Facts All Come with Points of View

They conceive a certain theory, and everything has to fit into that theory. If one little fact will not fit it, they throw it aside. But it is always the facts that will not fit in that are significant. ¹

Medical orthodoxy has always played a stubborn role in clinical medicine. The history of medicine is dominated by practices based on folklore, and therapeutic interventions were rife with placebos, snake oils, and purgative bleeding. Prior to the advent of antimicrobials, the standard of care for cellulitis in the early 1900s was treatment with ultraviolet lamp therapy as well as Horlick's malted milk, arrowroot, and junket, as well as a hot, liquid paraffin soap and water enema. ² The origins of disease were equally opaque. Hippocrates believed that malaria was due to dangerous fumes emanating from the ground and carried by the wind and mist. ³ It was not until over 2000 years later that Alphonse Laveran discovered the malarial parasite and Ross documented its mode of transmission. ⁴ It is little wonder that Voltaire, the Enlightenment's most prolific writer and philosopher, noted that “the art of medicine consists of amusing the patient while nature cures the disease.” ⁴

Lessons from history have implications for wilderness and austere medicine. While our field is as old as human history, we are a young subspecialty. Many of our practices continue to be refined as more data is collected and the science underlying a disorder is elucidated. Treatment for altitude illness, for instance, has been transformed over the past 150 years. Medications based on the relatively recent understanding of AMS's pathophysiology have replaced the use of coca leaves, a venerated practice in the Andes for thousands of years. ⁵

In this issue of Wilderness & Environmental Medicine (WEM), Gharraei et al describe another example of a paradigm shift in the care of frostbite. ⁶ As Gharraei notes, after observing thousands of cases of frostbite, Baron Dominque-Jean Larrey, Napoleon's surgeon general, described the deleterious effects of using a fire to warm a frozen part. ⁶ Larrey suggested that the frozen part should be rubbed vigorously with a low-heat substance (snow) and plunged into cold water. While modern observers obviously find this counterintuitive, Larrey's approach was the standard of care for over 100 years. Despite observations by several physicians on polar explorations in the 1910s, the US military supported this approach through World War I and into the early 1940s. ⁷

Gharraei recounts the contribution of William Mills, an orthopedic surgeon from Alaska, who helped alter and modernize the treatment of frostbite. Mills, who became one of the leading authorities on cold injury, built upon the work of Meryman in the 1950s and published a number of papers in the early 1960s describing treatment protocols for frozen tissue. Sixty years later, his recommended management is remarkably similar to the current Wilderness Medical Society (WMS) guidelines.

It is exciting, then, to consider the next phase of research in wilderness and austere medicine and how it may change present-day practice. In the current electronic version of WEM, several abstracts presented at the summer WMS meeting take small steps in refining our current practice. These small studies may help advance guidelines and close the gaps between evidence and clinical medicine. Hartridge et al designed a pilot study examining nebulized epoprostenol as an alternative to intravenous iloprost in the treatment of cold injury. ⁸ While only an initial investigation, it would be a remarkable advancement in frostbite management and suggests an avenue of research for further large-scale studies. An additional abstract from Tuttle et al examined the impact of acetazolamide on acute mountain sickness in hikers trekking in Nepal with a slow ascent profile, perhaps further refining how we use this disease-altering medication. ⁹

As a field of study in medicine matures, invariably, research is devoted to systems and health-care delivery. This issue of WEM includes an important paper by Kannan et al, who developed an emergency care delivery assessment tool for facilities functioning in austere environments. ¹⁰ Level 1 trauma centers do not operate in remote corners, where complex care and stabilization may be required but are unavailable. The work of Kannan et al may be transferrable to other remote domestic and international settings where front-line emergency care occurs out of necessity despite local facilities often lacking essential diagnostic capabilities.

The practice of wilderness and austere medicine has seen rapid growth over the past several decades. Interest in the field is affirmed by burgeoning fellowships and resident (and student) electives and the next generation of researchers continuing to identify gaps in science and explore innovations in clinical practice. WEM will continue to provide a forum for further explorations in our rapidly expanding field.