 Hello, I'm Dr. Lewis Meyers and this is Health Care Today. Welcome back. We've had a brief hiatus over the summer. I hope all of our listeners are enjoying their summer. We live in Vermont, which I think is the most beautiful state in the country. Our guest today who is on Zoom with us from Utah might disagree, but a lot of Vermonters, particularly this time of year, like to be outside enjoying all that Vermont has to offer. We want everyone to be able to do it, enjoy it, but also do it safely, and that's why I'm so pleased to have our guest today, Dr. Richard Ingebretson, on with us from Utah. He is one of the nation's experts on wilderness medicine. He's going to talk to us about what wilderness medicine is and some of the specific some of the specific things we can do to stay safe. Let me basically first introduce Dr. Ingebretson to you. Dr. Ingebretson is grew up in Utah in the Salt Lake City area. He graduated from the University of Utah master's and PhD programs in biophysics and subsequently has taught astronomy and biophysics to college students. He then went to medical school graduating from the University of Utah Medical School in 1993 and went on to do internal medicine residency at the University of Utah and a fellowship in emergency medicine, and he has worked clinically in those fields over the many years since. In addition, he has been involved in academia and he's associate dean of the University of Utah Medical School. He is a long-time environmentalist and a certified river raft guide has taken many trips down the mighty Colorado River and other rivers out west and is the founder and president of the Glen Canyon Institute. He's also the director of the Wilderness Medicine program at the University of Utah School of Medicine and he is the medical director of the Salt Lake County Sheriff's Search and Rescue. He has just returned a couple of days ago from two weeks in France where he was teaching students there about wilderness medicine. I would also add on a personal note Dr. Ingebretson and I met a very long time ago when we were both first-year students at the George Washington University Medical School before he transferred back to Utah. So I'm very pleased to welcome him to the show. Honored to be here, Lewis. Very, very honored. Thank you for having me, of course. Absolutely. Well, let's begin just a brief overview Wilderness Medicine. I think it's one of the newer subspecialties, if you will, in medicine and medical education. What is it and how did you get involved in it? Well, it came out of the fact that I was an outdoorsman. I was a hiker, climber, a river after and when I graduated from medical school, I actually saw a biker crash up behind our medical school and I really didn't know how to treat this guy very well and here I was a physician and so during my training and residency I became very keen on the idea that there needed to be more formal education for physicians and medical people particularly on Wilderness Medicine and so when I graduated there's my training. I went to the School of Medicine Curriculum Committee and said we need to teach Wilderness Medicine. Well, there really wasn't any curriculum at the time. You know, what do you teach? High altitude illness, frostbite, cold, hot, snake bites. I mean, we really had to come up with a curriculum. We called it Advanced Wilderness Lice Aborder, AWLS. And it came up with the program and we keep advancing it. Now we teach everyone. I think everyone in the world should have that and I am going to say just right now while if you'll let me just plug our website because most of our material is free. We have a podcast series called A-W-L-S. It's where we listen to podcasts. You can go there and listen and learn about how to be safe in the outdoors and you can go to WildMedU.org and look at our text books are free, look at our practice tests. Everything there on the side is free and learn about Wilderness Medicine. So just to start, but that's how it began and we have taught literally tens and tens of thousands of people trying to keep people safe in our beautiful world, particularly Vermont, which is the most beautiful state as we know, right? Well, thank you. One of the foundational differences it would seem to me between Wilderness Medicine and the more typical clinical medicine that we learn in medical school is that when you're out in the wilderness, you don't have all of the support systems that we would have, for example, in a hospital or we're in a more urban setting. So that you're really having to improvise, I would imagine, in ways that you might not have to in a more formal setting. Is that correct? Well, of course, that's absolutely correct. You don't have the tools of your trade when you're in a remote area. So one of the things we try to teach is emergency response that if someone is injured or profoundly ill, how to treat them. And we also look at ways of making diagnoses and determining whether a person needs to be evacuated into the front country to where they can get definitive care. They're not. But there's also something else, even more than that, is things that you really don't think about, sunburn, for example. People put sunscreens on and they don't know what is in them. We just finished a series, a new podcast and a chapter in our book on sunscreens, for example. What's in them? What's good? What's safe? And what should you have to prevent? So that people when they put sunscreens on know what they're putting on and which ones work and which ones do not. That's a new one. And how about water? Where do you get your water from? Do you take it with you or do you treat it? If you choose to treat water, how do you treat it? Everybody goes to the store and buys a filter, but does that work? No, you really should have two. But we go through our discussion on how to make sure your water is safe and make sure you're doing things to prevent. And the biggest problem people have out there are things that you don't really think about at home. For example, you don't really think about your shoes. But when you go in the backcountry on a hike, the shoes become probably the most important thing on your body because if you get a blister or you get foot pain, you're done. So we go through a lot of effort in making sure people take care of their feet, cutting toenails and making sure that the three arches in our feet are well protected, the proper socks, moisture, and get rid of friction blisters. So there's a lot to it. And categorizing and teaching, it's been a great challenge, but it's been a lot of fun for us. But there's a lot in wilderness medicine. And it can go on. But another example would be bugs. At home, you get bit by a bug, and if it's an irritant to you, but out there, it could be life-threatening if you have anaphylaxis or if you get real sick. So we go through a big process on how to treat bug bites and just any bites in general. So you are right. As you well know, I think one of Vermont is right now facing a crisis because basically much of the state has been under water this week. Major flooding. And people's lives are uprooted. They're having to wade through water, sometimes up to their waste, and how their homes have been flooded. Essentially, you're looking at almost a wilderness medicine right now. What would you advise people who are in these situations? Well, here's something about floods and water that we don't think about. I mean, there's the obvious danger of drowning, but there's also another danger that we overlook, and that is water brings up feces and fecal matter, both human and animal, and so we are subjected to those. And so our drinking supply is bad. And then the diseases that are carried in water that we normally don't worry about are going to be prevalent there. And we're sorry about what's happening back there. But water, apart from just drowning and being destructive, carries just an insane amount of disease. Yeah. Let's talk about some specifics, heat and cold exposure. When you talk to medical students or citizens who are taking your course, what kind of advice do you have about, of course, we're in the summer season now, so obviously it would be more heat exposure. But what kind of advice do you give? Well, when we talk about heat illnesses, the first thing we like to teach is that there is no such thing as cold. We often say keep the cold out or get in from the cold, but in reality, there is no such thing as cold. And when you put ice next to a body, you're not putting cold into summer, you're just drawing heat out. So the first thing we like to teach people is that our human body is producing just an insane amount of heat that is wasted out of our skin. And it needs to be going out constantly, unless you get into an environment where it's going out too quickly, like in Vermont in the winter, and then you try to trap the heat. So all of our bodies, it's a game of keeping heat in or getting heat out. A clothing, all of our clothing is designed to help facilitate that. For example, some things are designed to keep, well, let me put it this way, all our clothing is air. Air is how we trap our heat or let heat out. Air is a poor insulator, so when we buy clothes, we look at the amount of air that is in our clothing. And air is quite expensive. You can go to the store and spend $200 on a jacket. It looks real pretty, but all you're buying is air, and it's in bundles, it's in plastic bundles, but the point is that heat is the key. You either let heat out of your body or you keep heat in the body. And so if somebody's too hot in the summer up there, you want to put water on them because that will get heat out of them. If you're in the winter up there, you want to put air around us in coats or jackets or wool or something that will keep heat in. So we have to teach kind of what clothes are. We have to teach how heat enters and leaves our body, but just to always remember there's no such thing as cold. And when you put cold or you drink a cold drink, you're not putting cold into anything. You're just drawing more heat out. What about hydration? When people go on long hikes here in the summer, what do you advise in terms of hydration? Of course, that's the great question. Our entire glycolytic pathway, that is how we create energy is driven by water. And anytime we get down on water, you're subjecting yourself to both hot and cold illnesses. In the winter, we need a lot of water also. So staying hydrated is essential. And one of the things that the normal person, let's say the normal person, just anyone can do, is there's no specific rule, but you can kind of start looking at yourself and saying, am I getting a headache or am I thirsty? And just stay on top of that. And when you're drinking, you should also make sure that you're using drinking electrolytes and sugars as well. A lot of times you'll feel thirsty, you have water, but you're down on salt. So having fluids that have salt and electrolytes in it is important, but it's hard to drink too much water when you're hot. And just make sure you stay well hydrated. That's a real big problem. And if you get over hydrated, I mean if you get too hot, get water on you to draw that heat out. That helps. Let's talk for a moment about water safety. As I mentioned, you are a certified river guide. You've been on some of the big rivers out west. We have some big rivers right here in Vermont right now, much bigger than we are used to. What should people do to be safe around water? Well, a couple of things. Drowning is a calamity of young people and very young people. If you look at the numbers, the people who drown, whether it's on a river or at home, it's toddlers. So the number one thing we have to do is watch children. That's who drowns. It is children. And that is true worldwide. That is not just true in Vermont or in our country. It is true everywhere. Toddlers need to be watched. And you can't leave them alone for a minute. And these big rivers that are back in Vermont are pools or little ponds, buckets of water. Children will drown in them. So that curve drops off at about three, four, five years old. And then it peaks again, starting at about 16 to 20, but of teenage boys, much more than teenage girls. So the next group that are at risk are of adolescent boys primarily, although it's true of others, but it's the same kids that get injured on bikes without wearing helmets, car accidents because they are where seabills are going too fast. So it is a calamity of young people. Very few people die generally by comparison. Once they get about 25 years of age, people become more cautious and more careful. But watch the kids, particularly toddlers, keep them away from streams. And if you're on a river trip or if you're near, you want to make sure that you've got a life jacket on and that you have a rescue mechanism like if you do go down a river, keep those jackets so tight. Then the other thing you want to be very careful of, and this is another huge problem of drowning, not just in wilderness but at home, and that is drugs and alcohol. Kids who are impaired because or anybody for that matter, whether, and it's usually alcohol, they will have difficulty rescuing themselves and they'll fall in. And if you look at the numbers on river trips across the country, the vast majority of them are alcohol-related. You know, they get drunk on a river trip and then they fall in and they drown. So watch the kids, watch those young toddlers. It's an astounding high peak around two years of age where children drown. What are some, can you tell us one or two of the events that have happened either on your trip or on an associate's trip that's specific on your river trips where medical intervention was needed? Well, I can tell you that on the trips that I run around as a river guy, we never had a situation where we thought that somebody was going to need evacuation. We were always able to handle it and we were being very, very safe and I'm very proud of that. And that said, because of my work in search and rescue and it's all I can to share, I can tell you some situations. One, I'll tell the story briefly and this was a kid who was up in Idaho rafting. He was 20 years old. He overturned in a kayak and he didn't get out and when his friends got to him, his helmet had pulled back over his head and he had hit his forehead and they pulled him to shore and tried to revive him but he died. This is called the Payette River about 20 years ago. But what happened was the father of course was just grieved beyond words but he realized that the problem was that the helmet was not safe. Kids go out and spend 75 bucks on a helmet somewhere and they think it's safe but there's no regulations. I worked with the Bloomberg School down there in Hopkins not far from you and developed a helmet that has multiple straps and a swing that comes down in the back and when you tighten it, it will not come off. And it comes down low in the forehead and he changed the world of helmets. And so now what we like to tell people when they get on rivers and they go kayaking or rafting, they get on a helmet but wear one that's not going to come off. When you have a helmet on on a bike and you land, your helmet hits the ground first. But on a river, if you fall in, the helmet hits the water first and can push off. So we warn people now to make sure they get one of these brand new helmets that they produced out of that boy's death up in Idaho that is very, very safe. It changed the world of river rafting and they're all over. You'll see that but make sure you get a really good helmet on and wear it. In terms of people getting lost in the wilderness and sometimes it can be not far from quote unquote civilization and they don't have to be out in the middle of literally nowhere. We now, a lot of people have GPS of course which has been a big change in the last 30 years but GPS doesn't work everywhere and cell phones don't work everywhere. If someone gets lost, what advice would you give them? What are some of the things they should do if they realize they're out in the woods and they're lost? So this is a very good question and the one thing I am going to ask people to do is go to our site and you can read about this for free on our WildMedU.org site. We have a course called Search and Rescue. It's for people who do this very thing. There's a chapter and they're called Lost Person Behavior. Another one called Search Techniques. So what we have discovered in the new generation is that older people will go down because it's easier to walk to go down. Younger people know to go higher and they're stronger to go and get GPS. So one of the things you can do is if you're the searcher is go to our site and read about where people go. First of all, get help. I mean just contact Search and Rescue rapidly. Learn about where people go and why and the kids go up and the adults go down. Older people who get confused will lie down and start to cry and things. But here's the deal. The people that get lost and we need to trouble our kids. So here's one thing that we really want to emphasize. And it came out of the death of a young boy many years ago in California that only was about 200 yards from where he got lost. This young kid had gone off and it became lost. The family looked. They ended up having thousands of people looking for him. They didn't find him for a couple of days. He had died. But out of that came a thing called the Hugga Tree Program. And you can go anywhere online and read about Hugga Tree with kids. And one of the problems they have with kids is they're taught not to talk to strangers. So if you see Searching and they see a stranger, they won't talk. So what we try to tell kids, and you can do this, is tell them to hug a tree, stay next to a tree, and give young people, or anyone that matters, you might think you lost, give them a whistle. The kids can sound their, they have sounds on their phones, but give the kids a whistle that they can blow. And then they have found that if you give that kid a code name, a code so that you can say, here's the code. And so when people search for them, they can yell out the code. They can blow the whistle. And if they just tell them to hug a tree and not to move. And the find rates on children have just skyrocketed, just if you can get kids to hug a tree. And then they find them. And then to have a code name or a whistle so that they can blow it. And then they tend to find them much better. It's a really good and important issue. That's very, very helpful. Thank you. Let's talk about animals out in the wilderness. For some reason this summer we've seen a lot of bear sightings here in Vermont. Of course there are other animals as well, koi dogs and raccoons, etc. What do you tell people about approaching or avoiding animals when they're out and about? So of course the answer is to avoid them. And to be careful. There are some animals that are predators like bears and we'll think you're attacking them. So just stay away from them and talk to people on the trail as you're hiking. Have you seen animals? A lot of animals like cuckoos and mountain lions and all these cats will actually see you before you see them. But not with bears. We were hiking last summer up in the U.N. mountains in Utah. We were coming down late with a doctor buddy of mine and we came across two moose that were absolutely the most beautiful things I think I've ever seen. So we walked on them and they were enormous. Well we just stopped and kind of backed up because you don't want to get angry about a moose. We got on our maps and noticed a trail was going to go around them so we very quietly decided that we'd walk around them but if they get mad they'll just destroy you. So you always have these decisions. One of the reasons we go out Lewis is to see animals and to see the wildlife. What a blessing it would be to see moose or a bear but you just have to understand that they don't share that same hue. Obviously we'd rather not see a human and if you startle them. One of the things you can do is go into any... In one of our books we talk a lot about animals and how to approach them and be careful of them on a wild-bed youth site and that'll kind of tell you ways to avoid them but the blessing of being in our world is seeing these creatures but you do need to be careful especially about the ones who... The avoidance is the primary way to approach them Would you recommend people carry bear mace though? So specifically about bears you should carry bear spray. It's capsaicin powder, chile powder and they hate it. You have to be within about 30 feet. Oh my gosh they'll run away from it and so yes if you're worried about bears carry bear spray and it works they are strongly telling it's not to use guns now because you'll wound the bear and they'll just get angry and they'll attack but they will run from mace. A lot of videos online about the bear spray it works insanely effectively. Yeah, I absolutely carry bear mace. That's a good pearl. Let's talk about fire. I know that is more of an issue out west where you are. Fortunately here in Vermont we haven't yet been... Don't have as many forest fires and in fact this summer as I said it's just the opposite we're inundated with water but if you're in an area in the wilderness and you smell smoke and you don't know where the fire is coming from what should you do? This is an interesting thing. Where we see this it's interesting that you would ask this question because you know you have these three long trails in the United States that go from the southern border up to the Canadian border beginning with the Appalachian Trail and then the Rocky Mountain Trail and then the very, very, very popular Pacific Crest Trail begins on the Mexican-U.S. border and then goes all the way to Canada. These things are roughly about 7 or 8,000 miles takes three months to hike them and the problem that we're seeing now on the Pacific Crest Trail is the kids start late spring and then they end in August before they go back to school takes three months to hike these things tens of thousands of people are on there but they get into those fires in Northern California and the Cascades and so go move away. You don't want to be anywhere near them. So one thing you want to do is keep communications devices and like you said earlier you absolutely cannot rely on GPS and cell phones you really need sad phones you need to keep up on where the fires are and move away from them because you see people getting trapped get off the trails whether you're on the Pacific Crest Trail or just on a couple of day backpack you see the smoke know where the fire will be know before you go and just move away from them because it's a real problem and people get lost from each other in the smoke you may not be right in the fire but we've had cases on the Pacific Crest Trail some of those awful fires up in the Sierras where people get lost because they just couldn't see just keep communication lines open with people about where they are it's a big problem Now out west you have had a huge winter of snow in the Sierras that always brings up the concern about avalanches when people we have a lot of skiers here in Vermont not as many avalanches again I think as you do out west but what do you tell people about your country skiing well that's a real tender subject with me and with the people in this area because we lost a lot of people this year to avalanche and it's almost a tragedy I will tell you one case a young man in his upper 40s went up to the mountains east of Utah and Brighton in one of the ski resorts one Saturday morning to clean snow off his cabin and he had a scraper he leaned it up there and hit it and the whole snow bank from the top of his cabin came down on him and he suffocated and that was one that hit a lot of the community Hark is a very popular young man with a family and he was killed in a roof avalanche so they happen and you need to be on the lookout for them at all time for those of you who do go in the back country here is the thing do not go everywhere has a place you can call in the west we have the avalanche centers and you call them and if there is a risk don't go we lost 10 people were caught in avalanche between two canyons east of Salt Lake City one came up one side and the other from the other side and they were skiing on a hill that was 28 degrees now we say you shouldn't be on slopes 30 degrees and above you don't go on and my group we say 25 just to be safe and theirs was 28 degrees and they deemed it safe because that's what most of the books say and an avalanche came down and killed 6 of the 10 and it was just all young people and it was the day after a big snow storm the sun was out blue sky and that's when you want to go there were a lot of warnings but they chose a hill that people ski a lot but the new snow 28 degrees and it took 10 of them and the only reason the two others didn't die is one guy was able to get a couple of people out that helped dig out some of the others and just a tragedy so know before you go I know it's a huge temptation here because we were a big skiing community but we lost a lot of kids and remember it's not just skiers the number one death in avalanche comes you go up on the way up high and you turn around and you hit those cornices and the whole avalanche will come down and most of our deaths in Utah from avalanche this year were people on snowmobiles I should say snow burning snowmobiles and if it says don't go on a hill don't go on it just avoid them there's no way to survive an avalanche if you're in one you're just going to suffocate and what a way to die concrete like that so it's a real tender subject for that share we can't educate people and we still had a record number of deaths this year and indeed you are and just the last couple of minutes we have we've been talking about some of the terrible things that happened but I know over the many decades your great love for the outdoors can you talk a little bit about that and why it's been so important in your life to be outdoors and helping guide people through the outdoors is my life that it's who we are I mean we evolved in the outdoors it's part of our genetic makeup and we're meant to be outside and we're meant to explore and there's a big part of our Olympic system which tells us to get out and explore and see beautiful things and go places that you know sometimes logic wouldn't tell you to go but it's essential that we go outside mentally and physically it's essential that we take our young kids out there be careful with them make sure that you look at our work on children in the world and make sure you keep them safe but get people out there go out there and be safe you don't have to die in an ambulance you don't have to be mauled by a bear and you don't have to be injured and we should emphasize these are rare occurrences and the great majority of people do fine can you in the we just have a little bit of time left can you slowly repeat the information for your website because I think people would really be interested in that true I'll tell you and I can I tell you the podcast is and the podcast A-W-L-S like Advanced Wilderness Slide Support A-W-L-S wherever you listen to the podcast it's free we have about 90 podcasts now informative we have cases and then WildMedU WildMedU as in the letter u.org that's the University of Utah site the resources on there are free and we want you all to go there and learn and tell others about them and be safe in the back country in this beautiful world of ours I want to thank Dr. Richard Engelbretson for being with us he is yes and and sharing all of that you've learned over the years and and continue to do the work you're doing out there I want to thank everyone for being with us we will see you next month and hope you have a safe and really enjoyable summer thank you