ACEP WM fellowship curriculum. METHODS: In this study, the WM curricula components of EM residency and EMS fellowship were evaluated using the ACEP WM fellowship curriculum as a control. Potential curriculum gaps for each program type were identified. RESULTS: Of the 19 WM competencies developed by the ACEP Wilderness Medicine Section Fellowship Subcommittee and Taskforce, EMS fellowship covers more WM topics (16 topics, or 84%) than EM residency (12 topics, or 63%), and combined, they cover 89% of these topics. CONCLUSIONS: By expanding to cover two additional WM topics, all WM curricula topics recommended by the ACEP WM fellowship curriculum could potentially be covered in EM residency + EMS fellowship; however, the depth of education in each topic may vary. It may be beneficial for Graduate Medical Education (GME)-level learners for programs to implement hands-on educational experiences in WM topics.

A National Survey of Wilderness Medicine Curricula in United States Emergency Medicine Residencies.

INTRODUCTION: Wilderness medicine (WM) is a growing subspecialty of emergency medicine. In 2018, we surveyed all 240 emergency medicine residencies in the United States to assess the scope of WM education in emergency medicine training programs in light of the nearly 30% increase in the number of residencies since 2015. METHODS: A survey was e-mailed to the Council of Residency Directors in Emergency Medicine listserv and individual program directors of each of the 240 residencies. The survey included questions on educational content, format, number of hours taught, availability of conference credit, offering of an elective or fellowship, and several predefined WM curricula. We evaluated differences between 3-y and 4-y residencies using the χ2 test, where P<0.05 was considered significant. RESULTS: We had a response rate of 57% for completed surveys. Analysis showed 63% of respondent programs teach WM material. The majority (86%) partially or completely developed their curriculum, with 33% offering at least 1 of the predefined curricula. Thirteen percent taught with lecture only, 2% taught by hands-on only, and 85% used a combination of the 2. WM electives were significantly more likely to be offered by 4-y than 3-y residencies (P=0.009). CONCLUSIONS: Almost two-thirds of respondent residency programs teach WM material. Of these, only one-third teach any of the predefined curricula. Four-year residencies are more likely to offer WM electives but are otherwise comparable to 3-y programs.

Is it Time for Wilderness Medicine Fellowships to Join the National Resident Matching Program Specialties Matching Service?

INTRODUCTION: The national resident matching program specialties matching service (SMS) fills fellowship positions for 66 subspecialties. Wilderness medicine (WM) fellowships currently do not participate in SMS; instead, WM uses an offer date to fill positions. To be successful, at least 75% of the available positions within a subspecialty must be within the SMS match. METHODS: All 13 civilian WM fellowship directors recruiting for academic year (AY) 2019 to 2020 and WM fellowship alumni were surveyed regarding future participation in the SMS. Estimation of the performance of SMS for WM was calculated using data published by the national resident matching program. RESULTS: Fellowship directors from all 13 civilian WM fellowships and 60 fellowship alumni participated in the survey. SMS was supported by 62% (n=8) of fellowship directors and 55% (n=33) of fellows. Willingness to pay SMS fees was 54% (n=7) among fellowship directors and 60% (n=36) among fellows. Of matched applicants, 85% (n=51) obtained their top choice program. SMS, if implemented, was perceived to have no impact on matching a top choice program by 53% (n=31); however, 34% (n=20) believed SMS would improve the chance of an applicant matching higher. The match success of SMS for specialties with fewer than 30 programs is 74%. Of the 20 WM fellowship positions in AY 2019 to 2020, 16 were matched, for a success rate of 80%. CONCLUSIONS: There is insufficient support (<75%) at this time to institute an SMS match for WM. The offer date performed similarly to SMS for filling fellowship positions in AY 2019 to 2020.

Wilderness Medicine Simulation-Based Teaching Program for Medical Students in the UK.

INTRODUCTION: The UK undergraduate medicine curriculum provides insufficient opportunities for medical students to explore the field of wilderness medicine, despite interest in the area. The student-led Cambridge University Wilderness Medicine Society devised a low-cost wilderness medicine teaching weekend that can be replicated at other institutions. METHODS: The weekend course consisted of small-group lessons introducing the roles of the expedition doctor and expedition leader and the assessment and management of acute conditions in remote environments. This was followed by a 3-station circuit to teach the principles of casualty triage, splinting, and construction of rope stretchers. These skills were then practiced in simulations in which participants rotated roles as care providers and patients. Participant confidence was compared before the course and immediately on course completion using the related-samples Wilcoxon signed-ranks test with significance accepted at P<0.05. Usefulness of course content and perceptions of learning were also assessed. RESULTS: Sixty-one medical students attended the wilderness teaching weekend and completed the structured feedback questionnaires. Participants rated the course highly in terms of usefulness of course content (mean±SD=18.3±1.9, range=12-20) and perceptions of learning (mean±SD=37.6±2.6, range=31-40), with 92% of participants "strongly agreeing" that the course was of high quality. There was an improvement in perceived confidence after course completion (P<0.001). CONCLUSIONS: We have demonstrated that a teaching program consisting of structured, low-cost "teaching weekends" is a potential solution to the lack of centralized national wilderness medicine teaching and can be integrated, with minimal disruption, into the undergraduate curriculum.

Medicine in Extreme Environments: A New Medical Student Elective Class for Wilderness, Aerospace, Hyperbaric, Exercise, and Combat Medicine.

We developed an elective course titled Medicine in Extreme Environments (MEE) at the University of Texas Southwestern Medical Center for first- and second-year medical students. This course covered physiology, research, clinical practice, and career guidance regarding the fields of wilderness, space, hyperbaric, combat, and exercise medicine. The primary aim was to generate interest in and awareness of these seldom covered fields of medicine by exposing medical students to these disciplines during their preclinical years. A postcourse questionnaire was implemented to investigate whether the MEE course increased awareness of, interest in, and knowledge in the fields of medicine included in the curriculum. Through 2 iterations of the class, a total of 67 students enrolled in the course, and 38 students completed the questionnaire. After course completion, 95% felt they better understood the work and lifestyle of the fields covered, 100% learned more about concepts of each field, and 74% agreed that the elective influenced the direction of their future careers to include some part of the fields emphasized. Although only a limited number of students enrolled in this course, these initial findings suggest that the MEE curriculum may have some utility in promoting awareness of and interest in these medical disciplines among students who attend the course. With continued student and faculty support, this course will likely be continued annually at our institution. We believe that certain aspects of this course may be useful in helping develop similar courses at other medical schools.

Wilderness Medicine (Hypothermia, Dehydration, and Ankle Injury): A Pediatric Simulation Case for Medical Trainees.

Introduction: Wilderness recreation is increasingly popular among people of all ages. Pediatric providers should have the skills to counsel on risk reduction and respond to medical emergencies in remote settings. However, few physicians receive training in wilderness medicine, and this simulation-based curriculum aims to address that gap. Methods: The scenario features an adolescent male in a remote setting with hypothermia, dehydration, and an ankle injury. The simulation is not resource intensive, utilizing a simulated patient actor and minimal equipment. The case includes a case description, learning objectives, instructor notes, example of ideal scenario flow, and anticipated management mistakes. A didactic PowerPoint highlighting the learning objectives is included. Results: The simulation was carried out over 1 year in various settings, including urban parks, the wilderness, and the classroom, with 35 medical trainees. Thirty participants (11 medical students, eight residents, and 11 fellows) completed postsimulation surveys; more than 86% gave the highest score of 5 (strongly agree) when asked if the simulation improved their understanding of managing hypothermia, dehydration, and ankle injury in the wilderness. Discussion: This simulation case trains responders to recognize an injured hiker; activate the emergency response system; initiate appropriate treatment for hypothermia, dehydration, and an ankle injury; and stabilize for transport. It reinforces medical conditions unique to the wilderness, improvisation in managing medical issues outside of the usual health care environment, and teamwork/communication skills. This case has been found to be an effective learning tool for medical students, residents, and fellow physicians alike.

Implementing Wilderness Medicine Training for Undergraduate Medical Students in the UK.

The UK General Medical Councils' approved curricula share only 3 topics with the Fellowship in the Academy of Wilderness Medicine core curriculum, suggesting an underrepresentation of wilderness medicine (WM) in medical education. We developed a 5-mo course to address the gaps between these curricula to run in parallel with the conventional curriculum. Our 71-h course is composed of lectures and practical exercises. We set out to evaluate the effectiveness of this concept and assess its suitability for use by other institutions. The course was undertaken by 18 medicine and healthcare undergraduates. Semiquantitative evaluation of the course was done using participants' self-reported WM knowledge and interest before and after the course using a Likert scale. Participants were further assessed with a WM objective structured clinical examination. Before the course, students had a lower understanding of WM (2.8/5.0) and were not confident in prehospital medicine (2.5/5.0). After the course, knowledge and confidence increased in all teaching categories, with a mean gain of 1.4/5.0 (P<0.05). Students demonstrated competence in a range of WM categories by completing the WM objective structured clinical examination, with a pass rate of 82%. Providing students with a WM course is effective in introducing components of the Fellowship in the Academy of Wilderness Medicine curriculum and inspiring future engagement in the field. We have developed a framework for successful implementation of WM teaching and shown that the concept may be used in other undergraduate settings.

Swiss Mountain Guides: Medical Education, Knowledge, and Practice.

Background: Mountain guides work daily in remote areas and high-altitude locations where specific hypoxia-related and common medical problems may occur. Arrival of rescue teams can be delayed, so mountain guides often have to rely on their own capabilities to provide first aid. Therefore, IFMGA-recognized Swiss mountain guides receive a specific medical education and are equipped with a dedicated medical kit. This specific education has never been evaluated. Methods: A questionnaire was sent to all Swiss mountain guides through their national association. This questionnaire evaluates guides' activity, type, and frequency of medical events encountered, medical education, and use of the medical kit. Furthermore, clinical vignettes were used to evaluate their subjective and objective knowledge about prevention and treatment of specific altitude-related diseases. Results: A total of 467 guides completed the questionnaire, 54 (11.6%) of them were identified as high-altitude guides (HA-guides), because they spent ≥10 nights above 4000 meters each year. Mountain guides are more exposed to altitude-specific pathologies, such as Acute Mountain Sickness (AMS), High-Altitude Pulmonary Edema (HAPE), and High-Altitude Cerebral Edema (HACE) than to general medical conditions. A majority of participants (in particular HA-guides) considered altitude-related medical knowledge essential but judged their own education as insufficient. A majority of mountain guides were aware of nonpharmacological preventive measures and able to recognize altitude-related diseases. Mountain guides declared themselves as very confident in treating altitude-related diseases. Objective assessment of their knowledge showed some gaps, in particular related to the use of specific medications like nifedipine and dexamethasone. Conclusions: Swiss mountain guides' education in altitude medicine may be improved, in particular concerning the recognition and treatment of severe conditions such as HAPE and HACE. Better knowledge may be especially important for HA-guides. These data have induced experts in the field to adapt the guides teaching curriculum and medical kit.

Integrating Prolonged Field Care Into Rough Terrain and Mountain Warfare Training: The Mountain Critical Care Course.

Current prolonged field care (PFC) training routinely occurs in simulated physical locations that force providers to continue care until evacuation to definitive care, as based on the staged Ruck-Truck-House-Plane model. As PFC-capable teams move further forward into austere environments in support of the fight, they are in physical locations that do not fit this staged model and may require teams to execute their own casualty evacuation through rough terrain. The physical constraints that come specifically with austere, mountainous terrain can challenge PFC providers to initiate resuscitative interventions and challenge their ability to sustain these interventions during lengthy, dismounted movement over unimproved terrain. In this brief report, we describe our experience with a novel training course designed for PFC-capable medical teams to integrate their level of advanced resuscitative care within a mountainous, rough terrain evacuation-training program. Our goals were to identify training gaps for Special Operations Forces medical units tasked to operate in a cold-weather, mountain environment with limited evacuation resources and the challenges related to maintaining PFC interventions during dismounted casualty movement.

Low-Resource Tactical Combat Casualty Care Training for Peshmerga Units in Remote Areas of Kurdistan.

The Peshmerga are the official military of the autonomous region of Kurdistan, Iraq. There remains a high level of variability across Peshmerga units in medical equipment and training. Presumably, Peshmerga soldiers are dying from preventable causes of death due to combat-related injuries, just as US troops did before the introduction of Tactical Combat Casualty Care (TCCC) training and supplies. This report outlines the efforts of a small US-based collective to provide TCCC training at the TCCC for all combatants skill level to Peshmerga forces and develop members of the Peshmerga as trainers.

From the Mountain Top to the Sea Bottom: Training and Preparing for Wilderness, Environmental Medical Events William Binder, MD, MA, FACEP.

[Full article available at http://rimed.org/rimedicaljournal-2019-02.asp].

Learning from the Outside In: Incorporating Wilderness Medicine into Traditional Emergency Medicine Education.

[Full article available at http://rimed.org/rimedicaljournal-2019-02.asp].