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Posted January 21, 2003 

Medical Risk Screening Among Topics Discussed at O.B.H.I.C. Meeting

[Summarized by Loi Eberle, M.A., Educational Consultant
& Editor-in-Chief, Woodbury Reports, Inc.]

On January 9, 2003, the quarterly meeting of the Outdoor Behavioral Health Industry Council included regular working committee discussions, as well as guest speakers who discussed their areas of expertise with OBHIC members. The content of these presentations will be summarized later in this article.

One topic that sparked a great deal of interest was the discussion lead by a three-member panel of medical doctors who worked with wilderness programs and/or sports teams. They discussed the purely medical causes of potential fatalities in the field, how to assess the degree of risk associated with various kinds of symptoms described in applicants’ case histories, and what programs can do to reduce the risk of potential medical emergencies in the field.

In another session, Mike Hylman, a regional USFS recreational use/outfitter permit manager explained ways to improve relationships between outfitters and land use agencies. Later, Thomas Garriga, President of Positive Control Systems (PCS) led a discussion about the therapeutic hold techniques that are taught in his system.

Keith Russell reported on the status of the research activities he has been conducting through the U of Idaho, sponsored by the Outdoor Behavioral Healthcare Research Cooperative, the research arm of OBHIC. He also presented a proposal for a second study in which new data would be collected from participating programs.

Other OBHIC business included approving the minutes from the previous meeting, discussing membership applications and fees, and scheduling future meetings. Membership information will be posted on the OBHIC website:, which for the last three years has been hosted by Woodbury Reports at, and now will be hosted on OBHIC’s own site, and administered by Mark Hobbins of Aspen Educational Group.

More detailed summaries of the topics discussed at the OBHIC meeting will follow.

Medical Doctors Describe Ways to Better Screen for Risk Factors

A panel of three physicians who are experienced in wilderness and sports related medical issues qualified in the field of sports medicine discussed the question, “Why do kids who pass physicals still die in programs? Are there things that we should be aware of that we don’t currently assess?”

The panel consisted of: Dwayne Roberts, MD, CCFP, CCFP (EM), CAQ Sports MED, Director, Utah Valley Sports Medicine Fellowship, Utah Valley Regional Medical Center, Edwin Weigh, PA, Medical Consultant for the Catherine Freer Wilderness Therapy Expeditions; and Dr. Keith Hooker, sports physician, emergency room doctor, mountain climber, one of the founders of the Aspen Program, and a medical consultant for many wilderness programs

To begin the discussion, Dr. Hooker explained there is no cost-effective way of screening all the potential risk factors in applicants of wilderness programs; even major sports teams do not use expensive tests unless an applicant’s case history indicates the need for further testing. Dr. Roberts then described a relatively simple initial screening form, used both for sports teams and extreme sports competitions, that is based on published medical standards. They feel this same examination form is an appropriate tool for medical screening of applicants of wilderness programs, since these programs are less physically demanding than high school or collegiate sports, and certainly less demanding than extreme sport competitions.

This screening tool, called the Preparticipation Evaluation, is described in a 33-page monograph with the same name, which states: “The PPE has been in place for decades as an integral part of competitive sports. In fact, of the 51 state high school associations governing interscholastic sports (50 states and the District of Columbia), only one does not officially require a medical evaluation before a student can participate in high school athletics… In 1996… an American Heart Association (AHA) consensus panel developed recommendations specifically concerning cardiovascular screening to be included in the PPE. This was a major step forward in that a leading national subspecialty association achieved consensus on specific recommendations to improve the detection of cardiovascular abnormalities during the PPE…a major goal of the PPE is to identify athletes at risk for cardiovascular catastrophe. This has proved to be difficult at best. The evaluation currently recommended by the AHA, consisting of certain historical information and findings of the cardiovascular exam, has the potential to identify some, but not all, athletes at risk.” Further information about the PPE can be obtained at:

Although the monograph points out “the difficulty of detecting certain conditions that preclude sports participation,” the doctors on the OBHIC panel explained that question #5 on the PPE is considered to be the most important, cost-effective way for becoming aware of possible undiagnosed cardiac problems. These potential cardiac problems could either be due to an incomplete development of the heart, or due to problems of conductivity, the electrical activity involved in maintaining the beating of the heart. Conductivity problems are particularly troublesome, since they do not show up on an autopsy, but could responsible for cardiac arrhythmias that are the cause of a death.

“Yes” answers on any of the subcategories of question #5 indicate the advisability of further tests before clearing an applicant for participation. It was also emphasized that it is important that the professional doing the examination is fully aware of the level of activity for which the applicant is being screened.

Both the medical panel and the PPE monograph described “the (medical) history as critical in identifying athletes who may require further, more directed examinations.” In addition to the answers to question #5 on the PPE, knowledge of the applicant’s medical history, along with that of the mother and father is considered to be the most effective screening method for ruling out risk factors; 90% of potential medical problems can be identified in this way. This information is particularly important, it was explained, because even expensive tests like the echo-cardiogram do not show all kinds cardiac conductivity problems, though a “stress-echo” can be used to show some conduction problems.

The standard of practice is that if the PPE indicates potential cardiac problems, then a cardiologist needs to clear the person for participation. Also, the parents may need to sign a release of liability. It was felt that the parents should have to prove that a child is safe to go on expedition, if problems show up on the form; it should not be the responsibility of the program to conduct further tests in these cases.

The panel explained this screening is especially important because other factors can cause physical interactions. Stimulants, both prescription, such as Ritalin or Adderol, and non-prescription, such as methamphetamines, as well as antibiotics, can interact with anxiety and a high level of physical activity to increase the risk of cardiac arrhythmias, especially in the presence of undiagnosed cardiac problems. They also identified triptolines, a form of anti-depressants, as having a potentially dangerous interaction when these other factors are also present.

Emergency drugs used in the field can also cause dangerous interactions, especially when undiagnosed cardiac rhythm problems are present. It is important for programs to consult the same type of charts that pharmacists consult, if they need to administer emergency medication in the field to someone who is on prescription medication.

Dr. Hooker stated that in addition to cardiac problems, a few other conditions that would not be acceptable in the wilderness include: Seizure disorder, orthopedic problems that would keep the applicant from hiking, “sugar” disorders, such as diabetes and hypoglycemia, and asthma. Also, if there is a history of mononucleosis within the past year, it could have infected the heart or brain, causing further risk with increased physical activity. The presence of long-term alcohol problems in adult wilderness program participants can also greatly increase the risk of medical problems in the field. It was also pointed out that there might be different exclusions for sports than in the wilderness, because the wilderness is less of a controlled setting. Also, if there has been “heat stroke” or cold injuries in a person’s history, their system is damaged forever, and close monitoring is advised.

Another potential problem is being extremely overweight. The Body Mass Index (BMI), based on a ratio of height and weight, is a very simple measure that has a high correlation with risk for various conditions, as well as being a performance indicator. For example, the “IRON MAN” data shows that if a person’s BMI is just above average, there is no chance of that person being among the top one third of the finishers in that competition.

Another cause of potential medical risk in the field is electrolyte imbalance, which was identified as being more problematic than dehydration, and takes longer to reestablish proper balances. Electrolytes are especially needed for endurance events. If a person is complaining of dizziness, nausea, lightheadedness, they are kids at risk. The advice is to listen to them, and back them off from activity. It is a “salt issue.” Various forms of effective electrolytes were discussed, from tablets, bouillon cubes, Gatorade, to V8 juice. Also, it takes a period of hours to restore imbalances, so it is important to monitor electrolytes, as well as water, to keep hydrated. The observation was made that kids who get in trouble from a medical standpoint are the ones who are pushing themselves too hard. An important medical history question is to ask whether they have ever been treated for being dehydrated? Also, having an infection with a fever puts a person at risk, because they can’t control their body temperature well.

In terms of complications resulting from drug use prior to entering the wilderness, it was pointed out that the most dangerous time is the first 72 hours. The acute withdrawal phase can be dangerous, and must be closely monitored. Hiking hard and low hydration in combination with stimulant use all create risk, though the first 24 hours are considered the worst risk. After that, it has moved out of the system.

In addition to some simple guidelines, for example, “exercise is almost as good as prozac for depression, so is being an appropriate weight,” they concluded by stating that outdoor behavioral healthcare is rewarding, but risky work, yet statistically is pretty safe; by far safer than letting the kids remain on the street, doing their usual activities.

Permits and Outdoor Use Issues

Mike Hylman, USFS regional manager, described ways to develop good relationships with land management personnel, and potential changes the permit process. One major recommendation was to invite the local USFS administrators into the field, so that they can see what OBH programs are doing and why. At very least, he recommends that programs get to know well, the district administrator and the person to whom they are required to report.

In addition to this general advice, Dr. Rob Cooley of the Catherine Freer program suggested joining America Outdoors, to lend support to that group’s activities regarding the permit process. America Outdoors is active in promoting the Outfitter Policy Act, RS2477, which is opposed by some environmental groups because it would require non-profits to go through the same permit process as commercial outfitters and would allow motor access in some areas not currently permitted. Mark Hobbins suggested, and it was agreed by the OBHIC members, to join and contribute to America Outdoors.

The benefit of “fee retention” was discussed, which involves requesting a small percentage of the permit fees to stay in the district. The Missoula, Montana forest service district demonstration project was described, in which $900,000 of permit fees is spent locally on trail maintenance. In the past the concern has been that fee retention would create more local bureaucracy, but it was emphasized it could be used for trails. “Flat fees” were also advocated, which could be based on use, though it was pointed out that “low end” outfitters would probably have their fees raised in this case. Flat fees are easier to maintain and plan for. The feeling was the group should support flat fees and fee retention, and Mr. Hyleman implied the forest service could agree to this policy if it was requested by enough of the wilderness industry.

Mike Hylman also announced the availability of a variety of Forest Service utilities that are either for sale, or rent, many with surplus government structures. Further information can be obtained through the forest wide and region wide lists maintained by the Forest Service Engineers, starting with the local forest district.

Outdoor Behavioral Healthcare Research Cooperative (OBHRC) report:

Dr. Keith Russell informed the steering committee, chaired by Mike Merchant of the Anasazi Foundation, of the importance of the recent publication of the initial OBHRC study in a top tier journal. Now it can be stated that there IS published research on the benefits of this approach. Considered a “seminal piece”, the article was published under the title: “Perspectives on the Wilderness Therapy Process and Its Relation to Outcome,” by Russell, K.C., & Phillips-Miller, D. (2002) in the Child & Youth Care Forum, 31(6), 415-437. According to the abstract, “Findings indicate that physical exercise and hiking, primitive wilderness living, peer feedback facilitated by group counseling sessions, and the therapeutic relationship established with wilderness guides and therapists were key change agents for adolescents. These factors helped adolescents come to terms with their behavior and facilitated a desire to want to change for the better.”

In addition to running further regressions on this data for future journal articles, he is also conducting 24-month follow-up calls on the study participants. He also presented his proposal for another study, to test the relative effectiveness of Outdoor Behavorial Healthcare as a treatment model. His proposed study will address several hypotheses regarding “expected relationships between treatment, circumstances-motivation-readiness-suitability to treatment (CMRS), level of depressive symptoms, treatment intensity, aftercare intensity and outcome variables that focus on the reduction of substance use and depressive symptoms. Research methods include self-report questionnaires administered to adolescent clients and pre-and post-treatment, and at 6-month follow-up periods.”

Russell also emphasized the importance of developing a manual of OBH treatment that adequately describes the similarities of approaches used by various OBH groups in a way that is acceptable to each of them. While acknowledging that there were many variations in how various groups accomplish each of these recognized elements of OBH, by finding a common description that adequately describes this approach, they will make strides in being recognized as a treatment modality.

He summarized his remarks by emphasizing the need for the industry to continue to inform the public about the research that is being conducted and published. This is an important way for the effectiveness of Outdoor Behavioral Health to become more widely recognized.

(Feb 19, 2003) Loi Eberle, M.A, Educational Consultant and Editor-in-Chief, Woodbury Reports wishes to apologize to Redcliff Ascent Wilderness Experience 800-898-1244, Enterprise, Utah, for neglecting to identify Dwayne Roberts, MD, CCFP, CCFP (EM), CAQ Sports MED, Director, Utah Valley Sports Medicine Fellowship, Utah Valley Regional Medical Center, also as the medical director at Redcliff Ascent. Redcliff Ascent was instrumental in arranging Dr. Roberts’ role in this excellent discussion.

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