ER in the mountains: emergency medicine and wilderness elective at Cornell
Cynthia Santos writes on a challenging elective in emergency medicine, spent in the very different environments of a hospital and a national park.
The emergency medicine elective was broken up into a 2-week subinternship component at the Weill Cornell Campus of NY-Presbyterian Hospital and a 2-week wilderness medicine component. The wilderness component consisted of one week of lectures, workshops, trips to the Bronx Botanical Garden (Botanical Medicinals), the Bronx Zoo (Reptile House), and principles of Disaster Response taught by the EMS Special Operations Team. The final week took place in the backcountry of the Adirondacks involving High Peak and Lake Champlain ecosystems.
Saranac lake, New York
Most of my courses in medical school have centered around spending long hours at the library or more recently on the hospital floors. When I am on the floors I spend many hours looking up lab values, calling for consults, and writing notes. The actual practice of medicine, at least for medical students and interns, unfortunately involves much more clerical work than I thought. When you think of interns in any other field you think of young professionals dressed in suits shuffling papers around, typing reports, and doing whatever it takes to make a good impression on their superiors. Unfortunately for medicine interns and soon-to-be interns it is not much different for us. But, we jump through this hoop, like the many other hoops we have jumped through in the past, to get to that almost tangible place in our career that we dream about. Sometimes through this process we encounter moments that inspire us and renew our interest in medicine. We discover those key pertinent findings on a physical exam that affect their diagnosis and treatment, we are often the first to read a lab report or an imaging study that will forever alter our patients’ lives, we educate them about their disease, and we hold their hands when they are in pain.
On rare occasions, we are given opportunities to practice and study medicine outside of our usual elements. We have the opportunity to see and help treat diseases we only learn about in textbooks, we are placed out of our comfort zone and gain knowledge that not only changes the way we will practice medicine but also changes our core. Usually these opportunities are only available far away from our medical school and local hospital. For example, I have had opportunities like this in South America and in the Caribbean, my roommate in Tanzania, my other classmate in Thailand, etc, etc. But, when I heard I could have a similar experience right in my home school I was surprised. A classmate told me of an Emergency Medicine and Wilderness course taught at Cornell Medical School. “Where”, I first thought, “in Central Park”? Actually, it was in the Adirondacks.
The Adirondack Park and Forest Preserve in Northern New York at 6 million acres is larger than Yellowstone, Yosemite, Grand Canyon, Great Smoky, and Everglades National Parks combined and is the largest park in the nation outside of Alaska. “The Adirondacks shall be forever kept as wild forest lands” and with these words, written by the New York State Legislature in 1885, the Adirondack Forest Preserve was born. Nine years later, the Adirondacks became the first and only wild land preserve to obtain constitutional protection through the inclusion of Article VII, Section 7, the “forever wild” clause, into the state Constitution.
The elective was started by Jay Lemery, an ER physician at New York- Presbyterian who has been described as “a rising star in the field of wilderness medicine, whose fondness for the wilderness is matched only by his unrelenting sense of humor.” Jay recruited good friend and fellow emergency medicine colleague, Flavio Gaudio, whose impressive knowledge in botany and medicinal plants inspired me to read up on plants and even make my own nature flash card set. Finally, there was Todd Miner, a true outdoorsman, who is the head of the Cornell Outdoor Education Program in Ithaca and could probably write a book series about knot-tying. The three of them, with the enthusiasm of a handful of other emergency medicine physicians whose passions include botany, insects, venomous animals, international medicine, marine medicine, aerospace medicine, backcountry rescue and survival, were our teachers. As our textbook we had the bible of all wilderness textbooks, Paul S. Auerbach’s Wilderness Medicine. This book weighs 10.8lbs, 2316 pages long and has chapters entitled “Animals, Insects, and Zoonoses” and “Dehyration, Rehydration, and Hyperhydration” as well as “Ethnobotany: Plant-Derived Medical Therapy.” Our very own Jay Lemery is the author of the Aerospace Medicine chapter. The book makes Robbins’ Pathologic Basis of Disease seem wimpy. I borrowed the book from the library and after two overdue emails I’m still having a hard time returning it back; I love the thing.
This fall nine students from around the country came to Cornell to act as emergency medicine subinterns in the New York Presbyterian Hospitals and as wilderness emergency medicine responders in the Adirondacks. The subinternship experience of the elective was great. I was given the opportunity to close scalp lacerations, stitch wounds, reduce joint dislocations, and even attempt a lumbar puncture. I rode in EMS ambulances, pulled all-night shifts alongside my attendings, and for the first time in medical school I felt I actually became friends with my attendings. We even had nicknames for each other by the end of the elective; I being a Dominican from Queens became “Shanana”, Jay became “Jam Master J” and Flavio became “Flava Flav.” I could write a book about the connections I made with the other medical students. We only shared one month together, but it was an amazing one and I truly will remember them and hopefully will stay connected with some of them for years to come.
Our wilderness experience was filled with various clinical scenarios where we rotated from being “doctor in charge” to being the “victim of the day.” We had scenarios on acute mountain sickness, high-altitude cerebral edema, venomous snakebites, bear attacks, various limb dislocations, spinal injury, hypothermia, near-drowning, anaphylactic attacks, lightening injuries, and emergency airway management. We learned things like how to evacuate someone using just sticks and our rain jackets or some rope, how to make splints with just about anything, the many uses of duck-tape, how to perform a cricothyroidectomy in the field, how to manage asystole on the field s/p lightening strike, and what to do with an amputated limb or a dislocated eye s/p bear attack. We learned other general wilderness skills like how to make a fire, disinfect field water, use a compass, read all sorts of maps, avoid bear attacks and also be able to survive them, how to send out a search & rescue team, and how to canoe in not-so-nice conditions. The last skill ended up being more necessary than I thought after Jay and Flavio had to do an unexpected midlake canoe retrieval rescue scenario one rainy and windy day where my partner and I were the “victims of the day,” but unfortunately for my canoe partner and I, we were not acting. I learned the importance of knowing my limits then.
Lindsay Cammarata (left), fourth year at SUNY Stonybrook, Cynthia Santos (middle), third year at Weill Cornell, Barry Ladizinski (right), fourth year at Dartmouth, manage a near-drowning patient with possible cervical injury with attendant Chris McStay from NYP playing victim.
Throughout the course, I also found some of my favorite quotes, such as “all bleeding stops eventually,” and “in wilderness medicine… we bury our mistakes.” The practice of emergency medicine, especially in the wilderness, necessitates an ability to make quick independent decisions and to be able to adjust your approach to the patient as their condition evolves often without the aid of imaging studies or lab values. The emergency medicine physician has much fewer diagnostic tools available than the internist, specialist or the surgeon. On the floors I often hear complaints from nonemergency medicine personnel like “Why in the world did the ED make this diagnosis?” or “why didn’t the ER attending do this” or complaints like “another useless admission from the ER.” Earlier this week, I even had a neurologist sway me from entering emergency medicine by describing the physicians as “triage nurses.” During this elective and my experience in both the hospital and in the wilderness I developed a new appreciation to the challenges ER physicians face every day. Because of insurance reasons ER physicians have become the primary care providers of the community. However, they must be able to retain their role as emergency medicine physicians and respond to life and death situations quickly. They cannot wait for those MRI results or specific lab values. Medicine is practiced at a purer level. We diagnose and treat patients with a good history and physical exam, the aid of some quick and easily assessable technologies like EEG, x-rays, and ultrasound and most importantly with the knowledge we have learned from our studies. These skills should be fundamental in all fields of medicine. Studying these skills outside of the hospital and far from access to any fancy technologies only sharpens our history and physical techniques and forces us to realise the treatments that will save lives.
Cynthia Santos, 3rd year medical student at Weill Cornell Medical School, U.S.A.
Cds2006@med.cornell.edu