This month, the Federal Aviation Administration relaxed its rules on commercial use of drones. Among 10 programs awarded permission to operate commercially is Flirtey, a startup that promises to deploy defibrillators via drone to the scenes of medical emergencies. The pilot program begins in Reno, Nev., based at a network of FedEx stores. But beyond city limits, the system’s potential for remote care seems huge. Can a drone deliver a defibrillator to a climber halfway up Mount Rainier, or epinephrine to a child with anaphylaxis somewhere on a rafting trip?
Similarly, California-based Zipline recently announced a new generation of fixed-wing drones, geared to long-distance deliveries. The company has been delivering blood products via drone to Rwandan district hospitals since 2016. And some Australian teams have already proposed blood deliveries directly to accident scenes, in advance of pre-hospital responders.
The use of leading-edge technology in the remote setting has entered something of a renaissance, from delivery drones to point-of-care diagnostics. Naturally, I’m a little bit afraid of these things tanking mid-flight and raining epinephrine on my unsuspecting head during a day hike. Nonetheless, the use of innovative technology in austere medicine offers potential that shouldn’t be ignored by practitioners or educators.
Many wilderness practitioners still feel that the best medical kit is a roll of duct tape and a cell phone. I might add some safety pins and a Foley catheter. Others are gearheads — jazzed about goofy stuff that seems to either break or run out of power way too often. So what’s the best way to bring austere medicine into the 21st century without loading our backpacks full of useless gadgets?
The real advances seem to be in diagnosis and monitoring. Much work has been done on ultrasound in the wilderness, from the International Space Station to research at altitude. Handheld devices now make acquisition, transmission, and interpretation of images more accessible than ever. Smartphone-connected ultrasound devices that help clinicians interpret images aren’t far down the road, suggesting that sonography could be placed in the hands of community health workers or first responders without the necessity of an expert on the other end of the line.
Real-time monitoring is a key to both prevention and diagnosis. Last year, German researchers evaluated the efficacy of non-invasive intracranial pressure (ICP) monitoring in patients with subarachnoid hemorrhage. The preliminary results were promising, suggesting that larger studies could demonstrate that these devices may find use in the pre-hospital space as well. If non-invasive ICP monitoring makes prime time, we may see a revolution in the approach to high-altitude cerebral edema and acute mountain sickness.
Bringing high-tech interventions to remote areas may be harder. Cardiac arrest in the wilderness is often futile due to resource limitations and long distances. But in some cases, like avalanche burial or cold water immersion, prolonged resuscitation can lead to excellent neurologic recovery. Mechanical chest compression devices have been used for some time in helicopter EMS services, with the prospect of allowing longer pre-hospital resuscitations with high-quality compressions that might not be otherwise possible in the air.
In 2014, German researchers reported one of the first uses of an external chest compression device by a helicopter EMS service to resuscitate an avalanche victim. In this case the outcome was unfortunate, likely due to prolonged asphyxia. Nonetheless, the strategy will catch on. Will these devices start showing up next to AEDs in hard-to-reach locations, or in the caches of search-and-rescue teams?
My colleagues and I have been designing a new austere medicine course for medical students. We should feel obligated to embrace the impact of all this technology and prepare caregivers for the newest tech they’ll encounter in the field.
Sure, our lesson plans will include improvised splints, hypothermia wraps, and litters built from ski poles. But shouldn’t we be teaching students (and wilderness first responders, for that matter) how to interpret ultrasound images on a smartphone, when to consider some drone blood, or what increasing ICP might mean in a Himalayan trekker?
Wilderness medicine instructors should embrace leading-edge technology and introduce it along with the basics, since our students are helping to design a new era of austere medicine. My plan is to introduce the high-tech stuff right along with all the things you can do with a Foley (lots) and the uses of duct tape (endless). Hopefully doing so will help propel my own practice into the future.
Christopher Tedeschi, MD, MA, is assistant professor of medicine at Columbia University Medical Center (CUMC) in New York City and director of emergency preparedness for CUMC Emergency Medicine. He is especially interested in applications of wilderness medicine to global health practice and disaster response and preparedness.