Wilderness Medicine with Dr Stuart Harris

In this episode, we interview Dr. Stuart Harris. Dr. Harris is the founder and Chief of the Massachusetts General Hospital Division of Wilderness Medicine, and the Director of the MGH Wilderness Medicine Fellowship. He is a full-time attending physician in the MGH Emergency Department and an Associate Professor of Emergency Medicine at Harvard Medical School. He graduated from the Harvard Affiliated Emergency Medicine Residency in 2003. He has been conducting research with the Himalayan Rescue Association in the Mt. Everest region since 1999 and the U.S. Army’s Research Institute for Environmental Medicine since 2004, and is currently working on the next edition of Auerbach’s Wilderness Medicine . 

Transcript

Unknown: 1:02

I'm Captain Matthew Turner, and welcome to another episode of the gsacep Podcast. Today we're interviewing Dr Stuart Harris. Dr Harris is the founder and chief of the Massachusetts General Hospital division of wilderness medicine and the director of the MGH wilderness medicine fellowship. He is a full time attending physician in the MGH emergency department and an associate professor of Emergency Medicine at Harvard Medical School. He has been conducting research with the Himalayan rescue association in the Mount Everest region since 1999 and the US Army's Research Institute for Environmental Medicine since 2004 he is currently working on the next edition of our box wilderness medicine textbook. What first drew you to wilderness medicine? I think I probably I started in the wilderness before I got to medicine. So I kind of grew up Central Virginia, in a pretty wooded area that I could, you know, come home and run off into the woods, either on foot or on a bike and disappear for the afternoon, and so I think that was just at some level, was always around. My family loved hiking. The story about, I think I was two, three weeks old, and I was born in Nashville, Mom and Dad were training in Nashville and went out into the Smokey Mountains, where my family has some history, and evidently, a bear walked between mom and dad and me asleep in the tent as a two, three week old, and they're like, yeah, sorry. So I think that sense of and did a lot of white water boating as a family, and then, increasingly, on my own, and was very interested in mountains and mountaineering. And so I think from the time I was a pretty little kid and on into my teenage years, it just really turned on. And then halfway through college, I did a course with the National Outdoor Leadership School Knowles, and that was pretty seminal in a lot of different ways of how my life has developed since. So it was a 95 day course in the Wind River Range of Wyoming and everything from technical mountaineering skills to caving and climbing and winter mountaineering desert travel. So it's just it was a great introduction to So frankly, just feeling comfortable being outside, you know, whatever the environment. And so I think that's a huge portion of wilderness medicine for me. Part of it is the hard medical skills and learning how to diagnose and treat people even when you don't have some of the bells and whistles that we have in the front country, but part of it is just being able to not just survive, but to thrive as an individual out in those circumstances. So we were just talking with Jen Dow yesterday, who's National Park Services medical head for Denali, and I loved her since, you know, MD doesn't mean minor deity, it's like you need to be able to grab a shovel and be part of the team, and you might be able to display some medical talent that's of use at some point, but for the most part, you know you need to show up and be a team member and be able To take care of yourself, to know the technical skills, you know, and that could be rafting if you're on the grand or could be mountaineering if you're on Denali or in the Everest area. So you need to have both the camping skills, which I think people think are easy, and they are at some level, but they're demanding. And so it's, I mean, the same kind of thing through military training, and you know that sense of being able to exist with some degree of comfort and ability and whatever the environment is, and only then can you start being a good doctor, a good soldier, a good whatever. So that's a huge portion of what we do. So you mentioned Denali, what's the most remote place you've ever treated patient? As far as feeling remote, it was probably a little bit below Everest base camp when I was a fourth year medical student, so I didn't know. Wow. And I came across a Tamil Porter who was profoundly hypoxic and Disney and collapsed on the trail. And then the trail, if you've ever been up that way, is just, it's all Glacial Till that's melted out of the moving ice, and so it's really loose underfoot and jagged and in the trail changes sometimes day to day. And so I felt pretty alone on that evening, because it was right at the end of day, and had a pulse ox, and his respiratory rate and his oxygen saturation were about synonymous, which is not agnostic indicator, and there wasn't anybody else around, and that was in a time that was 99 so way the hell before anybody was using GPS or SAT phones or anything else. So it's pretty much just me and him as we slowly made our way down Valley and finally caught up with a couple other people who could help carry him and but I think I was probably the most out of touch with other humans in a time of need that I've experienced. Sir, yeah, that's quite literally about as remote as I can possibly think of. It's just it's so damn hard these days, and this has changed talking back. To Ukraine, but just the impact of Starlink on being actually removed from your fellow human. Yeah, it's pretty damn hard to get off the grid these days, which is, frankly, a pain in the ass, because, you know, like on my bike ride just now, my phone stays at home. I don't I take some solace and joy in the fact that, you know, I'm out there and nobody can get in touch with me, and, God forbid I need anybody else. It's like, too bad, you know, I take some refuge in that. And I'm usually pretty firmly on the grid when I'm in the front country. But these days, trying to get off the grid in the back country is pretty hard to come by. You know, you need to be in a pretty deep subterranean cave or a few other instances. But other than that. You know, with the star link, you can be on the grid in northern Alaska, 50 miles from the closest settlement, or in the Amazon, or wherever else. It's kind of crazy. That kind of leads to, like, the next question. So like, how does practicing medicine in the wilderness, would you say differ emotionally and mentally from working in a hospital? I mean, ideally, not at all. I think a huge portion of what attracts me to wilderness medicine. And just to be clear, I define wilderness medicine as resource limited medicine under austere conditions. It's terrible nomenclature, wilderness medicine. Nobody knows what in the hell it means. So for the last 25 plus years, I've been trying to help people to understand it. And I came across that resource, limited medicine under austere condition, 1520, years ago, and that's going to be the subtitle for the eighth edition of the textbook, just to try to help people to understand what it is we do. And so the the sense of practicing good medicine ought to be a universal a huge portion, I think, of what we can teach outside or in remote areas that is directly applicable to tertiary care, emergency department or ICU, is recognizing both the narrative, the power of diagnosis, of narrative, and the therapeutic power of narrative, of actually being there with the patient, listening to them, working through their story, rather than, you know, putting a computer between you and them, and you're typing along and putting in orders. And it's like, yeah, yeah, yeah, yeah, yeah. And it's like, patients recognize that. They recognize that as shit care, and it is because you're not engaging with them, and it's not, I think ultimately it's more cost effective, more time effective, more resource effective, to actually pay attention. And it can be three, four or five minutes, depending on how complex the care is. You know, if it's somebody I twisted my ankle, it can be 22 seconds go and do a good physical exam. And you can move ahead with some degree of thoughtful confidence. And so that ability to remove unnecessary technology that too often stands between us and our patients, I think, is important. I think the sense of giving you some confidence that we know a lot more than we think we do when we're in the front country, I think it's probably pretty useful. I think the sense of being able to expand care to wherever people are in need, kind of bizarre, that we force people to come to a concrete box to get care. And so the old saw about thinking outside the box. It's like, for me, the box is a hospital. You know, it's just thought. And care can come to die upon some occasions, or people know, a lot of our earliest work in the Everest area was building out tools and technologies to better understand the acute life threat of hyperbaric hypoxia, high altitude, how you could take a completely healthy 18 year old. And a lot of the work we did was with, are you familiar with the Etherium, the US Army's Research Institute for Environmental Medicine and natic mass? No, I'm not interesting. Yeah, it's a cool spot, and they've got a multi room, hyperbaric hypobaric chamber, a lot of thermal and mountain medicine. Just very thoughtful people, but so some of our work has been with them and in different places, but trying to push out technologies, get them the hell out of the hospital, and get them to where people are in need. So in, you know, the early zeros, oh 405, when ultrasound, I mean, I graduated from residency, and oh six, and we essentially had no Ultrasound Training. Dear friend and colleague of mine, Vicki noble, who's really become one of the gods of point of care ultrasound in the United States, she had to leave Boston to find, you know, anywhere they could train her in ultrasound, and came back and started our program. So but pushing ultrasound out of the hospital into the field, people are like, You can't do that. You know, it's expensive, it's fragile. You got nowhere to plug it in. The gel is going to freeze, you know, you're going to be down a device. And you know, this is reckless and blah, blah, blah. But as far as trying to find ways to better understand how low oxygen states, which are really the fundamental life threat, a heart attack or a stroke or GSW. And dumping your blood volume on the streets. You know, that's all ultimately tied together by lack of oxygen at the mitochondrial level, and so better understanding how hypoxia influences both the lung, but particularly the brain, we just don't know at this point. What we don't know is a vast amount. And you know, we ought to be a lot more modest than I think we are. And so we Peter vegan, Holt's, my early fellow, you know, got out there and got some tremendous data that now point of care, ultrasound and what we called comet tail signs, we now call bee lines. People are like, This is crazy. Like, yes, it is, but you know now it's absolutely standard of care, so it's, you know, things like that, where we can use more rigorous environments to better understand health on a day to day basis. Think we think of health as being, oh, well, this is a thing. It's like health is a continuously changing, evolving over biologic and geologic time, obviously, but changing minute to minute depending on the environment we're faced with. So you know, if you drop barometric pressure, if you drop oxygen percentage, if you drop availability of electrolytes or water or temperature changes, we are a continuously adjusting bespoke solution to the exact environmental conditions around us, and until we recognize health, as I say, as an ecological phenomenon, that you know, we exist as part of a magnificent, complex whole that we are part of, but we are not at the center of, and to think that human health can exist without the wide variety of whether it's bacteria on our skin and gut or all the other ways that living creatures allow us to be you know, we need to think differently about how we approach health and wealth in the future, because we're making dumb decisions just because we're disoriented. I actually, I've never thought of it like that, like health as an ecological phenomenon, as you mentioned, that that's actually, I think that's a really cool way to look at it. I think, I mean, it's almost, you know, where it's you think about poor Copernicus getting kicked in the head for suggesting that humans weren't at the center of the universe, and earth wasn't at the center of the universe. And, you know, day to day, it probably didn't make that big a difference whether, hey, the center of the universe or hey, I'm spinning on a rock around a molten ball of vision that's somewhere on the outer outskirts of a pretty nondescript galaxy, but you're fundamentally disoriented from the underlying reality, and I think that's what we face right now. I think a lot of the frustration and anger just in our communities, and certainly directed towards medicine, has its basis in that sense of disorientation, that people just sense that man, something is not right here, and it pisses them off. And frankly, it should. So how do we better align what we do with the underlying physical realities? I think would go a long way and maybe helping us to get along a little bit better and to deliver more thoughtful, more effective, more cost, aware, care, changing tack, just a little bit, coordinating rescue in a remote environment. Obviously, there's, like, a lot of planning, a lot of organization, a lot of teamwork that goes into that sort of thing. Could you provide some more information on that? So, I mean, it's kind of like a first aid kit. People ask, and it's like completely depends on so many different individual variables. So if you're your level of skill, you know, are you maybe have taken a first aid class versus a practicing position? You know, do you have an infinite budget? Do you have an infinite weight allotment and space allotment? Are you going to be climbing mountains with, you know, high kinetic trauma as a potential? Are you going to be out on the ocean, or you're going to be whatever? So what goes into rescuing, you know, in a deep cave, versus what you, you know, would experience in a combat circumstance or on top of a mountain can be wildly different than, I think, how you approach you really need to look at, what can I realistically face, and what resources do I have, and how do I organize them? Again, the changes in communication have in geo locating and things have made a huge difference, and just the recent recovery of the Special Warfare Officer, you know, from 7000 feet on a cliff in hostile territory. I mean, that was crazy. It was an insane operation, just degree of, I mean, of expertise, of attention to a fellow man, and ability to marshal resources like that. It's a pretty inspiring story. I completely agree. Obviously, like a lot of times, you'll be working in these remote, very austere environments, and even if you have communication, you're still oftentimes going to be the only medical provider for miles and miles. So what kind of mental pressure? Operation do you do into working for in those extreme environments? I don't know, maybe something wrong with me, but I love I've always liked being I worked pretty hard, and I done my study, and I've got a pretty big experience sometimes to draw from. And there's a tremendous amount of humility in recognizing how little I know. And I think that sense of being in a place like that, or circumstance like that, the ability to help somebody think I'm pretty well positioned to try to render at least humane care and hopefully high quality, effective care, it's funny that really hadn't bothered me. And I think the sense of I used to feel when I, especially when I was Resident a new attending, like going into an overnight shift in the MGH acute section, whereas, like, at that point, a lot more penetrating trauma and and, man, things are just crazy busy. In the sense of, you know, you were locked and loaded going into a shift, you were just, like, hard on. And I think, you know, having done it now for a long time, I think I have a little more bandwidth to sense things and to recognize where my attention needs to go, but especially in the early days, potentially, every patient is a new learning experience or a variation that. Man, it's like I need to be aware of this. I don't know. I think it's ultimately just takes a hell of a lot of work and attention and modesty and reflection and and then confidence that you know nobody knows everything, and nobody ever will know any everything. And how do you make sure you're providing the best possible care in a way that be proud of, if you were to look back is, I think that's all of medicine to a degree, but you can't hide sometimes, if you're the only one out there. Do you see any big changes coming to wilderness medicine in the future? Any new developments? Obviously, POCUS ultrasound really changed a lot of how we practice medicine in these environments. Do you see anything like that moving forward? I mean, I think fundamentally in the underwriting principle, and I think it'll be the first time a global general textbook of medicine has presented health as an ecological phenomena. So I think that's very basic. And I think something that wilderness medicine can certainly teach the rest of medicine, because the rest of medicine is so hyper, siloed and broken down by organ system and by the fourth nephron on the left kidney at the superior pole, like, really, you know who's taking care of the patient. So I think that's, in many ways, almost even more than the technology. I think we get sucked into thinking technology is somehow obviates our need to pay attention to the human in front of us. And how do you provide care? An ultrasound doesn't provide care. It might provide a diagnosis. But I think at the same time, as we touched on talking about Ukraine, and we were just over at Draper labs on Monday this week, which they do. If you're not familiar with them, you should be. They're pretty freaking cool. They do a lot of defense and sensing and kind of rapid manufacturing work, but that sense of we are really in a golden time of ability to lightweight remote sensing. They had a sensor that you could place, and they had placed it on a dragonfly was up flying around since it was it was a dead dragonfly, but it had flown at some point. But our ability to both gather data and with increasingly impressive artificial intelligence, you know, and a lot of our space medicine work is looking at exactly that, you know, we're getting enough data that we can begin to start to figure out not just how to diagnose disease, but to be aware of fundamental wellness in a way that we haven't been in the past, and especially as we go from low Earth orbit lunar as we've proven last week, we can communicate in real time, and if bad things happen, you got a bunch of MDS and PhDs around the console in Houston. But as we start going to the moon, you know you're talking about latencies of 510, 20 minutes, plus each direction. And so we're going to need to be able to have autonomous and high reliability means of diagnosis wherever they are. So I think that's pretty damn exciting. And so a huge portion of my work and responsibility in the last four or five years has been the space medicine fellowship that we started. Yes, sir, it's really cool stuff. I think the future is going to be really interesting, and I'm really looking forward to seeing when your textbook comes out. It's group effort. Um, there are bunch of great, great people working on it. So 130x chapters as of this morning. And, yeah, check. But I'm well over 250 authors, probably a lot more than that. Oh, wow. Alright. I. Nice six section editors, three senior editors, so we got a big team for a big book. Yeah, I know it's exciting to see it coming together. Well, I think that's actually all the time we've got right now. So thank you so much for taking the time, sir. Really appreciate so much.