John Price, M4, Class of 2020
The night was young when the radio crackled to life. We couldn’t believe our luck. They told us the search and rescue missions wouldn’t start for another week, but here we had someone that couldn’t continue their hike. Eager to test our skills, we quickly gathered our supplies into the truck ambulance. When I look back on all my clinical experiences, the Philmont rotation outside of Cimarron, New Mexico, is certainly my favorite. Established in 1938 as Philturn Rocky Mountain Scout Camp, Philmont Scout Ranch has become a center for high adventure and training.1 For emergency medical technician students and medical students like me, this site offers a unique clinical training in wilderness and prehospital medicine high up in the Sangre de Cristo Mountains of the Rockies.1 Below the peaks in basecamp, the Philmont Infirmary is the central hub for this medical four-week sub-internship rotation, and it all began on my first night.
A ranger was summoned as a guide with coordinates. The driver and ranger mapped our route and we were off. The headlights pierced the darkness with occasional deer and staff until we reached the gates. I hopped out and unlocked them, letting the truck through to get back in. We got to the first real backcountry turn. The road had more weeds than actual road, with even a stream running through it. The driver and ranger started to look questioningly at one another, but we continued, and the driver kicked it into four-wheel-drive and cautiously continued up the mountain in the dark.
A large portion of a tree had fallen across the road. This time, the driver said that we might not be on the right road. As a group of men somewhere within the 140,177 acres of rugged wilderness of Philmont for the first time and at night, we decided that clearly, we knew where we were. So, the ranger and I jumped out and dragged the branches off the road.1 As we continued up the rugged road, we came into a clearing with a group of flashlights on the far northern side that appeared to be shining in all directions. Before driving over the field, the driver hailed them over the radio but the response from the hikers in need of assistance indicated that they did not see any vehicle. The hikers indicated that they were able to move and so had started down the trail to the road. So, we continued up the mountain until we found the trail that would connect us to the hiker’s coordinates. It was hard to gauge the trail in the darkness, but it did look a wee bit abandoned. Undeterred, we donned our packs and headed up the trail. After reaching the first junction, we heard and saw no one.
Consulting the maps, the driver and ranger poured over possible routes the hikers could have taken. Ultimately, we went east. After arriving at the original coordinates, we knew something was wrong. If they were moving down the trail and we were going up, we should have met or saw something. After a few minutes of shouting into the darkness, the driver and ranger studied the maps and called the hikers over the radio while I continued walking on the trail to the next clearing. Once back, I discovered they couldn’t reach the hikers, nor did they want to say they were not experts on the area or navigation skills and thus shame their respective department. But they did discover an old alternative trail that the hikers could have used to reach the road. At a quickened pace, we detoured to second trail, encountering an even more derelict piece of real estate. In minutes, we found our truck and no hikers. Perplexed, the driver tried the radio one more time and got the hikers who indicated they had returned to the road and were slowly descending. We also got new coordinates that put us on the wrong mountain. As time progressed, I found that Philmont was not right for everyone.
Patient D arrived in a complete panic attack. My fellow medics, EMTs, paramedics and attendings started working right away. I tried to calm patient D’s service dog. I grew up on a farm with six dogs, but I never had any formal training on calming a terrified dog. Between my attending and I, neither of us knew whether a dog could tolerate human intramuscular formulations of haloperidol, lorazepam, diphenhydramine, individually, in combination, or even what doses to use. However, I’d been around canines long enough to tell this one was spooked and having had pit bulls and a former attack dog, I knew the damage a dog can do if it feels cornered. Its tail was between its legs as it tried to hide. It was definitely rattled. Fortunately, it was on a leash. I sat cross-legged and calmly tried multiple commands. Some registered but none were followed. Again, I gave the recognized commands and put out my hand for the dog to smell me. Unfortunately, the owner was freaking out in the same room and my Philmont uniform didn’t smell like my dog. I kept trying. The dog finally came up and sniffed me. After a few more hesitant moments, it climbed into my lap and curled up, making itself as small as possible. I began to praise and soothe it. As the minutes passed, it became calmer but certainly was not finding peace. I could see why. Its owner was bawling, shaking, and inconsolable. I realized I could not fully relax this dog with the patient there; the closer the animal got, the more its anxiety rose. However, the patient became more relaxed as the dog got closer. Over the course of an hour, I started inching towards the patient on the bed. Sometimes, I got too close and the dog would scurry off my lap to hide again. At that point, I had to restart the process. With time and cool water, I eventually reunited both patients, especially after learning the dog hated being on the bed. Both seemed to appreciate each other and the process of finding tranquility together began.
After a few more search and rescue radio calls that were very likely unnecessary, I finally had a real situation. I could tell from the grave voices of Nate, the chief/seasoned paramedic, and my attending. They were very serious that we had to get this camper off the trail without calling in a carrier team. The radio started to buzz with the patient identifiers, chief complaint, vitals and request for help. After passing Step 1, I could easily identify all the keywords from this correspondence that indicated he probably had acute appendicitis. Why they thought it was a good idea for all three of us to be in the same vehicle unsupervised after our washout on the mountain is beyond me. However, I did briefly study the map in the radio room before venturing forth. From the trailhead and cold stream crossing, we began our ascent and zigzagged up the trail. Compared to most other trails, this one was clean and recently restored. After a bit of time, we started to see black-charred remnants of trees. In the summer of 2018, Philmont had a huge fire that left huge portions unusable. With no root system to hold the soil in place, mudslides and flash floods became a worry. But the trees we passed were nowhere near the burn zone. The ranger noticed the driver and my attention on those trees and indicated that these individual trees all succumbed to lightning strikes. A quick nervous glance for 360 degrees identified no clouds, and we continued our ascension.
When we finally arrived at the top of the skyline, the ranger and driver briefly consulted their maps and we started down the emergency road. A couple of minutes later we decided better of it. We did a 180 and went the other way, promptly finding the camper and troop. The diagnosis was confirmed, radioed in, and descent initiated. If a patient has the right lower quadrant rebound pain or heel strike, it is a good thing. When the appendix bursts or the pain suddenly lessens, septic shock develops. As the patient was mobile and in pain, we were concerned but continued down the trail. At some point, we discovered that we missed the trail turn off to the truck. So, the ranger backtracked to get the truck and meet us at the new exit point by the ponies. Although the travel was slow, we made it. The driver started to give a report via radio and instructions were given to return to the infirmary. While he was handling this, the patient confided in me that his pain just disappeared. With this new information, we got back into the truck to rendezvous with an ambulance to transport for emergent surgery.
There are some things I wish I had known prior to this rotation that fell through the cracks.2 Before going, I was told to envision myself at the base of a mountain gazing upwards and then imagine having to zigzag up it as fast as possible. I trained on ellipticals and treadmills to prepare myself only to discover that going up the mountain also involved me carrying a 40-pound backpack. Next, greet the entire medic group when they arrive as official training will not commence until all are present. Third, address any concerns with the rotation coordinator or attendings as soon as possible. For example, the chief medic could share the schedule with the medics much earlier, allowing more time to plan. Likewise, the chief should also take more time to master the Philmont forms and protocols to lead and help the group. Lastly, every morning at Philmont, the EMT students check the emergency bags. If allowed to join and help them, the medic could build rapport with their team and familiarize them with the contents of the blue and red bags. These might seem minor things but will help relieve unnecessary stress during the rotation in the backcountry.
A short walk from the infirmary is the Tooth of Time Trader. It sells most things that hikers and staffers need or want, including regalia with Muir’s “The mountains are calling & I must go…” but I prefer the second half of the quote that speaks to dedication, “& I will work on while I can, studying incessantly.”3 Although classroom training is far from over, we pour ourselves over videos, protocols, articles, and anything else that will prepare us to be future physicians. As medical students progressing towards their fourth year and intern year of residency, we transition from didactic to application of acquired knowledge to further our own understanding and begin to build upon the learning blocks that medical school has established. The Philmont rotation is an ideal example of a bridge to help with this transition with increased, yet supervised, autonomy that empowers an unmatched clinical experience.
References:
- philmontscoutranch.org. About Philmont. c2018; Available at www.philmontscountranch.org.
- youtube.com. Philmont Infirmary. c2013; Available at www.youtube.com.
- Muir, J. (1873, 3 September). John Muir to Sarah Muir Galloway, September 3rd, 1873 [Letter]. Retrieved from https://www.adventure-journal.com/
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