Back of beyond

I presented the wmed paper to an informal group earlier this week, and it got me thinking about it again, especially combined with my thoughts about communities of practice. One of the suggestions given to me about the development of wilderness medicine is to back up from taking its present incarnation as a given, and to focus on its development—and that sounds precisely like a project to track the development of a community of practice.

The first step in this process is actually lots of fun. I’m basically reading old and new accounts of mountaineering and injuries. Two great sources for this information are the American Alpine Journal and Accidents in North American Mountaineering, both published regularly by the American Alpine Club. Back issues of both give a glimpse into different attitudes toward rescue and “second aid.”

I’ve also gone back to read (or sometimes re-read) historical accounts of expeditions. Climbing Annapurna nearly killed Maurice Herzog and his team in 1950. These guys were hard-core; before they could climb the mountain, they had to find it from a set of inaccurate scouting maps. The peak was visible from the valley far below, but its base was unreachable. It took weeks just to figure out how to get to the mountain. Critics say that Herzog’s account, Annapurna, gives short shrift to others who climbed with him—which is possible, as Herzog comes out awfully heroic, and returns to France with great fame—but the story is nonetheless gripping. Herzog was stricken with horrible frostbite on the descent, and subject to excruciating treatment in an attempt to save some of his extremeties. It’s truly grisly.

Also on the shelf are K2: The Savage Mountain, by Charles Houston and Robert Bates, and The White Spider by Heinrich Harrer. Houston’s and Bates’ account of the first American expedition to K2 is fascinating, and describes a feat of sheer mountaineering strength never matched: In a severe storm at 25,000 feet, Pete Schoening arrests the fall of five other climbers who were sliding down a 45-degree slope. Schoening’s act has come to be known as The Belay.

Unlike most of the wilderness medicine to which my own paper refers, all of these expeditions brought doctors with them to act as the expedition physician. This is still the case at places like Everest, where high altitude physiological research is done and doctors regularly go. That doesn’t necessarily mean that they’re available at the scene of all accidents, and if they were, that they could provide definitive care, but they’re around nonetheless. Interestingly, issues of liability are making it harder for smaller expeditions, in other places, to bring physicians along. That is one of the points where my focus—emergency backcountry medicine practiced by nonprofessionals—intersects with the practice of trained physicians: The unresolved issue of “best practices” in the backcountry leaves both amateurs and professionals in a tricky situation.

Today’s backcountry wilderness practices are descended from those of Annapurna’s Doctor Oudot, but they’re almost unrecognizable, especially when performed by non-physicians. Ultimately, I want to track that transformation, from physicians practicing in the wilderness to non-physicians training to perform comparable tasks—that will be the formation of a community of practice. Some of that particular story comes later (as a preliminary pointer, Stefan Timmermans has an interesting narration of the development of CPR in the United States in his The Myth of CPR), so for now I get to read these great mountaineering stories.