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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: www.obhic.org, which for the last
three years has been hosted by Woodbury Reports at
www.strugglingteens.com, 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: http://www.physsportsmed.com/issues/1999/08_99/glover.htm.
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.
CORRECTION: DR. DWANE ROBERTS IS MEDICAL
DIRECTOR AT REDCLIFF ASCENT
(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. |
