Clinical practice may be divided into two types of cases: those that are common, with providers getting lots of practice managing them; and those that are rare. We may practice the skills time and time again but might never even see one case in our lifetimes. Many of the topics in this issue of Wilderness & Environmental Medicine examine those cases which we may never see. For example, two articles (one case report and review article) examine field cricothyrotomy and its life-saving implications to critical patients; the airway maneuvers and actions of the providers likely saved the victim's life. Although we may never be presented the opportunity to perform this procedure in the outdoors, it is of practical and academic interest to learn about these rare cases and procedures, practice, and learn from others who have managed such patients.
Another rare case is described in a Letter to the Editor entitled “Pituitary apoplexy masquerading as acute mountain sickness.” One of the mantras of treating patients at high altitude is, “if someone is sick at altitude, the diagnosis is altitude-related until proven otherwise.” This case makes us reconsider this saying. While we teach laypeople to assume that altitude is the culprit of mountain sicknesses, seasoned clinicians must integrate all available information while being challenged with the task of diagnosing rare problems in the mountain environment.
That being said, there are many different approaches to treating wilderness medical problems. Dr. Jones relays the management approaches to high altitude pulmonary edema (HAPE) at the Himalayan Rescue Association (HRA) in Pheriche, one of the most well known high altitude clinics in the world. Clinicians at the HRA come from all over the world and have various backgrounds and training, and their management approaches to HAPE patients vary quite a bit as well. Articles such as this make us pause and ask what is truly best practice. Many times it is not known, as evidence for practice is not always plentiful for the mountain and wilderness environment.
Although the places that we practice medicine are wild, the care that we provide should not be. The Wilderness Medical Society's series of practice guidelines is an attempt to standardize the many different approaches to treating wilderness maladies. The WMS has published guidelines on anaphylaxis, high altitude medicine, frostbite, lightning, and eye injuries, with others soon to follow. We call on WMS members and readers to pursue research into those wilderness problems for which we have little data in order to develop more evidence-based wilderness medicine practices and to provide the evidence and research we need to provide the best care possible in the most austere environments.