Jay Lemery

Perspective: Environment, Biodiversity, and the Education of the Physician of the Future

Ours is an age of unprecedented levels of environmental alteration and biodiversity loss. Beyond the exposure to environmental hazards, conditions such as environmental degradation, biotic impoverishment, climate change, and the loss of ecosystem services create important health threats by changing the ecology of many pathogens and increasing the incidence and/or severity of certain noncommunicable conditions. They also threaten health in the future by weakening the Earths life support systems.Although physicians remain one of the most often accessed and most trusted sources of information about the environment, there is currently little emphasis on educating medical professionals about these environmental issues. This lack of training reduces the ability of most physicians to be efficient science-public interfaces and makes them ineffective at contributing to address the fundamental causes of environmental problems or participate in substantive environmental policy discussions. This is an important challenge facing medical education today.To turn medical students into effective physician-citizens, an already-overwhelmed medical school curriculum must make way for a thoughtful exploration of environmental stressors and their impacts on human health. The overarching question before medical educators is how to develop the competencies, standards, and curricula for this educational endeavor. To this end, the authors highlight some of the critical linkages between health and the environment and suggest a subset of key practical issues that need to be addressed in order to create environmental education standards for the physician of the future.

Recommendations on the Use of Epinephrine in Outdoor Education and Wilderness Settings

Flavio Gaudio, MD—Assistant Professor, Emergency Medicine, Weill Cornell Medical College, New York. Physician Advisor, Cornell Outdoor Education. David Johnson, MD—Emergency Physician, Maine. President, Wilderness Medical Associates (WMA). Jay Lemery, MD—Secretary, Wilderness Medical Society. Assistant Professor, Emergency Medicine, Weill Cornell Medical College, New York. Frances Mock, JD—Attorney in recreation law, North Carolina. Tod Schimelpfenig, EMT—Curriculum Director, Wilderness Medicine Institute, National Outdoor Leadership School (NOLS), Wyoming. Joanne Vitanza, MD—Physician in Asthma, Allergy, and Immunology, Colorado. Carl Weil, EMT—Director, Wilderness Medicine Outfitters, Colorado.

Wilderness Medicine Education in the City: A New Paradigm

The field of wilderness medicine continues to mature and is now making headway into urban medical institutions not historically viewed as repositories of backcountry care. We discuss these factors as well as offer our institution’s recent experience in developing a wilderness medicine curriculum as a rationale and a potential template for expanding educational and practice opportunities for other urban graduate medical education training programs.

Core content for wilderness medicine fellowship training of emergency medicine graduates

Wilderness medicine is the practice of resource-limited medicine under austere conditions. In 2003, the first wilderness medicine fellowship was established, and as of March 2013, a total of 12 wilderness medicine fellowships exist. In 2009 the American College of Emergency Physicians Wilderness Medicine Section created a Fellowship Subcommittee and Taskforce to bring together fellowship directors, associate directors, and other interested stakeholders to research and develop a standardized curriculum and core content for emergency medicine (EM)-based wilderness medicine fellowships. This paper describes the process and results of what became a 4-year project to articulate a standardized curriculum for wilderness medicine fellowships. The final product specifies the minimum core content that should be covered during a 1-year wilderness medicine fellowship. It also describes the structure, length, site, and program requirements for a wilderness medicine fellowship.

A Case for White Coat Diplomacy

NOW WHAT?!” IS THE LINGERING QUESTION BY RElief workers and Haitians as the acute phase of the earthquake disaster evolves into the chronic stages of rebuilding. As with the rest of its institutions, the Haitian health care system has been shattered. It functions only through the voluntary efforts by medical teams from around the world. “Now what?” is also the question with which policy makers are now struggling—how to best use the donations from around the world without creating further dependence on aid and stifling local initiative. As governments and nongovernmental organizations gather in the coming months at conferences to debate next steps, they should not overlook a relatively new participant on the global stage—the proliferation of universitybased global health programs. When considering resuscitating the medical system in Haiti, there is a readily available approach that practices reciprocal and sustainable engagement—the model of academic medicine. The scales of these programs vary, but their demographics share a few common denominators. They are sustainable in that they have a big enough talent pool to provide continuous, long-term engagement with partners. They are also reciprocal because academia has a well-worn path for professional groups to collaborate on projects and to create partnerships. Academic leaders who promulgate such programs understand investment in education and systems development, and the programs can provide outstanding patient care along the way. To date, many of these initiatives have been exclusively private or university grant-supported enterprises. However, the scope of the disaster in Haiti necessitates an initiative on a scale that can only be funded with large scale or government support. Funding for such programs to date has been limited to few governmental agencies, and it has been difficult to find backers in a time of budgetary constraint. But when viewed through the prism of diplomacy, such an endeavor—whether under the Department of State, the Department of Defense, or the National Institutes of Health— could serve a broader government mandate in the service of global health. A closer partnership between academic medicine and foreign policy could serve as a model for US diplomatic engagement worldwide. There is precedent for this. The US State Department has a long history of tapping into the best and brightest talent from the United States to promote diplomacy. Such grant-funded programs include musical performances, English-language initiatives, and sports team tours. The strategy is predicated on the premise that individuals will transcend politics to connect through the arts, music, and sportsmanship, and find mutual wellness, respect, and goodwill in return. By logical extension, medicine should be part of this list. By extending its mandate to include international medical outreach, the US diplomatic service could reap the benefits of engaging a talent pool of thousands of physicianambassadors whose goals overlap their own at the professional level, to foster reciprocal goodwill with US colleagues and, at the humanitarian level, to showcase US concern for the well-being of people in each country in which such a program is undertaken. Even before the Haitian earthquake, many advocated for an increased government role in supporting US health care abroad, even to the point of establishing a formal “Global Health Service Corps.” The case for such a program is strategically sound, and provides much needed resources to help improve health in the developing world. However, these programs will take considerable resources and necessitate steadfast leadership at the highest levels of government. Until such a commitment is made, private sector medical teams already providing local medical engagement should be bolstered through grant support and perhaps even educational loan forgiveness. Universities are well poised to have a larger role in global health. They are independent, are charged with promoting the public welfare, and have material and human resources to partner with institutions around the world. Some academic skeptics suspect that such government-backed practices will invite manipulation. They cite the Cuban national health care model as an example, in which the “Health of the individual [is] a metaphor for the health of the body politic.” However, the Cuban government operates arguably the largest medical school in the world with a welldeveloped practice of training graduates explicitly for overseas work, engendering tremendous goodwill abroad in the process.

Climate Variability, Vulnerability, and Natural Disasters: A Case Study of Zika Virus in Manabi, Ecuador Following the 2016 Earthquake

Abstract Climate change presents complex and wide‐reaching threats to human health. A variable and changing climate can amplify and unmask ecological and socio‐political weaknesses and increase the risk of adverse health outcomes in socially vulnerable regions. When natural disasters occur in such areas, underlying climatic conditions may amplify the public health crisis. We describe an emerging epidemic of Zika virus (ZIKV) in Ecuador following the 2016 earthquake, which coincided with an exceptionally strong El Niño event. We hypothesize that the trigger of a natural disaster during anomalous climate conditions and underlying social vulnerabilities were force multipliers contributing to a dramatic increase in ZIKV cases postearthquake.

Wilderness Medical Society Practice Guidelines for the Use of Epinephrine in Outdoor Education and Wilderness Settings: 2014 Update

The Epinephrine Roundtable took place on July 27, 2008, during the 25th Annual Meeting of the Wilderness Medical Society (WMS) in Snowmass, CO. The WMS convened this roundtable to explore areas of consensus and uncertainty in the field treatment of anaphylaxis. Panelists were selected on the basis of their relevant academic or professional experience. There is a paucity of data that address the treatment of anaphylaxis in the wilderness. Anaphylaxis is a rare disease, with a sudden onset and drastic course that does not lend itself to study in randomized, controlled trials. Therefore, the panel endorsed the following position based on the limited available evidence and review of published articles, as well as expert consensus. The position represents the consensus of the panelists and is endorsed by the WMS. In 2014, the authors reviewed relevant articles published since the Epinephrine Roundtable. The following is an updated version of the original guidelines published in Wilderness & Environmental Medicine 2010;21(4):185-187.

Wilderness Medicine in Academic Medical Education

expedition and traveling are well documented,8–13 a literature search exploring expedition mental health morbidity in this population revealed little. The exact origins behind many mental health incidents on expedition will perhaps never be discovered. However, the author would suggest (perhaps controversially) that the prevalence of people on expedition with known but undisclosed mental health problems is higher than pre-expedition questionnaires would imply. This idea is supported by anecdotal evidence gained over numerous years working as an expedition medic, wilderness medical instructor, and advisor to expedition companies. The reasons for patients not disclosing past medical history in the planning stage of an expedition are multifaceted. This author would welcome further, more rigorous studies into pre-expedition medical and mental health screening, in particular focusing on the 16–30year-old age group, which forms a large proportion of the charity and commercial expedition market.

Climate change and women's health: Impacts and policy directions

In a Policy Forum, Cecilia Sorensen and colleagues discuss the implications of climate change for womens health.

Wilderness Preparticipation Evaluation and Considerations for Special Populations.

Children, older adults, disabled and special needs athletes, and female athletes who participate in outdoor and wilderness sports and activities each face unique risks. For children and adolescents traveling to high altitude, the preparticipation physical evaluation should focus on risk assessment, prevention strategies, early recognition of altitude-related symptoms, management plans, and appropriate follow-up. As the risk and prevalence of chronic disease increases with age, both older patients and providers need to be aware of disease and medication-specific risks relative to wilderness sport and activity participation. Disabled and special needs athletes benefit from careful pre-event planning for the potential medical issues and equipment modifications that may affect their health in wilderness environments. Issues that demand special consideration for female adventurers include pregnancy, contraceptive use, menses, and ferritin levels at altitude. A careful preparticipation evaluation that factors in unique, population-specific risks will help special populations stay healthy and safe on wilderness adventures. The PubMed and SportDiscus databases were searched in 2014 using both MeSH terms and text words and include peer-reviewed English language articles from 1977 to 2014. Additional information was accessed from Web-based sources to produce this narrative review on preparticipation evaluation for special populations undertaking wilderness adventures. Key words include children, adolescent, pediatric, seniors, elderly, disabled, special needs, female, athlete, preparticipiation examination, wilderness medicine, and sports.