- Email: [email protected]
Wilderness Event Medicine
Wilderness and Environmental Medicine, 14, 236 239 (2003)
BRIEF REPORT
Wilderness Event Medicine Timothy E. Burdick, MD; Reed Brozen, MD From Dartmouth Medical School, Hanover, NH (Dr Burdick), and the Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Dr Brozen).
Objectives.—Wilderness Event Medicine (WEM), that is, the care of large groups of people participating in events in remote areas, is a rapidly growing subspecialty of wilderness medicine. Our goals are to report the injury rates from one wilderness event and to suggest ways to advance this emerging field. Methods.—We describe a 1-day wilderness hike and compare the injury rates from this one event with rates from other urban and wilderness events. Results.—Of the total 350 hikers, 6 persons presented for medical evaluation (5 dehydration and 1 orthopedic), yielding a rate of 17 evaluations per 1000 person-days of exposure. Only 1 person (or 2.9 per 1000) required medical assistance beyond oral rehydration. These rates are comparable to rates reported for urban events and other wilderness activities. Conclusions.—According to very limited reports, the rates of injuries in wilderness events are similar to those for urban events. We recommend defining a wilderness event as an event with more than 200 participants and where the time from injury to care at a medical facility is likely to be greater than 1 hour. We also suggest the creation of a database of wilderness events, including standardized terms for the descriptions of activities, terrain, injuries, and medical response. Such a database could be used to help event planners anticipate and perhaps prevent injuries and to prepare effectively for those injuries that do occur. Key words: wilderness event medicine, wilderness medicine, wilderness, injury, mass gathering, hiking
Introduction Medicine for mass gatherings has typically described the medical care delivered at urban venues such as a Papal visit or a professional sports event.1–3 More recently, it has come to include participatory sporting events such as bicycle rides for charity.4,5 Local emergency departments (EDs) may see significant increases in visits during these time periods, and temporary aid stations may have as many as 25 000 visits in several days.1,5 With the increasing popularity of wilderness events such as adventure racing, a new specialty seems to be evolving: Wilderness Event Medicine (WEM). Injury rates in wilderness activities (eg, hiking or kayaking) have been reported in the literature. Among hikers in small groups on multiday trips, injury rates are A previous version of this report was presented as a poster at the Summer Conference and Annual Meeting of the Wilderness Medical Society, Whistler, British Columbia, August 7–11, 2001. Corresponding author: Timothy E. Burdick, MD, Family Practice Residency Program, Central Maine Medical Center, 76 High Street, Lewiston, ME 04240 (e-mail: [email protected]).
approximately 2 to 6 per 1000 person-days of exposure.6,7 However, there are few reports from mass gatherings in the wilderness. Chang et al. describe the summer use of Yellowstone National Park as a wilderness mass gathering and report 0.5 emergency department visits per 1000 park visits.8 One week after the conclusion of an adventure race in Borneo, 44% of the 158 participants available to follow-up were diagnosed with leptospirosis.9 In urban mass gatherings, there was a mean of 3.2 (SD 3.2) patients per 1000 attendees.3 Another review of 12 urban mass gatherings reported rates of 1.5 to 18.5 patients per 1000 (mean 5.5, SD 3.6), with 3 events having rates greater than 14 patients per 1000 (two rock concerts and the 1991 Super Bowl).1 During an 8-day charity bicycle ride in California, the daily rate of physician evaluations was 24 per 1000 participants; there were an additional 1173 nonphysician encounters each day per 1000 riders, many for heat-related injuries.5 We describe the medical response of a search and rescue (SAR) team at a wilderness mass gathering involv-
Defining an Emerging Specialty ing 350 hikers at a 1-day event. We discuss the injury rates and make recommendations for standardized reporting of wilderness event medicine through an Internet database. Such a database could be used to predict injury rates and to recommend appropriate medical equipment and personnel. Wilderness Event Description This wilderness event was a 1-day, noncompetitive, fund-raiser hike organized by the New Hampshire chapter of a national breast cancer organization. Participants hiked in groups of 6 to 8 with at least one staff leader for the first 2 km, at which point individuals could hike at their own pace. Approximately 80% of participants reached the halfway point, and approximately 20% reached the summit. Hikers began descent no later than 1:00 PM regardless of their position on the mountain. The hike was located on Mount Washington, NH, the largest mountain in the northeastern United States. The trailhead was at an elevation of 610 m. Participants hiked up and back on the same trail, a total distance of 13.6 km with a vertical elevation change (ascent plus descent) of 2614 m (average slope of 19%). The first half of the trail was forested with moderate elevation gain. The second half was above treeline and included a steep headwall and a boulder field. The weather on the hike day was clear with winds of approximately 15 to 45 kph and temperatures of 27⬚C in the valley and 10⬚C at the summit. Participation was capped by the National Forest Service (NFS) at 300 participants and 50 volunteer staff. Participants were solicited through the organizer’s mailing database. Demographics were not recorded. Ages ranged from approximately 8 to 75 years with an estimated 65% women. Physical conditioning of participants varied from triathletes to people with sedentary lifestyles. Confidential medical information from participants was on file during the event but was not reviewed for this report. Emergency Preparedness Prior to the event, the hike organizers, in conjunction with the NFS and the SAR team, developed a safety plan that designated first aid stations, hike protocols, and evacuation routes. All participants received basic information regarding this plan weeks before the event and again on the morning of the hike. Medical personnel included a local SAR team with a total of 4 volunteers at 2 first aid stations. This team included a Wilderness EMT (W-EMT) instructor in his second year of medical school, 2 Wilderness First Re-
237 sponders (WFRs), and 1 person with Wilderness First Aid training. In addition, 8 hike leaders and participants also identified themselves as medical providers: 4 WEMTs, 3 WFRs, and 1 nurse. Additional SAR teams and an air medical transport team were on stand-by. A wilderness medical control physician was available by telephone. The average response time for local Emergency Medical Services was 20 minutes to the trailhead and 1 hour via access road to the summit. Estimated litter evacuation time from the midpoint of the trail was 6 hours. Communications involved a combination of handheld UHF and Family Service Radios (FSR). A local outdoor club maintained additional radio base units at the trailhead, the midpoint Ranger Station, and the summit. Landline telephones were available at the trailhead and the summit. Cellular telephones were not reliable on this mountain and were not used. Anticipated medical problems included hypothermia and hyperthermia, musculoskeletal injury, dehydration, and soft-tissue injury (abrasions, blisters). Potential medical emergencies included hypoglycemia, anaphylaxis, and acute coronary syndrome. Appropriate first aid kits were assembled and distributed to hike leaders. The SAR team carried an extensive medical pack, including IV fluids and an epinephrine kit. Evacuation litters and ropes were located at 3 permanent NFS caches. Event Medical Responses Of the total 350 hikers, 6 presented to first aid stations for medical evaluation during the 1-day event, giving a rate of 17.14 medical presentations per 1000 days of participation. Five persons complained of fatigue; one of these also complained of leg muscle cramps. First aid for all 5 persons consisted of oral rehydration with dilute sports drinks, snack bars, and rest. All 5 were ambulatory, but 2 of the hikers were evacuated to the summit road because of their slow progress and the late time of day. A sixth person tripped on a rock approximately 100 m from a first aid station; she complained of shoulder pain and a head abrasion. Her exam was normal except for tenderness over the scapula and a small temporal abrasion. The SAR team placed a sling and swathe on her injured shoulder and cleared her cervical spine. She ambulated without assistance to the base, where she refused transport to a medical facility. The following day she was diagnosed with a fractured scapula. She had no complications from the minor head injury. Discussion During our 1-day hike, the overall rate of participants presenting to first aid stations was 17 per 1000 partici-
238 pant-days. However, only 3 persons required evacuation and/or advanced medical evaluation (clearing a cervical spine in the field), giving an injury rate of 8.6 per 1000. Eliminating all 5 cases of mild dehydration (which would not be included in many reports) and using only the single orthopedic case yields a rate of 2.9 injuries per 1000 person-days of exposure. This range of rates, from 2.9 to 17 per 1000, is comparable to the range reported in the literature.1,3,6,7 Our report is limited by the study size (350 person-days of exposure). Our report demonstrates that the injury rate differs depending on what is classified as a reportable injury. The report of a mass bicycle ride, which also distinguished between injuries requiring physician evaluation (24 per 1000 person-days of exposure) and total presentations to first aid stations (1173 per 1000), similarly demonstrates the point that discrepancies in reported injury rates are influenced by differences in reporting practices.5 Infectious diseases have the potential to cause significant morbidity rates (31 per 1000),9 which may not be readily apparent to event organizers because of the delayed time of diagnosis. Currently, there are no guidelines about what constitutes a reportable injury at a mass gathering. There are also no recommendations about identifying illnesses, such as infections, that may present after the completion of an event. We suggest that authors publishing reports about injuries at mass gatherings report all cases evaluated by a medical provider during the event. Where there exists a strong possibility of delayed diagnosis (eg, infections), it would be valuable to create a system of reporting illnesses treated after the completion of an event, although there are significant barriers to implementing such a system. Furthermore, published reports should indicate 1) the distribution of the injuries by major diagnostic categories (eg, trauma vs medical; heat-related, musculoskeletal, soft-tissue injury, dental) and 2) the required level of care provided (eg, EMT, paramedic/ nurse, physician). Only with such reporting practices can we compare injury rates between events. Reported injury rates also differ because most authors do not clearly define the duration of the event. In particular, the low rate reported for Yellowstone National Park (0.5 ED visits per park visit) fails to define the length of the average park visit.8 Using their data (27 000 park visitors per day; 5700 employees; and 2807 total ED visits in 1 month), we recalculate the ED visit rate (visitors and employees) at 2.9 per 1000 persondays of exposure. This rate is comparable to the majority of mass gathering reports and identical to the rate calculated for our 1-day hike event. There must also be a standardized definition of wilderness event, placed in the context of other mass gath-
Burdick and Brozen erings. Mass gatherings are defined as any event with more than 1000 people: Class I events last a few hours with stationary spectators (eg, the professional sporting event at a stadium); Class II events last up to several days and involve mobile spectators who may become participants (eg, Mardi Gras or a golf tournament); and Class III events involve more participants than spectators (eg, a charity bicycle ride).5 We would add Class IV for wilderness events. We define a wilderness event as any gathering involving 1) more than 200 persons involved in the same activity or event and 2) time from injury to hospital care that is likely to be more than 1 hour. The threshold number of people is lowered because few events in the wilderness involve 1000 persons. The definition of wilderness medicine as more than 1 hour from definitive care is already accepted within the wilderness medicine community.10 This definition of a wilderness event will, of course, create some debate. Notably, the report of ED visit rates from Yellowstone National Park8 would not be classified as a wilderness mass event because the majority of the injuries treated in the ED were likely incurred less than 1 hour from the park hospital. Finally, we suggest the creation of a database for reporting on wilderness events. Welch11 used a database of wilderness injuries, based on almost 4000 person-days of hiking exposure, to estimate medical supplies required for future activities; this model has not been validated to our knowledge. After an event, organizers would access a Web site to input relevant data. The Web page would query the user about the number of participants and their demographics (age, fitness level, percentage of men and women); the duration of the event (hours, days, weeks); event activities (eg, hiking, biking, swimming); terrain characteristics (altitude, elevation change); weather (wind, precipitation, temperature range); injuries encountered (by severity and type, eg, mild soft tissue abrasion); number of encounters by medical provider (first responder, EMT, paramedic, athletic trainer, physical therapist, massage therapist, nurse, physician); and medical staff at the event (number of providers by training level). The user would also be asked to rate subjectively whether there were too few, too many, or just the right number of each of these provider levels. Once there was a significant number of event entries in the database, it could be configured to predict the required numbers of providers and medical supplies for future events. Two obstacles to this database will be 1) finding a sponsor dedicated to the long-term maintenance of the Web site and 2) advertising the site in order to get enough event entries. Perhaps the Wilderness Medical Society could take the lead in both areas. Wilderness event medicine is a newly emerging sub-
Defining an Emerging Specialty specialty. Although the few reports of injury rates in wilderness areas are of the same order of magnitude as those reported for urban venues, the lack of data makes it difficult to plan for future wilderness events. Currently, there are no validated, evidence-based guidelines for planning supplies and providers for wilderness event medicine. We hope that future research will advance this definition of wilderness event medicine, suggest standardized reporting practices, and create and advertise a database of events. Acknowledgments The authors acknowledge the support of the Dartmouth Medical School Community Services Committee and the Dartmouth-Hitchcock Medical Center for sponsoring the Upper Valley Wilderness Response Team. References 1. Leonard RB. Medical support for mass gatherings. Emerg Med Clin North Am. 1996;14:383–397. 2. Sanders AB, Criss EA, Valenzuela TD, et al. Analysis of medical care at mass gatherings. Ann Emerg Med. 1988; 17:825–828.
239 3. Michael JA, Barbera JA. Mass gathering medical care: a 25-year review. Prehospital Disaster Med. 1997;12:305– 312. 4. Montalto NJ, Janas TB. Medical coverage of recreational cycling events. Clin Sports Med. 1994;13:249–258. 5. Friedman LJ, Rodi SW, Krueger MA, Votey SR. Medical care at the California AIDS Ride 3: experiences in event medicine. Ann Emerg Med. 1998;31:219–223. 6. Gentile DA, Morris JA, Schimelpfenig T, et al. Wilderness injuries and illnesses. Ann Emerg Med. 1992;21:853–861. 7. Gardner TB, Hill DR. Illness and injury among long-distance hikers on the Long Trail, Vermont. Wilderness Environ Med. 2000;13:131–134. 8. Chang EC, Koval E, Freer L, Kraus S. Planning for an annual episodic mass gathering: emergency department and clinic utilization in Yellowstone. Wilderness Environ Med. 2000;11:257–261. 9. Stone SC, McNutt E, Talan DA, Noran GJ, Pinner R. Update: outbreak of acute febrile illness among athletes participating in Eco-Challenge-Sabah 2000—Borneo, Malaysia, 2000. Ann Emerg Med. 2001;38:83–86. 10. Forgey WW. Introduction. In: Forgey WW, ed. Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care. 2nd ed. Guilford, CT: Globe Pequot Press; 2001:ix–x. 11. Welch TP. Data-based selection of medical supplies for wilderness medicine. Wilderness Environ Med. 1997;8: 148–151.
BRIEF REPORT
Wilderness Event Medicine Timothy E. Burdick, MD; Reed Brozen, MD From Dartmouth Medical School, Hanover, NH (Dr Burdick), and the Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Dr Brozen).
Objectives.—Wilderness Event Medicine (WEM), that is, the care of large groups of people participating in events in remote areas, is a rapidly growing subspecialty of wilderness medicine. Our goals are to report the injury rates from one wilderness event and to suggest ways to advance this emerging field. Methods.—We describe a 1-day wilderness hike and compare the injury rates from this one event with rates from other urban and wilderness events. Results.—Of the total 350 hikers, 6 persons presented for medical evaluation (5 dehydration and 1 orthopedic), yielding a rate of 17 evaluations per 1000 person-days of exposure. Only 1 person (or 2.9 per 1000) required medical assistance beyond oral rehydration. These rates are comparable to rates reported for urban events and other wilderness activities. Conclusions.—According to very limited reports, the rates of injuries in wilderness events are similar to those for urban events. We recommend defining a wilderness event as an event with more than 200 participants and where the time from injury to care at a medical facility is likely to be greater than 1 hour. We also suggest the creation of a database of wilderness events, including standardized terms for the descriptions of activities, terrain, injuries, and medical response. Such a database could be used to help event planners anticipate and perhaps prevent injuries and to prepare effectively for those injuries that do occur. Key words: wilderness event medicine, wilderness medicine, wilderness, injury, mass gathering, hiking
Introduction Medicine for mass gatherings has typically described the medical care delivered at urban venues such as a Papal visit or a professional sports event.1–3 More recently, it has come to include participatory sporting events such as bicycle rides for charity.4,5 Local emergency departments (EDs) may see significant increases in visits during these time periods, and temporary aid stations may have as many as 25 000 visits in several days.1,5 With the increasing popularity of wilderness events such as adventure racing, a new specialty seems to be evolving: Wilderness Event Medicine (WEM). Injury rates in wilderness activities (eg, hiking or kayaking) have been reported in the literature. Among hikers in small groups on multiday trips, injury rates are A previous version of this report was presented as a poster at the Summer Conference and Annual Meeting of the Wilderness Medical Society, Whistler, British Columbia, August 7–11, 2001. Corresponding author: Timothy E. Burdick, MD, Family Practice Residency Program, Central Maine Medical Center, 76 High Street, Lewiston, ME 04240 (e-mail: [email protected]).
approximately 2 to 6 per 1000 person-days of exposure.6,7 However, there are few reports from mass gatherings in the wilderness. Chang et al. describe the summer use of Yellowstone National Park as a wilderness mass gathering and report 0.5 emergency department visits per 1000 park visits.8 One week after the conclusion of an adventure race in Borneo, 44% of the 158 participants available to follow-up were diagnosed with leptospirosis.9 In urban mass gatherings, there was a mean of 3.2 (SD 3.2) patients per 1000 attendees.3 Another review of 12 urban mass gatherings reported rates of 1.5 to 18.5 patients per 1000 (mean 5.5, SD 3.6), with 3 events having rates greater than 14 patients per 1000 (two rock concerts and the 1991 Super Bowl).1 During an 8-day charity bicycle ride in California, the daily rate of physician evaluations was 24 per 1000 participants; there were an additional 1173 nonphysician encounters each day per 1000 riders, many for heat-related injuries.5 We describe the medical response of a search and rescue (SAR) team at a wilderness mass gathering involv-
Defining an Emerging Specialty ing 350 hikers at a 1-day event. We discuss the injury rates and make recommendations for standardized reporting of wilderness event medicine through an Internet database. Such a database could be used to predict injury rates and to recommend appropriate medical equipment and personnel. Wilderness Event Description This wilderness event was a 1-day, noncompetitive, fund-raiser hike organized by the New Hampshire chapter of a national breast cancer organization. Participants hiked in groups of 6 to 8 with at least one staff leader for the first 2 km, at which point individuals could hike at their own pace. Approximately 80% of participants reached the halfway point, and approximately 20% reached the summit. Hikers began descent no later than 1:00 PM regardless of their position on the mountain. The hike was located on Mount Washington, NH, the largest mountain in the northeastern United States. The trailhead was at an elevation of 610 m. Participants hiked up and back on the same trail, a total distance of 13.6 km with a vertical elevation change (ascent plus descent) of 2614 m (average slope of 19%). The first half of the trail was forested with moderate elevation gain. The second half was above treeline and included a steep headwall and a boulder field. The weather on the hike day was clear with winds of approximately 15 to 45 kph and temperatures of 27⬚C in the valley and 10⬚C at the summit. Participation was capped by the National Forest Service (NFS) at 300 participants and 50 volunteer staff. Participants were solicited through the organizer’s mailing database. Demographics were not recorded. Ages ranged from approximately 8 to 75 years with an estimated 65% women. Physical conditioning of participants varied from triathletes to people with sedentary lifestyles. Confidential medical information from participants was on file during the event but was not reviewed for this report. Emergency Preparedness Prior to the event, the hike organizers, in conjunction with the NFS and the SAR team, developed a safety plan that designated first aid stations, hike protocols, and evacuation routes. All participants received basic information regarding this plan weeks before the event and again on the morning of the hike. Medical personnel included a local SAR team with a total of 4 volunteers at 2 first aid stations. This team included a Wilderness EMT (W-EMT) instructor in his second year of medical school, 2 Wilderness First Re-
237 sponders (WFRs), and 1 person with Wilderness First Aid training. In addition, 8 hike leaders and participants also identified themselves as medical providers: 4 WEMTs, 3 WFRs, and 1 nurse. Additional SAR teams and an air medical transport team were on stand-by. A wilderness medical control physician was available by telephone. The average response time for local Emergency Medical Services was 20 minutes to the trailhead and 1 hour via access road to the summit. Estimated litter evacuation time from the midpoint of the trail was 6 hours. Communications involved a combination of handheld UHF and Family Service Radios (FSR). A local outdoor club maintained additional radio base units at the trailhead, the midpoint Ranger Station, and the summit. Landline telephones were available at the trailhead and the summit. Cellular telephones were not reliable on this mountain and were not used. Anticipated medical problems included hypothermia and hyperthermia, musculoskeletal injury, dehydration, and soft-tissue injury (abrasions, blisters). Potential medical emergencies included hypoglycemia, anaphylaxis, and acute coronary syndrome. Appropriate first aid kits were assembled and distributed to hike leaders. The SAR team carried an extensive medical pack, including IV fluids and an epinephrine kit. Evacuation litters and ropes were located at 3 permanent NFS caches. Event Medical Responses Of the total 350 hikers, 6 presented to first aid stations for medical evaluation during the 1-day event, giving a rate of 17.14 medical presentations per 1000 days of participation. Five persons complained of fatigue; one of these also complained of leg muscle cramps. First aid for all 5 persons consisted of oral rehydration with dilute sports drinks, snack bars, and rest. All 5 were ambulatory, but 2 of the hikers were evacuated to the summit road because of their slow progress and the late time of day. A sixth person tripped on a rock approximately 100 m from a first aid station; she complained of shoulder pain and a head abrasion. Her exam was normal except for tenderness over the scapula and a small temporal abrasion. The SAR team placed a sling and swathe on her injured shoulder and cleared her cervical spine. She ambulated without assistance to the base, where she refused transport to a medical facility. The following day she was diagnosed with a fractured scapula. She had no complications from the minor head injury. Discussion During our 1-day hike, the overall rate of participants presenting to first aid stations was 17 per 1000 partici-
238 pant-days. However, only 3 persons required evacuation and/or advanced medical evaluation (clearing a cervical spine in the field), giving an injury rate of 8.6 per 1000. Eliminating all 5 cases of mild dehydration (which would not be included in many reports) and using only the single orthopedic case yields a rate of 2.9 injuries per 1000 person-days of exposure. This range of rates, from 2.9 to 17 per 1000, is comparable to the range reported in the literature.1,3,6,7 Our report is limited by the study size (350 person-days of exposure). Our report demonstrates that the injury rate differs depending on what is classified as a reportable injury. The report of a mass bicycle ride, which also distinguished between injuries requiring physician evaluation (24 per 1000 person-days of exposure) and total presentations to first aid stations (1173 per 1000), similarly demonstrates the point that discrepancies in reported injury rates are influenced by differences in reporting practices.5 Infectious diseases have the potential to cause significant morbidity rates (31 per 1000),9 which may not be readily apparent to event organizers because of the delayed time of diagnosis. Currently, there are no guidelines about what constitutes a reportable injury at a mass gathering. There are also no recommendations about identifying illnesses, such as infections, that may present after the completion of an event. We suggest that authors publishing reports about injuries at mass gatherings report all cases evaluated by a medical provider during the event. Where there exists a strong possibility of delayed diagnosis (eg, infections), it would be valuable to create a system of reporting illnesses treated after the completion of an event, although there are significant barriers to implementing such a system. Furthermore, published reports should indicate 1) the distribution of the injuries by major diagnostic categories (eg, trauma vs medical; heat-related, musculoskeletal, soft-tissue injury, dental) and 2) the required level of care provided (eg, EMT, paramedic/ nurse, physician). Only with such reporting practices can we compare injury rates between events. Reported injury rates also differ because most authors do not clearly define the duration of the event. In particular, the low rate reported for Yellowstone National Park (0.5 ED visits per park visit) fails to define the length of the average park visit.8 Using their data (27 000 park visitors per day; 5700 employees; and 2807 total ED visits in 1 month), we recalculate the ED visit rate (visitors and employees) at 2.9 per 1000 persondays of exposure. This rate is comparable to the majority of mass gathering reports and identical to the rate calculated for our 1-day hike event. There must also be a standardized definition of wilderness event, placed in the context of other mass gath-
Burdick and Brozen erings. Mass gatherings are defined as any event with more than 1000 people: Class I events last a few hours with stationary spectators (eg, the professional sporting event at a stadium); Class II events last up to several days and involve mobile spectators who may become participants (eg, Mardi Gras or a golf tournament); and Class III events involve more participants than spectators (eg, a charity bicycle ride).5 We would add Class IV for wilderness events. We define a wilderness event as any gathering involving 1) more than 200 persons involved in the same activity or event and 2) time from injury to hospital care that is likely to be more than 1 hour. The threshold number of people is lowered because few events in the wilderness involve 1000 persons. The definition of wilderness medicine as more than 1 hour from definitive care is already accepted within the wilderness medicine community.10 This definition of a wilderness event will, of course, create some debate. Notably, the report of ED visit rates from Yellowstone National Park8 would not be classified as a wilderness mass event because the majority of the injuries treated in the ED were likely incurred less than 1 hour from the park hospital. Finally, we suggest the creation of a database for reporting on wilderness events. Welch11 used a database of wilderness injuries, based on almost 4000 person-days of hiking exposure, to estimate medical supplies required for future activities; this model has not been validated to our knowledge. After an event, organizers would access a Web site to input relevant data. The Web page would query the user about the number of participants and their demographics (age, fitness level, percentage of men and women); the duration of the event (hours, days, weeks); event activities (eg, hiking, biking, swimming); terrain characteristics (altitude, elevation change); weather (wind, precipitation, temperature range); injuries encountered (by severity and type, eg, mild soft tissue abrasion); number of encounters by medical provider (first responder, EMT, paramedic, athletic trainer, physical therapist, massage therapist, nurse, physician); and medical staff at the event (number of providers by training level). The user would also be asked to rate subjectively whether there were too few, too many, or just the right number of each of these provider levels. Once there was a significant number of event entries in the database, it could be configured to predict the required numbers of providers and medical supplies for future events. Two obstacles to this database will be 1) finding a sponsor dedicated to the long-term maintenance of the Web site and 2) advertising the site in order to get enough event entries. Perhaps the Wilderness Medical Society could take the lead in both areas. Wilderness event medicine is a newly emerging sub-
Defining an Emerging Specialty specialty. Although the few reports of injury rates in wilderness areas are of the same order of magnitude as those reported for urban venues, the lack of data makes it difficult to plan for future wilderness events. Currently, there are no validated, evidence-based guidelines for planning supplies and providers for wilderness event medicine. We hope that future research will advance this definition of wilderness event medicine, suggest standardized reporting practices, and create and advertise a database of events. Acknowledgments The authors acknowledge the support of the Dartmouth Medical School Community Services Committee and the Dartmouth-Hitchcock Medical Center for sponsoring the Upper Valley Wilderness Response Team. References 1. Leonard RB. Medical support for mass gatherings. Emerg Med Clin North Am. 1996;14:383–397. 2. Sanders AB, Criss EA, Valenzuela TD, et al. Analysis of medical care at mass gatherings. Ann Emerg Med. 1988; 17:825–828.
239 3. Michael JA, Barbera JA. Mass gathering medical care: a 25-year review. Prehospital Disaster Med. 1997;12:305– 312. 4. Montalto NJ, Janas TB. Medical coverage of recreational cycling events. Clin Sports Med. 1994;13:249–258. 5. Friedman LJ, Rodi SW, Krueger MA, Votey SR. Medical care at the California AIDS Ride 3: experiences in event medicine. Ann Emerg Med. 1998;31:219–223. 6. Gentile DA, Morris JA, Schimelpfenig T, et al. Wilderness injuries and illnesses. Ann Emerg Med. 1992;21:853–861. 7. Gardner TB, Hill DR. Illness and injury among long-distance hikers on the Long Trail, Vermont. Wilderness Environ Med. 2000;13:131–134. 8. Chang EC, Koval E, Freer L, Kraus S. Planning for an annual episodic mass gathering: emergency department and clinic utilization in Yellowstone. Wilderness Environ Med. 2000;11:257–261. 9. Stone SC, McNutt E, Talan DA, Noran GJ, Pinner R. Update: outbreak of acute febrile illness among athletes participating in Eco-Challenge-Sabah 2000—Borneo, Malaysia, 2000. Ann Emerg Med. 2001;38:83–86. 10. Forgey WW. Introduction. In: Forgey WW, ed. Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care. 2nd ed. Guilford, CT: Globe Pequot Press; 2001:ix–x. 11. Welch TP. Data-based selection of medical supplies for wilderness medicine. Wilderness Environ Med. 1997;8: 148–151.