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Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Improvised Medicine

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"Improvised Medicine" by Dr. Kenneth IsersonImprovised Medicine, subtitled Providing Care in Extreme Environments, a new book (McGraw Hill Medical; $54 U.S.) by Dr. Kenneth V. Iserson, is intended for health care practitioners who will “operate outside your comfort zone and devise effective treatment solutions when the traditional tools (medication, equipment, and staff) are unavailable—or when you need to provide care outside your specialty.” Another way to say this is that it is a book for persons who will need to do basic medicine in fields other than their own in resource-poor situations. In my opinion, it hits the mark in most and misses the mark in only a few ways, as I will explain.

I need to begin by stating that I know the author quite well and have the utmost respect for him. Dr. Iserson clearly knows how to improvise, and “walks the talk,” deploying to remote environments and difficult situations. He’s a skilled author and practitioner. The advice he offers in this book is sound. However, there are both omissions (of some well-known and useful techniques and methods) and commissions (inclusion of material that is neither about improvisation nor caring for persons in “challenging field conditions”). The index is extensive, so is quite useful in assisting the reader to quickly search for topics.

What do I like about this book? I like a great deal. It is the best collection I have yet seen of improvised techniques and coverage of situations for which virtually all doctors are ill-prepared. When you are in a remote setting, it is essential to know how to disinfect medical equipment, build latrines, bury bodies, and deal with hundreds of medical problems using common non-medical materials at hand. This is not taught in medical school and in very few post-graduate programs. The chapter entitled “Anesthesia: Ketamine, Ether, and Halothane” displays some of Iserson’s best work. It is necessary, descriptive, complete and useful. Most of the topics chosen are relevant. The Macgyver aspect of this book is unique. Iserson is the master of the “jerry-rig” and so we learn how to turn a light bulb into a flask (handle it carefully!), a syringe into a stethoscope, and a safety pin into an airway stabilizer. Don’t have a finger tourniquet? Not to worry, Dr. Iserson will teach you how to make one.

The stated intent to provide information to practitioners to assist them to practice outside of their scope of practice is valid, but needs to be held within reasonable limits, because otherwise, everything in medicine would need to be covered. Perhaps it should be explicit that it is a book intended to teach improvisation within a definition of an “extreme” environment, perhaps in austere settings—the wilderness, global humanitarian, and disaster relief. There is a great deal of instructive writing about managing dental problems, which is terrific for doctors who don’t know the first thing about providing dental care. But what about the myriad improvised methods to close wounds? There is a description of standard closure with sutures, but essentially nothing about how to use tape, which is the more likely approach in a resource-poor environment. There is a description of how to perform escharotomies. This is advanced burn wound therapy and not unique to a resource-poor environment.  Post-traumatic stress disorder (PTSD) is the same in an extreme environment as it is close to home. Describing ultrasound findings without showing images is generally not helpful. Embalming a body? Iserson is correct in assuming that nobody is taught that in medical school or post-graduate residency training, but who cares? Appendix 1, which is a Hospital Disaster Plan designed for health care facilities in resource-sufficient regions, has nothing to do with the premise of the book. My quibbles can be summed up by my impression that with good intentions, this book over-reaches its title.  

That having been said, I truly hope that Dr. Iserson achieves sufficient success with the first edition of this book to warrant a second edition. In that book, I would like to see more consistency and depth to the topics chosen, so that all reasonable improvisational techniques are fully described and illustrated. I agree with covering situations for which there is necessity but insufficient training AND where procedures are involved, such as dentistry, body disposal, and emergency childbirth. Adding detailed pharmaceutical advice about managing migraines doesn’t seem to fit. 

It’s hard to do everything with one book and keep it to a size that is convenient, so the author will need to make choices. Having worked my way through six editions of Wilderness Medicine and five editions of Medicine for the Outdoors, I know how much work it takes to refine a book over time. Iserson’s Improvised Medicine is now an important part of my wilderness medicine library and I look forward to putting it into action soon.

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About the Author

Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.

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