Wilderness First Aid and Sports Medicine

To the Editor:

An editorial in Wilderness and Environmental Medicine, volume 20, by Past President of the Wilderness Medical Society, William Forgey, MD, ¹ stated that “it is time for the wilderness medical community to bring together experts to design a standard wilderness first aid curriculum [of] appropriate pre-hospital care training.” Since sports medicine is one of the only other specialties functioning out of the traditional office–hospital infrastructure, it would be more than appropriate to include input from and disseminate input to this subspecialty.

As observed by Welch, Clement, and Berman ² regarding wilderness guides and outfitters in a previous edition of this publication, there is no uniform industry standard of prehospital care certification for sports medicine physicians. Requirements for a “team physician” include having an unrestricted license to practice medicine with MD or DO credentials in good standing, possessing a fundamental knowledge of emergency care regarding sporting events and training in cardiopulmonary resuscitation, and having a working knowledge of trauma, musculoskeletal injuries, and medical conditions affecting the athlete. ³ Completing a sports medicine fellowship and having training in advanced cardiac life support are listed among “desirable” qualifications. The requirements for team physicians were published under the aegis of the American College of Sports Medicine and were subsequently endorsed by the American Academy of Orthopaedic Surgeons, as well as numerous other affiliated medical societies. ⁴

Otherwise, no national standard of care applies to health care providers covering athletic events, ⁵ be they stadium events within range of urban hospital facilities or remote sporting competitions hours away. Popular sports straddling the realms of Sports and Wilderness Medicine include adventure racing, surfing, skiing, and snowboarding competitions. Outdoor Emergency Care, ⁹ having been developed by both Wilderness Medical Society Past President Warren Bowman and Orthopedic Surgeon David Johe, while sharing endorsement from the National Ski Patrol and American Academy of Orthopedic Surgeons, seems an obvious “industry standard” curriculum for covering these crossover events. Advanced Wilderness Life Support, with its current endorsement by the Wilderness Medical Society and after personal recent completion of its course, seems another desirable choice.

The American College of Sports Medicine Sideline Preparedness Consensus Statement calls for an event physician to have organized all transport and Emergency Medical Services (EMS) for the event. ⁴ Does it still apply even if the ambulance fails to arrive, refuses to stay at the location, or gets called away on another emergency? Of course, when guidelines such as these are delineated within a specialty such as Sports Medicine, individuals who specialize may be held to an even higher standard of care than others in their profession because they are bound by the consensus statements of their recognized specialty. ⁵ Consensus statements have been upheld in ruling medical tort cases with legal precedent set by Knapp vs Northwestern. ⁶

Primary care sports medicine specialists volunteering and functioning as outdoor event physicians would benefit at least from awareness of wilderness first responder skills and outdoor emergency care skills, especially when their coverage extends beyond the immediate guaranteed presence of EMS personnel. It does not necessarily imply that any wilderness first responder certification will ever be mandated for “team physicians” but it merits attention from both Wilderness and Sports Medicine specialties. Wilderness and Sports Medicine will never be mutually exclusive in this regard, as a fundamental aspect of wilderness medicine is care of the athlete in remote areas. ⁷ In turn, care of the athlete in the field, in both urban and nonurban settings, is a fundamental aspect of sports medicine. It may have been stated best when the author of Outdoor Emergency Care (Bowman) described, in a separate article, the physician as a caregiver in areas not having immediate access of hospital facilities or EMS. It has striking applicability to any sporting event lacking EMS presence for one reason or another:

“The physician must be able to slip into a unique although temporary mindset that takes into account the difference between the resources available in the field and those he or she is accustomed to having available in a modern medical center. The usual practice aids such as laboratory or radiographic studies will be absent. The physician will have to rely on his/her 5 senses and good reasoning ability plus a few simple tools such as a stethoscope, thermometer, and flashlight in order to reach important decisions based on: 1) What is wrong? 2) How serious is it? 3) Can it be treated in the field, or is evacuation to definitive medical care necessary?” ⁸