Defining Remote

Understanding the challenges presented by remote environments


Before venturing to the ends of the earth, understand and prepare for the particular challenges that an injury or sudden illness will pose.
Exotic, far-flung destinations hold pristine sights full of natural beauty. But the more remote the location, the more difficult it may be to manage an emergency should one occur. Understanding the specific challenges presented by remote environments gives adventurers a leg up. These challenges include time, environment, resources and independent decision-making.

Time
In cities, towns and many resort areas, people are rarely required to spend more than a few minutes with individuals who are seriously injured. Emergency medical technicians (EMTs), paramedics, nurses or doctors are available to take over care within minutes. In the time it takes to call 911 and have an ambulance dispatched and arrive on scene, a patient can be in the hands of expert medical-care providers. In remote environments, however, traveling companions of those who become ill or injured may find themselves forced to give care to the best of their ability for hours or even days.

This means wounds must be cleaned thoroughly to prevent infection, and splints, wraps or slings may need to be constructed to limit further injury to bones and muscles. Medication may have to be administered, and careful notes should be taken to give to professional caregivers when an evacuation can be conducted.

When providing care over an extended period, there is more to it than just addressing patients' medical needs. Caregivers must also figure out how to help them stay nourished, hydrated, warm and able to relieve themselves. It isn't just training, planning and sound judgment that are helpful in extended-care situations; good bedside manner and a willingness to provide comfort and encouragement are important as well.

Environment
Hospitals, clinics and even ambulances offer climate control, shelter, light and other amenities that are not guaranteed in wilderness settings. Be prepared to care for injured traveling companions in darkness, rain and high winds when you visit remote areas. Be ready to face the sun's relentless rays, lethargy-inducing heat or finger-numbing cold as you administer aid. Since bad conditions can increase the potential for injury, it is quite possible you'll be called on to provide care in heavy weather, at night or in extreme temperatures. Evacuation to a higher level of medical care will not be necessary for every little annoyance, but be prepared for trips to the doctor for simple infections and other seemingly mundane problems to become daylong ordeals.

Resources
When an ambulance arrives at the scene of an accident, it comes loaded with equipment designed to provide assistance and relief to the sick or hurt. When no ambulance is available, you're stuck with the gear aboard your boat or in your pack. This means time spent deciding what equipment to bring on a trip is time well spent. It's worth brainstorming a variety of scenarios to improve your chances of being prepared for the most likely and most serious situations you may face. It also means you may need to improvise important gear you don't have with you. Effective improvisation of equipment is an essential skill in wilderness medicine.

Even where medical care is available in rural or remote areas, the imaging equipment necessary to determine injury severity may not be. Basic casting materials, medications and expertise in reducing fractures, for example, may likewise be unavailable. It might be necessary for a group to splint an injury using whatever padding and rigid materials are available. When doing so, immobilize the injury without restricting circulation, and always use lots of padding.

Group members may even need to build a makeshift stretcher that can be dragged along the ground or carried to transport a patient to a clinic, hospital or airstrip. This is appropriate except when a patient may have suffered a spine injury. When a spine injury cannot be ruled out, avoid moving the injured person unless there is an immediate threat to life or group members have the training to secure the patient to an available backboard — a device designed specifically for moving people who may have spine injuries. Some equipment should not be improvised.

Independent Decision-Making
When a satellite phone isn't available and you cannot get a cell signal, you may find yourself having to make decisions without the guidance of a doctor, DAN® medic or other expert. Good judgment and decision-making ability comes from training and experience. If you don't yet have these, travel with those who do. Ask your guides or tour operators about their training and emergency protocols before you book your trip. Some small resort islands have clinics in which physicians or nurses rotate through, but even in these cases the simplest diagnostic tests may not be available, and you may be faced with making significant decisions with less information than you would like to have.

When you are able to reach DAN, a doctor or local emergency services for consultation and evacuation, be ready to answer the questions they will ask. From the moment an accident occurs or symptoms of an illness first appear, designate a member of your group to keep notes on the evolving situation.

Preparation
Pack a headlamp and spare batteries in your first aid kit so you are prepared to help a traveling companion at night. Extra water, sunscreen and insect repellent will be appreciated by all if a group is forced to stop moving in an exposed area because of an injury or acute illness. Although space and weight are often at a premium when traveling off the beaten track, a spare insulating layer is very valuable if someone gets hurt. When in doubt about items like rain jackets or wide-brimmed hats, bring them. Good exposure protection will help maximize the number of able-bodied caregivers while minimizing the number of individuals who need help. Pack a notebook and pen so you can keep a record. A log of the patient's condition over time may be very valuable to medical professionals who take over patient care later.

Before you travel to a remote area, determine whether any immunizations are recommended for the area, and schedule those accordingly. Research the locations of the nearest clinics and hospitals, and find out the emergency number for the U.S. Embassy in the area where you're traveling. The websites of the Centers for Disease Control and Prevention, the World Health Organization and the U.S. State Department are good sources of this information. DAN Members can visit www.DAN.org to use WorldCue® Planner, a free benefit of membership, to find this and other information relating to traveler health, safety and security.

Sometimes travelers' primary-care physicians or dedicated travel clinics can provide precautionary antibiotics to treat simple infections should they occur. DAN does not support or discourage this; it is a decision to be made by the traveler and his or her physician. If you take any medication regularly, ask your physician about prescribing a backup supply you can keep in a separate place in case something happens to your medicine and it is not available at your destination.

Travelers with chronic health problems or uncommon medical conditions should consider carrying literature about their condition that they can share with a health-care provider. Some rare diseases that require treatment by specialists may be tricky to manage for practitioners who are unfamiliar with them. Ask your doctor to prepare instructions for emergency management of your condition so you are prepared for any complications that may occur. If there is a significant risk of an exacerbation of the condition, have an honest discussion with your physician about your medical fitness for a particular trip. It's possible that certain destinations might not be recommended due to their remoteness, but other, more popular, ones might be appropriate.

Consider getting training in wilderness first aid. With training, your preparation, decisions and judgment will improve. Since most people travel with their friends or family members, the well-being of your traveling companions may be a powerful motivator for seeking training.

Emergency Response
In the event of a serious illness or injury, contact local emergency services first if they are available and you have the means to reach them. Then call DAN at +1-919-684-9111. DAN medical staff will monitor your care, answer questions and, if you are a DAN Member, arrange for you to be moved to a better hospital if necessary. This may mean returning to your home country or traveling to a more populous area near your location.

Evacuation takes time; there are many logistical elements to medical transport. Air ambulances are not generally able to take off at a moment's notice. They must work with local authorities to obtain landing permits, exit visas and other documentation before moving patients. Immigration must be cleared in the destination country. The process may be expedited in a medical emergency, but it still must take place. Sometimes the patient will need to be transported to a larger airstrip so an air ambulance may safely land and take off. Immediate flights are not always possible at night or outside normal hours of operation; some airports close and will not open after hours even for medical emergencies.

Consider the logistical challenges imposed by remote environments before you set out, and you will be better prepared to provide care and comfort to your fellow travelers.

Learn More
If you enjoy remote travel or extended expeditions, consider getting trained in wilderness or remote medicine. The Wilderness Medicine Institute offers Wilderness First Aid, Wilderness First Responder and Wilderness EMT courses. Find out more at www.nols.edu/wmi.


© Alert Diver — Summer 2012